A surgeon is the one professional we expect to be nearly as perfect as possible, but sometimes you just can't prepare for human error. No amount of years of education or training in the medical field can prepare surgeons, or other medical professionals, for the mistakes they make while putting someone under the knife. These are their stories.
(Content has been edited for clarity.)
Even The Smallest Of Mistakes Can Be Costly
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“A man came in for a routine operation, and my wife worked second shift and had the man as a patient for a few days. She even met his daughters and spent some time talking with them, and she was touched by how loving the man and his family were. She came in one night, and the man was not doing well and had not passed a bowel movement since his surgery a few days prior.
My wife notified the doctors and made special mention of the patient’s deteriorating condition to the nurse taking over at the end of her shift. She had a day off, and when she came in next, she found out that the man had died. Apparently, the surgeon had nicked the man’s bowels. As a result, his abdomen filled with waste and slowly poisoned him. She was devastated, even more so when she discovered that the same surgeon had made other mistakes in the past. My wife left the hospital before she found out what happened to the doctor. There was an ongoing investigation, but she never heard the decision. She was disgusted by how many surgeries the doctors took. She would talk to the surgeons and see they were visibly exhausted before heading into the Operating Room.
My wife still hurts over the man’s death even though it was over a decade ago. She still wonders all these years later if there was anything she could have done, but she raised as many alarm bells as possible and followed all the necessary procedures.”
What About Bob?
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“In two years of clinical rotations during med school, I encountered a patient – we’ll call him Bob – many times. Everyone knew Bob. He had spina bifida with lower body paralysis that led to many other problems. Despite his miserable lot in life, he was always optimistic and cool about his situation. Even when cleaning out a rectal ulcer for him, one of the worst smells I’ve ever encountered in my life, he was still able to joke around and made the procedure no different than applying a band-aid.
Eventually, Bob had signed a Do Not Resuscitate order and requested no further surgeries. He was his mid-20s, and tired of all the procedures.
Anyway, I was on a 24-hour call when the nurse paged me to check on her patient, and sure enough, it was Bob. We knew each other by this point, exchanged hellos, then I saw that one leg was purple and twice the size of the other. This was an obvious sign of a blood clot and occlusion.
I woke up the senior resident on call, we rushed to Bob, we call the surgery resident on call, and they start prepping for immediate surgery. We hurriedly talked Bob into consenting, which he did reluctantly.
What we didn’t do was call his main doctor, or slow down to talk to Bob, or notify any of his family. And that fact haunts me years later. Bob did not wake up from the surgery.
His family and his doctor all arrived at the hospital that morning to find him not in his room, but in the operating room. He died in exactly the way he had decided he did not want to go, and no one got the chance to say goodbye.
Everything we did may have been medically correct, but that doesn’t make it not wrong. We were all new doctors so eager to save lives that we never stopped to wonder if we were saving the person.
I wish I could tell his family I’m sorry.”
Maybe Should Just Leave It Alone…
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“I was a junior doctor working in neurosurgery back in 2008 when one of the chief residents told me his most unfortunate moment. In order to have a patient’s head stabilized for surgery, he was using a frame that had a set of three spikes that held the head in place. Due to the angle he needed to approach from, this required the patient to be face down. As he was placing the head of the anesthetized patient on the frame, the head slipped and his eye landed on to the spike, perforating the eyeball.
Panicking and thinking that his career was ruined, the surgeon started to poke at the eyeball trying to work out what was what until the anesthetist told him to stop. They then called the ophthalmologist who came to tidy up what was now a ruined eye. After the surgery, terrified, the surgeon went to explain to the patient what had happened. Understandably fearing the worst, anger, distress and tears, he received the response of, ‘That’s okay. I was blind in that eye anyway!'”
Sometimes It’s Something So Simple And Easy To Overlook
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“When I was an intern in the surgery department, I remember this guy in his late 50s come to the Emergency Room complaining about some vague abdominal pain late one night. His medical history was free of any events except for absolute constipation for almost a week. My resident and I were thinking of intestinal obstruction and proceeded to do lab investigations for the patient and x-ray. The x-ray showed massive abdominal distention, so we decided to prepare him for abdominal exploration. After blood samples were withdrawn, and while we were waiting for the results, the patient asked if he could sleep a little on one of the beds in the department. He was calm, and there was nothing that required attention, so we thought, why not? One hour later, the lab technician called us, and we had the following conversation.
