Dr. Chang Makes Front Page News in Local Newspaper with Practice Merger

On January 31, 2014, Dr. Chang made front page news of the Fauquier Times local newspaper with his planned practice merger with Blue Ridge Orthopaedics and Spine Center to become part of the Greater Piedmont Medical Association. With this merger, he will be also joining Dominion Internal Medicine (Drs. Robert Lin and Michael & Jennifer Ackerman) as well as Urological Associates of the Piedmont (Dr. Pfeffer). In spite of this merger, the practice name, addres, location, staff, phone number, etc will all still remain the exactly same.

Read the article here!

Read More

ENT Question Bank iPhone App for Physicians and Residents

The AAO-HNS has released a nifty iPhone app that contains 400+ Q&A to test one's knowledge in the field of otolaryngology. Called AcademyQ, it is free for 10 sample questions, but $49.99 to access the entire question bank.

Although anybody can download the app (link to app store), it's really meant for busy ENT surgeons. This app may be worthwhile to quiz oneself on esoteric ENT trivia in between surgical cases and patient office visits where one might have a minute or two to go through a few questions.

The questions are similar to the ones one may encounter in the Home Study Course.

More debatable is whether such a question bank is helpful in preparing for Board-Certification or Recertification.

In any case, for example, one of the sample questions is:

Whether you get the question right or wrong, an extensive answer is provided to explain further:

Read More

Lawsuit for Botched Laser Vocal Cord Surgery

In February 2012, an ENT surgeon removed vocal cord polyps using a laser while the patient was asleep with a Medtronic Laser-Shield II endotracheal tube. Unfortunately, the laser perforated the endotracheal tube, ignited the 100% oxygen being used at the time resulting in catastrophic burns to the patient. [link]

Subsequent lawsuit resulted in favor of the patient who received an award totaling $30 million on 12/5/13.

What Happened?

Even though an endotracheal tube meant for use with laser procedures was utilized, if this specially designed tube sustains enough damage from the laser, it will either perforate or heat to a high enough temperature to ignite. Furthermore, 100% oxygen was administered by the anesthesiologist which just added gasoline to the flame.

Ideally, in such laser procedures, meticulous surgical technique is still required and care taken to avoid damaging the endotracheal tube, even if a "laser-safe" tube is used. The "weak" part of any laser-safe tube is the cuff that is inflated to make a tight seal between the trachea and the tube itself. As such, the cuff material is necessarily thin. Saline-soaked pledgets placed immediately above the cuff helps protect the cuff as well as use of a tube with two cuffs (in case one fails). Also, room air should have been administered to the patient in the event the tube fails in order to minimize oxygen in the area... and the patient placed temporarily on apnea whenever the laser is turned on.

The risk of fire among other reasons are why many ENT surgeons (myself included), have stopped using lasers for procedures done in the mouth and airway.

With vocal cord procedures, I still utilize cold steel techniques which has a zero risk of airway fire.

Sources:
Botched surgery will cost hospital. The Wenatchee World. 12/6/13.

Medtronic slips $18M verdict in surgical fire case. MassDevice. 12/10/13

Read More

ENT Doctor iPhone App Games

This was bound to happen sooner or later… thanks to @hobsonent who brought this to my attention.

This Nose Doctor iPhone app game basically is to try and remove nasal hair as well as boogers from different characters' noses using different instruments.

Another iPhone app game is Ear Doctor which deals more with ear problems (obviously).

Although these iPhone apps makes a game out of it, do ENT doctors actually professionally remove boogers, earwax, and nasal hair? We do… Regularly… For real… We are indeed professional ear and nose-pickers.

Read More

Presentation on Social Media Given at AAO-HNS Meeting in Vancouver, BC

It was with great honor and pleasure that I was asked by the American Academy of Otolaryngology-Head and Neck Surgery to co-present a 90 minute long mini-seminar on social media in medicine on October 2, 2013 in Vancouver, BC.

