Why You Shouldn't Knock Surgical Checklists

By John H. McCord, DPM

I walked into the operating room 10 minutes early as usual. The case was a complex repair of multiple fractures from a SUV vs. Harley wreck. None of the fractures were difficult to repair but there were four to set and fixate. The nurses laughed quietly when I hung a numbered checklist next to the X-rays. Everybody in the room laughed except the anesthesiologist, who, like me, is a licensed pilot. Checklists save your life when you’re flying an airplane. Forgetting a small detail like the fuel level or the proper functioning of controls can result in a crash so we use checklists. Surgery is not unlike a journey in an airplane. A surgery checklist should include the patient’s name, the diagnosis, the procedures and especially which foot is to be operated upon. I use a checklist even for the simplest cases. Explore the wrong interspace for a neuroma someday and you’ll be a checklist user too. I use templates and diagrams with the checklist. This is another airplane thing I’ve adapted to my surgical work. A pilot uses an approach plate when making an instrument landing. The approach plate has all of the necessary information on the airport plus a detailed diagram of the pattern of flight. An instrument landing is just like a complex surgery. A surgeon can get disoriented and cut a bone at the wrong angle just like a pilot can lose his sense of direction and crash the plane. My surgical checklist includes an equipment list. This lists special equipment needed for a particular procedure. The instrument landing approach plate has the same type of list. I don’t leave the ground in my plane without going through the checklist and I don’t start a surgical case without reviewing my surgical checklist and making sure all of the needed equipment is in the OR and functional. I rented a plane a few years ago to fly to Seattle. The general aviation airport in Seattle requires radio contact with approach control at least 30 miles out and contact with the control tower on another frequency. A large number of commercial airlines, military and private aircraft come and go from the Seattle airports. A pilot can get mighty busy changing frequencies, copying clearances and announcing position to the controllers. The airplane I rented was well equipped and up to the task. I didn’t have a checklist with me and kind of guessed my way through the process of making sure everything was there and worked. I took off for the 30-minute flight to Seattle. About 35 miles out, I turned to the frequency for Seattle approach and called for permission to enter Seattle air space. There was no reply. I called again and still heard no reply. I changed to a second radio and called with the same result. I could hear the controller talking to other planes but it was soon apparent that he couldn’t hear me. A quick check of the radios told me that neither was transmitting. I made a quick 180-degree turn just before I penetrated Seattle’s controlled airspace. An unauthorized penetration results in a stiff fine and possible revocation of a pilot’s license. My standard checklist now includes confirmation of a functioning radio before I leave the ground. I started a simple surgical case a few years ago. It was a metatarsal neck osteotomy that I planned to fixate with stainless steel wire. Hardly anybody uses wire anymore since the growth in popularity of pins and screws. They had wire in the hospital 20 years ago so I assumed they still did. I should have used a checklist. The case was going well. I had made a delicate cut to take a wedge out of the metatarsal neck and had drilled the holes for the wire. I said, “28 gauge wire, please.” The circulating nurse said, “Huh?” I repeated my request. The nurse shrugged, told me they didn’t have any 28 gauge wire and then went back to her paperwork. I couldn’t find anything to throw at her that wouldn’t injure her or destroy hospital property. The osteotomy was transverse so a lag screw was impossible to use. A pin or K-wire wouldn’t hold the three-dimensional correction I was seeking. I needed wire and soon more antiperspirant. That case influenced me to add an equipment list to my checklist. After some discussion, we tore apart several packages of wire suture and braided them together to close the osteotomy. The case ended well. The difference between flying an airplane and performing surgery is when things go wrong in surgery, you can’t simply make a 180-degree turn and fly home.

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