Proliance Surgeons Outlook v5i13

2 PROLIANCE SURGEONS OUTLOOK

www.proliancesurgeons.com 3

In this issue...Pancreatic CancerBringing greater awareness to illnessPancreatic cancer is the fourth leading cause of cancerdeaths in the U.S., second only to colorectal cancer ingastrointestinal cancer deaths. Despite current treatment,this disease remains one of the most deadly cancers, witha 5-year survival of less than 5 percent.

Thyroid Eye Diseaseand Orbital DecompressionHow surgery can helpEric Pinczower, MD discusses thyroid eye disease (TED),an autoimmune condition causing vision loss and bulgingof the eyes and associated with thyroid disease. Symptoms,diagnosis, treatment, the three steps involved in surgeryand what a patient’s prognosis can be, are discussed.

Understanding the Conceptof Never EventsKeeping mistakes out of hospitalsTwenty-seven “never events” have been compiled and listedby the National Quality Forum (NQF). This list delineatesthe 27 mistakes that are so serious they should never occur.These events have been identified in an effort to “createawareness and correction among health care outlets.”

In Every Issue...4 Health Care Advances

Welcoming remarks from theCEO of Proliance Surgeons

12 Proliance Surgeon’s Directory

5

8

14

Volume 5 • Issue 13

Welcome to the autumn edition of Proliance Surgeons Outlook. With thecurrent debate on health care reform, we, as providers, must take care thatcurrent advancements are not lost in the health care reform quagmire. Amidcries that our health care system is broken, we should remember a keyprinciple of successful reform. That is: recognize advancements our healthcare system already has made, and encourage more of them.

In the current crossfire of mud-slinging, the ability to encourageadvancements has been buried. Yet encouraging more of the advancementswe’re already making—not to mention simply holding onto what we have—must be acornerstone of successful reform. The advancements in medical treatments, pharmaceuticalsand surgeries are obvious. They have saved lives, reduced pain, restored mobility andproductivity and given patients longer, better lives.

Advancements in health care management are less apparent, but there have been majorcontributions to cost control and quality of care. Whatever reform is adopted should pointus to even greater gains.

Our experience at Proliance Surgeons offers valuable lessons in encouraging managementadvancements. In the past 15 years, we’ve built one of the nation’s largest surgical practices,emphasizing high-quality care and service for our patients, along with sensible cost control.Here are several principles that should be part of any reform:

Care for patients where it can be done best for the lowest cost. Through our 13 ambulatory(or outpatient) surgery centers, we perform many surgeries for a reimbursement that can be40 percent less than it would be if the same surgery were performed in a hospital. Given thecost savings and quality of care, reform should solidify physicians’ ability to own surgerycenters and expand the procedures that can be performed in them.

Create new risk-management solutions to lower malpractice costs. With our size, we’ve beenable to create our own solutions for malpractice coverage. These improve patient care andsafety while saving money for physicians and patients. Congress should either act on tortreform or enable more medical providers to unite in creating their own malpractice solutions.

Expand and share knowledge to improve best practices and patient safety. With 180physicians, we can develop and share statistically valid norms for best practices within ourgroup. For example, we track an already miniscule infection rate to drive it down and improveoutcomes even further. Such patient safety initiatives improve care, efficiency and cost control.

Establish and strengthen medical standards. In our ambulatory surgery centers, we developed andtested the surgical checklist for such centers and presented it, ready for adoption, to the SurgicalClinical Outcomes Assessment Program. Checklists should become even more common to guideconsistent treatment, enhancing medical outcomes, efficiency and consequently, cost management.

Support people’s ability to choose their doctors. Reform must fulfill President Obama’spromise that people can keep their doctors and health plans. When people are allowed tochoose, they seek the type of care they want. This provides an additional, important incentivefor patients to decide what they want and the doctors to provide it.

Phase in major reforms to avoid costly, disruptive mistakes. As Proliance has grown, we’velearned to change with care. That gives our organization time to absorb new elements. Suchdeliberate caution will be especially important in changing our nation’s infinitely larger, morecomplex health care system. Caution is essential in avoiding unintended consequences, whichcan compromise quality of care and cause costs to explode.

Reform is an incredibly difficult task. Building on our advancements will make it much morelikely to succeed.

David G. Fitzgerald, CEO


A publication from

Proliance Surgeons, Inc., P.S.Central Office

720 Olive Way, Suite 1505Seattle, WA 98101

(206) 264-8100(206) 264-8689 Fax

www.proliancesurgeons.com

President Jeffrey Remington, MD

CEO David G. Fitzgerald

CFO Gary Mayberry

Proliance Surgeons Outlook, apublication from Proliance Surgeons,is an educational resource for healthcare professionals as well as thegeneral public. The publicationcommunicates educational newsand trends involving bothorthopedic and general surgerytopics and contains various health-oriented articles of interest. ProlianceSurgeons’ goal is to increase publicawareness of surgical techniquesand innovations and their significantroles in orthopedic and generalhealth care.

The information contained in thispublication is not intended to re-place a physician’s professionalconsultation and assessment. Pleaseconsult your physician on mattersrelated to your personal health.

