Not Silly Anymore

Published 5:41 pm Thursday, March 7, 2024

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An orthopedic surgeon had several cases scheduled on a busy OR day. He saw each patient in the holding area and marked the proper site according to the permit.

Things were going smoothly. On the fourth case, he scrubbed and gowned then entered the OR where the techs had prepped and draped the patient’s right knee for an arthroscopy. He put the tourniquet up, then, holding the knife literally an inch from the skin, said, almost jokingly: “Let’s have our time out – we’re doing the right knee, right?”

The nurse flipped through the chart and read the permit.

“No,” she said.

“The left.”

Dumbfounded, he put the knife down and looked at the chart. She was right. The patient was permitted for a left knee arthroscopy.

He yanked the drapes back and looked at the patient’s left knee.

Staring back at him were his initials, drawn with a purple marker.

A few minutes and a fresh scrub and gown later, he was operating on the correct (left) knee.

Some years later, the same doctor was about to do a total hip arthroplasty when the nurse ran through her time out routine. By then, the time out had been expanded to include allergies, pre-op meds and various other details.

Barely listening, he caught the phrase: “forty milligrams of enoxaparin…”

“What did you just say?” he asked.

“The patient was given forty milligrams of enoxaparin in the holding area,” she replied.

That was supposed to be a postoperative DVT prophylaxis order, not a pre-op order. He looked down at the patient. She was tiny, not much more than ninety pounds, if that.

It was an elective procedure. Things may have gone well but he couldn’t risk a bleeding complication. He cancelled the case and did her surgery the next day.

Later, the doctor would readily admit he considered the time out a bit silly at first. But after having been saved twice by it, he never again operated without hearing a good time out to his satisfaction and thereafter remained a firm believer in it.


Amen, brother.

Many doctors who have been operating for years thought the same thing, right up until it saved them at the last moment, as it did this fellow.

Couple of points.

In the first case, the doctor initiated the time out. The supervising nurse usually does that.

Everybody in the room should stop what they’re doing and listen as the nurse makes the time out announcement. All should agree. It’s a bit unusual for the doctor to initiate the time out as most consider a “nurse” thing. Good for him. Get involved, surgeons, and don’t cut until you hear that time out.

Second point. The previous surgery in that room was a right knee arthroscopy. When they turned over the room, the techs left the knee brace clamped to the right side of the table. In comes this patient, the brace is on the right side, looking for all the world like it’s ready for the next case.

Which all assumed. With the brace already clamped on the right side of the table, they dutifully set about prepping the right leg. That is a classic example of how a wrong site surgery is generated.

Remember, assumptions can be deadly. You need to be sure. Always verify.

Third point. Didn’t anybody see that the surgical extremity was marked? The patient was lying there with the doctor’s initials clearly visible on the left knee, yet they prepped the right one anyway.

Not a person in the room noticed the obvious. I would have thought that nearly impossible.

The OR supervisor should get the staff together and instruct them to look at those marks and be ever cognizant of the correct site. Even before the time out is called, they should already know.

The nurse in that first case needs a good talking to. Sounds like her awareness and attention to detail were pretty- much down around floor level. To the nurses who read this, realize, you may be all that stands between the doctor who still thinks time outs are a nuisance and disaster. Get that time out done and do it smartly.

In the second case, the doctor barely caught the word “enoxaparin” while looking at x-rays on the computer. He nearly missed it. Doggonnit, when the nurse calls the time out, pay attention!

Stop the chatter and listen to the danged thing. You might hear something very interesting. The medication error was the result of a ridiculously confusing set of preprinted pre-op orders. The problem was easily remedied.

It’s about time everybody took the time out seriously. There here may come the day you develop acute appreciation for that little exercise.

J. M. MacDavid M.D. also known locally as Dr. John Kona can be contacted at