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.