Sep 8, 2006

Wake me when it's over...not before

A few weeks ago, I noticed a lump about the size of half an orange on my shoulder, at the base of my neck. Did you ever see that movie where a second head suddently grows out of a guy's shoulder? That was what I was half expecting to see.

With that mental picture, I rushed to the doctor. He obviously wasn't sure what it was, but sent me to the surgeon. The surgeon is, if I recall his framed credentials correctly, a "top doc." It turned out to be a lipoma - basically a lump of fat showing up where it isn't supposed to be.

The surgeon said nothing would show up on a CAT scan and recommended removing it. Not only was I scared of having to argue with myself any more than I do now, but the lump was also pressing on other things and hurting me, so I said OK. I told him I was concerned about anesthesia, having twice woken up in the midst of a surgical procedure while the guy was still cutting. At that point, you can't do much more than grunt or moan slightly. Flinching is another option, but perhaps not a good idea.

The surgeon said the same thing had happened to him, as a patient. He said he wanted to "put me to sleep" anyway because he was going to have to deal with little blood and lymph vessels. So far, so good.

The process at the hospital wasn't great, but tolerable until the anesthesiologist showed up, after I'd been soaking in a Valium IV for about 20 minutes. He wanted me to sign off on a release about the anesthesia, telling me I'd be sedated. I asked what he meant, and he said "twilight," not "sleep." I told him that wasn't going to happen, and why, and that "the surgeon said so." He looked in my mouth, asked me once again about false teeth, and changed the paper, which I signed. Then I had to go through a quiz with all the subsequent checkers about why the paper was changed.

What if I hadn't had been assertive? On the second surgery, I raised the issue but complied when the nurse anesthetist told me, basically, that if it hurt, I should tell her. People are intimidated in the hospital, and not inclined to argue much, especially when they've been given nice drugs in advance.

The operation either would have gone on, with the surgeon basically covering up the mistake hoping you didn't wake up and yell, "Get my lawyer." Or the operation would have been interrupted while the surgeon and the anesthiologist duked it out.

This is a highly rated hospital that has already done a lot of improvement work - it has a 30-minute guarantee in the ER, for example. They sent me home with a patient survey. Now they have the situation reported both verbally and in writing. But I doubt there will even be a meeting, much less an advance anesthesia verification (with the surgeon) added. After all, I'm just a patient and no harm was done.


Mark Graban said...

So the error was that they were going to put you only under "twilight" instead of full sleep??

Unknown said...

Yes. I realize it's safer, but not what the doctor ordered this time.

Anonymous said...

I used to work for a Fortune-50 medical device company, with responsibility for the anesthesia pumps. There are several 3-channel pumps designed to simultaneously inject 3 different anesthesias... freeze the muscles, sedate the brain, and pain. We always heard stories (on competitor pumps...!) how one channel would malfunction and the patient would be conscious throughout the procedure but unable to move or otherwise indicate they could feel everything. Just sign the check...

Mark Graban said...

Kevin, what a nightmare scenario. I hope hospitals are listening to Dr. Deming's old (but often ignored) advice of not buying anesthesia pumps on (cheapest) price alone!

Karen, thanks for sharing your personal story.

Karl On Sea (twitter: @karlonsea) said...

Working on Lean every day, and helping people understand the shortcomings of their own processes by drawing "Blue Peter Style" (look it up - it's a BBC children's programme) process maps, I'm not really surprised at this.

If it were a sitcom, it'd be really funny (Doctor [Scottish accent - probably Paisley, or maybe even East Kilbride]: "OK, dose him up on th' jellies we lifted from that nice wee old lady, AND then he can sign the release form or just a book of blank cheques . . ." Patient: "Oh Aye, an' if ye have any o' that smack, I'd not say no . . . . Oh . . . brand newwww!").

But it's not. The internal supply chain for documentation is plain and simple just broken. The link from the surgeon to the anaesthesiologist is missing, and although there's the 'voice of the customer' present, it's only AFTER they'd given you the meds to make sure that any competent lawyer would be able to show you weren't capable of making a rational decision.

The thing is, that this example is kinda obvious, but its symptomatic of why I shy away from medical clients. If you get the value stream muddled in production or service-sector organisations, the worse that can happen is you lose some money, and customers go elsewhere. Do the same in medical . . . and someone can end up dead.

Hard to recover from that one.

But on a lighter note, I hope you've recovered. If it grows back, perhaps the lipoma could take control next time, and have the argument for you with the anaesthesiologist. Chances are, IT won't be affected by the Valium . . .

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