I was on an aircraft in early October, and the flight attendant was discussing aircraft information and emergency procedures. As I looked around, I discovered that most passengers didn’t appear to be paying any attention. They didn’t look at the booklet or listen to any of the instructions—probably because they’d flown before and assumed they “knew it all.” I had a sudden epiphany: I fly on approximately 100 aircraft per year to lecture to groups—how often am I as complacent as my fellow passengers?
But the insight didn’t stop there. Later that month, I was speaking at the American Association of Surgical Physician Assistants (AASPA) meeting about the drug Ofirmev, and how PAs need it to prevent the adverse effects of opiates. Suddenly, I found myself discussing the fact that PAs, along with our physicians and so many other prescribers, are often tuning out when we come across a subject we think we know. We become apathetic, and we may project that apathy to our patients.
The scenario with the flight attendant is being replicated every day in operating rooms across the country when we have a “time out” at the beginning of a case. The circulating nurse mentions the patient’s name, the proposed information, the date of birth, allergies and the medications and tests that have been given. The surgeon, first assistant, anesthesia personnel and nursing staff are prepared to do a procedure, but we still have wrong-site surgery and multiple errors that cause harm to the patient, their families, the hospital system and healthcare’s reputation as a whole. Everyone involved in these cases is culpable, and they could be sued by the patient’s attorney. These are sentinel events, and many times they end in the death of a patient. But they are avoidable if we listen and apply the protocols, procedures and attitudes needed in an OR.
In my talk about malignant hyperthermia (MH) I explain how these errors can be corrected by a proper H&P, asking the patient appropriate questions, having an MH cart and backup should there be two episodes simultaneously, having every person in the OR trained to deal with an MH event and having yearly drills. No one should be exempt from these procedures, including the surgeon.
And now for my final epiphany. Suppose you are a member of the OR staff, and there is a sentinel event that will make you a defendant in a litigation. Are you covered by your insurance? Yes, the hospital has an umbrella policy, but are you protected by a personal liability insurance policy? Without it, you suffer the final result of apathy: You have not protected yourself, your career, your home or your family, and you have lost your reputation with little chance of gaining employment in the field that you love.
Many a PA has been thrown under the bus because of an umbrella policy. A personal liability policy has only one person’s name on it and is defended by someone with no interest in the hospital or doctor.
Ideally, every PA who has been sued should write about their experience and share it with their colleagues. We are walking in a sandstorm and clarity is needed to see the apathy and have an epiphany.
Robert M. Blumm, MA, PA-C, DFAAPA, is a past president of AAPA and a national PA consultant, activist and conference speaker. Contact him at firstname.lastname@example.org.
See also: The Black Swan: Have You Missed One?