Mark the site campaign

MARK THE SITE
 

A Surgeon's interaction in the Operating Theatre

This is a real conversation that happened in a real surgical operating theatre in India a few weeks ago. It probably happens every day.

Surgeon, standing to the right of a patient under general anaesthesia for hernia repair asks: 'which side is the hernia?'

Assisting surgeon: 'I don't know. I did not see the patient.'

Surgeon: 'Who saw the patient?'

Assisting Surgeon: 'The house surgeon from the previous shift'

Surgeon: 'What does it say in the notes and consent?'

Assisting Surgeon: 'Hernia repair, obviously'

Surgeon in anger: 'Obviously!! But which bloody side?'

There were a large group of people in that operating theatre, junior nurses, medical students and other staff. None of them will speak to the chief unless they are spoken to. Silence for a few moments.

Surgeon in exasperation: 'Does anybody know the side?'

Medical Student puts her hand up.

Surgeon very impatiently: 'Tell us. What are you waiting for?'

Medical student says: 'I don't know for sure, but I was standing on the right of the patient's bed when I examined him and I had to reach out across to feel the hernia. So it must be the left side.'

Surgeon: 'Left it is then. Let us get this done'

Very lucky day. The patient did have a left hernia. The medical students had seen two other hernia pre-op patients the same day and extremely fortunately they were all left groin hernia.

Wrong Site Surgery WSS

(and wrong site procedures: wrong site anaesthetic, implement fitting, etc)

Sadly not all patients have lucky days like the above patient.

Wrong site surgery happens 40 times a week in the USA. http://www.washingtonpost.com/national/the-pain-of-wrong-site-surgery/2011/06/07/AGK3uLdH_story.html

Wrong site surgery is estimated to happen once a year in a typical hospital with 300 beds Clarke, J.R., Johnston, J., and Finley, E.D.  Getting surgery right.  Annals of Surgery;246(3):395-405, Sept. 2007.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959354/pdf/20070900s00006p395.pdf

Surgeons have a 1 in 4 chance (i.e a very high chance) of being involved in a wrong site incident

Wrong Site Procedures: Wrong side anaesthetic – is happening more and more with not much attention paid to it. There are a number of interventions done in wrong patients, a large number of unnecessary procedures done on right patients. Even the statistics for these are difficult to find.

Though the evidence comes from the west there is no reason to believe that other countries (such as India) have any less incidents or better practices.

The impact of these are dreadful with life long suffering. Life long dialysis if the wrong kidney is taken out or a kidney transplant with the complex lifelong medication to be taken after that, wrong eye – blindness, wrong leg, etc. It does not need to be major operations even after lesser wrong procedures it is possible to have wound infections, chronic wound pain etc. These are just physical. The psychological effects are much worse and affects not just the patient but families, friends and whole communities. Trust in healthcare providers – hospitals, doctors, nurses – irreversibly damaged.

The internet is full of events, episodes and tragic histories of patients who have suffered wrong site surgery. If you want examples they are only a couple of clicks away.

Solutions

It is very easy to write about solutions but it is well recognised that any solutions against wrong site surgery is very difficult to put into place, difficult to practice and not always successful. That is no reason not to try to reduce it by any means possible.

Some of the more effective solutions are thought to be:

The operating surgeon to see the patient on the day of the surgery and MARK THE SITE on the incision or as close to the incision as possible.

If the procedure involved a symmetrical organ the opposite side i.e. the side without the pathology is marked with a big NO; that may help.

Some surgeons write the name of the procedure (including the side if appropriate) on the incision line – that helps.

Check lists that include surgical site marking

Improving the culture so that any member of staff however low down in hierarchy is able to speak up when WSS issue is suspected

Our own suggestion (though not research based) is to empower the patient by asking a competent patient (any one who is able to give consent should be a competent patient) or a competent relative to mark the site of the procedure in the presence of the operating surgeon. After all it is reasonable to assume that the patients have a vested interest in the surgeon not operating on the wrong part of their body.

Even if it is a non-symmetrical organ procedure or a midline procedure make it a habit to mark the patient so that you can have standardised preparation protocol. It will really help a patient some day, if you are a doctor it will surely help save your career.

MARK THE SITE

This is a campaign we are specifically starting for South Asian countries (e.g. India) but is also relevant to many developing healthcare systems (e.g. African continent).

Surgeons

Please pledge today that you will mark the site of the incision on all patients on the day of the surgery.

Anaesthetists

Please pledge today that you will not begin anaesthetising a patient unless you see the site marked on the patient's body. If there is no mark please ask your surgeon to check and mark it before anaesthesia is commenced.

