Five months into my second-year of residency I burned the cystic artery.
I’d been operating a bunch at one of the smaller hospitals, starting to gain a bit of confidence in my clinical judgment and a newfound trust in my hands. Just like learning piano, I had a few basic songs memorized and, while I still needed an occasional throat clearance to redirect me or a gentle hand placed over mine for guidance, I knew the sequence of keys, and could hit the right notes most of the time.
Then, the more senior resident at the hospital came down with Covid, and I was left to cover two people’s jobs at once – hers being the much harder gig. I held her consult pager, answering calls from the ED while stationed in the operating room almost non-stop from 7 AM to 6 PM. I would be assigned full days of cases slightly beyond my technical comfort level, and would have to juggle pages about other patients with ruptured spleens or life-threatening kinks in their bowels. It was stressful – both because of the complexity and severity, but also because of the time crunch. It was also undeniably exhilarating.
Weirdly, 10 days of working at this fast-paced rhythm with a mix of adrenaline and intermittent terror, reminded me of a hike I once took in Joshua Tree. With far less water than we were advised to carry and nightfall encroaching, my then-partner and I scurried along this arid, sun-soaked trail, in a race against the elements. We were both nervous the whole way, sweat soaking our clothes, rationing our one water bottle between the two of us, but it also felt like a game of survivor, with fear and fun inseparably blended. By the time we’d descended to the final destination, a palm-tree oasis, we were elated, and had forgotten the worries that chased us through the desert. Similarly, at the end of my operative and consult days, I felt such overwhelming relief and a sense of accomplishment that I almost forgot the panic I experienced during the daytime. Every day I watched myself grow as a clinician, as a surgeon, and felt my confidence expand in leaps and bounds under the duress.
One day, I was assigned four cases with Dr. A, two of which were gallbladder surgeries, cases that should be reasonable for a second-year resident, but were still fairly new to me. Dr. A – always impeccably dressed outside of the OR in big, flouncy skirts and either knee-high black boots or patent pumps in various shades of pink and blue – intimated me. One of our most vocal advocates for women in surgery, she was polite, but had a visible edge that I suspected was best avoided.
During our first case, she asked how many laparoscopic inguinal hernia repairs I had done myself. Zero, I told her honestly. She apologized, but said that she would do most of the case then. I didn’t mind, I held the camera for her and learned by observation. During the second case, a gallbladder removal, she let me take the reins. At first, I felt like I was moving through the familiar motions: finding a transparent area of tissue, indicating that no major vessels were lying in it, and then cauterizing it, cutting through it with electrical heat. This would gradually expose the “critical structures,” the major duct and artery that I would then need to clip on two ends with tiny metal clips, before cutting between them, safely severing structures, while avoiding bile or blood spilling out of them when transected.
It’s hard to admit, even now, but I think from the outset, I wanted to show her that I could handle the case. I wanted to demonstrate the kind of confidence she exudes (which frankly, is the opposite of how I normally present myself) and show that I could handle the promotion, taking on a more senior resident’s job. But in trying to prove myself, I wasn’t careful enough.
After just a few moves around the tissue, I unknowingly cauterized too deeply. At first there was a little bleeding, but that can be normal. A couple seconds later, there was a sudden gush and then a pulsatile bleed. Bright red blood pooled around the gallbladder and I could barely see where we needed to go next.
Within seconds, Dr. A had taken over the instruments and was suctioning up as much blood as she could. “You can’t do that,” she said, “That was very unsafe. What were you thinking?” I must have turned 1,000 shades of red beneath my mask, acutely aware that I had made a horrible mistake. There’s nothing worse than being yelled at when you know you deserve it. The baseless yelling, the mean surgeon who just likes to air his grievances, is somehow more tolerable to me. When I know I haven’t done anything to be ashamed of, and yet received harsh feedback (which happens not infrequently in the world of surgery), my ego can withstand it. But in this case, where I instantly recognized and felt the weight of my error, I couldn’t handle external feedback on top of my internal voice which was already screaming “How could you fuck that up? You might have hurt this patient.”
The hours that followed included calling the chief resident into the OR who gracefully took over, and calmly stopped the bleeding. The rest of the case was relatively uncomplicated. To Dr. A, I kept saying something along the lines of “Oh my god, I am so sorry. I can’t believe I did that.” She stopped reprimanding me at some point, but also didn’t offer any comfort. I had to endure this one without the padding of kind words.
