It Was All My Fault That a Patient Died.

Back in the late 1980’s, I was working as a junior general surgical registrar. In such a role, I was allowed to perform minor surgery, often unsupervised. Back then, general surgeons were commonly performing carpal tunnel release surgery although nowadays, they are performed predominantly by specialist hand surgeons. I operated on a man who had bilateral Carpal Tunnel Syndrome.  The surgery was performed under a local anaesthetic block which means that his arm was made numb and he was able to be awake for the duration of this short case. I operated on one side.  All went well.  About three months earlier, he had been operated on the other side by one of colleagues (who was at the same level of training as myself).

Totally unbeknown to me was the fact that an intern had ordered pre-operative blood tests, an electrocardiogram and chest X-Ray in the week prior to the surgery.  These tests in an otherwise well man with no co-morbidity and having a procedure under a local anaesthetic block is unnecessary. I was to learn that this was the case about 8 or so months after performing the surgery and by this time, I was working rotation at a secondment hospital.
I was one of two carbon copied doctors on a letter that had been written by a cancer surgeon.  The other cc doctor was a respiratory physician.  

The surgeon described the history that had led to the presentation by this patient with symptoms. He wrote “somebody had operated on this patient and not checked his CXR which at that time showed an obvious coin lesion in the lung”.  It was intimated that the patient could have been cured of cancer if diagnosed at that time had the CXR result had been checked at the time.  It was very obvious that he was apportioning blame on me for not checking the result of a test that I had not even known or should have expected to have been performed. It was interesting that the same unnecessary work up had been performed for the patients first carpal tunnel operation a few months earlier.  I could see exactly how this would have happened on the second occasion where an bewildered intern just followed what was done on the  previous occasion.

http://grammar.about.com/od/ab/g/Bad-News-Message.htm

I was devastated to receive this letter.  I did not dare communicate with the surgeon to explain my case as I truly believed at that time, any disagreement with the surgeon would be the end of surgical career. Over the next 18 months, I continued to be copied in on correspondence outlining the patient’s demise in spite of curative attempts and ultimate death.  Every time I received these letters, I would fall into depths of depression for several days but I would always develop a mechanism to cope. When the letters arrived, dread would fill my face before opening the envelope as I always knew what lay within.  I would go to a room by myself and read it again and again and again.  I looked at it as being my problem and could not feel I could raise it with anybody, including my partner at the time or my surgeon mentors.  He had amassed incredible power in surgical politics and was not one to be reckoned with.  I was totally and absolutely petrified of him.

Periodically I would think of this case and it was not until some 15 years after the event that I would seek closure. This matter had ruminated in my head like a festering sore.  This process began went I was invited to a 50th birthday party and at dinner happened to be seated next to the respiratory physician who was involved in the case.  I found myself opening up to him about this story that I had kept locked away for so many years.  It was quite liberating to be able to speak about it for the first time.  It was amazing that he seemed to remember the case.  The physician was less than complimentary about this surgeon's general behaviour over many years that had been characterised by bullying, narcism and arrogance.

I had copies of the letters and selected additional clinical information and certainly more than enough evidence for commencement a bullying claim.  I had already briefed a high profile lawyer who was eager to take the case,  Given the particular high profile of the individual and what she considered to be unjust treatment, she was prepared to commence this case without any cost to me. I reflected and asked her to allow me do one last thing before commencing litigation.

I took the step of writing to the surgeon who at this stage was a national figure. He was  big fish to fry if I were to take the matter further. He wrote a meticulously neat hand written letter to me explaining that he regrettably had no recollection of the matter and wished that I had been able to raise the matter with him at the time. The final paragraph was repeated unreserved apology.

Whether the apology was disingenuous or not, I felt that I had got this matter off my chest and he was now aware of what I had experienced as a result of his actions. The act of opening up about this case and to then communicate my story to the perpetrator was extraordinarily liberating to me and to the extent that I had lost energy to commence litigation that was destined to make the press.  

