About My Journey

Veterinarian of the Year

Just over a week ago, I had the honor of receiving the Association of Shelter Veterinarians 2018 Veterinarian of the Year Award. I’d learned that I would be receiving the award a couple months before, and at the time had been pretty stunned. Me? Seriously?

As you know from this blog, I do research and writing projects, some with other people, and more on my own. Since I work on my own, outside of any institution or organization, I don’t have committees, approval, or funding (except on a few projects I’ve worked on with others, for which I have written grants), I don’t have an institutional mission telling me which research topics are of interest to the university, a big donor, or the board of directors, and which topics may be too uncomfortable, difficult, or controversial. For me and my interests and tendencies (i.e., doesn’t always play well with others; has trouble recognizing the preeminence of authority figures), this has mostly been convenient. It has allowed me to follow my interests of the moment, to ask and then try to answer awkward or thorny questions, and to wander.

But it has also meant that I often don’t know how many people have even noticed what I’ve written, if they have read it, and what they think of it. It also means that I have learned to become my own publicist. Thus, I’m writing this braggy blog post in the same way that I worked on press releases for my last two papers– putting it out there because if I don’t announce my own accomplishments, who will? (OK, probably ASV will later, beyond their post in a closed Facebook group, but I want to show off now!).

The Award

Here is a description of the award– this is its first year, so I’m the first recipient:

2018 ASV Veterinarian of the Year Award

Established in 2018, this award recognizes remarkable members of the Association who have been outstanding in their role as a veterinarian to improve community animal health and wellbeing. The ASV’s intent in conferring this award is to bring attention to excellence in shelter medicine by recognizing those who serve as exceptional role models of the profession. Veterinarians serving in municipal, private, and/or non-profit shelters and other community animal endeavors are eligible; current ASV Board Members are ineligible. The award designee will receive a plaque, a shelter medicine textbook, and a $250.00 donation to an organization of his/her choice.

The award was presented at the ASV annual reception in Tampa on October 11, in conjunction with the ABVP (American Board of Veterinary Practitioners) conference and the ASV annual meeting.

IMG 8803 768x1024 — Elizabeth Berliner used an appropriate amount of humor while sharing details of my nomination.

Elizabeth Berliner submitted the nomination and described some of the my work– from pot bellied pigs to Shelter Animals Count to ergonomics and of course spay neuter.

IMG 8812 768x1024 — Way too excited to be here. Also, maybe Brenda shouldn’t have given me her extra drink ticket.

I gave a bit of an acceptance speech, the main gist of which was, “The research that I do is all about you– the shelter and spay neuter vet– because I want to support what you do, and who you are, because you are super cool.”

Later in the evening, the ASV presented this year’s Meritorious Achievement Award posthumously to my friend Kelly Farrell, who died last year but had been one of the most forward-thinking spay neuter vets I’ve ever met. Her family came to accept the award and it was sad, touching, sentimental, lovely, and heart-wrenching.

How do I have time for research?

I think sometimes people with “regular” jobs (meaning, 5 days a week working for someone else) assume I must do the same, and that any research or other work that I do is on top of this standard work schedule. That’s not really the case– here’s how my work schedule actually works.

My Spay Neuter Work

I love my spay-neuter work, and also, it keeps me “honest” (meaning, grounded in the reality of daily practice) in my research. But because of the model of spay-neuter that I do, I only actually do surgery about 110 days a year.

When I was starting my clinic in 2006 and being mentored by Leslie Appel of SOS in Ithaca, NY, Leslie recommended that I do MASH spay neuter just 2 days a week. She had started her MASH clinic working 5 days a week, then 4, and it was too much, even for her energetic, extroverted self, with the long work days in addition to the lifting, packing, unpacking, driving, etc. I have found that for me, three days of surgery in a week is do-able, but is also enough. With holidays, vacations, conferences, and odd weeks containing Saturday clinics (Saturdays, of course, count both for the week before and the week after), this works out to my 110-120 annual clinic days.