Nurses

Ward Nurses: Please pledge today that you will not let any surgical patient leave your ward to go to operating theatres unless their surgical incision site is marked by the operating surgeon.

Theatre Nurses and allied theatre staff: Please pledge today that you will not allow patients through the main doors of the theatre unless you see the surgical incision site marked.

PATIENTS (and relatives)

Please pledge today that you will not leave the ward/bed and enter operating theatres unless there is a mark on your body at the surgical incision site.

Pharma companies and their sales reps
Please provide doctors with a skin marker pen as a part of the various complimentary items that you provide and ask the doctors to use them to mark the surgical incision site

Everyone

Please forward the link for this blog to at least two persons. Alternatively cut and paste and send the information to at least two persons.

Write to hospitals, politicians, news media outlets or any other action that spreads the message.

Let this be a campaign be owned by us the normal public (such campaigns are normally lead by institutions/organisations/etc)

Primum non nocere is a fundamental principle of medical practise. Causing permanent harm by wrong site surgery is against that principle. It may not have happened to you yet but look at the numbers it is happening all over the world, it may happen to you unless you take definite action about it; irrespective of whether you are a healthcare professional or general public.

MARK THE SITE

©M HEMADRI 

Follow me on twitter @HemadriTweets

Increased Quality and Reduced Cost - Possible in India

I have a long held view that quality is inversely proportional to cost which means as for a given activity as the quality improves cost decreases. This is actually possible in India as well.

Let me share a clinical anecdote that may illustrate my point. It may be dated and trivial to many current readers but was very relevant to the patients and clinicians at that time.

In the late 1990s I was working as a surgeon in Sir Ivan Stedford Hospital, Ambattur, Chennai, India (http://www.ammfoundation.org/SirIvanStedefordHospital/index.html). This is a charitable hospital where we used to charge very small nominal amounts of money to provide services. A few rupees for out-patients, few tens of rupees for scans and so on. Being India, one of the commonest operations performed happened to be surgery for hydrocele. The way it was conventionally performed may be very familiar to many of you. The operation of course ended with a large bandage tightly applied to the scrotum with the purposes of avoiding problems like pain, infection, haematoma, oedema etc. These patients were also put on antibiotics for 10 days or more. Many of these patients used to come back with soiled dressings and the exact problems that doctors were trying to avoid. Doctors used to wonder what else could be done to improve the situation.

Not using a bandage was thought to remove an all important barrier that avoided exposure of the scrotal wound to the unhygienic toilet situation in India and despite using 10 days or more of antibiotics infections were happening. Barrier and antibiotics thought to be bulwarks against contamination and infections were not working.

I actually thought the tightness of the bandage caused oedema and increased pain. The presence of the bandage increased sweat and moisture in an already humid perineal area in a warm country. The bandage also easily became wet because of the toilet washing habits of the country and acted as a rich environment to create infections.

Having worked in England where the scrotal bandage was not routinely used after scrotal surgery, I took the bold step of not using scrotal bandages to hydrocelectomy patients much against the advise of my friends and colleagues. Of course, I suggested the use of the proper scrotal support clinical hosiery which was either not available or when available was very expensive. An alternative had to be found. I simply asked my patients to buy 7 of the cheapest 'A' or 'Y' front underpants from the shops opposite the hospital otherwise I would not operate on them. I used these normal commercially sold underpants over a couple of pieces of sterile gauze placed on the scar, changed once a day by the patients themselves, in the place of scrotal bandages for my patients changed by clinical people. Most of my patients found this very amusing. Some were resistant, perhaps hesitant, because the had not worn such a type of undergarment before. My colleagues were of course greatly humoured by what they thought was my naivety and enthusiasm.

In a few weeks, post operative follow up clinics were showing that my patients were walking in and walking out in super speed and for the rest of the surgical team there remained the usual levels of post op problems with pain, oedema, infections. Having eliminated the scrotal bandage which I thought was causing the problems, I then moved to single dose prophylactic antibiotic as I used to do in Britain.

Word of mouth and social observations in a local context those days was of course as fast as twitter or facebook now. The talk was about how patients spent less money on changing bandages and buying antibiotics while getting good results. Soon my colleagues avoided scrotal bandages, used undergarments as I recommended and moved to a shorter course of antibiotics often just 3 doses (instead of the usual 10 days).

Of course the people who charged for the change of dressings and the people who sold antibiotics were not happy. But I can tell you who were happy, the guys who sold the undergarments. They were really happy. 7 undergarments per hydrocelectomy patient in a hospital that did hundreds of hydrocelectomies, they must have been ecstatic. Well, I know they were, as one of them approached me and offered a commission to me (his bloody nerve) if I could recommend patients to buy the undergarments specifically from his shop – no different from the drug store chap then!

