Apologies to Dr Gawande for stealing the title of his book for this post on complications, all medical students read this at some point I think and rightfully so, it is a jolly good book.
I have had a bit of a crisis of career choice recently and have wobbled a bit within my chosen area of surgery with which subspecialty to choose. I have had years to decide on this but I am torn between the exciting and dramatic with often devastating complications and the solid and dependable with less life destroying complications A surgeon is a different sort of doctor, we pick up a knife and cut into a live person, ostensibly to help and to cure and at least to alleviate suffering but there is short term pain in this act and a risk of serious disaster caused by our operation. Lay people are frequently interested to know what it is like to wield a knife and I never quite know what to say. What is it like to be a pilot and fly hundreds of people up to 36000 feet, or to be a stripper and hold the attention and the desire of every man in the room? The answer I feel like giving is that it is brilliant fun and a great privilege to do this job and I think I am seriously lucky. That’s not what they mean though, they want to know about cutting through virgin flesh and having a life literally in your hand. Not many surgeons think about that day to day, there are moments when you do have that those thoughts but they are rare. The first time I took a small, sick child that only I had seen to theatre, I had a sense of apprehension as I made the incision that if I was wrong and she didn’t have a belly full of pus I would feel wretched. The first and only time I took a clamp off a ruptured and irreparable aorta (that we had taken to theatre thinking it may be fixable) and let the patient bleed out on the table I felt the weight of the knowledge I had essentially just ended a life.
I have been responsible for my share of complications over the years, as we who cut people all have been unfortunately, it is a surety that at some point someone will be harmed by an operation regardless of surgical skill and clinical decision making. One of my bosses, for whom I have the utmost respect and hold in high regard, has a good theory on dealing with this problem. He says that we should walk away from an operation with no regrets, that we should not want to replace a single tie, or check the haemostasis, or wash some more etc. The test of this is that if the patient then goes on to develop a complication you don’t berate yourself, as you know it was as good an operation as could have been done and you have no wish to do it differently.
Still though, complications are hard to deal with and I recall my first solo appendicectomy who took a whole week to finally get better. I felt I had done a good operation and took it rather personally that the man did not feel immediately better and went on to stay in hospital for a week. I came to dread coming to see him on the ward round as both of us had not had our expectations met, I had not adequately prepared him and had told him he would soon be much better and get home in 24 to 48 hours.
Nowadays I know that this is not abnormal after a bad appendicitis and I don’t have such high and unrealistic expectations of outcomes in the immediate post operative period. I have a colleague who consents people with every possible worse case scenario and tells them at length, sometimes with the aid of a textbook, just what he is going to do and how hard it all is. The result of this is that his patients think he is a hero when things go well and nobody is surprised when they go badly. I don’t recommend his technique.
In settling on a subspecialty I have thought long and hard about what sort of complications I want to deal with, and in the end I have wimped out of the big stuff, not for lifestyle reasons, not because I can’t be bothered with ten hour cases but because I simply can’t bear the big complications.