Proliance Surgeons Outlook is published by Oser-BentleyCustom Publishers, LLC, a division of Oser CommunicationsGroup, Inc., 1877 N. Kolb Road, Tucson, AZ 85715. Phone (972)687-9035 or (520) 721-1300, fax (520) 721-6300, www.oser.com. Oser-Bentley Custom Publishers, LLC specializes increating and publishing custom magazines. Inquiries: TinaBentley, [email protected]. Editorial comments: KarrieWelborn, [email protected]. Please call or fax for a newsubscription, change of address, or single copy. This publicationmay not be reproduced in part or in whole without the expresswritten permission of Oser-Bentley Custom Publishers, LLC. Toadvertise in an upcoming issue of this publication, please contactus at (972) 687-9035 or (520) 721-1300 or visit us on the Webat www.oser-bentley.com. October 2009

Health Care Advances

Pancreatic Cancer 2009Bringing greater awareness to illness

Pancreatic Cancer 2009Bringing greater awareness to illnessBy James Schopp, MD


Pancreatic cancer has been making thenews recently, highlighted by the deathsof opera singer Luciano Pavarotti andCarnegie-Mellon professor Dr. RandyPausch, the courageous battle of actorPatrick Swayze and the successfulsurgery for Supreme Court JusticeRuth Bader Ginsburg. This increasedawareness reflects the fact thatpancreatic cancer is the fourth leadingcause of cancer deaths in the U.S.,second only to colorectal cancer ingastrointestinal cancer deaths. Althoughthe incidence has remained fairly stableover the past couple decades, therecontinues to be an increase in new casesdiagnosed in the U.S.—approximately33,000 per year. Despite current treat-ment, this remains one of the mostdeadly cancers, with a 5-year survivalof less than 5 percent.

Risk factors have been identified forpancreatic cancer. Men are 40 percentmore likely than women and African-Americans are 50 percent more likelythan Caucasians to develop this cancer.These differences may be related tosmoking habits, where smoking maydouble the risk of developing this can-cer. Smoking may even account for aquarter of all cases. Diabetes increasesthe risk by 60 percent, and chronicpancreatitis increases the risk several-fold, but symptoms from either ofthese conditions can also be the firstsign of pancreatic cancer. A family his-

tory of pancreatic cancer is present inabout 10 percent of patients, and afirst-degree relative with the cancer in-creases the risk two to three times.

Diagnosing pancreatic cancer clinically

can be difficult given the location ofthe pancreas deep in the upperabdomen posterior to the stomachand anterior to the spine, makingsymptoms minimal or absent andclues on physical exams frequentlylacking. Symptoms can include dullepigastric or left upper quadrantpain radiating to the back, anorexia,weight loss, nausea, vomiting,indigestion or jaundice. Becausethese symptoms can be nonspecific,they may be present for weeks ormonths before a diagnosis is made,often mistaken for other illnesses.A physical exam may reveal upperabdominal tenderness, jaundice or apalpable nontender gallbladder.Hepatomegaly, liver nodules, ascitesor supraclavicular/periumbilical lymphnodes signify advanced disease.Laboratory tests may show elevatedliver function tests (bilirubin, alkalinephosphatase, SGOT) in cases withjaundice, or elevated lipase if thecancer causes pancreatitis, but mayalso be normal. The tumor markerCA 19-9, when elevated, maysuggest pancreatic cancer, althoughit can be normal in some patients withpancreatic cancer or elevated in somebenign conditions such as pancreatitis,cirrhosis, and cholecystitis. The bestuses of CA 19-9 are evaluatingresectability pre-op (very high levelssuggest advanced disease) andmonitoring for recurrence after surgery.

Imaging studies are very helpful indiagnosing pancreatic cancer. Ultrasoundand CT scan of the abdomen arefrequently obtained initially to evaluateabdomen pain or jaundice. Ultrasound

demonstrates lesions in the pancreatichead and biliary ductal dilatation well,but is limited in visualizing body or taillesions. Ultrasound is readily availableand inexpensive, but is operatordependent and can be limited by bowelgas or body size of the patient. CT scansshow lesions through the entire pancreaswell, but are less sensitive at detectingsmall i.e. <15 millimeter, lesions. Inaddition, CT scans are very useful fordetecting metastatic disease of the liveror peritoneum, identifying abnormallymph nodes, and assessing vascularinvasion, which, taken together, canprovide a reliable determination ofresectability. MRI scans provide thesame information as a CT scan, and anMRCP can provide detailed images ofthe biliary and pancreatic duct much likethe traditional ERCP. The ERCP, whiledemonstrating abnormalities of the bileduct and pancreatic duct, is also usefulfor obtaining cytology as well as insert-ing bile duct stents.

An endoscopic ultrasound (EUS),performed by a skilled gastroenter-ologist, is an excellent tool foraccurately diagnosing small cancers, fordifferentiating a pancreas mass frompancreatitis, for evaluating vascularinvasion and lymph node enlargementand for obtaining tissue for cytology.

Men are 40 percent more likely than women and African-Americans are50 percent more likely than Caucasians to develop this cancer.


However, EUS is less available, highlyoperator dependent and more invasivethan other imaging tests.