Dr. Wendy Stern (Vice Chair - Public Relations Committee of the Board of Governors of the American Academy of Otolaryngology/Head and Neck Surgery) along with Dr. John Carter (AAO-HNS Section for Residents and Fellows) organized this talk coordinating 4 speakers including:

• Dr. Lawrence Simon (Assistant Professor at Louisiana State University) providing an overview of social media and its pervasiveness
• Myself from the view of a private practice
• Dr. Julie Wei (Division Chief at Nemours Childrens Hospital in Orlando, FL) from the perspective of an academic medical practice
• Dr. Lee Eisenberg (Associate Clinical Professor at Columbia University) portraying the medical-legal pitfalls of social media

During this presentation, it was great to hear, see, and meet other otolaryngologists active in social media including @ENTinTraining, @ent_amy,@ithinkalot as well as blogger Dr. Bruce Campbell (Reflections in a Head Mirror; aka @headmirror).

One of my former mentors at Duke University, Dr. Richard Scher, was also present.

Here's a few tweets related to this event...

Read More

Pro Golfer with History of Leukemia and ENT Emergencies

The New York Times published a story about pro golfer Laura Kueny who was diagnosed with acute lymphocytic leukemia at 3 years of age and the harrowing experiences she had to go through to beat the cancer.

It certainly brought back memories when I was a resident at Duke University and was filled with dread whenever I got consulted to evaluate a sick child with leukemia undergoing treatment.

It is breathtaking just how sick such children are... what in a normal child is not considered an ENT emergency like strep throat, tonsillitis, sinusitis, and ear infections, are now considered an emergency. Such common childhood infections can literally kill a child undergoing chemotherapy and/or bone marrow transplant. With cancer treatment, these kids have no immune system and significantly reduced ability to clot due to platelet loss.

Being poked and prodded is a given... but there's also the ENT endoscopies and surgeries that often need to be performed to either save a life or to just figure out what germ is causing an infection so the appropriate powerful antibiotic can be given.

Making a hole in the eardrum as well as nasal endoscopies are routinely performed in order to culture the pus present.

Tonsillectomy surgery can be a particularly harrowing experience for an ENT surgeon as it can be literally life-saving and life-ending all at the same time. A bad tonsillitis can overwhelm what little immune system these children have in spite of antibiotics and emergency tonsillectomy may need to be performed to help the child recover from a potentially lethal infection... BUT... performing this type of surgery when platelet counts may be non-existent can also result in life-threatening blood loss. In the end, the child remains intubated after surgery while getting IV platelet infusions, and the entire oral cavity packed with gauze to provide direct pressure to manually stop bleeding for a few days. Once the gauze packing is removed and no bleeding is seen, extubation can proceed.

Sinus surgery for persistent sinusitis can also result in a nosebleed that just will not stop bleeding thereby requiring prolonged nasal packing.

And is it worth it in the end?

Yes... for what used to be a death sentence has now become one of the more curable cancers.

Source:
Golfer Leaves Hospital as a Survivor, Returns as a Winner. New York Times 6/22/13

Read More

New Movie Trailer for Fauquier ENT YouTube

It has been an amazing experience with how successful our videos have been on YouTube. We now have 60+ different videos of ENT procedures that has been viewed over 247 million times since 2007. We also now have over 12,300 subscribers to our video channel.

To celebrate, a movie trailer of sorts has been created to introduce new viewers to the sort of videos they will see and will continue to see from us.

Check it out! And... if you haven't yet subscribed to our video channel, please do so!

Read More

Nice ICD10 Booklet for ENTs

The American Academy of Otolaryngology (AAO-HNS) has put out a sample ICD10 booklet of sorts which may come very handy once ICD10 usage becomes mandatory in 2014. ICD stands for "International Classification of Diseases" and is the way physicians code for a given medical problem. It also is one way health insurance determines what tests or surgeries will be approved or not.

The current ICD system being used is called ICD9.

Within ICD9, an acute ear infection (whether right or left side) would be coded as 382.9.

With ICD10, more detail is contained. For example, ICD10 code H66.002 is left acute ear infection without rupture.

Although ICD10 will contain much more detail about the medical condition being described, with increased detail brings more headaches as one ICD9 condition may now have 10 other related ICD10 codes that need to be specified.

Which means ENT related ICD codes which used to all potentially fit on a one page cheat sheet may now take over 10+ pages booklet.

The AAO-HNS was nice enough to compile a booklet of the most common medical diagnosis with their ICD10 codes for the otolaryngology specialty.

