Wrong Site Surgery Performed by ENT

In 2010, an ENT performed a tongue tie release on a 5 years old child who was supposed to undergo a tongue lesion biopsy (apparently 1cm in size over the central dorsal tongue). Tongue tie release was NOT consented for nor discussed with the parents who expected a tongue biopsy to be performed instead. In the investigative report performed by the Department of Public Health:

"When the surgeon was asked whether he examined the patient in the preop area prior to the surgery, he stated, "Usually, I don't examine anybody. I sometimes visit... In this case, there was no time to do a pre-operative visit. From now on, I need to see the patient prior to the surgery." [link]

According to the record, time-out WAS performed. Consent WAS in the chart for a tongue lesion biopsy. Records indicated that all mandated check-lists and time-outs were performed.

So what happened?

1) Surgeon Error: Let's face it... the surgeon made a mistake. Ultimately, it is his responsibility to ensure that the procedure goes smoothly which by definition means doing the correct procedure.

Seeing patients before surgery probably would have prevented this error. Not seeing the patient prior to surgery is not good practice.

Even if a surgeon employs a nurse practitioner or a physician assistant to see patients for him in the office or in the hospital, before any surgery, he personally should examine and discuss the upcoming surgery with all patients.

As an aside, at least once per week, I have patients calling who desire to schedule surgery without wanting to see me first for a consultation appointment. There are many reasons why I mandate that a patient MUST first be personally seen by me in the office PRIOR to any surgery scheduling. Preventing this scenario is one good reason why.

2) Nursing Error??? If the nurses knew what procedure was supposed to be done (according to the report, they did)... they should have spoken up! If they were too afraid to speak up, they should have contacted management to speak up for them... or ask the anesthesiologist to say something.

After all, patient welfare supersedes all else. Having wrong site surgery is the exact opposite.

However, to be fair in this particular situation, I do not believe the nurses knew what the surgeon was doing. Why???

The procedure was being done inside the mouth and a small child's mouth at that... honestly, nobody except the surgeon and possibly the anesthesiologist can really see what the surgeon is doing. The instruments used for tongue tie release is very similar to what would be used for tongue lesion biopsy.

3) Time-Out and Check-List Error: In a typical day, there are so many time-outs and check-lists being performed that it starts to get muted into background noise. It's just like the alarms and blinking lights that I imagine an instrument panel of a sophisticated machine would be for somebody who stares at it all day, everyday. You hear/see it... but than you don't hear/see it.

What people notice are sounds that are unusual for a given situation.

For example, cars make all sorts of noises when being turned on and moving somewhere. However, most people don't actually "hear" the sounds being produced by the car because of our lack of attention to it, because it is repetitive and continuous.

However, if one day, the engine starts knocking, that certainly gets a driver's attention and remembered.

Time-outs and check-lists suffer from inattention... even if performed.

They are a wonderful tool, but utterly undependable for long-term use.

So what would work given it must be done per regulations??? My suggestion would be to mix it up to prevent it from becoming "background" noise.

Have the time-out performed by different members of the surgical staff on every case rather than the same person. Ring a bell before doing time-out one time. On another time, have everyone dance a short jig before doing it. Whatever is done, do NOT make it repetitive which otherwise risks being inadvertently ignored.

The key is to make it different and notable each and every time in order to focus attention and prevent the task from becoming muted into the background.

Source:
CA Fines 14 Hospitals for Medical Errors. Health Leaders Media 8/31/12

Reference:
California Human and Health Resources Department of Public Health Report. 5/18/11

Same Doctor Visit, Double The Cost

On August 26, 2012, the Wall Street Journal published a story describing a situation whereby a patient who sees a physician employed by a hospital essentially pays double out-of-pocket what they would have paid for the same exact office visit with a physician NOT employed by the hospital.

I actually wrote about this situation in January 21, 2012.

Beyond what the Wall Street Journal reported, what's going on?

Assuming all things equal whereby a private practice physician and a hospital-based physician are equally competent and the supporting staff for each are both equally good (such assumptions are debatable in some circles, but will be ignored here), it all comes down to money.

When a patient sees a private practice physician, the government-established fee schedule only incorporates payments to the physician.

When a patient sees a hospital-based physician, the fee schedule not only incorporates physician payments, but also additional payments to the hospital.

Now, the patient doesn't pay what insurance covers in either scenario, but typically there is a copay or coinsurance payment that the patient is responsible for that typically is 20% of the total charges.

