Pitfalls in Veterinary Surgery

You can tell its a great read when the book is tabbed.

Professor Geraldine Hunt is a trailblazing veterinary surgeon who developed, among other things, novel surgical approaches to portosystemic shunts. In the course of her work, she’s also made errors.

Every surgeon does, but Professor Hunt has shared hers in the edited textbook Pitfalls in Veterinary Surgery, in an attempt to foster a culture of learning and improving patient outcomes.

As a former student of Professor Hunt, I sought out a copy and found this a compelling read. She discusses errors, mistakes, near-misses, but – importantly – reflects on these and considers how they can be avoided, and how outcomes can be improved, in the future. It was fascinating to read that someone so unflappable, courageous and clever was kept awake at nights by concerns that many veterinarians can relate to.

Professor Hunt took some time out to answer our questions about the book.

What is your current day job? 

I retired from full-time veterinary surgery in June 2015. My husband and I bought our 46-foot Leopard catamaran (Alchemy 1) and since then we have focussed on outfitting it for off-shore cruising. We have lots of family and friends visiting for up to 3 weeks at a time, and spend most of our time away from port so I take care of logistical things like menu planning, provisioning and making sure we we know where all our supplies are stored. I learned a lot about project management in my University positions and those skills have come in very handy. During my first year of retirement, I also spent a lot of time writing and editing the book. I also help my sister from time to time in her small animal practice.

When did you realise you would specialise in surgery? 

I originally wanted to pursue small animal medicine or cardiology (once I gave up ideas of becoming an equine vet), but my partner at the time also wanted to specialise in small animal medicine, so we felt we would be more employable as a couple of we were not both in the same discipline. During my PhD, I realised I liked the challenge and reward of surgery, so that's how things went from there.

Why did you decide to write a book about pitfalls and errors? 

I was approached about writing a conventional surgical textbook, but I felt there were a number of other texts out there that were very good, and even if they had slightly different approaches or ideas to mine, I did not feel strongly that I needed to "reinvent the wheel" so to speak. However, I had identified some other things that just did not come across in regular textbooks. I felt that a personal narrative could be useful, where the reader could get into the life and mind of a surgeon on a day-to-day basis, and hopefully gain a sense of what went on behind the scenes and the process by which I made decisions, whether they ended up being right or wrong. 

You have documented cases in great detail. Were you collecting this data as you went along, ie in the hope you might write a book like this one day? 

The thought of writing this particular book did not occur to me until about two years before I retired. Fortunately, the publisher was happy to take a risk with an unconventional style of book, and to wait until I had time to write it after I stopped working. I have always used case examples in my teaching, and have taken a lot of photographs through the years, so most of the chapters were based on a topic I had presented repeatedly in rounds or in lectures.

Do you think some degree of surgical prowess is innate, or can it be completely learned? 

Surgical prowess comes from a combination of knowledge, technical skill and temperament. You can learn the first two; the third will either help, or it will be something you need to overcome. A really good surgeon has a balance between being decisive and not too timid, and being considered and thoughtful. A good surgeon can act quickly when required, but take their time under other circumstances. This might require you to push forward when you are nervous, or hold back when you are feeling confident, and takes some people well out of their comfort zone.

What do you see as some of the common errors in veterinary surgery or practice? 

I think most errors stem from being in a rush, being tired, not having good back-up and not being able to see what you are doing. 

Some of the errors discussed in the book occurred in the process of learning. How can these be reduced? 

Checklists are a proven way of reducing errors. If you have to learn something without supervision, the checklist might be as simple as, "have I read the surgical text?", "have I discussed complications with the client?", "am I familiar with the anatomy of this area", "have I discussed this with my colleagues?". In short, have you done your due diligence in preparing yourself, the client and the patient before you start.

How can vets in general practice improve their surgery while minimising risks to patients? 

Be self-reflective and honest about their skills, have regular surgical rounds with colleagues or vets in other practices, debrief on mistakes they might have made, find ways to gain practical skills, like attending wet labs or doing cadaver dissections, and invest in the correct instrumentation (including lighting, suction and magnification) depending on how intricate the procedures are.

What is the difference between an error and a mistake? 

I suspect everyone would have a slightly different view of this, but in my vocabulary I think an error relates to judgement, and a mistake relates to technical performance. Both result in an adverse outcome that could have been avoided. Surgical sequelae are different; these may occur whether an error or mistake was made or not. 

You discussed the impact of errors on patients and clients, but also on the veterinary team. How do errors impact the vet team? 

This is complex. Students and techs can feel just as guilty as vets and they may feel more helpless, because they do not have primary responsibility for the case. Different members of the team might have different ethical positions, and in the case of students, they may be trying to work out what their ethical position should be. Students, techs and reception staff may have a closer bond with clients (or even the pet) than the veterinarian, as they have been involved in nursing and communications.

Some of the cases involve errors or misunderstandings in communication with clients or referring vets. How can errors of communication lead to bad outcomes? 

Errors in communication with clients will result in misalignment of expectations (costs, prognosis, time in hospital). Errors in communication with other members of the treatment team might result in incorrect dosing, delays in treatment, or even the wrong treatment. Communication is not just "telling", or "listening".; it can be difficult, and every vet should develop a technique to help them ensure that important concepts are not only communicated, but understood by the person with whom they are communicating. Likewise, we should reflect whether we are correctly interpreting things communicated by the people with whom we are working. 

Do you have any advice for future vets or veterinarians? 