I destroyed the documents.  The matter was over from my perspective.  The chapter was closed.  I did not think about this story again until the recent media coverage of harassment in the medical workplace.  I have my blog and here is my story. Do you have a story to tell?

Click below for:-

Background to my relationship with the surgeon discussed is covered in the short piece that precedes this post.

Feeling Like You Have No Control Over Your Destiny

This very short blog piece serves as some background information for the next piece.

When I was a surgeon in training, there was obvious rivalry between two members of the unit. If one of the pair liked you, your time with the other was going to be challenging if not miserable.  It wasn’t necessarily vice versa because you could always be facing the wrath of both with the result of saying goodbye to your surgical career. You did not have a choice. It was like the sorting hat in Harry Potter that chooses your house.  

The surgeon who did not take a shine to me was often critical and certainly made little effort to engage with me about matters unrelated to surgery. This did not worry me so much for the fact that I was in constant fear of having my career axed if I put a step out of place.  I was not one of the "boys" - I was from an ethnic background, went to a public school and had no interest at that time in rugby union.  I was everything that establishment surgery was not.  My colleague mentioned in my next blog piece was one of the "boys" and went on to socialise with him outside the work setting.

He enjoyed having an audience in his operating room. Typically there would be 12 to 15 people and depending upon the week it might be other doctors, nursing students or physiotherapy students.  On one occasion, he left me to close the wound so he could step out to make some phone calls. When I reached the skin closure, he came back into the room and yelled at me "Gee Henry, you're meant to be getting better, not worse" and stormed out of the room.  For that moment, it felt like there were 100 people in the room.  I was totally and absolutely humiliated.  

This was the most stressful period of surgical training.



Related Blog Piece - click below
It was all my fault that a patient died

How Cancer Spreads.

Think of London as an overcrowded uncontrolled population of humans. Humans are like the cells that make up a cancer. Think of London as a primary cancer. I think of it as being an aggressive prostate cancer that wishes to progress but it could be any type of cancer. During the 1700’s and 1800’s, boats set sail across the oceans to find new lands to conquer. Initially, the journey provided many hazards to prevent these boats reaching their destination just in the same way that our blood stream and lymphatic channels have defences that destroy cancer cells as they enter into the circulation. Over time, new skills were acquired such as better boats, better sailing practices and the ability to fight journey related diseases such as scurvy. In a similar way, cancer cells entering into the circulation develop new skills to overcome the defence mechanisms in the circulation by mutations and are eventually able to reach their destination afar. 

Once the boats reached their destination, Sydney in Australia being a perfect example, there were local challenges to be overcome in order to survive and grow. These included food and water supply as well as battling a hostile indigenous population. This is a similar situation to when cancer cells attempt to implant at a place distant to their primary location after surviving and travelling throughout the circulation. When prostate cancer arrives in bone, the immediate instinct of bone is to mount an attack against the foreign invaders.  In a similar way to acquiring the skills to survive and travel through the circulation, the cells must now acquire the skills to overcome the local host defence mechanisms.  When this occurs, the cells are able to set up a colony and expand and gradually consume the host organ as they had done to the primary organ. 

When we look at the population of humans under the microscope during the period of British colonisation, the humans in London look the same as in Sydney.  When we look at cancer cells from the primary and compare them to the ones seen in the secondary or metastasis, they likewise look the same. 

To recap the British colonisation model for metastasis, London is the primary cancer, the oceans the circulation, and Sydney a secondary cancer or in other words a metastasis of London. 

Penile Reduction Surgery - What's the Truth Behind This Story?

Over week gone by, the Murdoch press were at it again with absolute rubbish click bait articles which effectively ridiculed a teenager who needed to have surgery to reduce the girth of his penis.  The article shows an image of an American football with the caption “An American football ... not usually used as a simile when describing the size and shape of a man’s manhood.”   Well, they aren’t attributing that comment to anybody because it is they who are saying it to draw attention to the article.  I won’t give the URL for the link to various Murdoch news outlet articles as I am not in the business of giving them anymore weblink clicks than they deserve. 

