Video Transcript
When you have a bad surgical outcome, you have to look at the surgical team as a whole. You cannot assume that the error was the surgeon’s. More often than not, it is. Even when the error is from someone else on the team, the surgeon, as the captain of the ship, may still be responsible for someone else’s error, but you need to look at it wholly. For example, I had a case many years ago where my client went in for a hip replacement. It should have been a very simple surgery. During the surgery, when she woke up, she came out and she had been cut from the top of her hip all the way down to her knee. Her leg had been broken and reset, and she had rods. It was a shocking outcome. The obvious question first is: what did the surgeon do wrong? Upon having the case reviewed by a surgeon and surgical nurses, I discovered that the surgeon didn’t do anything wrong. What happened was that the circulating nurse was supposed to mix two packets of cement to put in the gun to hand to the surgeon so that when he went to fill the implant, he was ready to go. He put the gun in, he pumped it, and it suddenly stopped. To his shock and amazement, when he looked at the circulating nurse, he said, ‘Why is it—’ and she had the second packet. She said, ‘Oh, I’ll mix it for you now.’ What she did not understand, because she had not been properly trained by the hospital, was that she had to mix them at the same time. She had to fill the gun full and give it to the surgeon, and he could not start with one packet of cement, allow it to start hardening while she created the second packet, put it in, and then finish the job. So he had to rip everything out, break up the cement that was setting with a mallet. It broke the bone, and my client ended up with rods. That’s a catastrophic surgical outcome, but it actually was not surgeon error. It was circulating nurse error, and it was the fault of the hospital, not the surgeon.
