2024 | Volume 25 | Issue 2
Clinical information is now at our fingertips. Electronic safety systems have replaced the need to remember surgical maxims taught by crusty old surgeons. Or have they? The types of clinical pitfalls causing serious harm have not changed since my internship. Diagnostic errors are the root cause of 45 per cent of serious adverse events (SAEs)1 . SAEs generally start with simple errors, not complex decisions, and cause irreversible harm and death. Why do we keep repeating the same mistakes—generation after generation, year after year, and rotation after rotation?
’Changing signs means changing pathology‘2 was well known during my internship. Lacking access to CT, neurological changes were immediately reported and considered deterioration until proven otherwise. Today, despite electronic safety systems providing timely warning, failure to recognise and respond to deterioration continues unabated. Observation must be followed by action. ’Cat like observation and masterful inactivity‘does not apply in deterioration.
’What must I not miss‘3 was the repeated refrain of neurosurgeons. While ’common things are commonest‘, there is almost always one diagnosis that might kill your patient. Safety experts call this ’preoccupation with failure‘. High reliability organisations prepare for failure by proactively using systems and processes before harm occurs.
For example, in children, swallowed or aspirated button batteries can be deadly if missed. Simple chest radiograph is close to harmless4 but is often frowned upon. The reluctance to irradiate children can be riskier than the condition itself. To channel Samuel Shem, “no one deserves to die without their fair share of radiation”5.
’Never let the sun set on undrained pus‘ is one of a plethora of perceptive pustulent pronouncements in surgery. Delegating drainage to radiology, generally less invasive, often leads to delay. Undrained pus can and does lead to overwhelming sepsis. Mortality in sepsis increases for every hour of delay in treatment6. Sometimes ‘surgical steel is a chance to heal’.
’Beware the quiet child‘7 reminds us that children are usually active. Quiet children are either up to no good, or unwell. Children are often dismissed at triage as ’just tired‘, only to return later seriously ill. Listen to parents and maintain a high index of suspicion. If taking blood, an abnormal serum lactate is very helpful.
In post operative deterioration ’it’s the operation, until proven otherwise’. Nearly 30 per cent of serious adverse events after surgery are related to the operation itself—especially in cardiac procedures8,9. Because an operation went technically well, we look elsewhere for a cause of deterioration, causing a delay in diagnosis (cognitive bias). Counterintuitively, reducing surgical morbidity and mortality depends on early recognition of complications and improvement in the rescue rate, not reducing the occurrence of a complication itself10.
‘Time waits for no one’ may not strictly be surgical, but poor outcomes often relate to time. Untimely delays in trauma resuscitation, door to balloon time in cardiac angioplasty, time to antibiotic for sepsis, and time spent on the operating table all lead to increased morbidity11. Leaving registrars to struggle alone at night in theatre, fossicking in Calot’s triangle or fishing in the Pouch of Douglas is detrimental to patients and not good supervision.
Maxims are effective tools helping to cut through complexity and trigger action in the face of analysis paralysis. The evidence base for maxims is hard won experience, and while maxims may be old, they still deserve our respect.
References:
(1) NSW Clinical Excellence Commission Biannual Report July-Dec 2021 https://www.cec.health.nsw.gov.au/Review-incidents/Biannual-Incident-Report/saer accessed 14 Feb 2024.
(2) Dr John King, Neurologist Royal Melbourne Hospital
(3) Mr David Brownbill Neurosurgeon Royal Melbourne Hospital
(4) “Understanding Radiation Risks from Imaging Tests”. American Cancer Council https://www.cancer.org/content/dam/CRC/PDF/Public/8383.00.pdf accessed 13 Feb 2024.
(5) “Rules of the House of God” Samuel Shem 1978 ISBN 0399900233
(6) “Empiric Antibiotic Treatment Reduces Mortality in Severe Sepsis and Septic Shock From the First Hour: Results From a Guideline-Based Performance Improvement Program” Critical Care Medicine. 42(8):1749–1755, AUG 2014 Ricard Ferrer et al
(7) Professor John Hutson AM Paediatric Surgeon Royal Children’s Hospital Melbourne.
(8) Dharap SB, Barbaniya P, Navgale S. Incidence and Risk Factors of Postoperative Complications in General Surgery Patients. Cureus. 2022 Nov 1;14(11).
(9) Author's own data.
(10) Ten-year Trends in Surgical Mortality, Complications, and Failure to Rescue in Medicare Beneficiaries, Fry, Brian T.; Smith, Margaret E.; Thumma, Jyothi R et al Annals of Surgery: 2020 May;271(5):855-861
(11) Prolonged operative duration is associated with complications: a systematic review and meta-analysis. Hang Cheng et al Journal of Surgical Research Volume 229, Sept 2018, pp134-144