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Recently, a helicopter dropped off a Spaniard on the roof of the South German cardio-thoracic hospital I work at.Working for a German car-maker in Brussels and attending a business meeting in a provincial Bavarian town he had suffered a heart-attack, was picked up from the local hospital he had initially been taken to and flown to my city for open-heart surgery.As we admitted him on ICU and prepped him for surgery, a Portuguese nurse fluent in Spanish was called to translate. German nurses attended. Two Portuguese radiology technicians took an X-ray, communicating with the patient in Spanish. An Italian anaesthesiologist appeared, having the Portuguese nurse translate his German to Spanish and reverse. A Moroccan cardiac surgeon came and obtained the patient's consent in French. A Greek cardiologist stopped by for a UCG. A German co-worker of the patient's arrived by car and talked to him in French. The Portuguese nurse called the patient’s Spanish wife in Belgium to inform her.Having followed too much of US politics lately, two things struck me as extraordinary as I was watching the familiar scene:With all the tasks and details to mind in such cases, cost and coverage are never ever on the list. An EU citizen working in an EU country is fully covered all over the EU. It’s such a no-brainer no one even bothered to check the guy's insurance card.The other observation was how, with all the nationalities and languages buzzing about the room, no one was a foreigner to any other.I'm old enough to remember borders and border controls, currency exchanges, language barriers, supposedly irreconcilable cultural differences between European nations.Now, thanks to free flow of labour and academic exchange, people actually LIVE with each other.There. This is Europe.

One of my patients was to undergo laparoscopic surgery. During counseling I informed him that if the surgery became difficult, or if there were operative complications, we would open up. This statement is pretty standard (for example, bleeding during laparoscopy may, sometimes, be difficult to control). He refused consent for letting us open him up in case of an emergency. I think he felt that if he consented, we wouldn't try hard enough to complete the procedure by laparoscopy. I referred him away.On another occasion, a few months after I started my private practice in Delhi, I saw a lady with what may have been a Munchausen syndrome (the patient pretends to be mentally ill). (At that time I didn't know about this disorder.) This lady had eaten some pins and needles: these showed up on a plain X-ray. There were many of these, and I wondered how she could have swallowed that many, but her three brothers assured me that it was an accident. They said that the pins had been there for several days. I decided to consider surgery after a day: however the check X-ray just before surgery showed that she had passed them out. I canceled the surgery, thinking she and her family would be happy. An hour later, her brothers walked into my office and demanded a repeat X-ray. I was surprised, and initially disagreed, but they were so insistent that I relented. A repeat X-ray showed needles inside her abdomen! Except that these needles were clearly not the ones she had initially swallowed. So I told them that she had swallowed fresh needles immediately after the cancelation of surgery, and recommended a psychiatrist. I also said that the new needles would likely be passed out, so there was no need for surgery. Then the brothers argued with me for about two hours, demanding that I operate. I kept refusing, until they finally told me that the surgery was required because their religious guru had said that if the girl underwent surgery, their family problems would be over. At this point I flatly refused to operate, and asked them to find someone else. It was a little scary: each of these brothers was twice my size.

“Ah good morning Mrs Jones. So just to confirm, it’s the left hip that’s been bothering you?”“Yes doctor, that’s right.”And the surgeon writes “right hip” on the surgical form.Or a surgeon has a list of three right hip replacements followed by a left one—and loses count.I’m using hip replacement as an example because it’s much commoner for these mistakes to occur—and for understandable reasons. Surgeons are not idiots or bastards, but people, and human error is inevitable.In addition, you can’t tell from the outside which is the diseased hip, unless you have X-ray vision; again something surgeons do not possess. For amputation surgery, the limb to be amputated is usually visibly diseased or otherwise abnormal.There are also horrifying cases where the patient has known all along that surgeons were going to operate on the wrong side but didn’t speak up, because “the surgeon seemed so certain that I thought he must know what he was doing”.In my hospital, the surgeons now mark the operative site with an indelible marker, while confirming with the patient what’s to be done. If there is any doubt, the surgeon will refer to the X-rays and scans to be certain. That way, even if the patient is asleep there is a way to confirm the surgical site.And lists where laterality can get mixed up (like hips, knees and cataracts) are booked in such a way that we do right hips all the way, or rights in the morning and lefts in the afternoon, so that nobody gets caught out by the unexpected left one in the middle of the rights.Amputation where it isn’t required sounds very strange to me. For an operation like amputation, the patient must consent in advance. If I saw a surgeon who seemed about to amputate a healthy limb, I would challenge him, and if necessary call his clinical director, or the chief of surgery, before the damage was done.