THE COST OF AN ERROR
Safe Surgery at Cooley Dickinson Hospital?
By Melvin Steinberg
During a gall bladder operation at Cooley Dickinson Hospital in 1998, a surgeon who was very short on sleep severed my common bile duct. This is the duct through which bile made in the liver flows to the small intestine where it is used in digestion.
MELVIN STEINBERG: Operating Room Victim, Advocate for Change
By Edward Shanahan
A scientist and researcher by training and professional experience, Melvin Steinberg retired in 1994 as a professor of physics at Smith College where he had taught since 1962.
He is still affiliated with the Scientific Reasoning Research Institute, which is based at UMass and which is involved in research in the area of science education.
Retaining a trace of a soft Southern accent, Steinberg spent his formative years in Montgomery, Ala., not too distant from Selma, where his mother was born. He did his undergraduate work at Georgia Tech and the University of North Carolina, received a masters degree from the University of North Carolina, and in 1955 received his doctorate in physics from Yale University.
Before coming to Smith, he held teaching positions at Stevens Institute of Technology in Hoboken, N.J. and UMassAmherst. When he started out, his field was theoretical physics, and at Yale his thesis adviser was Lars Onsager, who later became a Nobel laureate.
Steinberg recalls that as a graduate student he gained a minor reputation as a maverick when he estimated worldwide radiation exposure from U.S. nuclear weapons testing activities in the Pacific.
He prepared a paper on the subject for the American Physical Society in Washington, but could not find a scientist at Yale to sponsor his appearance. My assessment was they were afraid to do it.
Through friends he made contact with Albert Einstein at Princeton, who agreed to be his sponsor. However, Einstein died shortly before Steinbergs appearance, although the talk touched off a flurry of media interest in the subject. Steinberg saw himself then, as now, as a public spirited citizen.
Since 1980 his research interest has shifted from mathematical physics to the problems of science education, he says. With grants from the National Science Foundation and U.S. Department of Education, a team of college and high school teachers led by Steinberg has created a curriculum for teaching electricity to beginners of all ages, which is now being used in some 3,000 high schools.
He believes that his efforts to bring the subject of operations performed by sleep-deprived surgeons to the attention of the Cooley Dickinson Hospital leadership ultimately led to stonewalling on the part of authorities there.
Based on his personal experience and his subsequent research on the issue, he wrote an article to the New England Journal of Medicine and a letter to the American Medical News, neither of which would publish his findings and comments.
Of the surgeon who performed the crucial procedure that is the basis for his account, Steinberg says: Hes a terrific guy, he doesnt shade the truth and he doesnt withhold. Whenever I write on this issue, I run it by him to get his OK about my own truth and fairness.
Addressing his on-going effort to gain public attention for the subject, Steinberg says: I see it as a civic duty to carry this out. Others will have other adjectives.
Steinberg and his wife, Adele, have two grown children and live on Washington Avenue in Northampton.
Severing the common bile duct is a well known and much feared type of surgical mistake. The pioneer of modern gall bladder surgery in the United States has described its consequences as devastating to the patient. The years-long consequences for me personally have shown this assessment to be no exaggeration.
After noticing his mistake, the surgeon sewed the cut ends of the bile duct back together. But scar tissue growing in the wound blocked flow through the duct after just a few weeks, causing bile to back up into my liver. That created a life threatening crisis.
The surgeon sent me to Massachusetts General Hospital in Boston for damage control procedures. Specialists there punched a hole in my right side and onward through the middle of my liver, to create a path for inserting a balloon into the upper end of the bile duct. The balloon was then inflated to dilate the damaged area of the duct.
A year later bile began backing up into my liver again, and the surgeon sent me to a different group of specialists at Massachusetts General Hospital. They passed optical devices and a balloon through my throat, onward through my stomach and small intestine, and into the lower end of my common bile duct. They inflated the balloon to dilate the duct, and inserted plastic stents (of increasing width over three monthly cycles) to hold the bile flow channel open while a more benign pattern of scar tissue was growing.