‘Hey, you have a patient named [patient’s name]?’
‘Yes, he’s in the surgery Emergency Room.’
‘What is he doing in the surgery Emergency Room? His blood sugar is through the roof!’
CLICK
I put down the phone and ran toward the patient. He was having a diabetic attack, and we didn’t know. When I reached his bed, he wasn’t asleep… he was dead. We tried to resuscitate him and even called for help, but it was too late. He didn’t mention anything about his blood sugar when we asked him. We failed to see that a patient with that kind of diabetic attack could be presented by abdominal pain.
I will never forget the look on his sons’ faces. He came to the hospital looking so good, walking on his feet and died within an hour because we failed to do a basic test that wouldn’t take more than 30 seconds. I couldn’t sleep for weeks.”
The Surgeon Cost This Man Everything
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“My grandfather underwent surgery when I was around 9 to fix a tumor he had that would have had him dead in 6 years at most. The doctor ended up botching the surgery and somehow practically destroyed his brain, resulting in him forgetting how to speak English, walk, or even do basic life functions, crippling him to a chair, forcing him to speak Spanish relatively incoherently, while not being able to do much but eat through a tube, being watched over 24/7, while we were all worrying about him.
He ended up dying a few years later a painful death. I felt so terrible for him, remembering him watching recordings of himself dancing with his wife, laughing and telling jokes to everyone, and being so sad when he realized he can’t do that anymore, more or less even talk to me. We couldn’t even sue the doctor because of some legal crud and that man probably felt no remorse.”
A Lesson Learned
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“When I was a medical student on my surgery rotation, I was in the Operating Room with only the attending surgeon. The residents on service were otherwise busy, so the attending decided, ‘Fine, I’ll do it with the student.’ It’s a relatively straightforward case, placing a gastric tube for a patient who couldn’t eat. The institution I now work at frequently does these under laparoscopic visualization, which is seen as overly cautious by some. Not me.
The attending put a scope down the patient’s esophagus, and I had to push a large needle toward the scope. He pointed a light towards the skin when he entered the stomach, and I pressed on the patient’s skin, and I could feel the screen, showing we were in the right place. I thought I took that exact same position and angle and introduced the needle, except it didn’t show up on screen. So I pulled back, pressed again and tried again and didn’t see it. The attending grew frustrated and told me to push the needle deeper. I had a twinge of concern, but eventually rotated the needle, which was several inches long. Eventually, the resident showed up and tried to find the needle but could not visualize it. He switched places with the attending, and after another try, he got the needle into the stomach, and we finished placing the tube.
I came back a few days later to find out that that patient died from internal bleeding. One of the multiple needle pokes – or possibly a cumulative effect – had injured arteries in the abdomen. Now, I know not to ignore that gut feeling, and I know that even ‘low-risk’ procedures have a risk of catastrophe and always take care to mention that when preparing patients for surgery.
I harbored guilt over it throughout medical school and still had hesitation the first time I did that procedure as a resident.”
Trick Or Treat?
“If you work as a physician in an acute setting, don’t dress up for Halloween. My supervising resident had to tell a family that their daughter had cancer while dressed as the Cat in the Hat. Respectfully, he took off the hat.
I work in a children’s hospital and what we do is take turns ‘trick or treating’ every Halloween. So we get to have fun and wear costumes, but we also don’t do clinical work while dressed up.”
Hopefully They’re More Careful Next Time
“Over the course of a surgeon’s clinical practice, something will go wrong. Thousands of surgical errors occur annually and cost the health system a lot of money, but not all errors necessarily result in medical malpractice suits.
A colleague once told me of a case years ago where they performed a neurosurgical procedure on the wrong side of the brain because either the nurse or technician had incorrectly marked ‘Left/Right’ or flipped the x-ray over, and the operating team didn’t bother to double check the side or verify what they were doing.
The correct side is verified MANY times now before proceeding.”