For a change, it is actually a true story about an American teenager who did need surgery to reduce the girth of a significantly large penis. The details of the case were published on line ahead of print by the prestigious journal called the Journal of Sexual Medicine. It was actually up on line in mid November 2014 so it has taken a while before news outlets got hold of story.

The case is about a 17 year teenager who was born with sickle cell anaemia. Individuals with this condition have a tendency for blood to congeal in vessels and therefore affecting the flow of blood to various organs.  One of the organs that can be affected is the penis and the most problematic complication for the penis is that of priapism. Priapism is a prolonged erection of the penis.  It is unpleasant, unwanted and not uncommonly associated with pain.  This teenager had experienced three such episodes of priapism since he was 10 years of age for which emergency treatment was required on each occasion.  A complication of priapism is damage to spongy tissue that fill the corpora cavernosa of the penis.  The copora cavernosa are the paired structures in the shaft of the penis that distend with blood to become erect.  Damage to the spongy tissue of the corpora lead to ballooning of the spongy tissue also known as aneurysmal dilatation.  With the integrity of the spongy tissue damaged, the corpora became distended and so much so that its girth was creating both physical and functional disability.

The surgery to reduce the girth of the penis involves excising segments of the coverings of the corpora cavernosa and suturing closed the defect.  The end result is reduced calibre corpora cavernosa.

Image from https://freelyshout.com/source/Corpora_cavernosa

Forget the talk of football sized penises, this unfortunate teenager has been unlucky enough to have an inherited disease that lead to the complication of priapism which in turn was complicated by aneurysmal dilatation.  This is obviously a very rare condition and it is unlikely that a similar case will reported any time soon.

Given that the real story behind this case lies behind a pay wall, the junk press finds it easy to stray from the truth and hence my reasons for summarizing the principal details of this case in this blog piece.

If You Pay, OMICS will Play. All Abstracts Accepted to Predatory Publisher Organised Conferences.

Many of my colleagues are aware of my thoughts about predatory journals and their associated conferences.  They often update me with articles they have seen on the subject or interesting spamming emails that they have received. 

Of particular note at this present point in time is the OMICS run conference called UROLOGY 2015.  I have already mentioned on Twitter several times on how they relentlessly spam me about this conference. 

In one of their emails, it almost sounds like they are getting a bit short with me for not getting on with accepting their invitation to pay high registration fees for the privilege of presenting at their meeting. “With due respect we had asked you…….” 

Hmmm, I am so sorry

Its associated journal, Medical and Surgical Urology has recently changed it’s Editor in Chief. The outgoing Editor in Chief claims that he did not even know that he was holding that position and has never seen or read a manuscript associated with the journal. Once alerted to the fact that his image and bio was up on the journal website (appears to have been taken from his university website), he immediately requested that it be removed.  They have since installed a new Editor in Chief.  I hope that the real guy knows he is there. 

Now back to this conference.  A colleague (I presume this to be the case) has anonymously sent me some correspondence between him or herself with the UROLOGY 2015 conference organisers.  They have taken the abstract from an article that I published in the Australian and New Zealand Journal of Surgery (Yes, this is a real journal which is indexed on Medline/Pubmed). Some additional text has been added and I think it is hilarious.  

Firstly, the authors names sound a bit dodgy, especially the last name. What’s haemorrhoids got to do with prostate biopsy apart from the fact that they might make the procedure a little more uncomfortable.  

Now for the additional sentences:- The last sentence of the Background is “We're sure this conference is BS”.   Under Objectives is “This abstract was especially plagiarized from original author who is known to be critical of predatory publishers and conference organisers.” I guess that they are talking about me.

Under Conclusion, the last sentence now reads “No idea how this got accepted”.

Not sure how to feel about having my work taken and modified and then submitted to an OMICS conference. Rather than feel outraged, I guess it is an honour that my unknown colleague chose my work above others to copy.  Clearly, nobody has really read the abstract.  It is clearly case of submit and if you are prepared to pay, your abstract will be accepted. I suspect that the urologists of the organising committee have nothing to do with the abstracts but the quality of the meeting is associated with their names. 

