Thomas B. Hugh

Corrosive ingestion and the surgeon

Although ingestion of corrosive substances is relatively rare, such events may have devastating effects on the upper gastrointestinal tract, present major problems in management, and consume considerable health resources. The low frequency of corrosive ingestion in developed countries means that individual clinicians have limited experience with managing these patients who may require care by emergency room physicians, gastroenterologists, and surgeons. This review aims to summarize current information about this injury, most of which is reported in subspecialty publications.

Laparoscopic bile duct injury: understanding the psychology and heuristics of the error.

Bile duct injury is an important unsolved problem of laparoscopic cholecystectomy, occurring with unacceptable frequency even in the hands of experienced surgeons. This suggests that a systemic predisposition to the injury is intrinsic to cholecystectomy and indicates that an analysis of the psychology and heuristics of surgical decision‐making in relation to duct identification may be a guide to prevention. Review of published reports on laparoscopic bile duct injury from 1997 to 2007 was carried out. An analysis was also carried out of the circumstances of the injuries in 49 patients who had transection of an extrahepatic bile duct and who were referred for reconstruction or were assessed in a medicolegal context. Special emphasis was placed on identifying the possible psychological aspects of duct misidentification. Review of published work showed an emphasis on the technical aspects of correct identification of the cystic duct, with few papers addressing the heuristics and psychology of surgical decision‐making during cholecystectomy. Duct misidentification was the cause of injury in 42 out of the 49 reviewed patients (86%). The injury was not recognized at operation in 70% and delay in recognition persisted into the postoperative period in 57%. Underestimation of risk, cue ambiguity and visual misperception (‘seeing what you believe’) were important factors in misidentification. Delay in recognition of the injury is a feature consistent with cognitive fixation and plan continuation, which help construct and sustain the duct misidentification during the operation and beyond. Changing the ‘culture’ of cholecystectomy is probably the most effective strategy for preventing laparoscopic bile duct injury, especially if combined with new technical approaches and an understanding of the heuristics and psychology of the duct misidentification error. Training of surgeons for laparoscopic cholecystectomy should emphasize the need to be alert for cues that the incorrect duct is being dissected or that a bile duct injury might have occurred. Surgeons may also be trained to accept the need for plan modification, to seek cues that refute a given hypothesis and to apply ‘stopping rules’ for modifying or converting the operation.

Laparoscopic bile duct injury: Some myths

Bile duct injury is a serious and feared complication of laparoscopic cholecystectomy. Examination of four frequently repeated statements about this problem in the literature, and in the medico‐legal expert reports indicate that these statements are not supported by valid data and, therefore, can be termed ‘myths’.

Balancing "no blame" with accountability in patient safety.

n engl j med 362;3 nejm.org january 21, 2010 275 To the Editor: Wachter and Pronovost (Oct. 1 issue)1 question the “no-blame” paradigm in patient-safety improvement and suggest the adoption of explicit punitive approaches to poorly performing physicians. We counsel caution. In a longitudinal study over a 2-year period in a large facility,2 we found that penalties did not deter undesirable behavior. Rather, penalties drove evidence of noncompliance underground, encouraging people to conceal it and thus perversely reducing accountability. Drawing the line between blameworthy and blameless acts was difficult and involved subjective judgments of observers about the foreseeability of harm, reasonable care, and prudence. The question was: Who was permitted to draw that line?3 And who reported “violations”? In the example of hand hygiene described in the article, those difficulties are compounded by uncertainties in the evidence base about when and how hands should be washed.4 In our study, peer intervention was more effective in generating accountability and desired change than punitive administrative action; less blame led to more accountability. Our research clearly suggests that by demanding penalties, we might stifle accountability rather than enhance it.

A just culture after Mid Staffordshire

There has been much public and media outrage in the wake of the scandal about the standard of healthcare delivered at Stafford Hospital. Using published evidence in the safety literature, we examine the distinction between our need to understand what happened, the practical need for preventing recurrence, and the age-old philosophical need to explain suffering. Investigations of what happened can identify the many detailed explanatory factors behind a particular outcome—including the actions and assessments of individual caregivers. These, however, do not necessarily constitute the change variables for preventing recurrence, as those might lie elsewhere in the governance of a complex system. And neither says much about the nature and apparent randomness of suffering in the particular circumstances of individual patients, even if that might be a most pressing question people want answers to in the wake of such a scandal. To promote safety and quality, we encourage a sensitivity to the differences between understanding, satisfying demands for justice, and avoiding recurrence. This might help a just culture in the wake of Mid Staffordshire, as it avoids expectations of an inquiry—independent or public—to do triple duty.

Surgical sense and legal non-sense - Chappel v Hart revisited.