The Wrong Kind Of Positive
“I conduct HIV testing. One morning I showed up to work extremely tired because I couldn’t sleep the night before. This guy came in for a test, we went through the pre-counseling, and then I told him to step out for a few minutes while I awaited the results. Once he came back to get his results, I told him to take a seat, and the first thing that came out of my mouth was, ‘Your results are positive,’ and then I saw the look on his face and that’s when I realized I messed up. I then said, ‘Oh no no no, I meant to say negative.’ I almost gave the guy a heart attack.”
It Was MESSY
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“We once had a patient in the ICU with major abdomen trauma. He had gone to the Operating Room and was too sick to be able to close his abdomen, so we left it open. We had a piece of plastic, like a bag, covering his intestines, and then we placed a vacuumed sponge dressing on top of that, called a wound-vac.
At one point, the patient’s nurse called me into the room to look at his abdomen because she thought she saw pieces of the bowel seeping out of the bag and getting sucked against the wound-vac. I agreed and thought the bowel looked dusky as well, so we called the doc to come and look at it.
The resident came in, took off the wound-vac and the bowels had become swollen from the fluids and trauma and out came his guts. We would tuck the bowels in one side, and they’d spill out the other. Here we had this guy in his bed, disemboweling and we could not get everything back in him, in the bag, or anything.
Luckily, the patient was sedated, and we had other medications to control any problems with his blood pressure and the guy wasn’t overtly bleeding, but it was MESSY. We had to step back and say, ‘Well, how do we get this guy’s guts back inside him?’
We ended up having to call in six other people to help tuck things here and there until he could get back to the OR to get everything back into its proper place.”
This Doctor Received A Lesson In Empathy
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“One time I failed a patient. I was on my first clinical rotation in a rural Emergency Room, and a woman came in with a miscarriage, her second one. While we were talking, she mentioned she was new to town, didn’t know anyone, and her husband was away for the weekend. When we gave her the diagnosis, her eyes became teary, and then we left to make arrangements. The doctor didn’t say he was sorry for her loss or comfort her in any way, which I instinctively wanted to do.
When I went back to her room to give her her appointment time, she was in pieces. It really got to me. The five seconds it would have taken me to say those words, put a hand on her shoulder, call someone, or simply offer some tissues, I didn’t do it. Instead, I let my fear of not knowing if I would be showing too much emotion or slowing down the doctor stop me from being human.
The silver lining is now I do what my gut tells me. I’ve soothed babies from exhausted parents, picked up crying family members off the floor, and have even discussed comic book heroes with kids getting stitches because that’s the kind of person I am, and the doctor I want to become.”
Right In The Jugular
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“We were putting up a central line for a drip with an 18G needle (relatively big compared to most needles) in the patient’s external jugular. All of a sudden, the needle went right into the jugular. We all started panicking because usually with a drip, the needle is meant to come out and only the plastic remains, but now we had lost the needle INSIDE this guys jugular.
Before we could even fish it out it was gone. I looked at the fellow surgeons and nurses and before we could do anything, we rushed him right into theater. After a few minutes, we fished the needle out near his subclavian vein – closer towards the shoulder – and we breathed a sigh of relief.”
Incorrect Diagnosis Leads To Multiple Deaths
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“I had a 9-year-old girl brought in one night with her parents complaining of fever and respiratory distress, presenting with coughing and wheezing. The kid was out of it, and the parents were upset. I thought it was Bronchitis, but I admitted her and ordered treatment for her fever and cough as well as throat cultures.
I was with another patient when the kid started hallucinating, sobbing and spewing everywhere. I figured it had to do with the fever, so I packed her with ice, but she died maybe a half an hour later. This wasn’t my first death, but it was one of the worst. I couldn’t tell the stiff neck since the kid was out of it. She also couldn’t tell me anything else that would point to simple or complex seizures.
She died of meningitis. Completely wrong diagnosis. To make matters worse, we called in all her schoolmates and anyone else we could wake up just in time to see three other kids die. The rest got antibiotics quickly enough.
If I had caught it sooner, those kids might have been treated in time.
We couldn’t trace the source of the virus, but my best guess is that an adult contracted it and then passed it on until it was extremely aggressive and set loose on a schoolroom full of kids.
