Blood, Sweat & Tears

Becoming a Better Surgeon

Stahel, Philip F

• Publisher: tfm Publishing Ltd
• Year: 2016
• ISBN:
  9781910079287
• Topic: Medicine
• Subtopic: Surgery & Surgical Medicine

All surgeons want to be better surgeons... They work hard to be respected by their peers, appreciated by their patients, and valued by their communities. Most of the estimated 200 million surgeries performed worldwide every year go as anticipated, with positive patient outcomes. However, the number of surgical complications and preventable medical errors still remains unacceptably high. Why are experienced surgeons still creating so many adverse events? More importantly, what can surgeons do to better address the situation? Blood, Sweat and Tears — Becoming a Better Surgeon seeks to answer these questions. The book provides pragmatic examples on how good surgeons can grow from being technically brilliant to becoming empathetic and capable of providing safe, compassionate, and more effective patient care. Blood, Sweat and Tears — Becoming a Better Surgeon follows trauma surgeon Philip Stahel's 20-year journey from his 'rookie years' in internship and residency, to his development as a global patient safety advocate, renowned academician and teacher, and compassionate surgeon. The book touches on why our current patient safety protocols and checklists fail to keep patients safe and how a physician-driven initiative with credible leadership is needed to build a sustainable 'culture of patient safety.' Written for a wide audience and based on the paradigm that "good judgment comes from experience which comes from poor judgment", Blood, Sweat and Tears — Becoming a Better Surgeon provides in-depth coverage of all the critical and timely components of safe surgical care, relates practical tips for improving the quality of partnerships between surgeons and patients, and offers a practical guide on how to reduce the learning curve to becoming a better surgeon. Reviews1) I applaud Dr. Stahel for presenting a rich compilation of his honest and remarkable first-hand experiences and the collective work of doctors and health care leaders to reduce the endemic variation in medical quality that contributes to the #3 cause of death in the U.S. today — medical care itself. Marty Makary MD, Author of The New York Times bestseller, Unaccountable 2) "Blood, Sweat & Tears" is a great book, one of a kind, and destined to be a medical classic. What makes the book exceptional is the narrative about a difficult human endeavor, often done imperfectly, by humans who have been told they should be 'perfect'. This quintessential paradox is why this book is a practical story about life and will likely be of interest and enjoyment to many outside the realm of medicine. Wade Smith MD, Co-founding Editor, Patient Safety in Surgery3) Blood, Sweat & Tears: How to Become a Better Surgeon is a remarkable book that emphasizes empathy and communication, provocatively authored by a surgeon. However, as the reader will soon discover, Philip Stahel is not your ordinary surgeon. I strongly recommend every health care provider read this book. I further recommend this book be mandatory reading annually for every medical student, intern, resident and fellow-in-training, most especially chapters 3 and 4, which epitomize William Osler's advice, "Listen to the patient - he is telling you the diagnosis". In these 20 chapters, the many other insightful quotes alone are worth the purchase price.Jerome M.Buckley, MDRetired CEO/Chairman, COPIC CompaniesAssociate Clinical Professor, University of Colorado School of Medicine 4) The life of a surgeon is difficult. Life and limb threatening problems do not necessarily occur at convenient times. Surgery is not for the weak as it requires physical strength, emotional stamina, and unquenchable intellectual curiosity. Underneath these prerequisites lies the most important of all surgical requirements: