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When an OR case goes wrong: More than technical skill needed


Blogger Henry Rosevear, MD, discusses lessons learned from his first experience in the OR while on his own when things did not go exactly as planned.


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Dr. Rosevear is in private practice at Pikes Peak Urology, Colorado Springs, CO.

As a resident, I spent countless hours in the OR doing complicated cases on patients with bad pathology. During that time, I spent so much time concentrating on the technical aspects of the cases that it never occurred to me there were other lessons to be learned about the OR. As a result, I thought I would share my first experience in the OR while on my own when things did not go exactly as planned.

To start, this is not a “how-to” blog. I am not trying to teach anyone how to be a technically better urologist. Rather, I hope to convey the lessons I learned that day and how my behavior during the incident has had a lasting impact on my practice. If you have questions on ureteroscopy, I recommend attending the World Congress of Endourology, where I am very confident I will not be an invited speaker.

My case involved a healthy 54-year-old man with a 10-mm proximal ureteral stone. The case started off great. I easily passed a wire beyond the stone and then accessed it with a flexible scope. The stone fragmented well and about 45 minutes later the stone was dust. I then decided, for good or bad, to place a stent with the string attached. The stent went in easily but while I was draining the bladder, the scrub tech saw the string and for unknown reasons decided to grab and pull it. And yes, when I checked on x-ray, the proximal portion of the stent was now in the bladder.

I paused. I took a really deep breath. I thought about just walking away but since the stent went in easily the first time, I decided to simply replace it. I put the scope back in and placed a wire in the renal pelvis. This time, though, when I tried to push the stent back into the renal pelvis, it would not go. It would advance about 1 cm proximal to the ureteral orifice and no further.

I tried changing wires to something stiffer and that didn’t work. I could easily pass a 5F catheter up the ureter but not a stent. I shot a retrograde to look for damage to the ureter, and it was pristine. I tried different brands of stents. I even passed a second wire up the ureter and tried to pass a stent over that. Nothing. At this point, I looked up and saw that I had now spent well over an hour trying to pass the second stent. I also noticed that the OR was now full. The charge nurse was there, two other techs were there, and another older woman was there, who to this day, I have never seen again.

I was angry and a bit confused. I again considered leaving the patient unstented, but after all this time manipulating his ureter I was confident I worsened any ureteral edema. So I passed the 5F catheter up the patient’s ureter and into the pelvis, placed a Foley, tied the catheter to it, and admitted him. I then walked out of the OR to talk to the family. In the end, he did fine. He had no pain after the procedure, I pulled the ureteral catheter on postoperative day 2, and a renal ultrasound 6 weeks later was free of hydronephrosis.

About a week after the incident, I found a note in my OR inbox asking me to see the charge nurse. When I found her, she sat me down and starting talking about the incident. At first, I thought I was in trouble. I had been expecting to hear from the Morbidity and Mortality Committee but hadn’t and thought perhaps this is how the process started.

I was wrong. She wanted to congratulate me on how I handled myself during the case. She, a nurse with 30-plus years of experience, stated that I appeared to be a seasoned surgeon and that the OR staff without exception was impressed. I told her that I thought the opposite; I had managed to take a procedure that any first-year urology resident should be able to do and turn it into an hour-long ordeal. In the end, I had failed. She laughed at me and said, “Shit happens in the OR” (a direct quote). It wasn’t what I did but rather what I didn’t do. During the incident, with the exception of apparently taking frequent, very deep breaths (which I wasn’t aware of), I didn’t yell at anyone, didn’t curse, and didn’t even appear fazed. I just worked though the problem until I found a solution.

Before that case, I knew intellectually that bad things occasionally happen in the OR and that cases are rarely as pretty as videos make them appear. I always assumed that I would be judged by the OR staff on my technical skill, and to some degree that is certainly true. After that day, though, I learned a lesson I had not been taught in residency, namely: How you emotionally handle a situation is almost as important as how you handle it technically. I thank the charge nurse for being blunt enough to point that out to me.

If you have a good story about tough situations you encountered early in practice and the lessons you learned from it, please email me at UT@advanstar.com.

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