Viewpoint FROM THE CHIEF MEDICAL EDITOR

The Risky Business of "You Must"

Larry E. Patterson, M.D.

I have a good friend who is, shall we say, risk averse. He has way more insurance than most of us, takes extra medicines to make sure his lipid profile is pristine and if you are invited to his house for dinner there is always twice as much food prepared as needed — just in case. Conversely, I have other friends who take crazy and unnecessary risks at almost every turn of their lives. Most of us fall somewhere in the middle of these two extremes.

This past summer I read a good article in a fine peer-reviewed journal reminding us about the risk of intraocular ocular injuries due to the inadvertent release of cannulas from syringes.¹ I know this can happen because 15 years ago I watched an instantaneous peripheral iridotomy occur as a cannula shot out of my own syringe. Thankfully, my patient ended up with no apparent visual disorder.

However, I was concerned about the recommendations contained within the article: Not only should the cannula be secured to the syringe by the assistant, but this should be double-checked by the surgeon. The authors continued, "The surgeon must personally secure all surgical instruments, including cannulas, phaco tips, and intraocular lens injectors, before inserting them into the patient's eye."

Now I don't know about you, but when statements such as these are made in peer-reviewed journals (you know, the kind they reference in malpractice cases), I get a little uncomfortable. Yes, these complications can happen, and yes, we need to be vigilant and careful in our training and techniques. But I don't always personally double-check everything before I operate. I have a wonderful staff with excellent training and to recheck everything they've already done seems to be of questionable effectiveness. Fortunately I own my own ambulatory surgery center, where I always have the same excellent eye-surgery team. I might feel differently were I in a hospital with a rotating crew with variable eye-surgery experience.

I'm just not sure where the double-checking would end. Many equally important tasks are performed by others on the day of surgery: a balance should exist between personal execution of duties and delegation.

Use Caution With Weighted Words

But back to that article: I don't think it's helpful to use the word "must" in regard to opinions that are nowhere near the standard of care. And I would ask the editors of all these journals to please use caution in publishing such prescriptive statements.

Even while my cautious friend would have probably liked the article, I am almost certain he wouldn't like the 80-minute cataract-surgery time.

Reference

1. Rumelt S, Kassif Y, Koropov M, et al. The spectrum of iatrogenic intraocular injuries caused by inadvertent cannula release during anterior segment surgery. Arch Ophthalmol. 2007;125:889-892.