You can download the pdf or MS Word doc here.

Read More

ENT Sued for Wrongful Death from Airway Closure

Media reported on a malpractice case whereby in October 2010, a woman presented to the emergency room at Ochsner Medical Center (Louisiana) with symptoms of sore throat, neck pain, and painful swallowing.

A CT neck performed at that time revealed "swelling in her neck and a narrowing at the top of the throat" [link]. Patient was given a strong pain medication to help with her discomfort (presumably a narcotic), admitted into the hospital, and ENT consulted for further evaluation and management. Unfortunately, the patient's airway completely closed early the next morning resulting in a massive brain injury due to oxygen deprivation with eventual withdrawal of life support four days later.

Lawsuit against the hospital and ENT among others pending.

What could have happened?

Based on the limited information provided, it seems that the airway swelling noted on the CT scan could have been due to a large peritonsillar abscess, throat tumor, or epiglottitis.

A peritonsillar abscess is basically a tonsillitis gone real bad with pus collecting under the tonsil causing it to swell. This condition could have been treated quickly with an incision and drainage.

Epiglottitis is when the "throat flap" becomes infected resulting in massive swelling which can lead to airway closure. Typical management would include IV antibiotics, IV steroids, and close observation. If airway truly becomes critical, an awake tracheostomy should be pursued. However, medical management is most always tried first if airway is still patent (albeit narrowed).

Throat tumor (ie, cancer) is pretty much a large growth in the throat causing airway narrowing. Treatment is an emergent awake tracheostomy followed by biopsies to determine what type of cancer is present so that treatment can be pursued as quickly as possible.

It is unclear from media reports exactly what was causing the airway narrowing and whether ENT had even seen the patient until the airway closed off. Also unclear was whether the ENT was made aware just how critical the airway was.

A tragedy...

Source:
Daughter of woman who died from brain damage after airway swollen shut sues hospital. The Louisiana Record 4/15/13

Read More

Some Facts About Q-Tips and Ears

In this week's episode of "Girls" (Season 2; Episode 9 "Girls Gets Dark"), Hannah grappling with OCD, inserted a Q-tip deep into her ear canal and "heard air hiss out the hole" due to perforating her eardrum.

Although this scene came out of a TV show, this scenario is not uncommon and results in many ENT office visits every month for not only eardrum perforations, but bleeding due to trauma to the ear canal skin.

Some facts about Q-tips as it relates to the ear...

It should never be used to clean earwax within the ear canal. In fact, on Unilever's website (the maker of Q-tips), the company explicitly states that Q-tips should only be used to "gently around the outer ear, without entering the ear canal." [link]

In fact, the word "ear" appears less than a dozen times on the entire Q-tip website.

Apparently, Q-tips are meant for many other uses beyond ears which play only a very small role in the world of Q-tips.

• Cleaning tiny spaces in ventilator grates
• Applying polishes to silverware
• Dust picture frames
• Clean keyboards and the computer screen
• Applying wood stain
• Clean tracks and grooves of medicine cabinets
• Clean small compartments of washing machines
etc, etc, etc

Read More

ENT Uses Laser Resulting in Patient Death

In 2010, an ENT used a Sharplan laser with an Omniguide Sidefire Adapter to address a superficial lip hemangioma.

The tip of the laser probe was inserted through a small incision made to one side of the hemangioma and activated. Seconds later, the lip and surrounding tissues immediately swelled up indicating trapped gas. A second incision was made in an attempt to release the buildup of gas (analagous to popping a balloon to release air). A short time later, the patient's vital signs dropped and in spite of life-saving measures, was pronounced dead within 2 hours.

The official autopsy report declared death due to "arterial embolism." [link]

What happened?

In the operation of the Sharplan laser, there are two channels present in the laser probe. One channel carries the laser and the other channel carries compressed helium gas that flows over the probe tip to cool it down (a laser is essentially a very focused beam of light and is quite hot... just like direct sunlight which is unfocused).

The helium gas pressure flow can be varied between 50-70 psi (pounds per square inch). Just for a frame of reference, car tires are pressurized to about 35 psi.