Here's an example using the Medicare fee schedule from 2002. I elected to provide "old" 2002 data as this information can be found easily and corroborated, but rest assured, the numbers are starkly different and perhaps more lopsided today. Medicare was selected as it is the bar to which all other insurance plans are typically based on.

In a physician run private practice, the only charges that are incurred is from the "Physician Fee Schedule". In a hospital-based practice, a patient incurs not only the physician fee schedule, but also additional charges based on the "Outpatient Prospective Payment System".

As you can see, the physician fees are slightly higher in the private practice setting compared to hospital-based practice... BUT, given the additional hospital charges involved with a hospital-based practice, the patient ends up being charged more per service for a simple clinic visit ($16.48) than if they had been seen in the private practice office ($10.06).

The cost differential for the patient is far worse with any procedures ($62.62 versus $342.47).

For the same exact procedure or service, a patient automatically ends up paying more to be seen in a hospital-based practice.

This payment system is the same whether you go to a tertiary care teaching hospital like Massachusetts General Hospital or a tiny 98-bed community hospital.

As an aside... for any physicians employed by a hospital, it behooves you to consider this differential payment in terms of how a hospital determines your salary and productivity. Do they consider ONLY the physician fee schedule or do they also take into account the outpatient prospective payment system?

I should also mention that Congress is considering abolishing the outpatient prospective payment system for clinic visits only. Click here for more info.

Source:
Same Doctor Visit, Double the Cost. WSJ 8/26/12

Hospital-Based Practice Versus Physician Private Practice. Fauquier ENT Blog 1/21/12.

Elimination of Differential in Medicare Payment for Clinic E&M Services Furnished in Hospital-Based Outpatient Departments Proposed. Martinedale 12/10/11

Medicare rules for hospital-based clinics. American College of Surgeons. Vol 87, No 4

Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System. Congressional Research Service. 8/6/2010

Bi-Lobed Zenker's Diverticulum

In the not so distant past, I saw a patient who suffered from a bi-lobed Zenker's Diverticulum. Zenker's diverticulum for those who don't know is the abnormal development of a pouch in the throat causing symptoms of phlegm in the throat, food regurgitation, swallowing difficulties, and aspiration.

Most Zenker's Diverticulum is composed of a single central pouch. However, there are more rare varieties such as this bi-lobed pouch seen on barium swallow.

However, at time of surgery (endoscopic staple diverticulostomy), the bi-lobed nature of the pouch essentially disappeared.

Video of how the surgery is performed:

Financial Issues with Emergency Room Specialist Care

Imagine this scenario... A young child is playing in the yard when her pet dog bites her face. Bleeding, the child is rushed to the emergency room and the emergency room doctor offers to suture up the child's face.

The next question a parent will probably ask (or demand) is the desire for a plastic surgeon to suture the face instead of the emergency room doctor.

As such, the plastic surgeon is called in and sutures up the face beautifully.

The child and family goes home and that's when the financial nightmare begins...

The plastic surgeon bills the family for $2,000 for services rendered in the emergency room. The plastic surgeon does NOT participate with their health insurance plan and being a non-participating provider, the bill for care provided is directly sent to the child's family.

Outrageous?

Unfortunately, it is not unusual... and there are lawsuits now pending both against specialist physicians as well as against patients regarding who pays the medical bills.

Here is an article portraying a hand surgeon who has sued numerous patients regarding just this scenario. Most specialists will either write-off or accept any amount after being sent to collection.

Background

If a patient has a medical problem, a call to the medical office is made to see the doctor. However, before the appointment is made, both the patient and office checks to ensure the visit will be covered by insurance. If not, a call to a different medical office is made until one that participates with the patient's insurance is found. However, if the patient decides to see a physician who does NOT participate with his health insurance company, he will be responsible for the entire bill (the office visit will not be covered by insurance).

The same is true for outside specialists called into the emergency room. These outside medical specialists participate only with certain insurances. As such, if they perform services on a patient whose health insurance does not cover that particular medical specialist, the patient will get the entire bill.

Emergency room care IS covered by insurance... because it is an "emergency," but services performed ONLY by the emergency room staff applies. NOT services by outside specialists called in.

What to Do?

So what is a patient to do in order to avoid a surprising large bill?

Ideally, have all services performed by emergency room staff and avoid services by outside specialists. If it is not life-threatening (like a facial dog-bite... ugly, but not life-threatening), have the emergency room doctor do all he can. Than follow-up as an outpatient with a specialist who participates with your health insurance plan.

