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Surgical mistakes
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of sexual and physical abuse on women’s mental health. Lancet 1988; 1: 841–45. Bifulco A, Brown GW, Adler Z. Early sexual abuse and clinical depression in adult life. Br J Psychiatry 1991; 159: 115–22. Hall LA, Sachs B, Rayens MK, Lutenbacher M. Childhood physical and sexual abuse: their relationship with depressive symptoms in adulthood. IMAGE: J Nursing Scholarship 1993; 25: 317–23. McCauley J, Kern DE, Kolodner K, et al. Clinical characteristics of women with a history of childhood abuse. JAMA 1997; 277: 1362–68. Cheasty M, Clare AW, Collins C. Relation between sexual abuse in childhood and adult depression: case-control study. BMJ 1998; 316: 198–201. Singer M, Anglin TM, Song L, Lunghofer L. Adolescents’ exposure to violence and associated symptoms of psychological trauma. JAMA 1995; 273: 477–82. Fromuth ME. The relationship of child sexual abuse with later psychological and sexual adjustment in a sample of college women. Child Abuse Negl 1986; 10: 5–15.
24 MacMillan HL, Fleming JE, Trocme N, et al. Prevalence of child physical and sexual abuse in the community. JAMA 1997; 278: 131–35. 25 Acierno R, Resnick HS, Kilpatrick DG. Health impact of interpersonal violence 1: prevalence rates, case identification, and risk factors for sexual assault, physical assault, and domestic violence in men and women. Behav Med 1997; 23: 53–64. 26 Gorey KM, Leslie DR. The prevalence of child sexual abuse: integrative review adjustment for potential response and measurement biases. Child Abuse Negl 1997; 21: 391–98. 27 Herman J, Russell D, Trocki K. Long-term effects of incestuous abuse in childhood. Am J Psychiatry 1986; 143: 1293–96. 28 Heim C, Newport DJ, Heit S, et al. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA 2000; 284: 592–97. 29 De Bellis MD, Lefter L, Trickett PK, Putnam FW Jr. Urinary catecholamine excretion in sexually abused girls. J Am Acad Child Adolesc Psychiatry 1994; 33: 320–27. 30 Population reports. Ending violence against women: volume XXVII, number 4, series L-11. December, 1999.
Uses of error: Surgical mistakes Of all mistakes in medicine, surgical errors often appear the worst. The evidence of a surgical mistake is physical and cannot be obscured by time or interpretation. An operation is a distinct point of intervention that is easily identifiable. The end points in surgery are often more concrete and immediate than in medicine—survival or death, cure or failure. I had just started working in plastic surgery and was involved in the care of a 36year-old construction worker who had been knocked down by a truck. He had a fracture dislocation of his knee that had required extensive orthopaedic work, revascularisation and fasciotomies. He was doing well and we decided to graft his fasciotomy wounds. In the operating room, I examined the injured leg. There was an eschar of non-viable skin where the truck had impacted, just below the anterior aspect of the knee. I decided to debride this area as the tissue was clearly dead. I could then skin graft the resulting defect and save the patient yet another operation. I took my knife and carefully started to shave the eschar off, expecting to find a bed of healthy tissue for my skin graft. When I removed the eschar, I found myself looking at the fracture site with the orthopaedic surgeon's nice shiny plate across it. There was nothing I could graft onto. I was confronted with a major problem. Normally we could move a local muscle, such as the gastrocnemius, around to cover the defect. With such extensive vascular injury, a transposition flap or a free tissue transfer was practically impossible. I was faced with a 36-year-old man with an open fracture, exposed metalwork, and no easy reconstructive option. As my consultant pointed out later, the leg would get infected, the patient would get osteomyelitis, and need an above-knee amputation. I should not have started debridement without planning for all the potential consequences. Luckily my consultant's skill saved the patient’s leg and he walked out of hospital three months later. The episode taught me some important lessons. First, that we are always skating on thin ice. Even in routine operations, disaster may only be a slip of the knife away. Second, we all make bad decisions. There do not need to be extenuating circumstances or a chain of error; sometimes we just get it wrong. Finally, realising that I could make such a poor decision has made me reluctant to condemn colleagues who have also made mistakes. Perhaps if we were all slower to blame and quicker to understand, it might be possible to learn from our collective errors rather than consigning them to the bin marked “only happens to other people”. Shehan Hettiaratchy Division of Plastic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
THE LANCET • Vol 358 • September 15, 2001
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of sexual and physical abuse on women’s mental health. Lancet 1988; 1: 841–45. Bifulco A, Brown GW, Adler Z. Early sexual abuse and clinical depression in adult life. Br J Psychiatry 1991; 159: 115–22. Hall LA, Sachs B, Rayens MK, Lutenbacher M. Childhood physical and sexual abuse: their relationship with depressive symptoms in adulthood. IMAGE: J Nursing Scholarship 1993; 25: 317–23. McCauley J, Kern DE, Kolodner K, et al. Clinical characteristics of women with a history of childhood abuse. JAMA 1997; 277: 1362–68. Cheasty M, Clare AW, Collins C. Relation between sexual abuse in childhood and adult depression: case-control study. BMJ 1998; 316: 198–201. Singer M, Anglin TM, Song L, Lunghofer L. Adolescents’ exposure to violence and associated symptoms of psychological trauma. JAMA 1995; 273: 477–82. Fromuth ME. The relationship of child sexual abuse with later psychological and sexual adjustment in a sample of college women. Child Abuse Negl 1986; 10: 5–15.
