Excellence and Reliability as it relates to spinal surgery.

1. Excellence and Reliability in Spinal
Surgery
Spiro Antoniades, M.D.
Upper Chesapeake Medical Center Spine Conference
May 2nd, 2014

3. 12 Labors:
Labor 1: The Nemean Lion
Labor 2: The Lernean Hydra
Labor 3: The Hind of Ceryneia
Labor 4: The Erymanthean Boar
Labor 5: The Augean Stables
Labor 6: The Stymphalian Birds
Labor 7: The Cretan Bull
Labor 8: The Horses of Diomedes
Labor 9: The Belt of Hippolyte
Labor 10: Geryon's Cattle
Labor 11: The Apples of the Hesperides
Labor 12: Cerberus

5. Delayed Greatness and Glory Immediate Wealth and pleasure

7. • reliability
• An attribute
of any system
that
consistently
produces the
same results,
preferably
meeting or
exceeding its
specifications.

9. 1. Age
2. chief complaint
3. history of present
illness
4. PMH/PSH
5. SH
6. Medicines
7. PE
8. Xrays
9. MRI
10. Assessment
11. Options
12. Plan

13. Questions:
Don’t lead
• You hacked into John’s account and copied his essay didn’t you?
• We’re doing the right hip aren’t we?

14. Patient narratives, mission statements, explanations,
understanding the world

15. Caesar Marcus Aurelius Antoninus Augustus
Born 121AD Died 180AD age 58
Look to the essence of a thing, whether it be a point of
doctrine, of practice, or of interpretation.

16. • UC 2009 xray cervical 3 views cost: hospital $100 interpretation $175

19. Gottfried Wilhelm von
Leibniz (1646- 1716)
German philosopher
and mathematician.
• S'il n'y avait pas le
meilleur (optimum)
parmi tous les
mondes possibles,
Dieu n'en aurait
produit aucun.
• If there were no best
among all possible
worlds, God would
not have created
one.
• Théodicée (1710)

20. 75 w L UE pain ataxia

28. ACDF
• http://youtu.be/qNMEAAc756o
• 24:18 spinal cord
• 40:00 bone graft
• 1:28 both grafts in and plate

32. • “The test of a first-
rate intelligence is
the ability to hold
two opposed ideas in
the mind at the same
time, and still retain
the ability to
function.”
• ― F. Scott Fitzgerald,
The Crack-Up

35. Repetition

36. Clumping of information

38. Consistency and routine

39. Mos maiorum
• The mos maiorum ("ancestral
custom"[1] or "way of the elders,"
plural mores, with maiorum a
genitive plural; cf. English "mores")
is the unwritten code from which
the ancient Romans derived their
social norms.
• It is the core concept of Roman
traditionalism,[2] distinguished
from but in dynamic complement
to written law.
• The mos maiorum was collectively
the time-honoured principles,
behavioural models, and social
practices that affected private,
political, and military life in ancient
Rome.[3]

40. Self Reliance (1841) Ralph Waldo Emerson
• The other terror that scares us from
self-trust is our consistency; a reverence
for our past act or word because the
eyes of others have no other data for
computing our orbit than our past acts,
and we are loath to disappoint them.
• A foolish consistency is the hobgoblin of
little minds, adored by little statesmen
and philosophers and divines. With
consistency a great soul has simply
nothing to do. He may as well concern
himself with his shadow on the wall.
Speak what you think now in hard
words, and to-morrow speak what to-
morrow thinks in hard words again,
though it contradict every thing you
said to-day. — 'Ah, so you shall be sure
to be misunderstood.' — Is it so bad,
then, to be misunderstood? Pythagoras
was misunderstood, and Socrates, and
Jesus, and Luther, and Copernicus, and
Galileo, and Newton, and every pure
and wise spirit that ever took flesh. To
be great is to be misunderstood.

