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an online version of the magazine Spring/Summer 2006
Features
Anatomy of a Surgical Dilemma
> Surgeons Bruce Perler and Glen Roseborough share their thoughts about what went wrong.
 
  The woman had only months to live. Should the operation still have gone ahead? Once a week, Hopkins surgeons come face to face with cases that didn’t unfold as planned.
By Ramsey Flynn
 
 
 
 

It’s 6:30 on a Tuesday morning in January, still pitch black outside, and 65 people in white lab coats are swarming into a conference room in the Hospital to talk about a handful of the more troubling operations performed by the Department of Surgery in the previous week. The case review sheets lie in a scattered stack on a narrow credenza near the doorway, sharing the table surface with coffee, donuts, bagels and chunks of fruit.

Modest socializing wells up among colleagues, but the mood is all business as the participants file in and quickly scan the sheets, all bearing the heading “Privileged and Confidential.” The grid lists seven operations that did not unfold as hoped. Three cases ended in death. One of them will get the full treatment during the next hour. The physicians involved have known for a week that this review was coming and are prepared to see their decisions thoroughly dissected before their peers. They’ve taken seats side by side in the second row.

 

Like their colleagues at academic medical centers across the nation, Hopkins surgeons have gathered for nearly 90 years to engage in sessions like these, called morbidity and mortality conferences—known as M and M meetings. Here, in tucked-away conference rooms beyond public scrutiny, a tug-of-war between candor and obfuscation plays out as physicians try to figure out why certain cases ended badly. By going over each disappointing outcome in excruciating detail, they’re hoping to avoid similar pitfalls in the future.

Some surgeons believe an easygoing analysis of cases that went awry encourages straighter answers and is less threatening to physicians’ egos. Others are convinced that stating openly where the blame belongs works best. But blame tactics can make sessions feel like hostile prosecution. And the fact is, not all unforeseen results arise from technical errors: Disappointing outcomes may also stem from decisions about whether to operate at all, or from the nature of the patient’s disease itself.

Still, no matter the cause, these discussions call into question the judgment of even the finest practitioners of modern medicine. And despite calculated efforts to remove any blame-fixing, professional reputations are on the line—and in a group setting.

 

“So let’s get started,” says Julie Freischlag from across the room at precisely 6:38. As department chair, Freischlag has targeted this case for special attention. She takes her seat near the front of the small auditorium, determined to probe not only for technical errors but to also learn whether the decision to operate was justified.

With Freischlag’s nod to the podium, a petite surgical resident with a distinctly Bulgarian accent commences rattling off the most essential details of today’s centerpiece case. The audience will learn nothing of the patient’s race or religion or social status; only the cascade of escalating clinical issues that brought her to Hopkins.

Residents now serve as the chief presenters in surgical case reviews.
> Residents now serve as the chief presenters in surgical case reviews.

The 67-year-old woman arrived with complaints that she had no mobility or sensation in her right leg. Her left leg was little better. Both feet were cold. But these symptoms only hinted at the mountain of underlying challenges that first confronted physicians here.

“Severe coronary artery disease since 1988,” presenting resident Christina Vassileva notes at the top of her list. The condition began to impede blood flow to the patient’s legs 18 years ago. When the circulation problem became unmanageable through anticoagulation therapies, surgeons created a new pathway for the blood flow by bypassing two disruptive aneurysms in the arteries that ran through her abdomen to her legs—a fix that was reaching the end of its remedial lifespan when she arrived at Hopkins. “Pulmo-nary hypertension,”Vassileva continues ... “coronary artery disease ... history of pneumonia ... extensive deep vein thromboses ... hepatitis C from a transfusion ....”

And then the kicker: The patient had been battling inoperable liver cancer for several months. Even if the symptoms that brought her here could be defeated, the woman’s life could ultimately be extended by only a few additional months.