I’m also inventory, boss, budget-master, and book-keeper/accountant, making it a legitimately full-time job, but as time has gone on, these tasks get easier since the clinic schedule, budget, and mission barely change. What this means is that often, I have time on my hands to think, listen, explore, and learn.

My Research

It never would have occurred to me that I could do research and write scientific journal articles on my own without being part of a university or other institution. But back in 2007, when I was a part of the first Spay Neuter Task Force, I got involved with a project to analyze and publish shelter intake and euthanasia data from New Hampshire and Austin TX (since I already had years of NH data). Julie Levy, the experienced but overcommitted researcher in the group, recognized a potential time-management boon and offered that I could be first author if I wrote the paper. I jumped at the opportunity, and thus with her guidance and that of Jan Scarlett, I learned the ins and outs of writing and revising, peer review and eventual publication. Once I had been through the whole process with one journal, it was suddenly conceivable that I could do it again, and on my own. So when I found a question that kept coming up in the spay neuter community, and when I could figure out a way to find (or at least get closer to, and explore) an answer, I did so.

But Why?

During lunch at the SAWA/ National Council on Pet Population research day in 2016, a university researcher asked me why I did research if I didn’t have to. As we talked it was clear to me that what she resented about her own work was the impositions of the university structure, rules, and systems on her research. Whether it was funding or approvals or imposed timelines, the system made research a hassle rather than fun. By doing research outside of such a system, I’ve avoided a lot of that hassle (also, by doing survey-based research outside of an institution, I’ve been able to avoid needing to find an independent human subjects committee to evaluate and approve my research). So I get to learn deeply about a subject and ask interesting questions. What’s not to like?

But Library Access…

How do I get access to journal articles without being part of a university? At home, I have the same limitations as any other internet user. But like many people, I live just a few towns away from a university. And like many universities, it has a library that allows everyone access. When my list of otherwise inaccessible articles on Google Scholar gets long enough, I head on over to the university library and download to my heart’s content. It’s not as easy as having access at home, but it works, and it’s sometimes fun to have an excuse to spend a few hours hanging out in the fancy university town, drinking soy lattes and eating ciabatta.

Life outside

And of course I have a life outside of veterinary medicine: family, pets, walks in the woods, video games, novels, binge-watching Netflix.

So anyway, thanks to those who chose me for this award, and thanks to all of you who have participated in or read or shared my research. I hope you’ve gotten as much out of it as I have ♥

IMG 4818 577x1024 — My other accomplishment on October 11: Achieving level 40 in Pokemon Go. This has required countless hours of antisocial behavior staring at my phone. Just ask my mother or my wife.

Complicated, Part 4

IMG 4452 1024x229 — View from the top of Mount Cube in NH last week. This may have been too much of a climb for 7 weeks post-op but the view was worth it.

Three weeks ago, I went to see my surgeon, the ob/gyn who performed my hysterectomy last fall. The last time I had seen her was in January, the day my complication was diagnosed. In my mind, though, she had been present throughout my various procedures and recovery, even after the urologists took over my care and our only continued connection was through what I sent to her. I had talked with her once after the urologists placed my drains, and after that, emailed (my preference, a consequence of my lifelong terror of the phone). I had sent her my article during those first weeks, and she emailed back that it described her own experience. Time had separated us more by the time of my visit, but I kept her up to date with plans and surgery reports.

We had become entangled by concern as I worried as much over her experience as my own. So to the extent that my meeting with her last month was a conclusion, I was sad to see her go, and I felt unaccountably lonely that day. This long, shared experience, that wasn’t really shared but perhaps co-imagined, had made me want to cling to that connection. But yet, what to do with it? And the awkward: she is not my colleague; we are not friends.