If an outside specialist MUST be called in, ask whether this specialist participates with your health insurance plan. If not, ask how much the specialist will charge for services rendered. Be aware, if the outside specialist actually comes into the hospital, a consultation fee will be charged (typically around $100-$200). If a procedure is performed, a procedure charge will be present (hundreds to thousands of dollars).

A patient can request whether there is a different doctor who can be contacted should the specialist on-call not participate with his/her health insurance plan. However, be aware that typically only ONE doctor per specialty is on-call to the emergency room at any given time and as such, an alternative doctor may not be available.

Once you are aware of the charges, you as the patient needs to decide whether to proceed with specialist care or not.

Be aware that the insurance coverage issues also applies for specialist consultations during a hospitalization and not just in the emergency room.

Bottom Line

Simply going to the emergency room does not mean all medical services will be covered by insurance, especially services provided by a medical specialist.

If specialist care is required in the emergency room, just ask whether the specialist participates with your health insurance plan, because if not, be aware that you directly will get a bill.

That's just how the medical system is set up currently.

Guns n' Roses Rocker Duff McKagan Underwent Sinus Surgery

Duff McKagan, the bassist of Guns n' Roses, apparently underwent sinus surgery back in December 2010.

According to media reports, his sinus cavities developed significant scar tissue due to years of cocaine abuse.

Sinus surgery due to scar tissue is a relatively rare indication for surgery, but required if they block sinus cavities leading to recurrent sinus infections.

Cocaine abuse more typically causes other sino-nasal abnormalities especially septal perforation.

Exactly what type of sinus surgery Duff McKagan underwent is unclear, but for sinus scar tissue, balloon sinuplasty is typically the route taken and can be performed in the office.

Balloon sinuplasty is when the sinus openings are enlarged using a balloon and can potentially be performed in the office assuming no anatomic contraindications (significant deviated septum, nasal polyps, etc).

However, before sinus surgery is considered in a patient who is suffering from recurrent sinus infections whether scar tissue is present or not, a workup is typically required followed by maximal medical management.

A typical workup includes a CT sinus scan, allergy testing, and nasal endoscopy. If allergy testing is significant, aggressive allergy management is required prior to surgical consideration.

Depending on the CT scan and endoscopic findings, there are two "flavors" of sinus surgery: traditional and balloon sinuplasty.

Traditional sinus surgery, otherwise known as functional endoscopic sinus surgery, is when all sinus disease is physically removed endoscopically from the nose and sinus entrances are enlarged.

Source:
Duff McKagan explains sinus surgery. SFGate 12/17/10

Motley Crue Bassist Facing Sinus Surgery

Dr. Feelgood may be just a song by Motley Crue, but the band's bassist, Nikki Sixx may be facing sinus surgery.

Per his twitter comment on June 27, 2012:

"Spent a lot of the day at the doctors. The 80s and the damage done. Yes the sinuses are a mess. Eventual surgery. The price we pay."

Typically, before sinus surgery is considered in a patient who is suffering from recurrent sinus infections, a workup is required followed by maximal medical management.

A typical workup includes a CT sinus scan, allergy testing, and nasal endoscopy. If allergy testing is significant, aggressive allergy management is required prior to surgical consideration.

Depending on the CT scan and endoscopic findings, there are two "flavors" of sinus surgery: traditional and balloon sinuplasty.

In traditional sinus surgery, otherwise known as functional endoscopic sinus surgery, is when all sinus disease is physically removed endoscopically from the nose and sinus entrances are enlarged.

Balloon sinuplasty is when the sinus openings are enlarged using a balloon and can potentially be performed in the office assuming no anatomic contraindications (significant deviated septum, nasal polyps, etc).

Exactly what type of sinus surgery Nikki Sixx will pursue is not clear, but regardless of what method is selected, there will be a period of recovery afterwards which almost certainly will include saltwater sinus rinses.

Our office provides both sinus surgery options as well as in-office sinus surgery.

Source:
Nikki Sixx needs surgery for sinus problems. SFGate 6/28/12

Scientists Publish Research on Breakthrough Treatment for Tonsil Stones

Title sounds very exciting... even more so when I realized it was talking about the research paper that I co-authored with fellow ENT colleague Dr. Richard Thrasher on a new way of addressing tonsil stones.

I never really considered myself a "scientist,"but glad to hear that at least somebody considers me one!

This article apparently came out on MedicalXpress, a medical news website. It has also been picked up in a few other channels as listed under sources.