I think this exercise confirms what we expect from an OMICS run conference.


Related blog posts on Predatory Publishing

Predatory Journals. Academics Are as Much a Part of the Problem
Photon Journal is a clear nominee for the worst predatory journal
OMICS Publishing - pseudo-academia? predatory?

I thought my surgical career was over before it began

I have just read this piece by Dr Rinjana Srivastava and she identifies a problem within the medical profession that only one from within could express with such clarity.

http://www.theguardian.com/commentisfree/2015/feb/06/how-doctors-treat-doctors-may-be-medicines-secret-shame

It reminds me of being on the receiving end of bad behaviour from colleagues and I felt that it was about time that I put this down in writing.

When I was a junior doctor, surgical training programmes in Australia were all hospital based. You would be accepted onto a training programme at your hospital and you would work within that system for the duration of your training toward specialisation. You had to keep your head low but not so low that you would not be noticed.  If you upset any surgeon in any specialty, you ran a significant risk of automatic exclusion. The chances of getting onto a training programme outside of your hospital system was low as they tended to be parochial and would appoint from within.

I will never forget seeing the poor treatment of a colleague who was a year or so senior to me. He was an outstanding doctor and it was generally held within the hospital network literally being ‘pick of the draft’ and was going to essentially walk into the next available surgical training position. At about 6 months before the interviews, he inadvertently slept in on his first day of a new rotation, which also happened to be an operating session.  The surgeon took a vindictive dislike of that talented young doctor. He was blackballed from succeeding in his application for the next available training position. That doctor had little choice but to go to another hospital to re-establish himself and it was several years later that he would then enter surgical training. This sent shockwaves through the hospital system and sent a strong message that we needed to do everything within our power to avoid upsetting anybody. 

Now for my story. As a junior doctor, I thought I was going okay. I had been a ‘finalist’ for the best intern award and I had passed my surgical primary examination on first attempt and had not managed to offend anybody. The surgical registrar under whom I was working was particular self confident and very much a larrikin type of individual. His self confidence and decisiveness was something that I had initially felt was something to aspire to. On the morning ward round, we looked a patient who had been operated upon the day before.  The leg was very swollen and the registrar felt that it was within acceptable limits and felt reassured given that there was no blood in the drain. 

A few hours later, I did a further quick ward round of the patients I was most worried about. For the man with swollen leg, it was my impression that the swelling was worse. I called the operating room to speak with the registrar. The phone was placed on loudspeaker and he reiterated that he was happy that all was fine and besides ’the drain had nothing in it’. I went back to the ward with my tail between my legs. An hour later, I reviewed the patient again and felt that things had progressed further.  On this occasion, he came out of the operating theatre to have a look and was again satisfied that all was fine.  A further hour later, I thought things were again worse and I could no longer feel pulses in the foot. On this occasion, I walked over to the vascular ward and got hold of a portable doppler and confirmed that the pulses were barely if at all audible. Apart from becoming increasingly swollen, the leg was now starting to look blue. I called up theatres and was again placed on speaker phone. The eye rolling was palpable and he again affirmed that his assessment of the patient was that everything was fine. With given tone of voice, I felt humiliated.

What was I to do? Keep my head low with the knowledge that I had done what was expected of me or step it up? I then decided to call the consultant surgeon who was nominally in charge of this case - I had to hold the phone away from my ear as he yelled "How dare you call consultant surgeon? The patient is a public patient and is managed by the registrar."

That moment, my only thought was with the patient who was going to lose his leg. I found myself  wandering almost aimlessly in the ward corridors trying to work out what to do next. It just so happened that a consultant vascular surgeon walked around the corner and I dared to approach him.  He wasn't even on call for emergencies but given the gravity of the situation, I asked if he could please come and look at this patient - he agreed and the moment he set eyes on the patient, I could almost see him mouth the words "Oh F**K"

We had the patient in the operating room within an hour. I scrubbed in to give a hand. The moment the leg was cut into, blood burst out and splashed all over the theatre light and ceiling. The blood in the thigh was under such pressure that it was compressing the flow of blood to his leg. The registrar dropped by and in a cheerful voice said "Yeah, I thought that he had had a bleed into his thigh."