With the underlying cancer condition trumping all others, the dilemma came into sharp focus—how much intervention should the physicians apply, given its short-term value? If surgery was indicated, how much quality of life could this woman gain amid the inevitable trauma of extensively sliced tissues and the time it would take to heal from the operation? Even more ominous: Could a patient in her condition survive at all? In short, was there more to be lost than gained by attempting surgery?

 

On the mid-January day when the woman first became Bruce Perler’s patient, he spent considerable time reviewing his grim choices in trying to offer her some relief. At 55, Perler possesses the avuncular manner that comforts worried patients and their families. His understated self-confidence and thinning hairline hint at the vast sea of clinical wisdom he’s gathered during his 30 years in medicine. With a CV thick with research distinctions and career accomplishments, this is a specialist who’s long been a go-to guy for a broad range of high-level consults in vascular surgery. Department head Freischlag feels lucky to have Perler as chief of the division that is her own surgical specialty.

Shortly after the woman’s arrival, Perler’s workup team found that she had no detectable pulses at all in her right leg; the limb looked like a lost cause. It was cold, immobile and incapable of sensation. If left in place, the dying appendage loomed as an imminent threat to this patient’s life. But the major surgery required to remove the leg posed its own considerable risks in someone with such complex problems.

The distressing variables conspired against easy answers. Might the physicians restore some circulation to her legs by reducing the clots with high doses of the blood-thinning drug heparin? Should they instead attempt to remove the clots with minimally invasive surgery? Or should they take the “easy” way out by amputating one or both limbs? And, finally, with mere months to live even in the best-case scenario, how much would this patient gain with any of these options?

Meanwhile, the patient was anxious. Her blood pressure was high. The pain in her legs was so intense that it crippled her mental state, making it necessary for her husband and two grown sons to act on her behalf during doctor-patient decision-making.

Perler met with the family and found everyone reasonable, intelligent—and realistic. It might be necessary to remove at least one of the woman’s legs, he told them, but before considering the trauma of an amputation, he wanted to try heparin to see if that might improve the circulation. Everyone agreed the primary goal was to reduce the patient’s pain. The family seemed to accept that the woman’s maturing cancer would soon take her life.

 

The modern M and M conference dates back to the early 20th century, when a Harvard surgeon at Massachusetts General Hospital developed what he called an “end result system” to gauge surgical performance and outcomes. His idea was that if surgeons were expected to share information with colleagues about how patients fared after being operated on, they could subject themselves as a profession to correction and scrutiny. The idea soon caught on at other academic medical centers, and Hopkins apparently adopted the tradition in the 1920s.

Former department chair John Cameron religiously participates in these sessions.
> Former department chair John Cameron religiously participates in these sessions.

Over the generations, M and M protocols at Hopkins have invariably changed as successive department chairs have given the sessions their own stamp. During the legendary 18 years (1985–

2003) when John Cameron was at the helm, for instance, the sessions proceeded in Socratic fashion, with Cameron quizzing surgeons on the details of their cases. Though these oral exams could sometimes feel embarrassingly direct to those on the receiving end, Cameron devotees contend that his command of practice and literature made the weekly grillings educational.

When Julie Freischlag assumed the chairmanship of Surgery in 2003, she introduced several new ideas. The function of moderator would rotate among division chiefs or the department chair, residents would present the cases, and key cases would be subjected to “evidence-based analysis”—summing up outcomes in previous patients with similar diagnoses as reported in the literature. And, of course, all cases would continue to be scrutinized for their core rationale: Did the procedures help or harm?

 

Thirty-six hours after Perler put his patient on heparin treatment to improve circulation in her legs, the medication had failed to bring relief. Quite the reverse: The woman’s pain had accelerated so acutely that her family requested urgent intervention. Perler agreed, but was forced by a professional commitment out of town to delegate the operation. He chose one of his most skilled surgeons, seasoned vascular ace Glen Roseborough, for what promised to be a difficult procedure—operating to restore some circulation to the patient’s legs to help her out of her agony.

