Surgical Time-Out, circa Year 2050

In the year 2050, surgical time-outs have reached a new level of safety to ensure the utmost care and risk reduction for patients.

Unlike the primitive time-outs performed in the the first decade of the 21st century (2000-2012) which involved one designated individual to confirm prior to incision (Basic9), the patient name, surgical site, performing surgeon, allergies, antibiotic administration, positioning, x-ray name confirmation, fire hazards, and fall risk, significant additional safety checklists have been implemented to create a new state-of-the-art culture of safety both in and out of the operating room.

In 2015, surgical time-outs extended to also include electrical and air quality checks (Environ2) along with separate mandatory time-outs of the Basic9 before, during, and at conclusion of surgery.  To ensure minimal air contaminants as well as maintain the highest performance of all electrical equipment in the operating room, the Environ2 requires a separate electrical and environmental engineer to certify all equipment and confirm air quality at a level of no more than one contaminant part per trillion to the 10th power in 35 separate locations within the operating theater. The Environ2 checks are double-confirmed by the circulating nurse who has been granted broad powers to cancel surgery for any reason without consequence if there are any concerns with the operating room environment that may increase infection risk for the patient as well as sub-optimal performance of any and all equipment used to perform the surgery.

In 2020, the Total5 was added to Basic9 and Environ2 which truly heralded the onset of state-of-the-art surgical time-outs. Total5, developed jointly by the Harvard School of Public Health and National Institute of Medicine, involves a comprehensive time-out of any and all individuals entering into the operating room in the knowledge that surgical outcomes are affected by personnel movement into and out of the operating room whether from contaminants on the skin or clothing of staff to infections that they may or may not be harboring. In rare cases, given the recent terrorist attacks both biological as well as chemical, the Total5 would additionally eliminate such threats.

As such, Total5 involves for each and every staff member that enters the operating room to undergo "individual time-outs":

1) Geiger counter check

2) Body pat-down by TSA (whose duties have tremendously expanded from initial airport security)

3) Metal detector check

4) Chemical check (specifically looking for arsenic, mercury, formaldehyde, etc as well as drug screen)

5) Biohazard check (routine organisms include MRSA, VRSA, C dif, HIV, hepatitis, etc as well as more exotic organisms like Ebola, Swine Flu, Anthrax, etc).

A separate consent must be in the chart for each and every individual who is present for the patient's surgery with their Total5 report.

The Basic9, Environ2, and Total5 surgical time-outs collectively have ensured a 360 degree safety net for the patient.

But... it is not until now in the year 2050 that the surgical time-out has reached a penultimate state with the expansion of the Total5 to Total10. In addition to the original Total5 for surgical staff, 5 additional time-out checks of surgical staff is now required. Continuing with #6...

6) Retina scan (to confirm staff identity)

7) Fingerprint scan (to double-check staff identity)

8) Malpractice insurance check (if positive, consent must be in chart to ensure patient was aware of any malpractice committed by any surgical personnel doctor or nurse)

9) EKG to ensure peak cardiac health of staff member

10) EEG to ensure a rested mind at peak performance of staff member

As with the Total5, Total10 report for each staff member must be included in the patient consent in the patient's chart.

There was some confusion whether each staff member can undergo just one Total10 per day, but with new regulation acknowledging possibility of patient infection contaminating personnel as well as staff member fatigue that may progress throughout the day, a Total10 MUST be performed before each and every surgical case.

For any further questions on surgical time-outs, please contact your local hospital JCAHO executive liaison.

The Four Types of Patients Seen in a Surgeon's Clinic

Over the years, I have found that patients can be loosely grouped into 4 different types. Nothing particularly wrong with any type, but it does help me to approach patients appropriately if I can get a sense of what type they are.

The four types are:

Type A:  If a surgery can "fix" or "cure" me such that I won't have to take medications every day of my life, than let's do it.

Type B: I will never consider surgery unless it is a life-threatening situation. If a medicine can help, why do it???

Type C: I will consider surgery only as a last resort when all else fails.

Type D: They thought they were Type B or C, but over time, they realize they are Type A.

Why is this important?

Because if a patient is Type B and surgery is recommended, the patient often develops an automatic distrust of the surgeon. The patient may see the surgeon as a "gun-slinger" who likes to cut people.

If a patient is Type A and the surgeon approaches them like Type B or C, such patients may come out of a visit quite disappointed and at worst, upset that the surgeon will not do what they want.

Ultimately, for a happy clinic encounter, a mutual understanding needs to quickly happen otherwise a mutual discord may snowball ultimately leading to a second opinion with another surgeon.

Of course, there is a more complex dynamic going on, but it's a good over-simplification.

HIPAA Allows for Regular Email Communication Between Patients and Physicians

There is a widespread mistaken belief that HIPAA prohibits physicians from communicating with patients using regular un-encrypted email as well as with other physicians about patient care.

HIPAA, for those who don't know, is a law that requires patient information to be kept private with safeguards. Email (such as yahoo, gmail, aol, etc) is not considered a secure form of communication.

However, HIPAA does allow for such un-secured email communication under certain circumstances. I quote from the horse's mouth:

"Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual. If the provider feels the patient may not be aware of the possible risks of using unencrypted e-mail, or has concerns about potential liability, the provider can alert the patient of those risks, and let the patient decide whether to continue e-mail communications."

As such, it may be worthwhile for a patient to acknowledge the following statements before an email can be sent from a practice website using un-secured email:

"I understand email is not considered secure and as such, is not considered a confidential method of communication."  

"By your sending an email to us, you are giving permission for us to reply by email."

Even if private health information may be included, that's fine if, I quote from the horse's mouth:

"Further, while the Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between health care providers and patients, other safeguards should be applied to reasonably protect privacy, such as limiting the amount or type of information disclosed through the unencrypted e-mail."

Read more about un-secured email communication as it relates to HIPAA here from the Department of Health & Human Services.