What essentially happened at the time of the procedure was helium gas built up within the lip under too high a pressure. Some of this helium gas (as a bubble) entered the blood stream where it blocked blood flow to vital organs like the brain and/or heart resulting in death

To prevent this complication, when using a Sharplan laser, the manufacturer specifically states to keep the probe perpendicular and at least 5mm away from contact with soft tissues. The probe should be completely away from any blood vessels.

I did want to add that Sharplan lasers are no longer made. In fact, it is also appears that the company that makes this laser no longer exists.

Take home message?

A surgeon should be the master of the tools he uses. Not understanding the operation of a tool can lead to unintentional, but disastrous mistakes.

Secondary message?

Lasers are dangerous, even if used properly.

There's a reason why many ENT's (including myself) have voluntarily elected to no longer use lasers at all for any purpose. Lasers introduce additional risk to a procedure that can be performed in alternative and safer ways with just as good an outcome.

It's not just arterial embolism that can occur. Lasers can also cause life-threatening hemorrhage from blood vessel damage (death of a 5 years old child), airway fire (laser can ignite oxygen), blindness (laser can reflect off metal surfaces and bounce into somebody's eye), etc.

Smart Laser, Dumb Surgeon

If lasers must be used, depending on the procedure, there are two different "styles" of laser that can be utilized. For simplicity's sake, I'll describe these two laser types as:

1) Smart Laser, Dumb Surgeon
2) Dumb Laser, Smart Surgeon

For style #1, the "smart laser, dumb surgeon," the laser is used much like the flash of a camera. You just have to aim the laser in the general vicinity of whatever it is the surgeon wishes to address, typically a vascular lesion like a hemangioma. When the laser is activated (typically a KTP or PDL laser), the laser selectively attacks the lesion without damaging the surrounding tissue. The surgeon is "dumb" in that all he has to do is crudely aim the laser in the general vicinity and the "smart" laser will do the rest. Watch a video of this type of laser in action here.

For style #2, the "dumb laser, smart surgeon," the laser (typically a CO2 laser) is used more like a handgun. It needs to be precisely aimed, precisely activated, precisely used. If the surgeon makes a mistake in aim, activation, or use, unintentional damage (and even death) may occur. The surgeon has to be "smart" in that he needs to precisely guide the "dumb" laser which will destroy anything in its path.


Source:
California Health and Human Services Department of Health Report. Report completed 12/3/10. Received by Licensing & Certification Office 6/15/12.

Read More

Is Patient Abandonment in the Operating Room Ever Justified?

I ask this question mainly because there WAS an ENT who WAS sued for NOT abandoning his patient in the operating room [link]. No way to verify, but additional details can be found in this facebook post.

Imagine this hypothetical scenario (as details from original case are not available)...

You are an ENT surgeon in a rural community hospital performing a fairly difficult but elective sinus surgery on a 12 years old child with cystic fibrosis with extensive pan-sinus nasal polypoid disease. Given the extensive nasal polypoid disease, a fair amount of bleeding is occurring which was not unanticipated.

Suddenly, you get a phone call from the emergency room regarding a patient with progressive difficulty breathing suspected to have epiglottitis.

What do you do if you are the only ENT in the hospital?

Do you "abandon" the 12 years old child in the operating room, still bleeding, still under general anesthesia and attend to the ER patient who himself might die without an emergency tracheostomy? Doing an evaluation to determine how critical the ER patient may take anywhere from 15 - 60 minutes including the tracheostomy itself. Keep in mind that 99% of the time, a tracheostomy is NOT necessary.

And, if a tracheostomy WAS needed, you are now performing two different surgeries in two different rooms simultaneously which must break some rule somewhere... perhaps JCAHO?

Or, would you finish the surgical case first, and than proceed to see the ER patient?

What if you are the only ENT available in the region let alone the hospital? No fellow ENT colleagues to call upon for help. General surgery is "unavailable" or not comfortable with performing tracheostomies especially given ENT performs all tracheostomies in the hospital?

