Errors and failures are what drive us to be better.  That is why it is called a practice.

We somberly circle the operating table, everything draped in blue like we are attending a baby shower.  The patient, a man in his early thirties, is fast asleep.  I am on my surgery rotation, a medical student so green I am not even allowed to hold the camera for this laparoscopic cholecystectomy, a medical procedure using small incisions and elongated tools to remove a diseased gallbladder.  I am working with a doctor who is the head of the department, an internationally renowned specialist in general surgery.  She is prepared a hundred times over to perform this operation.  She knows this patient’s anatomy may be different from average, but she has accounted for this and is ready to proceed.

She states the patient’s name and procedure as part of the medical time out, then announces in a calm voice, “Let’s begin.”  Controlled, confident incisions create the port holes, and soon our instruments are placed.  The camera finds the target, and the gallbladder looms large, an oblong deep green avocado snuggled up against the watermelon pink of the liver.

My surgeon grips the gallbladder and starts to pull it away from the surrounding tissue, but it sticks fast, adhering to the liver.  No biggie.  She anticipated this.  She introduces a blunt tool and carefully works it between the organs, gently breaking scar tissue.  A more cantankerous adhesion becomes apparent, and she applies a pair of scissors to trim the bands apart.

The work is slow and tedious.  Each touch of the tools creates a raw wound on the liver, and blood starts to ooze.  For long minutes, the surgeon focuses on the gallbladder, plying careful pressure to free it enough to begin work on vessels that must be clamped and cut before detaching it completely.  

But soon the atmosphere in the room changes.  Something everyone watching the screen has been noticing suddenly reaches the front of our collective consciousness.  The surgeon asks for the camera to be directed downward, examining the floor of the abdominal cavity.  Each scarified area is trickling small rivulets that coalesce into a deep pool in the abdomen, a spring thaw filling up a glacial lake.  There’s a lot of blood.  Too much blood.

“Suction,” the surgeon commands, and a thin tube enters the pool, striving to remove the increasing volume.  The level drops, but slower than hoped.  As soon as the suction is removed, the lake returns and grows.  New tools are introduced: cautery, powders, synthetic sealants, suction again, all to stop the bleeding.  More blood is flowing now.  As soon as one area seems to slow, another opens up, or trying to close one makes the bleeding worse.  The camera lens turns red.  The surgeon cleans it, then reintroduces it.  The lake is higher now, almost reaching the gallbladder.  

The surgeon pauses, then curses in the same calm voice.  She asks the anesthesiologist to draw some labs.  We need to know the patient’s blood counts.  Without pausing further, she says, “Let’s convert to open.”

The tools are removed, and the surgeon makes broad incisions to expose the liver and gallbladder to the naked eye.  I am handed a retractor, a claw-like tool that grips the edge of the skin and holds it back to provide good visualization for the surgeon.  As soon as we are deep enough, she redoubles her efforts to staunch the bleeding.  Gauze, suture, more sealants, more powders are placed over the bleeding liver.  At times, it seems we are gaining ground, and the surgeon pauses to observe.  But very soon, the ooze breaks through, dripping like a rainfall from a leaky roof, and she goes back to work.  More gauze, more suction, more powder.

This continues for twenty minutes.  The lake grows.

The surgeon, gloves dripping, steps back from the table and leans forward, resting her hands on the edge of the sterile field.  She looks at the floor.  She curses again, then again, the same word as before.  I wonder if it is the only one she knows.  

She talks briefly with the anesthesiologist.  The labs are back.  The blood counts are low.  The patient’s heart rate is beginning to pick up.  Not enough blood is circulating.  We hold a rapid conference.  Should we continue?  Give the patient a transfusion?

Quit?

The lake rises.

The surgeon sighs, then curses again, the same word.  She doesn’t know what to do.  She stares at the gallbladder, peacefully resting in its place as blood trickles all around.  Bleeding she can’t stop.  Finally, decisively, she states, “Let’s pack up and close.  We’ll get him to the ICU and transfuse.”  Again, the swear word.

“Pack up and close” refers to placing sterile gauze in the abdominal cavity and sewing or stapling the overlying skin shut, providing pressure to the wound and hopefully stopping bleeding.  It is a resignation, an acknowledgment that nothing more can be done here today.  We will need to stabilize the patient, get him back to a safe condition, and then come back to the OR to try again later.  

Of course, there is no certainty the bleeding will stop.  No guarantee we will be back here again.  This man’s life is in jeopardy.  Everything is in doubt.

I look at the surgeon.  When people wear surgical masks, you learn to read eyes.  Right now, her brow is furrowed, staring at the abdomen as her hands move almost automatically to replace the tissues.  The eyes are angry, frustrated, and worried.  But there is also a glimmer of wonder, inquisitiveness, a hunger for answers.  She has performed this procedure thousands of times and taught hundreds of residents how to do it.  She has researched it, lectured on it, conferred with decorated colleagues worldwide on how to perform it properly, safely, and with good outcomes for the patient.  

But this person doesn’t know that.  His gallbladder doesn’t care.  All her preparation, knowledge, and skill is ineffective against the life lying on the table now.  She gazes fixedly on the body that beat her today.  Then she shakes her head, sighs, and turns her attention wholly to her hands.

She breathes, to no one in particular, “I have never had to pack up a patient in my entire career.”

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It is common to assume those in positions of mentorship never make mistakes, that they are immune to imperfection and error.  We view them as living charmed lives, never feeling the grip of uncertainty or sting of defeat.  Such thoughts contribute to our own insecurities, knowing the faults and weaknesses that lie within us.  They can cause us to avoid the possibility of failure by refusing to try, or to cover our doubt with empty bravado.  Worse, they can rob us of the joy and confidence that grow from honest success, cowering in the shadow of “Imposter Syndrome” which tells us that, despite victories, we are fundamentally flawed, and inevitably, someone is going to find us out.

Although this was a tragic episode for the patient and my doctor, I am grateful I was present.  I saw failure can happen to the best of us.  I learned not everything is under my control.  I was given permission to keep trying, even if success is not guaranteed. 

Eventually, I made my own mistakes.  But errors and failures are what drive us to be better.  That is why it is called a practice.

So try hard.  Do your best.  Keep going, even if you fail.  

Permission granted.