Absite Smackdown! · Episode 40: Surgical Misadventures, Frogger, and Absite Smackdown!


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Jessica: Hi guys. Welcome back to The Absite Smackdown podcast. This is your host, Jessica. And with me today is Dr. David Kashmer. Hi Dr. David.


Dr. Kashmer: Jessica. It's good to be back.


Jessica: It's always a pleasure having you on sir. So basically this week, I really want to talk about surgical misadventures.


Dr. Kashmer: Ohhhhh...surgical misadventures.


Jessica: So what got me thinking about surgical misadventures is I was trying to figure out (for my blog) what common mistakes residents make when they're learning and learning surgeries. And when researching that I kept coming across to articles on malpractice and things like that. And it said the most common mistake was usually critical thinking errors. Do you have any insight on that, Dr. David?


Dr. Kashmer: Yeah, we really need to watch using medical malpractice claim data and tort law data to decide where our root issues are for surgical misadventures, then more broadly outcome issues in healthcare. You know, it sort of catalogs things differently than what we might, you know, think of them as surgeons.

For example, if a surgeon cuts an iliac artery because the area is stuck and the person had multiple iliac artery bypasses or a distal bypass is from that area is that really a thought error? Is that really a cognitive error? No, but you know, med malpractice data or tort law data may say, well, the surgeon misidentified the area. Sort of, but really it was just so stuck and we'd all acknowledge that as surgeons. Now that said, Jessica, I will tell you: there's a great book called Gordon's Guide To The Morbidity and Mortality Conference.

And the M and M is, as you know, our Morbidity and Mortality conference where we try to learn from how things went. And I won't get into how M and M has some biases. In the moment you make a decision, you don't have perfect data. You have limited data, but I'll tell you Gordon's Guide to the M&M includes the thought that most issues, in fact, in Surgery, have their roots in decision making errors. They’re thought errors. And it's interesting because that's one of the ones we actually least commonly talk about. So thought errors really are a big deal ultimately for how we decide things in Surgery.


Jessica: Okay. So for surgical misadventures, do you have any good stories to tell in that area? And also are they critical thinking errors or is there something more to it?


Dr. Kashmer: The fact of the matter is when you see any problem in healthcare, a bunch of things had to line up to cause that. We call that the Swiss cheese model of errors in healthcare. There are a lot of holes in the cheese and they all kind of have to line up--some patient factors, some personal factors, some technical factors, all of these things to see a surgical misadventure. I kind of think of it as a game of Frogger more than cheese.

Because cheese just sort of sits there, but Frogger? The cars are kind of coming different speeds and there's a lot going on and there's a lot of bright colors. So I think of outcome problems more like lines of traffic related to lines of traffic in a game of Frogger. And, I guess that dates me because I don’t think anybody plays Frogger anymore.

I don't know how to do it with the analogy with Mortal Kombat. I don't have that. I can't do it with Mario cart either, but I can say that Frogger is good.

And I do have a story. For example, once upon a time and we have to be careful how we talk about these, a patient was in the recovery room when the surgeon walked out and said, “Oh, well we just need to go back to the OR.” He was real relaxed about it. And the staff said, “Oh, okay, well patient's doing fine and everything.”

He said “Yeah, you know, we realized after we finished everything that we'd put the gallbladder in this bag and we put it over the liver to kind of leave it there and wash the area out and like good safe surgeons, make sure it's completely dry with no oozing. And we looked around the rest of the belly because the patient had some other things that we had to do beyond the gallbladder, which we don't typically do. But unfortunately we never did go back and get that bag with the gallbladder in it. And it's still in there. So their gallbladder is in a little bag. It's kind of see-through plastic bag that we use. They're fine. We just probably should take that out. And you know, and that'd be the safe thing to do.”

And so they did, and it did require another anesthetic for the patient. Now what lined up to allow this to happen? First, yes the staff member had been working a whole bunch lately. Sure. Second, they had a relatively less experienced assistant than what they normally had. Third. They were interrupted multiple times during the case by things they shouldn't have been. Fourth, the patient had some extra stuff they had to do. And this is the difference between, you know, what really causes issues in Surgery and healthcare versus the illusion of it that we get on retrospective review.

