“There are two kinds of guilt: the kind that drowns you until you are useless, and the kind that fires your soul to purpose.”

Sabaa Tahir, American Novelist

     My turn to experience the humbling reality that doctors make mistakes came about four years later, when I was the senior resident on the surgical oncology service at Sloan Kettering Cancer Center in Manhattan.  We completed several months of rotations there, where we assisted in complex procedures such as tumor resections and gained hands-on experience in advanced post-operative care for cancer patients. This allowed us to develop specialized skills in surgical oncology and better understand the challenges faced by patients undergoing cancer treatment.

      There was a very nice fifty-six-year-old man who had come in with liver cancer.  He was a songwriter and did a lot of background work for several Broadway productions.  He had pictures of his two cats posted around his hospital bed and always talked about them.  His liver cancer was not amenable to safe surgical resection, but we were going to try to surgically insert a probe into the tumor and freeze it to kill cancer cells.  We took him to the OR and opened his abdomen.  The tumor was large, and several cryotherapy probes were placed through the liver into the center of the tumor.  Sub-zero liquid nitrogen was injected into the tumor, and an ice ball spread out from the probe as we watched closely on an ultrasound image to assess the extent of the freezing.  We wanted it to extend to the edges of the tumor, but not beyond, into normal tissue. 

     He did okay after surgery, but developed a problem with ascites, or build-up of fluid within the abdomen. This problem sometimes occurs after liver surgery.  Enough fluid would build up that he would have breathing difficulties, as his swollen abdomen pushed up against his lungs.  It was my job to do a paracentesis, a drainage procedure, every three or four days.  I prepped his skin and injected some local anesthetic.  A soft plastic catheter was threaded over a large needle, and I punctured this through the abdominal wall, then would slide the catheter over the needle into the abdomen and pull the needle out.  It was really more like a spear than a needle.  I was usually able to drain three or four liters of fluid.  While I stood there letting the fluid collect in the bottles, we would talk about various things.  The process took 30-45 minutes, so we would kill the time talking about our cats, or his next Broadway project, or what he had overheard the nurses saying about the doctors.  Over about two weeks, we got into a pretty steady routine, and I actually looked forward to our chats. 

     On the last day, everything seemed very routine.  He was a little short of breath, and his abdomen was distended with fluid.  I passed the needle, but instead of getting my normal yellow fluid gushing out, air came out.

     That’s strange, I thought.   I must have a leak in my connections. Somewhere a loose connection was letting air into the system.   I checked all the connections and everything seemed okay.  I manipulated the catheter a bit but couldn’t get it to work.  I decided I would ditch the whole set up and get a new one.  I reset everything up and did a new puncture at a new site.  About three liters of yellow fluid drained out, a little less than normal, but everything went just like it always had.  He thanked me and said he could breathe a lot better.

     Must have been a faulty catheter with a crack or something, I thought.  I put on a bandage, finished our conversation, and left.

     About three hours later he was having extreme difficulty breathing, his heart was racing, and his blood pressure was dangerously low.  His abdomen was hard and distended.  He was transferred to the ICU and ended up intubated and on a ventilator pretty quickly.  An abdominal x-ray showed that his bowel was extremely dilated, and he had a huge amount of free air in the abdomen.  Air or gas visible inside bowel is okay, it’s supposed to be there.  Free air within the abdomen, but outside the bowel, indicates there is a hole somewhere in the bowel.  Air and large amounts of bacteria leak out.  There are many reasons why someone might end up with a hole in the bowel.  Diverticulitis, ulcer disease, bowel dilation from obstruction or dysfunction, complications of chemotherapy, advanced infections, inflammatory bowel diseases, perforated tumors, or complications of procedures, like someone poking a large needle into the colon, are a few of the reasons.  Whatever the cause, it is fatal unless quickly corrected with surgery.  There is a large amount of bacteria present in the gastrointestinal tract, and as long as it stays inside the intestines, things are fine.  If the bacteria get out into the abdominal cavity, the patient can rapidly progress to septic shock from overwhelming infection.  Organ systems begin to shut down because of the shock.  The patient goes on to die within several hours or days, unless you can operate and control infection.  The goal is to resect or repair the damaged portion of stomach or intestine and wash out the abdomen as much as possible to stop the infection.

