AANS Neurosurgeon | Volume 29, Number 1, 2020


Complications and Bad Outcomes: The Neurosurgeon’s Nightmare

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Yeah, it’s a nightmare, but that’s neurosurgery. Land of nightmares. There are plenty more nightmares in your future, pal.

                                                – by Frank Vertosick, MD, “When the Air Hits Your Brain1

In his 1996 book, “When the Air Hits Your Brain,” Dr. Frank Vertosick highlights individual events instrumental in shaping how he emerged from residency as a final product. Early in his operative career, he triumphs in his successful outcomes and becomes overly confident in his abilities. It is quickly pointed out to him by a mentor that it is not only the successes that define a surgeon, it is also the response to inevitable disaster that reveals a surgeon’s true character. “You aren’t a neurosurgeon when you clip your first aneurysm; you become a neurosurgeon when an aneurysm first blows up in your face.”1

Shortly thereafter, Dr. Vertosick struggles with the neurologically devastating result following his first intraoperative aneurysm rupture. As the patient awakens hemiplegic and aphasic, Dr. Vertosick anguishes over the outcome. He eventually becomes too hesitant to continue operating – and even contemplates quitting neurosurgery altogether. He reaches out to a prior senior resident, Gary, now in practice, for advice. It is Gary who provides the description of neurosurgery as the ‘land of nightmares’ and emphasizes that it is essential for its practitioners, Dr. Vertosick included, to deal with, learn from and then move on from complications.

Like Dr. Vertosick, I can vividly remember the first major complication resulting from a surgical procedure in which I was involved as a neurosurgical resident. The patient’s new postoperative pain, paraparesis and bowel and bladder difficulties were psychologically paralyzing for me and I too avoided not only the patient, but, for a brief time, similar operations. I was fortunate enough, however, to observe the response of the attending surgeon, who would spend countless hours daily at the bedside explaining the complication and counseling the patient and family. He taught me complications were devastating for patients, but should also be, to a degree, for the surgeon. Complications invoke self-doubt and require repeated confrontation with the result, as patients and families require the frequent presence and comfort of their doctor while navigating new realities. Although this presence is required, an angry patient may not welcome it. The attending neurosurgeon of this case skillfully navigated these challenges, projecting culpability, confidence but not hubris and a plan to improve on the current situation. Simultaneously, he would perform the very same procedure three additional times that week with superb results.  

Since that complication when I was a resident, I have unfortunately experienced plenty more ‘nightmares’ and become acutely aware of the thin line neurosurgeons straddle between success and devastation. There are daily reminders that the management of neurosurgical disorders holds a unique potential for stripping individual patients of their most basic as well as complex, abilities: movement, sensation, vision, swallowing, speech, cognition, personality and more. Personifying Theodore Roosevelt’s man in the arena, it is a neurosurgeon, “Who at the best knows in the end the triumph of high achievement, and who at the worst, if [s]he fails, at least fails while daring greatly.”2 Maintaining the equanimity to manage triumphs as well as failures, complications and bad outcomes, is essential to the effective practice of neurosurgery.

As Gary counseled Dr. Vertosick, managing complications requires:

  • Striking a delicate balance between establishing a connection with patients and maintaining a distance that allows for objective clinical decision-making;
  • Being forthright with patients, families and oneself when complications occur;
  • Discussing complications and commiserating with colleagues;
  • Learning from mistakes and altering one’s practice when necessary; and
  • Having confidence to move on quickly to treat each subsequent patient well.

Having these techniques painfully reinforced on several occasions, I personally have worked to improve from each complication. Despite this progress, each complication and bad outcome still haunt, but now, like Dr. Vertosick, I am able to realize that:

“I had indeed done my best; my best just wasn’t good enough. I [accept] the nightmare of the past and [await] the nightmares of the future.”


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1. Vertosick, F. (1996). When the air hits your brain. W.W. Norton & Co.

2. Roosevelt, T. (23 April 1910). Citizenship in a Republic. Sorbonne, Paris.


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laurence kleiner | February 6, 2020 at 1:30 pm

Well written article. Reminds me of some sage advice I relieved as a chief resident from my mentor; a gifted academic, thoughtful and deft surgeon -junior attending named James Kenning. He counseled me,” Lar, when the aneurysm blows up in your face and all hell is breaking loose remember, IT’S NOT YOUR ANEURYSM.” The underlying theme here was to remain calm, assess the situation and do what you were trained to do. Another residential perspective from M.R. Katz, was that each aneurysmal surgery leaves skid marks in your shorts and takes 6 months off your life.
As neurosurgeons we display our badges of courage in different places; some plaques, some scars. By nature of our specialty, we must be our own worst critics, through only by adherence to this credo can we continue to venture into the operative theatre and perform to the best of our abilities, wielding judgment as well as a scalpel. Our patients and their family expect and deserve no less.
Perhaps best stated by Polonius, ” This above all:to thine own self be true, and it must follow as the night the day,Thou canst not then be false to any man.” WS, Hamlet