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Managing patients with complications; Offer compassion, create continuity – and bring a solid plan

Writing a piece on complications warrants the standard hedging sentence to start, so here it comes: "My career is not garnered with more complications than others; however, I do operate – and thus complications do arise at an expected frequency."

No one wants to be known as "the complication guy," especially not early in their career. Complications can be a topic more comfortably discussed late in one's career, however, once ample recognition has been achieved. There's still shame associated with having complications, even if we know that all of us experience our allotted share. Things that have gone wrong remind us that we aren't perfect. In our specialty, we aim to be perfect.

Some surgeons back away from talking about their complications, but I choose to share my experiences as a young attending – as I believe that handling complications is something that's a difficult part of our job and does require an active management strategy. The surgical management of complications is a topic that can be read about in books; however, the interaction with the patient who has a complication is less written about.

A Texas pearl

My experience of complications comes from my five years in practice. I don't back away from complex cases, but I also choose my patients wisely. I also have experience from being a resident/Fellow and watching senior surgeons handle unfavorable results. However, it struck me during my training that attending surgeons rarely interacted with patients who had a complication. Doctor-patient complication interactions are a sensitive subject and for obvious reasons are not suitable for a large – or even a small – audience. The surgical management of the complications are explained and understood. Nevertheless, the actual interaction is not focused upon.

I was lucky enough to get a true Texas pearl served to me during residency training. I found it hard to believe at first, but I now can confirm these words of wisdom and share them. My enlightening moment occurred at a cadaver dissection course of the hand. During lunch, a very famous Southern surgeon informally commented about a case that had been up for discussion at a recent conference. He casually said: "The most grateful patients you will ever get are the patients who have a complication that you successfully manage." This was not at all one of those catchy one-line phrase that we as surgeons say to easily avoid a complex topic. It sounded like well-reflected and wise words from a master of surgery. But still I couldn't fully believe it. That somehow just had to be an exaggeration and at least a little bit of fluff, I thought.

How should one handle complications? First of all: NO communicational strategies can compensate for poor decisions, bad surgery or poor surgical technique. If you aren't a good surgeon, you won't be able to salvage the procedure and appropriately help your patient with complications appropriately. You'll just continue down a slippery slope.

However, a good surgeon with a good plan and excellent execution in the salvage will still feel the sense of failure that hangs in the air. We all know the feeling of a complication from a re-explored flap, for instance – at first, it's a deep-seated abdominal ache, black butterflies, that turns into a slightly nauseating feeling that turns into an annoying headache – or maybe if you're lucky, just an annoying itch. Much depends upon the scale of the complication's consequences and how good you are at fixing the problem. Your body somehow screams at you to avoid exposure to these unpleasant facts – and avoid exposure of your perceived failure. Still, that deep-seated ache will not resolve by ignoring patients who need to be managed and seen.

Adopt the patient's perspective

Looking at the situation from the patient's perspective offers the all-important view. The patients in this situation are afraid, first and foremost. They've had the stressful experience of having surgery in the first place and are now faced with an untoward event and a "great unknown." Where do things go from here? No preoperative consent can ever cover these questions. The patient most likely has never seen anything like what's happening and will be overwhelmed.

In a fearful situation without support we, as humans, tend to react by fight or flight – surgeons, as well as patients. If you, as an inexperienced surgeon, let your fear or anger take command and abandon or distance yourself from the patient at this time of extreme trial, you'll likely be the target of all the fears and anger of the patient.

Remember that the patients have seen you in clinic before, and they know and trust that you are a good surgeon. The fact is that the deep-seated abdominal ache of yours does not come from the patient; it comes from within. I always tell my residents that the patients they feel the most uncomfortable dealing with are the ones they should spend the most time with during rounds or in clinic.

One should avoid focusing on the perceived failure in this situation and instead focus on the patient and the situation at hand. Problem-solving is what we do as surgeons. That's our job. This allows a structure for us as young surgeons to manage unexpected events.

Be available – no matter what

As a surgeon, you can't lose your composure during unexpected findings in the O.R. You can't walk away from the O.R. without resolving the situation. The same applies for postoperative care: You can't lose your composure with unexpected postoperative findings. It takes strong surgeons, confident in their skills, without any chips on their shoulders, to manage complications correctly. It's our job to be a steady and strong captain who takes the complication on our shoulders and steers the patient to calmer waters.

We have to be available, and we never abandon a patient. We have to see them as often as needed, even if deep-down we really feel that we don't want to. It actually isn't that unpleasant – it only gets unpleasant when we ignore and abandon.

After a couple of years, I realized that the ache in my stomach will probably never completely disappear, even if it gets a lot less prominent. I believe it has to do with our unattainable wish to be a perfect surgeon without complications. It's part of the pain in our important strive to improve ourselves as surgeons – a motivating factor that plays part in our learning process.

The importance of continuity

My experiences in a socialized healthcare system, where ownership of patient and ownership of complications is a much less prominent factor in practice, further illustrated the importance of continuity and support for patients experiencing complications. In some socialized systems, patients unfortunately often can be seen in clinic by one surgeon; be operated on by a second surgeon; and cared for postoperatively by a third surgeon or by multiple different residents on a daily basis. This is detrimental to continuity and ownership of care.

I've learned that fear and anger at times is directed at the official person who at that specific point in time is representing "the system," even if he or she isn't the actual surgeon having performed the procedure leading up to the complication. I've also surprisingly learned that any captain will do, as long as the complication is successfully managed and continuity is provided. However, not surprisingly, the reputation of the primary operator will suffer if he abandons ship and allows the vessel to be managed by another surgeon.

As I mentioned earlier, I don't recall overhearing any conversations between attendings and patients that involved a complication. My own approach has been to be informative, balanced and honest. I don't exaggerate or diminish. I will first confirm that I understand their frustration and that this is a complication, a result which is not intended. I inform them about where we're at, what options are available, where we are going and how this will affect the patients care with regard to results (cosmetic, function and so on) and to time. Specifically, time in the hospital, delay of any other relevant treatments, time in rehab and so on. I address all questions and inform them that I'll see them every day, and that I'll follow them until the complication and all issues are resolved.

For hostile patients (this has only happened once with a patient who was unknown to me from before), I'll let the patient blow off any steam as necessary, for whatever time necessary. I'll listen carefully to what's said – and while listening, plan how to address the issues mentioned. It's important to remember that the hostile patient is really a scared patient.

The lesson of the teacups

"Complications mean wound care" is another thing I remember being told during residency. This was one of those one-liners that you hear, a phrase that's clearly to the point but that perhaps doesn't qualify as a wisdom. The field of post-bariatric surgery is full of complications. I intermittently managed post-bariatric patients in my previous job and once found myself in a situation where an abdominoplasty incision had ruptured due to a very large seroma. The treatment was conscientious wound-care for several weeks.

During this period of wound care, before the complication was adequately treated and corrected, I received a kind letter and a gift "for being there." I was given two teacups. This caught me very much off-guard and offered me a flashback to that day in Texas where those wise words were uttered. Of course, I also remembered the comment about complications and wound care...

Though I was a believer all the time, I did have my doubts – but after receiving the teacups, I stopped doubting. I was honestly surprised that a patient would bring me gifts for not abandoning her care. But of course, it makes sense. The patient was later taken to the O.R. for a revision. A good result was achieved, and the patient was satisfied.

I do favor those teacups for reflective tea time.

Dr. Sandberg is head of Head and Neck Reconstruction and an assistant professor at Karolinska Hospital, Stockholm.