An appalling tale of surgical “teaching” in the operating room

As much as I write about the foibles, pseudoscience, and misadventures of cranks and quacks that endanger patients. However, never let it be said that I don’t also pay attention to the foibles and misadventures of real doctors that endanger patients. Sometimes that occurs due to incompetence. Sometimes it’s due to the persistent use of invasive modalities that have been shown not to work far longer than they should have been abandoned (e.g., vertebroplasty) . Sometimes it’s poor judgment. Of course, because I’m a surgeon, I tend to gravitate towards discussions of surgery when I leave my usual bailiwick of discussing alternative medicine, antivaccinationism, and various other skeptical topics.

So it was when yesterday I saw discussion of a post over at KevinMD by a surgeon who blogs under the pseudonym Hope Amantine (or apparently used to blog) over at Simple Country Surgeon entitled A lesson in the OR that prepared this doctor to be a surgeon. It is a story of training, a story that was clearly intended by its author to be a “real life” story of how a senior surgeon taught Dr. Amantine as a resident to handle a dangerous situation. The problem is that it was appalling on so many levels. You’ll see why as soon as you see the story. As a surgeon, albeit one who doesn’t do such large, risky cases anymore, I sort of understand what Dr. Amantine was trying to get at, while at the same time the story disturbed me greatly.

Dr. Amantine’s article tells the tale of a case she did during her training. It was an elective repair of an aortic aneurysm. The reason surgeons repair aortic aneurysms when they grow to a certain diameter is because, beyond a certain diameter, the risk of rupture becomes unacceptable, and the larger such aneurysms grow the greater the risk of rupture. As you might imagine, a rupture of the largest blood vessel in the body is an immediately life-threatening occurrence. At first, the blood is contained in what we call the retroperitoneal space by membrane that lines the surface of the abdominal organs, the peritoneum. That can last mere moments after the rupture to even a few hours, but sooner or later the pressure will break through the peritoneum, allowing the blood to flow freely into the peritoneal cavity, basically into the abdomen. When that happens, the game is up. Exsanguination is rapid. Indeed, the vast majority of ruptured abdominal aortic aneurysms (AAAs) are rapidly fatal before the patient even has a chance of being brought to the operating room. A few, however, remain contained, and there is a chance to save them.

To achieve that, however, a vascular surgeon must not only be skilled but must not fold under pressure. Learning to remain calm and collected, to do what needs to be done, not to let his emotions affect his technical skills. It’s the only chance to save the patient’s life. Indeed, part of the reason I ended up going into surgery relates to an experience I had the very first day of my surgery rotation as a third year medical student. The first part of my rotation was on vascular surgery, and that very day a man with a ruptured AAA was brought to the OR. I remember it well, even though it happened nearly 30 years ago. I remember the blood everywhere. I remember helping the nurses in the OR check unit after unit of blood as the anesthesiology team tried frantically to keep up with the massive blood loss. I remember the skill of the surgeons as they labored to save this man’s life and how, somehow, they didn’t freak out, didn’t yell, didn’t lose their cool in any way. There I was, a third year medical student early in my clinical rotations, almost completely inexperienced, and I felt part of the team. The team failed to save the man, but it wasn’t for lack of trying.

So it is through that lens, that memory, that I read this, with a mixture of understanding and horror, Dr. Amantine’s account of how her attending surgeon reacted during an elective AAA repair as she dissected around the inferior vena cava (IVC). The IVC is the largest vein in the body and runs right next to the aorta. Now there’s a difference between arteries and veins when it comes to repairing them. Arteries are muscular and thick. They are fairly easy to sew. Veins, on the other hand, are thin-walled and frightfully easy to tear. It is in general, all things being equal, actually more difficult to repair a torn vein or to sew two veins together than it is to repair an artery or to sew two arteries together. Now that you know that, judge this passage:

So here I was, handling the plane (the layer, or space) around the IVC with care to avoid ripping it. It seemed like the intelligent thing to do. My attending asked, “Why are you being so dainty with your dissection there?” I answered that I wanted to avoid ripping the cava because they’re so much harder to fix.

Big mistake.

I take it he interpreted my comment as fear, and decided upon a teaching moment. He took his scissors and incredibly, before my eyes, and with no warning or preparation of any kind, cut a one-inch hole in the cava.

I was stunned. As I tried to process what I just saw, incredulous that he would actually intentionally make a hole in the cava, and as dark blood poured out of the hole, the tide rising steadily in the abdomen, he remarked, “Well, are you just going to stand there or are you going to fix that?”

And so I did. Whatever thoughts I might have had about his behavior, his judgment, and his sanity (and believe you me, there were many), I put my fingers on the hole to stop the flow. I suctioned out the blood that had already escaped, and irrigated the field, the Amazing One-Handed Surgeon did nothing to help me. This exercise was clearly a test. I got two sponge sticks to occlude flow above and below the hole which I instructed him to hold in position (which he dutifully did), and then I got my suture and I fixed the hole. No problem.

