Thursday, April 29, 2004

Both Medpundit and Medrants have recently posted on this study published in this weeks New England Journal of Medicine. From the Medscape synopsis:

Of 2,164 men with inguinal hernias enrolled from one of 14 VA medical centers and randomized to open or laparoscopic repair, 1,983 had surgery, and 1,696 (85.5%) completed two-year follow-up.

There were recurrences in 87 (10.1%) of 862 patients in the laparoscopic repair group and in 41 (4.9%) of 834 patients in the open repair group (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.5 - 3.2). Complications occurred in 39.0% of the laparoscopic repair group and in 33.4% of the open repair group (adjusted OR, 1.3; 95% CI, 1.1 - 1.6).

However, the laparoscopic repair group fared better than the open repair group in terms of pain on a visual analog scale on the day of surgery (difference in mean score, 10.2 mm; 95% CI, 4.8 - 15.6) and at two weeks (6.1 mm; 95% CI, 1.7 - 10.5), and they returned to normal activities one day earlier (adjusted OR, 1.2; 95% CI, 1.1 - 1.3).

My thoughts:
I reserve laparoscopic inguinal hernia repair for two types of patients: bilateral hernias and recurrences. The rationale for bilateral hernias is that the discomfort can be severe after a bilateral open repair. Re-do hernias benefit from laparoscopy due to the posterior approach used, avoiding the scarring from the previous operation, hopefully minimizing the potential for nerve or vas deferens injury. An open preperitoneal technique has also been described. The only time I have done a primary laparoscopic inguinal hernia was on a patient that also had a ventral hernia that was repaired laparoscopically. It recurred.

The widespread use of mesh has become a great equalizer in the repair of hernias. Used to be if you wanted a very low recurrence rate you had to go to a place like the Shouldice hospital where all they did were herniorraphies. Now using the plug-and-patch method described by Rutkow and Robbins, I have a known recurrence rate of less than 1 percent. I call it a "known recurrence" rate because in private practice, unlike in a study, a patient may go find another surgeon if they do recur.

I tend to hold laparoscopic inguinal hernia repair in the same regard as laparoscopic appendectomy, a procedure that is very good and possibly better than the open technique under certain circumstances. Outside of those circumstances, however, laparoscopy brings on additional expense and potential complications with minimal improvement over the open procedure.

Wednesday, April 28, 2004

Haven't been able to post due to the very busy weekend on call, operating until 6PM Monday, and full office yesterday. I cleared my day to allow for a deposition this morning which took all of thirty minutes. Let me tell you about my weekend...

FRIDAY: Got a call from a local hospital about a patient who was kicked in the neck and their CT scanner was broken. "Can we send them to you for a CT?", they ask. "If it is negative can I send them back?", I reply. "Well, our ENT surgeon is out of town...blah,blah,blah..", is the response. Patient arrives and I find that the referring physician had neglected to mention that the assault was FIVE DAYS AGO. Patient also has what they themselves describe as a "major nerve problem". CT was negative. We discharged them ASAP since I am not a "nerve problem" doctor.

Another patient came in with a bleeding pseudoaneurysm from an A-V graft in their upper arm. This is caused by the dialysis personnel sticking the same place on the graft every time which leads to weakness in the graft material. Eventually it thins out so much that it bleeds. A lot. I took this patient to the OR and excised the pseudoaneurysm an placed an interposition graft. This patient also had secondary hyperparathyroidism which resulted in calcification of his graft. I had to punch holes in his old graft with a 22 gauge needle just to be able to pass my suture through. This graft had so many things wrong with it that the likelihood of thrombosis was high. Turned out that it did on Saturday.

Diabetic comes in with a "bump near his anus". Turned out it was a perineal abscess the size of a golf ball. Finally got to bed at 2am

SATURDAY: Early morning call for a cyclist struck by a vehicle. Intoxicated. Claims he's a "stunt man". Since the resident found a smear of blood on rectal, had to do a rigid sigmoidoscopy. Found nothing but hemorrhoids. GI scoped him few days later and found a polyp. Later that morning a stab wound to the flank arrived. CT showed no major injury so they were watched for awhile in the ED and then sent home. Placed a difficult dialysis catheter, and finished rounds and consults at about 5:30 pm, and slept until 11 pm when I woke up and had supper. Fell back to sleep...

SUNDAY: Only to be awakened by a call from another referral hospital at 1 am. Old guy stabbed in the chest. Had a hemothorax with about 800cc's of blood. Couldn't get an airway. Lifesaving maneuver performed by placement of a cricothyrotomy using a #5 ET tube. It's difficult to ventilate and oxygenate a 350 pound man through a soda straw. Shortly after arrival I took him to the OR for an emergent trach. Whenever I would place retractors to better see inferiorly, It would cause his O2 sat to drop. Finally got a extra-long trach in place. This was one of those situations where time seemed to stand still, but when I finished the case I discovered that the procedure had only taken 30 minutes.

