Second opinion please

BMJ 1996; 313 doi: (Published 14 September 1996) Cite this as: BMJ 1996;313:694
  1. Colin Douglas

    Many years ago as a junior doctor I watched a surgeon in trouble. A procedure in the neck turned into a deep, dark hole spilling blood. No one panicked, but since the operation threatened to become a thoracic one a second opinion was sought from a senior thoracic surgeon.

    As it happened I had never encountered this luminary, but he was much admired and mimicked among the irreverent young—“Don't apologise, dear boy. My fault entirely. I employed you”—and therefore instantly recognisable when he arrived—indeed far more stylish than the best of his many imitators. He swept in and took charge. The crisis passed. The patient lived.

    A few years later, in one of those pub sessions where junior doctors mull over the triumphs and disasters of their elders and betters, I thought I was about to hear the tale again—same surgeon, same procedure, same deep, dark hole filling with blood. Heard it, I thought. I was wrong.

    Weeks previously the surgeon, in similar difficulties in the root of the neck, had pressed on alone and got into serious trouble. The witness was detailed and unsparing. Hardened collectors of hospital horrors put down their pints and listened awestruck.

    In search of the source of bleeding he had divided the clavicle and in doing so had nicked the subclavian artery. Then the deep dark hole did not just fill with blood. It spouted the stuff. They continued to press on, splitting the sternum in the hope of controlling the torrent at the root of the subclavian. They failed. The patient died.

    In the pub the informal inquest was searching but sympathetic. The previous incident was duly taken into consideration, the obvious question being why, on the second occasion, had no second opinion been sought from someone who went into the thorax a bit more often and not just as a last resort.

    There was an obvious answer. The thoracic surgeon he had asked the last time had since retired. Anyone he might have asked now would certainly have been his junior, perhaps unknown, probably untrusted. So no second opinion.

    I am not a surgeon, but continue to admire those who go down into deep, dark holes that sometimes fill with blood. And I recognise too that their need for a second opinion might on occasions be far more pressing than mine as a physician. But for surgeons and physicians both, asking for the help of another consultant is a matter of trust, of familiarity, and the expectation that advice will be prompt and usually right.

    Until about six weeks ago 1 knew exactly what to do about the more difficult chest problems that came my way. I could assure the patient that another physician would call soon, that he was a pleasant and clever chap and would probably help a lot. I knew him well. We had graduated together and remained friends over the years. His opinions were swift and sensible, his courtesy to patients and staff unfailing. He helped and, in the kindest way, educated us too. Six weeks ago he died. And now I know a little of what the surgeon must have felt when his trusted second opinion was no longer there.—COLIN DOUGLAS, doctor and novelist, Edinburgh

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