And yet, as I spoke with her, I found myself wanting to ask questions like a colleague/ mentor/ teacher/ friend more than as a patient. What did you see, what did you do, what (if anything) have you changed? And to explain what I had surmised, technically: that my injury was subtle and would have been hard to detect at the time of surgery, my ureter at first patent, then after 20 days blocked, then, soon after, ruptured. That my best guess is a devascularization injury to the ureter that caused it to deteriorate slowly. That, at the end of surgery before closing, everything might have looked normal.

Long before I had my surgery, I knew that she was a low volume surgery provider. I know the data: that, statistically, lower volume surgeons have higher complication rates. I knew it before my own surgery and thought but didn’t seek to make a change. I probably could have asked to go to the large referral hospital in the same town– I certainly could have withstood the awkwardness of the request. Perhaps I partly thought that the odds were still (and ever) in my favor, as they were. Statistical risks don’t get you far as an individual. I liked her hands.

Why would high-volume surgeons have lower complication rates than low-volume surgeons? Partly it may be the development of the manual, physical skill of surgery. Practicing a fine motor task leads to greater skill, and perhaps in this case the more you practice the greater the skill. But I think also that there is an accumulation of knowledge about anomalies and an abundance and diversity of feedback as one does surgery more often.

In some surgeries and for some complications, the feedback is immediate. This fast feedback enhances learning because the error and the consequence are memorable and easy to connect. These complications may be painful or scary or intense in the moment, but the connection between cause and effect is never in question.

IMG 4484 1024x768 — Immediate Feedback. Do not pet the pussycat’s belly when she is on catnip! (No pussycats were harmed in the production of this photo. One human was slightly sore but entirely to blame.)

In my case, the feedback was long delayed. By the time I had my ureter reimplantation surgery, suture from the original surgery had dissolved, scar tissue had formed, and the original injury was completely obscured. Even worse, the only way that my surgeon knew about my progress and the only way she saw my surgery report was that I sent these things to her. Otherwise she would have had no follow-up or feedback at all after the complication had been recognized. Without my efforts, her knowledge of my complication would have been limited to the findings on the day of its discovery.

This lack of feedback feels perverse. It is the consequence of privacy laws and complicated, diverse, and poorly interconnected systems in medical care. But it is not the way to support doctors or to improve the quality of care they provide.

Atul Gawande describes the need for a more robust feedback loop in medical care in this Freakonomics Podcast episode (and talks about how immediate feedback interventions– like the use of anesthesia in surgery–catch on much more quickly than delayed-feedback ones — like antisepsis).

I wish I could end this post with some brilliant solution to this lack of feedback, but for now, I only have the observation. I suspect the problem is less prevalent in veterinary care both because of less emphasis on privacy (no HIPAA for pets), and because of less complexity and specialization in the systems of care. I’d like to think that Atul Gawande is right when he says in this podcast that we’re in the MS DOS phase of medical information systems, and that at some point in the future, systems will be integrated enough to provide medical providers with the feedback they need.

As for me, other than being determined to climb bigger mountains than my current fitness level would indicate, I am doing well. My incisions are all healed and my various tubing has all been removed. Other than follow-up with occasional ultrasound exams, I’m done with this whole process of complication and repair.

I’ll end with a few more pictures from my hike last week on Mt. Cube (scroll back up to the beginning of this post to see the panoramic view from the mountaintop).

IMG 4451 E1528477357969 1024x545 — A smaller view from Mt. Cube. A wood frog.

IMG 4459 E1528477448780 1024x940 — Another small view from Mt. Cube. Rhodora (Rhododendron canadense) is bright and showy, but only ankle height.

Return to Work

Image 1024x1015 — No tropical beaches during my “vacation” – just good old Vermont mud season.

As I prepare to go back to work tomorrow after my 20-day “surgical vacation” (see here for why I needed a surgical vacation), I have been reminded of one of the reasons I first became interested in human factors and ergonomics in veterinary practice: our willingness to work while physically injured or unwell. Eleven years ago I was talking to a vet who bemoaned the fact that the technicians and schedulers at the spay neuter clinic where she worked weren’t taking into account that her surgery speeds were slower because she had broken her arm only the week before and was working with a cast on her arm. I was in awe at her toughness, but then recalled working the previous fall with a broken finger (just a small fracture of an extensor process, and just my fourth finger, not an “important” one), and two years later thought little of returning to work the week after my own hip fracture.

