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Second in a series – Eds.

Cheryl McCoul wanted to keep walking.

The 51-year-old woman with dark brown hair and flecks of gray spent all her free time building her dream cabin in the Big Horn Mountains. Her energy was evident in how she raised her four children and the jobs she took over the course of her life, continually reinventing herself.

She was the only woman in her college class to study welding. She seasonally herded sheep for nearly a decade and worked on a dairy farm. She taught welding at Central Wyoming College.

Her family remembers her as a hard worker who also trained horses and dogs.

“She just couldn’t stand or sit around and watch people do things,” husband Alex McCoul said. “She could do two or three things all at the same time.”

A healed broken back from when a horse bucked her still bothered her, though. The increasing pain shortened hiking trips and hampered four-wheeler rides to check on the cabin’s progress. Climbing stairs became nearly impossible.

The Buffalo woman made an appointment for an elective spinal fusion with a Jackson orthopedic surgeon at St. John’s Medical Center.

She went under anesthesia for the surgery the morning of Jan. 20. She didn’t wake up.

“I don’t know that we could have done anything
different except not have the surgery,” Alex McCoul said a few weeks after her death. “She was afraid if she didn’t have it she’d be in a wheelchair in a couple years. You can second-guess everything if you want to.”

St. John’s fewest surgeries

The surgery attempted on McCoul was one of the rarest procedures performed at St. John’s in 2008, according to public records obtained by the News&Guide through a lawsuit.

Five patients had an anterior posterior lumbar surgery last year. There were no anterior lumbar fusions performed in 2006 or 2007, according to the data.

McCoul’s operation in January was to be the fourth operation for her surgeon in 2009, her family said doctors told them. By contrast, Intermountain Spine Institute in Salt Lake City does an estimated 300 spinal fusions annually.

McCoul’s doctor recommended an anterior approach, which required a general surgeon to open her from the front. Once abdominal muscles and organs are pushed aside, the orthopedic surgeon performs the corrective spinal fusion.

The technique provides access to a better surface for the spinal lumbar fusion procedure and also prevents some destruction of back muscles. It also exposes abdominal organs to potential harm.

Doctors told the family a major vein had torn. They couldn’t repair it. McCoul was flown to University of Utah Medical Center in Salt Lake City so a vascular surgeon could try to fix the vein. She died after arriving that evening.

The anterior approach is only done in about 10 percent of the spinal lumbar fusion surgeries the Salt Lake institute does, Dr. Reed Fogg said. The other 90 percent are done posteriorly, or from the back, because that happens to be surgeons’ preference at the institute. The institute has a vascular surgeon on-site to assist when the anterior approach is done, nurse and case manager Joyce Mcneill said.

Records obtained by the News&Guide and published online allow readers to determine how many times any surgical procedure was done at St. John’s in 2008. Information on the frequency that an institution performs a procedure can be critical in how potential patients choose where they have elective surgeries, experts say.

Other orthopedic operations, relating to the bone and skeletal systems, are also among the rarest of surgeries at St. John’s.

One of those is hip replacements, although the number is rising. In 2006, St. John’s medical staff performed a total of nine replacements. The number climbed to 24 in 2007 and 29 in 2008.

Hip replacements are a surgery that hospitals should strive to do many of to ensure a better outcome, said Barbara Rudolph, of the health care watchdog The Leapfrog Group for Patient Safety. The group emphasizes safety transparency, encourages hospitals to voluntarily report surgery outcomes, and rewards hospitals that do so by directing employers and patients their way.

There are some operations where a patient might want to choose an institution that performs the procedure at a certain volume, experts say.

“For hip surgeries, if they are not doing many, that is not so good either,” Rudolph said.

The same is true for major spine surgeries, she said.

“You would like it in a place with more surgeries than fewer,” Rudolph said.

Leapfrog does not list a minimum number of spinal fusion surgeries a hospital should do to ensure hospital staff competence and patient safety.

HealthGrades, an independent nonprofit that provides health care information for consumers, does not rate St. John’s for total hip replacement or for back and neck surgeries (spinal fusion).

However, the organization does name St. John’s as a high volume hospital for hip fracture repair, but gives it only one star in quality ratings under the category “major complications.” One star is marked as “poor” among the high-volume hospitals in Wyoming.

The major complications rating “is a measure of the percent of patients that had at least one major complication arise during or following their procedure as compared to the total number of patients having the same procedure in the same hospital,” according to the HealthGrades Web site.

Other surgeries on the low-volume end are less common, such as knee joint biopsy (four for 2006), removal of abdominal fluid (seven) and partial removal of arm bone (one).

Accommodating surgeons

Incoming physicians, and the different services they offer, are contributing to a rise in surgeries at St. John’s.

The hospital expanded from two to three operating rooms a few years ago to accommodate an influx of surgeons, Surgical Services Director Tina Romaine said. The third room was for additional operations so doctors didn’t have to do them in the middle of the night, she said.

In addition to physician demand, the move came after much input from surgeons and organization changes with anesthesia staff, hospital spokeswoman Karen Connelly and Chief Financial Officer John Kren said.

Anesthesiologist Marc Domsky, who has been at St. John’s since 2003, said the primary reason staff in the operating rooms is so busy is because of the additional surgeons. While newer services are not reflected in the three-year data because they have only been in Jackson for the last year or so, they are making an impact.