24 MacMillan HL, Fleming JE, Trocme N, et al. Prevalence of child physical and sexual abuse in the community. JAMA 1997; 278: 131–35. 25 Acierno R, Resnick HS, Kilpatrick DG. Health impact of interpersonal violence 1: prevalence rates, case identification, and risk factors for sexual assault, physical assault, and domestic violence in men and women. Behav Med 1997; 23: 53–64. 26 Gorey KM, Leslie DR. The prevalence of child sexual abuse: integrative review adjustment for potential response and measurement biases. Child Abuse Negl 1997; 21: 391–98. 27 Herman J, Russell D, Trocki K. Long-term effects of incestuous abuse in childhood. Am J Psychiatry 1986; 143: 1293–96. 28 Heim C, Newport DJ, Heit S, et al. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA 2000; 284: 592–97. 29 De Bellis MD, Lefter L, Trickett PK, Putnam FW Jr. Urinary catecholamine excretion in sexually abused girls. J Am Acad Child Adolesc Psychiatry 1994; 33: 320–27. 30 Population reports. Ending violence against women: volume XXVII, number 4, series L-11. December, 1999.
Uses of error: Surgical mistakes Of all mistakes in medicine, surgical errors often appear the worst. The evidence of a surgical mistake is physical and cannot be obscured by time or interpretation. An operation is a distinct point of intervention that is easily identifiable. The end points in surgery are often more concrete and immediate than in medicine—survival or death, cure or failure. I had just started working in plastic surgery and was involved in the care of a 36year-old construction worker who had been knocked down by a truck. He had a fracture dislocation of his knee that had required extensive orthopaedic work, revascularisation and fasciotomies. He was doing well and we decided to graft his fasciotomy wounds. In the operating room, I examined the injured leg. There was an eschar of non-viable skin where the truck had impacted, just below the anterior aspect of the knee. I decided to debride this area as the tissue was clearly dead. I could then skin graft the resulting defect and save the patient yet another operation. I took my knife and carefully started to shave the eschar off, expecting to find a bed of healthy tissue for my skin graft. When I removed the eschar, I found myself looking at the fracture site with the orthopaedic surgeon's nice shiny plate across it. There was nothing I could graft onto. I was confronted with a major problem. Normally we could move a local muscle, such as the gastrocnemius, around to cover the defect. With such extensive vascular injury, a transposition flap or a free tissue transfer was practically impossible. I was faced with a 36-year-old man with an open fracture, exposed metalwork, and no easy reconstructive option. As my consultant pointed out later, the leg would get infected, the patient would get osteomyelitis, and need an above-knee amputation. I should not have started debridement without planning for all the potential consequences. Luckily my consultant's skill saved the patient’s leg and he walked out of hospital three months later. The episode taught me some important lessons. First, that we are always skating on thin ice. Even in routine operations, disaster may only be a slip of the knife away. Second, we all make bad decisions. There do not need to be extenuating circumstances or a chain of error; sometimes we just get it wrong. Finally, realising that I could make such a poor decision has made me reluctant to condemn colleagues who have also made mistakes. Perhaps if we were all slower to blame and quicker to understand, it might be possible to learn from our collective errors rather than consigning them to the bin marked “only happens to other people”. Shehan Hettiaratchy Division of Plastic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
THE LANCET • Vol 358 • September 15, 2001
887