Dr. Witherspoon: Too Many Hoops

An orthopedic surgeon was about to start his third case, a total knee replacement. While in the holding area, the nurses reviewed the patient’s paperwork and found everything in order. His history and physical listed the primary diagnosis as “osteoarthritis, right knee.” The surgical consent was signed for a right total knee arthroplasty and the vendor was there with the components. The patient put a mark on his right knee, as requested by the nurse. They administered prophylactic antibiotics through his i.v. line and took him back to the OR. 

He was prepped and draped. The nurse gave her “time out” announcement and read aloud the consent for a right total knee arthroplasty. The surgeon took the knife. The nurse noted the start time. They were underway. 

But something wasn’t quite right. The surgeon hesitated, the knife hovering just above the skin. 

“I thought this guy was a hip,” he wondered out loud. 

He put the knife down and asked the circulating nurse to call his office. The staff looked quizzically at each other as she dialed the number.

He asked to pull the patient’s chart and read the office notes. 

Everything in the chart referenced an arthritic hip, including a standard pre-operative statement about a total hip arthroplasty, noting the patient’s agreement to that procedure. There was nothing in the chart about his knee. 

The case was canceled. 

DR. WITHERSPOON SAYS: 

That was close! He almost took out a perfectly good knee. That would have been a first-class disaster. 

Everything was in order, the H&P, the consent, all of it. Only problem, it was all for the wrong operation. What happened? 

The surgeon employed a physician’s assistant (PA). When a patient was to have surgery, he was given an appointment with the PA, who took care of all the preoperative arrangements. The PA did the H&P, the consent, ordered the appropriate labs, notified the vendor, and various other details. 

It was a busy practice. The PA saw patients in his clinic, did pre-op workups, assisted in surgery, was working on a computer project for the office, among other duties. It would be fair to say the fellow was pretty much getting flogged. As one might imagine, he had fallen into the habit of cutting corners, so to speak, now and then. 

Fairly widely, it seems. When this patient walked into the room for his pre-op appointment, the PA asked him how he was doing. The patient said he was fine, just his knee was hurting. 

Without so much as a glance at the chart or an examination of the patient, the PA did an entire workup for a knee replacement, based on that one comment: consent, H&P, scheduling, all of it. Probably took him 5 minutes. 

Now then. Before I get into the specifics regarding this case, I should mention that hip disease can cause referred pain to the knee. This may occur in adults, but more commonly in pediatric patients. The infamous slipped capital femoral epiphysis is famous for that. I had a markedly obese thirteen-year-old referred to our clinic for knee pain. As I watched him limp down the hallway, I said to the medical student standing next to me: “That’s a slip.” 

Peds ortho pinned both hips the next day. 

Occasionally, this hip-to-knee referred pain occurs in adults, so the good doctor will always document a hip examination if there is any confusion about what’s causing knee pain. Remember that; hip disease can present as knee pain. Even fractures. I guarantee, if you’re in this business long enough, that little axiom will rear its head, usually when you’re least expecting it. In this case, it seems the patient just happened to be experiencing some knee pain when he showed up for his pre-op appointment with the PA, as everything else in the chart was all about the hip. 

Now back to this case. Lesson learned? 

First of all, most PA’s, like doctors, nurses, and the rest of us in health care, do meticulous, excellent work, some of the finest I’ve ever worked with. I’m not making excuses for this fellow, but no matter if it’s a PA, neurosurgeon, or bricklayer, if overworked with an impossible work schedule, inevitably, quality is going to deteriorate. 

Things are going to happen. This guy did no examination and didn’t even open the chart. He just shot-gunned the whole process based on a single comment by the patient when he walked into the room. 

Inexcusable, to be sure. But don’t overwork these people! Put in an impossible situation with too many hoops to jump through, they’re going to adapt, they’ll start cutting corners, rushing through the routine stuff to get to the next task, already overdue. Classic breeding ground for disaster. 

Next, when this case occurred, the protocol specified the patient mark the surgical site in the holding area. That has changed such that the surgeon himself must mark the sight. Had that been the requirement, he might have caught the mistake then, before almost opening the knee. 

Surgeons, talk to your patients before they go back and make those marks. 

We are also tasked with updating the H&P before taking the patient back to the OR nowadays, easily done in the computer age: just boot it up and add an update comment. Interestingly, this requirement would not have helped in the discovery of the mistake and may well have increased the likelihood of the doctor proceeding in error because the H&P was done by the PA. The entire document referenced the wrong operation and that is what the doctor would have reviewed and updated. 

Finally, why did this patient sign a consent for a knee replacement and mark his knee for surgery when he had been followed for over a year for a bad hip? Nowadays, the nurse will specifically ask the patient in the holding area: “What is the doctor going to do to you today?” It’s amazing how many don’t know or just plain screw it up when they struggle to explain what’s about to happen to them. 

It never ceases to amaze me, the number of cases we have reviewed where patients had not a clue as to what their medical problems or treatment plans were. For the millionth time, ol’ “broken record” here will say it again: Doctors, educate your patients!! 

If nothing else, for Pete’s sake, make sure they know what you’re gonna do to ‘em before you take ‘em back to the OR!

Can’t believe I have to say that. 

J. M. MacDavid M.D. also known locally as Dr. John Kona can be contacted at WitherspoonInstitute23@ gmail.com.