A doctor was forced to implant a screwdriver shaft during an orthopedic surgery:
“There on the back table was a sterile stainless steel metal shaft of a screwdriver that measured the same diameter as the rods that I intended to use. I then used a bolt cutter and measured the rod just to be sure. I then put bone graft on both side in order to fuse his spine. The rest of the surgery proceeded without any incident,” says Dr. Robert Ricketson.
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McGuiver to the rescue.
As hospitals adopt the ‘just-in-time’ delivery that manufacturing has it will become commonplace that patient care is delayed waiting for parts.
Some blueblazer gets the bug to do this, watches inventory deplete over a quarter or two and during this temporary decrease in purchasing reports that the new ‘just-in-time’ inventory system is saving bundles of money. In reality it is a small one time only shift of money from stock to cash flow that can not be replicated again. The blueblazer claims the success and moves on to some other project. In order to function without unreasonable delays the purchasing group must eventually increase inventories, or cause other areas of the budget to suffer. Any time we wait in the OR money winds up paying overtime for the staff. The physicians just have a few more hours of their lives sucked away for hospital inefficiencies.
Oh, and don’t forget the patient.
The rods should have been there before the operation began.
The patient? There was a patient? Who knew?
Sometimes, it will help patients to check a doctor’s background. This doctor practiced in Edmond, Oklahoma before moving to Hawaii and his record in the Oklahoma Medical Board of Licensure website shows:
01/21/1999 Suspended License Alcohol/Substance Abuse
Narcotics Violation/Over-Prescribing
60 Days suspension ending 1/31/99- followed by 5 years probation. Prescribing controlled dangerous substance to a family member or personal use; Writing false or fictitious prescriptions for controlled substances.
I’m sure the lawyers on both sides know this by now.
We should be careful not to rush to him just because he is a fellow physician. He was not substituting one type of implant for another, but instead trying an illogical device that was obviously a bad idea. We can try to blame someone else, but it was ultimately this doctor’s poor judgement that led to a failed operation.
How can a surgeon begin a proceedure that requires implantable hardware without being absolutely certain the required hardware or prosthetic device is not in the OR?
The physician was informed three times the set was complete before surgery. The patient had heart disease, diabetes (uncontrolled), and hypertension. He bled 1500cc when the doctor was informed there were no rods. Wait 2 hours for rods? What do you think? The patient suffered no neurologic injury or spine damage. The patient fell two months later dislodgeing his left rod. A third surgery by another doctor left a large hematoma with neurologic injury for 5 days before the hematoma was removed. By then it was too late. The patient later became paralyzed as a result of the hematoma. That’s what you don’t get from the news. All isn’t what it seems.
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