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Not a Clue


Not a Clue

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 “degenerative arthritis, right knee.”  The consent was signed for a right knee replacement.  The vendor was ready with knee components.

The patient himself initialed his right leg with a purple marker, as requested by the nurse.  They started the prophylactic antibiotics in the holding area and took him back to the OR.

He was prepped and draped in the usual manner.  The OR staff did their “time out,” with the circulating nurse reading aloud the consent, which read: “right total knee arthroplasty.”  The surgeon took the knife.  The anesthesiologist noted the start time.  They were underway.

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

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

He put the knife down and pondered a moment the patient that lay before him.  He then asked the circulating nurse to call his office.  The staff looked quizzically at each other as the nurse lifted the telephone off the OR wall and dialed the number.

The doctor asked his office girl to pull the patient’s chart.  When she had it in hand, he asked her to read the office notes to him.

Everything in the record referenced end-stage degenerative arthritis of the right hip.  The last entry was a preoperative note planning a total hip arthroplasty.  There was not a word in the chart about a knee problem.

The surgeon cancelled the case.



Doctor Witherspoon Says:

Dr Witherspoon

Sufferin’ catfish!  This guy almost whacked out a perfectly good knee.  That’s as close as it gets to disaster.

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

The surgeon employed a physician’s assistant (PA).  When the surgeon determined the patient was to have surgery, the patient was given an appointment with the PA, who took care of the pre-operative arrangements.  The PA scheduled the surgery, did the history and physical, filled out the consent, ordered the pre-op labs, notified the vendor, and various other details.

It was a busy practice.  The PA saw patients, did pre-op work ups, assisted in surgery, was working on a computer project for the office, among other duties.  The fellow was pretty much getting flogged, as it were, and had fallen into the habit of cutting corners, now and then.

Very widely, it would seem.  When this particular patient walked in the room for his pre-operative appointment, the PA asked him how he was doing.

“Not too bad.  My knee’s hurting, though,” the patient said.

Without so much as a glance at the chart or a physical examination, the PA shot-gunned all the paperwork for a total knee replacement:  H&P, consent, scheduling, vendor notification: the works.  It probably took him five minutes.

The doctor had been seeing him for over a year for well-documented hip disease.  He even had normal knee x-rays on file.

Now then.  Before I get in to the specifics of what there is to learn from this inexcusable almost-first-class-disaster, there are a couple of points to make.

Hip disease sometimes is manifested by referred pain to the knee.  This is particularly true with pediatric cases.  Perthes and, in particular, the infamous slipped capital femoral epiphysis, are famous for showing up with knee pain.  Any child with knee pain must have an examination of the hip.  I guarantee, if you’re in this business long enough, that little axiom will manifest itself when you’re not particularly thinking about it and least expecting it.  Remember that:  pediatric knee pain mandates an examination of the hip.

Recently I had a markedly obese thirteen year old referred to our clinic for knee pain.  As I watched him limping down the hallway coming towards the examining room, I said to the medical student standing next to me: “That’s a slip.”

Peds ortho pinned both hips the next day.

Occasionally, this referred pain occurs in adults so the good doctor will always document a normal hip exam if there’s any question about where knee pain’s coming from.

Back to this case.  Lessons learned?

First of all, PA’s are no different from physicians, nurses, nurse practitioners and other health care providers when it comes to the responsibilities we have to our craft.  I have been profoundly impressed with their expertise and have absolute confidence in their abilities.

Yet, we are all vested with extraordinary trust, and our mundane, daily regimen, no matter how taxing, must ring true to that trust.  I’m not making excuses for this individual, but if anyone is abused or overworked, you’re asking for trouble.  This guy did no examination and didn’t even open the chart.  He just shot-gunned all the paperwork based on a single comment by the patient when he walked in the room.  Inexcusable.  Certainly.

But beware!  Don’t overwork these guys!  Put in an impossible situation with too many hoops to jump through, people are going to adapt, they’ll start cuttin’ corners, rushing through routine stuff to get to the next task, already overdue.  Classic breeding ground for bad things to happen.

Next point.  When this mistake took place, the protocol was to have the patient mark the surgical site.  That has changed and now the doctor must mark the surgical site in the holding area.  That new requirement might have made a difference in this case, as the surgeon may have discovered the error in the holding area and avoided an unnecessary anesthesia.

Third point.  Marking the proper site was devised to avoid a wrong-site surgery, most commonly the wrong limb, i.e., left as opposed to right.  The nurse might ask the patient what surgery he is to have and the patient may respond: “Fix my right leg.”  Fair enough.

But what part of the right leg?  Hip?  Knee?  Ankle?  In the holding area, the nurse interviewing the patient should make sure the patient knows not only what side or limb is to undergo surgery but exactly where on that limb the surgery is to take place.

Final point.  Why in the Sam Hill did this patient sign a consent for a knee replacement operation when he had been worked up for over a year for a bad hip?  This doctor, an excellent surgeon, was known to be, upon occasion, a bit of a fast talker.  In ‘n’ outta there, so to speak.  Are we sure his patients are getting the big picture?

It never ceases to amaze me, the number of cases we have reviewed involving patients who 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 danged-sure they know what you’re gonna do to ‘em when you take ‘em to the OR!

Can’t believe I have to say that. 

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