Positive Outlook - Issue 8.0 - Nov 2014

Between a Rock and a Hard Place

This section is written by one of our insured physicians describing events and situations in the real clinical world.  Doctors are constantly put in situations of doing what is best for their patients while trying to avoid a target on their backs at the same time.

Stephen Zabinski, MD is one of our insured orthopedic surgeons.  In this issue, he discusses an important situation:  How to deal with a procedure-related complication.  Though the example below is orthopedic, it pertains to any situation where things don’t go according to plan.

Stephen Zabinski, M.D. - Intraoperative fracture during total joint replacement is a well-recognized complication of the procedure.  The importance of appropriate treatment and disclosure is the topic of discussion.

Intraoperative fracture remains an inherent risk during routine total joint arthroplasty (TJA).  Implant design, necessary bone preparation techniques, surgical approach variations and patient related factors, such as osteoporosis and avascular necrosis,  are all factors in why this remains a reality for surgeons during routine and revision TJA.

This procedure related complication does not,  in itself,  constitute a deviation in standard of care. The meticulous management of the event once it occurs intraoperatively,  as well the postoperative care and disclosure to the patient and family,  are keys to avoiding litigation.

Intraoperatively, it is vital to take a deep breath and assess the situation as fully as possible.  Do whatever is required to understand a given situation (obtain intraoperative x-rays or even remove the implant if needed). Then make a decision on what is the best strategy for the given situation.

It is vital to not worry about time delays and their impact on the rest of the day's schedule. Do what is best for the patient even if it requires waiting for the arrival of  non-stock components  from an outside source or a second surgical approach/incision. Take comfort leaving the operating room knowing that you have handled the issue in the best of all possible ways.

Post-procedure, assess how the additional  operative procedure and any necessary alterations in the patients rehabilitation may impact patient care. Alterations in your care path plan of the elective TJA patient may be required. VTE prophylaxis, urinary management , medical management (ie. cardiovascular, renal, hematologic ), length of stay and discharge disposition are some of the aspects of patient care that may be affected.

It is also important to communicate the event and any alterations that may be required in the patients care path plan to all aligned health providers both in the hospital and downstream during the patient's recovery process. Making sure that everyone who cares for the patient knows fully about the issue and the management plan shows your effective leadership as surgeon and "captain of the ship".

Lastly, full disclosure of the complication to the patient and their family is vital in avoiding litigation. Bring copies of post-op x-rays to assist in explaining the fracture and how it was managed. Explain how and why fractures occur routinely during TJA and accordingly why you as the surgeon and your staff are always prepared for this eventuality.

Patients will often have concerns about how the event will affect both their short term and long term recovery and operative result. Discuss openly and honestly alterations that may be required in their postoperative management and the risk / benefit analysis that occurs in making decisions about such alterations. Give them realistic timeframes for recovery. Writing down a simple timeline for the patient and family remains an incredibly simple but effective communication tool.

In summary, if you perform procedures on a routine basis, you (like me) will encounter procedure related complications.  Appropriate  management, customization of the patient's care plan and effective communication are the keys to avoiding litigation in these patients.