Handling medical errors

She was a thin built woman of 27 with a shy smile on her face. Clad in a black kurta with a white dupatta, she looked like a young college girl. Saraswathi (name changed) had come to our clinic with complaints of something protruding just below the skin over the scar of her family planning surgery done 3 years ago. She had noticed it even at that time, but it did not trouble her much then. But now even when there is a strong gush of air on that spot, or when her clothes gently rubbed over the area, it led to severe pain. She sat by my colleague who was seeing her and said, “Doctor, the pain is too much. Can you please do something about it…” 

 

My colleague took her to the examination couch, made her lie down, and examined the scar. She found a small bit of suture material used to close the inner layer of the abdomen wall, protruding sharply just below the skin. This was the reason for her discomfort. She called me to the examination room, and I confirmed that there was some suture material sticking out just below the skin. We can clearly feel it firm and sharp creating a constant friction over the undersurface of the skin. We discussed and decided that we need to cut the skin over the suture area and just remove that bit of suture material and close the skin with a small suture. 

 

I think it is appropriate here to provide a brief description of abdominal surgeries and suture materials. The abdominal wall has strong muscles and several layers beneath it as a protective guarding for all the soft organs like the liver, spleen, stomach, intestines that lie within. For performing surgeries inside the abdomen, the surgeon must open the abdominal wall in layers and then after the surgery has to suture them back in the same layers securely. If the closure is not appropriate, then the person may develop weakness over the area of the scar and the abdominal contents like the intestine may protrude outside. This is called abdominal hernia or ventral hernia. Any surgery involving the abdomen runs this risk. Therefore, all surgeons are very cautious about closing the abdominal wall in layers. There is a lot of research regarding how to suture the abdomen, what technique to be used and what suture material to be used. The current consensus among surgeons is that one of the important layers, the rectus sheath, must be closed with continuous suture using an absorbable suture material. Absorbable suture materials are materials made of biopolymers and these get absorbed over time. Therefore, the material also disappears, and it provides adequate support till the time the body heals the rectus sheath and re-create a secure abdominal wall. 

 

In Saraswathi’s case the surgeon who had opened her abdomen to do a sterilization surgery, had closed the rectus sheath using non-absorbable suture material. So, even after 3 years of the surgery the material was still there and causing irritation. So, we got ready for the procedure. In as much as Saraswathi wanted the pain to go away, she was scared that we were asking her to undergo another procedure. “Is it necessary doctor?” she kept asking repeatedly. We spoke to another gynecologist to ask their opinion and got confirmation that what we were planning is the right course of action. However, the gynecologist mentioned “send her to a surgeon to remove the suture material”. It was not clear to us why she asked us to send her to a surgeon. The procedure seemed too trivial to put her through the arduous task of going to see a surgeon, who is at least 80 km away from the village. So we decided that we will do the procedure. 

 

We reassured Saraswathi and convinced her to undergo the procedure. I scrubbed in as the main surgeon and my colleague assisted me. We gave her generous local anesthesia and made a cut over the skin. The suture material was right there. We held it with our instruments and made a small nick and cut it. It came off easily. Just as we were rejoicing having completed the procedure successfully, some more blue colored suture material became visible. I held the remaining material and pulled, and it kept coming. I pulled more and more came out. Suddenly it dawned on me that this was a continuous suture with a non-absorbable material, and I had only cut and removed the knot. The remaining material was still there in the rectus sheath and as I pulled it kept coming. I was totally unprepared for this. I must have anticipated and planned for this, but I hadn’t. Beyond a certain point, the material stopped coming out and was stuck to the deeper material. At this point Saraswathi started wincing in pain. We had only given local anaesthesia to make the skin numb. The deeper tissues were still capable of perceiving pain. Now that the adherent suture material was being tugged at, it caused her severe pain. So, we stopped pulling at the material and cut it and removed whatever we had managed to pull out. Saraswathi was starting to have more pain. We closed the skin at this point and dressed up her wound and brought her out of the procedure room. When she went home later that afternoon, she was in substantial pain. We sent her home on some painkiller medications. 