After the case, the chief resident pulled me aside. “Listen,” he said. “I know you feel bad. And I’ve been there before. I know you just want to put your head in the sand, and never look up again. But you can’t do that. People make mistakes. We all make mistakes. And you just have to get back in the operating room, and keep going.” The tears that had been dwelling in my throat for the past two hours made their way to my eyelids where I tried to blink them back, not wanting my stoic, military-attitude chief to witness my tears.
“Okay,” I said. “I’m ready for the next case.”
“Oh,” he replied. “Um…she’s not gonna let you do this one. She asked me to take over for the rest of the day. But you have to be there, stand next to me, and I’ll let you jump in when I can.”
My heart sank into my stomach. I was being punished. I scurried off to the bathroom, and silently broke down in the furthest stall before returning to the operating room with visibly red, puffy eyes. But I stood there, watching my chief operate, and when the most critical parts of the procedure were done, the duct and artery already divided, he asked if I could step in and take over. Dr. A allowed it.
The rest of the day was a blur, but I vividly remember not being able to sleep that night. The case haunted me. Although the patient was okay and had even gone home, I felt worried, embarrassed, and disappointed in myself. The confidence I had been building for weeks, and more rapidly over the course of my time covering for the more senior resident, completely shattered before my eyes. No longer was I racing down the trail with equal parts fear and joy. Instead, nightfall had come early, and I was alone to contend with my shortcomings. Over the next week or so, I thought about the case nonstop, hot tears welling up in my eyes at random intervals throughout the day. Then one day, I heard the patient was back in the hospital with a postoperative complication. This time, I cried on a bench outside the hospital, letting the cold Autumn air dry my face.
One month later, I stood up in front of a room full of my attendings and colleagues to speak about the case. The patient’s complication was entirely unrelated to the bleeding, and had since resolved. He was home, and he was healthy. Nonetheless, because he returned to the hospital and required readmission 30 days within his operation, I was required to submit the case for presentation at our weekly Morbidity & Mortality conference.
The M&M, as it’s known, is a historic surgical practice, where residents present the stories of patients who either had complications after surgery, requiring repeat hospital stays or further surgery, as well as the stories of those patients who died after surgery. We have to submit each and every complication or death, but only a few cases are presented each week, and I had the unfortunate luck of being selected. I tweaked my slides and practiced my lecture a thousand times. While preparing, I heard from another surgeon that Dr. A was upset with me. Since I hadn’t approached her to debrief the situation, she suspected I wasn’t taking my mistake seriously enough. My jaw dropped when I heard this. If anything, I was taking my mistake too seriously, found myself waking up in the middle of the night thinking about it, and had followed the patient’s hospitalization closely, even though I wasn’t assigned to care for him. I was beating myself up but apparently, I hadn’t shown off my bruises enough.
Before the M&M, Dr. A and I spoke to clear the air and review the details of the case. She told me not to punish myself too harshly, but also to name my mistakes in the future – admittedly, a thing I believed I had already done. She also told me that if I had approached her after the case to debrief, I might have had the chance to do the next one. “Maybe I would’ve let you take over for the non-critical portions,” she offered. I did, I reminded her. I stood in the operating room, waiting for another chance, I just didn’t beg for it. But still, I held the instruments in my miraculously steady hands and got right back on the horse, peeling the gallbladder off the liver bed. The truth is, the thought of discussing things with her between cases had, in fact, crossed my mind, but I was too emotional, too vulnerable to tear-shed that day. I left our conversation frustrated, but with a commitment to address my errors head-on in the future, even if that comes at the expense of letting an attending or a senior resident witness my tears.
At M&M, I looked out at all the people responsible for training me as a future surgeon. I looked out at my senior residents, equally responsible for ensuring that I become a “safe” surgeon, but also helping me become a more confident one. I made eye contact with some of my co-residents, the people who started this journey alongside me, who are always my benchmark for where I “should be” in terms of technical skills, but who also feel like the only people in the hospital I can speak to openly about the obstacles we face. With my hands stabilized in my white coat pockets and chin up, I began:
“I made a mistake.”
It was the first, but won't be the last.
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