About the same time another hospital calls....
Dr. X: I have a blah blah year old man stabbed in the anterior right upper quadrant...
Me: You don't have a general surgeon to handle this?
Dr. X: No, we only have surgeons available during daytime hours (I wish I had that job!)
Me: Was he stabbed above or below the costal margin?
Dr. X: Well, um, ahh, lets see... At this time I resist the temptation to ask if Dr. X had even examined the patient. I am not reassured by his answer. It gets even worse.
Dr. X: The patient just returned from CT.
Me: Why did you get a CT?
Dr. X : To determine the extent of injury....
Me: Well if it is negative that means you won't need to send him, correct?
Dr. X: Well, ah no, I think we will still need to send him.....
As this conversation was going nowhere, I gave in and accepted the transfer. When he arrived he had a 5mm puncture site in his RUQ. Given that Dr. X told me the knife was described a "foot long" unless he was stabbed with an epee injury was unlikely. Discharged Monday.

Man stabbed and slashed with a boxcutter by his wife. Multiple wounds with one on the flexor surface of the wrist actively bleeding from the distal ulnar artery. Given that finding the artery was ligated. Palmar arch found to be intact by doppler. Discharged Monday.

Placed a dialysis catheter in the psuedoaneurysm patient from Friday.

Call from the ED at the Hospital of the Sisters of Blessed Confusion about a "painful recurrent hernia". How long has the patient known about the recurrence? Oh it just happened , I am told. The ER guy hadn't even tried to reduce it with or without drugs. Please try, I ask, and give me a call back. They give him some pain medicine and get it reduced. I go see the guy and he tells me the hernia has been present for about a year. Come see me in the office...scheduled for surgery this Friday.

MVC with multiple facial, extremity, and intra-oral lacerations. The on call facial trauma physician was resigning from staff at the end of the month and refused to come in so I put his face back together. Discharged Monday.

Young woman in MVC with open hand fracture. Almost avulsed her thumb. She lost so much blood from this that she required 2 units of packed cells to stabilize her BP. Transferred to orthopedics Monday.

Young man stabbed and beaten. Right pneumothorax. That makes five stabbings so far.

MONDAY: 1am man fleeing from police on a motorcycle. Crashes bike. Some concern of a shooting. What looks like an entry wound over his left iliac spine. Also with hypotension, an open elbow fracture and a 20mm Hg difference in leg pressures. To the OR found to have a renal vein avulsion, splenic and liver lacerations. Out come the spleen and kidney. On-table angiography reveals no arterial injury. Pelvic fracture underlying puncture site. No evidence of shooting found. Required a good deal of blood products and fluid. Became cold, acidotic, and coagulopathic. So just like this guy he gets himself one of those open abdomens. I plan to take him back for second look today. By this time the magnificent hour of 7am arrived and I was free....

Saturday, April 24, 2004

On call this weekend. Got to sleep at 2 AM this morning, had a case at 7:30, and just finished with rounds. I'll try to post some later today or tomorrow.

Wednesday, April 21, 2004

Scissors left in woman after surgery

A Sydney woman demanded an explanation Tuesday from a hospital where a pair of scissors were left in her abdomen after surgery and said she planned to sue.

Pat Skinner, 69, had part of her colon removed at Sydney's St. George Hospital in May 2001. But she said that she continued to suffer intense pain in her abdomen for months after the operation.

Eventually, she demanded doctors x-ray her abdomen. They did and discovered the 6.7-inch pair of scissors, which were removed in October 2002.

After wrong side or wrong-site surgery the most worrisome thing in the OR is leaving something behind you shouldn't have. While such cases as the one above and a few others get widespread attention, the situation is not an uncommon one:

About 80 times a year in the Philadelphia region, the tools of surgery - gauze, scalpels, needles, retractors and the like - are found left behind in patients.

This mistake occurs about once in every 3,800 surgeries in Southeastern Pennsylvania, an Inquirer analysis of hospital billing data has found.

When it does happen it's not cheap:

A northern New Jersey woman who developed a hernia and severe scarring from gauze left in for six months won a verdict of $5.8 million in 1996.

"It's not a question of whether you lose but how much you lose," said Peter Leone, a former Princeton Insurance Co. vice president now with the malpractice insurance start-up, NJ Pure. Even when there is little harm, he said, the cost to a hospital can be $50,000 to $150,000.....But the system is far from fool-proof. Chunliu Zhan, a physician and researcher for the federal Agency for Healthcare Research and Quality, found that this mistake occurs 2,700 times a year in the United States - a rate that closely tracks the Philadelphia region's.

Zhan found that a foreign body added four days to the average hospital stay and led to $36 million a year in added charges. More troubling, he said, about 57 people died from this mistake in 2000, the year he analyzed.

Leaving an instrument, sponge, or needle behind is almost indefensible as it falls under the legal principle of res ipsa loquitur which means, for the purposes of this discussion, that the mere presence of the retained foreign body (RFB) provides for negligence.