     The attending and other residents and I talked about different reasons why he could have developed a perforation.  There were lots of reasons why a patient like him would have this problem.  But it was also true that before I did that paracentesis that morning, he was fine, then afterward, he had a hole in his bowel.  For this problem to have another cause would be a highly unlikely coincidence.  I mentioned the paracentesis, and the flash of air that I had gotten initially.  They paused for a minute, then agreed that was not the most probable cause of the problem.  I don’t know that they really believed that, but did not want to place blame.

     I looked at the x ray with a sense of overwhelming denial.  There had to be some mistake.  He had been fine this morning, just like always.  I thought about the catheter, and how I had gotten out nothing but air with the first puncture.  No fluid, although there had been three liters in there.  Usually, the bowel is sort of floating around in the fluid, and the needle never gets near it.  Once you pull the needle out, the remaining drainage catheter is soft and pliable, designed to not puncture things like bowel wall.  But there’s only one way to get that much free air – a perforation of the gastrointestinal tract.  His colon must have become dilated for some reason, so when I punctured the abdominal wall, the needle just poked all the way into the colon.  I got back air because the catheter was inside a big gas-filled colon, not because the catheter was faulty or had a leak or a bad connection.  So when I pulled it out, I left a hole in the colon, where it leaked air and bacteria into the abdominal cavity.   I tried to convince myself that maybe it was a spontaneous perforation, for one of those reasons the attending had mentioned.  But I knew it was my fault, it was the needle that I had pushed through the abdominal wall, into the colon.  As much as I wanted to deny it, it had to be the reason.

     We talked to his family about surgery.  That would be the only chance for him to survive.  His wife and son were very clear that he did not want any additional surgery. 

“We had this talk right after Jim was diagnosed, and we found out it couldn’t be removed.  We spent a long time with the kids talking this over.  He never wanted to be someone who kept desperately trying to hang on, when there was no hope.  He doesn’t want to die on a ventilator with a feeding tube and lines and IV’s.  He doesn’t want another operation to prolong his life when we know he will die from his cancer.  We decided we would try the cryotherapy, then it was in God’s hands.  He doesn’t want surgery, even if it means he dies today, instead of in 6 months from his cancer.”  She struggled to complete her sentences, pausing as tears welled up in her eyes.  Her son quietly agreed.

     Soon after that, they stopped his sedation and took him off all the life support devices.  He was fairly heavily medicated for pain control, but I heard that he was able to actually talk to his family a little before he became unconscious.  I couldn’t bring myself to go talk to him, I didn’t want to intrude on his time with his family, and I didn’t want to have to face him, knowing that I was responsible for his dying.  He died about four hours later, with his family gathered at his bedside.  We could probably have saved him.  He may have ended up with a colostomy, but he very likely would have lived.  He would have lived to be able to die from his liver cancer.

     Intellectually, I knew it was perfectly reasonable for someone with terminal cancer to not want to have any major surgery to prolong life.  But I wanted him to have the surgery, to live through this, so I could feel better about what I had done.  It was selfish and egocentric, but it was so strong and overwhelming.  There was some relief, though, because we would never know for sure what had happened.  If we did the surgery, and saw a puncture in the colon right where I had placed the needle, it would be certain, everyone would know it was my fault.  With no surgery, no one could say for sure, and I could try to maintain the belief that somehow, coincidentally, he had a spontaneous perforation the same day I had the problem with the paracentesis.  When I look at this honestly, I am very sure I caused his death. 

     So, Dr. Kaczanek was absolutely right.   I guess we all eventually cause harm, even though our intention is to heal.  I had learned by that time how to deal with bad outcomes.  I learned not to dwell on them and let them interfere with all my other responsibilities to other patients.  Learn something from the experience and move on.  Dwelling on grief just becomes counterproductive and crippling to your ability to continue caring for other patients, so we become very good at compartmentalizing those feelings. 

     It was a long time, several years, before I talked about this with anyone.  To develop a bond, a strong doctor/patient relationship with someone, and then do something to harm them so profoundly that they die, is absolutely devastating.  It shakes your confidence to the very core.  It makes you wonder if you belong in a field where people depend on you to make their lives better.  I went over every step, every detail, over and over, trying to understand why, and what I should have done differently, and how I could have caused someone to die.  I try to console myself by remembering that he would have died from his cancer anyway.  But he shouldn’t have died on that day, the way he did, from a perforation of his colon.  He should have had the chance to go home again, write another song, see his beloved cats again, make peace with his family and friends.  He should have died in his own home, when he was ready.  I took that away from him, and I still wonder if he could ever forgive me.