the patient. With his emphasis on patient care found through empathy, shared decision making, and attention to detail, Dr. Stahel is telling the surgeon of today and tomorrow about the way to quality improvement and self-fulfillment.The emphasis on empathy is a crucial but neglected part of quality improvement. Why do our patients so frequently not adhere to our instructions? Putting yourself in the patient's position creates an essential surgeon-patient bond that underlies an optimal outcome. Dr. Stahel did not write the golden rule of "love thy neighbor as thyself", but it is clear that he sees this as an essential part of the surgeon-patient partnership. Both surgeon and patient will feel this effect, and it will pay dividends for both parties in the near and distant future.It is an important but disturbing reflection that many medical students lose their empathetic qualities during their clerkship years. There are many reasons that underlie this loss including our role models, the frantic pace of clinical activities, and the lack of clear direction as to the medical student role. Importantly, Dr. Stahel gives us a path to finding our empathy by rediscovering our humanism. Relating to the janitor, the nurse, and other members of the care team as people is an important first step in understanding the common ground that we share with our patients. Letting each member of the surgical team call the professor by his first name clearly tells the staff that all are important and essential. Giving his phone number to his patients shows the trust that Dr. Stahel shares with those who trust him.As I reflect upon my own 35-year career in surgery, I remember the eagerness with which I first approached operating room days. "A chance to cut is a chance to cure" and "the only way to heal is with cold steel" were chants that my fellow residents and I would often repeat. The operating room was its own sanctuary away from many realities of patient care. With time, I have learned to appreciate other parts of patient care. In the clinic, I have a chance to know the patient as a person, and I have an opportunity to educate the patient as I would want to be educated. My path to becoming a better surgeon is far from over but my time to accomplish this is short. I truly wish that I had read such a book many decades ago as I began my life in surgery, but back then no such work was available. With Blood, Sweat, & Tears, Dr. Stahel has directed me to some needed tools that might help me reach this laudatory goal of ongoing quality improvement. I am most appreciative for his reflections and observations, and I remain hopeful that perhaps someday I might become a better surgeon.Ted Clarke, MDOrthopaedic Surgeon and CEO and Chairman of COPIC, Denver, Colorado 5) As a veteran Registered Nurse I feel that this book is a must read for anyone in health care! Dr. Philip Stahel has a very down to Earth writing style and compassionate approach to patient care. Reading this book has reinvigorated my love of nursing and passion for patient care. Kerry Olson, RN6) Blood, Sweat & Tears is a unique book - clearly one of a kind, and surprisingly not just of interest to those who work in healthcare. The book has a captivating narrative flow and the medical aspects are very easy to understand for non-clinical/laypersons as well. I will be sending my "baby boomer" parents a copy as it becoming increasingly important for the community to understand the complexity and challenges of our current healthcare system. My take-home point from this book is that we can and we should be involved in our healthcare choices and ask important and pertinent questions. If you're like me, and you're interested in patient safety and eventually receiving high quality medical care if you ever become a patient, if you have a sense of humor, and you would like a different perspective on healthcare, this is the book for you! Nicole Morgan, MHA