An excellent review, authored by everyone's favorite surgeon-writer, Atul Gawande, found here and summarized here and here .

The study found that in the instances when these types of errors do occur, they happen during emergency procedures, or in operations where there is a sudden change in plan. Additionally the research revealed that the higher a patient's weight the more statistically likely it is that an object will be inadvertently left behind.

"Often when you hear about these kinds of cases, people assume it is due to negligence," said Atul Gawande, MD, MPH, of BWH. "But we found that these errors usually occur despite teams following proper procedures. These errors tend to occur in unpredictable situations, such as emergency operations, that challenge standard protocols."......In emergency operations, retained object errors are nine times more likely to happen, the study showed. It was also determined that these errors were four times as likely to happen when the operation involved a change in procedure.

All hospitals follow procedures that mandate an inventory of all tools and sponges be taken before and after a procedure. But Gawande's research concluded that, while the careful counting of instruments is a valuable safety precaution, in over two-thirds of the cases objects were retained despite proper procedures being followed.

After statistical analysis of the records, Gawande estimated that at least 1500 errors of this type occur each year in the United States. However, given that over 28.4 million inpatient operations were performed in 1999 alone, such errors happen rarely, the study found. In fact, the current research showed that these type of errors occur in approximately 1 in every 9,000 to 19,000 surgeries that involve an open cavity.

Some advocate the routine use of x-rays to rule-out RFB, but critics of this approach opine that the post procedure counts are important as well and may not be taken seriously. Another problem with this approach is that some things used in the OR such as towels, penrose drains, vessel loops, and umbilical tape are not radio-opaque. On the other hand, towels and drains are not routinely counted during a case. The routine for counting varies from hospital to hospital. At big hospital the blades, sponges, and needles are counted at least twice (three times if a space within a space, such as the uterus, has been entered) during closure and the instruments are counted twice as well. At the Sisters of Blessed Confusion hospital most of the instruments are kept on a second back table and brought forward as they are needed. Those are the only ones that are counted.

This is one of those "but for the grace of God go I" situations. I don't personally count the parts and tools myself, I depend on the scrub techs and circulators to do so, and I know of no surgeon that counts his own stuff. This is a patient safety issue that has potential for improvement.

Tuesday, April 20, 2004

Mr Page has a response to my post about the potential changes to the 80-hour workweek limits. His analysis of the NRMP data is as follows:

But let's look at that data at little more closely. It turns out that of the 31,140 participants in the match last year, only 19,392 were matched to a PGY-1 residency. Now, it could be true that some of these doctors are so horrendously bad that not a single program wanted them. But that's probably not the case for most. A good chunk of those medical school graduates probably chose not to apply to certain residency programs. In other words, they would rather not do a residency, wait a year, and then apply again.

I am afraid that Mr. Page made an incorrect assumption. From the above I can only assume that he thinks there are almost 12,000 unmatched, unemployed physicians out there. The data in question is located in Table 2 of the PDF link above. I have reproduced it below:

Total Applicants 31,140 (100.0%)
Withdrew 3,717 (11.9%)
No Ranking 2,177 (7.0%)
Active Applicants 25,246 (100.0%)
Matched PGY-1 19,392 (76.8%)
Unmatched PGY-1 5,855 (23.2%)

Now while 31,140 people participated in the match in 2004, only 25,246 of those submitted rank lists. The reasons for those not submitting rank lists are not clear. Maybe they had to repeat part of the fourth year, failed USMLE 2, or wanted to do research. Some specialites such as ophthalomolgy also have their own match which may account for some of the withdrawals. (i.e. the applicant enrolled in the NRMP as a "backup" plan but got out when they got their other slot). I doubt the logic of "they would rather not do a residency, wait a year, and then apply again" is applicable. At least it wasn't when I was in medical school. A one-year gap in training leads to all sorts of "please provide details on a separate page" issues when filling out applications for things such as licensure, board certification, and provider panels. Another question that is not answered is how many of the 11,849 (or 5,855 if you count only the unmatched people) found positions outside the match? Not all of those that did not match were bad students. Many medical students are give bad advice on program selection or rank-list strategy, which can lead to a call to the Dean of Students office on Black Tuesday. Given the large numbers of unfilled primary care slots these people were likely to find a program to their liking. Regardless, the fact that there are so many positions that go unfilled makes it unlikely that the ACGME will allow more to be created.

Almost forgot to respond to this:

You'll notice from the NRMP data that specialties like dermatology and opthamology, known for their less strenuous lifestyle, filled every one of their residency positions. It was the surgery and internal medicine programs that left lots of open slots.

Derm and ophthamology are known for their "less strenuous lifestyle" and the desirability of such a lifestyle makes those specialites competitive. Another issue is the number of positions. According to the above data there were a total of 294 PGY 1&2 derm slots in 2004 with only 4 ophthal slots in 2004 (as stated before, they have their own match). So the numbers lend themselves to high fill rates. Even general surgery with 1,044 positions had a fill rate of 84 percent, twice that of family practice.