You have great passion, talent and dedication. But you will face challenges and you will make mistakes. None of us are perfect. Develop your own safety net as you progress through your career. The whole group of people and patients to whom you are responsible, and with whom you work, will make a great support team if you allow them to.

Thank you Professor Hunt for your time. You can purchase Pitfalls in Veterinary Surgery through Wiley. 

What do plane crashes have to do with veterinary medicine?

This sort of view, though serene, isn't my favourite...

What do plane crashes have to do with veterinary medicine? On the surface, not a lot. But dig deeper and there’s much we can learn from air plane incidents and the crews that rise to the occasion.

I’ve held a fascination for air crash investigations (and Air Crash Investigations), motivated in part by a “concern” about flying. When I visited Canada last month for the One Welfare Conference and mentioned to delegates that one of the things I knew about Air Canada was the famous GimliGlider incident, a number of them spoke to me about the incident with awe and pride. I was even taken on a tour of the site of the landing – in which all 61 souls on board survived – by a very generous colleague. (You can watch the episode about Air Canada flight 143 from Edmonton to Winnipeg here, and understand why Bob Pearson is one of the top ten guests I'd invite to a dinner party if I could).

The thing about air crash investigations is that they really have perfected the morbidity and mortality conference. Veterinary teaching hospitals have caught on and now investigate incidents and “near misses” like their medical counterparts, but nothing surpasses the rigor of the air crash investigation.

For those who are nervous about flying, investigations like these are a comfort for several reasons. Firstly, they usually prove that a series of errors, oversights or misses are required to cause a catastrophe. Secondly, they result in changes – the aircraft system is changed, parts may be recalled, so a similar incident never happens again. And third, it’s good to know that a whole industry is focused on learning maximally from errors.

So it was that I found myself engrossed in Highest Duty by US Airways pilot Captain Chesley Sullenberger (aka Sully) and the late Jeffrey Zaslow, on the flight back to Australia. For those who don’t know, Sullenberger led a team who landed Flight 1459 into the Hudson River after a terrible (for the birds and the engines) bird strike which destroyed both engines of the plane. They had 208 seconds between bird strike and impact on the water to make decisions which saved the lives of all 155 people on board – but they had no chance to prepare. (You can see a documentary about it here) (I acknowledge that it is no small matter that bird strike is termed for its impact on the plane, not the Canada Geese who were killed in this incident. It is likely that they were killed instantaneously).

Canada Geese fly over the racetrack at Gimli, where an Air Canada flight made an emergency landing back in July 1983. In these case birdstrike was not a factor, but when I visited the track the birds happened to be there.

The book contains a fascinating account of Captain Sullenberger’s incredible training, but also a couple of memorable insights that I’ve picked out here.

• “A delay is better than a disaster” – this was a quote that Captain Sullenberger had found in a fortune cookie and kept. In any profession where lives depend on operators, be they pilots or surgeons, preoccupation with meeting targets and being fast can cost lives. As Sullenberger wrote, “Integrity is the core of my profession. An airline pilot has to do the right thing every time, even if that means delaying or cancelling a flight to address a maintenance or other issue, even if it means inconveniencing 183 people who want to get home, including the pilot. By delaying a flight, I am ensuring they will get home. I am trained to be intolerant of anything less than the highest standards of my profession. I believe air travel is safe as it is because tens of thousands of my fellow airline and aviation workers feel a shared sense of duty to make safety a reality every day. I call it a daily devotion to duty. Its serving a cause greater than ourselves.” (p320). Systems change and they can be flawed. Throughout the book, while not placing any blame on any airline, Captain Sullenberger discusses the way airlines and protocols have changed, sometimes emphasising profit over safety. He provides a lovely overview of the system he works within, a perspective that can be lost when you’re in the thick of things. This is important in campaigning for change.
• Sullenberger points out, throughout his book, that the things that make him great at his job – like putting feelings aside in times of crisis, being out of contact and away a lot, being very analytical, and being lovely to passengers, crew and later all of the people who recognised him from the news – make him less great at relationships. Hurrah for the honesty. “I try,” he writes. “But sometimes, by the end of the day, you can feel like you’ve said everything you’ve wanted to say.” (p75). And this: “I’m cordial and gracious to everyone, and genuinely interested in their stories. Sometimes, when I get home, I can be frazzled and used-up and short-tempered. I can be impatient with the girls. ‘You have your priorities wrong,’ Lorrie has told me firmly. ‘As nice as you are to strangers, that’s the same nice you need to be to me and the girls’” (p314). Anyone been there?
• The best job in the world is “the job you would do if you didn’t have to”, because that is what will motivate you to “toil in obscurity” and work hard. “People who love their jobs work more diligently at them. They become more adept at the intricacies of their duties. They serve the world well…I flew thousands of flights in the last forty-two years, but my entire career is now being judged by how I performed on one of them. This has been a reminder to me: we need to try to do the right thing every time, to perform at our best, because we never know which moment in our lives we will be judged on.” (p327).

What’s most inspiring is the nature and extent of training he did, but also the fact that he’s humble. His entire team – like the veterinary team – had to think under pressure, work out which rules would help and which ones to discard to save lives. Captain Sullenberger’s book is definitely worth a read, and probably a bit more educational – and I’d say inspirational – than the film. You can find it here http://www.harpercollins.com.au/9780062561206/ Next on my reading list is QF32 by Richard de Crespigny, about this flight.