Laparoscopy has a limited role in stag-ing pancreatic cancer. Its usefulness isin confirming unresectability in caseswhere the pre-op imaging suggests thispossibility. The peritoneal surfaces andliver can be inspected, and tissue canbe obtained for diagnosis. Recoveryfrom this procedure is quick, andchemotherapy can be initiated soon.

Surgery offers the only possibility ofcure, meaning that, if the cancer can’tbe excised, then it can’t be cured.Pancreatic cancer presents in the headof the gland about 60 percent of thetime, of which only 20 percent areresectable, and presents in the body ortail 40 percent of the time, of whichabout 5 percent are resectable.

Cancers located in the head, neck, oruncinate portions of the pancreas requirea Whipple pancreatico-duodenectomyresection. This procedure includesremoving the head, neck and uncinateportions of the pancreas, along with thedistal portion of the stomach, the distalhalf of the common bile duct, the entireduodenum and the surrounding lymphnodes. The GI tract continuity is restoredby anastomosing a segment of jejunumto the remaining portions of the pan-creas, bile duct and stomach. This oper-ation typically requires five to sevenhours, with complication rates about 20percent–30 percent and mortality ratesof about 1 percent–2 percent.

A cancer located in the body or tail ofthe gland requires a distal pancreatec-tomy and splenectomy, which comprisesabout 10 percent of all pancreaticcancer operations. This operation isshorter, has fewer complications and hasa quicker recovery. However, since thesecancers usually cause less symptoms and

present at more advanced stages, theyare less likely to be resectable for cure.

Survival after surgery (whether Whip-ple resection or distal pancreatectomy)approaches 20 percent at 5 years, witha median survival of 20 months. This5-year survival is higher following aWhipple resection than a distal resec-tion, with tumors <2 centimeters, withno lymph node spread, and with neg-ative surgical margins. Post-operativechemotherapy and radiation doesprovide an improved survival as well.

In summary, pancreatic cancer contin-ues to have a poor prognosis, with over-all survival less than 5 percent of allpatients. Despite current treatmentmethods, however, this cure rate has notimproved in recent years. With earlyrecognition of symptoms, expeditiousevaluation using labs and imaging

studies and an aggressive surgicalapproach, hopefully, more successfuloutcomes will be realized.

Dr. Schopp completed

u n d e r g r a d u a t e

studies at the

University of Illinois

Champaign-Urbana

and medical school

with honors at the

University of Illinois

Chicago. His residency was at the

University of Illinois and Cook County

Hospitals. He is a member of Phi

Beta Kappa and Alpha Omega Alpha

Medical Honor Society. He has been

practicing in Tacoma since 1991 and

has special interests in pancreatic,

gastrointestinal, laparoscopic and

hernia surgery. He enjoys running,

astronomy, sports and traveling with

his wife.


Thyroid Eye Disease and Orbital DecompressionHow surgery can helpBy Eric Pinczower, MD


Thyroid eye disease (TED) is an auto-immune condition that causes visionloss and bulging of the eyes and isassociated with thyroid disease. Thisbulging is due to orbital musclesand fat initially becoming inflamedand then infiltrated with fibroustissue. TED is associated mostcommonly with Grave’s Disease andrarely Hashimoto’s thyroiditis. It isunknown why these autoimmunediseases affecting the thyroid alsoaffect the muscles and fat that arelocated in the orbit behind the globe(eyeball). No other muscles in thebody are affected. It is clear, however,that even with elimination of thethyroid disease, the eye disease maypersist or worsen. Some patients withTED never even have the thyroidcomponent, and even a single episodeof thyroiditis may permanently affectthe muscles and fat as well as theposition of the globes.

Symptoms of TED include the charac-teristic appearance or “stare,” retractionof the lids, double vision and chroniceye irritation. This eye irritation canpossibly lead to corneal damage fromexposure. Active TED can compress theoptic nerve and cause vision loss, colorvision loss, restricted eye movement andeven complete blindness.

Diagnosis is made usually by the

characteristic appearance. A full evalu-ation is required to look for subtle visualdeficits. Laboratory tests are required tomonitor and treat the thyroidcomponent of the disease. Treatment ofTED includes controlling the thyroid

disease, local care with lubricatingointments, sometimes with steroidmedications and sometimes withradiation therapy. The steroid medica-tions and radiation decrease orbitalmuscle inflammation so these treatmentsonly work during the active inflamma-tory phase of the disease. This stage lastsone to three years. Steroids are especiallyuseful when vision is threatened.Steroids, due to their many side effectsneed to be used with extreme caution.

Surgery for TED is managed in threesteps. These include: 1) Orbital de-compression surgery for bulging eyesor compressed optic nerves 2) eyemuscle surgery for double vision and3) eyelid surgery for the stare andcorneal exposure. Many of the ill ef-fects of TED can be managed by or-bital decompression surgery. Thissurgery is done by Dr. Eric Pinczower,an otolaryngologist (ENT surgeon),

and Dr. Bryan Sires, an ophthalmicplastic surgeon. Dr. Pinczower prac-tices with Proliance Eastside ENT inBellevue and Dr. Sires is in privatepractice in Kirkland. Dr. Pinczowerand Dr. Sires have been performing or-

bital surgery together since 1995when they both were faculty membersat Harborview Medical Center and atthe University of Washington.

