I attended dozens of morbidity and mortality conferences as a resident. I heard cases that ranged from the seemingly impossible to the mundane, but for some reason, it was always just a conference. That changed after residency. As I wrote in a blog last year, I had an OR case that didn't go as planned. I'll admit that while that case certainly deviated from the way I had planned, I don’t know if I ever truly considered it a complication. The patient in that case did fine, so while I certainly thought a lot about the case, in the long run, it didn’t bother me that much.
A couple more recent cases are less clear. While both were difficult to stomach, they taught me valuable lessons. For the lawyers out there, I changed a few random details of these stories to ensure this blog is HIPAA compliant.
Case 1: Persistent flank pain
The first case involved a young man with no prior abdominal surgeries and a long history of intermittent right flank pain. The pain was associated with drinking large volumes of fluid. Prior to seeing me, his primary care doctor had obtained an ultrasound that showed a moderately enlarged right renal pelvis with no ureteral enlargement and a CT with contrast showing a clear crossing vessel. The parenchyma was preserved and the patient was absolutely confident that his pain only correlated with drinking large volumes of fluid. Based on his story and the imaging that I had, I diagnosed him with a right UPJ obstruction secondary to a crossing vessel and took him to the OR for a right robotic pyeloplasty. I did not do a renal scan before surgery.
In the OR, the case went fine. The ureter was easy to locate, the crossing vessel was obvious, and after isolating the ureter and transecting it, no urine leaked out until I further opened the ureter. I always find it somehow reassuring when during a pyelopasty that if the ureter is cut at the location where I think the obstruction is and no urine leaks out despite a nice full pelvis, it’s a sign I am doing the right thing. I proceeded to remove a segment of ureter and did a nice spatulation before suturing things back together. I placed a stent across the anastomosis. (Of note, the original paper by Anderson and Hynes describes a stentless anastomosis, but that itself is controversial [Br J Urol 1949; 21:209-14].)
A drain was left and removed after 2 days with minimal output and a normal Jackson-Pratt creatinine. The patient felt great and went home. He had some flank pain for the next 6 weeks, which I thought was related to the stent so I wasn't entirely sure if his original pain was gone, but a renal ultrasound before the stent came out showed no enlargement of the renal pelvis. I removed the stent and his pain was back. I repeated the renal US and it showed no significant enlargement of the renal pelvis. I finally ordered a renal scan that showed that the side of the operation had a minimally increased t 1/2 compared to the other side but nothing at all obstructive. (t 1/2 6 vs. 8 min). Given the patient’s pain, I even went so far as to perform ureteroscopy to look for an anatomic cause of his obstruction and saw nothing but a completely wide-open UPJ.
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His pain persists to this day. I’m perplexed. I don't know what I did wrong. I don’t know if I did anything wrong. Did I make some small technical mistake during the case that resulted in his ongoing pain, or did I simply have the diagnosis wrong from the beginning? I don’t know. In retrospect, the only thing I would have done differently is to obtain a renal scan before the operation. I do know that every time a patient walks into my office with flank pain, this particular patient comes to mind.
In no way am I saying that I don’t make mistakes. I tell everyone who asks that I am nothing more than a small-town overpaid plumber. The biggest mistake I have yet made in medicine (at least that I am aware of) occurred as a junior resident when I missed a calf compartment syndrome following a robotic prostatectomy (J Endourol 2010; 24:1597-601). That case seems more straightforward to me; I had never heard of a compartment syndrome after a robotic prostate, and that diagnosis was simply not on my differential until it was too late.
Case 2: Young man with rock-hard prostate
The second case that brought home to me the reality of what we do is a bit different. A college-aged man came to my office reporting that about 6 months prior, he had an episode of urinary retention. He went to his local college ER and had a catheter placed and then removed a few days later. He had no problems voiding after the catheter was removed, and he didn’t seek follow-up care. About 2 months later, he went to the ER again in retention and this time the ER doctor couldn’t insert a catheter. The local urologist was contacted and also failed to get in a catheter, but did place a suprapubic tube.
Cystoscopy the next week showed a bulbar urethral stricture with a possible polyp near the stricture. The urologist did manage to get a small catheter past the stricture to drain the bladder. He was scheduled for urethroplasty, but his insurance company then decided that he needed to do that procedure at home and not at college, as it wasn’t an emergency. After some other delays taking about 4 months, he came to my office.
Given that 4 months had passed, I was curious if he could void on his own, so I removed his urethral catheter, clamped the SP tube, and set him up for a combined retrograde urethrogram and voiding cystogram to define the stricture before considering surgery. I asked him to come back in a few days once the imaging was done.
Something didn’t seem right though. I remember going home that night and being bothered by the case. The patient was a bit gaunt and was reporting some weight loss and back pain, but I couldn’t put my finger on what was bothering me.
Three days later when he came into the office, the RUG/voiding cystogram showed a stricture, but it wasn’t in the bulbar urethra. It seemed more proximal, almost prostatic. I wasn’t sure exactly what was going on at that point, so I did a rectal exam.
I remember walking out of the room immediately after the rectal exam after telling the patient that I would give him a chance to clean up and nearly vomiting. The rectal exam was evil, revealing one of those rock-hard prostates with obliterated edges. It was the prostate of an 80-year-old man with a five-digit PSA. I ordered a stat CT that showed a huge mass in the pelvis (either prostatic or bladder) with multiple lung masses and evidence of metastases everywhere. Biopsy of the lesion showed rhabdomyosarcoma. He went to the big children’s hospital nearby and expired of complications related to chemotherapy a month later.
‘Normal and human’ feelings
Patients die. Surgeries sometimes don’t work. Despite our best efforts, we make mistakes. It’s all part of our job, but it is not a part that I am comfortable with. When I think about those cases, the case of the missed diagnosis is the easiest for me to grasp. I didn’t include an unusual diagnosis on my differential and as a result, a patient was hurt. It doesn’t make me feel any better, but I at least have some understanding about how to avoid making the mistake again. The other cases are different in that while there are small details I would change in each (a renal scan in the first and an immediate rectal exam in the second), I don’t know if that would have changed the outcome, especially in the rhabdomyosarcoma case.
In the latter case, what helped me most was a 2012 New York Times article, “When Doctors Grieve” by Leeat Granek, which led me to her article in JAMA Internal Medicine entitled, “Nature and Impact of Grief Over Patient Loss on Oncologists' Personal and Professional Lives.” That article helped me understand that what I was feeling was normal and human. It also helped give me the courage to talk about the experience with one of the older general surgeons in town. Our conversation wasn’t more than 10 minutes long over bad coffee in the surgeon’s lounge, but the simple fact that I could talk to someone else who had been through similar situations made all the difference.
I decided to write this blog after coming across a recent article in The Guardian about doctors grieving and being reminded once again that the lessons I learned, the experiences that I have in medicine, are not unique to me or my practice. Rather, these are experiences that all of us have and I hope that by sharing them here, I can help other young physicians as they start off in practice. I look forward to hearing from anyone else who has also had a similar learning experience.
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