Roseborough brought all the right skills to the equation. A Canadian-trained practitioner, he had completed his residency at Hopkins and amassed a formidable record in vascular surgery. With 15 years of medical experience by the age of 40—seven of them in vascular surgery—Roseborough had developed a commanding authority in some of the very specialties this patient would most require, including minimally invasive surgical techniques, thoracoabdominal aneurysm surgery and limb salvage surgery.

The initial plan was to remove the massive clots that had formed inside the aged arterial grafts within the woman’s abdomen. But as Roseborough and surgical resident Christina Vassileva homed in on the graft sites, they soon found their first big surprise: The arterial tissues adjoining the grafts had dilated into aneurysms the size of golf balls. Thick with scarring complications, the ballooned tissues promised to dramatically slow the procedure.

Only now did the surgeons get their first clear look at the extent of the blockage in the right leg. The clot was a chronic thrombus extending all the way through the upper right leg and down to the knee. The left side wasn’t much better. The planned reconstruction time suddenly graduated from the expected 90 minutes to more than six hours. Still, when the two surgeons finally closed the incisions, the operation appeared to provide the patient with relief. The new grafts had returned the blood flow to her legs.

Informing the family that the procedure had gone well, Roseborough transferred the woman to the ICU. Soon after midnight, however, when he was finally ready to leave the unit, the picture had changed dramatically. As the fatigued surgeon prepared to head home, he learned that the woman’s vital signs had plummeted, her heart had slipped into a dangerous rhythm and her pressure had dropped. Soon she was bleeding from the site of the surgical incision, from IV sites and from her nose.

Roseborough then learned the patient had developed another ominous complication, “compartment syndrome.” Her abdomen had become distended with fluid, causing intra-abdominal pressure that made her kidneys collapse and then stop functioning.

Alarmed, Roseborough ordered the patient returned to the OR, where he and a vascular fellow commenced an urgent search for the culprit behind the sudden decline. Had the aggressive heparin therapy affected the patient’s ability to clot? Had the grafts failed? Had one of Roseborough’s vascular probes punctured a sensitive vessel?

Now, as Roseborough and the vascular fellow opened the patient’s abdomen to relieve the pressure, they found the grafts still strong, with no vessels ruptured. They found no blood pooling in her abdomen, a perversely bad sign: It meant there was nothing they could repair, nothing they could do to reverse this patient’s decline. The woman’s heart was beating erratically as they closed her, and her blood pressure dropped again suddenly. Immediately, the surgeons started her on units of fresh frozen plasma, but her vital signs refused to stabilize. At 3:17 a.m. on January 19, the woman went into cardiac arrest and died.

 

What went wrong with this case? As the conferring surgeons prepare to unravel that puzzle, Freischlag turns first to Perler. From his central position in the auditorium, Perler cuts to the chase about the one pivotal decision that most haunts him: From the outset, was the decision to save both of the patient’s legs ill-advised? “My gut feeling,” he says, “is that sometimes you have to lose a leg to save a life.”

Seated immediately to Perler’s left, surgeon Roseborough cites his frustrations with the aneurysms in her groin. The damaged grafts had unduly prolonged the clot-removal procedure—a heavy tax on any patient’s system, but more so on such a compromised patient.

Freischlag goes back to the woman’s downward spiral after the second operation and turns to one of the most skilled trauma experts in the room, Edward Cornwell. Cornwell addresses what he considers the case’s core dilemma. “Every instinct of our training,” he says, “is to save limbs whenever we can.” This woman’s many physical problems posed cruel obstacles to that plan, Cornwell admits, but the idea of amputating both her legs and forcing her to face her final months in life as a double amputee would be unappealing to any caring surgeon.