Orbital decompression surgery en-larges the bony cone of the orbit. Thisprovides more room for the enlargedmuscles and fat and takes pressureoff of the nerves allowing the eye tomove back in the socket. If one thinksof the eye as a scoop of ice cream in acone, the orbit is decompressed byopening the medial and lateral sides ofthe cone which allows the scoop(eyeball) to sink down. An average of0.5-centimeter decrease in protrusionis achieved, although this may varydepending upon how the operation isdesigned and individual healing.

Prior to consideration of orbital de-compression, the patient will see bothDr. Sires and Dr. Pinczower. Dr. Sires

Pre-Op Post-Op

Thyroid eye disease (TED) is an autoimmune condition that causes visionloss and bulging of the eyes and is associated with thyroid disease.


has tremendously improved the accuracyand safety of this operation. Call (425)216-7200 or (425) 451-3710 for aconsultation appointment.

Eric Pinczower, MD,

FACS is a Board Cer-

tified Otolaryngolo-

gist Head and Neck

Surgeon who prac-

tices in Bellevue with

Proliance Eastside

ENT. His interests

include sinonasal problems, nasal recon-

struction including cosmetic rhinoplasty

and the surgical treatment of sleep disor-

ders as well as general otolaryngology. In

2009, Dr. Pinczower was again awarded

measures eye position and examinesthe patient for visual compromise. InDr. Pinczower’s office, the sinuses andnose are evaluated and a CT scan isobtained to determine the feasibilityof the decompression. The data fromthe CT scan is later fed into the Land-marx™ computerized intraoperativelocalization system in the operatingroom which allows us to haveGPS-like ability when operating onthe patient’s sinuses or orbital walls.

Dr. Pinczower performs the medial,and inferior if needed, decompressionutilizing endoscopic techniquesthrough the nose and sinuses. This isan extension of the sinus surgerythat would typically be used forchronic sinusitis. During this portionof the procedure, Dr. Sires monitorsthe exact amount of decompressiondone—both by watching the operationlive on monitors and by following theprogress on the Landmarx™. Then Dr.Sires, via a small incision at thelateral canthus, where the upper andlower lids join, performs a lateralorbital decompression by drilling outthe bony wall of the lateral orbitand removing orbital fat. The combi-nation of the lateral and medialdecompression allows the globe tomove straight back, significantly de-creasing the risk of double vision ifeither decompression was done alone.

This surgery is done as an outpatientprocedure, meaning no hospitalizationis required. Most patients resume fullactivities within 10 days.

The usual indications for orbital decom-pression are visual symptoms or chroniceye irritation and corneal exposure.However, more and more patients areseeking out the surgery to correct thetypical cosmetic deformities of thethyroid eye disease stare. The advent ofcomputerized intraoperative localization

“Best Doctor” by Seattle Magazine.

Dr. Pinczower went to medical school at

the University of California and did his

surgical and specialty training at the Uni-

versity of Southern California. He then

spent eight years teaching his specialty at

the University of Washington, a portion

of that time he was the Chief of Oto-

laryngology at Harborview. He remains

a Clinical Associate Professor at the UW.

Dr. Pinczower is married to a physician

and has three daughters. He loves all

outdoor activities, especially skiing and

surfing. He takes great pride in helping

his patients and never gives up on

difficult problems.

Artist: Jason Schrampfer


As one of the country’s largest surgicalpractices, Proliance Surgeons, Inc., P.S.,performs emergency and elective op-erations, treating illnesses and injuriesthat affect us all. Proliance’s orthopedicsurgeons have expert knowledge ofgeneral orthopedics and additionalspecialized training in sports medicine,joint reconstruction, arthroscopic sur-gery, spine surgery, hand surgery, footsurgery, fracture care, and majororthopedic trauma. Our general sur-geons have further specialized trainingin otolaryngology ENT), vascular,bariatric, and colorectal surgery.

CARE CENTERS

Bellevue Ear, Nose andThroat Clinic1135 116th Ave. N.E., Suite 500Bellevue, WA 98004(425) 454-3938

450 N.W. Gilman Blvd., Suite 203Issaquah, WA 98027(425) 454-3938

Cynthia K. Anonsen, MDAlice Lee Kuntz, MDSamson J. Lee, MDDaniel R. Seely, MDRoger S. Zundel, MD

Cedar Surgical3124 S. 19th St., Suite 220Tacoma, WA 98405(253) 301-5050

Leaza M. Dierwechter, MDW. Michael Johnson, MDJames J. Schopp, MDVirginia A. Stowell, MD

Edmonds Orthopedic Center7320 216th St. S.W., Suite 320Edmonds, WA 98026(425) 673-3900

James R. Alberts, MDBrian D. Cameron, MDDarcy S. Foral, MDLawrence J. Fowler, MDMichael B. Lee, MDWren V. McCallister, MDJeffrey P. Remington, MD

Everett Bone and Joint1100 Pacific Ave., Suite 300Everett, WA 98201(425) 339-2433

Howard B. Barker, MDLawrence J. Fowler, MDRalph T. Haller, MDTodd W. Havener, MDBill K. Huang, MDPeter J. Kinahan, MDJeff R. Mason, MDClay M. Wertheimer, MD

Evergreen Orthopedic Clinic12911 120th Ave. N.E., Suite H-210Kirkland, WA 98034(425) 823-4000