Clinical complications reduced – i.e. quality improved. Cost reduced.

Okay, this example is not about whole systems, scientific proof, published evidence and other high & mighty things. It is one little example. What I cared and what our patients cared is that we had lesser clinical problems and we achieved it by doing/using/costing less. Perhaps hydrocele surgeons in India are no longer using scrotal bandages and 10 days antibiotics - that is why this anecdote may be very dated but the general lessons are in my view still valid.

Increasing quality while decreasing costs can be achieved in India as well. Perhaps due to the large number of people who are around the poverty line this concept becomes even more relevant to India. We must remember that though the GDP is high the per-capita money is very low in India. Individual doctors are not dealing with the mighty high GDP India; individual doctors deal with the individual patients of low per-capita India. That is why low cost high quality care becomes essential.

©M HEMADRI 

Follow me on twitter @HemadriTweets

COMPLICATIONS OR HARM AND THEIR IMPACTS

COMPLICATIONS OR HARM AND THEIR IMPACTS

M HEMADRI

'Complication' is such a sanitised word. When doctors and nurses speak about complications the language is purely technical, distant and mostly third party. When the complication comes true, it is of course none of those, it is very personal; physically and emotionally hurtful with huge trauma to to the sufferers and their families, in so many ways that we can never understand or even describe.

The following is about a series of extraordinary real life happenings that relates to a normal British person from Portsmouth and his family. The words are a cut and paste from the court judgement with a few minor changes to help normal reading.

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• The patient was aged 39. His father had for several years been undergoing kidney dialysis treatment and was suffering from renal failure. The patient was anxious to give his father the opportunity of a better quality of life in his well earned retirement by donating his own right kidney, thus sparing his father further dialysis treatment. The operation was performed on 26^th February 2008. The hospital admits that the operation was performed negligently, and to a degree recklessly. There are proceedings before the General Medical Council against the surgeon in question.

• The consequences of the hospital's negligence have been catastrophic for the patient and his family: physically, psychologically, emotionally and financially. Although the patient's right kidney was successfully removed and transplanted, the patient suffered irreversible failure of the left kidney. In fact he should never have been advised to undergo the operation at all given the grave dangers involved. That negligent advice was compounded by serial mistakes during the operation itself. The patient's life was saved only after many hours on the operating table during which he received over 100 units of blood and fluid transfusions.

• During the course of the operation the patient suffered further complications which have had far reaching consequences: a minor myocardial infarction; ischaemic damage to the bundle of nerves known as the lumbo-sacral plexus, which supply the right leg and foot; a thrombosis of the inferior vena cava.

• The patient was left in total renal failure. He was in hospital for nearly two months, during which he started to receive haemodialysis. He developed a serious drug induced confusional disorder. There were further re-admissions to hospital in March and April 2008, following which he received dialysis treatment three times a week as an outpatient for a year. This treatment affected him profoundly. He became severely depressed, frequently contemplating suicide. He contracted serious infections, one of which necessitated a further admission to hospital for four days in October 2008.

• The patient's own act of altruism and family devotion in donating a kidney to his father, which cost him so dear, was reciprocated by the patient's sister. With the same outstanding altruism and family devotion she in turn donated a kidney to the patient, at very considerable psychological and emotional cost. That operation, performed on 27^th March 2009, was successful. It released the patient from an indefinite regime of dialysis. However, he lives with the constant fear that his body will reject the kidney and it is common ground that when he reaches his early sixties that kidney will require replacement. This uncertainty, and his experiences generally, have left him with an understandable obsession about his health.

• Unfortunately a recurrent infection was imported with his sister's kidney, cytomegalovirus viraemia (CMV). This is a constant source of worry. So is his blood creatinine level which, if raised, can be a sign of kidney rejection.

• The renal failure the patient suffered increases significantly the risk that he will suffer from ischaemic heart disease and a stroke. Consequently he adopts a very careful lifestyle and diet. He has had high blood pressure and high cholesterol levels which cause him constant worry. The immuno-suppressant drugs he takes, in particular to control the CMV, greatly increase the risk of his developing other debilitating and life threatening conditions. The consequence is that he has become fastidious to the point of obsessional about personal and general hygiene, which impacts upon the whole family. He can be irritable and overbearing. He is prone to bouts of weeping.

• There are further serious physical consequences. The nerve damage suffered during the negligent operation has resulted in altered sensation below the right knee. There is hyper-sensitivity, pain and loss of sensation in various parts of the right foot, and clawing of the first and second toes. He has had surgery on the first toe. Further surgery had been planned to straighten and fuse the toes but this drastic measure may be avoided by regular injection of botulinum toxin for life. The issue surrounding this problem with his foot has a bearing on his residual earning capacity. Currently he is unable to run, and walking on uneven ground and stairs presents some difficulty.

