Risk Awarenes in Endoscopic Operating Theater Artin Ternamian by Tamer Seckin
Tamer Seckin: Hello, this is Dr. Tamer Seckin in Bari at the 17th Annual ISGE Meeting, women's health from diagnosis to treatment. I am with Dr. Artin Ternamian from Toronto, Canada. He has been very well known in the ISGE circles and around the world with his contribution to the laparoscopy work, his guidance towards complications and preventing them. We will focus today not generically on the complications, yet not on the overall philosophy behind complications, how it relates to the social and the politics of medicine, the healthcare and he will look us, we are going to wind the tape backwards and he will give us a backward look how the complications relates to all.
Artin, it was a beautiful presentation today and I really want you to go back. We know what happens in the OR. We know what we survive to do and it is always a doctor that has been implicated yet the hospitals and the big industry, – things do pass without being reporting through the right channels and we never progress. I want to take the microphone and really go and work on this in the next five minutes, inner thoughts with your experience layer by layer. Thank you.
Artin Ternamian: All right. Listen, the presentation today or the session that we had dealt with complications of endoscopy in general terms. There were people who presented and talked about the laparoscopic complications specifically and other people talked about the hysteroscopic complications. My contribution at the end of that session was to talk about risk awareness. As I was telling you a minute ago, risk awareness was a term and a concept that I was not introduced to as a resident, neither were you, I am sure. This idea developed over the last decade or so since healthcare particularly in the U.S. and in Canada encountered celebrated cases. By that I mean terrible disasters that were well publicized that affected my patients and your patients. These celebrated cases raised awareness among healthcare professionals, among government professionals and insurers and the industry to the fact that if we continue doing what we have been doing this far there are some incidences of serious complications that are not going to go away. In fact, the literature shows that over the last 25 years of endoscopy, if you like, the incidence of inadvertent primary port insertion has not changed. One of the presenters today quoted the number of 0.16% throughout from the 1988 publications all the way to the 2004 by chaperones publication shows that that incidence has not changed. Obviously, it means that no matter how well we have evolved in a certain direction those increments of risk have stayed the same.
When you look at other disciplines like the nuclear industry or like the military or like mining, they also have risks in whatever it is that they do, but their approach to risk has been a little bit different than what we have had. In medicine for many, many reasons, we tend to look at risk in a certain way that if the patient has not suffered a disastrous accident we had a tendency of turning the page, going home, lighting a candle and thanking the Lord that nothing more serious happened and tomorrow morning we go back to work and doing the same time that happened yesterday or last month or last year. So the system did not have an integrated method of learning from near misses. Whereas other industries like the nuclear industry or say military submarines, whenever they have a near miss they almost make a federal case out of it and they try to learn from these experiences, so that next time they avert such an event. As long as we as practitioners partner with institutions and/or insurers with this focus in mind, I think over the years we would be able to bring down the incidence of inadvertent error a lot better than what we have done over the last 25 years. Because ultimately industry insurers, governments, you name it, and administrators are our partners. Whether we like them or not, they are in the soup with us and their interests and our interests and our patients interests can be aligned along the same line with the objective of looking at what we have done and how we can do it differently and better.
Obviously because we are human and not superhuman, even though we want to think about it that way, there will be incidences where we will have accidents. So any surgeon today that stands up and professes that he or she has never had a serious complication either has not been in practice long enough or maybe he is not telling us the whole truth. So if the error is an inevitable part of the equation of practice, we have to learn how to capture those. This irrespective of the consequences to a certain extent and look at it in a constructive way to try to devise systems that will avert the next disaster.
Now risk awareness is the prerequisite to improving patient safety because if I am not convinced that there is a problem and you are not convinced that there is a problem then there is no problem and therefore why are we looking for a solution? But risk awareness is the first step to the beginning of a chain reaction of change towards minimizing inadvertent errors. Risk awareness creates a partnership between the physician, the patient.
Tamer Seckin: Hospital.
Artin Ternamian: The hospital and everybody in the room and I have always maintained that the first, whenever you talk about risk awareness in laparoscopy that by far the most important increment is primary port insertion because no matter how you look at it the literature and the evidence has shown that primary port insertion is the most risky part of the whole process…
Tamer Seckin: Not the various.
Artin Ternamian: Port insertion in general.
Tamer Seckin: In general.
Artin Ternamian: So when you look at the port insertion in general and you de-structure it and restructure it in a less risky way, maybe we would be able to shift the statistics and improve that increment in laparoscopy. Now obviously for reasons that you know, I have been involved with visual entry for a long time. I am convinced that visual entry is an integral part of surgery because basically surgery and endoscopy have two main components. One is the visual and overlapped on that is the ______.
Tamer Seckin: Okay, yes.
Artin Ternamian: So if you isolate the one and you left with the other, you are on the risk of getting into problems a lot more than if you have both working together. So either you are going to lose the vision or you are going to lose the touch and in the process entry becomes a lot more riskier theoretically than if you have both to buffer whatever it is that you are doing.
Tamer Seckin: To wrap it up, for all of the ISG listeners around the world, our members, subscribers, young laparoscopists and older laparoscopists who are overconfident that they have never had any complications, some may, but still now being specific, the trocar injuries and intraoperative electrical injuries and postoperative late injuries, when we look at altogether and look back on the overall experience and I could tell you from my experience and my – as long as you recognize complication in laparoscopy, you will –
the patient will be fine because these laparoscopists are doing this long time. If there is a vascular injury even they know that they have to go in within minutes to seal it and call the right person, even there should not be any problem, really.
The biggest problem is the late recognition and some electrical problems. Here comes the maintenance of the equipment, the precision of the technical gadget we use and there are lot of times these issues are hospital dependent issues. In other words, the physician may have even his own private instruments or scissors or many different things manipulated but overall the control of the unit and its overall care and some issues around is the hospital's responsibility. When you look at back cases that you have experienced to what degree hospitals are really aware of their own responsibility in the endoscopic OR and they maintain a record of excellence or precision in the way they take care of their instruments? I mean in other words, if I am setting this cyst to pure cut 100, is it true pure cut 100? I practice in a couple different hospitals. I can tell you by experience it is not the pure 100. In every hospital it is different pure 100. I feel it from the way the tissue cuts.
Artin Ternamian: Yes.
Tamer Seckin: So I am asking you is there any enforcement or some guidelines for the hospitals for internal mechanism that they should be doing? If they are not doing to what role the surgeons have to implement that or enforce that?
Artin Ternamian: You know, what you are saying is true. There is no question that administration and paying partners have a fiduciary responsibility to make sure that everything that you and I use on our patients is at a certain standard, because ultimately we all lose at the end, not only the patient, not only the physician but also the administrator.
Tamer Seckin: I thank you very much, Artin. It is a pleasure to have you in Bari.
Artin Ternamian: Yes, thank you.
Tamer Seckin: I know you can talk.