Letters & E-mails

Treat the Patient, Not the Monitor
Re: "The Case for Capnography" (November, page 55). Just finished reading Mr. Snyder's article on capnography for use during "MAC or IV sedation cases." I have a couple of quick comments. I do these cases on almost a daily basis and have done so for more than 20 years. I have rarely used, nor felt the need to use, capnography to increase the level of safety I provide for my patients. I feel that the routine use of this technology may lead to treating the monitor rather than treating the patient. I use a cheap and simple device known as a pre-tracheal or pre-cordial stethoscope on every case. Changes in respiratory patterns are recognized in a more timely fashion than with capnography and require no expensive monitor or fancy cannula. I also do not send my patients to PACU in a condition where they run much of a risk for further airway obstruction. In fact, most walk with me, even after an eight-hour procedure, or would be capable of walking.

Though Mr. Snyder did not note it, the American Association of Nurse Anesthetists also has standards for monitoring. While it's a bit vague, it does address the issue of CO2 monitoring by saying, "Continuously monitor end-tidal carbon dioxide during controlled or assisted ventilation including any anesthesia or sedation technique requiring artificial airway support."

Jay Horowitz, CRNA
Quality Anesthesia Care Corp.
Sarasota, Fla.
[email protected]

The Problem With Surgical Site Marking
We are often asked if there is a gold standard for site marking patients for surgery. Clearly, most institutions in the United States are either using the surgeon initialing system or the universal "YES" system. Is one the best?

Proponents of surgeon initialing rightfully argue that it is essential for the surgeon to see and talk to the patient before surgery (how could anyone intelligently argue against this?). Yet this system has an unintended but inherent flaw. It can leave the nursing staff with the mistaken perception that site marking is the surgeon's job and therefore not theirs.

Proponents of the universal "YES" system rightfully argue that variability (different initials for different surgeons, for example) is the hobgoblin of quality control, and that each patient should be marked in the same standardized way for surgery. Yet this system also has an inherent flaw of its own. It can leave the surgeon with the sadly mistaken perception that site marking is the nurse's job (which is OK with them because they are good surgeons, and wrong-site surgeries only happen to bad surgeons).

The truth be known, the only system that fully engages the entire surgical team in the site-marking process (and make no mistake about it — the entire team must be engaged to prevent mistakes) is a hybrid of the above two systems. The countersigned universal "YES" system insures that each patient will be marked in a standardized fashion, and that the surgeon, via countersigned initials, will verify the accuracy of the marking. Extra work? Yes. Practical to implement in all institutions? Perhaps not. But if there is a gold standard, this is probably it.

Those who think we are already doing too much to prevent wrong-site surgery are wrong. Most cases of wrong-site surgeries are perfect storms — multiple small breakdowns in our safety nets that conspire to produce much larger surgical mistakes — and these perfect storms can happen at any time and in any place, even to good doctors and even to good nurses. Given the fact that wrong-site surgeries continue to occur with unacceptable frequencies despite all of our efforts to date, one can easily argue that we have yet to do enough. Until we mark patients for surgery in a truly universal fashion, we will not be doing all that we can do to avoid wrong-site surgeries.

Steve Lober, MD
Athens Plastic Surgery Center
Athens, Ga.
[email protected]