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AAOS Now

Published 2/1/2012
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Elliott H. Leitman, MD

Be Mindful of the Autopilot

Knowing when to pay attention can make the difference

As a pilot as well as an orthopaedic surgeon, I am familiar with the parallels frequently drawn between the two professions. A recent string of airline crashes attributed to the pilot’s loss of control raised concerns that pilots have, to some extent, lost experience in manual piloting and become less able to cope effectively if the autopilot disengages. The use of the autopilot is so universal in commercial airliners that the pilot flies the plane manually for just a few minutes of each flight.

The parallel in orthopaedic surgery to flying manually is mindfulness—that awareness and attentiveness to our own actions, particularly in the performance of routine tasks.

In his article, “What does it take to make our practices safe?” (AAOS Now, May 2011), S. Jay Jayasankar, MD, laid out some key elements—mindfulness, leadership, decision-making skills, and attitude—that surgeons need to practice safely. As I reflect on a particular patient whom I treated in May 2005, I can see how these elements helped me avoid a tragedy.

The patient
My patient was a 45-year-old man with osteogenesis imperfecta (OI). He was admitted right before the Memorial Day weekend with a right femoral neck fracture. He had a telescopic intramedullary rod, which had been in place for several years. Although this was not a complex fracture, I was uncertain of how to treat it in an individual with OI and a rod in place.

I reviewed his radiographs and spoke with the patient, thinking that I could transfer him to the tertiary center where he received his orthopaedic care. His orthopaedist, however, was not anxious to treat him over the summer holiday weekend and suggested that I use multiple cannulated screws. Once he advised me on the procedure, I was confident in my plan of action.

Life’s distractions
I told my wife that I had a quick case to do on Saturday morning and would be ready to go to the pool by noon. She knew better than I that quick cases are rare, particularly at our trauma center where a more urgent case could bump me out of the operating room (OR). I could sense her disappointment. This is a set up for “get home-itis,” a term I learned in flight training that can lead to errors in judgment.

Although the case was not too difficult, I did not initially appreciate that the neck was anteverted. It took a few more attempts than normal to insert the guide pins, but I finished in about 45 minutes, dictated, and was ready to roll.

Then the post anesthesia care unit (PACU) paged me. “What did they want?” I thought. “Probably couldn’t read my orders.” But instead, I was informed that the patient’s toes were numb and that he was in a lot of pain.

Attitude, decision-making, leadership
“It is Memorial Day weekend. My wife and family are waiting to spend the day with me. I’ve done this case a hundred times. Nothing could go wrong. It is a resident-level case. The nurses are idiots; the weekend nurses are the worst. I know more than they do. Pain? The patient is a wimp; it was a 2-inch incision,” I thought.

Today, I wonder whether my decision making might have been different if I had been on the highway or at the pool instead of in the dictation area when I was paged. We did not have residents, so I might have told them to call a surgery intern to evaluate the patient. How much time would it have taken the intern to respond to the page and see the patient? Would he or she have made the correct diagnosis? Ultimately, who would have been responsible for this patient?

I took a deep breath and headed for the PACU. The patient’s foot was mottled and he was in pain. I thought to myself, “I was not near any vessels. Why this appearance? Vasospasm?” I moved his leg and the color and sensation returned. Motor had been intact. Pulses were palpable. I was almost ready to head home.

I observed a few more moments, and saw the pulses disappear. Pain was increasing in the leg and had spread to the flank. To my dismay, the vitals showed that he was hypotensive.

I wondered whether I had hit the iliac vessels. I called the vascular surgeon, who performed an evaluation and agreed that there was indeed an injury. We were headed back to the OR. I informed the patient’s wife of the injury.

With the fracture fixed, was my involvement completed? The vascular surgeon did not need my assistance. But as I thought about leaving, I began to wonder, “Would that be leadership?”

I returned to the OR with the vascular surgeon. Indeed, I had penetrated the iliac artery with a passage of the guide wire. A synthetic graft was needed to restore blood flow to the limb.

Again, I spoke to the patient’s wife. I told her that I inadvertently caused the injury and why I thought that this injury had occurred in this circumstance. I felt terrible, and she thanked me! I had almost killed her husband and she thanked me for saving his life!

The impact of mindfulness
Six years later, I still reflect on this case. Mindfulness means situational awareness or observation without bias or distraction. I certainly had distractions on that beautiful May afternoon. As surgeons, we must recognize when distractions are present and be more vigilant. In many cases, I will not even look at the OR clock to avoid creating a conflict in my mind.

Many decisions that day could have led to an adverse outcome. In many circumstances, the mishandling of complications leads to litigation. The clinical signs of an ischemic limb were obvious, but could have easily been overlooked because it was so unlikely with this procedure. In my “experience,” such a complication could not occur.

It was my duty to personally evaluate the patient, call the consultant, and see my patient safely through his corrective surgery. Too often we are quick to give phone orders without directly communicating with colleagues. A good surgeon/leader listens to the input of patients and nurses and makes them feel part of the team.

In this case, an alert nurse called me and I responded appropriately to her concerns. I valued her assessment and, as a result, she truly had the greatest contribution in the care of this patient. As Dr. Jayasankar recently told me, “the value that our team members add to our team’s work is directly proportional to the value we place on our colleagues and their contribution.”

Being decisive is another leadership quality that nurses and patients want from physicians. But when things go awry, we often want to avoid the reality of the moment. We must be frank with our patients and their families.

More than orthopaedic knowledge and skills
As surgeons, we are ever striving for patient safety. Our patients can be harmed when we lack the proper knowledge or skill sets to treat them. More frequently, however, patients are harmed when physicians fail to be mindful, lack leadership, and exhibit poor decision making or communication skills.

These skills take years to develop but are frequently dormant due to complacency (the ‘autopilot’) that, ironically, the familiarity of experience sometimes tends to foster. The Orthopaedic Risk Manager articles in AAOS Now remind us of our human limitations and professional duties so that we may be vigilant.

Elliott H. Leitman, MD, is in private practice at First State Orthopaedics in Newark, Del.; a member of the AAOS Medical Liability Committee; and a lieutenant colonel (retired) in the U.S. Army Reserves. He can be reached at ehlmd@mac.com

Editor’s Note: Articles labeled Orthopaedic Risk Manager are presented by the Medical Liability Committee under the direction of contributing editor S. Jay Jayasankar, MD.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

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