14841 179th Ave. S.E., Suite 330Monroe, WA 98272(360) 794-3300

8301 161st Ave. N.E., Suite 102Redmond, WA 98052(425) 882-1661

Richard L. Angelo, MDJames A. Champoux, MDCamille M. Clinton, MDMark A. Freeborn, MDRobin R. Fuchs, MDJames F. Green, MDRonald V. Gregush, MDKenneth C Lin, MDCraig M. McAllister, MDGregory J. Norling, MDJ. Scott Price, MDJames R. Robbins, MDJeffrey L. Stickney, MDJames D. Swenson, MD

Evergreen Surgical Clinic12333 N.E. 130th Lane, Suite 420Kirkland, WA 98034(425) 250-4700

Kelly A. Clinch, MDJohn S. Ebisu, MDMarion C. Johnson, MDHarry A. Kahn, MDJames G. Mhyre, MDMichael A. Towbin, MD

Northwest Orthopaedic Clinic10330 Meridian Ave. N., Suite 270Seattle, WA 98133(206) 526-8444

2409 North 45th St.Seattle, WA 98103(206) 633-8100

Herbert R. Clark, MDRobert S. Clawson, MDTimothy P. Daly, MDLawrence J. Fowler, MDAllen W. Jackson, MD

Northwest Surgical Specialists1560 N. 115th St., Suite 102Seattle, WA 98133(206) 363-2882

Mark T. Brakstad, MDPaula L. Denevan, MDAlison L. Perrin, MDTerence M. Quigley, MD

Orthopedic Physician Associates601 BroadwaySeattle, WA 98122(206) 386-2600

1600 E. Jefferson St., Suite 600Seattle, WA 98122(206) 325-4464

M. Kevin Auld, MDJames P. Crutcher Jr., MDJustin L. Esterberg, MDAlexis Falicov, MDJeffery L. Garr, MDK. Elizabeth Garr, MDLawrence E. Holland, MD

Scott E. Hormel, MDE. Edward Khalfayan, MDRichard M. Kirby, MDMartin G. Mankey, MDMichael K. McAdam, MDSt. Elmo Newton III, MDCharles A. Peterson, MDJohn W. Robertson, MDTodd J. Seidner, MDEugene “Pepper” Toomey, MDSean D. Toomey, MDJay B. Williams, MDWilliam J. Wilson, MDRobert A. Winquist, MDEva Young, MDRichard A. Zorn, MD

Orthopedic Specialists of Seattle1801 N.W. Market St., Suite 403Seattle, WA 98107(206) 784-8833

2409 North 45th St.Seattle, WA 98103(206) 633-8100

Philip R. Downer, MDJonathan L. Franklin, MDCharles A. Peterson II, MDJoel A. Shapiro, MDJ. Michael Watt, MDWayne Weil, MD

Proliance Eastside ENT1800 116th Ave. N.E., Suite 102Bellevue, WA 98004(425) 451-3710

8301 161st Ave. N.E., Suite 200Redmond, WA 98052(425) 869-4855

Tom F. Gumprecht, MDJennifer L. Heydt, MDEric F. Pinczower, MD

Proliance Eastside Surgeons6505 226th Place S.E., Suite 101Issaquah, WA 98027(425) 313-0775

Edward Freimanis, MDBrian J. Plaskon, MD

Proliance Orthopaedic and Sports Medicine1231 116th Ave. N.E., Suite 100Bellevue, WA 98004(425) 454-5344

1135 116th Ave., N.E., Suite 510Bellevue, WA 98004(425) 455-3600

510 8th Ave. N.E., Suite 200Issaquah, WA 98029(425) 392-3030

Clayton B. Brandes, MDJames D. Bruckner, MDThomas H. Castle Jr., MDThomas D. Chi, MDJeremy A. Idjadi, MDTodd E. Jackman, MDGregory A. Komenda, MD

Peter R. Mandt, MDAshit C. Patel, MDSteven S. Ratcliffe, MDMatthew J. Robon, MDMichael J. Sailer, MDJohn L. Thayer, MD

Puget Sound Ear, Nose, and Throat21616 76th Ave. W., Ste. 112Edmonds, WA 98026(425) 775-6651

15021 Main St., Ste. KMill Creek, WA 98012(425) 337-4810

9730 3rd Ave., N.E., Ste. 201Seattle, WA 98115(206) 526-9999

Henry S. Chang, MDTyler G. Kimbrough, MDJohn T. Parker, MDDuncan A. Riddell, MDShawn E. Rogers, MD

Puget Sound Orthopaedics 7308 Bridgeport Way W., Suite 201Lakewood, WA 98499(253) 582-7257

1515 Martin Luther King Jr. WayTacoma, WA 98405(253) 572-2663

Julian S. Arroyo, MDW. Brandt Bede, MDJohn M. Blair, MDSpencer A. Coray, MDDale L. Hirz, MDMichael J. Martin, MDGavin Smith, DPMSteven M. Teeny, MDAlan B. Thomas, MD

Rainier Orthopedic Institute3801 5th Street S.E., Suite 110Puyallup, WA 98374(253) 845-9585

