Managing Complications Part 1: Yourself 
Richard Davis, Pitman Mbabazi, Gady Barutwanayo, Robert Sinyard, Mardi Steere 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction: The Second Victim Syndrome 
 
Complications are an inevitable part of being 
a surgeon. Surgery is by its nature a complex process, 
prone to unexpected outcomes no matter how careful 
you are, or how perfectly executed your treatment 
plan was. And yet, complications take a human toll. 
This is true for the patient, of course: they suffer 
more pain, a longer recovery, and possibly 
permanent disability or death. But the human toll of 
a complication also falls on you, the surgeon. You 
watch another human being and their family suffer 
because of something you were involved in. It is 
natural for you to feel guilt, shame and fear. This is 
the Second Victim Syndrome: psychological and 
emotional trauma experienced by a medical provider 
due to an adverse patient event.  
One of our goals is to help you walk your 
patient and their loved ones through a complication. 
But before you can do that well, you must walk 
yourself through the process. You must deal with all 
the “baggage” that comes with a complication. In the 
process of recognizing and dealing with a 
complication, the best possible outcome is for you 
to remain a healthy human being and to become 
a better surgeon.  
Every experience, no matter how painful, has 
a lesson that will help both your future patients and 
you. It is all too easy to hide from that lesson by 
ignoring it, blaming others, distracting yourself with 
work, or covering up your feelings with drugs or 
alcohol. It takes great courage to face the facts of the 
complication and learn from it. But if you refuse to 
do this, you do a disservice to yourself, the patient 
involved, and to your future patients.  
 
Please do not skip ahead to Part 2, the chapter 
that tells you how to deal with patients and their 
families. In order to deal well with these people in 
these volatile situations, you must first deal with 
yourself. If you are deceiving yourself about what 
happened, that self-deception will come out. The 
family will ask difficult questions. If you have not 
done a thorough assessment, including your own role 
in the outcome, they will know that “something is 
wrong.” When families sense that “something is 
wrong,” they will assume, rightly or wrongly, that 
they are being lied to.  
Our treatment of this subject is a 3-part series: 
Parts 1 and 2 of “Managing Complications” naturally 
leads to Part 3, “Defending Yourself from a 
Lawsuit.” Patients and families sue when they 
believe they are not being told the truth or not being 
treated with dignity. In this sense, the best defense is 
actually an offense of kindness, humility, and 
honesty. Self-reflection, therefore, must be the first 
and most important step in preventing lawsuits and 
dealing with them when they occur. 
 
A Classification System for Complications 
 
The best way to analyze what happened is to 
remove all subjectivity. One way to do this is to 
apply a framework to all adverse events, before 
deciding on the appropriate next step. At Kijabe 
Hospital we divide complications into 5 categories:  
 
Category Description 
1 
Anticipated death or complication 
following terminal illness 
2 
Expected death or complication given 
clinical 
situation, 
despite 
taking 
preventive measures 
3 
Unexpected death or complication, 
not reasonably preventable 
4 
Potentially 
preventable 
death 
or 
complication: Quality or Systems 
issues identified 
5 
Unexpected death or complication 
resulting from medical intervention 
 
Category 1: Anticipated death following a terminal 
illness 
 
KG is a 45-year-old woman whom you 
previously operated on for jaundice with an 
intraoperative diagnosis of biliary tract malignancy 
and metastatic disease in the liver. Now she has 
recovered from the operation. She receives 
appropriate palliative care and dies one month later. 
The family is distraught, as many of them never 
accepted her terminal illness and still felt that God 
would heal her.  
 
Managing Complications Part 1: Yourself 
Richard Davis, Pitman Mbabazi, Gady Barutwanayo, Robert Sinyard, Mardi Steere 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
In this scenario, it is important to recognize 
that even though you did nothing “wrong,” you will 
still feel sad and even grieve. Recognize that you 
need not feel guilt or self-recrimination here, despite 
the fact that you operated on someone and they died. 
If you do feel these things, remind yourself of this 
fact.  
 