Patient abandonment is defined as:

• Failing to transfer a patient to an appropriate level of care
• Failing to respond to calls from a hospital regarding a patient
• Refusing to care for a patient after arranging the patient's admission
• Failing to treat a patient until new coverage is arranged

Proving patient abandonment includes:

• Your doctor had a duty to treat you - a duty was created when the physician-patient relationship was established
• You had a reasonable expectation that your doctor would treat you
• Your doctor failed to treat you although he or she was obligated to do so
• You suffered injury as a result

Well, according to one lawsuit, it seems that the ENT was required to abandon his patient in the operating room and attend to the ER patient. The lawsuit stemmed from the fact that the ENT did not abandon his patient in the operating room and the ER patient did die as a result of not being attended to quickly and competent emergency tracheostomy performed. Of course, the settled lawsuit also blamed the hospital, general surgery, and anesthesiology.

However, abandoning a patient on the operating room table is also tantamount to medical malpractice according to the very definition of patient abandonment.

And, I would not be surprised if the patient on the operating room table would have sued the ENT if he DID leave the operating room in the middle of surgery to attend to another patient for a long period of time (and even starting another operation without ever finishing the abandoned patient's surgery first).

What to do?

I have no answer...

Doing an emergency tracheostomy is HARD, even for someone who has performed hundreds of elective tracheostomies. I know... I've done perhaps a half-dozen emergency trachs in my career so far. In this particular lawsuit, I found it incredible that a hospitalist (not a surgeon) was the one who finally attempted the emergency tracheostomy (albeit unsuccessfully).

Do you consider the patient you are CURRENTLY caring for has a higher priority than a patient you have never met, even if possible life-threatening illness is involved? (Keep in mind that when called for an airway problem, that 99% of the time, an emergency tracheostomy is not needed.)

OR, do you prioritize the patient you have never met given the possible life-and-death circumstances involved, even if 99% of the time, no surgical airway is required.

What would YOU do? What should you do? Feel free to comment below!

The way I see it, the ENT would have been sued no matter what decision was made. It would have been a lose-lose and lose proposition.

By deciding to stay with his current patient, the ENT was sued by the ER patient's family. If the ENT left his current patient on the operating room table, the ENT would have been sued for abandonment. If the ENT did abandon the current patient and the ER patient still died in spite of an emergency tracheostomy, the ENT would probably be sued for wrongful death by the ER patient's family AND the patient he abandoned on the operating room table.

Source:

Hospital settles wrongful death lawsuit. Curry Coastal Pilot 10/31/12

ADDENDUM 12/5/12:
Information obtained from an anonymous source reported that the ENT who was sued ultimately had charges dismissed with prejudice. It was maintained from the beginning that the ENT's obligation was to the patient on the table and that there was no doctor-patient relationship with the deceased.

I also find it interesting that the hospital where the lawsuit occurred, now does not even have ENT coverage at all. I guess that's what happens when a lawsuit occurs when there's only solo specialist coverage. I'm predicting that this hospital will have a very difficult time to recruit another ENT to work there given this case even though the ENT was ultimately found blameless.

Read More

ENT Surgeon Sues Spine Surgeon for Wrong Sided Surgery

Wrong sided surgery is extremely rare occurring anywhere from 0.09 to 4.5 per 10,000 surgeries performed.

It is almost unheard of when the patient is a surgeon as well.

On Nov 13, 2012, media reported that an ENT surgeon (plaintiff) sued his spine surgeon (defendant) over wrong-sided surgery.

The ENT surgeon had spine surgery in 2011 for low back pain which was allegedly due to pinched nerves. The treatment called for laminectomy surgery on the right side which entails bone removal to prevent the nerves from being pinched further thereby alleviating pain.

However, the ENT surgeon claims wrong-sided surgery in that left back surgery was performed rather than the right side. The spine surgeon claims he performed a left-sided approach to the right side.

Here's a video news report which includes radiological images that does appear to show bone removal on only the left side (rather than the correct right side).



Although it may seem like an open and shut case of malpractice for wrong-sided surgery, as in most cases of medicine, it is not that straightforward.

Given I'm not a spine surgeon, I asked my good colleague Dr. Jeffrey Wise who is a spine surgeon with Blueridge Orthopedic and Spine Center to comment further in this particular case.