Five new orthopedic surgeons are listed with privileges in the St. John’s physician directory for 2009, raising the total from seven to 11. Three joined Teton Orthopaedics – Drs. Jeremiah Clinton, Doug Weiss and David Khoury. Dr. Angus Goetz practices with Orthopaedic Associates, and Dr. Rafael Williams of Snake River Orthopedics practices solo. The new physicians are bringing new skill sets for knee, shoulder and hip operations.

St. John’s also assisted with a salary guarantee to Dr. Michael Rosenberg, who is with St. John’s Surgical Group. His employment added another general surgeon to the valley.

Another growing area of surgery is with ear, nose and throat physician Dr. Marty Trott, who moved to Jackson in the fall of 2008. He said he performs close to 15 surgeries weekly amid the dozens of patients he sees daily. He takes out tonsils, inserts tubes and operates on the thyroid, parathyroid, voice organs and sinuses.

Physician credentials

St. John’s officials say that a thorough background check and protocol are followed before any surgery is allowed to be performed.

To begin with, physicians in a given specialty have a core group of skills they have already related to that field, St. John’s interim CEO Pam Maher said.

A physician coming in can’t just start doing a surgery, but must go through an “objective” medical staff process that ensures the physician is qualified and the hospital is equipped, Maher said. The doctor receives permission to do a surgery after approval from a credentialing committee, joint conference committee and medical executive committee that ends with the board of trustees’ endorsement, Maher said.

St. John’s medical staff office also does background checks on physicians who have moved to Jackson to track any disciplinary actions or previous mistakes a doctor has made.

“We see the bad outcomes,“ Maher said.

Doctors must have the prerequisites and the training, and if they don’t have them they have to go get them, she said.

Physicians have to receive credentials for the operations they conduct, St. John’s Chief of Nursing Kathleen Music said.

An internal committee goes over the different requests surgeons make when they want to start offering a different kind of operation. The committee reviews a physician’s training, education and past history.

The medical executive committee approves the information before it goes to the board of trustees. The committee also handles peer review cases for when an unexpected outcome, such as an injury or death, occurs.

Any sentinel errors, or “unexpected events,” are forwarded to the Joint Commission, a nonprofit regulating body that monitors hospital quality and safety.

Hospitals collect data to monitor their performance in two particular areas that have to do with surgical procedures, Joint Commission spokeswoman Elizabeth Zhani said.

The first is an operative or a procedure that places patients at risk of disability or death. The second is to find any of the differences between diagnoses before and after the operation. The commission weighs the data it collects during a hospital’s voluntary accreditation process.

Hospitals also are supposed to report “unusual” deaths and accidents to the state. Each hospital decides what is “unusual,” said Clay Van Houten, emerging diseases section chief in Wyoming.

However, the information remains confidential to encourage medical facilities to keep reporting, Van Houten said.

“We are not to release any information,” Van Houten said.

The information is aggregated so people know what is going on and it provides a snapshot of events statewide, he said.

A patient concerned about risks before a surgery should speak with the doctor performing the operation, Music said.

Generally, people who play a more active role have better outcomes, said Dr. Carolyn Clancy, physician and director for Agency of Health Care and Research Quality.

“Everything in health care is about communication and information,” she said. “People assume that information is flowing seamlessly between doctors and hospital, and that often doesn’t happen.”

An over-arching challenge is asking questions, which “can be a little intimidating,” Clancy said.

“Often health care is a little chaotic, but it’s also important in terms of safety and knowing procedures in the past,” she said.

Community hospital focus

Having a list of surgeries available presents an ongoing dialogue about where St. John’s, a publicly supported hospital with 48 acute-care beds, should be spending its resources, said hospital board President Dr. Emmy Knobloch.

“We are working very hard as a hospital to do what we do well and refer out what we don’t do well,” she said. “That is a moving target.”

Knobloch serves on the medical executive committee and is chief of medicine. She said the committee is actively looking at what surgeries medical staff physicians perform, as well as results.

“We want to know what is appropriate for us to do,” she said.

One way to do this has been to look at the number of surgeries and measure that to complication rates, she said.

The mantra of becoming a great community hospital, without necessarily being everything to everyone, was part of trustee Smokey Rhea’s campaign platform.

When running for the board last fall, Rhea emphasized that St. John’s should focus on what it does best. Rhea lost the election, but was appointed to the board in July.

She suggested the board prioritize care and form partnerships with University of Utah and other larger hospitals to establish credibility without major investments to St. John’s.

Staff should concentrate on what is done well “and not so much what can we specialize,” she said.

Maher said she and other hospital officials will look at what services county residents want to have done at St. John’s as part of the hospital’s upcoming community assessment.

Recently named board senior adviser Dr. Lou Hochheiser said that when he went to the hospital three years ago staff helped him decide to go elsewhere for appropriate care.

“It’s a good example that we don’t have everything in this community,” but hospital staff can coordinate to get the care for a patient, he told trustees when he interviewed for a board appointment.

A patient should go to a facility where, if something goes wrong, there is security in knowing another specialist or doctor can back up, Rudolph of Leapfrog said.

“Health care providers should let [patients] know if there is another facility that is less risky for certain types of procedure,” Rudolph said.