Chapter 1: Complications

“Medieval man was a cog in a wheel he did not understand; modern man is a cog in a complicated system he thinks he understands”

-Nassim Taleb, The Bed of Procrustees: Philosophical and Practical Aphorisms

The sickest patient I ever saw was in the cardiac surgery intensive care unit (CSICU) during my 3rd year of residency.

After a 28 hour liver transplant two attending anesthesiologists transferred a patient to the CSICU. Considering liver transplant patients usually go to the surgical ICU (SICU) I knew this was a strange case. He had a fresh liver transplant, continuous dialysis for renal failure (CRRT), an open abdomen with an Ab-thera device preventing his organs from falling out, and an open chest with two large plastic tubes connected to an extracorporeal membrane oxygenation (ECMO) machine.

My patient with central line, ventilator, ECMO (heart lung machine), and CRRT (continuous dialysis)

During the surgery the patient developed a blood clot which traveled to the right side of his heart, causing heart failure. Cardiothoracic surgeons were called and an emergent sternotomy was performed. He was connected to an ECMO machine, which takes deoxygenated blood from your right atrium, oxygenates it, then pumps it to your aorta to the organs of your body. After ECMO, the liver transplant was completed. His chest and abdomen were bleeding too much for safe closure so they were left open. His heart, lungs, liver, and kidneys failed yet he was still technically alive.

Unfortunately his brain was without oxygen for too long. He was pronounced brain dead in the CSICU 36 hours later. Considering thousands of livers are successfully transplanted every year why did this guy have this horrible complication? Early that morning at 0400 I explained the situation to his family. How do you tell them we did everything right and it didn’t matter?

Sometimes in medicine poor outcomes occur for no discernable reason; even when doctors do everything correctly. My first year practicing medicine I was the intern on the general/trauma surgery service. We had a healthy 44 year old gentleman who developed a perforated colon from diverticulitis, a pathologic weakening of the colon wall. I helped operate on him in the middle of the night, removing his diseased section of colon and creating a colostomy. He recovered uneventfully until post-operative day 5 when he developed worsening abdominal pain. My senior resident examined his colostomy. It was black and dead.

We took him back to the operating room, resected 15cm of dead colon and made a new colostomy. He recovered and left the hospital one week later without further complications. Later that month my senior resident presented his case to the entire surgery department to see if his complication could have been avoided. After reviewing the operative technique and post-operative management everyone agreed the patient had received the best care possible. The most senior colorectal surgeon said he has seen this complication once during his fellowship 30 years ago. He has created and managed more colostomies than anyone in the hospital (and probably the country). His eyes softened then he said “it just happens sometimes, don’t take it personally”.

I could tell our patient didn’t fully trust our surgery team after his complication. My attending surgeon felt awful. He did everything right and still had a poor outcome. Worse still we couldn’t tell the patient why it happened. I will never forget the way the patient looked at my attending. For a doctor there is no greater shame than to be distrusted by your patient. Surgeons and anesthesiologists care deeply about their patients. They understand surgery is very dangerous and they must perform at the highest level for favorable outcomes. But this was different. What do you do when you perform at the highest level and you still fail? How do you not take it personally?

Published by Nabil

Nabil Othman, MD is an anesthesiology resident physician at Cedars Sinai Medical Center in Los Angeles, CA. As a Michigan native he advocates calling carbonated, sugary beverages "pop". When he is not an indentured servant in the hospital he enjoys CrossFit, telling everyone he meets about CrossFit, and attempting dangerous hikes in Hawaii with his college roommates.

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