Level 2: Expected death given clinical situation, 
despite taking preventive measures 
DL is a 22-year-old laborer who suffered a 
pelvic fracture during a fall. On arrival he is 
hemodynamically unstable with an apparent pelvic 
fracture. FAST Ultrasound shows no intra-
abdominal fluid. He transiently responds to 
resuscitation with crystalloid fluids and blood. You 
stabilize his pelvis with a bedsheet, then you perform 
extraperitoneal pelvic packing while an orthopedic 
surgeon places a pelvic external fixator. He is 
admitted to the ICU, where you continue 
resuscitation with fresh whole blood donated by 
several members of the hospital staff. Despite your 
efforts, he dies. The family is inconsolable. One man 
in particular becomes quite angry, blaming you for 
not “doing something” and calling your facility “a 
hospital of death.”  
 
 
Once again, in this scenario you did nothing 
“wrong” and in fact you gave this young man every 
chance he could have had under the circumstances. 
Maybe elsewhere he would have survived with an 
interventional radiology intervention; in your setting 
that was not possible. But the adrenaline-fueled 
operation, and the volatile interaction with the family 
members, will take a toll on you and on the team 
(including the blood donors!) You need to separate 
the feelings of sorrow for what happened, from 
(false) guilt for what happened. A careful, rational 
analysis of the events will help you do this.  
 
If there were any missteps in his care, take 
this opportunity to learn from them. Did you wait too 
long to take him to the operating room? Was the OR 
not able to take him right away? Did the laboratory 
have difficulty processing blood in a timely manner? 
Learn from these events and address any system 
issues that arose, while recognizing that the outcome 
was probably not affected unless the delays were 
extreme. 
 
The chance for self-recrimination here is 
high: if everything didn’t go perfectly, if your 
performance wasn’t 100% spot-on, you might blame 
yourself for the outcome. Be realistic. The patient 
had a non-survivable injury and you did your best. 
Take what lessons can be learned, be honest with 
yourself about what those lessons are, and move on.  
 
Category 3: Unexpected death, not reasonably 
preventable with medical intervention 
 
WW is a primigravid 23-year-old woman 
with no significant obstetric history who undergoes 
a cesarean section for failure to progress, yielding a 
healthy baby girl. On postoperative day two, she is 
walking in the hallway and suddenly collapses. She 
cannot be resuscitated and dies. Postmortem reveals 
a massive “saddle” pulmonary embolus.  
 
 
In this situation, the death is completely 
unexpected but on further investigation there was 
nothing you could have reasonably done to prevent 
it. Verify that this is true: did she have any signs of a 
coagulation disorder in her obstetric history, such as 
multiple pregnancy losses or a previous venous 
thrombosis during pregnancy? Did she have calf 
tenderness or unexplained tachycardia before her 
collapse? If so, there may be a system issue for you 
to address, such as standardized assessment of 
patients or training of the staff. If there were warning 
signs that were ignored, this complication moves into 
Category 4; otherwise it remains in Category 3. 
 
 
Category 4: Preventable death. Quality / system 
issues, opportunities for improvement 
 
MW is a 45-year-old man with long standing 
obstructive jaundice. Workup revealed very elevated 
bilirubin 
and 
transaminases, 
disordered 
coagulation, and a stone impacted in the distal 
common bile duct. You admit him, resuscitate, 
administer Vitamin K and offer him cholecystectomy 
and common bile duct exploration. You discuss the 
risks of general anesthesia given his liver 
dysfunction. Once he is as fit as possible for surgery, 
you operate. During the dissection, you injure his 
Managing Complications Part 1: Yourself 
Richard Davis, Pitman Mbabazi, Gady Barutwanayo, Robert Sinyard, Mardi Steere 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
portal vein. He has profuse bleeding, losing 1L of 
blood before you get control. Anesthesia gives 2L of 
crystalloid and 2 units of blood. He awakens from 
surgery, but on postoperative day 3 he becomes 
hypotensive and encephalopathic, with worsening 
liver enzymes. Ultrasound does not show blood in his 
abdomen. He worsens and despite your best care he 
dies.  
 
