Henry Jay Przybylo, MD, a pediatric anesthesiologist and associate professor of anesthesiology at Northwestern University Feinberg School of Medicine, in Chicago, recently published “Counting Backwards: A Doctor’s Notes on Anesthesia,” which is available through W. W. Norton & Company. Dr. Przybylo’s more than three decades of professional experience provides ample material for this look at the “most common but most mysterious procedure in medicine”—anesthesia. In this excerpt, he discusses a few mistakes he has made in his career, and how they have affected him.
A legend in my career, Frank Seleny, was the anesthetist in chief who accepted me into his program as a pediatric anesthesia fellow, trained me, and finally hired me. One day early in my career, he pulled me aside and advised me that it would take ten thousand anesthesia cases before I would understand the limits of my ability. To paraphrase Donald Rumsfeld: There are known knowns, and known unknowns, and then there are unknown unknowns. Frank taught me the value of recognizing and limiting the unknown unknowns.
The next step toward expertise is understanding that shortcomings should not provide avenues for criticism, but motivation for change. This revelation struck me midcareer. It called for me to open my mind to become willing to seek continuous improvement. To recognize that mistakes are not always a sign of incompetence that should be buried (no medical pun intended). As Niels Bohr, the Nobel Prize–winning physicist, put it: “An expert is a man who has made all the mistakes which can be made in a very narrow field.” I believe I’ve made them all, plus one.
One mistake from early in my career remains at the forefront of my memory—not for the injury to the patient, but for the damage to my ego. I was working with the Learned One, the brightest attending and the most particular about process. The surgeon was another legend of my career, Casey Firlit. At the end of the procedure, the patient took an unexpected giant breath just as I switched off the ventilator that had delivered his breaths throughout the case. There was but a fraction of a second for this to occur, but it was like trying to take a breath with a plastic bag tied tightly around the head. His chest sucked in as he used all the energy he could muster to take a breath. He developed a strong negative pressure inside his chest that injured his lungs, causing pulmonary edema. He emerged from the anesthesia, I pulled the endotracheal tube unaware of the injury brewing, and pink, frothy fluid poured from his mouth.
My heart sank as I realized I was the cause of his pulmonary edema; fluid leaked out of his lungs. His oxygen level started dropping, and the breathing tube needed to be replaced to create positive pressure in the lungs and stop the fluid leak. The Learned One just looked at me, but the pain was piercing. My care, or lack of it, had caused a patient to be injured. Casey said little. The patient was transferred to intensive care, and I had my first very difficult discussion with a family. Several hours later my patient was awake and fine. But I had let three of the most important people in my life at that time down: the patient, the Learned One, and Casey.
The pride I feel after a case of a critically ill patient ends successfully fills me to bursting. It’s true that not all of these cases end well. That’s the cost and the burden I carry as those patients forever inhabit my memory.
Two times I have been accused of medical negligence, and both anger me. In both cases I was part of a team that tried to preserve a life, and both times I was soon dropped from the suit. But the accusation is enough to hurt, and regardless of the lack of proof, I still must list both cases when I apply for privileges anywhere.
Far worse and more haunting than the two claims of negligence was the case of Spencer. Multiple congenital defects required multiple surgical procedures on multiple parts of his anatomy, from the top of his head to his hips. Early on, a tube was inserted into the trachea in his neck, bypassing a blockage above, and it remained until a surgically improved airway was obtained.
He came for a finishing procedure, the tracheostomy removed and healed. I placed the breathing tube with difficulty and an improvised technique. The procedure went as planned, and I transferred Spencer to the intensive care unit with the breathing tube in place. My intention was to allow Spencer to recover fully from any and all residual medications that might alter his breathing, and I left with orders to contact me prior to removing the tube.
The following morning, as I was in the procedure suite providing care, the endotracheal tube was removed without my knowledge. Spencer died. While I stood one hundred feet away, Spencer died. Nobody could manage his airway in the manner I did. I failed to be clear or persistent enough to prevent an overzealous physician from going rogue. Personal beliefs prevented the family from pursuing a claim.
Sometimes the pain of failure extends past the patient.
The fact that anesthesia is iatrogenic—I am not a healer—elevates complications to another, higher level of guilt. One of my worst complications came through an extension of my hands.
A misshapen head is a curse borne by the owner but noticed by everyone. Surgeons have gone to great lengths to correct a deformed skull. Not all have achieved the desired effect. Long before I came to meet Carter, he underwent surgery and therapy that left him with defects—holes—that exposed his underlying brain to trauma. A strike in the right place would not be deflected by the bony skull. With his skull exposed for a lengthy procedure, and with significant blood loss, Carter’s temperature dropped. My resident became concerned, despite my assurance not to worry—that near the end of the procedure we would correct the hypothermia. Without discussing his plan with me, the resident placed a warm compress on Carter’s skin. When the surgical drapes were removed, a patch of skin was left burned and leathery.
I wanted to let go a primal scream. My resident’s action had been stupid. Even though he was the one to place the compress, I was the one accepting all responsibility and the one to accept the blame. I didn’t yell. There were no “goddamnits.” There was a parade of “shit, shit, shit, shit, shit.” My talk with the family gave new meaning to the walk of shame.
Carter’s family was, beyond all expectations, reserved and understanding. He and his family refused to file a malpractice claim. Instead, when he returned for some follow-up surgery on his head, the plastic surgeon repaired the burns. I cared for Carter several more times at the family’s request. After the third or fourth procedure, I asked his family: “Why do you always request me? This was one of my worst complications.”
The response at first stunned me, then became clear: “That’s easy. Now, every time he goes to the OR, I know he has a guardian angel.”
They were so right.