20920 SR 410 EBonney Lake, WA 98391(253) 845-9585

Wendall W. Adams Jr., MDSteven C. Brack, DOWendy L. Heusch, DOFrederic L. Johnstone II, MDEric G. Puttler, MDNeal H. Shonnard, MDJohn T. Steedman Jr., MDAnthony B. VanBergeyk, MDSteven K. Yamamoto, DO

Skagit Island Orthopedics1401 S. LaVenture Rd.Mt. Vernon, WA 98274(360) 424-2400

2511 M- Ave., Suite DAnacortes, WA 98221(360) 424-2400

Jimmy Y. Cui, MDDaniel M. Hanesworth, MDCurtis W. Rodin, MD


Proliance Surgeon’s Directory

Jonathan B. Shafer, MDRichard V. Williamson, MD

South Seattle Otolaryngology16259 Sylvester Rd. S.W., Ste. 505Burien, WA 98166(206) 242-3696

David C. Green, MDPeter F. Maurice, MDPatrick H. McClean, MD

Southwest Seattle Orthopaedic and Sports Medicine16259 Sylvester Road S.W., Ste. 501Burien, WA 98166(206) 243-1100

Alan D. Barronian, MDWilliam L. Clark, MDPaul Degenfelder, MDRoger Y. Wong, DO

Surgery Associates16122 8th Ave. S.W., Suite D-1Burien, WA 98166(206) 244-1680

Andrew J. Haputa, MDMichael M. Kennelly, MDMarco A. Sobrino, MD

Surgical Associates of Edmonds7315 212th St. S.W., Suite 201Edmonds, WA 98026(425) 778-8116

Carol J. Cornejo, MDKurt E. Harmon, MDThomas J. Jurich, MDSteven D. MacFarlane,MDMichelle J. Sinnett, MDMichael Zammit, MD

Surgical Specialists1412 S.W. 43rd St., Suite 201Renton, WA 98057(425) 228-6076

Michael F. Burke, MDMichelle J. Eden, MD

Valley Orthopedic Associates4011 Talbot Rd. S., Suite 300Renton, WA 98055(425) 656-5060

27005 168th Pl. S.E., Suite 201Covington, WA 98042(253) 630-3660

Michael D. Allison, MDCraig T. Arntz, MDWilliam P. Barrett, MDTraci G. Barthel, MDSusan R. Cero, MDB. Daniel Chilczuk, MDKaya Y. Hasanoglu, MDJohn M. Hendrickson, MDChristopher R. Howe, MDJohn P. Howlett, MDFredrick S. Huang, MDEric J. Novak, MDMark C. Remington, MDNiket Shrivastava, MDJason H. Thompson, MDMartin S. Tullus, MD

Robert G. Veith, MD

Washington Hand Surgery12911 120th Ave. N.E., Suite H-10Kirkland, WA 98034(425) 823-4224

1535 116th Ave. N.E., Suite 200Bellevue, WA 98004(425) 283-5230

Todd M. Guyette, MDAllison J. MacLennan, MDEdward R. North, MDSteven L. Reed, MDSteven D. Sun, MDLoryn P. Weinstein, MD

With 42 care centers, eight MRI cen-ters, six physical therapy clinics, and13 surgery centers conveniently lo-cated throughout Washington’sKing, Snohomish, Pierce, Island, SanJuan, and Skagit counties, Proliance’s178 physicians and its providers de-liver the highest quality care avail-able. For more information, includinga list of physicians and directions toour clinics and centers, please visitwww.proliancesurgeons.com.

Additional Services

AMBULATORYSURGERY CENTERS

Edmonds Center forOutpatient Surgery7320 216th Street S.W., Suite 140Edmonds, WA 98026(425) 673-3750

Everett Bone and JointSurgery Center1100 Pacific Ave., Suite 100Everett, WA 98201(425) 317-8535

Evergreen OrthopedicSurgery Center12911 120th Ave. N.E., Suite H-110Kirkland, WA 98034(425) 216-7000

Evergreen Surgical Clinic Ambula-tory Surgery Center12333 N.E. 130th Lane, Suite 420Kirkland, WA 98034(425) 250-4700

Issaquah Surgery Center6505 226th Place S.E., Suite 102Issaquah, WA 98027(425) 313-0776

Lakewood Surgery Center7308 Bridgeport Way S.W., Suite 102Lakewood, WA 98499(253) 584-5252

Proliance Highlands Surgery Center510 8th Ave. N.E., Suite 100Issaquah, WA 98029(425) 507-0800

Seattle Orthopedic Center Surgery2409 N. 45th St.Seattle, WA 98103(206) 633-8100

Seattle Surgery Center900 Terry Ave., 3rd FloorSeattle, WA 98104(206) 382-1021

Skagit Island Orthopedic Surgery Center1401 S. LaVentureMt. Vernon, WA 98274(360) 434-2480

Southwest Seattle Ambulatory Surgery Center275 Southwest 160th St., Ste. 200Burien, WA 98166(206) 988-0927

The Surgery Center at Rainier3801 5th St. S.E., Suite 210Puyallup, WA 98374(253) 445-4285

Valley Orthopedic Associates Ambulatory Surgery Center4033 Talbot Road S., Suite 270Renton, WA 98055(425) 226-2041