“There are many forces coming together to harm or even kill the patient — their physician should not be one of them.”

Arnold S. Relman, MD (1923-2014)

Editor Emeritus

The New England Journal of Medicine

January 10th, 1994

Drip, drip, drip…

Bright red blood fell in large droplets from a red rubber Jackson-Pratt drain into a collection bag hanging beneath my patient’s bed in the intensive care unit.

He was bleeding out. Drop by drop.

Drip, drip, drip…

I forgot his name within days of his death. I do not know it now. I never learned what he did or where he was from. All I knew about him was that he was 54 years old, overweight, indulged in fatty foods, rarely exercised, and had a tattoo of an anchor on his left shoulder. He’d had an open aortic repair 6 hours prior to my arrival. I was about to start my second 14-hour night shift as a cardiothoracic surgical intern. According to the notes left for me by my attending, Dr. Gassner,² the diseased aortic tissue had been removed and a synthetic polyester graft was placed. The surgery had been a complete success. The cursory sign-out sheet handed to me by the departing dayshift intern stated “n.t.d.” (nothing to do) in the column of pending action items.

But now, there was a problem. I could not stop the patient’s bleeding.

We had an additional 11 postoperative patients in the ICU. They were all complicated — a devil’s brew of heart transplants, aorto-coronary bypasses, and cardiac valve replacements. Most of the other patients were intubated and largely deaf to the bleeding man’s painful moans. The 54-year-old grimaced and groaned. He begged, “Please help… please help…” Over and over. Despite the ongoing administration of painkillers it was clear he was in significant pain. The surgical nurses knew something was wrong.

The source of bleeding was evident. I suspected it, and the nurses knew it.

He had a leaking anastomosis. All the classic signs were there: abdominal pain from irritation caused by the free blood filling his peritoneum, nausea, rapid heart rate, low blood pressure…

But most obviously, the Chinese water-torture drip of blood.

The charge nurse who only just yesterday had welcomed me with a warm smile and a pat on the shoulder now stomped up with a frown and delivered her non-negotiable request: “You have to call the surgeon.” I knew she was right. But, still, I hesitated. Calling Professor Gassner, only hours after the surgery, would be tantamount to my admitting I could not take care of his patient. Worse, it would be akin to accusing him of botching the operation.

Drip, drip, drip…

Three weeks earlier I had stepped aboard a plane and took one last lingering, backwards glance at the verdant mountains surrounding Bogotá. Following my graduation from medical school, I had spent 2 months backpacking through Venezuela and Colombia.

I was hopping from hostel to hostel with my best friend from medical school, Martin. We made our way from Caracas on Venezuela’s fertile coast with its colorful fishing boats, up into the highlands peppered with banana plantations to San Cristóbal, a mountain city nestled in the northern Andes. Right on the border with Colombia, San Cristóbal was a dangerous place. In fact, Colombia was a country everyone had warned me about; a country wracked by insurgency, stricken with constant paroxysms of bloody violence. The notorious FARC — Fuerzas Armadas Revolucionarias de Colombia — operated on the border and we heard many stories of waylaid travelers. Crossing the border was not easy; we encountered numerous groups of armed men and had to talk our way out of some dangerous situations.

Despite the multiple warnings, I found Colombia to be a country of endless natural beauty. The landscape was picturesque, from the lush Orinoco river basin to the floral explosion of the Amazon jungle. Wherever we traveled, we encountered warm, selfless people who welcomed us, two young strangers, into their homes with open arms.

While in Colombia, Martin and I bunked with a poor family of six in the mountain town of Tunja. We’d stayed up late with our hosts, swapping stories, drinking coffee, and sharing a bowl of natilla, a cornstarch-based custard. It poured rain that night. Martin and I slept on the floor and I was awakened by the steady “thud-thud-thud” of water dripping in through the roof and onto my pillow. Despite the hard, cold, and now wet accommodation, I had never been happier.

I recalled that same “thud… thud… thud…” of water 3 weeks later in the cold and antiseptic halls of the largest academic medical center in Europe. The sound was nearly identical but the emotions it provoked in me were torturous.

Drip, drip, drip…

We changed the bag beneath my patient’s bed seven times. And still it filled with fresh blood.

Unsure of how to proceed and certain that the man’s bleeding was a complication from his surgery, I swallowed my pride and rang Professor Gassner. It was 1:30am and he greeted my call with immense displeasure.

“What is it?”

“Um… I… hello… sorry, Sir…” I stuttered, fumbled, tried to explain what my concerns were. He shot me down immediately, with a crushing fierceness he’d perfected over a lifetime of bending interns and residents to his will.

“Are you suggesting there was a problem with my surgery?” He snarled.

I hedged, backpedaled.

“I suspect it’s a leaking anast-…” He cut me off and told me I was mistaken.

He said that it was my job to figure out what was going on and that, most likely, I’d missed something. Surely he considered my appraisal of the situation to be cursory and unpolished.

He hung up before I could even respond.

I didn’t know what I had expected to hear. Professor Gassner, like all of the attending surgeons on the staff, was a god. And lowly mortals did not question their gods. His word was Holy Writ. His actions inscrutable. If there were problems, I owned them.

I came away from the call even more defeated. The charge nurse could see it.