Saturday, April 17, 2004

The Parkers all piled into the family truckster yesterday and went to the place where Mrs. Parker and myself grew up. Our respective parents live within fifteen minutes of each other so while we are staying at my mother-in-laws house I took the kids to spend most of the day with their other grandparents. A good time was had by all. We typically make it up here every two months but with this being north Georgia it seems as if it is changing all the time. Every time I visit I can't help but think, what if????
My desire throughout college and medical school was to return to my hometown and practice, a desire no doubt shared by some of my physician readers. I actually had a job offer in my hometown but I turned it down for two reasons. One was, and while I love my family very much, I was afraid it would be a cross between a Tennessee Williams play and Everybody Loves Raymond. The other was that the guy who offered me the job had a reputation held by the medical community in town of being a jerk to other physicians and co-workers. Physicians who's counsel I sought bluntly told me that my own judgment would be suspect if I took the job. The pay was also lousy starting off.
In this month's Bulletin of the American College of Surgeons is an article titled Retirement:An opportunity to revisit "the road not taken" in which the author writes about retirement and job satisfaction. A medical rendition of A Pirate Looks at Forty, if you will. About how the choices seem clearer in the present than they did in the past. And sometimes we regret our choices. Did I take the correct "road in the woods"? The road that led to medical school, then to surgery, then to residency, and finally where I am today. I seem to think so, but only time will truly tell

Friday, April 16, 2004

Both Medrants and 2md recently have provided analysis of two articles that appeared in the April 12th and April 19th editions of American Medical News. While DB wants to give the new system time to work out, Cameron sees potential trouble.

From the April 19th paper:

Preliminary results of an Assn. of American Medical Colleges survey tell of a year of significant challenges within graduate medical education as it reshaped resident training to comply with the new 80-hour work week.

Sunny Yoder, AAMC director of health care affairs, presented these initial findings at the Accreditation Council for Graduate Medical Education conference in Chicago in March.

According to an Internet survey of resident program administrators, the specialty facing the biggest compliance hurdles was surgery, with 67.7% of 105 surgical programs represented in the survey saying they were greatly challenged by the new work hours. This was followed by neurological surgery, internal medicine, ob-gyn and thoracic surgery.

No surprise here. Not only are surgery residents involved with care of inpatients, clinic patients, and going to conferences and other such "educational activities", as all residents are, but they also have to spend a little time in that part of the hospital known as the operating room. When you have to squeeze all that into 80 hours per week, the operative experience is sure to suffer. Since each resident has to have a certain number and type of cases before they can graduate, residencies may take longer to complete.

Meanwhile Mr. Page rants on the April 12th article and fears the ACGME is out to repeal the thirteenth amendment:

The Accreditation Council for Graduate Medical Education is considering modifying duty-hour standards for residents in response to feedback from program directors

First of all, they're basing this on feedback from Program Directors? Of course the Program Directors hate the new rules. They have to spend money on new residents because they can't stretch out the old ones anymore. What happened to listening to the residents? That's why we changed the rules to begin with, right?

While program directors may not like the new rules they aren't usually evil incarnate either. The program directors job is to ensure that the residents in a program get a good postgraduate education so that they can 1) pass their boards and 2) be good doctors. As far as "spending money on new residents" I don't think that the ACGME has been allowing programs to expand to make up for the lost hours. Reviewing the data from 2004 U.S. graduates filled only 54.8% of internal medicine slots (overall 97.4% filled), 71.3% of peds slots (97% overall), 41.4% of FP slots were filled by U.S. grads (76.8% overall) and surgery had 84.8% U.S. fill and 99.8% overall. So with the situation as is, there isn't likely to be any new slots created. Moving along..

Also under review is the 10-hour rest period following in-hospital call. The ACGME is looking at ways to credit residents for sleep gotten during the on-call period and counting it toward the recommended break.

In other words, if you nap between 2am and 5am, the hospital can let you go at noon that day and demand you come back at 7pm for another night of work. This doesn't sound like a huge change from the bad old days of sleep-deprived patient care.

I think a more reasonable interpretation of the above statement is that if you get three hours of sleep the night before, you can stay until 3pm the following day instead of having to leave at noon. I agree wholeheartedly that residents call burdens could be diminished significantly if they didn't have to do so much scut work.

