Lecture excellence and reliability in spinal surgery: 2nd version

Excellence and Reliability in Spinal Surgery

Spiro Antoniades, M.D.Upper Chesapeake Medical Center Spine Conference

May 2nd, 2014

12 Labors: Labor 1: The Nemean LionLabor 2: The Lernean HydraLabor 3: The Hind of CeryneiaLabor 4: The Erymanthean BoarLabor 5: The Augean StablesLabor 6: The Stymphalian Birds

Labor 7: The Cretan BullLabor 8: The Horses of DiomedesLabor 9: The Belt of HippolyteLabor 10: Geryon's CattleLabor 11: The Apples of the HesperidesLabor 12: Cerberus

Delayed Greatness and Glory Immediate Wealth and pleasure

• reliability • An attribute

of any system that consistently produces the same results, preferably meeting or exceeding its specifications.

1. Age2. chief complaint3. history of present illness4. PMH/PSH5. SH6. Medicines7. PE8. Xrays9. MRI10. Assessment11. Options12. Plan

Questions: Don’t lead

• You hacked into John’s account and copied his essay didn’t you?

• We’re doing the right hip aren’t we?

Patient narratives, mission statements, explanations, understanding the world

Caesar Marcus Aurelius Antoninus AugustusBorn 121AD Died 180AD age 58Look to the essence of a thing, whether it be a point of doctrine, of practice, or of interpretation.

• UC 2009 xray cervical 3 views cost: hospital $100 interpretation $175

Gottfried Wilhelm von Leibniz (1646- 1716)

German philosopher and mathematician.

• S'il n'y avait pas le meilleur (optimum) parmi tous les mondes possibles, Dieu n'en aurait produit aucun.

• If there were no best among all possible worlds, God would not have created one.

• Théodicée (1710)

75 w L UE pain ataxia

ACDF

• http://youtu.be/qNMEAAc756o

• 24:18 spinal cord

• 40:00 bone graft

• 1:28 both grafts in and plate

• “The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.”

• ― F. Scott Fitzgerald, The Crack-Up

Repetition

Clumping of information

Consistency and routine

Mos maiorum

• The mos maiorum ("ancestral custom"[1] or "way of the elders," plural mores, with maiorum a genitive plural; cf. English "mores") is the unwritten code from which the ancient Romans derived their social norms.

• It is the core concept of Roman traditionalism,[2] distinguished from but in dynamic complement to written law.

• The mos maiorum was collectively the time-honoured principles, behavioural models, and social practices that affected private, political, and military life in ancient Rome.[3]

Self Reliance (1841) Ralph Waldo Emerson• The other terror that scares us from self-

trust is our consistency; a reverence for our past act or word because the eyes of others have no other data for computing our orbit than our past acts, and we are loath to disappoint them.

• A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines. With consistency a great soul has simply nothing to do. He may as well concern himself with his shadow on the wall. Speak what you think now in hard words, and to-morrow speak what to-morrow thinks in hard words again, though it contradict every thing you said to-day. — 'Ah, so you shall be sure to be misunderstood.' — Is it so bad, then, to be misunderstood? Pythagoras was misunderstood, and Socrates, and Jesus, and Luther, and Copernicus, and Galileo, and Newton, and every pure and wise spirit that ever took flesh. To be great is to be misunderstood.

Avoid Complications

• BLEEDING, INFECTION, PARALYSIS, DAMAGE TO SPINAL CORD AND/OR NERVES, DAMAGE TO ESOPHAGUS/TRACHEA/ARTERY TO BRAIN/VOICE BOX NERVE, DIFFICULTY SWALLOWING, NON-UNION OF BONE, NEED FOR MORE SURGERY, ADJACENT LEVEL DEGENERATION, PERSISTENT PAIN, WEAKNESS, NUMBNESS IN NECK AND/OR ARMS, SPINAL FLUID LEAK, HOARSE THROAT

The chains of habit are too weak to be felt until they are too strong to be broken