Of course for some veterinarians, the physical pain that they experience is directly related to their work, and often it’s chronic—for example, spay neuter veterinarians attribute 91% of their musculoskeletal discomfort entirely or in part to their work. In chronic cases, the injury isn’t an event but a process, so missing work would often at best only be a temporary fix.

There are plenty of good reasons for our tendency to work through injury and physical compromise. Whether in spay/neuter, shelter, or general practice, many of us work in small practices as the only veterinarian, or one of only a few veterinarians. Missing work due to injury or illness only means more work upon return, disappointed clients, patients left untreated, and loss of revenue (for the practice, and often for the individual as well). We often have little or no provision to cover for our absences, so we feel pressured to come back.

One interesting study found lower rates of musculoskeletal discomfort but higher rates of missed work due to discomfort among veterinarians working in regulatory practice compared with clinical practice—perhaps a reflection, as much as anything, on their ability to get coverage and financial compensation during their absence.

IMG 4408 768x1024 — It can be boring sitting at home recovering, unless you have a Cat Butt Coloring Book and a mystery novel.

Also, it can be boring sitting at home waiting to heal, and it’s easy to feel wimpy while taking time off. (Interestingly, despite the preponderance of women now entering veterinary medicine, veterinary culture still glorifies stereotypically masculine toughness)

Our tendency to work while injured or physically compromised combines nicely with our tendency to self-treat (see here and here). A 1988 study on veterinarians and trauma states: “Self-treatment of injuries was common. Four per cent of veterinarians reduced their own fractures and dislocations, 20% sutured their own lacerations, and 67.5% self-administered antibiotics.” In instances of bite wounds, this self-treatment may lead to greater complications; as far as I can find, the consequences of veterinarian self-treatment for other injuries hasn’t been studied.

In my current case, of course, self-treatment wasn’t an issue or an option (though I did have more than one spay-neuter veterinarian suggest that they should have been the one to perform my initial hysterectomy surgery).

In any case, I’m fortunate because, other than a 4-week restriction against lifting, I am physically capable and ready for my return. I was able to schedule the time off that I needed to heal and didn’t need to push myself to go back as soon as I could walk or drive. Now, it’s time to get back to work!

For those of you who are curious, my own surgery on April 10th was a ureter reimplantation surgery with a psoas hitch. For a do-it-yourself, detailed description of the surgery and some useful illustrations of the psoas hitch, see this paper. Basically, in order to prevent tension on the new connection between the healthy part of the damaged ureter and the bladder, the surgeon tacks the bladder to a nearby hip flexor located along the spine. What results is a bladder that slants to the side of the injury.

Several days after surgery, once I started moving around more, I could feel the pull and soreness of my psoas muscle, especially when I made a big step up with my left leg or put my left leg across my knee to put on a sock or tie a shoe. The feeling of having a strained muscle is still there a bit, but much less than it was a couple weeks ago.

IMG 4407 577x1024 — A pikachu visits me in the recovery ward. I don’t think the nurses saw her.

I stayed in the hospital for 3 nights, which was a day longer than expected, but with my mild postoperative anemia and my wife showing the first symptoms of what turned out to be a case of anaplasmosis on the same day as my surgery, it seemed wise to spend the extra night. (Never fear, a quick diagnosis and the wonders of doxycycline made quick work of the tick borne menace).

My Foley catheter was removed 10 days post-op, after a cystogram showed no bladder leaks, so now, for the first time since January, I no longer have to carry around a bag of my own urine. Small victories…

Complicated, Part 3

My first week back at work after my nephrostomy and abdominal drain were placed, I had a major wardrobe malfunction. I was wearing a leg bag on each leg, strapped to the front of my thigh with elastic bands. I was kneeling on the floor, examining a large, handsome hound dog, and I felt a dampness spreading across my left knee. My vet tech and the shelter staffer who were helping us saw it too.