41. Avoid Complications
• BLEEDING, INFECTION, PARALYSIS, DAMAGE TO SPINAL CORD AND/OR NERVES,
DAMAGE TO ESOPHAGUS/TRACHEA/ARTERY TO BRAIN/VOICE BOX NERVE,
DIFFICULTY SWALLOWING, NON-UNION OF BONE, NEED FOR MORE SURGERY,
ADJACENT LEVEL DEGENERATION, PERSISTENT PAIN, WEAKNESS, NUMBNESS IN
NECK AND/OR ARMS, SPINAL FLUID LEAK, HOARSE THROAT

42. The chains of habit are too weak to be felt until they are too strong to be
broken

46. VIGILANCE AND ATTENTION TO DETAIL

47. SURGERY, PATIENT, DAY, FIELD, SOCIETY,

48. Focus on the current task

49. Being Uncomfortable: necessary for growth and novelty
Exploitation versus Exploration

50. The default pre selected option

53. TEAMWORK

60. Pattern Recognition (individual and collective)

62. • Team Building
• Like
• Admire
• Respect
• Intelligence
• Industry
• Integrity

63. Names, listen, respect, save face
Praise, perspective

64. Team comprised of a coalition of the willing

66. Like the people you shoot and let them know
Robert Capa

67. Structured communication

70. Preoperative and postoperative Briefing or huddle

73. Korean Air Cargo Flight 8509 Dec 1999
57 year old captain 8k hours 747 experience and 33 yo 1st officer 200 hrs experience
1st officer failed to bring mistake to the attention of the captain until it was too late

74. 5.8 magnitude earthquake in Virginia on 8/23/11

75. Any worker can stop the Toyota assembly line for a safety issue

76. Niccolo Machiavelli(1469-
1527) & The Prince
• …[The only way to guard oneself from flatterers is
by] letting men understand that telling you the truth
doesn’t offend you. However, when every one is
allowed to tell you the truth, the respect for you
lessens.
• Therefore, a wise prince should hold a third course
by choosing the wise men in his state, and giving
only them the freedom of speaking the truth to him,
and only on those things that he inquires of, and of
none others. But he [the prince] should question
them upon everything, listen to their opinions, and
then form his own conclusions.
• With these councilors… [the prince] should carry
himself in a way that will let each one of them
understand that the more freely he [the councilor]
speaks, the more he will be preferred. Outside of
these [councilors], he [the prince] should listen to
no one, and pursue what is resolved on, and be firm
in his resolutions. He who does otherwise is either
overthrown by flatterers, or is so frequently
changed by varying opinions that he falls into being
disrespected [by the people].
• A prince, therefore, ought always to seek guidance,
but only when he wishes and not when others wish;
he ought rather to discourage every one from
offering advice unless he asks it. However, he ought
to be a constant inquirer, and afterwards a patient
listener concerning the things of which he inquired.
And additionally, on learning that any one, on any
consideration, has not told him the truth, he should
let his anger be felt.

77. checklists

79. FAILURES AND MISTAKES
Recognize it immediately
Real apology if necessary
Create a new SBAR
Accept it personally

84. Breathing
vivid imagery
practice
meditation
focus
relaxation in steps
worse case scenario plan

85. Vivid imagery

86. • anx·i·e·ty: a
feeling of worry,
nervousness, or
unease, typically
about an
imminent event
or something
with an uncertain
outcome.
• fear : a
distressing
emotion aroused
by impending
danger, evil, pain,
etc., whether the
threat is real or
imagined; the
feeling or
condition of
being afraid.

88. Who are you? Co-worker? Client? Man on the street?

89. Be the character and unleash your subconcious

90. Viktor Frankl, M.D.
1905- 1997
Everything can be
taken from a man or
a woman but one
thing: the last of
human freedoms to
choose one's
attitude in any given
set of circumstances,
to choose one's own
way.
The last of human
freedoms - the
ability to chose
one's attitude in a
given set of
circumstances.

91. Thanks

95. Richard P Feynman
Theoretical physicist(1918-1988)
• In 1974, Feynman delivered the
Caltech commencement address on
the topic of cargo cult science, which
has the semblance of science, but is
only pseudoscience due to a lack of
"a kind of scientific integrity, a
principle of scientific thought that
corresponds to a kind of utter
honesty" on the part of the scientist.
He instructed the graduating class
that "The first principle is that you
must not fool yourself—and you are
the easiest person to fool. So you
have to be very careful about that.
After you've not fooled yourself, it's
easy not to fool other scientists. You
just have to be honest in a
conventional way after that."[42]
• “bending over backwards to show
how maybe your wrong”

96. Power, warmth, engagement

97. Be the character

102. Zeno of Citiumearly 3rd century BC
Stoicism teaches the development of self-
control and fortitude as a means of
overcoming destructive emotions
1. Goals must be in your control
2. Accept what cannot be changed
3. Be prepared to lose everything

106. Surgical
Consent
Not under duress
Legible
Simple language
clear

110. • MRI Cost UC 2009:
Hospital $377
interpretation $175