My main problem with work hour limits is this: A residency is designed to take a freshly-minted MD and over 3,5, or 7 years turn them into an attending who can work unsupervised and possibly alone in the real world. The 80-hour limit places an artificial reality that is often not the case outside of a residency program. Because I wasn't restricted to 80-hour weeks as a resident, I have gained knowledge of how fatigue affects my judgment and skills. I was able to gain that knowledge while under close supervision, so mistakes were avoided. How will the current residents respond to fatigue and stress after they graduate? Is patient care compromised if the first time they get fatigued is when they are on their own with no one looking over their shoulder? If the old yarn of "surgeons work harder in residency than in private practice while internists work harder in private practice than in residency" is true how will work-hour limits affect this? The program versus real-world argument is further bolstered by Mr. Page's next excerpt:

The ACGME also said it found some programs were so focused on being technically compliant that they were ignoring aspects of patient safety. One program in New York City, for example, was assigning its on-call resident to cover two separate hospitals blocks apart, a situation that was completely unworkable

So this residency program refused to hire enough residents to cover all of its patients' needs....And THAT's the justification for relaxing the rules? Instead of letting them slave-drive their existing doctors, how about we demand that they hire more well-rested doctors? In other words, how about we enforce the rules?

Guess what? In most cases physicians outside of residency programs cover more than one hospital at a time. Mr. Page's solution seems to be to put the ACGME limits into law. Talk about paternalism in medicine....

Wednesday, April 14, 2004

No joy in River City this week as the secret hospital police are in town making their triennial visit. What a load of fecalent vomiting. Are the inspectors so dense that they think the hospital looks and runs like this all the time? What the surveys create is some sort of medical-based Brigadoon where the ideal hospital only appears every three years. JCAHO also institutes all sorts of inane requirements on hospitals such as four raised bedrails equal a restrained patient and making the radios in the OR go through inspection by the biomed department that it is almost comedic. There have been months of reviews and drills and "mock reviews" that is seems like preparation for Operation Overlord. The only advantage of the visit so far is the surgeon's locker room has gotten a fresh coat of paint and some worn floor tiles have been replaced.
I have so far been able to skillfully avoid being sucked in to any JCAHO activities, but there are several days left to go. If stopped and ruthlessly interrogated I will hand them this and say it is from the new patient orientation pamphlet:

While a trip to the hospital is rarely pleasant, here are some tips to help you prepare for the experience:

Before entering a hospital for treatment, weigh your holistic health-care options against your wish to actually get better.
If you have a wok at home, it's a good idea to get some bedpan practice before the pressure is on.
Some drugs react violently with alcohol; some don't. Ask around.
If you are going to the hospital for treatment of a severed limb, remember to bring the limb.
Bring your regular medications with you to the hospital. God only knows where the hospital finds theirs.
Read a couple of Newsweek articles about your condition. This information will allow you to second-guess your doctor's every move.
Be forewarned: Hospitals apply a vast mark-up to the items in the in-room minibars.
Wear clothing that is loose-fitting and comfortable, yet appropriate to bleed in.
If you behave like a brave little soldier, you may be offered ice cream.
Whatever you do, don't check into any facility called "General Hospital." That place is full of back-stabbing, narcissistic lunatics.
Pack several extra pairs of slippers. Slippers in the hospital are like cigarettes in prison.
Before knocking out an intern and stealing his uniform, make sure he's your size.
Many patients complain that hospitals cut their stay short. Don't be coerced into signing out until you're dilated to 10 cm and the baby's head can be seen.
Bring $500 in fives to "grease the wheels," if you get my meaning. The good mashed potatoes.
If bruised, find a hospital known to have a good bruise ward.
Keep in mind that, today, many procedures can be performed on an outpatient basis. Some can even be done outside.
When you arrive at your hospital room, decide which item you'd be willing to accept as the final thing you see on this earth.

Then I will run for my life......
From The Onion

Tuesday, April 13, 2004

One of the earliest posts on this blog was a collection of annoying habits that patients engage in that drive me nuts. I've been on call 3 of the past 5 days and physicians did more during those days to get under my skin than anything that the patient's did. Time for some bile venting.....

Referral Madness: If you want to send all of your consults to a certain surgeon or group of surgeons, be my guest. As a primary care physician that is your right. What is not fair is to send your insured patients to one group and then try to pass off your uninsured patients to other surgeons. Don't be surprised when your surgical consultant doesn't buy your lame B.S. excuse as to why your usual surgeon is not available. Also don't be surprised if your surgeon politely declines your consult.

Daytime Friends: Even if your patient has coverage, a wide variety of illnesses and beeper difficulties can befall your usual surgeon after The Tonight Show starts. This is really dirty pool since it then falls to the unassigned surgeon since often this patient is in the ED.

Don't Call us, We'll Call You: I am the first to admit that I often drop the ball on this one. If you have a consult, please call your consultant, and your consultant should call you in return. Doing so is a must if your consult is STAT. Don't expect me to get out of bed and come in and see your patient while you stay in bed without the benefit of a phone call.

Speaking of Staying in Bed: Patient comes to ED with problem in the dead of night. ED physician sees patient and calls primary care physician. Primary care physician admits patient over the telephone. Primary care physician orders STAT surgery consult without seeing patient. Primary care physician goes back to sleep. Surgeon fumes. (As a resident I would take the passive-aggressive route and call a referral physician who did that as labs, x-rays, and other tests come in. Great fun)

I know I'm sounding petty but unfortunately the above situations occur almost weekly. In the interest of fairness I invite my fellow medbloggers and readers to opine on the shortcomings of the surgeons in their lives.