All he said was, “Good job.” And we proceeded to complete the case uneventfully.

Dr. Amantine went on to describe how appalled she was but correctly noted that the culture in surgery is very hierarchical. In fact, I tend to liken it to the military. There is a very defined chain of command, from intern to resident to senior resident to attending surgeon. You do not bypass the chain of command, and you do not question your superior without very good reason. Non-surgeons might not understand, but there are definite reasons for this culture. The surgeon in the operating room is absolutely responsible for the life of the patient in a very personal way. He is, after all, given the incredible privilege and power to legally take sharp objects to living human flesh in order to rearrange a fellow human being’s anatomy for therapeutic intent. It’s an honor that is hard to understand unless you’ve actually experienced it and a profound responsibility. While it is true that surgical culture is becoming more collaborative and less top down, with surgical checklists, time outs, and mandates that if anyone sees something going wrong or that isn’t right it is his duty to question, there does still have to be a “captain of the ship.” That will never entirely go away, although that role has become noticeably less authoritarian just in the couple of decades that I’ve been a fully trained surgeon. That is, for the most part, a good thing.

So, in the context of decades ago, it’s not entirely surprising that Dr. Amantine reacted thusly:

Though I may not have agreed with his actions on that day, I do understand them. How do you teach someone to take charge when there is a crisis? I am certain that if I was put on the spot and shriveled and sniveled, and couldn’t control the bleeding, he would have taken over. And I would have failed.

Ultimately concluding:

So on that day, when the vascular attending cut that hole in the cava, he was preparing me, both for the oral exam, and for life as a surgeon. He wanted to see if I could handle it.

I guess I made the cut.

Which is absolutely the wrong attitude. Yes, I, too, can understand how an established surgeon might romanticize such an incident as having “forged her in fire.” Here’s the problem. There is another aspect of being a surgeon that is at least as important as her ability to perform under pressure, if not more so. That is, very simply, the Hippocratic admonishment not to do intentional harm to a patient. When we say, “First, do no harm,” that is our promise to the patient that we will do our best for him and we will not do anything intentionally to cause harm. That is not to say that the patient will not be harmed. Surgery in and of itself is controlled harm, as cutting into the human body inherently causes trauma and harm. Every time we operate on a patient, we are committing a form of controlled assault that causes some harm. In this case, even under the most charitable assessment of what the attending surgeon did, at the very minimum the patient was harmed by the additional blood loss (remember, Dr. Amantine described blood welling up in the abdomen, which doesn’t sound like a trivial additional loss of blood to me), more time under anesthesia to complete the repair, the necessity to occlude the IVC during the repair, and the placement of a repair in the IVC that put the patient at risk of bleeding to death if the repair were to fail. There is no excuse.

We do surgery not because we wish to do harm, but because the damage to the tissue we cause is outweighed by the therapeutic effect of the surgery itself, the aforementioned forcible rearrangement of the patient’s anatomy. Key to that is not to cause unnecessary damage, and what is intentionally making a one inch hole in the biggest vein in the body but causing intentional harm? That it was allegedly done in order to train Dr. Amantine to be able to fix the IVC if ever she accidentally cut into it during a case doesn’t matter and doesn’t justify such a betrayal of the patient’s trust.

I can’t help but contrast this to how a surgeon with whom I trained as a resident handled it. Like the surgeon described by Dr. Amantine, he was supremely confident and skilled, the very epitome of the “cowboy surgeon.” Indeed, he intimidated the residents mightily. As we would struggle through a case, he would guide us through, but he did have a tendency to yell. I didn’t understand it then, but I do now. It was just that he was frustrated. He knew he could do what we were doing so much more easily, so much more gracefully, and so much less clumsily. But he was so dedicated to teaching that he would let us as residents blunder through the case, trying to guide us along the way, to show us the way, realizing that to learn we had to find at least part of the way ourselves and to figure out how to get out of trouble. He could do this because, as he sometimes said to us, there was no trouble, surgically speaking that we could get into that he couldn’t get us out of, and there was no way he was going to let us get into trouble that threatened to cause serious injury to the patient. Sometimes he just couldn’t help himself and his frustration watching us newbies blunder got the better of him.

He had our backs, though. I’ll never forget one Morbidity and Mortality conference in which we were discussing a case I did with him that was complicated by bleeding that necessitated a return trip to the operating room. When I was being questioned about it, he interjected, “I made that decision” (because he did) and got me off the hook. Some attendings let residents twist in the wind at M&M, but not this surgeon.

Now here’s the kicker. The reaction to Dr. Amantine’s post was furious and uniformly negative, both in the comments and in the Twittersphere, and yesterday there was an addendum:

Author’s note 7/8/2015: This is a fictional article. No one was harmed, then or ever, in my care or in my presence. I apologize for any remark that may have been misconstrued.

