Wednesday, July 11, 2007

Lights, Camera, Inaction!


A hand surgeon I know told me about a lawsuit. He'd removed a ganglion from someone's wrist, and the incision had gotten infected. After pretty routine wound care, with not much hassle for the patient other than wearing a bandage for a couple of weeks, it healed with no after-effects. But the guy sued. Digging in his heels, since it was a routine and minor problem, the surgeon refused an offer to settle, and went to trial, during which the plaintiff's attorney brought in a giant-sized blow-up photo of the wound at its gooiest, set it on an easel in front of the jury, and left it there for the whole case. (Must have been a very quick decision, on the patient's part, to sue!) The jury found for the plaintiff. A reader mentions the idea of video-taping operations. I'm of two minds.

"Can we get a camera in here? I want a picture of this." I've done that a few times, for various situations. I like showing pictures to patients, assuming they want to see them. And nothing beats the real thing: I've shown some pretty ugly appendices to people when they've asked; everyone enjoys seeing their gallstones. Some of it, I suppose, is the drama: surgeon demonstrating his brilliance and his ownership of the situation with visual aids. For sure, it's also about communication and understanding. It's the back-end of the time I always took before surgery to draw diagrams or show pictures of what I planned to do. So yeah, in theory, if a patient asked me to videotape an operation, part of me would want to comply.

Early in the history of laparoscopic surgery, which is visualized indirectly on a TV screen, it was nearly routine -- at least for many surgeons -- to videotape the proceedings (it only requires having a recorder in the system; no special cameras or intrusions, since the whole thing is done with cameras in the first place) and give a copy to the patient. Now, far as I know, it's a pretty-much universal recommendation of malpractice defense attorneys, and insurers, that surgeons NOT record operations. Why? Simple: in the same way that that barf-inducing, gargantuan photo swung a jury, so have videos, even -- hard as it might be to believe -- when nothing was all that significant. Hands shake instruments around. Bleeding occurs; it's cauterized in an effluvium of smoke that can fill the screen. Things are picked up and dropped; bile and stones run out of gallbladders. It happens. But, in the context of a patient having some unspecified post-operative problems, much can be made of these images when they're on a big screen in living color.

I'm a ham. I like having students and other medical people watching when I operate, and I love telling them what I'm doing. I've even set up mirrors so patients could watch me repair their inguinal hernias, holding things up and showing them their own anatomy (mirrors because if they were sitting up, I couldn't expose the area properly.) If bleeding occurs, I'm perfectly comfortable saying something like, "Oh lookie there, better get that guy..." With my attitude, I can control the situation. And, although I never did, I could take down the mirror. I've welcomed husbands/others into my office surgery when I've done breast biopsies under local anesthesia when the woman has wanted it. But I always have them sit down, on the opposite side of where I'm working, holding hands but not able to see. It's less about not wanting an observer, and more about not wanting to worry about them passing out onto the floor. Once was enough.

But I've not agreed to have a family member actually observe an operation. Proud as I am of my surgical abilities, much as I like to hold forth during an operation, I'd feel extra pressure to be perfect; I'd worry that the person simply wouldn't understand the occasional left turns that an operation takes, the inadvertent "oops." And, as I said in my previous post, there's enough pressure already. Any way I can avoid extras, I want it; and so, I'd think, would the person lying there. Videotaping is the same thing, only more so, for the reasons I've already mentioned. If good surgery requires concentration -- and it does -- then any distraction is a bad thing; some more than others. A present family member, or worry over a recording device is a distraction. Human nature, even in a surgeon.

The one exception to the no-visitor-in-the-OR mantra -- which isn't by any means a CIA-level "slam dunk" -- is parents accompanying a small child into the OR. I've not had a problem allowing it during the induction of anesthesia, as a means of dealing with the kids' fears. But I leave it to the anesthetist: some are OK with it, some aren't. I've watched kids snuggle in their mothers' arms while the mask is held to their face, to be whisked onto the OR table as they drift off, at which point Mom is escorted out. On the other hand, there are ways around it: drugged lollipops, for example, that gently hammer the child before leaving the pre-op area.

I've been known to ask for particular anesthesiologists for some kids, when I thought that sort of TLC was indispensable. In the same way, if a patient really wants a recording of an operation, I'd say she or he has a right to look around for a surgeon who feels comfortable doing it. But they should be understanding of those that don't; and that includes, I'd say, most. Which leaves a small pool (ought I add: of questionable judgment?) from which to choose. And, of course, along with the rest of us, they can blame it on the attorneys.

31 comments:

Petri said...

