Never Say Oops in the OR


As a first year surgery resident, you don’t get to do much operating.  Mostly minor procedures and the simplest OR cases, especially the ones the more senior residents have no interest in, like removing skin lesions or biopsies, that sort of thing.  One of the most common surgical procedures left for the first year residents was the insertion of the chronic indwelling venous access catheter, an implanted device to facilitate infusion of medications, long term antibiotic therapy, or long term IV nutrition.Minolta DSC

This was not only a straightforward procedure, it was a very common procedure at the main University hospital we trained at.  Our service performed this operation over a dozen times a week.  As such, it wasn’t long before even the first year residents felt comfortable in the procedure.  And as first year surgical residents, it wasn’t much longer before we were feeling pretty cocky about our skill in performing this seemingly straightforward procedure.  Of course, as first year residents we had not yet internalized one of the most important tenets of all surgery:  There are no small operations.  Even the most routine procedure, the most mundane biopsy, can go horribly wrong if not approached with the respect deserved by every patient.

Towards the latter part of our first year, the residents spontaneously devised a kind of competition.  As we got really experienced in the procedure, it got to the point where we could  comfortably complete the operation in less than fifteen minutes.  When it went well, that is, which was about 95% of the time.  A couple of us were so “good” that we could occasionally complete the entire operation in about seven minutes.  So an informal competition started up amongst the first years, a hypercompetitive lot by nature, to see who could complete the operation the fastest.  It got to the point where the real objective of the resident was to have the catheter in and be suturing the closure before the attending finished scrubbing, so you could tell him when he walked in not to bother gowning up.  Attendings loved not bothering to gown up.  More time for coffee and chatting up the nurses.

It’s not hard to see where this is going.  The operation of inserting a chronic venous access catheter has nine distinct steps for its successful completion.  I know this, because as we first year residents began operating faster and faster, we managed to screw up each and every one of them.  As was the tradition in our residency program, every time a new screw-up was committed, it was named for its original perpetrator.  My class was instrumental in naming every possible screw-up related to chronic venous catheter insertion.  For the decades that followed our completion of the program, an errant first year resident could be heard being admonished by his attending not to “pull a Geller” or any one of the numerous other maneuvers we invented.  (A complete list of all the named maneuvers is available upon request, but I must pause here just to mention the Schwarma maneuver, in which the very last stitch at the conclusion of the operation is deftly passed right through the catheter, necessitating starting the procedure all over from the beginning.  Schwarma was asked to leave our program after his first year and went on to father many children during his career as a cruise ship physician.)

Step one of the procedure involved introducing a long, large-bore needle into the subclavian vein, a very large vein (about as thick as your little finger) that lies just under the clavicle (collarbone) in the upper chest as it carries blood back from the arm to the heart.  Unfortunately, this was a blind procedure in those days, made a bit more challenging by the fact that the subclavian artery, a large pulsatile structure carrying the entire blood supply to the arm, lies immediately adjacent to the target vein.  And the lung, an organ that really doesn’t like being stabbed by needles as it tends to collapse like a punctured balloon, is located immediately behind the target vein.  Inadvertent puncture of each of these anatomic structures had been accomplished thousands of times by countless surgical residents for decades.  We, therefore, were already trained in the precautions necessary to avoid these structures.  We were much more creative.

As I said, back in those dark old days of my training, this was a “blind stick.” (Currently, technology has progressed to allow real time ultrasound guidance of the procedure.) As a blind procedure, the surgeon is reassured that he had struck the correct anatomic structure with his needle by seeing the gentle return of dark red, venous-type blood from the hub of the needle when the syringe was disconnected.  It was appropriate, however, to quickly cover the hub of the needle with your finger so as to prevent air from being  sucked into the low pressure venous system.  This is called an air embolism and can immediately lead to a cardiac arrest or stroke.  This was to be avoided, having already been done many times as well.  One afternoon, towards the end of our first year, one of my first year colleagues named Dr. Sweetness was performing this procedure, smoothly and confidently proceeding before his attending came in the room.  Actually, he had begun before his attending was even in the operating suite, not that unusual at the time but a sign of cockiness for a first year resident.  Sweetness was pretty cocky at this point, as were we all.  Dr. Sweetness inserted the needle and was immediately rewarded with a flash of blood.  Rather than carefully consider the nature of the blood return, however, he immediately assumed it to be venous and clamped his finger over the hub of the needle.   Like I said, he was moving pretty fast.