The stents have been out now for almost three years, but I cant help wondering what will happen if my bile flow channel closes up again. That things may get worse is never completely out of my thoughts.
I decided to tell this story because my personal experience and the surgeons candidness provide a case study that reveals a systemic potential for surgical mistakes at Cooley Dickinson Hospital. I feel a duty to help others in my community understand this potential for mayhem -- and what needs to be done to remove it as a threat to their well being.
WHAT WENT WRONG?
My surgery involved removing the gall bladder by cutting the attached cystic duct -- a short tube through which bile stored in the gall bladder flows into the common bile duct (and mingles with bile coming directly from the liver). The cystic duct is near the common bile duct over its whole length, which places the common bile duct in danger of being cut accidentally while the cystic duct is being cut intentionally.
The surgeon told me that an abnormal location of my common bile duct had led to his surgical error. He said this duct tends to thrash around during a violent gall bladder attack like the one I had, and in my case had migrated to a location directly under the cystic duct -- where it was severed by the same scissors stroke that cut my cystic duct.
The surgeon knew about my violent gall bladder attack the day before my surgery. But during the operation he did not look for evidence that could tell him if this event had moved my common bile duct to a place where it would be endangered by his scissors. He located my cystic duct and he cut it -- without knowing where my common bile duct was actually located and without using x-ray imaging to try to find out.
An operation televised in 1982 shows Dr. E. J. Reddick -- the pioneer of modern gall bladder surgery mentioned above -- injecting a dye into the cystic duct to permit x-ray imaging of the bile duct system. This enabled him to steer clear of the common bile duct. Dr. Reddick told me in a recent telephone interview that he uses x-ray imaging to guide his gall bladder surgery in every case. He said he has performed many thousands of operations without severing a single common bile duct.
Not all surgeons use x-ray imaging in every gall bladder operation. A surgeon in Northampton told me he does not use it if he can visualize where the common bile duct is located. He always uses x-ray imaging, however, when he is unable to locate the common bile duct visually.
The surgeon who operated on me told me he can usually count on the assistant surgeon to keep me out of trouble -- but did not get that kind of assistance in my case. He said he had asked the assistant surgeon Is it O.K. to cut now? and received an affirmative response. When I asked the surgeon where the assistant surgeon had thought my common bile duct was located just before it was severed, his painfully honest reply was: I dont know. We never talked about it.
How could two highly experienced surgeons agree that it was O.K. to cut now -- without trying to obtain x-ray evidence that my common bile duct would be out of harms way when they cut my cystic duct and without even discussing the location of my common bile duct?
The surgeons honesty pointed to a plausible answer to this question. He told me that he and the assistant surgeon had been on call the night before my surgery, and became involved in emergency surgery which cost them most of that nights sleep. The surgeon explained his personal time sequence to me, from which I estimate he had at most two and a half hours sleep before operating on me. Anyone with some adult life experience can relate this situation to the disaster the two surgeons presided over early the next morning: Their judgment during my surgery was very likely impaired by sleep deprivation.
COMPLACENCY AT THE TOP
I asked the surgeon later what might be done to prevent surgery by sleep-deprived surgeons from occurring in future. He suggested that I talk to the Cooley Dickinson Chief of Surgery, Dr. Alvah Hinckley, who arranged a meeting with the hospitals CEO, Craig Melin. During a three-way discussion, Mr. Melin asked Dr. Hinckley to develop a new hospital rule that would no longer allow surgeons to schedule elective surgery for the morning after they are scheduled to be on call for overnight emergency duty.
Dr. Hinckley kept me posted about his Internet search for information on sleep deprivation of surgeons, and about his efforts to design a new regulation that would work for diverse surgical groups. But his communication with me stopped after a few weeks -- and I received a letter from Mr. Melins office stating that the hospital leadership was satisfied with existing policies. This decision to keep policies in place that permit sleep-deprived surgeons in the operating room highlights the contribution of hospital leadership to surgical mistakes.