Once this man's leg had been saved, I thought to myself that on this day, my surgical career easily have come to an end. I could not help but to think what would have happened if I was wrong about the diagnosis.  Thankfully things have changed a lot since then.


Addendum 8 February

To respond to questions as to what happened afterwards?  Back then, morbidity and mortality review meetings essentially did not exist.  To this day, I am not even sure that the consultant surgeon in charge even knew of this complication.  The registrar went onto to become a consultant surgeon and I have had no contact with him since.

A week of so later after the event, I bumped into the consultant surgeon who had yelled at me over the phone. I took the diplomatic approach and apologised for calling him. He responded in a kind forgiving voice and and said to me "Well we all learn from our mistakes".  As for the vascular surgeon, we became friends and I am forever grateful for his assistance.  He was an example of how there are brilliant role models for human beings as surgeons out there and one who led by example. 

Keep the Penile Cancer prevention argument out of the Neonatal Circumcision Debate

A commonly used argument to support the use of neonatal circumcision is the proven relative risk (not necessarily a significant absolute risk) benefit in preventing cancer of the penis.  The purpose of this discussion is not to argue over the role of circumcision to prevent infections such as HIV (that's for another day) but to discuss why making an argument that it prevents penile cancer to justify recommending routine neonatal circumcision is a misuse of statistics.

Let's first set the context correctly. I am writing this from the perspective of residents of Westernized countries.  Cancer of the penis in Westernized countries is very uncommon.  The figures vary depending on which publication you look at and when the data was collected but using the very worst figures, the incidence is around 1-2 per 100,000 population.   

Penile cancer is most commonly seen in men who are uncircumcised but there are often other factors additional to this.  These include poor hygiene, poverty, smoking, human papilloma virus infection, sexual promiscuity, sex with animals and others.  In my relatively limited experience of diagnosing and treating penile cancer, the majorities have been in uncircumcised men who were living in poverty and had poor hygiene.  When we look at this list of risk factors, it is clear that many of these are much less of an issue in Westernized countries than developing countries.  Before criticism is raised about sexual promiscuity and lack of condom protection still being a problem in Westernized countries, it pales into insignificance when compared to some developing countries.

Now let's compare the incidence of breast cancer. The incidence in Westernized countries is about 100-125 case per 100,000 population. Yes, this is a huge difference compared to penile cancer. Recommending circumcision to prevent penile cancer is like recommending bilateral mastectomy to prevent breast cancer. Okay, you might argue that bilateral mastectomy is a substantially more major operation that a circumcision? Fair enough. Why don’t we instead consider skin cancers involving the ear lobes which are not only far more common that penile cancers but to prophylactically remove the earlobes to prevent cancer in that location is not a major operation.

Another consideration is how many neonatal circumcisions would have to be performed to save one diagnosis of penile cancer? We do not have good data on this in the Western world because the incidence is so low. We cannot extrapolate data from developing countries where the incidence is relatively high.  Without having the necessary data to make a number needed to treat analysis, we can make an intuitive assessment of this. Lets take the incidence in Israel which is about 0.1 cases per 100,000 where almost all are circumcised.  Let’s take the incidence in Australia which is about 1 case per 100,000.  It is obvious that the NNT is going to be massive. Imagine having to carry out 10’s of thousands of circumcisions just to save one diagnosis?

If zealots are using the argument that circumcision significantly reduces the risk of penile cancer to justify a stance of routine neonatal circumcision, they might as well support a far stronger argument for performing routine bilateral mastectomy to prevent breast cancer.  

Remember that this blog piece is not an argument about whether circumcision can reduce the risk of penile cancer but the fanciful argument that this is why we can justify routine neonatal circumcision in Westernized countries.  Keep the penile cancer argument out of the circumcision debate in Westernized countries.