Step two of the procedure is to insert a flexible  guide wire through the needle into the patient’s venous circulation, actually passing the wire near the chambers of the heart.  I should digress at this point to mention that it is important not to insert the entire wire into the vein, but rather to hold onto its end.  My fellow resident, Dr. Napoleon, failed on one occasion to follow this simple rule.  He neglected to maintain control of the end of the guide wire, which he smoothly and accidentally introduced completely into the patient’s vein, where it proceeded to pass downstream into the heart and lodge there.  This trick, thereafter known as the Napoleon maneuver, necessitates immediate abandonment of the planned operation and stat consultation with a cardiologist for percutaneous fluoroscopically guided extraction of the rogue guide wire.  This also required a very embarrassing conversation with the patient and his family, a conversation that never failed to upset the attending surgeon.

But I digress.  Sweetness smoothly introduced the guide wire and maintained control of its end throughout.  He did not, however, appreciate the fact that he had introduced the guide wire into the subclavian artery, not the vein.  In and of itself, this would not be remarkable, for as I mentioned, this particular maneuver had been done literally thousands of times.  Usually, however, the operator was immediately aware of the error when, upon removing the syringe from the end of the needle, bright red blood (not deep purple as it should be) sprayed like a fire hose into your face.  At that point, the surgeon need only fight the urge to curse or say “Oops”  (“Never say ‘Oops’ in the OR”) and remove the needle from the wrong vessel, then to hold pressure until the body’s natural tendency to recover from our screwups takes effect.  No permanent harm, no foul, as they say.  Unless, of course, you don’t realize what you’ve done.

This particular patient also had the unfortunate combination of low oxygen saturation in his blood stream and low blood pressure introduced by the inexpertly administered anesthetic provided by the first year anesthesia resident.  Therefore,  Sweetness didn’t realize he was in the artery.  Not just in the artery, though.  As luck would have it, Sweetness had managed to enter the subclavian artery extremely close to its takeoff from the aorta.  You know the aorta, the single largest blood vessel in the human body that carries the entire output of blood from the heart.  It tends to bleed very vigorously and fatally when injured.

Now, even that would probably have been kind of okay, if Sweetness at any point realized what was going on.  But this was a blind procedure, the usual cues had been taken away by his equally youthful anesthesia colleague, and Sweetness smoothly and confidently proceeded; still with no attending in sight.  Step three of the procedure is to gently and smoothly pass a dilating catheter over the guide wire, called an introducer.  The introducer is a gracefully tapering, somewhat flexible plastic straw that serves the function of gently stretching a hole in the wall of the blood vessel so that the catheter can be introduced.  I say ‘somewhat flexible’ because it is actually quite stiff–it has to be to perform its function.  It is, therefore, necessary to introduce this device with some degree of trepidation and finesse.  Sweetness had the finesse part down pat–it was the trepidation that was missing at this point.  Sweetness smoothly and expertly passed the introducer over the guide wire, a maneuver that he had performed without incident almost a hundred times before.  On this occasion, however, through a combination of bad luck, rushed technique, and inexpert assistance on the part of his anesthesia colleague, passage of the stiff-walled introducer device caused the root of the subclavian artery to be torn from its origin on the aorta.  This, of course, resulted in a large tear in the aorta.  The patient, already quite ill, proceeded to hemorrhage massively into his chest cavity.  The attending surgeon walked into the operating room just in time to see his patient, supposedly there to undergo a relatively minor procedure, receiving CPR on the OR table.