Come on, I know you want to....


Friday, April 09, 2004

Bariatric surgery taking on the chin from multiple sides. First off from MSNBC: Gastric bypass riskier than many patients know

In 1991 Diana Nejbauer hit 261 pounds and was thrilled to undergo surgery to reduce the size of her stomach. But the procedure didn't work. "I was sick from the very beginning," says Nejbauer.
Not only did she vomit constantly, but her weight, which fell initially, started climbing back up to where it had been. "It was devastating. I couldn't believe it," she adds......Catherine Bast's husband Dave died from complications of his weight-loss surgery. "We would have never went through it knowing all the risks," she says.
No one knows the complication rate from obesity surgery because there is no national registry to track it. Estimates of the death rate alone are as high as 2 percent.

Buyer's remorse with appliances and automobiles is one thing, with surgical procedures it is something else entirely. I wonder if Ms. Bast's husband's informed consent did not mention death, or did he sign it without reading it The fourth paragraph of the informed consent papers used at the Acme Surgical Corp reads as follows:

As a result of this procedure being performed there may be material risks of: INFECTION, ALLERGIC REACTION, DISFIGURING OR PAINFUL SCAR, BLOOD CLOTS OR PULMONARY EMBOLI, SEVERE LOSS OF BLOOD, LOSS OR LOSS OF FUNCTION OF ANY LIMB OR ORGAN, PARALYSIS, PARAPLEGIA, QUADRIPLEGIA, BRAIN DAMAGE, CARDIAC ARREST OR DEATH. Loss of blood may require transfusion of blood or blood products which carries a risk of exposure to viral hepatitis and AIDS.

Pretty clear to me. I'm not denying that some paint a rosier picture than others and may gloss over the risks, but saying you "would have never went through it" if you knew the risks begs the question: Why didn't you ask?

Liability carriers are also taking a long, hard look at the risks of bariatric surgery:

To date, MAG Mutual Insurance Company has incurred $3,838,071 for 24 bariatric surgery claims. Most of these claims have been filed in the last two years. Frequent postoperative complications included gastric leakage, blood clots, respiratory compromise and wound infection. Although most of these claims resulted from recognized complications, the allegations which brought the physicians into the cases were usually failure to timely recognize complications and intervene.

And they look at danger areas by providing examples:

A 30-year-old man had a laparoscopic Roux-en-Y procedure at a hospital’s newly opened bariatric surgery clinic. The night after surgery he developed leg pain which was documented in the medical record, but not reported to the attending surgeon. About 6:00 AM he arrested. Resuscitation was successful, but the patient suffered moderate brain damage and is permanently disabled. Physicians and patients are at risk when support staff is inadequately trained.

A 47-year-old hypertensive diabetic woman, weighing 400 lbs underwent laparoscopic adjustable gastric banding. She did well initially, but soon became noncompliant with her dietary restrictions. She developed erosion of the stomach and had to have corrective surgery and subsequent removal of the device. She sued her bariatric surgeon alleging that she was not properly informed and in fact was not a good candidate for surgery. This case illustrates the need for informed consent, extensive informed preoperative screening and psychological evaluation before surgery.

This scenario is similar to what we have faced twice in the past year:

In 1997 a 35-year-old, 325-lb woman flew to a distant city to have an open Roux-en-Y procedure because there were no local surgeons who performed bariatric procedures. The procedure and hospitalization went well, and the patient was released after five days to be followed by her local surgeon. She experienced nausea and vomiting after returning to her home. The local general surgeon treated her with Phenergan which relieved the nausea. She presented to the Emergency Department the next day with low-grade fever and nausea. Again she was treated and sent home. That night she was transported to the Emergency Department in shock. The shock resulted from sepsis and peritonitis caused by a leaking suture line. The patient died. A case was brought against the local surgeon, and the Emergency Department physician who allegedly did not recognize the known complication. This case points out the danger of taking over postoperative care when not familiar with the procedure or its complications.

We have become involved with patients that have had their surgery elsewhere and presented in our town with complications. (We do not perform bariatric surgery at the Acme Surgical Corp.) These patients are difficult to manage for many reasons. The main reason is the complications themselves. Once "fixed" these patients don't want to return to their original surgeon and we inherit them. Often these patients have underlying emotional or psychiatric issues which can make things more problematic. And inevitably litigation is involved. Few things rankle a surgeon like having to take care of another surgeon's complications. Another Piece of Resident Wisdom that has been ingrained in me is sometimes known as "Frankenstein's Rule":

You create the monster, you live with the monster

Well moving on, some medical insurers are cutting back on bariatric coverage:
Insurers trim bariatric surgery coverage

As America grows fatter, some insurers' coverage of weight-loss surgery is becoming leaner.

BlueCross BlueShield plans in Florida and Nebraska are among those who recently announced they no longer would cover gastric bypass surgery. CIGNA Corp. has stopped coverage in four states and is looking to withdraw coverage in more states as contracts expire.