The relationship between medicine and the law has always been uneasy. Many doctors have a perception that the legal process is ill-equipped to unravel complex technical issues when experts disagree about medical care. Judges, on the other hand, by their own account often fail to understand expert evidence and find deficiencies in the way it is presented to them. Expert evidence is sought by courts to assist in making decisions about disputed facts. The High Court noted in Rogers v Whitaker (1992) 175 CLR 479 that in medical malpractice litigation ‘Courts rely heavily, and in some cases, almost exclusively, on expert medical opinion’. Judicial evaluation of expert evidence utilises the forensic tools of examination-in-chief and cross-examination and there is an expectation that experts will be objective and not an advocate for either defendant or plaintiff. The reality of medical malpractice litigation is far removed from this utopian ideal, notwithstanding Codes of Conduct and other recently introduced court rules. This occasionally results in serious defects in the presentation and judicial understanding of medical expert evidence and sometimes produces legal outcomes that seem nonsensical to practising clinicians. Chappel v Hart, an oft-cited Australian judgment, involving an allegation of a failure to warn about the risk of injury to the recurrent laryngeal nerve (RLN), demonstrates these weaknesses. Examination of the surgical evidence in that case discloses what may be perceived as a miscarriage of justice, with extremely severe personal and professional consequences for the defendant doctor. Rogers v Whitaker reshaped the landscape of the legal obligation of doctors, particularly surgeons, to warn patients of the risks of medical treatment, imposing an onerous duty to consider the significance of a particular risk to a particular patient, no matter how rare the probability of that risk eventuating. Chappel v Hart appears to have extended that obligation to an absurd extent without consideration of the probability of the risk, which, it turns out, only ever eventuated in the case of the plaintiff, Mrs Hart.

Pregnancy Complicated by an Insulinoma

Summary: The case of a 33‐year‐old patient suffering from severe hypoglycaemia due to an insulinoma during the first trimester of pregnancy is reported. The diagnosis was established on clinical grounds and by the demonstration of hypoglycaemia, inappropriate hyperinsulinism and an increase in the percentage of circulating proinsulin. Dietary therapy maintained blood glucose at a satisfactory level from the 9th to the 17th gestational week. Localization of the tumour was achieved at that time by limited CT scanning with a narrow field. A 2 cm tumour was removed from the head of the pancreas and the blood sugar levels and insulin secretion returned to normal. Pregnancy proceeded normally and a healthy male infant weighing 3,880g was delivered at term. Ten months after delivery both mother and child were well.

Getting surgery right is more complex than it appears: A new look is needed at aberrant procedures

Newspaper headlines such as ‘Not a leg to stand on’ and ‘So the brain tumor’s on the left, right?’ are the shocking public face of the rare but intractable problem of incorrect surgical procedure. There is no agreed shorthand that encompasses the variety of disasters recognized as ‘wrong’ surgical procedures – wrong patient, wrong side, wrong site, wrong procedure or wrong prosthesis. ‘Aberrant procedure’ (AP) is suggested as a useful term, defined as an unintended deviation from the planned purpose of an operation or procedure. APs occur in every specialty. The majority of reported APs happen in the operating room, but many unreported cases probably occur elsewhere in hospitals or in outpatient facilities. Accurate estimates of incidence cannot be determined because self-reporting and surveys almost certainly underestimate the frequency of aberrant procedures by a factor of 20 or more. Additionally, the denominator (total number of procedures undertaken in the study sample) is often uncertain. Much published data about APs relies on malpractice claims reports, a biased view because it includes only patients with significant injury. Near-misses that do not cause patient harm are especially likely to be unreported, even though they are an important marker for system deficiencies that may lead to severe injuries. These difficulties in the precise monitoring of the frequency of APs result in an absence of data demonstrating the effectiveness of preventive measures. APs meet the description of a ‘normal accident’, a term coined by Perrow to describe unanticipated adverse outcomes in complex and tightly coupled systems. As such, they cannot be completely eliminated. Despite that reality some authors have suggested zero tolerance of surgical APs is the only acceptable view, an approach that has been endorsed by a number of official organizations. In other words, it is suggested that the aspirational goal should be complete prevention, even though that is impossible to achieve. The Joint Commission on Accreditation of Healthcare Organisations (JCAHO) in the USA made elimination of wrong-site surgery one of their first National Patient Safety Goals in 2003, and a number of specialist associations and learned colleges, including the Royal Australasian College of Surgeons (RACS), have declared similar goals. Many health authorities throughout the world have taken steps to mandate protocols to prevent APs . An Australian protocol was developed by the former Australian Council for Safety and Quality in Health Care, in conjunction with the RACS, based on material developed by the Department of Veterans’ Affairs in the United States. In April 2004 Australian Health RISK MANAGEMENT

Gastric antral patch oesophagoplasty for iatrogenic tracheo-oesophageal fistula.

Acquired tracheo‐oesophageal fistula is a devastating condition, usually occurring as a late manifestation of oesophageal or other thoracic malignancies. In these cases palliation by placement of an oesophageal stent is the preferred option, but management of a large non‐malignant fistula is more complex. In many patients in whom primary repair of the defects is not possible oesophagectomy may be seen as the best treatment. We present a case of a large tracheo‐oesophageal fistula repaired with a gastric antral patch oesophagoplasty and intercostal muscle flap.

Re: Chappel v Hart: res judicata?

I thank Dr Fernandes for his comments. Perhaps it is worth reiterating the facts in this case. Dr Chappel did an endoscopic (Dohlman) operation on Mrs Hart for a pharyngeal pouch. An oesophageal perforation occurred, but was resolved with conservative treatment. Mrs Hart sued Dr Chappel because of a post-operative vocal cord palsy (VCP), a complication about which she was not warned. There were no allegations of negligence in the performance of the operation. Mrs Hart agreed she would, in any case, at some time have submitted to the operation. Her sole claim was that had she been warned that she would have deferred treatment, thus possibly avoiding the complication. The trial judge found Dr Chappel negligent in failing to warn and awarded Mrs Hart