Brain Surgery

My high school friend and I used to love the phrases “it’s not rocket science” and “it’s not brain surgery,” metaphors that allow you to compare any task to what is implicitly considered the most complex, mentally taxing jobs one could ever aspire to.  In medical school—for about 5 minutes, anyway—I set my sites on mastering neuroanatomy.  But when I couldn’t keep straight the differences between the spinothalamic tract, the fasciculus cuneatus, and the pineal gland (and what exactly is brain sand?) I gave up my dream of being a brain surgeon.  My friend, in what I believe was just an effort to spite me, went on to work for General Dynamics as—you guessed it—a rocket scientist.  Since those days when I limped through my neuroanatomy final my friend never let me forget my shortcomings.

A story out of Rhode Island caught my eye this week.  The largest hospital in the state was just fined $150,000 after a surgeon mistakenly performed surgery on the wrong fingers of a patient’s hand.  The penalty would not have been levied had this not been the fifth wrong-site surgery since 2007.  In a previous screw-up a head and neck surgeon managed to operate on the wrong side of a child’s mouth during surgery to correct a cleft palate.  As you ponder how this sort of thing happens you may find yourself thinking “It’s not like it’s brain surgery, after all.”

Actually it is.  As you can see from this chronology I pulled from The Providence Journal, the majority of the incidents at Rhode Island Hospital (and others in the area) involved mistakes made by neurosurgeons.

Dec. 12, 2001: A Rhode Island Hospital neurosurgery resident drills holes in the wrong side of a patient's head, in a procedure to relieve bleeding on the brain. The CT scan was placed backward on the viewing box.

2004: A Miriam Hospital anesthesiologist inserts a catheter on the wrong side of the neck of a patient about to undergo a procedure to bypass a blocked artery.

March 2005: A Women & Infants Hospital obstetrician removes the ovaries of a woman who was supposed to have only her uterus removed, confusing the woman with another patient who had the same last name.

September 2006: A neurosurgeon at Roger Williams Medical Center drills into the wrong side of patient's head in an emergency procedure to drain blood after an injury.

January 2007: A Rhode Island Hospital neurosurgery resident and a nurse place a drain on the wrong side of a patient's head to remove blood.

July 30, 2007: A neurosurgeon at Rhode Island Hospital cuts open the wrong side of a patient's head, also to drain blood.

Nov. 23, 2007: A Rhode Island Hospital neurosurgery resident starts to operate on the wrong side of a patient's head in a bedside procedure to drain blood on the brain. Health Department reprimands the hospital and fines it $50,000.

So, if the brain surgeons can’t get it right what’s the likelihood that the rest of us can?  Every year more than 40 million patients are admitted for surgery at U.S. hospitals, while another 31 million undergo outpatient procedures.  With this volume of surgical arts and crafts shouldn’t we expect that mistakes like these are nearly inevitable in at least a few cases?

If you’ve been a patient for any procedure in the last couple of years you may have noticed a new protocol called a “surgical time-out.”  This is where the entire surgical team halts everything for a moment to verify that they’re doing the correct surgery on the correct site on the correct patient—preferably done while the patient is awake and able to voice any last minute objections.  The surgeon also has to personally mark the site intended for surgery.

When we first initiated this I thought it was a little silly and redundant.  After all, there aren’t many places I can actually hide a pacemaker and most people’s hearts are located in the same general vicinity.  It’s not like I plan to amputate anybody’s limbs or try to drain brain fluid.

But even in my narrow realm every patient is a little different.  The pacer sometimes belongs on the right instead of the left and I occasionally do heart catheterizations through the artery in the wrist rather than in the leg.  Other issues are brought up in the time-outs as well, such as drug allergies (antibiotics are a particular concern), laboratory anomalies (is the kidney function adequate for the dye we use?), and patient-specific preferences (does the patient prefer more or less conscious sedation than usual?).

Since the new guidelines were initiated only 5 years ago it may be too early to tell if there has been a decrease in surgical errors in this country, but I have to believe it will make an impact.

Let’s hope it does in Rhode Island, anyway—and soon.  Not only have our colleagues there botched up the care of a handful of patients, they’ve also managed to demystify the unimpeachable aura of brain surgeons.  Now if only I could just find some dirt on those rocket scientists.