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

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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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