Sometimes things just go wrong ...

A 16 year old severely handicapped boy is referred for a PEG as he has become increasingly difficult to feed and often vomits after food.  Placement of a PEG tube under general anaesthesia is organised. The GA is difficult as the patient is frightened, very strong and with no understanding of what is happening.  After a difficult 30 minutes, the patient is asleep and you discover this impassable oesophageal stricture in the distal oesophagus. 
WHAT WOULD YOU NOW DO? 

■ Abandon the procedure

But the boy wants to eat!

■ Refer for a radiologically placed PEG

But you have found a 'fixable' cause!

■ Dilate stricture and not place a PEG

Yes! Your job is to help him!

■ Reintubate with a slim endoscope and place a PEG

Forget the PEG!

■ Dilate stricture and place PEG

Keep everyone happy? He doesn't need a PEG!

Explanation

This is a recent "real case" of mine!

Endoscopy is unforgiving, a bit like surgery. You have to make the correct decision within a limited time. Tomorrow, OTHERS will be equipped with a "retrospectoscope" which gives them a perfect vantage point from which they can decide if you did "right" or "wrong". 

In this case, I went ahead and dilated the stricture without placing a PEG. A day later the patient was back eating solid food as normal and the request for a PEG feeding tube was quietly forgotten. 

Arguably, this was the "wrong" decision and the "correct" thing to do may have been to simply abandon the procedure, send the case back for re-discussion by our Nutritional Multidisciplinary Team, obtain informed consent and then reschedule the procedure in a month time or so.  

However, the stricture was clearly the cause for the vomiting, sending the patient back with the job unfinished would have delayed the necessary dilatation, put the patient at further risk of aspiration and subjected him to another traumatic general anaesthetic!  Arguably the wrong thing to do! 

But of course, it could have all gone wrong! Oesophageal dilatations are linked with a 1:100 risk of a perforation. Had the family had an opportunity to consider a dilatation? No!  Was the patient 'consented' for this? NO! Had you taken samples to ensure that it wasn't a malignant stricture first? NO (but why would a 16 year old have oesophageal cancer?),   

Therapeutic endoscopy is an odd mix of "thinking on your feet", accepting that sometimes "things go wrong" and working in a team where you can forgive yourself and where others are forgiving when things do go wrong. 

As a supervisor, sooner or later your trainee will have a serious complication. Surprisingly, we don't recieve any training in handling this!  If it's your trainee, bring the conversation somewhere private. Go for a coffee after the list or ward round and hear your trainee tell the story of what happened. Listen and be sympathetic. Usually, I think that this could have happened to anyone.  Of course there are things which 'just happen' to anyone. 

Like perforating an oesophageal dilatation or bleeding at polypectomy. But 'unavoidable mishaps', are more likely to happen to the unskilled trainee or deskilled colleague! 

When looking into a trainee's complication, I try to consider the following 6 'dimensions': 

1. Was there time pressure? (last case of the list?)
2. Should the trainee have been supervised? (where was the supervisor?)
3. Did poor communication contribute (with patient or staff)  
4. Is the trainee appropriately upset or over-the-top inconsolable? (some have unreasonable expectations that nothing ever goes wrong. They shouldn't do therapeutic endoscopy)
5. Later I would ask the staff who was in the room how the trainee seemed during the list.  Was he/she frustrated, insecure or content and happy? Was the trainee under pressure to 'prove' himself/herself? 
6. What do the other staff in the room have to say ?   

Actively considering these elements can give you an insight into why it happened.  Furthermore, it may provide a clue as to how to help. Should the trainee have fewer cases on the list?  Is further supervision required? 

Finally, supporting your trainee with the coroners report, speaking to relatives and advice on what to expect at the visit to the coroners court is invaluable to the trainee.  This is just some of my thoughts to add to your own !