You know, you sit in M and M and you just, you think to yourself, “Oh gosh, that was so thoughtless”. But come on. This surgeon is a great surgeon. Who's done this all the time. He (the surgeon was a he in my story) has been excellent throughout his career. And I'm not telling stories out of school because I'm not saying where or when, but rather saying, you know, this is a very excellent surgeon. We have a couple words I want to share for the audience out there. One is “schadenfreude” which is German for “dark joy”. It's the joy you experience when someone else has a problem. so like in M and M you're sitting there and you hear about it and you chuckled to yourself. Ha ha. “That would never be me” you secretly tell yourself. Oh boy, that guy deserved it because of something…it's really dark. And there's a word for that. It's called dark joy or schadenfreude, the dark joy at someone else's pain or suffering, and M and M gives that illusion. Now, schadenfreude is an accepted English word.

Like it should have been so easy to just remember--just to take this thing out and how could you ever leave it? But reality is very different.

The surgeon had 18 things going on well beyond what we would typically expect someone to do. And there were patient factors and a bunch of other stuff. So really the patient did have to endure another anesthesia, Jessica. But the fact of the matter is really they were fine. There was no harm done to them really in terms of outcome or disability or anything like that. In fact, this surgeon went the extra mile for them, give them a good safe surgery in a case where they could have had oozing and some other things owing to some additional factors they had. So that's just one example of a sort of a surgical misadventure. It seems so simple on the face of it. Why didn't you just take out that bag with the gallbladder in it? But really there's so much more to it.


Jessica: I mean, I know I shouldn't laugh at that story but I got this visual of, you know, at Thanksgiving where you have to reach up and pull out the bag of all the other stuff that's in there. And that's all I could think about when you're telling this story. And I know that's so inappropriate. It was the visual I got. I do understand though, because even if you're very talented, you do something a million times and you do it a certain way. When you have someone interrupting you constantly or all these unknown factors, it's…it's never perfect. It throws you off and bad things happen when it’s a perfect storm. When there's so many contributing factors to make something that usually is just clockwork go askew.


Dr. Kashmer: Well, you're so right. And unfortunately sitting in the either the courtroom or around the table or at M and M, it gives the illusion that you had perfect information. Everything that you kind of should have known, you knew. You had the lab value. Why didn't you see it? Even though you really never did because it was buried somewhere or something similar. So those things suffer from what's called a retrospective bias. Sometimes it's called the retrospective bias of tort law when it comes to legal stuff, because you're looking backwards on the situation and look after you thought about it for hours and you have all the documents in front of you. It sure is clear, but at 2:00 AM, when the lab doesn't really have the document to you, even though the timestamp on it was 1:00 AM (but it really wasn't resulted in the computer until 3:00 AM) and all those little things add up to make it really not that clear. And the term for that is the fog of war. Fog of war is just all these things going on at the same time that make it unclear. And then the accumulation of all these little things that prevent you from imposing your will on the disease or whatever that's called “friction”. So all these little things that add up to prevent you from doing what you do a million times, like taking the bag, the gallbladder with the bag around it, taking that out, that's friction and fog of war and all these different things that really are a lot of what go into medical issues where they have a suboptimal outcome. So that's just one little surgical misadventure and there's really a lot behind it.


Jessica: I loved that story and I think it was very interesting. And I do know that you always try to be professional and, you know, be correct and not make anyone look bad or sound bad, but I really would love to know just because not only were you obviously a resident yourself going through all of this, but then you also ran a residency program. I really, really want an example of when a resident, not maybe just from decision-making, but just from still being in the learning and getting the experience. Just maybe it doesn't have to be a huge misadventure, but just maybe a misstep rather than misadventure. Maybe one that's maybe commonly made by a lot of residents when they're learning that could pertain to just not having experience. Is there anything like that that you could tell us?