It's not just bariatric surgery being targeted. According to the Center for Studying Health System Change, insurers, under pressure from employers, are increasingly looking at eliminating coverage for procedures perceived as high-cost and unnecessary.

But bariatric surgery is a particularly high-profile and popular procedure. Nationwide, the estimated number of gastric bypass surgeries -- touted by celebrities such as singer Carnie Wilson, TV personality Al Roker and "American Idol" judge Randy Jackson -- climbed more than 500% between 1993 and 2003, from 16,800 operations to more than 103,000, says the American Society for Bariatric Surgery. This comes as the proportion of Americans with a body mass index of 40 or more -- at least 100 pounds overweight -- increased fourfold between 1986 and 2000, from one in 200 to one in 50. Insurers that pay for the surgery typically require a BMI of 40 or more for coverage, or 35 for patients with serious comorbid conditions.

But firms cutting coverage say they can't afford to keep paying for what they see as risky surgery, with a reported death rate of three out of 1,000 procedures, that is increasingly being done by less-qualified doctors.

The insurance companies are arguing the exclusion on economic grounds, despite the problems of obesity:

At this point, however, many employers and insurers aren't ready to trade short-term financial pain for possible long-term gain, especially with the likelihood a patient will change employers or plans before they benefit from any future cost or health benefit from the surgery.
Employers "are clearly looking for cost management," said Razia Hashmi, MD, MPH, medical director and vice president for coverage policy with CIGNA, which this year dropped coverage for weight-loss surgery in Arizona, Florida, North Carolina and Texas. A 2003 survey by Mercer Human Resources Consulting found that among companies with more than 500 workers and employer-sponsored health plans, 52% chose not to cover bariatric surgery.

The lack of foreseeable economic benefit, combined with the cost of managing complications due to marginally-trained surgeons have made bariatric surgery less appealing to insurers. This will cause many patients to finance the procedure themselves, as was the case before insurers began to pick up the tab. Bariatric surgery began to attract surgeons for me reason that Willy Sutton robbed banks, because that is where the money was.
But why only bariatric surgery? There are multiple other procedures that have been studied and found to have minimal benefit. Examples include spinal surgery for pain, adhesiolysis for pelvic pain, and knee arthroplasty to name a few. But those operations don't have the high mortality rate that bariatric surgery does and haven't gotten the "bad press" that gastric bypass has. I don't think it is "discrimination against the obese " as some quoted in the above article opine.

Wednesday, April 07, 2004

Early April means it's time for the Masters and all of the hub-bub associated with it. While I went for several years before I started medical school, I never went during my four years in Augusta. The wise heads at MCG always had spring break during that time and while there were some good parties to go to, and some students were lucky enough to get to work the first aid tent during the tournament, it was very difficult to get around town during that time. Some of the permanent populace of Augusta made a tidy sum from renting out their houses to people coming into town.
Masters week was also entertaining because Augusta and Augusta National were put into the media spotlight. In addition to the sideshow last year created by Martha Burk you can always count on some sort of "gotcha" story focusing on poverty or crime in Augusta, contrasting it with the House that Bobby Jones Built.

I've been posting alot today because I'm on call for the next two days and I look to be pretty busy.

Added another link to "The Housestaff" Rich Lassiter who is a graduate and a current EM resident at The Finest Insitution of Medical Education In America.
Surgeons Who Play Video Games Err Less

All those years on the couch playing Nintendo and PlayStation appear to be paying off for surgeons. Researchers found that doctors who spent at least three hours a week playing video games made about 37 percent fewer mistakes in laparoscopic surgery and performed the task 27 percent faster than their counterparts who did not play video games.
"I use the same hand-eye coordination to play video games as I use for surgery," said Dr. James "Butch" Rosser, 49, who demonstrated the results of his study Tuesday at Beth Israel Medical Center......The study on whether good video game skills translate into surgical prowess was done by researchers with Beth Israel and the National Institute on Media and the Family at Iowa State University. It was based on testing 33 fellow doctors 12 attending physicians and 21 medical school residents who participated from May to August 2003.

Guess I'll try to get in my three hours here today.
The Department for the Prevention of Surgery (that's anesthesia, if you were curious) cancelled my case today. What to do.....