MRI

Eastside MRI12911 120th Ave. N.E., Suite H-120Kirkland, WA 98034(425) 823-4226

Edmonds Orthopedic Center MRI7320 216th St SW, Suite 320Edmonds, WA 98026(425) 673-3900

Everett Bone and Joint MRI3102 Colby Ave.Everett, WA 98201(425) 258-8110

Orthopedic Physician Associates MRI900 Terry Ave, Suite 100Seattle, WA 98104(206) 694-6665

Proliance Highlands MRI510 8th Ave. N.E., Suite 110Issaquah, WA 98029(425) 507-0810

ProSports Imaging N.W.3801 5th St. S.E., Suite 120Puyallup, WA 98374(253) 864-4106

Seattle Orthopedic Center MRI2409 N. 45th St.Seattle, WA 98103(206) 633-8100

STAR MRI8009 S. 180th St., Suite 105Kent, WA 98032(425) 656-0711

PHYSICAL THERAPY

Edmonds Orthopedic Therapy7320 216th St. S.W., Suite 320Edmonds, WA 98026(425) 673-3916

Evergreen Orthopedic Physical Therapy12911 120th Ave. N.E., Suite H-220Kirkland, WA 98034(425) 216-7075

Proliance Sports Therapy and Rehab of Bellevue1200 112th Ave. N.E., Suite C-260Bellevue, WA 98004(425) 462-5006

Proliance Sports Therapy and Rehab of Issaquah510 8th Ave. N.E., Suite 340Issaquah, WA 98029(425) 313-3055

Seattle Orthopedic Center Physical Therapy2409 N. 45th St.Seattle, WA 98103(206) 633-8100

Skagit Island Orthopedic Physical Therapy1401 S. LaVentureMt Vernon, WA 98274(360) 424-2400



By Peter J. Kinahan, MD

Understanding the concept of

Keeping mistakes out of hospitalsNever EventsThe concept of “never events” hasbeen developed over the past 8 to 10years with an initial list of 27 “neverevents” finalized in 2002 at therequest of the federal government bythe Institute of Medicine (IOM). Atthat point, there was an estimate thatmedical errors in hospitals causedbetween 44,000 to 98,000 deaths inthe United States each year. This made“never events” the eighth leadingcause of death in the United States.

The 27 never events compiled by the Na-tional Quality Forum (NQF) describes 27mistakes that are so serious they shouldnever occur. These events have been iden-tified in an effort to “create awareness andcorrection among healthcare outlets.”

• Surgery on the wrong body part.• Surgery on the wrong patient.• Wrong surgical procedure performed

on a patient.• Object left in patient after surgery.• Death of a patient, who had been

generally healthy during orimmediately after surgery for alocalized problem.

• Patient death or serious disabilityassociated with use of contaminateddrugs, devices or biologics.

• Patient death or serious disabilitydue to the misuse or malfunctionof a device.

• Patient death or serious disabilityassociated with intravascularair embolism.

• Infant discharged to the wrong person.• Patient death or serious disability

associated with patient disappearingfor more than four hours.

• Patient suicide or attempted suicideresulting in a serious disability.

• Patient death or serious disabilityassociated with medication error.

• Patient death or serious disabilityassociated with transfusion of blood orblood tri-products of the wrong type.

• Maternal death or serious disabilityassociated with labor and delivery in alow-risk pregnancy.



vice events; patient protection events;care management events; environmentalevents and criminal events.

Many “never events” are obviousviolations of the standard of care andrequire no explanation. However,lumbar surgery is an example of a“never event” in which surgery is per-formed on the correct patient, usingthe correct surgical procedure, but per-formed at the incorrect surgical level.There is no product or device eventpatient protection event, care manage-ment event, environmental event orcriminal event. Consequently, it isextremely important that all precau-tions are undertaken in order to preventlumbar surgery at an incorrect level.

• Patient death or serious disabilityassociated with the onset ofhyperglycemia, a drop in blood sugar.

• Death or serious disability associatedwith failure identifying hyperbili-rubinemia.

• Severe pressure ulcers acquired inthe hospital.

• Patient death or serious disability dueto spinal manipulative therapy.

• Patient death or serious disabilityassociated with an electric shock.

• Any incident in which a line designatedfor oxygen or other gas to be deliveredto a patient contains the wrong gas oris contaminated by toxic substances.

• Patient death or serious disabilityassociated with a burn incurred inthe hospital.

• Patient death associated with a fallsuffered in the hospital.

• Patient death or serious disabilityassociated with use of restraintsor bedrails.

• Any incident of care ordered by orprovided by someone impersonating aphysician, nurse, pharmacist or otherlicensed health care provider.

• Abduction of the patient.• Sexual assault on a patient.• Death or significant injury of a patient

or staff member resulting from aphysical assault in the hospital.

A March 3, 2008 updated list from theNational Quality Forum, divides theseevents into more easily definable groups,including surgical events; product or de-


In an effort to provide continuousquality improvement in our practiceand decrease the risk of never eventsoccurring, we have adopted a series ofprocesses to minimize lumbar laminec-tomies performed at the wrong level.