Evidently, My ICU Has A Helluva Skylight

True Stories From The Front Lines Of Medicine

Patients die.  It is a sad fact of life for all physicians, but particularly acute for us surgeons.  When I operate on an individual, they have entrusted me with an incredibly personal, invasive, singular interaction; an interaction that is intense and unique. Like up to my elbows in their innards kind of intense and unique.  As such, whenever one of my patients dies, it is a personal loss for me, a loss that one never really gets over.  As I sit here, I can see the faces and hear the voices of literally scores of individuals, young and old, men and women, with whom I have sat, and held their hands, promised them that I’d do my very best for them, and watched as they died, despite my efforts and promises to the contrary.  And then went to tell their husband, or wife, or father, or mother, or child that their loved one was dead, and I was sorry.  It happens.  For some reason that I’ve never figured out, though, only the nice patients die.  The really irritating, obnoxious ones never die.  Ever.  There’s a lesson in there somewhere, but one you probably shouldn’t share with your children.Minolta DSC

About six years into my practice as a busy academic general surgeon, I saw an elegant, elderly gentleman in my office in consult, Mr. Smith.  He was 81 years old and sharp as a tack, well spoken and funny.   A recent colonoscopy performed to evaluate anemia had discovered a bulky cancer in his colon, just above the rectum.  He was referred to me for surgery.  I sat with him and explained the situation, the nature of the surgery that I recommended, the four or five days he’d probably need to spend in the hospital afterwards, the nature of his anticipated recovery.  He was accompanied by his two adult children, who seemed more concerned and put off than their father; each of which asked appropriate and intelligent questions.  I assured one and all that, despite the diagnosis and the gentleman’s age, I thought he should do well and had an excellent chance of being cured from his disease.  We scheduled the operation.

The operation, like most, went very well.  The tumor was indeed large but without invasion into adjoining organs or obvious metastasis.  I successfully maneuvered the senior resident scrubbed with me away from cutting the ureters during the dissection.  Blood loss was minimal, the tumor removed smoothly, the bowel’s continuity restored.  The anesthesiologist was impressed with the old man’s resilience and heart, having turned not a hair throughout the procedure.  As was common practice, however, I directed the residents to admit the gentleman postoperatively to the Surgical ICU, just to be on the safe side and monitor him closely.  You learn quickly that the frail and elderly patients do very well if treated well, but they don’t take a joke very well.  One complication, the kind that more robust patients will tolerate and overcome, will often lead to this type of patient leaving the hospital by way of the loading dock.  So, the SICU for a day or two, just in case.

That operation had been my first of the day.  I completed my list of surgery and donned a white coat over my scrubs to make evening rounds.  I had already rounded early in the morning with the residents on all the inpatients on my service, so evening rounds were limited to those I had operated on earlier or that I felt would benefit from a second look before I went home for the evening.  My last stop this evening was to the SICU to visit my nice, elderly patient from whom I had resected the colon tumor that morning.  I entered his room to find the gentleman hooked up to all the usual devices, the monitors beeping happily.  The patient was lying in the bed and appeared perfectly comfortable, his eyes open and staring at the ceiling.  I smiled and greeted him by name, but he ignored me.  I didn’t recall him being hard of hearing, but there was a lot of noise and distraction from all the machinery in the room, so I wasn’t surprised by this.  I spoke more loudly, asking him how he was feeling and assuring him that the surgery had gone just as planned, that the tumor had been removed completely and without difficulty.  He ignored me the whole time, continuing to stare at the ceiling.  I grew quite concerned and finally shook him gently by the shoulder and called his name again more insistently until, finally, he took his eyes off the ceiling and looked at me.  He smiled, recognizing me and acted like I had just arrived.  I repeated that the surgery had gone well.  He just nodded and went back to looking at the ceiling.  This was starting to piss me off.  I mean, come on, just a quick “Thanks, doc,” would do.  A little acknowledgement of an effort well done, another life saved–though, of course, it’s just my job, you know, just what I humbly do each and every day.

“Mr. Smith, are you okay?” I finally asked, irritated.  “Yeah, fine, doc,” he says, still not taking his eyes off the ceiling.  “What are you looking at?” I finally ask, looking up and not seeing anything more interesting than faded ceiling tiles.