As others chime in, it becomes clear that, faced with similar dilemmas, the rest of the surgeons in the room would have made the same choices as Perler and Roseborough. But if they come up against a case like this in the future, surrounded by such a collection of complex questions about operational procedures, they will now be prepared. They will have heard their peers discussing the pitfalls, one by one.

But Freischlag has one more question: How do the operational decisions made by the surgeons in this case stack up against other cases with issues like these? To make sure these M and M discussions aren’t restricted solely to anecdotes and opinions from colleagues, the department chair has recently introduced a process called “evidence-based analysis,” in which the presenters search the literature to find outcomes data for similar patients.

Current department chair Julie Freischlag has introduced changes.
> Current department chair Julie Freischlag has introduced changes.

The lights are dimmed and surgical resident Vassileva unveils a slide presentation about the clinical history of patients with occluded arteries similar to the case at hand.

The bottom line of the evidence suggests that such patients who receive new grafts do better over time than those who don’t. But it also suggests that the graft sites themselves are prone to deteriorate from continued atherosclerosis that can combine with hypertension to produce thinning of the tissue combined with excess growth—developments that create a “perfect storm” of factors that could produce precisely the sort of aneurysms that complicated the operation that has just been discussed.

 

The entire presentation has unfolded in about 38 minutes. But what can this gathering of busy surgeons do with the information they have just shared? Do they come away as better practitioners? Will future patients benefit?

M and M conferences today might well play a more crucial role than ever before. With Johns Hopkins determined to become a leader in the national quest to help caregivers learn from their disappointing cases, these candid discussions offer a forum for helping physicians to avoid pitfalls. Still, well-known patient safety experts like Hopkins critical care specialist Peter Pronovost feel that M and M conferences are ripe for upgrades. The talks are structured with a limited vision, he says, chiefly because only physicians are typically invited to take part.

“What about the way nurses see the problem?” Pronovost asks. “What about the OR tech people, the administrators? By inviting everyone who touches the process into the room, the M and Ms could go a lot further as an educational forum.”

In Freischlag’s M and M conferences, a number of nurses, nurse practitioners and OR techs do sit in, but few other departments, according to a recent Pronovost survey, open up their meetings. 

Surgeon Glen Roseborough wonders, meanwhile, if Hopkins’ M and M process might benefit with a more aggressive approach. “I think this was a very tame M and M,” he says of his own case. The most quality-compulsive surgeons, he believes, are attracted to the rigor of high standards. Seeing those standards applied both in practice and review can perpetually help people like him improve their game. Like many of his colleagues, Roseborough is proud of his ability to self-prosecute and frustrated when others won’t do the same. 

Still, Roseborough can’t think of how he would have approached his own case differently, even with the benefit of hindsight. For him, he says, such cases “beg the question: What are we supposed to do for someone like this? Is there a correct level of intervention we should be exercising with a terminally ill patient?”

As a product of Canada’s nationalized health system who also once served within the United Kingdom’s similar structure, Roseborough has long been impressed with how the American medical culture is geared to go to unusual lengths for every patient. “In the UK,” he says, “a case like this would have been handled with a morphine drip and a hearty ‘cheerio.’”

Bruce Perler also ruminates about the session. Sitting in his office two weeks after hearing his case second-guessed, he’s philosophical. “This case really was that kind of end-of-life circumstance because of all the malignancy issues,” he says. “We faced a series of bad options, and it was a matter of trying to pick the least unattractive.”

As for his feelings about subjecting his decision-making to the scrutiny of a roomful of peers and subordinates—let alone his chair, Perler has no doubts. “I want their review,” he says, “but the most important opinion is the one from the person I meet in the mirror each morning. It’s about my conscience.”
 
 
 
 
Features
 Taming the Beast
 Anatomy of a Surgical Dilemma
 
Departments
 Circling the Dome
 Medical Rounds
 Annals of Hopkins
 
Class Notes
 Match Day 2006
 Rounding Through the Ages
 Lock Conley Looks Back and Blushes
 
Opinions
 Post-Op
 
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