I turned on the saline and advanced the hysteroscope slowly. As the uterus distended, my camera was able to pick up the image of a long and narrow uterine cavity - very unusually shaped. The small black-hole passageways leading to the fallopian tubes which should have been visible on both the right and left side were conspicuously absent.
"Here, let me take over." I handed the scope over to my attending. She advanced the scope slowly, gently, revealing the same oblong cavity that was rapidly growing shorter as the camera advanced ever inward. The fluffy surface of uterine lining was then suddenly gone and our monitor screen revealed long loops of bowel. "And, we've perforated the uterus. We cannont continue," my attending announced as she calmly removed the hysteroscope. "Get a CBC now, and again in 3 hours," she instructed while checking for blood at the cervix. "Have her follow up with me in clinic on Friday."
The guiding philosophy behind residency training is that we learn to manage various medical conditions by being exposed to patients with that condition and participating in their care. As OBGYN residents, we compete for deliveries, c-sections and hysterectomies so that we will become proficient at them. You're not considered competent to do a hysterectomy on your own in the community until you've done a certain number under supervision. But there is no set number of complications you are required to deal with before you are allowed to practice on your own. Complications happen. Uteri get perforated, major arteries get transected, umbilical cords get prolapsed. How do we learn to cope with these events if we're never exposed to them? There is a conflict of interest here between being responsible for my own education and providing good patient care that I never anticipated would exist when I started med school. Certainly we don't try to cause complications. Hopefully they happen often enough on their own without any help from us. But we are still in the unenviable position of hoping that they happen. Doctors aren't suppose to hope that bad things happen to their patients. And, in actuality, medical and surgical residents don't hope that anything terrible happen to any particular patient; we only hope for complications in the global sense.
The patient did fine. "Perforations at the funuds usually seal themselves and don't bleed," my attending had said. "We just have to watch her closely for awhile." I brought the issue up with my senior resident, who had had a perforation of her own the very next day - coincidently enough, with the same attending. Her opinion:
"Don't try to cause complications. Just be grateful when they happen."
