Photo credit: By Jerry Hecht Restrictions [Public Domain] via Wikimedia Commons
By Hasan Kakli M.D.
It is inevitable that in the course of humans caring for humans, mistakes will be made. Much of our healthcare resources are devoted to implementing systems and checklists to prevent their occurrence or to mitigate their effects. And while ideally we would work in an error-free environment, this is an unattainable goal. However, the pursuit of perfection keeps us going like the proverbial carrot in front of the donkey.
As with any journey, medicine is fraught with chances to err. In medical school, our mistakes usually result in lost examination points. But as we continue on this journey, the stakes rise, as do the consequences. The manner in which we deal with these difficulties molds us as clinicians. Any given adverse event can be dealt with in one of three ways: 1) We can choose to largely ignore it or quickly dismiss it as a statistical anomaly, 2) We can allow it to consume our conscience and disrupt our confidence, or 3) We can evaluate our deficiencies by confronting them and readjust our approach.
Nearing the end of my fifth coronary artery bypass graft my attending asked me, “You ready to close?” I had done it a few times before and had learned that driving a steel wire through bone to close the sternum is a lot harder than he made it look. But I was getting the hang of it and anxiously waited for my opportunity to cap off an otherwise beautifully routine cardiac re-vascularization. “Yes Sir,” I said with restrained glee. With the chest and mediastinal tubes placed, I approximated the chest with three wires in the manubrium and four in the sternum. While we were transporting our patient to the ICU I noticed that the mediastinal tubes were a juicier than normal, but I was confident that after re-warming and correcting coagulopathy in the ICU, it would dry up like I had seen countless times before. 30 minutes passed. Temperature is normal. Platelet count, INR, ACT, fibrinogen level, all within normal ranges. But over 150 ccs of sanguineous output filled the collection chamber. And then the blood pressure began to drift. My attending sat a few feet from the bed, head in hand. “We’re going back.” Impossible I thought. It was dry when we closed. No way could the patient have a surgical cause of bleeding.
Less than 20 minutes later there it was staring me in the face. My second sternal wire had transected the right internal mammary artery. Words could not describe my shame. I had worked my entire adult life to preserve life and here I had nearly ended it. At that moment I thought I would be better off never seeing the inside of an OR again. With a comforting, “Don’t worry about it Kakli,” my attending fixed it with a simple figure of eight stitch. “Just make sure you hug that bone as close as possible so you avoid the IMA territory.”
On post op day #2, my patient was extubated and now came the daunting task of explaining my nearly fatal error. For the past 48 hours I could not see anything other than that pulsatile jet from my ill-placed suture. With his wife at bedside I recounted the events and our surgical findings, preparing myself for the inevitable verbal onslaught. I’ll never forget.
“It’s ok,” he said with a smile, “You’re still learning. I’m just thankful that you found out what was going on and fixed it.” We all come across moments in our lives which re-charge us and remind us why we devoted ourselves to our chosen paths. Such was this moment for me. I could never have guessed I would exit his room holding back tears of happiness rather than tears of humiliation. The next time I closed and every time thereafter, I invariably remember my mistake. But instead of allowing it to undermine my confidence, I use it as an experience to improve my patients’ outcome.
I often think how exceptional it is that a few millimeters of variance can have such a profound outcome. But we have chosen an exceptional career. And if we are to succeed in it we must confront our mistakes and learn from them without allowing them to disrupt our focus. Our patients deserve it.
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