It was probably my worst day in medicine.”
What Do You Do When The Surgeon Runs Out?
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“During my second or third heart catheterization, my senior doctor yelled, ‘Oh, no!’ ripped off his surgical gown, and ran out of the room. Apparently, he came down with food poisoning and made a run for the bathroom, never to return.
I had just positioned these catheters with wires into the sleeping patient’s heart, and now they were just hanging out there pulsating with each heartbeat. I had never previously made it to this point in the procedure and was wondering where to take it from here. I was looking at the vitals and monitors like, ‘Okay, what do I do now?’
The senior cardiology fellow in training was taking a nap and not returning any pages or calls, and there were no other doctors around. Finally, the surgical tech assisting me with the procedure gave me a nudge to flush the catheters to prevent blood clots and death. After a few minutes, the tech removed the catheters and wires. Surgical techs often get treated like crap, but they have saved ALL of the fellows in training and senior doctors many, many times in complicated situations.”
He Refused To Own Up To His Major Mistake
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“When I was 18, I was told to get my impacted wisdom teeth removed. I went to a surgeon who informed me I would be put on general anesthetic (totally asleep) and the teeth would be broken up to be removed.
Day of surgery, I go in. Because of how messed up you get on anesthetic, my mother was scheduled to pick me up after a couple of hours. She arrived and was informed that I was still in surgery. After nearly another two hours of waiting, she felt like something wasn’t right and called my father. He came in and was likewise informed I was still in surgery. At some point, they finally said they wanted to see me and threatened to call the cops.
It was then revealed that my jaw had been broken.
Instead of breaking up my wisdom teeth, the surgeon had tried to take them out in one piece, and on the very first tooth, he snapped my mandible. It popped up into the muscles in the back part of my cheek, coming up against two nerves. He wired it shut in a panic, without consent or an X-ray. Turns out the reason you take an x-ray is because you need to make sure the bone is set. My bone was not set.
Over the course of the next two weeks, the bone didn’t heal because it wasn’t set correctly, and instead it slowly sawed through my trigeminal nerve, destroying sensation in the lower right half of my face. I looked like a stroke victim because I had very little control over it. This was probably the most pain I’ve ever been in in my entire life; I took liquid Vicodin (remember, jaw wired shut) every 2 hours, could barely sleep and needed help with tasks like walking up stairs and going to the bathroom because of the pain and medication. It was Hell on earth.
We eventually found a doctor to fix it; he had to re-set the bone. This was about a 6 hour surgery and a 2-night hospital stay. The bone was so badly out of whack that it needed a plate and seven screws installed to stabilise it. My jaw was wired another 10 weeks while that healed and of course, the nerve damage is permanent. You can definitely tell which side was busted, from both the surgery scar and the lop-sided smile. Plus I don’t have as much control there as I should and sometimes I bite it and do a lot of damage since I can’t feel it.
The original doctor who broke it refused to admit responsibility or pay any of the damages (presumably he was told by malpractice lawyers never to admit to messing up), so I sued. In the deposition, he said he broke up the tooth, which of course he hadn’t. I had the tooth to prove he was lying, after which we settled for the amount of damage, but about 75% of it ended up going to things like lawyer fees so I still came out behind on all that.”
They Realized The Mistake A Little Too Late
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“A new hospital opened in my city, and one of the first surgeries performed was a leg amputation. We all thought everything went well, but then we realized that the doctor mistakenly amputated the wrong leg.
The patient didn’t die, but I can’t imagine his quality of life improved after that.”
Wrong Family
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“My brother is a surgeon, and during part of his residency, he had to work in the pediatric unit. He was working with two newborns. One was getting much better and fighting for life. He was going to make it through fine. The other baby was hours from death, and it looked like he wasn’t going to make it.
My brother was in charge of informing the families and realized that he mixed up the families about 15 minutes after he broke the news. He mistakenly told the family with the healthy baby that their child wasn’t going to make it, and then he told the family with the dying baby that their child was going to be okay. He then had to go back out to the families and explain the situation. It had to be devastating for those parents to be given a glimmer of hope and have it ripped away from you not even an hour later. That was most upset I’ve ever seen my brother. He was destroyed.”