I Survived: A surgical screwup

I consider myself to be a pretty good surgeon. At our five-doctor small animal practice, I perform a variety of complex surgical procedures, from arthroscopy and laparoscopy to TTAs (tibial tuberosity advancements). So when my young associate called me in to assist with an emergency, I was confident.

The clients were new to our practice, and they brought in their 1.5-year-old Labrador retriever, Chloe, with acute abdominal distension and fever. An ultrasound revealed that the dog's left kidney was normal, but there was only a mottled area where the right kidney should have been. Free fluid was present in Chloe's abdomen, but she wasn't azotemic. A high white blood cell count and anemia along with elevated pancreatic enzyme levels didn't seem out of line with my top suspicion: a ruptured right kidney.

We went right into surgery and removed an enlarged, hydronephotic kidney that had virtually split in half. I wasn't able to identify a ureter on that side, plus Chloe was missing her right uterine horn, which led me to suspect a congenital abnormality with secondary hydronephrosis in this young dog. Chloe's abdomen was filled with a large amount of fluid and inflammation, so we lavaged the area aggressively. Chloe recovered uneventfully and went home the next day.

One month later, Chloe returned to the practice with the same signs: fever and abdominal distension. An abdominal radiograph stopped my associate and me in our tracks. In the right cranial abdomen was a radio-opaque marker from a lap sponge. Our hearts sank.

We wondered how we should tell the clients. My associate had been out of school for only a year and was envisioning speaking to the licensing board next. I told her, "Don't lie. Let them know we think there was a problem from the previous surgery and Chloe will need to be explored." The owners agreed and, while still reeling from the shock, we removed the sponge, along with a large amount of granulation tissue from the area where the ruptured kidney had been. The abdomen cultured negative and Chloe's recovery was again uneventful.

Not wanting to drop any more stress on my already nervous associate and because I was the head surgeon, I decided to speak with the owners. I explained the error and that we suspected it was the cause of Chloe's complications. They were obviously upset and looked at us like we were a bunch of quacks. They wanted the initial fee for the nephrectomy refunded. I kept very calm and apologetic but declined to refund the initial surgery since the sponge didn't change the fact that the initial surgery was necessary. We would, however, cover any costs associated with the sponge and its complications. I also informed them that I wouldn't skimp on care—Chloe would receive all the medications and tests she needed at our expense.

Sensing that the clients needed more explanation about how a sponge could be left behind like this, I explained that the sponges were used to block off the liver during resection and had become blood-soaked and difficult to see. But ultimately, we failed to account for it and the buck stopped with us. I made it clear that we would institute new policies to prevent this from happening again. I also told them I was doing what I'd taught my kids to do when they messed up: admit your mistake, apologize, and do anything you can to make it right. I gave the clients my personal cell phone number and told them they could call anytime with concerns. I made time and even came in on my days off if Chloe needed to be seen. When Chloe was hospitalized overnight, I came back to check on her and called the owner around bedtime with updates. Communication was key.

Chloe did great for another month, then returned yet again with the same signs. Feeling sick ourselves, we went in again and found an intense inflammatory response around the pancreas with the intestines adhered together in a tight ball. After an hour of desperately trying to free the intestine from these masses of inflammatory tissue, it became apparent that we weren't going to be successful. I called the owners and told them I couldn't save Chloe. They consented to euthanasia.

We were all devastated. This was a bouncy young lab who'd gone through too much for a dog her age. I told the owner that the inflammatory reaction didn't make sense to me and I wanted to send in histopathology. The husband consented but didn't see much point since Chloe was already dead. I told him I wanted to find out why the body was still so inflamed and hadn't responded to our treatments. I'd already learned a lot on this case, and I knew that histopathology might give us a final answer.

A few days later I received the results. Chloe's abdomen was full of adenocarcinoma, likely of pancreatic origin. I was stunned but somewhat relieved. I'd never seen pancreatic cancer in such a young dog. At least we had an answer.

Looking back, the case could have gone very differently. We could have covered up our mistake—admittedly, this was our first impulse. We could have told the owner when we found the sponge that Chloe had a pancreatic abscess and we needed to resect it out. After all, a pancreatic abscess would have explained the symptoms and lab work—Chloe's pancreatic enzyme levels were always elevated and her white cell count was very high. We could even have charged for a second surgery and made a nice profit on our error.

Our staff, however, knew about the radio-opaque marker and knew it was a sponge. We have a truly wonderful staff of dedicated, caring people. I would never ask them to be complicit in lying to a client. I wouldn't sleep at night knowing I had 20 people trying to keep a secret. Staff morale would plummet and word would eventually leak out anyway.

In our small town reputation is everything. Once it became known that we couldn't be trusted, my practice would be doomed. I'd invested a lot financially and emotionally in Chloe's care, but I stood to lose much more if my clients and staff lost faith in me.

I also could have lost a very good associate. I could have blamed the error on her since it started out as her case. But I was the head surgeon and ultimately responsible for the procedure. I had no way of knowing which one of us put the sponge there, so I took full responsibility. I could also have told her not to admit our mistake. But asking her to lie would have cost me all credibility in her eyes. If I chose to be completely honest in the hardest times, I hoped she'd see I'd do the same with her—and expect honesty in return.

As we dealt with Chloe, I could see that the stress was affecting my associate. I told her that this was a hard time but she had to keep things in perspective: As long as she was honest, did everything with the best interest of the pet and client in mind, and kept working to become a better veterinarian, she didn't need to agonize over any case. She'd done all she could do, and that's what most clients want.

In veterinary school, they told us always to charge the client, even in a case like this, since not charging would be admitting guilt. But I'd already admitted guilt—Chloe wasn't born with a sponge inside her—and charging them would have been tough to justify. This was my fault and I would make it right. It cost the practice some money but paid huge dividends with the trust I gained from the clients, my team members, and my associate. This trust can't be bought, but it can easily be lost.

We're blessed to have salvaged our relationship with Chloe's owners, who now bring their other dog to us. We also now have a technician and a veterinarian in charge of sponge counts, and I am more humble about my greatness as a veterinarian.

Dr. Scot Hodkiewicz owns Lake Geneva Animal Hospital in Lake Geneva, Wisc. Please send questions or comments about this article to ve@advanstar.com.