Does it make surgeons more comfortable if you relate to them ahead of time you aren't an overly litigious person, that you are grateful for their intervention, and that you won't sue unless he decides to sew a dead cat into you? Or would that just be inviting carelessness?

Sid Schwab said...

limiting my dead cat options just makes things worse...

I can't recall someone bringing up their lack of litigiousness in advance; if they did, it might make me think they were litigious...

Actually, I don't know. I think a certain amount of tension will always be added by extra eyes, be they direct or indirect.

Michelle said...

I for one was thrilled to get pictures from my surgeon of my gallbladder surgery. I think I'll scrapbook them : P
It was kind of comforting to have evidence that everything was in hand while I was in la-la land.

rlbates said...

My patients love pictures of the excess skin removed when an abdominoplasty (tummy tuck) is done. They like pictures (& I do too as it proves I removed the fat) of the fat removed during liposuction. But all that is a far cry from video taping or someone watching over your shoulder (just waiting for something to go wrong). For those of you non-surgeons, think about someone video taping you do your job. Would it be in amazement or to learn or to critic? Perspective means a lot.

Anonymous said...

The issues cited by Dr. Schwab are much the same reasons why many hospitals are reluctant to allow videotaping during labor and delivery.

I have been in the courtroom and seen the effect on the jury that these pictures and videotapes have on laypeople. What seems absolutely normal and routine to healthcare providers can look absolutely awful to laypeople. The soundtrack of the typical banter, dirty jokes (usually told by the nursing staff) and discussion of weekend plans that happens in the OR during surgery only makes things worse.

And then you have the occasional situation in which a layperson is taping, faints at the sight of blood or the smell of cautery, and faints right on top of you, or drops the camera into the sterile field. The soundtrack really sounds terrible then as everyone starts cursing!

The Enormous Clinic

Anonymous said...

On another medical blog of a resident doctor, he frequently puts up photos of his operations that relate to a particular procedure he might be discussing. In a preamble to his site, he states that he can legally use these photos on the internet because of a photography clause in the general consent form that the patient signs before surgery.

Even though the patient can't be identified, I'm a little surprised that this clause allows a doctor in training to appropriate OR photos and put them on a public website for his own personal use. It's one thing if they are used for hospital training purposes or for evidence that will be part of the patient's medical records. But it seems that they are available to anyone with hospital access to take freely, even with the possibility of profiting from them.

Just curious, Dr. S., if you consider this ethical?

Lynn Price said...

My heart goes out to the hand doc for losing the suit. What a pile of crap. Guess that's why I was excused from serving jury duty on a medical case.

Sid Schwab said...

TEC: not to mention the soundtrack of a skull hitting a tile floor...

anon: if I were to use a photo in that way, I'd ask the patient's permission, no matter what the permit said. However it would be extremely hard, if not impossible, for anyone to identify the actual patient in such a picture. I don't know, specifically, about the ethicality. A flippant answer would be, if you have to ask, it probably isn't.

Anne said...

Wanting to get money out of someone's misfortune is rather sick. Aren't medical lawyers aware of the potential for plaintiff B.S.? I nearly died not once, but twice during two out of twelve surgeries, and I didn't push the money button. No license-deserving physician should have to worry about being sued. TORT REFORM!

buckeye surgeon said...

People are suing and winning for wound infections? Are you kidding? Did that hand surgeon represent himself? Or hire his drunken brother-in-law?

Sid Schwab said...

You know what they say: picture's worth a thousand words. Or, in this case, several thousand bucks.

Anonymous said...

I'm an electronics engineer; when in for a recent surgery, I attached a small transmitter to my ID bracelet. Well, some things went wrong, which resulted in a longer and more difficult recovery. Odd, my surgeon never mentioned these problems. I sued. My surgeon--and THE ENTIRE SURGICAL TEAM--failed to mention these problems.

When my lawyer brought in the tapes, they all settled very quickly.

Sunlight is the best disinfectant. Given the number of dirty insects in the operating rooms, you can't get enough of disclosure!

Anonymous said...

Attached a small transmitter to your bracelet???? I truly hope you're joking. As an electronics engineer, you should have known about the danger of any unapproved electronics devices in the OR. Not only does that seem illegal and foolish but is pretty disgusting behavior. Almost seems as though you were seeking surgery as a tool for a lawsuit. Was your operation by any chance a brain biopsy?

Anonymous said...

Considering the rather strict laws against unauthorized recording I find your story rather unlikely.

And for what it's worth if a patient asked to videotape a surgery to make sure I did it right.. yeeaaaahh. Bit of a red flag.

very tall man said...

I don't believe that small transmitter story.

