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

Tongue Taste Map is a LIE!

As children, we all learned about the 4 different taste qualities the human tongue can appreciate: salty, sugar, bitter, and sour. Savory or umami was added in 1985. "Calcium" has been proposed in 2008 as well as more recently, "fatty" taste.

Along with the 5 (and possibly more) taste qualities we all had to memorize at some point, we also had to memorize the taste map of the tongue (yes... I know umami is missing):

Well... what a waste of time to memorize the tongue taste map because it is wrong!!! This tongue taste map was originally sketched by Edwin Boring in 1942 and has since been frequently reproduced in textbooks, wine classes, and biology courses.

The tongue taste map delineates specific areas where certain taste qualities are perceived better than in other areas like the state of Texas is distinctly a different region than Montana.

However, reality is a mish-mash patchwork spread unevenly throughout the tongue that is different for each person.

Each of the ~5000 taste buds found on the surface of the tongue contain clusters of over 100 taste cells with receptors that have different degrees of sensitivity to molecules carrying MORE than one basic taste and that these clusters are distributed across the entire surface of the tongue.

Bottom line?

Tongue taste map is a lie.


Reference:
The cell biology of taste. JCB vol. 190 no. 3 285-296, doi: 10.1083/jcb.201003144

Receptor seeks ligand: on the way to cloning the molecular receptors for sweet and bitter taste. Nat. Med. 5:381–382. doi:10.1038/7377

A Map of Taste. NYT 3/19/12

Dr. House of TV Fame Would Never Survive in Real World

Would YOU as the patient see a doctor who is a well-known jerk, abuses drugs, gives the wrong diagnosis more often than not, and is known to like ordering very invasive tests??? Be honest...

The other week, a patient with a chronic cough exclaimed to me that she wished the fictional character Dr. House of TV fame actually existed in real life, because he was somebody who can diagnose anything.

I looked her straight in the eye and told her that somebody like Dr. House in the real world would be a physician nobody would want to see for many reasons:

1. In the real world, patients expect doctors to have the correct diagnosis from the beginning (might forgive one wrong diagnosis). Dr. House seems to always get things wrong multiple times before he gets it right. I seriously doubt most patients would have stuck around as long as they do on the TV shows before going elsewhere.
2. In order to achieve that correct diagnosis, Dr. House seems to pursue invasive tests which in reality is something patients rarely like to pursue... and often get second opinions to determine if really needed.
3. Dr. House is fairly abrasive with his colleagues and even with his own patients which pretty much guarantees one star ratings on physician rating websites like HealthGrades.com and Vitals.com.
4. Dr. House is addicted to vicodin, morphine, and cocaine... That pretty much guarantees loss of hospital privileges and perhaps even his medical license to practice in the real world. Furthermore, what would you do as a patient if you found out that your doctor abuses drugs??? Most will go elsewhere.

So given what I know patients want in reality, it boggles my mind why patients in the real world think Dr. House is so great and wish a fictional character like him truly existed.

To flip things around... the real question is why aren't real world patients more forgiving of physician fallibility like those on TV? I'm the first to admit that physicians (in the real world) are not perfect though the expectation is that we are.