After review of available publicized information, Dr. Wise felt that there were several possible explanations of what may be going on:

1. It was truly wrong-sided surgery that the spine surgeon is trying to cover up.
2. The correct surgery WAS done utilizing an opposite side technique.
3. It may be lack of informed consent on the part of the spine surgeon (the approach was not explained clearly to the patient).
4. The ENT surgeon may have misinterpreted the informed consent and not understood the procedure.
5. The correct procedure was done and the ENT surgeon did not have the result he was hoping for or he may have wanted to be disabled for secondary gain.

Some facts...  It is possible to do right-sided back surgery via a left-sided approach as illustrated in the textbook diagram shown in the video with the tubular retractors.

In fact, it is indeed easier to decompress the lateral recess and exiting nerve root of the spine from the opposite side via the open approach. The surgery can also be done via a minimally invasive approach (as in this case), but it is not considered standard approach of most spine surgeons who would usually use the tubular system and go on the same right side for a unilateral decompression.

On another note, the decision on the necessity for spine surgery is interesting because in the pre- and post-axial MRI pictures shown in the video, while there is clearly a spine defect on the left, the pre-op picture does not show any pathology that suggests surgery was even needed. Perhaps there are more images that do show the nerve compression better, but they are certainly not shown in this article.

From a legal standpoint, it would be possible to prove or disprove that wrong-sided surgery was done if there is clearly bone removal visualized from the right side (presuming spinal stenosis was the diagnosis for which surgery was performed) or a disc herniation was no longer visible (if a disc herniation was the problem). This scenario would favor the neurosurgeon.

However, if the bone on the right side (or disc herniation) was still present, that would favor the ENT surgeon.

Unfortunately, based on the limited publicized images shown, it is impossible to clearly tell from the images shown or information provided in the article. Again, the images shown do not show a surgically justifiable lesion to begin with and only show bone removal from the left spine.

- Dr. Jeffrey Wise

Source:
INVESTIGATION: Surgeon v. Surgeon in wrong-side surgery case KFOR.com 11/13/12

References:
Avoiding wrong site surgery: a systematic review. Spine (Phila Pa 1976). 2010 Apr 20;35(9 Suppl):S28-36.

Read More

ENT Surgeons Who Use daVinci Robot

Readers know my skepticism on the practicality of the daVinci robot in ENT head and neck surgeries.

However, that does not mean that I do not doubt its effectiveness in certain unique situations... as well as market forces that use such high (and expensive) technology to market a given hospital's services.

In any case, plenty of patients have asked me if there's any ENT surgeons who use the daVinci robot in the region.

There are... and here are two that I am aware of.

Dr. David Shonka at UVA
Dr. Stan Chia at Georgetown

Read More

Sinus Surgery Lawsuit Ruled Against ENT

A patient who had undergone endoscopic sinus surgery suffered detachment of the extraocular muscle resulting in double vision that required further surgical intervention.

A jury found against the ENT and ambulatory surgery center rewarding $2.5 million dollars to not only the patient, but also the wife "for loss of consortium".

Damage to the eye and vision is part of the normal consent process for endoscopic sinus surgery when considering the geographic proximity of the eye and sinus cavities.

Eye muscle injury as in this case is particularly relevant when surgery is performed on the ethmoid sinus cavity which is located between the eyes (purple in illustration). Risk of injury is even higher when powered instruments are used like a diego sinus shaver.

Although informed consent appears to have been present, the jury still found for the patient:

- $1.5 million to Mr. Dias for pain and suffering
- $0.5 million for loss of service
- $0.5 million to his wife for loss of consortium.

This case appears to suggest that informed consent does not really provide any legal protection. A bad outcome regardless of consent implies sufficient cause for lawsuit... and winning.

This case also suggests that any bad outcome can affect a patient's ability to have intimate relations with a spouse which is sufficient cause for lawsuit and winning.

I wonder if I now have to add to the informed consent (which may not afford me any legal protection) the possibility of "loss of consortium" with a spouse.

Source:
Patient Awarded $2.5 Million After Suffering Endoscopic Sinus Errors. Outpatient Surgery Magazine 9/5/12

Read More

Find an ENT Doctor App

If you have an iPhone or Android, get the ENTLink App... You can search for an ENT by current location or by zip code. The search can be narrowed to a specific specialty area (laryngology, neuro-otology, rhinology, etc) as well.