Of course, it’s not too unusual to end up with damp spots on my clothing at some point during exams. Puppy pee, slobbery dogs, wet or muddy paws.

I said, “That wasn’t the dog”

I could feel the urine still running out of the leg bag. It had been pretty full, and I don’t know if the dog had bumped it, or if my scrub pants had rubbed against and dislodged the end cap as I knelt, or if just the pressure of my flexed thigh against the full bag was enough to push the cap off.

I stood up, laughing, embarrassed, trying to kink the end of the bag to stop the flow, but to no avail. Immediately the urine ran down my leg and filled my shoe. Someone handed me a towel and I wrapped myself in it, asked my tech to get my spare clothes out of the vehicle (pro tip: always have spare clothes in the vehicle), and ran to the bathroom to change.

I emerged from the bathroom barefoot but dry, my urine-soaked clothes and shoes stuffed into a plastic bag to launder once I got home. I slipped my feet back into the snow boots I had worn to work that morning.

“Do you want me to run those through the wash for you?” the shelter staffer offered.

“Are you sure?” This seemed a bigger imposition, and more personal, than the initial, urgent cleanup. And I was just the visiting vet, only there a day a month, not her friend or co-worker or boss.

She took the bag back to the laundry room, and by the time I was ready to go home, the clothes and even the shoes and socks were clean and dry.

Fortunately, I’m not a leader who relies on dignity or control over others to bolster my authority. I’m confident, but I joke about my weaker points and don’t mind occasionally playing the fool (or being, accidentally, made foolish).

Like most veterinarians, I had never studied leadership when I got my first job with management duties, nor later when I started my own business (Spay ASAP Inc, a nonprofit MASH mobile spay neuter clinic). Later, I was introduced to organizational ergonomics during my ergonomics masters program, and then I attended a 2-day course at Emancipet called Surgeon to Leader.

One of the topics we discussed was the difference between management authority and leadership authority. Management authority is structural: it comes from a job title, and allows you to say, “because I said so.” Leadership authority is granted by each individual: it happens regardless of whether you have managerial power. With leadership authority, people follow because they want to, not because they have to. They follow because they believe that together, you will achieve something worthwhile that neither of you can achieve alone.

In my own workplace, I have management authority over only one other person: the veterinary technician who I’m paying to be there. But I strive for (and can only function with) some level of leadership authority, to inspire those who work for other entities and those who volunteer to believe that what I’m asking them to do is useful and worthwhile. I could aim to gain that leadership authority by inspiring awe, but like the awkward alien in the Gary Larson cartoon, I’d be bound to fail (or fall) eventually. Instead, I earn what leadership authority I have by working hard and allowing others to feel involved in and integral to that work.

A few days ago, a veterinarian friend emailed about how she had been fighting the perfectionism in veterinary medicine by admitting openly to staff when she didn’t know something, instead of sneaking off to look up the answers. She points out her mistakes and near misses rather than trying to hide them, seeking to emphasize that we’re all human and therefore not perfect. When she does this, she may be not only helping to break down the harmful self-imposed norm of perfectionism in the veterinary profession, she may also be making it safe for the other people that she works with to look at, talk about, and understand error as well. And by doing that, as I wrote about last time, she may actually be making her practice safer– all by being openly imperfect.

Like my friend, I also try to point out to my staff the things I could have done better when I’ve made a mistake or had a complication. Also like my friend, I find it’s easier to admit my shortcomings to others than to accept them in myself. It’s funny how, even knowing what I do about complications and coping, it feels far less shameful to be soaked in my own urine than to know that I have caused harm to an animal. And while that shame can be a short-term motivator to change (no more leg bags at work for me, only fanny packs), it’s not a productive or sustainable way to generate process improvement because it’s hard and painful to think about something shameful, so it’s hard to use the experience to analyze, reconstruct, and modify a work process.