The reluctance of physicians to admit that fatigue could compromise their performance is another potent contributor to surgical mistakes. A medical affairs journalist for the American Medical Association told me in a telephone interview that neither the AMA nor the College of Surgeons has guidelines for hospitals regarding sleep deprivation of physicians -- though the AMA does have guidelines regarding physician impairment by drugs, alcoholism and illness.
This lack of AMA concern about sleep deprivation contrasts sharply with the regulation of airline pilots, truck drivers and nuclear power workers by laws that prohibit working when their judgment might be compromised by lack of sleep. It supports professional tolerance of such sorry situations as 42 percent of house physicians at a hospital in San Francisco believing that a fatigue-related mistake was responsible for the death of at least one patient under their care -- reported by sleep researcher William C. Dement of Stanford University Medical School in his book The Promise of Sleep.
The AMA leadership appears to have no problem with a status quo that leaves patients in jeopardy of unsafe surgery. What about the Cooley Dickinson leadership? At a meeting arranged by Mr. Melin in 1998 to discuss how the hospital should respond to my surgical disaster, a hospital official responded to my suggestions by telling me surgery at Cooley Dickinson is so good that two Northampton physicians brought out-of-town relatives here for surgery. Why not? These VIP patients could be steered by their MD sponsors away from possible encounters with sleep-deprived surgeons -- a privilege not available to everyone.
A later letter to me from Mr. Melins office offered more complacency. Since my surgery was elective, the letter said, the surgeons could have postponed it if they believed lack of sleep had impaired their judgment. This ignores the reality that a surgeon is captain of a close-knit team, and highly reluctant to upset the after-work plans of team members. Try to imagine how difficult it would have been for the surgeon who operated on me -- without any mandate by a hospital regulation -- to tell an exhausted team dreaming of a free weekend to go home that Saturday morning and return Saturday afternoon or Sunday. I asked the surgeon if I had got this dilemma right, and he replied that I had.
WHAT CAN BE DONE?
Do I harbor enmity toward the surgeon? No. He has stood faithfully by me through difficult times. His honesty has made it possible for me to learn what happened to me. And I have been back to him for other surgery. I see a good surgeon and a good human being, working in a flawed system that thrusts surgeons into morally ambiguous situations while imposing needless dangers on patients.
I do, however, have strong feelings about the need to change the fate of future victims of this system. Why isnt Dr. Hinckley -- the elected leader of the Cooley Dickinson corps of surgeons -- insisting that his hospital complete the reform that he was once energetically working on? Why isnt Mr. Melin, the administrator responsible for the ethical as well as the financial health of the hospital, supporting the reform for which he once asked Dr. Hinckley to rewrite the rules?
And what about responsibility for the financial health of Medicare? My hospital stays, together with the services of whole teams of medical technologists and their marvelous equipment, cost Medicare tens of thousands of dollars. Have those responsible for policy decisions at Cooley Dickinson no obligation to help bring avoidable social costs of this magnitude under control?
The problem of systemic unsafe surgery at Cooley Dickinson Hospital that I have discussed can be eliminated. The hospital leadership simply needs to adopt a new regulation to the effect that:
SURGEONS MAY NOT SCHEDULE ELECTIVE SURGERY FOR THE MORNING AFTER THEY ARE SCHEDULED TO BE ON CALL FOR OVERNIGHT EMERGENCY DUTY.
Until such a rule is adopted, sleep-deprived surgeons will certainly and needlessly claim more victims. The problem is much like that of a busy intersection without a traffic light. It will help future victims little to note that most other hospitals have the same problem and are doing equally little about it.
Until such a rule is adopted, individuals can protect themselves by agreeing to have elective surgery during morning hours only with those surgeons who guarantee in writing that they are not scheduled to be on call for emergency duty the previous night.
Protection for the entire community could emerge through an initiative by physicians whose work is connected to Cooley Dickinson Hospital. These physicians could petition hospital administrator Craig Melin, on behalf of the public they serve, to implement the above regulation. A successful petition for this kind of rigorous safe surgery policy at Cooley Dickinson could spread across the country, providing a new dimension for protection of life by physicians.