VIGILANCE AND ATTENTION TO DETAIL

SURGERY, PATIENT, DAY, FIELD, SOCIETY,

Focus on the current task

Being Uncomfortable: necessary for growth and noveltyExploitation versus Exploration

The default pre selected option

TEAMWORK

Pattern Recognition (individual and collective)

• Team Building

• Like• Admire• Respect

• Intelligence• Industry• Integrity

Names, listen, respect, save facePraise, perspective

Team comprised of a coalition of the willing

Like the people you shoot and let them knowRobert Capa

Structured communication

Preoperative and postoperative Briefing or huddle

Korean Air Cargo Flight 8509 Dec 199957 year old captain 8k hours 747 experience and 33 yo 1st officer 200 hrs experience1st officer failed to bring mistake to the attention of the captain until it was too late

5.8 magnitude earthquake in Virginia on 8/23/11

Any worker can stop the Toyota assembly line for a safety issue

Niccolo Machiavelli(1469-1527) & The Prince

• …[The only way to guard oneself from flatterers is by] letting men understand that telling you the truth doesn’t offend you. However, when every one is allowed to tell you the truth, the respect for you lessens.

• Therefore, a wise prince should hold a third course by choosing the wise men in his state, and giving only them the freedom of speaking the truth to him, and only on those things that he inquires of, and of none others. But he [the prince] should question them upon everything, listen to their opinions, and then form his own conclusions.

• With these councilors… [the prince] should carry himself in a way that will let each one of them understand that the more freely he [the councilor] speaks, the more he will be preferred. Outside of these [councilors], he [the prince] should listen to no one, and pursue what is resolved on, and be firm in his resolutions. He who does otherwise is either overthrown by flatterers, or is so frequently changed by varying opinions that he falls into being disrespected [by the people].

• A prince, therefore, ought always to seek guidance, but only when he wishes and not when others wish; he ought rather to discourage every one from offering advice unless he asks it. However, he ought to be a constant inquirer, and afterwards a patient listener concerning the things of which he inquired. And additionally, on learning that any one, on any consideration, has not told him the truth, he should let his anger be felt.

checklists

FAILURES AND MISTAKESRecognize it immediatelyReal apology if necessaryCreate a new SBARAccept it personally

Breathingvivid imagerypracticemeditationfocusrelaxation in stepsworse case scenario plan

Vivid imagery

• anx·i·e·ty: a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome.

• fear : a distressing emotion aroused by impending danger, evil, pain, etc., whether the threat is real or imagined; the feeling or condition of being afraid.

Who are you? Co-worker? Client? Man on the street?

Be the character and unleash your subconcious

Viktor Frankl, M.D.1905- 1997

Everything can be taken from a man or a woman but one thing: the last of human freedoms to choose one's attitude in any given set of circumstances, to choose one's own way.

The last of human freedoms - the ability to chose one's attitude in a given set of circumstances.

Thanks

Richard P Feynman Theoretical physicist(1918-1988)

• In 1974, Feynman delivered the Caltech commencement address on the topic of cargo cult science, which has the semblance of science, but is only pseudoscience due to a lack of "a kind of scientific integrity, a principle of scientific thought that corresponds to a kind of utter honesty" on the part of the scientist. He instructed the graduating class that "The first principle is that you must not fool yourself—and you are the easiest person to fool. So you have to be very careful about that. After you've not fooled yourself, it's easy not to fool other scientists. You just have to be honest in a conventional way after that."[42]

• “bending over backwards to show how maybe your wrong”

Power, warmth, engagement

Be the character

Zeno of Citiumearly 3rd century BC

Stoicism teaches the development of self-control and fortitude as a means of overcoming destructive emotions

1. Goals must be in your control2. Accept what cannot be changed3. Be prepared to lose everything

Surgical Consent

Not under duressLegibleSimple languageclear

• MRI Cost UC 2009: Hospital $377 interpretation $175