Source:
Scientists Publish Research on Breakthrough Treatment for Tonsil Stones. MedicalXpress 6/20/12

New Minimally Invasive Technique to Treat Tonsil Stones Developed by Dr. Chang. Fauquier ENT Blog. 6/14/20

Ear, Nose & Throat Journal publishes research on breakthrough treatment for tonsil stones. EurekaAlert 6/20/12


Reference:
Coblation cryptolysis to treat tonsil stones: A retrospective case series. Ear Nose Throat J. 2012 Jun;91(6):238-54.

New Minimally Invasive Technique to Treat Tonsil Stones Developed by Dr. Chang

Dr. Chang developed an innovative minimally invasive technique to treat tonsil stones using coblation technology. His findings have been published in this month's ENT Journal. In fact, his research made the front cover of the journal! Dr. Richard Thrasher of ENT Centers of Texas was a co-author in the study.

This technique called coblation tonsil cryptolysis is unique in that it can be performed in adult patients without sedation using only local anesthesia, much like laser tonsil cryptolysis. As with laser cryptolysis, pain is significant for only a few days and most adults can resume normal diet and activity within 1 week. In contrast, tonsillectomy entails significant morbidity for several weeks. However, coblation avoids the significant disadvantages of laser use, including the potential for airway fire, retinal damage from reflected scatter, dealing with plume from vaporized tissues, oral/facial burns, and the high cost of purchasing and maintaining laser equipment. After a single session of coblation tonsil cryptolysis, a significant decrease and even elimination of tonsil stones can potentially be achieved.

Read more about this mode of treatment here.

Read the research article here.

Costs of Surgery... How Is This Calculated?

So I have blogged about this topic a few times in the past, but there still seems to be confusion regarding the costs of surgery.

As mentioned in the past, the cost of surgery is broken down into basically 3 separate charges:

• Surgeon's charge
• Anesthesia's charge
• Hospital's charge

So... after surgery, a patient typically will get 3 bills; one each from surgeon, anesthesia, and hospital.

At least in the United States, the three charges are completely separate from each other to the point that anesthesia will have no idea what the charges for the surgeon as well as hospital will be.

Same goes for the surgeon... the surgeon will know his charges, but will have no idea what the charges will be for anesthesia and the hospital.

Even if the surgeon demands to know what anesthesia and the hospital will charge for a surgical procedure (s)he will perform, a specific charge will not (can not) be provided in the United States typically.

Why is that?

If I am going to perform for example, a tonsillectomy, why can't anesthesia give even me the surgeon a specific dollar amount of what anesthesia will charge? Why can't the hospital administration provide me the hospital charges?

Here's why... or at least part of the reason why in the United States...

Surgeon's Charge

The surgeon's charge is set. For a given surgeon, his/her charge will remain the same regardless of time or difficulty of the surgery. It may be different between different surgeons... but for a given individual surgeon, it will always be the same for a given procedure.

For example, if the surgeon's tonsillectomy charge is $250. It will remain $250 whether it takes 15 minutes or 3 hours. It will remain $250 if the surgery was technically difficult or a piece of cake.

So, the surgeon's charge is easy. It is what it is.

The harder question to answer is what the anesthesia and hospital charges will be...

Anesthesia Charges

Anesthesia charges on a per time basis (in increments of 15 minutes) on top of a "base" charge that depends on the surgical procedure.

For example, let's say a given anesthesia group has a base charge of $500 for tonsillectomy.

Let's also assume this particular anesthesiology group charges $500 per 15 minutes of anesthesia.

SO... if the surgeon performs a tonsillectomy and it takes the surgeon 30 minutes to perform the procedure, the anesthesia charge will be $500 base charge PLUS $1000 for the time ($500 per 15 minutes) for a total anesthesia charge of $1500.

If it so happens that the surgery takes only 15 minutes... than the anesthesia charge will be $1000 ($500 base charge plus $500 for the 15 minutes surgical time).

In other words, for the SAME exact surgical procedure, the anesthesia charges may be different for different patients depending on how long the surgery takes.

Hospital Charges

Different hospitals calculate their charges differently... but in essence, the hospital will charge whatever it cost them to allow the surgery to happen in their facility plus a nebulous "profit" factor.