But don't police videotape all interviews these days to weed-out inappropriate duress techniques.

Seems like it would be a good way to show that frivolous lawsuits are indeed frivolous.

Sid Schwab said...

I was going to comment on that comment as well, but everyone else has done a pretty good job of it.

Anonymous said...

To Anon. re pics. First, there isn't a library of patient pics where anyone can walk in and sign them out for the weekend.
Second, you don't think anyone is learning anything from the pics? Haven't you learned anything? I doubt that the actual patient would even recognize their own gallbladder, spleen, insert body part here____, head CT, Barium enema, etc. What is the problem you have? Is it about someone possibly making a profit off of something that you can't be privy to? Do you think the patients whose pics are in medical texts are drawing royalties? Better go copyright or trademark your body and all it's parts so no one can take advantage of you that way! When you go in for surgery, DON"T SIGN THE CONSENT!

makeminetrauma said...

Wow, another can of worms, Sid.
I used to scrub for an Orthopod who would routinely allow family members in the room to observe minor procedures, ie carpal tunnel rls, knee scopes, etc. if they were done under regional or local anaesthesia. As far as I know he still does it and has not had a problem. On one hand, I believe it takes away the mystery and some anxiety for the family. They always seemed very thankful for the experience. However if we're talking general abdominal surgery, laparoscopic anything, thoracic, etc. I can't imagine family in the room (or home movies). It's a lot harder for the lay person to understand what goes on in those instances. Besides, you can't put a tourniquet around someones neck to make it nice and clean and bloodless.

Imagine the volumes of legal fodder OR-Live must go through to web cast entire operations. And A non is worried about a few still photos......

tran said...

From a patient's point of view, I think that operations should be videotaped, otherwise if something does go wrong the patient has no advocate there as a witness. I wonder how many gross medical errors are noted in the record as "unforeseen complications."

Sid Schwab said...

tran: you can't pass off problems simpy with such words as "unforseen complications." If something goes wrong, it's there in person. As I'd have said to that anonymous poster with the bracelet: if the only way to find out something "went wrong" is by some sort of audio/visual record, then it must not have been very wrong. If something has no consequences that would be known "in the flesh," seems to me, it must not be a big deal. I've accidently made a hole in the bowel, for example, sewed it up, with absolutely no consequences. No biggie. And I dictate it into the record, absolutely. So does everyone else. Complications, forseen or unforseen, are important to the extent that there are observable consequences. Little booboos that can be easily fixed with no effect on the outcome are not really "complications."

Sid Schwab said...

MMT: I've seen an opthamology center where family can sit outside the OR, separated by a glass wall, behind which is a large TV with the patient's eyeball bigger than life, in living color, being sliced. Yikes.

Eric, AKA The Pragmatic Caregiver said...

It's getting somewhat common in high-end ENT suites to throw in a couple high-def monitors to show the through-the-scope view. Seeing is believing...my mother was shocked (SHOCKED!) at what all was in there - and I for one wish the video wasn't quite so good.

I also happen to have a DVD of the repair of a sub-gingival tooth condition that is, in the eyes of the experts who have evaluated my case, an "excellent teaching case - once or twice in a career would a general dentist see something like this"-kind-of-thing, and it's been *EXTREMELY* useful in trying to evaluate ongoing treatment options - they don't have to lift a flap of my gums to see what's inside again - it's all there in glorious Technicolor. I am eternally grateful that the department makes use of the capability, and there was no trouble getting a copy of the video.

Finally, a caution to surgeons about pictures. . . I had some surgery a few years back to repair two tendons and a nerve laceration (oopsie). The procedure was planned to be done under a Bier block, but they weren't 100% successful at getting me numb. In addition, the surgery was delayed by more pressing matters. So by the time I got in there, I was quite "comfortable" on Versed, pretty well numb from the shoulder down, and headed for a date with Morpheus.

The next thing I remember was being in the PACU, and looking at the clock on the wall and going "Geez, that took forever". I apparently didn't *quite* make it all the away to awake-and-aware for a few hours. No big, no major complications. An hour or so later the surgeon came around, and we chatted, and he said we'd talked on the way out of the OR and he'd shown me digital pictures of the repair.

Here's the thing: I have no conscious memory of that event. But OMG, I have this incredibly visceral response to seeing pictures of hand trauma or tendon surgery now - it is so deeply imprinted - I get sweaty, my heart pounds, I feel faint. It's insane - nothing bothers me, but those pictures, left in my brain at that time, are now potent triggers. I'd ask, as a concerned patient, that you wait for show-and-tell until the patient is extremely functional.

Eric

Sid Schwab said...

