Every so often, someone tells a story that reminds you the hidden curriculum belongs to all of us. For this Field Note, I am honored to feature a guest essay by my colleague and dear friend, Dr. Unwanaobong Nseyo, a pelvic reconstructive surgeon at Weill Cornell Medical Center in New York City. The essay won the American Urological Association’s 2018 Resident Essay Contest. In this piece, she reflects on humility, complication, and the quiet lessons that accompany even our most familiar operations.
“It is unwise to be too sure of one’s own wisdom. It is healthy to be reminded that the strongest might weaken and the wisest might err.”
Mahatma Gandhi
I assumed it would happen in the context of something bigger, more challenging, more daring, more controversial. I approached each major case with the guarded expectation that this would be the one where I would truly be humbled. Would it be the level IV caval thrombus? Or the post-chemo RPLND? When those cases came, I was ready, and yet each one would pass without the slightest perturbation. That nothing had happened yet didn’t make me feel confident, just lucky. I knew I wouldn’t pass through training unscathed; I just didn’t know how my slice of humble pie would be served. I would learn soon enough, at the beginning of my chief year.
The event occurred in August at the VA. By that time I felt that I was starting to settle into my rhythm. Having been at the VA for four months prior as a senior, I was primed to hit the ground running. And run, I did. I knew there was definitely an unquantifiable amount that I needed to learn but I also gave myself a small self-congratulatory pat on the back. I had faced the beast of chief year head on and so far was still standing.
Until I wasn’t. My sense of confidence and self-assuredness laid the groundwork for my teachable moment.
In some ways, it was like any other day and yet in the most crucial ways it was not. It was several small deviations that all aligned in a synergistically unfavorable way. Discussions of adverse events and system errors revolve around the same phenomenon, the “Swiss cheese model,” in which breakdowns at multiple layers of protection result in a systems failure.
At the time, the holes in my cheese seemed trivial. The busy clinic was standard. However, we were one resident down with a resident on vacation, and we had a brand new intern with limited urology experience. The balance was tipped by the patient that showed up from his nursing facility for his post-op suprapubic tube change, although his appointment had been canceled.
Bolstered by my sense of self-confidence, I decided to accommodate the patient on my own. Better yet, I would kill two birds with one stone and teach the intern how to place a suprapubic tube. I glanced hurriedly at my growing stack of clinic charts, knowing that I would need to quickly change the suprapubic tube to prevent myself from falling behind.
I proceeded to replace the suprapubic tube in the standard fashion. However, in my haste to return to the clinic, I neglected one last step: I did not flush the catheter after repositioning to confirm its placement in the bladder.
Eight hours later, the patient returned to the emergency department with complaints of abdominal pain and imaging demonstrating an intraperitoneally placed suprapubic tube.
My first thoughts went to the patient, and once I was reassured that he was going to be okay, those thoughts turned inward. I immediately felt foolish and ashamed. Who doesn’t know how to successfully replace a suprapubic tube? Or worse yet, who doesn’t know how to appropriately assess whether or not a suprapubic tube was replaced correctly? The doubt was slowly but surely creeping in as replacing suprapubic catheters was something that I had, up until this point, checked off my mastery list long ago. And yet here I was with irrefutable evidence to the contrary.
As surgeons, we work in a space firmly bookended by life and death. Doing so requires the utmost respect for human life. In the setting of the operating room, it is often easier to appreciate the gravity of the work in which we participate. But as I reflect on my own post-procedural complication, I appreciate how important it is that this same degree of reverence is applied to all patient encounters. There is no detail too small to overlook, if only to pause long enough to fully assess the information. To pre-judge a situation as “routine” is to devalue that experience; and for me, it led me away from my guiding principles to be thorough, to double-check, to confirm and verify before making a final decision.
Thankfully the patient suffered no more than the inconvenience of having his suprapubic tube replaced. I am grateful that my lesson did not come at any greater expense to the patient, and I know that it will serve as a constant reminder to approach the practice of urology with humility.