Drip, drip, drip…

I redoubled my efforts to stop the bleeding but it was useless. I ordered repeat labs, coags, another CBC, and more blood products.

I ran through every scenario I could think of. Every possible test. Nothing was working. Finally, I asked the disgruntled charge nurse what I should do. She threw up her hands, exasperated. “You’re the doctor!”

My patient’s moans continued. His pleas left me weak. As terrible as it may sound, I was glad when another patient’s condition acutely worsened and I had the brief luxury of being distracted attending to her needs. Still, it was only a temporary respite.

Drip, drip, drip…

I steeled myself for the confrontation I knew I had to have.

I paged Professor Gassner again at 4am. Within minutes, he called me back, his voice trembling with frustration. I could barely get the words out of my mouth, explaining the acuity of the situation again. I tried to describe in as much detail as I could what was going on and I asked him politely to come in.

He hung up on me again.

Finally, at 7am, Professor Gassner burst into the ICU. As he pushed past me, I attempted to brief him but he barely listened. When he saw the patient, he became livid. “Why the hell didn’t you call me earlier?!”

I would not have a sufficient answer. I was a mortal after all.

There was a joke that made the rounds about how interns took the blame for anything. Attending surgeons would ask junior house staff ironically: “Why did you assassinate JFK?” The interns would reply something like, “I don’t know, Sir. I’m really sorry!”

“There is no time,” Professor Gassner shouted as he took charge of the situation like a commanding general. “We have to reopen his abdomen now.”

I held the retractors while he filleted open my dying patient’s gut right there in the ICU. The belly was awash with blood and it spilled in a torrent onto the tile floor at my feet. “Oh my God,” one of the nurses whispered, shocked at the sight of the devastation.

Professor Gassner packed the belly with dozens of laps for temporary bleeding control before getting to work on the revision anastomosis. He was ruthless, convinced that only his hands — the same hands that had caused the bleeding — were capable of saving the victim beneath his scalpel.

“Anastomotic leak…” he said bluntly. “You should have known.”

As he worked and I assisted, I was sweating through my scrubs. All the stress was taking its toll. One of the nurses watched, horrified, as beads of sweat rolled off my face and dropped into my patient’s open abdomen. I was a wreck.

After an hour of surgery, my patient flat-lined. Professor Gassner cracked open the left side of his rib cage, stuck his hand inside and began manually pumping the empty heart. Nothing was going to save my patient now.

The drip… drip… drip… slowed, and then stopped.

Professor Gassner tossed his gloves and turned to the nurse and me. “Close the belly. Don’t bother with how good it looks. Doesn’t matter now.”

I was beaten, exhausted, and defeated. I sutured my patient up slowly and carefully, with Professor Gassner’s words playing on an endless loop at the back of my mind.

My patient’s end was horrible. He had been suffering and begging for help that I could not provide. He died on my watch. As I sewed together his flesh, I could not think beyond our shared misfortune. I did not wonder about his family or friends, and the loved ones left behind.

I did not think to burn his name in my memory.

I felt more absorbed about my own miserable situation than about my patient’s demise. I was emotionally numb — a robot without a soul. I looked at my own actions from a third person’s vantage point. This allowed me to live on and to continue pursuing my surgical training.

I had neither the energy nor the luxury to show empathy.

That haunts me to this day.

My failure still gives me sleepless nights, though the horrific experience clearly pushed me to become a better surgeon, a better physician, and a better person.

It wasn’t until nearly 20 years to the day of my first patient’s death that another tragic demise made me realize the enormity of the emotional and professional gulf I had crossed since my first days as a doctor.

Her name was Elena Sanchez.³ She showed me that over 20 years of surgical training and practice I had not only become an empathetic surgeon, but also a spiritual one.

²Name changed to avoid any resemblance to actual individuals.

³Name changed to avoid any resemblance to actual individuals.

“Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.”

Florence Nightingale (1820-1910)

January 13th, 2014

Elena was 35 years old.