 
Scenarios like this one are all too familiar to 
experienced surgeons: patients who have absolutely 
no margin for error. And they seem to happen more 
often in resource-limited settings, where patients 
present with advanced disease, and non-surgical 
interventions aren’t available. This man’s illness left 
no room for mistakes; to minimize anesthesia risk, 
the operation needed to be both quick and technically 
perfect. A high-volume bleed, and its resulting fluid 
shifts, probably pushed his liver beyond what it could 
tolerate.  
 
This type of complication is painful to 
honestly assess. Instead you might rationalize, 
saying “his liver dysfunction was just too severe. I 
really did my best.” And you may be right- perhaps 
he wouldn’t have survived even a perfect operation. 
But a more honest assessment reveals that the blood 
loss likely contributed to his death.  
 
Do not lie to yourself by brushing these 
feelings aside. You need to deal with them. 
Remember, the desired outcome here is for you to 
remain a healthy human being and become a better 
surgeon.  
What can you learn from this event to become 
a better surgeon? Is your fine dissection technique 
everything it could be? Could you benefit from some 
coaching in this regard? (See “Becoming a Better 
Surgeon.”) How about positioning yourself and the 
patient better so your hands will be steadier? (See 
Approach to Positioning the Patient and the 
Surgeon.) Do you need to work on controlling 
hemorrhage from a large vein? (See “General 
Principles of Hemostasis and Hemorrhage Control”) 
If you ignore the role your skills or judgment played 
in the outcome, you will not automatically seek out 
these lessons. Your skills and judgment will stay the 
same.  
What can you do after this event to remain a 
healthy human being? First, recognize that 
contributing to someone’s death has an effect on you. 
Don’t try to ignore it, acknowledge it. Talk with your 
peers, a more senior surgeon whom you respect, or 
even a counselor. Don’t forget to talk to your family 
as well. We discuss this matter further below. 
 
Category 5: Unexpected death resulting from 
medical intervention 
 
JN is a 70-year-old man with long standing 
right lower quadrant abdominal pain. After thorough 
investigation, you decide to perform a diagnostic 
laparoscopy. During surgery, you note extensive 
adhesions around the cecum. You are unable to 
complete the operation laparoscopically. You loosen 
the retention sutures at the Hasson port site, remove 
the port, and convert to open appendectomy. After 
removal of the appendix, you close the right lower 
quadrant incision and tie the umbilical port site 
retention sutures. Postoperatively, the patient 
develops ileus and abdominal distention that does 
not resolve. On re-exploration after 7 days, you find 
that one of the umbilical retention sutures has looped 
around and strangulated a piece of small bowel. You 
resect the dead bowel and perform an ileostomy. He 
worsens, 
developing 
abdominal 
compartment 
syndrome and intractable hypotension. Finally, 
despite maximal ICU support, he dies.  
 
 
 
Scenarios like these should be very rare. But 
they will happen if you operate enough. There really 
is no way to rationalize this: a healthy man with a 
relatively minor problem died because of a surgical 
intervention. He died because of a mistake you 
made.  
 
There are always lessons to be learned here, 
so learn them. Close the Hasson port site 
immediately when you convert to an open operation. 
Be mindful that bowel can be injured during 
abdominal closure. Don’t blame the resident or the 
scrub tech; as the surgeon you are ultimately 
responsible for what happened.  
 
But also don’t fail to acknowledge what 
effect this event will have on you. A legitimate 
Managing Complications Part 1: Yourself 
Richard Davis, Pitman Mbabazi, Gady Barutwanayo, Robert Sinyard, Mardi Steere 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Category 5 complication must be dealt with properly, 
starting with yourself.  
 
Managing Yourself After Complications 
 
You will need to talk to the family 
immediately. Explain what happened as best you can 
tell. Avoid the kind of statements that a lawyer might 
make, such as “I cannot comment on that.” Be open 
and honest with them, as you are and will be with 
yourself. We discuss talking with the family more in 
“Managing Complications Part 2.” 
 
