[Excerpted from the Keynote Address presented at the Annual Meeting of the American Society of Geriatric Otolaryngology, Scottsdale, Arizona; January 19, 2018.]
With a shock I watched the mouth of the 1-week-old infant fill with blood. It had seemed so simple when my senior partner said, "You don't need to go to the OR. Just snip it," in response to my query as to whether the infant with tongue-tie should be booked for formal division and closure under general anesthesia. Although I had performed frenuloplasty in the OR on numerous occasions, I had never "just snipped it," nor had I ever considered performing the procedure on a 1-week-old in the clinic. But I recognized that I had made a serious error when I made the second snip to make it perfect. Until that moment I had never considered the implications of performing the supposedly simple procedure in the clinic, several hundred yards through a rabbit's warren of hallways from the well-staffed OR suite.
Reviewing options quickly, I picked up the infant in the crook of my arm, grabbed a 4 x 4 gauze sponge, and applied pressure with my index finger. Telling my technician to call the OR and tell them I was on my way, I stepped through the door to face several dozen pairs of curious eyes, and two frightened faces. In as calm a voice as I could muster, I said "I got a little bit of bleeding so am going to take him to the OR for a stitch. Come along with me and we will do the paperwork when we get there."
The rest of the story was uneventful, but when reflecting on the event over the intervening three and a half decades, I realize that I had failed to fully consider the implications of what my partner had proposed before I was doing it.
I suspect events such as the one related above are not rare. Moreover, I suspect many readers of this editorial will have similar stories from their own practices or those of their colleagues. This commentary was driven by the assumption that the recent increase in the numbers and complexity of office-based procedures has likely led to an increase in both the frequency and severity of unanticipated, and occasionally devastating, events. The death of Joan Rivers in an outpatient endoscopy suite focused public attention on the risks of performing common procedures in uncommon settings. (1)
Interestingly, in its infancy otolaryngology was a leader in office-based (and even kitchen-table) procedures. Over the century or so of the specialty's existence, otolaryngologists have performed many procedures in their offices. Patients who underwent tonsillectomy at home "on the kitchen table" are still encountered occasionally, and many practicing today recall rigid bronchoscopy and esophagoscopy performed in the clinic "back room" during their residencies.
Changes in technology, desire for patient comfort, and recognition of the danger of some procedures eventually led to the migration of many procedures into the hospital. Many of these were performed initially as...