Family Webicine

By Rod Moser, PA, PhD

Although some medical providers like to consider themselves a different species from the rest of the population, doctors are human. Humans are imperfect; humans make mistakes. Someone once said that “Doctors bury their mistakes.”  This is a bit macabre, but sadly, it is true. Some medical mistakes are fatal. When medical providers make little mistakes, should they acknowledge them promptly and apologize? I think they should. A malpractice attorney may argue that an apology is an admission of guilt; one that cannot be easily defended. In many malpractice cases, all a patient really wants is an apology and some heartfelt compassion. When they don’t get it, they will settle for cash.

Earlier in 2011, I had a particularly large kidney stone wedged in my ureter that required surgery to get out. While I was being prepared for surgery, a nurse following orders was about to inject an antibiotic into my IV line – an antibiotic that has caused a serious, life-threatening reaction in the past, and one that was clearly “flagged” in red on my chart and on my wrist band. Did I get an apology? Nope.

For the third time this year, I had to undergo general anesthesia. My last surgery was to repair my torn rotator cuff in my left shoulder. There were a couple of big mistakes that time around: I was listed as a woman on my identification bracelet (which explains the letter I received about a week prior telling me I was overdue for my pap smear and mammogram), and the surgical tape used to keep my eyes shut during the procedure left me with cuts on both my eyes!

If you’ve ever had a paper cut on your finger, you know those little cuts can be painful. Now, imagine one on both of your eyes. The experience of a deep corneal abrasion is one that you are not likely to forget.

The first thing that should be done in this case is pain control. I needed some topical anesthetic for my eyes. A few drops would give me about fifteen minutes of pain relief until I could get my eyes carefully examined. No dice. The surgery center does not do any eye procedures, so they did not have any topical eye anesthetics or topical antibiotics available. Someone offered to go to the hospital pharmacy and get some sulfa drops. I have not prescribed (or personally used) sulfa eye drops for two decades. Why? They burn! The first time I used them for an eye infection, I immediately stopped using them for patients, especially kids. The anesthesiologist was busy on the next case, so he was not available.

I have to say that the painful eyes took my mind off of my painful, post-surgical shoulder. As soon as I was released, my wife immediately drove me to my optometrist. He is an old patient of mine who I consider a friend. When I called their office, they told me to come right in.

A quick exam revealed the corneal abrasions. The optometrist handed me some sample eye drops to use. I was allergic to the drops that he gave me, but I didn’t say anything. This was a “little mistake” since he did not double-check my chart. I had some drops at home anyway. Under the circumstances, I forgave him. As a matter of fact, I never mentioned it.

Later that evening, the surgeon called to check on me. I mentioned the corneal abrasion and he was very surprised. Apparently this had never happened before. He said that he would talk the anesthesiologist about it. I informed him that I was under care and aware that most of these abrasions heal in a few days. It took about five days before my eyes were pain-free and normal again.

A week later, I was sitting in the orthopedic waiting room waiting for my post-op appointment. I spotted another woman seated nearby sporting the same, identical sling. We introduced ourselves and shared our misery. When I mentioned my corneal abrasion, she informed me that she woke up with the same problem.  As a nurse, she knew it was caused by the taped eyes – eyes that were not patched prior to the taping. I encouraged her to mention it to the orthopedist, but she didn’t. When I had my post-op exam, I commented on the coincidence: two people, same surgery, same anesthesiologist, and same corneal abrasions.

Our medical group routinely sends out evaluation forms so that patients can comment on their experiences. Of course, I told the corneal abrasion story and rated the anesthesiologist poorly. Less than a week later, I received a letter of apology that stated (a) he tried to call me and there wasn’t any answer. I was home during this entire time; (b) this never happened to him before, and (c) I couldn’t have talked to the other patient with an abrasion since I was discharged hours before her procedure was finished. Apparently, he failed to realize that we didn’t meet in the recovery room, but in the waiting room a week later during our post-op visits.

I have been sitting on the letter, debating whether I should just “drop it,” or write back and correct some of his misconceptions about my comments. Did he think I lied about the other patient?  Clearly, I am going to set him straight. He has another letter of apology to write to this nurse.

His letter of apology was appreciated, but I would have rather had a face-to-face or phone dialogue. Had it happened to anyone else, perhaps he would be facing a nuisance, malpractice suit.

I will tell him to (a) be more careful from now on; put a soft eye patch over the closed eyes first and then the tape; (b) call and check on ALL of your patients within 24 hours, and (c) stock the recovery room with an eye tray containing a topical anesthetic and a selection of eye antibiotics.

I cannot believe that I was the first person ever to get a corneal abrasion after general anesthesia, but perhaps I was the first one who was knowledgeable and assertive enough to complain. Mistakes happen, but only a fool would consider this a rare event and not take the appropriate steps to make sure this never happens to anyone…ever again.

I will write a response to his letter today.

Do you have a question for Dr. Moser? Ask away in our Ear, Nose, and Throat community.