 

When we debriefed after the clinic that evening, I was worried about the whole episode. We had cut part of the suture material that had been holding the rectus sheath. Two things could happen – (1) the hard suture material could have cut through the rectus sheath as we pulled at it and could damage the integrity of the abdominal wall (2) since the suture was partially cut and removed, it could lead to weakening of the recuts sheath and thus hernia in the future. Not only this, but we had also tugged on the suture material leading to severe pain. We were worried if we had inadvertently tugged at some structure inside the abdomen. This could mean the risk of an infection spreading from outside to inside the abdomen, which could result in a deadly complication. I was very anxious. That evening we went to Saraswathi’s home to check on her. It was a village about 7-8 km from the health centre. When we went there, the room was dark. There was a thin ray of light coming from the gap in the window which had not closed completely. The situation was quiet, and she was lying in one corner of the room on a mattress that was spread out on the floor. She was curled up to one side. When we went inside the room, we could see her face contorted in pain. I felt a strange discomfort in my stomach, the vague sense of having done some irreversible damage. We asked our community health worker, who was her next-door neighbor, to closely monitor her and inform us if she develops any problems. I was very much worried and spent a restless night imagining all kinds of horrible consequences. 

 

Just as the next day broke, I got up from a fitful sleep with a sour taste in my mouth and a very bad feeling. I called my colleague, and we discussed in depth about Saraswathi and what all mistakes we had done. My colleague once again called up the community health worker and followed up on Saraswathi. We felt reassured once we heard that she was doing well. The next week when we went back to the health center, Saraswathi was there. She walked into the room with a big bright smile. She thanked us profusely for helping her out as her pain had completely gone. This was a very crucial moment for us. We could either say “All is well that ends well” and let it be. Or we could explain what we had done, and what is the worst that could have happened, and how she was lucky to have not had any of those horrible things. We had decided that we owed her the information and sat down for a difficult conversation. We explained the whole thing slowly, in Tamil and with as little use of jargon as possible.

 

Throughout this time, Saraswathi was smiling at me. There was no sign of any worry, concern or even understanding of what I had said on her face. “Did you understand what we explained to you? Were you worried why we kept following up on you so many times, called you so many times and visited you at home?” I asked her. 

“No doctor, you cared for me so much. No doctor has cared for us like this” she said, and again gave the same shy smile. 

 

Later that afternoon during the clinic staff meeting, we discussed Saraswathi with all the staff including the nurse, the medical records staff, the housekeeping staff and listed out the various problems in the treatment of Saraswathi and what we should learn as a team from this experience. 

1.     We were totally unprepared for the continuous suture and how it must be handled. We must have anticipated that the knot that we could feel just under the skin must have been the end of a continuous suture. The steps of the procedure must have been thought through and discussed. We failed to do it. We never asked what is this suture material a part of? We saw a suture material and we went in to remove it. 

2.     The gynecologist had in all her wisdom advised us to refer her to be seen by a surgeon, but we had not taken it seriously. We never thought through that this is a matter of integrity of the rectus sheath. 

3.     I operated with a sense of ‘savior complex’. I wanted to “save” Saraswathi. I felt the invincibility that comes from being a doctor in an underserved area. I must have avoided this. 

4.     We never gave Saraswathi enough time to think this through and get a second opinion, or even ask anyone close to her. We kept saying that it is a “simple procedure” and “there won’t be any problem” – the usual things we keep saying to all patients on whom we do procedures. Saraswathi asked us repeatedly whether the procedure was necessary. We never engaged with her question. No procedure is ‘simple’ or ‘without any problems’. We learned that we must engage with their anxieties and think through the procedure with them. 

 

This whole episode was a great learning experience for us. We made the decision to have two difficult but important conversations – the first with the patient explaining the mistakes we made, the second with the medical team explaining our learnings from what had happened. One would think this would compromise the trust of the patient and the team on the doctor, but on the contrary, this transparency and willingness to accept our fallibility, earned us tremendous trust. 

 

A friend of mine was talking to me about how a surgeon had performed an unnecessary umbilical hernia surgery, which had been complicated with an infection because of which they had to open the surgical site again and remove the mesh used for repair. This had completely damaged the abdominal anatomy of the lady who had undergone the repair. Following this, the surgeon had started writing costly and high potency antibiotics for all patients as a defense mechanism. This would only harm the community as indiscriminate use of antibiotics would only lead to the bacteria developing resistance to these antibiotics and the antibiotics becoming worthless in the future. 

 

We learned that the first step towards improving quality is to acknowledge our errors, reflect on our actions and take collective, transparent remedial actions to salvage the situation. I am quite sure that Saraswathi did not understand the things we explained to her, even though we tried to explain it in such simple words. She asked me a doubt, “Doctor, does this mean, I have chance of getting pregnant again?” This doubt was so innocent, and I explained to her everything again. But I still am not sure if she really understood what we explained. I am not sure if Saraswathi or her family would have been so forgiving if things hadn’t gone well. But this episode has taught us that we are not at all infallible and the only way we can handle our errors is to be transparent about it and learn and evolve with it.