SO, a given hospital charge will include the:

• Salary of all the personnel used in the surgery (surgical tech, registered nurse, circulating nurse, anesthesia tech, secretary, etc)
• Equipment used during the surgery (IV lines, needles, anesthesia tubing, masks, endotracheal tube, surgical equipment, etc)
• Medications used during the surgery (gases, IV drugs, etc)
• Facility costs expended during the surgery (electricity, water, oxygen, medical waste disposal, etc)

To take the example of tonsillectomy, the hospital charges will include all the equipment, medications, personnel, and facility costs utilized during the tonsillectomy surgery.

In Summary, the Cost of Surgery is... It Depends

Given anesthesia charges vary based on the time duration of surgery regardless of WHAT the surgery is as well as hospital charges which may vary based on how much was "expended" during the surgery regardless of WHAT the surgery is, the anesthesia and hospital charges are moving targets which roughly correlate with how long the surgery takes.

The surgeon can certainly state what their charges will be up-front because this charge is fixed, but anesthesia and hospital charges are NOT fixed and depend on a certain time factor regardless of WHAT surgical procedure is being performed.

Because of this time dependence, that's why anesthesia and hospital charges can not typically be obtained prior to surgery in most places.

That's also why most places can't (won't) post the total cost of surgery up-front.

Of course, if a given surgeon is very consistent and always takes 15 minutes to perform surgery and always uses the same exact equipment, than anesthesia and the hospital may be able to provide an "averaged" charge up-front.

It is also not uncommon that additional "discounts" may be offered based on a patient's income.

Some places like the Surgery Center of Oklahoma somehow persuaded the anesthesiologist, surgeon, and facility administrators to sit around a table and force an agreement on a fixed TOTAL charge for different surgical procedures. Once an agreement is made on a fixed charge for each, an up-front cost can be publicized... but this can never happen as long as anesthesia and hospital refuses to agree to a fixed charge and rather stick with a time-based framework to determine their charges.

Surgery Center Posts Prices of Procedures

Given the uproar over the lack of transparency of surgery prices, it was only a matter of time before an operating facility in the United States (oversea facilities have already done so) takes the step of posting the cost of surgery... a set cost that is exactly what a patient pays. Complete cost transparency.

The Surgery Center of Oklahoma is an AAAHC accredited facility since 1998 and has over 40 participating surgeons. And they are the first that I'm aware of that has taken the step of posting the cost of surgery on their website. The caveat being the cost shown ONLY applies to those who do not have health insurance.

On their website, they state:

"Transparent, direct, package pricing means the patient knows exactly what the cost of the service will be upfront. Fees for the surgeon, anesthesiologist and facility are all included in one low price. There are no hidden costs, charges or surprises."

Keep in mind that this cost is NOT just the surgeon's fee, but also includes the anesthesia charges as well as facility charges. Read more about such charges here.

So what are the charges? They have it all posted on their website!

But below is a list of charges for ENT procedures as of 6/3/12 (surgeon, anesthesia, and facility charges all bundled into a single charge). The webpage also includes prices for general surgery, orthopedics, urology, ophthalmology, etc.

I wonder if other facilities in the United States will start following suit???

Neck
Thyroidectomy		$ 6,160.00
Lymph Node Excision / Biopsy		$ 2,255.00
Ear
Myringoplasty		$ 2,400.00
Bilateral Myringotomy with tubes		$ 1,700.00
Tympanoplasty		$ 5,060.00
Tympanoplasty - Mastoidectomy		$ 7,050.00
Mastoidectomy		$ 6,640.00
Inner Ear - Stapedectomy		$ 5,390.00
Ossiculoplasty		$ 5,060.00
Cochlear Implant		$ 8,800.00
Foreign Body Removal		$ 1,500.00
Nose
Bilateral SMR Turb		$ 2,700.00
Sinus / Turbinates 1 side		$ 3,795.00
complex		$ 4,950.00
Sinus / Turbinates both sides		$ 4,510.00
complex		$ 5,885.00
Septoplasty		$ 3,550.00
Septoplasty and Sinus/Turbinates		$ 5,060.00
Nasal Fracture Simple Closed		$ 1,900.00
Nasal Frature Complex Open		$ 4,015.00
Throat
Tonsillectomy		$ 3,050.00
Adenoidectomy		$ 2,695.00
Tonsillectomy and Adenoidectomy		$ 3,695.00
Adenoidectomy and BMT		$ 3,300.00
Tonsillectomy and Adenoidectomy and BMT		$ 4,400.00
Frenulectomy		$ 1,600.00
Uvulopalatopharyngoplasty		$ 5,445.00
Diagnostic Laryngoscopy with biopsy		$ 2,970.00