At the preoperative visit, the patient’shistory, physical exam and laboratoryinvestigations are reviewed and docu-mented, including radiographic find-ings such as MRI, CT scan or plainfilms. If there is any question aboutthe number of lumbar vertebrae or theanatomy, care is taken to specificallydocument this information. At thetime of the preoperative visit, the risksand benefits of surgery are discussedwith the patient and informed consentis obtained and signed by the patientand the surgeon, as well as witnessedby one of the staff employees. Thepreoperative visit generally occurswithin a week prior to the planneddate of surgery.

On the day of surgery, the patient isseen by the preoperative nurse, whoreviews the consent with the patientverbally. The patient is also seen bythe anesthesiologist, who also dis-cusses the planned surgical procedureand anesthesia options. The surgeonsees the patient, reviews the surgicalconsent, history and physical and con-firms with the patient the planned sur-gery including the correct side andmarked surgical site. The site is ini-tially marked by the preoperativenurse. If the patient is able to, Pro-liance has the patient mark his or hersurgical site.

In the preoperative holding area, afterreviewing the patient’s history, physi-cal examination, radiographs andsigned surgical consent, the surgeonmarks the lumbar region with theirinitials and notes the planned side andlevel of the surgery so that they will be

clearly visible once the back isprepped and draped. In addition, amark is placed to indicate the level ofsurgery on the back of the calf on theinvolved side in an area that will bevisible once the patient is positionedon the table.

In the operating room, many steps aretaken to confirm the correct patient,as well as the appropriate side andlevel of the procedure. In most cases,our lumbar laminectomies are doneunder a spinal anesthetic, and al-though the patient is somewhat se-dated, they usually aid in positioningthemselves on the table. The radi-ographic studies are present in theroom and are placed on the view boxor brought up on the computer screenso there is no question of there beingany errors such as a different person’sfilms or the wrong level being shown.

Once the patient is positioned on thesurgical bed and prior to prepping, a

C-arm is brought into the room andfluoroscopic evaluation of the lumbarspine is performed. This is done twoways. The initial examination is donewith an external marker which ismetallic and is used to roughly iden-tify the appropriate level. Followingthis, the skin is prepped over the lum-bar spine and a spinal needle is placedin the superficial tissues down to thelevel of the lamina only to again con-firm the appropriate level of the spine.This area is marked on the skin with asurgical marking pen. The C-arm isthen moved out of position. The pa-tient is then prepped and draped.

The standard of care in our surgical cen-ter for lumbar procedures is to performan X-ray once the patient is prepped,draped and positioned on the operatingtable. This X-ray is then used as a guideto minimize the length of the incisionneeded and identify the surgical site. Un-fortunately, especially with some pa-tients’ body habits, it is possible to


deviate from the angle of the originalmarker and expose an incorrect level inthe spine. This is a known risk, and es-pecially if there are abnormalities atmore than one level of the spine, it is pos-sible for the surgeon to be “fooled” intothinking he is in the appropriate leveleven when there may be more profoundpathology at a different level. In order toensure accuracy, a second or follow-upX-ray, or fluoroscopic evaluation, isroutinely performed intraoperatively.

Prior to making an incision, a surgicalpause is performed. The anesthesiolo-gist, nursing staff, circulating staff andsurgeon are all present and the contentis reviewed. In addition, the surgical sitemarking is compared and confirmedverbally with all individuals in the roomconcurring with the surgical pause. Thesurgical pause includes confirmation ofthe patient’s name, position on thetable, planned surgery, preoperativeantibiotics and radiographic evidence.A surgical incision is made only afterconfirmation of the above information.

The lumbar laminectomy is then per-formed with a subperiosteal dissection

exposing the lamina and ligamentumflavum, which is divided and partiallyexcised along with a portion of thelamina of the level above and belowthe level of pathology.

The fluoroscope is again introducedinto the operating room and, under ster-ile conditions, is carefully manipulatedinto position. Hard copy images areobtained confirming the appropriatelevel of surgery with a metallic objectcarefully placed at the disk level andwith a radiographic image presentwhich includes the sacrum so it is possi-ble to count levels up from the sacrum.

A copy of this is kept in the patient’soperative record.

The nerve root is then retracted to-wards the midline and the rupturedportion of the disk is removed, thewound is irrigated, hemostasis isacquired and the wound is closed.

The patient is checked in the recoveryroom and subsequently seen backpostoperatively in the office a week to10 days following surgery.

Our goal as surgeons is to providequality care by promoting the safestprocesses for treating patients and re-ducing the risk of any adverse events.Adhering to our detailed surgicalpractices has enabled our site to im-prove health outcomes by identifyingand preventing never events, whichpose potentially serious consequences.

Peter J. Kinahan,

MD attended the

University of British

Columbia, Vancou-

ver, BC for both

undergraduate and

medical school. He

completed an in-

ternship at Dalhousie University in

Halifax, NS in 1986 before returning

to UBC and completing his residency

in 1991. Shortly thereafter he began a

practice in Mission, BC. He joined

Proliance Surgeons, Everett Bone and

Joint in 2001. He is an American

Academy of Orthopaedic Surgeons

member and is affiliated with Provi-

dence Everett Medical System. His in-

terests include skiing, fishing, boating,

oenology and travel.





Proliance Surgeons, Inc., P.S. thanksthe following advertisers, withoutwhom this issue of Proliance SurgeonsOutlook would not have been possible.

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