• The patient has also been much distressed by urinary difficulties. For a time self- catheterisation was attempted. He found it a dreadful experience. Urinary frequency bedevils his daily life, and results in broken nights for him and for his wife.

• The medication he takes has had unpleasant side-effects including the profuse growth of unwanted body hair, the development of skin acneiform lesions and the deposit of facial and abdominal fat. His inability to exercise has also led to undesirable weight gain. Prior to the operation, the patient was a healthy, fit and active 35 year old man. He took great pride in his health and fitness, running several kilometres each morning to set himself up for the working day. He had enormous energy. He was cheerful, optimistic and extrovert.

• Now the picture is very different. At the age of 39 his daily life revolves around his health worries. He is constantly fearful of infection or changes which may increase the risk of the kidney being rejected. Any venturing from the strictly enforced hygiene of the home is fraught with anxiety. He lives with the certain knowledge that the kidney will require replacement by the time he reaches the age of 61 and that this will be preceded by symptoms of progressive renal failure. It is agreed that his life expectancy has been reduced by 10 years.

• The patient's wife says that the patient is a shadow of his former self. He is lacking in energy. He is exhausted by 9 pm and generally has to be in bed by 10 pm. He is moody and irritable. Their marriage, though very strong, is constantly under strain. The children have been affected and distressed by their father's condition and behaviour and he has bridges to build there.

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The above example was of course extraordinary, further the issue reached the court of law otherwise we would not have heard it in such a profound and full sense. It might have reached us through the press in which case we would have discounted it for journalistic embellishment. In reality most if not every healthcare related 'complication' has impacts on patients' lives which are significant but we will never hear about it.

Perhaps it is time to start describing some of the possible known effects of complications on patient's lives should be described in a way that it really affects patients lives. Let me explain. Do you think the hospitals, doctors or nurses when explaining or consenting patients for surgery ever tell them 'if you had one of the severe complications your marriage could be constantly under strain; your children could be affected and distressed by your condition and behaviour and your may need bridges to be built with them as a result''?

For instance When we talk about surgery on blood vessels in the limb we mention 'amputation' as a possibility. Does that really describe anything to a patient who has never experienced or seen amputation before? Perhaps we ought to tell them how in the initial days even to move from side to side in a bed they would need support, their entire body will need to put in daily heroic effort to cope, they will not be able to do any sort of work for many months, if everything goes well it will hurt during wound healing, during dressing change, during physio, during limb fitting, when using the limb. When goes wrong it will hurt more, more often and for longer – if it goes wrong even more it will hurt every day of their lives (phantom limb pain). They will need to know that the pain will need strong pain killers, strong pain killers will cause constipation, constipation could cause fissure which will hurt even more. They would need to know that if the wound breaks down their raw cut bone could stick out. Well, even after these descriptions we haven’t even made a start on the long list and impacts in a proper way!! These are only physical.

Perhaps we need to tell them that they may not be able to drive a normal car; the pain could drive them to become an alcoholic if they are lucky and a drug addict if they are unlucky. Perhaps they need to know that their family and friends will provide sympathy which the patient could misinterpret and end up feeling patronised resulting in phenomenally strained relationships all around.

God help us avoid complications.

Complications are true complications only when every effort at our command is made to avoid them from happening and yet they happened, otherwise it cannot be called a complication; it is called harm. As an illustration, if a patient developed deep vein thrombosis due to omitted drug thromboprophylaxis, poor mobilisation, poor hydration or pelvic injury at surgery that DVT is healthcare caused harm; similarly if a spinal or epidural catheter was removed without regard to when chemical thromboprophylaxis was given and the patient developed spinal cord problems, that would be harm caused by heal. DVT prevention is an easy example, there are thousands of other ways that healthcare's omissions, commissions and disagreements hurt patients; they can no longer be euphemistically called complications any longer.

Here is something uncomfortable, a number of these problems happen because of us (organisation or individuals) though we are often unable to even recognise that.

Once again, the impacts of complications on peoples lives is something that healthcare professionals would not be able to even begin to understand, or describe. There are specific tried and tested methods to avoid harm or to reduce them to their minimum possible. Most healthcare providers do not have to do world beating cutting edge stuff, they only have to put in some effort to just avoid harm in healthcare. If it was done that would count as Success in Healthcare.

© HEMADRI

Follow me on twitter @HemadriTweets

Ref: http://www.judiciary.gov.uk/Resources/JCO/Documents/Judgments/xyz-judgment-14022011.pdf