Dr. Kashmer: You're really pushing me, but okay. I've got one. I want to preface it with residents are, you know, future colleagues. They're there to learn. And, they, our job is to, you know, to patiently bring them along in a way that's safe for the patient and for them. And once upon a time, when I was running a trauma and emergency surgery program, I had a very good chief resident with me. So this is much more than you typically get for an exploratory laparotomy in trauma. It's, you know, it was a patient who had pretty much almost bled to death from their spleen after a motorcycle accident. There's a device you can use called a fish. Its real name is the Glassman visceral retractor if I remember right, but it's like a plastic device that slides over the bowels and viscera.

And you close a thick, tough layer, the fascia of the belly, while you utilize this device (I guess sort of shaped like a fish) over the bowels. So you can kind of protect them as you stitch everything else up. And then you pull this device out. Well, instead of using that plastic device that has like a rope and a string on it that lets you pull it out, you can also use an operating room towel. And some of these are radiopaque. You do an X Ray and you can see them. So I said to my colleague, “Okay, I always use a towel over there”, because we did that in a transplant fellowship a lot. We just put a towel in. And then this metal device that is like a long thin, basically, you know, very flat piece of metal (often called a ribbon or malleable retractor) that you slide above the towel and beneath the layer of fascia that you're going to close.

And what you do is you can use this metal to kind of push down on the towel and it shows you the edge of that fascia very well to make it easy to stitch this closed where normally it can be tough. So you do a similar thing with the fish, but I just happen to use a radiopaque towel and we're doing that. And I’m just making sure this resident who's a chief resident, but new to me, just making sure they know how to do it. And they did. And so it all is fine. They were doing it just right. And I said, okay, I’m going to speak with the patient’s family, I'll be back in a moment. He was closing the fascia, which was acceptable at this time and in this program to have the resident staff, especially chief resident close the fascia. That was normal and customary at this center especially for a resident at that level.

So I said, “Hey, just remember to get the towel out of there, buddy” as I walked out of the room. Some surgeons would not have come back to the room and thank God I did.

After I left the room, you know, the music went up, everybody started talking, the nurses started doing a million things instead of paying attention to what he was doing…but not just the nursing staff, everybody. And I know that because when I came back in, I kind of stood at the door for a minute. I was learning the place and what was going on. And so I just stopped in again and as he's tying down the final knot that we'll complete closure of the belly I said, “Hey, how did that towel come out?” I knew they could be tough to remove.

And he just looked at me and he goes, “Ohhhhhh”, and I said, “Ohhhhh”, and he said, “Ohhhhhhh”.

I went on and coached him to get it out, trying to be really relaxed about it. And meanwhile, I'm thinking, “Oh my God”. I asked “Is that knot tied down yet?” He said “No, no, we're not tied down yet.” I said, “Okay, well I usually take my finger and I sweep the towel from the edge at the top or the bottom. It's the easiest place to get it out. Once you get the edge out, the rest comes out pretty easily.” He said, “Oh, okay.” And he took it out.

He said he had everything else out. I said, okay good. And I asked actually, before we took it out, “How is the instrument count?” And they said, “Oh yeah, everything's fine.”

Fine? Well they clearly weren't fine. They don't count those towels apparently at that center. Even though those towels are radiopaque, you will see them on x-ray. Not every center uses radio-opaque towels for this.

This long story, Jessica, is to tell you that I had a near miss. I almost had a retained entire OR towel in the belly, which, I was very fortunate that I happened to come back. And I just thank God, every day, because that would have been a problem if the knot were tied and the patient went to recovery.

And again, I think these towels were radiopaque at the center. I would have seen it on x-ray, but at some they're not. And I do believe the one that we were using was radiopaque. I try to make sure they always are. But that was a near miss. It would have been very hard to tell. We may not have even gotten an X Ray early and the patient may have had a complication, like a fistula with the bowel stuck to it. And I just really feel very fortunate that it did not happen in that case. But there you go. Just dumb luck.


Jessica: Yeah. And I'm sorry I put you on the spot, but that is a great story. And I think probably something that's kind of common, you know, with the towel count. Did we leave anything in the patient? So again, you know, you coming back, I think that just attributes to you being a doctor and having the experience and checking in on someone that doesn't have the years of your experience, because you've gone through your steps. You've done everything. So, I mean, I think that was a great story.