Below we break this topic down into several 
domains:  
 
Thinking Honestly 
 
Take time later on, when you have a few 
uninterrupted minutes, to really think about what 
happened. Now that the “heat of battle” has died 
down, you will recall details that you might not have 
noticed. You will remember things that you saw and 
heard, and they will take on new significance. Other 
memories and realizations will come through in the 
next few days and weeks as you think further.  
Take notes on your reflections. Include even 
details that you are sure you’ll remember. The safest 
and most confidential way to do this is to write an 
email to yourself. As you continue to develop this 
email thread, it becomes an important record. It is for 
you only; you do not need to mention to anyone that 
it exists. But it will be invaluable to you if there is a 
lawsuit. Often litigation occurs years later, when 
your recall of specific details has faded.   
 
Participating in Department or Hospital Audit 
Process 
 
We have used errors of technique to illustrate 
our Category 4 and 5 complications. However, errors 
of diagnosis, judgment, or communication can also 
be at play. In the Chapter “Improving as a Surgeon” 
we explore this subject further as it relates to you.  
 
Your hospital must have an Audit, Morbidity 
/ Mortality or Quality Improvement process in place. 
If it does not, start one using a classification system 
such as ours. It is especially important to identify 
system issues- improving these can have a dramatic 
effect on patient safety. The truth is, most adverse 
events are due to systems issues rather than 
individual poor judgment. Examples include failure 
to act on abnormal vital signs and recognize a 
deteriorating patient, or malfunction of crucial 
equipment during an emergency. These must be 
addressed through a root cause analysis and 
correction of the system factors that caused the 
complication (see “Quality Improvement.”) This 
process depends on a well-conducted audit.  
During the audit, be open and honest about 
what happened. If you are overly concerned about 
your reputation, lying and shifting blame will get you 
a reputation… as someone who lies and shifts blame. 
If you are in a culture where such behavior is 
expected, or modeled by the leadership, you have a 
bigger problem than this one complication. (See 
“Culture and Culture Change”) 
 
Using Healthy Behaviors and Avoiding Maladaptive 
Ones 
 
A Category 4 or 5 complication takes an 
emotional toll on you. It is all too easy to hide from 
this toll. The most obvious and natural way to hide is 
to become busy at work. You are, after all, an 
important surgeon and people are depending on you. 
You will likely take this approach without even 
meaning to. Be aware that this happens; try to 
counteract it by deliberately taking time to process 
what you’re going through.  
 
Losing yourself in your work is one way of 
“hiding” from a complication. Another is simply not 
talking about it. Out of shame, or concern for your 
reputation, or fear of losing patient referrals, you just 
may not want to discuss the complication. This 
approach is also easy to take without realizing it. But 
you need someone, a trusted friend or group of 
friends, who will understand the situation and listen 
and respond to you. We discuss this further below.  
 
Be careful using drugs or alcohol to deal with 
the feelings of guilt or shame after a complication. 
Yes, these will make the feelings go away 
temporarily. But as we state throughout this chapter, 
such feelings should be met directly and used to 
make you a better surgeon and a healthier person. 
Using substances to numb your feelings will derail 
this process.  
Managing Complications Part 1: Yourself 
Richard Davis, Pitman Mbabazi, Gady Barutwanayo, Robert Sinyard, Mardi Steere 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Discussion with Peers 
Whatever the stage of your career, whether 
resident, junior consultant, or seasoned veteran, there 
are bound to be others around you who have 
experienced similar events and can understand. 
Discussing what happened will help you process it in 
your own mind. Your peers will inevitably share 
similar experiences that they possibly hadn’t ever 
discussed with anyone else. Their friendship and 
support will be vital. 
If you are in a culture where your peers are 
your competition, confiding in them can be 
dangerous. But such a culture is not a healthy one. 
Overall, unhealthy cultures are more likely to 
produce complications and bad outcomes. Do what 
you can to change the culture- find one trusted friend 
and be open with them. Encourage, by example, the 
process of analyzing and owning your mistakes and 
trying to improve from them, even though others 
might be trying to hide theirs. You will be surprised 
at the “ripple effect” of such a small act: the culture 
may well begin to change. The healthiest cultures are 
the ones that naturally provide a collegial and 
supportive environment. 
 