“Heaven,” he says, smiling.

“I’m sorry?  What was that?”

“Heaven.  See?” he says, pointing up.  “I see heaven.  And angels.”  He’s smiling, goes back to ignoring me.

“Stacy!” I yell out the door.  Mr. Smith’s ICU nurse, Stacy, comes running in.

“Something wrong, Dr. Geller?”  She can see I’m upset.

“What did you give this guy?”

“Nothing, Dr. Geller.  I was just in a few minutes before you, asked if he wanted something for pain.  He said he was good, I didn’t give him anything.”

“You gave him Demerol, didn’t you, Stacy?”  Demerol was notorious for giving elderly patients hallucinations.

“No, I didn’t, Dr. G.  Why, what’s wrong?”

“Mr. Smith is looking at heaven up there,” I say, pointing.  “And angels.”


“Yeah.  Oh.  Maybe you can check to see what they gave him down in Recovery, before he came up.”

“That was before noon, Dr. G.  Don’t think they gave him Demerol.  I’ll check, though.  Anything else?”

“Yeah.  Everything. Get everything, stat.”


“Stat, Stacy.  EKG, blood gas, complete metabolic panel, CBC, chest x-ray.  Now.  And get the ICU resident, tell him I need him in here, please.”  I start to examine Mr. Smith while he continues to smile beatifically at the ceiling.  ICU resident arrives, asks what’s up.  I explain that Mr. Smith here is seeing angels, which I believe is not a good sign.  I would like him to pay particular attention to my patient tonight.  Please.  No problem, he says, in that special resident’s tone of voice that implies that I’m an idiot.  Which I don’t mind, as long as he watches my patient.

Of course, Mr. Smith’s exam is completely normal.  His vitals are perfect.  His abdomen is soft, his incision clean and intact.  Every test comes back perfectly normal.  Mr. Smith is still smiling at the ceiling as I throw up my hands and head home.  He doesn’t say good night.

I’m awakened by my beeper at 3 AM flashing the STAT PAGE signal.  I don’t even look at the number, I know it’s going to be the ICU.  I pull on my clothes and drive like a crazy person to the hospital.  Judgmental ICU resident and Stacy are busy coding Mr. Smith.  Billy, the former college football star turned ICU nurse, is doing the chest compressions.  Who’s the idiot now, huh?  “What happened?” I ask, examining Mr. Smith’s belly.  Which is still perfectly soft.  His incision still looks great.  Only problem is the guy has no heartbeat.

“No idea,” overconfident resident and Stacy say in unison.  “He was fine ten minutes ago.  No problem.”

“Hold compressions,” I say to Billy, watching the monitor. Nothing.  “Call it.  What time?”  I hadn’t put on my watch.  [Brief Aside:  If you have been following this blog, you have probably already figured out that you really do not want me running your code.  Really.]   I leave to wash my hands and call Mr. Smith’s children.  The daughter thanks me (next of kin always thank you when you tell them their loved one just died) and says she and her brother will see me in the morning.  I feel like crap and go home to go through my usual postmortem ritual at 4 am of sitting at the the kitchen table, eating lots of cookies and milk as I try to figure out just how I screwed up this time.

The next morning I sit down in the conference room with Mr. Smith’s children.  I feel awful.  “I’m so sorry about your Dad,” I begin, but they cut me off.

“Please, Dr. Geller, don’t be upset.  Dad was fine with it.”

“I’m sorry?  Fine with what?”

“Dad told us he wouldn’t be coming home.  He made all the arrangements.”  I’m just staring at them, trying to get my mouth closed again.  “Really, Dr. Geller.  Please don’t be upset.  We really appreciate everything you did–”

“Killing off your Dad, you mean?”

“No, not at all.  Dad really liked you and I know he’d tell you that he really appreciates everything–”

“If he were still alive, you mean?”

They nod.  “Exactly.  We’re good here, Dr. Geller.  Really.”

Just wish I was.