Mea maxima culpa—Dealing with surgical complications

His eyes became sunken and retreated backwards. His face grew pale. Within seconds, a lifeless corpse replaced the spirit of a once vivacious, living being. My mind was paralyzed, but my instincts remained engaged. Without delay, I initiated chest compressions, glaring intently at the monitor and hoping that the asynchronous beats would somehow reorganize into a familiar rhythm again; but they did not. Instead, the tracing flattened. This man and his soul had drifted away, and there was no way I could call him back. He was gone forever, and in the recesses of my mind, I felt I was in some way responsible.

In medicine, a “complication” refers to the unfavorable evolution of a disease, condition, therapy, or procedure. By and large, complications are unintended, and, particularly in surgery, they frequently occur with little or no advance notice. Occasionally, complications arise without any true reason as to how or why they occurred. What is clear, however, is that the costs associated with most complications are high—sometimes conferring unnecessary morbidity and premature mortality, which is every surgeon’s nightmare.

Much interest is frequently placed on understanding how to avoid the varying types of complications, but little is ever spoken regarding how to conduct oneself when, indeed, confronted with the reality of an undesirable surgery-related event. This notion has emerged as being critically important to us as surgeons, given that we are now judged not only by the scope and adeptness of our surgical skill, but also on the bases of the short- and long-term complication rates associated with the care we provide.

Invariably, we will all face complications. Even those whom we hail as masters and experts of our craft can recall complications that have haunted their clinical practice. To this point, there are few situations in which specific complications are essentially unavoidable; they just happen. Yet, irrespective of the context, we must recognize that in almost every situation—regardless of the setting—rests an opportunity for the surgeon to be inquisitive, to be transparent, to be introspective, and to learn from the moment at hand.

In whatever way we choose to address our complications, either in our clinical practice or on the basis of consultation, we must challenge ourselves to be responsive in identifying sentinel causality. We must demonstrate equipoise between self-assessment and constructive peer censure. We must continue to recognize the inherent frailties of the human experience and work toward shifting from a culture of blame and duplicity to one of accountability and trust. Finally, we must be dedicated to delivering responsible, patient-centered care in a safe, collegial environment that includes equitable treatment and full disclosure to all patients and families alike. These tenets may represent the way forward in our specialty and inarguably will define how well we are able to truly advance our profession beyond the veil of complications.

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