Discussion with a Mentor 
We cannot overstate the importance of a 
mentor. Ideally you will seek one out before adverse 
events happen. You can then go to this person and 
discuss the events with them, building on a strong 
relationship that already exists. If you do not have a 
mentor, find someone with more experience in your 
field, whom you respect, and ask them if they would 
be willing to play this role. If you are a trainee, a 
mentor is even more important. Choose one in the 
same specialty if you can, and of the same gender if 
possible. Most (but not all) senior surgeons are glad 
to play this role in a surgeon’s career, so if the first 
one you ask is not willing or able, don’t be afraid to 
ask someone else.  
 
Discussion with your Spouse or Significant Other 
 
Your spouse or significant other also needs to 
know what is happening. Your shame may be 
deepest here; you may need them to respect you and 
believe that you are good at your job. But you will 
carry a Category 4 or 5 complication with you for a 
while. Those who are close to you will be able to tell 
that something is wrong. You owe it to them and to 
yourself to talk about it. Most likely the response you 
get will be supportive and understanding. In any case 
it will be better than the response you get when they 
know you’re carrying something on your own and 
hiding it from them.  
 
Your Faith 
 
If you have a faith tradition, this is the time to 
lean on it. Prayer and meditation can calm you and 
help you reflect on what happened in a detached way. 
Holy scriptures may bring you comfort, or you may 
read them with a new perspective on suffering given 
your circumstances.  
 
Mourning, Seeing a Counselor and Taking Time 
Away 
 
Making a mistake that directly or indirectly 
causes someone else to die is like a death in your own 
family. You need time to “mourn” this loss the same 
way you would mourn the death of someone close to 
you. Do not underestimate the need to spend 
protected time away, free from clinical care 
responsibilities. You may think you cannot leave 
your practice, but you should: even a few days away 
will give you time to rest and reflect on what has 
happened. In some cases, you may even need a few 
sessions with a professional counselor. This is not a 
sign of weakness. And there is no need to tell others 
about these sessions if you don’t want to. But a 
counselor is trained in ordering and processing grief 
and stress, just as you are trained in your field. There 
will definitely be some benefit to having a few 
sessions with them.  
 
The good news is that if you face these 
feelings of loss, guilt and shame, they do get better 
in time. If you pretend they aren’t there, they will 
stay below the surface and continue to affect your 
actions. Trying to do so is as ridiculous as trying to 
pretend that you aren’t affected after a loved one 
dies. Of course you are affected!  
Managing Complications Part 1: Yourself 
Richard Davis, Pitman Mbabazi, Gady Barutwanayo, Robert Sinyard, Mardi Steere 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Having Category 4 or 5 complications is part 
of being a surgeon. The only way to not spill water 
is to not carry water. And yet, you must come 
through the process as a healthy human being, and a 
better surgeon who has learned from your mistakes. 
Becoming a great surgeon requires learning from bad 
outcomes without becoming a monster in the 
process. In this chapter we have presented a way to 
recognize your emotions and to use them to learn the 
lessons that must be learned. Again, we encourage 
you to follow this process, difficult though it may be. 
The alternative, hiding from the facts and from your 
emotions, is not healthy and will not lead to personal 
or professional growth.  
 
Richard MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
Pitman Mbabazi MBBS 
AIC Kijabe Hospital 
Kenya 
 
Gady Barutwanayo 
AIC Kijabe Hospital 
Kenya 
 
Robert Sinyard MD MBA 
Massachusetts General Hospital  
USA 
 
Mardi Steere MD MBA FAAP FACEP FRACP 
Royal Flying Doctor Services 
Australia 