As for me, I’m counting down the days until my ureter reimplantation surgery (3 weeks and one day!). Between now and then I’ll be working at a half dozen spay clinics and attending a couple of conferences, the 2018 International Symposium on Human Factors and Ergonomics in Health Care in Boston, and the New England Federation of Humane Societies annual conference in Nashua, and hope to bring back all sorts of interesting ideas (and avoid wardrobe malfunctions).

Complicated, Part 2

IMG 1411 E1468078218778 1024x1024 While I can only speculate about the causes of the surgical error in which I was a participant but not a witness, I do know a few things about errors in surgery. One of the most confounding things about surgical errors (besides figuring out how to recover from them) is why they happen at all. Why, when I do the same procedure the same way every time, does this one time result in a complication?

Previous authors have spent a lot of time thinking about error taxonomy in surgery, anesthesia, and elsewhere, and while the answers aren’t always simple, they can be categorized. (The types of error that can happen in surgery are summarized nicely in this article by Cuschieri.)

Errors in execution or perception

Many surgical (and anesthetic) errors stem from differences in individual patient anatomy or physiology that reveal vulnerabilities in an existing technique or protocol—a technique or protocol that is adequate in most but not all circumstances. These can be some of the most difficult errors to identify and understand. An example might be a veterinarian who tightens the ligature around every cat’s uterine body and vessels using one pound of pressure on the first and second throw of her ligature knot. In most cats, this will be sufficient, but in a few (probably in-heat) cats, it likely will not, and those cats may bleed from the ligated vessels and perhaps require re-operation and re-ligation.

This inadequate ligature tension is an error in technique that in most cats causes no harm. In each cat, there is the possibility that it will be adequate, or not. The solution to this error would be to tie all uterine body ligatures with greater tension (say, 2 pounds of tension), or to use a cue from the patient to determine when ligature tension is adequate in that patient (such as observing tissue blanching under the ligature).

Other errors in execution in surgery may be due to lapsed attention or to a mistaken perception. Attention lapses are more plausible than one might think: proficient surgeons use habitual motions and automatic processing, rather than the more deliberate and slow techniques of the inexperienced surgeon (again, see the article by Cuschieri). This automaticity allows for efficient and minimally traumatic surgical performance and is essential to practice, but it may also allow for inattention. Often if a problem arises, the surgeon will perceive an inconsistency between her mental picture of the surgery and real life, which will focus her attention and allow her to adapt to the new surgical circumstances. If not, the problem may go unnoticed and result in a complication.

A mistaken perception may go hand in hand with automaticity or with inexperience. Anatomy varies, and the surgeon may not see what she expects to see where she expects to see it. A misidentified organ, vessel, duct, or tissue can easily be severed or ligated.

Latent (system) errors

Another type of error that happens in practice may be a systematic error, a problem in the organization and allocation of time and resources. This latent error is a gap that is present at all times, but may go unnoticed and uncorrected, especially if no harm comes from it.

Professor James Reason makes the analogy of Swiss cheese, in which each slice of cheese is a layer of defense, and it is only in certain unlucky circumstances when the holes in these layers align to allow an accident or injury to occur. Reason Swiss Cheese 1024x796

In veterinary practice, an example of a latent error might be limited or infrequent observation of patients recovering from anesthesia. In perhaps 99.8% of patients, there will be no problem if they are observed only intermittently during the period after they have begun to rouse from anesthesia but before they are fully ambulatory. But in a few patients, that gap, that latent error, will be the hole in the system through which they fall. (The post-op period is the highest risk period in small animal anesthesia – perhaps because of the inherent danger of this time period or perhaps because of this common latent error of limited observation post-operatively.)

In many practices, especially with good luck and a low volume of surgeries, this particular organizational practice may not result in a patient death for many years. If and when one finally does occur, it seems to happen out of the blue, but is really a combination of this individual patient’s physiology combined with the latent error in observation, perhaps also combined with other transient or latent circumstances.

