Groucho Marx said it best, "A child of five would understand this. Send someone to fetch a child of five." Thanks to one of our loyal bloggers, TSB finally became motivated to post on last week's report by the Boston Globe's Liz Kowalczyk, regarding neurosurgeons at Beth Israel Deaconess (BID) that had operated on the wrong levels during spine surgery on three patients. Seems like BID is having a difficult time digging out of this negative publicity. Unfortunately for the patients, the surgeons apparently miscounted while identifying the levels to be operated on, and proceeded to operate on the adjacent level above or below the affected vertebral bodies.
Dr. Kenneth Sands, Senior Vice President of Health Care Quality at the Boston hospital, declined to identify the surgeons, but he did add that "both surgeons were experienced," thank God, and had taken the "time out" to verify the type and location of the surgery. Could these surgeons be members of the Louisville 5 spine basketball team? They took a time out and diagrammed a play so that they could execute the procedure. No one ever said that surgeons were good at counting, it's not like we're asking them to design an algorithm so that we could manipulate some financial instrument. TSB assumes that by time one gets out of residency most spine surgeons have learned how to count to seven, count to twelve, or count to five.
What's even more entertaining is when Dr. Sands attributes this occurrence to pilot error. Can anyone imagine what would happen if an airline pilot miscalculated the length of a runway, or, missed the runway on approach, or, decided to land on the runaway for departing flights? We would have what is commonly known as FUBAR. Fortunately for these patients, by the sounds of this report, these were not fusion procedures. But what really jumps out in this report is that one patient's back pain had gotten better even though the surgeon operated on the wrong level. Could that procedure have resulted in a placebo effect? By decompressing the adjacent level the patient supposedly felt better. But it gets better.
The neurosurgeon and the fellow assisting him had a difference in understanding how to count and mark the correct vertebrae. Let's see one comes before two, two comes before three, etc.... The hospital reported that state and federal authorities had found deficiencies and that hospital administrators are addressing the problem by hiring an arithmetic teacher, while adopting a checklist developed by NE Baptist Hospital to help surgeons mark the correct vertebral body.
Considering that most insurance companies will not pay for these trial run procedures, BID administrators were kind enough not to bill the patients and will be sending them to an all expense paid vacation in Barbados, of course right after their attorney's get through suing the hospital. You got to love America, it doesn't get any better than this. TSB wants to know, is this act coming to your local town?