Of course, you can search for the same information from the website.

Download the app for iPhone and Android.

Read More

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

Read More

ENT Sued for Malpractice for Hearing Loss Due to Acoustic Neuroma

A patient has sued an ENT for failing to workup an asymmetric sensorineural hearing loss (nerve hearing loss greater in one ear compared to the opposite ear) that allegedly deviated from standard of care that ultimately led to permanent hearing damage and facial paralysis.

Since January 2008, the plaintiff saw the defendant ENT who performed 3 audiograms that revealed an asymmetric sensorineural hearing loss. In 2010, the plaintiff suffered a sudden sensorineural hearing loss at which time an MRI scan of the head was performed revealing a "large" acoustic neuroma (benign tumor of the hearing nerve).

Resection of this tumor resulted in a visible facial droop, permanent hearing loss, and cognitive deficits due to partial removal of brain tissue.

According to plaintiff, had the ENT performed MRI scan when asymmetric sensorineural hearing loss was first detected (presumably back in 2008), he never would have suffered from these defects.

Read about the case here.

Normally, if and when asymmetric sensorineural hearing loss is first detected, some type of workup is typically performed (auditory brainstem response and/or MRI scan of the head) unless there are extenuating factors present in the history. Such extenuating factors include old age and/or significant loud noise history that may lead to asymmetric hearing loss such as shooting (which often causes left greater than right nerve damaged hearing loss in right-handed shooters).

Apparently THREE audiograms were performed over time. If there was progressive worsening of the asymmetric sensorineural hearing loss, than MRI should have been performed and/or at the very least an auditory brainstem response testing (ABR). IF the audiograms showed stable asymmetry over time, it can be argued that absolutely no further workup is needed.

The key question in this case is had the defendant ENT obtained an MRI in 2008 when asymmetric sensorineural hearing loss was first detected, the acoustic neuroma would have been discovered earlier thereby preventing the permanent hearing loss he later suffered in 2010 along with facial paralysis and cognitive defects that occurred after surgical resection.

A couple problems with this line of reasoning from a purely medical perspective:

1) Acoustic neuromas grow at a rate of 1mm per year on average. As such, if the acoustic neuroma was large in 2010... it most certainly was large in 2008 being only 2mm smaller.
2) As such, surgical resection of the "large" acoustic neuroma had it been performed in 2008 probably would have resulted in the same outcome of permanent hearing loss, facial paralysis, and cognitive defects.

Hypothetically, had the MRI been performed back in 2008 revealing the large tumor, the options that would have been presented to the defendant patient would be:

1) Surgery
2) Radiation
3) Observe

Given it is established that the acoustic neuroma was large even in 2008, any type of intervention whether surgery or radiation, most certainly would put at risk the facial nerve which runs alongside the acoustic neuroma. Permanent facial paralysis and hearing loss most certainly is not an uncommon outcome after intervention.

One could even argue that in all likelihood, ALL the defendants current complaints would have occurred 2 years more quickly had the MRI scan of the head and subsequent intervention been performed.

Observation would have only lead to the current sequence of events.

As such, did malpractice occur?

Given the same outcome would probably have occurred, the defendant physician may argue that malpractice did not occur.

Should the defendant ENT have ordered the MRI scan of the head back in 2008 when an audiogram he obtained showed the asymmetric sensorineural hearing loss?

Probably though this might be debatable depending on patient's prior noise history and exact audiogram findings. Most definitely if the audiograms revealed a progressive worsening of the asymmetry over time. Most likely not if the audiograms remained the same over time.

Would knowing there was an acoustic neuroma present in 2008 have changed the patient's ultimate outcome?

Probably not given the large size.

Source:
Couple sues physician for medical malpractice. The West Virginia Record 7/10/12

Read More

ENT as Comic Book Hero (or Villain)

I had no idea that ENTs with our head mirrors are relatively common in the comic book world alternately portrayed as heroes or villains. (Most of us have upgraded to a headlight powered by battery, but some of us ENTs still use a head mirror.)

There is a Family Practice physician who has compiled all the situations where ENTs were portrayed in comic book settings in his blog Polite Dissent.

The full list can be found here.

I have reproduced a few of my favorites below:

Read More

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.

Read More