If you are interested in learning more about human error and error taxonomy, I would recommend any of the books or articles by James Reason. For some excellent and thoughtful essays on complications and learning in surgery, read Atul Gawande, especially his books Complications, Better, and the Checklist Manifesto.

As for me, I’m doing well. Yesterday I went snowboarding and got to enjoy the remnants of snow and a blue-sky sunny day. An extra wrap of spandex around my waist (a maternity product borrowed from my sister) kept the tube and pouch snug and in place, so no wardrobe malfunctions during my outdoor fun.

Frequently asked question: I have been asked by several people whether I still need to pee “the old fashioned way” after my recent nephrostomy tube placement. Yes! My left kidney drains into the nephrostomy bag (my newfangled bladder), while the right kidney still has a good ureter and drains into my old fashioned bladder. That means that I have to pee twice every time I go to the bathroom since I have two bladders to empty. Downside: bathroom visits take twice as long. Upside: I only have to go to the bathroom half as often.

Complicated, Part 1

Drain 2 E1518818991664 1024x867 On the same day my article on coping with complications was published online, I met with my doctor. I was recovering slowly from my hysterectomy and eight weeks along, my belly was still sensitive and swollen.

A week later, I was in the hospital, one tube draining my belly, another in my left kidney. My left ureter had been damaged during my hysterectomy, and urine had been leaking into my abdomen. The first drain would remain in place for 10 days to relieve the abdominal pressure and drain the urine that had accumulated in my abdomen, while the drain in my kidney, a nephrostomy tube, would send the urine from my left kidney into a bag I would carry with me for months like an external, second bladder.

It will be two months before the urologists surgically reimplant my left ureter into my bladder, before they dissect through the scar tissue and reveal the injury. Until then, we won’t know the nature of the injury or what could have been done to prevent it.

In veterinary surgery, ureter damage during ovariohysterectomy is rare enough that this complication isn’t reported in most studies of spay neuter complications (one summary of the literature on spay neuter complications mentions only 3 case reports ). Ureter damage during spay is like the monster under the bed: it is the star of horror stories that happened to someone else, never actually seen or experienced by you or anyone you know but still terrifying and perhaps possible.

The strange, compacted, biped anatomy of humans, though, places the ureters in the surgical field and at risk during hysterectomy. Ureter damage happens in about 0.5-2% of hysterectomies in women and can be the result of ligation, kinking by suture, transection/ avulsion, partial transection, crush, or devascularization. Exactly which of these happened may become clear during my ureter repair this spring, but until then is only guesswork.

So my doctor is left in that unenviable circumstance of having an unresolved complication of indeterminate cause. The long delay between my surgery and my return with symptoms would make the details of my surgery itself difficult or impossible to recall. The unknown error (and known result) leaves her hanging, no guidance for improvement, no specific oversight or action to correct in her next surgery, or the surgery after that. Only worry, and caution. I recognize the feeling, and the fear.

At my initial surgery, the humor in being a spay neuter veterinarian undergoing a hysterectomy wasn’t lost on me, nor now is the unfortunate coincidence of writing about surgical complications and then experiencing one. I appreciate the perspective and can’t help but use it as an opportunity to keep exploring the experience from within the domain of human factors and ergonomics. In addition to considering surgical complications, my experiences of the last few weeks and months have led me to think about topics as diverse as error taxonomy and latent error to organizational leadership. Between now and my repair, I plan to explore these topics here. Stay tuned!

As I wait for my repair, I am fine and happy, and feeling physically better than I have in months, despite the nephrostomy tube and external “bladder.” This morning I went for a 9 mile ice skate at Lake Morey, and it felt good to be out on the ice and moving on such a beautiful day.

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So much ice and blue sky!

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Sign on the ice by the pond hockey area. No, I didn’t. But I can pee standing up now…