I call BS. Here’s why. First, the doctor doth protest too much. There is no surgeon who can accurately say that no one has ever been harmed in her care or in her presence. We have all inadvertently caused harm, and we have all had patients whom we operated upon and probably shouldn’t have, thus resulting in harm. Our goal is to make the number of those patients as tiny as possible, but the number will never be zero. Claiming that a patient has never been harmed in her care or presence is either a delusion or a lie, unless the qualifier “intentionally” is added, which it was not. Second, in response to the criticism in the comments, Dr. Amantine responded:

I completely understand your shock and horror. As one of the other commentators remarked, it was a different era. Time will tell if we are better or worse off today… I can tell you that since much has changed in the last twenty years, surgical residents today touch instruments much less often, and many report feeling unprepared for the rigors of attendingship when they have finished their training. Their work hours are restricted, their experience likewise, and I have seen more than a few young attendings that can’t operate their way out of a paper bag. They have been trained in a kinder, gentler environment, and that is great as long as every operation goes as planned. They’re rock stars with computer keyboards, however…!

In answer to your objection, the only stake in the game is the well being of the patient – the one on the table, and every one whose life I will ever be responsible for. Don’t think for a moment I take that responsibility lightly.

When there is a computer simulation that adequately prepares surgeons for unexpected anatomy, findings, and intraoperative unplanned “events,” I will be the first one to sing Hallelujah. It hasn’t been invented yet – so until that time, you better pray that you never get a hole in a cava. But if you do, you better hope that the person holding the knife can actually fix it in less than the five minutes it will take for you to bleed to death.

Dr. Amantine’s response sure doesn’t sound to me as though her story was fictional. Neither did her other comments after her article. If the story were fictional, why didn’t she just come out and say that right away? Why was the story not labeled as fiction? Instead, she made excuses about how it was a “different era,” how surgeons today can’t operate, and how there is no good way to teach a surgeon how to remain calm and perform when disaster strikes. Yes, as surgeons, all of us have accidentally gotten into a large blood vessel at one time or another, and it’s critical to know how to control the bleeding and repair it. Making holes in living patients undergoing elective surgery is not the way to teach residents to be able to do this. Yet that’s what Dr. Amantine seemed to be making excuses about.

It’s also impossible not to note that it was only after the criticism came raining down on her on Twitter did Dr. Amantine claim that the story was fictional. Maybe it was fictional (it does have the air of being apocryphal about it), but if it was fictional she sure didn’t give any indication until after the shitstorm got really intense. Then she deleted her blog (which is gone as of this writing, as is her Twitter account). Also, as a surgeon myself I have encountered enough other surgeons over the years whom I view as potentially arrogant enough to do something like put a hole in the IVC in order to see if a resident can repair it.

So is this story true? Hell if I know. It rings true to me as a surgeon, having seen misbehavior such as thrown instruments in the OR on occasion, but on the other hand I’ve never witnessed a surgeon intentionally injure a patient that way. I also can’t help but wonder how one would dictate that part of the procedure for the operative report. Dictate the truth, and it’s there what you did in black and white, for all to see. Claim it was an accidental injury to the IVC (which can certainly happen during a AAA repair), and you’ve lied in the medical record. In the end, I conclude that Dr. Amantine probably did relate a true story and only backtracked when the criticism became too intense, and Kevin Pho, the Kevin in “KevinMD” let her:

Which drew a response so spot-on that I have to include it:

Or, even if the story is indeed fictional, it was a monumental screw up to have published it without labeling it as fiction. Truth be told, I’ve noticed over time that KevinMD.com has gotten more uneven in the quality of blog posts that it publishes. There are still some great posts, but I’ve come across more and more stinkers like this. (There’s even been the occasional infiltration of medical pseudoscience and rants by doctors complaining that evidence-based medicine is an affront on physician autonomy.) Perhaps Dr. Pho should spend more time on quality control. Strike that. There’s no “perhaps” about it. KevinMD used to be great; now, not so much.

As for Dr. Amantine’s story, I think of it this way. I’ve been in medicine 30 years now, counting medical school, and I can’t imagine a time when intentionally cutting a hole in a major blood vessel in order to provide teaching fodder for a resident would ever have been considered acceptable behavior by a surgeon, although I have encountered surgeons who, I thought, might be capable of doing such a thing. I find it heartening, however, just how negative the reaction to this story has been among physicians and surgeons. Maybe Hope Amantine and Kevin Pho will get the message and come clean about (1) whether this story is fiction or not fiction and, if it was fiction, (2) why it wasn’t labeled as such and (3) why Dr. Amantine responded in the comments to criticism in a way that sure sounded as though the article had been nonfiction, which really makes me think she was lying when she later claimed the story was fiction.

Dr. Amantine’s and Dr. Pho’s readers deserve no less.

ADDENDUM: Kevin Pho has removed the story from KevinMD.