Erik: that reminds me of when I was working a summer construction job in college, traipsing in the woods playing lumberjack. I managed to cut my thumb with my trusty double-edged axe, which I sharpened compulsively while waiting for the Cat to push over another tree. It needed stitches, and the doc told me I should lie down. "Nah," I told him. "I'm going to med school this fall. No problem." He shrugged. When I saw the tendon -- or more properly as I watched and "heard" the needle pass through it, I was about to say "Uh, think I'll lie down" when the doc looked at me and said "Uh, think you should lie down..."

tran said...

Thank you, Dr. Schwab, for your reassuring explanation to my post. Judging from the mean spirited comments from some of your readers (I assume are doctors) on this thread to patient fears or paranoia, I don't think they realize or appreciate the profound trust that a vulnerable and scared patient has to place in them. I'm about to have surgery and have yet to meet the surgeon. I'm really nervous. I hope he'll be as thoughtful as you.

happyj said...

Dr. Schwab,
I was able to watch my exploratory surgery to determine which of my organs the gall stones were blocking, but the side-effect of the medicine they gave me was a loss of memory of the event. I've always been so bummed out that I couldn't remember seeing such a cool thing! I did however get to take home a video tape of my laser eye surgery! Really cool. I wish all of my surgeries could have been taped so I could watch them.

justme said...

happyj,

GOOD for you!!! And good for your doctor. I envy you----not just that you got to see your insides, but that you had such a good connection to your doctor that you both trusted each other.

I understand that surgeons have a huge responsibility, surgery is dangerous, but....if there were a way that doctor and patient could really understand that neither is perfect, but we are in this together, it would be wonderful.

enrico said...

Re: the hand surgeon--I agree with Buckeye: was this a real-life, "My Cousin Vinny?" That's what expert witnesses are for!! Get a couple of docs on the defense to get up and say, "This is totally normal granulation tissue," show even grosser pictures next to the "after" of a smiling thumbs-up from the patient, yatta yatta.

I think recording is an each-case-on-its-merits decision, and I think the flexibility of intraoperatively changing from "no" to "yes" record should be considered, if the surgeon feels that they've gotten into a sticky wicket and need some video proof that undue complications could arise. (the reverse, turning "off" a camera due to complications might as well come with shelling out the cash right then and there)

It was frustrating for me when my wife had her C-section, I was treated like any old OR-virgin-Dad, told to sit there, don't do this, don't do that, now you have to leave, etc. Grr. Even though the OB knew I was a med student who had attended many surgeries and was totally cool w/me being there as much as I wanted, it was out of his hands (younger doc, no hospital political pull, alas).

I'm a natural shutterbug and want to videotape/take pictures of everything, no matter how trivial, and I'd naturally want to see things over and over again (like a coach watching team films), so this would be interesting for me in the future.

beajerry said...

But the soundtrack possibilities are so tantalizing!

"Working In A Coal Mine" for a C-scope?

"Shattered" for a lithotripsy?

"Please Bypass This Heart"? (Yes, an actual Jimmy Buffet song) for... too obvious?

Kimma said...

I've watched some of the operations they show on medical channels and, from a layperson perspective, even when everything is going totally right it looks all wrong. I had no idea how rough surgery was beforehand.

I can see why the jury would think the wound horrific, because they have no idea what normal is. Possibly because what you see in fictional OR shows is very sanitised.

I can see why a surgeon wouldn't want people seeing their work because chances are that someone with no medical training will completely overreact.

DHS said...

I've just finished my plastics rotation (hello dr bates!) where we would routinely photograph anything and everything - I bought a new camera phone so that I could photograph the xrays and op reports of all the ops I did or assisted in. In fact, we had surgeons ask for a new pair of gloves intraoperatively so they could go, pick up their camera, take the photo themselves, then deglove in a sterile fashion.

Anonymous said...

I also made a recording of my physician. Thank goodness! It wasn't in surgery, but for the pre-op a week before and then again right before the surgery. He didn't do the surgery he was supposed to do. I had verbally informed the nurse who did the consent (he delegated this) that the form was wrong, but she pointed to a part of the consent that read "and may perform other additional procedures" and said that it would be covered by that. Then she lied about it. Thank goodness I had a tape. This is my second go-round with malpractice and falsified records so I was better prepared.

Personally I recommend making a recording of any verbal agreements with healthcare providers when the stakes are high. Too many say or promise one thing and do another. I live in a state where one party recording is legal, thank goodness.

P.S. Now I have these tapes showing blow by blow how wrong site/surgery occurs. I'm thinking of sending them to a teaching institution, or posting online so others can learn from my provider's mistakes. Any ideas?

A