Ten years prior, in her mid-twenties, she had been the victim of a brutal car accident that left her paralyzed from the waist down. Despite her terrible injury, Elena had a good quality of life. She was an artist, a painter of landscapes and portraits, and reveled in paint’s ability to capture light on canvas. Elena was married and had two young children. She came from a large extended family who stayed very close; father, mother, brothers, sisters, and cousins getting together frequently for BBQs and fishing trips.

Lately, however, she’d been bothered by increasing pain from a bone spur on her hip that had eroded through the skin envelope. This is a frequent complication in paralyzed patients due to pressure on the skin when seated in the same position for a prolonged period of time. Ironically, while paralyzed patients typically can’t feel the skin below the spinal cord injury level, they can nevertheless suffer from chronic pain. Elena’s increasing amount of pain in a seated position dramatically imposed on her quality of life and prevented her from doing the things she most enjoyed, such as painting and playing with her young children.

The plastic surgeon who saw her recommended a fairly simple procedure to close the hole in her skin and to hopefully stop the radiating pain in her hip. He planned to perform a rotational flap and asked me, as a consulting surgeon, to remove the bone spur during the same operation.

The day of the surgery, I walked to the pre-operative area and introduced myself to Elena and her father. I explained my role as a consultant to her plastic surgeon. I clarified to both of them my minor role in the case and outlined my plan to shave the bone down to allow the wound to be covered by her primary surgeon. I reassured them that this would be a straightforward procedure from my side.

In the pre-operative area, I spent about 30 minutes with Elena and her father to answer all of their questions. I gave both of them my business card with my name and cell phone number, and emphasized that I would be available any time to address further questions or concerns. By the time our discussion came to an end, they both understood that there was little to get anxious about.

Still, Elena appeared nervous.

Confidentially, her father told me, “Elena had a bad feeling about this surgery last night, and she wanted to cancel. I convinced her to get it done, because I want her to resume her quality of life. She’s not even able to paint anymore.”

I told him that I fully understood Elena’s anxiety, and I assured him that our entire team would take excellent care of her.

“She’ll be okay, right?”

“Yes,” I said. “She’ll do well.”

Her father kissed her on the cheek, and Elena was wheeled into the OR.

The surgical procedure went perfectly.

As soon as we were finished, I walked back to the family waiting room together with the primary surgeon. We were anxiously greeted by Elena’s father and an extended part of her family and circle of friends.

“Everything went well, as planned. There were no intra-operative problems or complications.”

I rounded on Elena the same evening and the next morning on the inpatient ward. She was awake and doing well overall, yet still bothered by some postoperative pain.

When I rounded again on the third day, I walked into Elena’s room expecting to see her and her caring family. I was astonished to find the room completely empty. My heart sunk when the intern on the floor told me that Elena had been transferred to intensive care overnight. Completely surprised and rightfully outraged, I rushed down to the surgical ICU. I found Elena lying unconscious in her bed, intubated and mechanically ventilated. The nurse at the bedside must have noticed the bewildered look on my face. She turned to me and said:

“Oh, you didn’t know? The neurosurgeons have just declared her brain-dead.”

My heart skipped a beat.

Turns out that Elena had been given an overdose of intravenous fentanyl for pain control. At 2am the preceding night, she apparently stopped breathing. Global brain ischemia resulted. The chain reaction leading to her death was all too common: a patient in pain, an overworked nurse, a short-staffed ward, a medical error, and a split-second instance of negligent care. The end result was death.

Elena’s passing was a sudden shock to all of us.

I was as heartbroken as her family. I silently cried with her father as the team disconnected her breathing tube.

Elena had overcome so much in her life; from the car accident that took her freedom of walking, to the chronic pain that she had been fighting in recent months. To see her die in such a meaningless, random way was all the more crushing. She’d come so far and left behind so much. Two young children to be raised without a mother. And all her unfinished paintings.

Today, I still think of Elena and ...