Surgical Complications

“There is a saying about surgeons, meant as a reproof: ‘Sometimes wrong; never in doubt.’ But this seemed to me their strength. Each day surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one's knowledge and abilities are never perfect. Even with the simplest operation, it cannot be taken for granted that a patient will come through better off - or even alive. Standing at the table my first time, I wondered how the surgeon knew that he would do this patient good, that all the steps would go as planned, that the bleeding would be controlled and infection would not take hold and organs would not be injured. He didn't, of course. But still he cut.”

- Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science

I had a few complications today in surgery. Psychologically dealing with this is always hard for me. It used to be worse: I would keep replaying tapes of what happened in my mind. I wouldn’t be able to sleep. I’d think about what the patient was going through every day. I’d keep thinking, what if I had just done that? it would have all been so much smoother. Why don’t I have a job that doesn’t involve blinding people if I mess up?

It’s not quite as bad now, but it still weighs on me a lot. And it’s hard to talk with anyone who understands: none of my closer friends outside of work are physicians. Dave is probably the closest though he’s yet to actually see a cataract surgery. It’s an awkward thing to talk about with work colleagues—like they say in residency, having a complication is like losing your virginity: you want to get it over with, but you don’t want to get a reputation for it. I’m flying solo for the most part, and while people occasionally commiserate about difficult situations, it usually doesn’t involve admitting one’s mistakes.

It’s exacerbated by the fact that I work part-time. That was always the dilemma of my career: I want to operate. I love working with my hands. I would be really sad if I couldn’t scrub in. But I want to be home the majority of the time. And you just can’t really be the surgeon you could be working part-time: it’s hard to generate as much volume, and you’re not around to handle perioperative issues or track results over time. I picked a field where it’s as good as it could get: I cut into eye or skin one out of the two days a week I work. But it’s not the same.

And then I think: complications are a part of surgical life. I practice in a rural, relatively underserved satellite office, where people are nearly blind before they want to get surgery, so the majority of my cases are harder ones going in. Removing one brunescent cataract is harder than doing twenty nascent ones. Most of my cases are done in a local OR without highly experienced staff. Cataract surgery is the most common and probably one of the safest surgeries done in this country, but it’s still surgery. Things happen. I don’t know if everything will go as planned, or whether some sudden eye movement on the patient’s part, or slip of the hand or loss of visibility on mine, will suddenly change a five-minute case into an hour-long case. I don’t know if an infection or retinal detachment will blind the patient months or years down the line.

And I am not perfect. I’m not perfectly experienced. Sometimes I’m tired, or hungry, or needing to pump, and though I don’t think I let that affect me too much, perhaps it does. In the heat of the moment, when I stare into the scope and feel my heart racing, I don’t always know if I make the right decisions. Perhaps it’s the substrate, perhaps it’s me, perhaps it’s the staff and environment I operate in, perhaps some combination of it all.

I try now to see that complications provide a chance to learn: I suppose the truly tragic thing would be if I never learned and improved. All great surgeons I know have stories about complications to tell, many about situations worse than the ones I’ve found myself in. They are an exercise in humility. They are a keen reminder that what I do is never something to be taken cavalierly. They are evidence of the uncertain nature of medicine, and that empathetic care can sometimes be most expressed in unexpected suffering.

I know complications will happen, but I still hate it when they do. It still bothers me a lot, and I don’t know if that will ever change. But I don’t want it to paralyze me: I want to learn what I can and do my best to move on.