Sunday, 13 June 2010



Whenever you are talking medical procedures with other medical students or doctors "morbidity and mortality" is  often bought up. This is referring to the risk of adverse effects or death. This can be referring to the end results of a disease, or the risks of a medical procedure. "This procedure is associated with a high risk of morbidity and mortality" would suggest that the procedure is risky, because it is likely to cause damage (e.g. paralysing the person) or kill them. These terms are bandied around throughout the medical education, and I hadn't really given much thought as to what they mean. Events this week have put a new light on things.

The week included me in theatre again, following a patient through who had colorectal cancer. Cancer of the large bowel is a common cancer, and there are a variety of techniques for treating these. This patient had a low level cancer, in the actual rectum, and as such needed a procedure that would remove this cancer without leaving any parts behind. This procedure is called an AP resection (Abdominoperineal resection), in which the anus is cut around, and the colon is cut half way along, and the colon is pulled out of the hole where their anus was like a long sausage. Sounds exciting, if not a little disgusting.

The patient was a drinker, knocking back most of a bottle of spirits a day until his diagnosis of cancer 6 months ago. Since then he had gone tee-total, but his liver had still suffered the damage, and his skin showed the characteristic jaundiced colour that would be expected. With the liver damage he had suffered, the patient had been advised by the doctors that surgery was not the best course of action - other cancer treatments had been tried such as radiotherapy, but the cancer remained. The patient didn't want to die of cancer, so had opted to go for the surgery. It was discussed with the doctors and the surgery was planned to go ahead.

The surgery was planned to be carried out laparoscopically (keyhole) - meaning the colon would be cut and freed up using keyhole surgery, and then the external anal sphincter would be cut around and the colon pulled out. Minimal trauma, minimal blood loss and a faster recovery. This surgery took over 6 hours because of the slow painstaking way the surgeon had to progress through the cutting of the colon. The liver makes many of the proteins in the blood which help it clot (it is like the factory of the body) so that this alcoholic liver damage meant that the blood found it much harder to clot. Because of this, every cut which was made had to be quickly sealed.

Part way through the operation the surgeon decided that he needed to see an inpatient (as in someone who is currently residing within the hospital) as a matter of urgency, and left the patient lying there, keyhole surgery tools inside, under anaesthetic for about 15 minutes whilst he saw this patient and returned. The anaesthetist and scrub nurses said they had never seen something like this before - I was pretty shocked as well - seemed somewhat unprofessional.

The surgery was taking some time, so myself and the colleagues went to a clinic, and one of the nurses in theatre promised to phone me once the operation was reaching a move exciting bit. There is only so much you can watch of the colon being slowly worked away from the abdominal wall before you start getting bored. We were called back after a while to see the conclusion of the operation.

Unfortunately, during the keyhole surgery part of the operation, a major artery was caught by one of the instruments and the patient's abdomen started filling up with blood. The emergency demanded that the patient was opened up 'properly' for the bleeding to be stopped, which it was, and the operation finished using this cut in the belly. The colon was removed through the hole where the anus used to be, very odd, and us medical  students then got to examine the colon, find the cancer, look at the different regions, see the descenting turn to sigmoid, the sigmoid to rectum. The patient had lost 10L of blood (replaced by anaesthetist, obviously) We then went home.

The next day we found out that the patient had died an hour or so after the surgery had finished due to excessive bleeding which couldn't be stopped and metabolic acidosis. That seemingly healthy patient who had been chatting away in the anaesthetic room before being put under had just not woken up. The patient who would have probably had another year or two without the operation. The patient who, had the operation gone perfectly, still probably wouldn't have had any longer than he would have had with the cancer due to the decompensated liver disease. Why was he operated on? I suppose it's patient choice, and he was well aware of the risks. Could the operation have been done any better? There were some obvious lackings within the operation - such as the consultant leaving part way through, and the artery which was clipped, but both of these are not enough to have caused him to die. What will the coroner record? Alcohol related death, due to the liver dysfunction causing the unstoppable bleeding? Surgeon related death, as the cuts the surgeon made ultimately killed him? Or death by misadventure, he chose to have the operation, and signed the consent form which told him there was a high risk of mortality? How does the surgeon feel, does he feel he killed this man, or does he just feel it is part of the job? I am not sure I could deal with such pressures after such a thing happened.

As I was meant to be presenting on a teaching ward round the following day, I presented the patient who had died. I took the group to the mortuary and presented the patients history, his reasoning for the surgery, the surgery and the aftermath. The patient was shrouded in blankets covered in blood, he had kept bleeding long after death was recorded. I thought it would be a learning experience, 'high risk of mortality' is not just something you say. It means something. There are always these risks, and nothing this serious should be undertaken without careful thought on all sides. The student who was with me in the operating theatre was on this ward round as well, and unfortunately ended up very upset and had to leave. Feeling pretty guilty about this, perhaps I shouldn't have taken everyone to the mortuary. I know many medical students haven't been down there and I thought it would be a good learning experience. I suppose seeing the person you last saw chatting away avidly lying there cold and still isn't great.

On a more positive note, I learned a lot from this whole experience, the consultant seemed to really like the 'twist' I put on presenting a patient (though morbid, educational) and apart from this an otherwise cheery week.

Sorry this post has been written in haste, I am off to see Bon Jovi tonight. It is sobering how such calamities can happen, people can lose their lives and their loved ones and our lives just go on like normal. I suppose it is necessary to create at least some degree of distance from such problems, otherwise you will never be able to last in a profession like this.


  1. i sometimes think patients are given too much choice, in the sense that even though they are explained the procedure and the risk-benefit ratio, i don't think they fully comprehend the potential disaster waiting for them.

  2. Hello
    Thank you for this post, I have never really had think about it the way you have just presented it.
    Thank you, and enjoy Bon Jovi

  3. Very true Alujna, but can there be such a thing as fully informed consent if the patient hasn't got a medical degree?

  4. To an extent I agree with Alujna, but I still think patients should be given a choice in such important surgeries. The most important thing is that patients are made to see the real implications and given accurate information as to how risky it is.