A Young Physician’s Toughest Trial May Be Confessing Mistakes

“Love” is a dangerous word in philosophy or theology. But a Christian cannot escape using it in describing the spiritual life. In love, one puts one’s own person at risk-exposing one’s own dignity for possible rejection, disappointment, and even possibly annihilation. Love requires the exposure of the soft underbelly of one’s person. The vulnerability of another requires a response in love. And love requires vulnerability.

Vulnerability is at the core of love, because love requires risks. It means, at the very least, exposing oneself to the risk of rejection. It means focusing on the needs of another and thereby forgoing some of one’s own (often unconscious and reflexive) self-protective mechanisms. If another human being has been made vulnerable and one reaches out in genuine love, one is thereby also made vulnerable.

I can best illustrate this with a story. Early in my internship year, I cared for a patient with advanced breast cancer who had developed a pleural effusion (fluid between her lungs and her chest wall) as a result of the spread of her cancer. She was certainly dying, but awake and alert and having great difficulty breathing because of the effusion. We decided that she needed to have the fluid removed by a procedure called thoracentesis. In thoracentesis, the skin is anesthetized and a needle is inserted through the chest wall, between the ribs. A small plastic catheter is inserted through the needle, attached to a syringe, and the fluid is drained. When the appropriate amount of fluid has been drained, the catheter is then removed. In her case, this procedure had a palliative purpose-removing the fluid would help her shortness of breath. The oncology fellow asked me to perform the procedure.

Now I had seen this done a few times as a medical student, and I had helped to perform it once, but I had never done one on my own. It was clear to me, however, that the fellow expected as a matter of course that I was already quite skilled in this procedure. Fearful of seeming less skilled than expected, I answered, “Sure,” and proceeded to prepare the equipment to perform the procedure.

I spoke to Mrs. Hertz,* explained what we planned to do and why, obtained her written consent, and proceeded to perform the thoracentesis. With a slight give, the needle penetrated into the space where the cancerous fluid was located and a straw-colored liquid flowed effortlessly back into the syringe. The patient appeared comfortable, with no pain or additional shortness of breath.

I breathed a sigh of relief. I had done it.

I next proceeded to thread the sterile plastic catheter through the needle so that I could take off a large volume of fluid. We thought she needed to have at least one, or maybe even two, liters of fluid removed in order to make her feel more comfortable. But then, as I was inserting the catheter, the flow of liquid suddenly stopped. Thinking that the catheter might have become kinked, I pulled it back into the needle to try to reposition it. The catheter seemed stuck for a second, then suddenly came back easily. A moment later, the catheter was out of the needle and I realized that the end of it had sheared off somewhere into the fluid filled space between her lungs and her chest.

I broke into a sweat. “How are you doing there?” I asked.

“Just fine,” she replied. “It doesn’t even hurt a bit. You’re a great doctor.”

I wasn’t sure how to respond. I blurted out, “Well, for some reason the flow of the fluid has stopped. I’m afraid we didn’t get much out, and this may not have helped so much. But we’re going to have to stop.”

“OK,” she said. “You’re the doctor.”

My heart was pounding in my chest. What had I done? I should never have tried this without more supervision. Not only was I was stupid, I was clumsy. I had visions of the plastic floating around in there. I wondered if its jagged edge might get stuck somewhere between her chest wall and lung and cause a puncture. Maybe it would become infected. I wondered what I could do or should do.

WISDOM FROM THE ELDERS

So I ordered an X-ray (which was standard after such a procedure anyway) and with trembling hand I paged the fellow.

I remember vividly how very kind he was. I had expected an upbraiding, but he was calm and constructive. He told me, first things first, that the patient was stable and at least for now seemed no worse for the wear. We looked at the X-ray together, and the catheter tip was just sitting there at the bottom of her lung cavity. He told me that everybody makes mistakes, and that I should not be too hard on myself. He told me that I should make this a learning opportunity-first, that I should never be afraid to ask questions or ask for help out of fear of what someone else might think of me, especially when this put patients at risk. Second, in this specific case, that one should never pull back on this type of catheter, whether it is inserted into a body cavity or a vein, because the design makes shearing off the tip very likely.