Dr. Kashmer: Well, I would also say that you don't want to micromanage…especially your chief residents. You want them to become ready to be independent practitioners by the time they get there. So the question is how do you bring them to that level without micro managing them? How do you balance, you know, respect for them as a future colleagues? And it's just really hard to do, you know, if you just close the fascia yourself all the time, which is what many surgeons do, because you're worried about, med malpractice and all the different things that can be brought up. And we struggle with that every day as teachers in the modern era of surgical education. I don't have an easy answer for it, but I do want to share with everybody that I learned the word, I didn't know this at first, I believe it's called “gossypiboma” which is the fancy term for retained surgical towel or like a Ray tech or one of these cloth things in the abdomen. Again it's called “gossypiboma”.


Jessica: Well, that is a great story. And thank you so much for sharing. I know it's not super uncomfortable to tell the bad things, but you know, it's something that we can learn from, and I'm sure that there are some residents or some doctors out there that just hearing the struggle or hearing these stories, you know, they shake their head, they laugh, but then they also, you know, feel a little better in case some things ever happened to them that they find regrettable without sleep or without experience.


Dr. Kashmer: Yeah. True. I mean, the question is always, “Are you the person who it's schadenfreude for and who experiences dark joy at these stories?” Or are you the person who thinks there but for the grace of God go I? As in thank God that wasn't me. I really feel for that guy. And, I've as I've gone on in my career, I started off much more as the, you know, kind of schadenfreude camp. Later in life I’ve gotten to more of the “I get it and am lucky that didn’t happen to me“. I think, that comes with experience and I hope that’s something I can pass along.

Really, you know, we want to just make the lines of Frogger lineup so that we don't have these issues. And we don't just misattribute every issue that we have to, “Oh, that person just did something dumb” because in a similar situation, you know, smart people will act similarly.

So the gallbladder in the bag got left in not because that surgeon was suddenly stupid for once in his life, but more likely distracted by a million things going on. And I think that should really be one of the take home messages from our surgical misadventures talk today. There's gotta be a lot of stuff that line up to produce one of these surgical misadventures.

Typically some we can control like our mental model of what's going on and our cognitive stuff. Are we making good decisions? Are we technically able to do this? All those things. Some we can control more directly, but any opportunity we have to influence, you know, work environment and these kinds of things. And then there's some things we can influence like a busload of people comes in and our system overwhelmed. We just have to do the best we can. There are some things we're just not able to control completely.


Jessica: I definitely agree that, you know, you can only control what's in your line. Studying, knowing your material mentally going through the surgery and knowing what you're supposed to do. You can't control interruptions, you can't control, if there are other things that are happening in the procedure that were unexpected. You can only control what you know, and make the best decision that you can at that time. And I mean, that's really important just to, you know, the difference between being humble and having hubris. I love that word “hubris”. It’s really about just trying to do your best.


Dr. Kashmer: Well you're right. And I'll tell you this: it relates to Absite Smackdown. One of the reasons to write it for me was as a refresher to make sure that I kind of have the basics still. And that was very useful. But also there've been times, when I was a resident, that I wish I'd had things like the lectures available so I could review quickly anywhere. And the book chapters or the book in my pocket to look stuff up pretty quickly for, “Hey, I'm about to do this hepatobiliary thing and there’s that replaced right hepatic artery--that's a pretty common arterial variant. It sits behind the common duct. I know, I shouldn't really be there, but it may be in the area…” These kinds of things. And you know, that was really part of the incentive for me to do this book and just all the time and everything. And it was very useful and I just hope additionally, other people find it useful for the same stuff. Just as a quick review for residents staff before they walk into any hepatobiliary or breast procedure, and they can just pull this thing out or they can watch the video that day or the day before on any platform. So I really hope that they find it useful for that because I sure have.


Jessica: I mean, yeah, it definitely is useful for them, but as you have said yourself, it's useful for you as you know, an attending surgeon just to have that quick little reminder. So just one of the many things that's great about Absite Smackdown.

Dr. David, it was great having you on, I loved hearing the stories, getting to see that little side of you. So thank you again for coming on and I look forward to working with you again. Thanks for tuning in guys. You have a great day and again, #AbsitesSmackdown!

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