Tuesday, April 06, 2004

DB has a post on this New York Times story about the match and the lawsuit attempting to derail it. DB makes some excellent points:

Popular residencies could (and therefore probably would) decrease their financial stipends. To get a dermatology slot you might work for much less than today.
Less popular residencies (either specialty or location) might increase their stipends to try to attract residents. This could lead to bidding wars - financially helping some residents in the short run.
It follows that considerations other than the quality of training would have a greater influence on residency training
Timing would become a greater issue. Students would start seeking positions in their 3rd year rather than their 4th year. Programs would encourage this trend to insure that they "fill" their positions. However, 3rd year students often change their minds about specialties. Thus, students might reneg on their committments, leaving programs scrambling to find replacements.
The above comment seems absurd - until one examines subspecialty fellowships in internal medicine, which have exactly that problem.
(and they let them get away with it?)
The stresses on applicants would increase without the current standarization

While Dr. Centor diplomatically calls a world without the match as one with "increased chaos", I think it would be akin to anarchy. Imagine the situation described above. Imagine taking calls from headhunters as a third (or second)-year medical student. Imagine getting postcards with the pitch "Consider this postgraduate medical education opportunity in sunny Florida!!!" Those things were annoying enough to get as a resident.
A ranking meeting in a world without a match could certainly be interesting according to a commenter to my Match Day post:

When John got a 240 on his USMLE Step II but he wants 45K, Stephen on the other hand took three times to pass but he only wants 30K. Who should we take?"

Who indeed. Anyway the results for the 2004 match are here. Makes for interesting reading. Of the 1044 categorical surgery spots, 885 were filled by U.S. graduates, up slightly from last year. 2 surgery programs didn't fill, compared to 9 last year. Contrast to the 46 IM, 38 pediatric, and 221 family practice programs that had open slots. And those numbers are better than last year's. Radiology and derm don't seem to have that sort of trouble, however.
Busy day in the office. But I found some time to monkey with the links...
The shooting victim mentioned here and here had his abdomen closed yesterday. We have since stopped his paralytics and plan to extubate him today.

Sunday, April 04, 2004

From "The Vent" in the April 5 Atlanta Journal-Constitution:

As a surgeon, it's priceless to see the look on my patients' faces when they realize I'm the same skinny guy they used to shove into lockers in high school.


Apparently some think that its not being used enough.....

A drug that cuts the rate of breast cancer by 50 percent in women most at risk is not being used as much as it could be, because doctors are failing to offer it and some patients are confused about taking it, researchers reported Monday.

Women may be afraid to take the drug tamoxifen because it raises the risk of cancer of the uterus, as well as the risk of blood clots that can cause heart attacks, embolisms or strokes, the team at Northwestern Memorial Hospital in Chicago found.

They looked at the records of 219 women with higher-than-average breast cancer risk. Only 63 percent of the women were offered tamoxifen and only 26 percent accepted, they found......

Tamoxifen, a pill used to treat breast cancer, has been shown to reduce cancer rates by 49 percent in women who have a high risk of the disease either because they have had precancerous lesions, a strong family history, or for other reasons.

My goodness, why wouldn't women want to reduce their breast cancer risk by almost half? This article has fallen prey to the old statistical bogeyman of absolute versus relative risk, and how that effects decision-making. The basis for those recommendations is the NSABP P-1 trial A Clinical Trial to Determine the Worth of Tamoxifen for Preventing Breast Cancer, also known as the Breast Cancer Prevention Trial or BCPT. The results, found here indicate that 368 out of 13175 women had either invasive or in situ cancers diagnosed during the follow-up period, an incidence of 2.79 percent. In the placebo group 244 out of 6707, or 3.64 percent had a cancer diagnosed, compared with 124/6681 or 1.86 percent in the Tamoxifen group. So while the absolute reduction of breast cancer was by about 1.8 percent, the relative risk numbers get the play. More on how that affects decision making later on. As expected the absolute and relative risk numbers were better in patients with atypical ductal hyperplasia and lobular carcinoma in situ. Of the Tamoxifen group 18 out of 6681 (0.26 percent) developed a pulmonary embolus, compared to 0.089 percent (6/6707) in the placebo group (RR=3.01), 0.52 percent developed a DVT, compared with 0.32 percent in the placebo group (RR=1.6), and for endometrial cancer 36 of 6681 in the Tamoxifen group (.053 percent) had a diagnosis, compared with 15/6707 (0.22 percent) in the placebo group (RR=2.53). Of course the risks were higher in women greater than age 50, and the prevention benefits of Tamoxifen also start to increase after that age.

So while taking this medication may reduce your risk of developing breast cancer by fifty percent , it can raise your risk of endometrial cancer 150%, increase the risk of DVT by 60% and raise the risk of PE by 200%. It can cause an increased chance of uterine sarcoma and cataracts as well.

Now if the woman has had a hysterectomy, the endometrial cancer risk is eliminated, and the endometrial cancer is diagnosed at an early stage if a uterus is present. The risk of thromboembolic disease is roughly equivalent to that of HRT. But those numbers can be plenty worrisome for woman considering this for prevention.

Determining risk has been assisted by computer-based Gail algorithms. Such tools may be found here and here. They will take a number of factors such as age at menarche, relatives with breast cancer, gravidy and parity, and number of biopsies done to deliver 5-year and lifetime estimated absolute risks. Anything above 1.6%-1.7% is considered "high risk". The participants in the BCPT all had a risk percentage >1.66%.

So when a woman is told that her risk of developing breast cancer over the next five years is 2 percent (meaning her chances of NOT developing breast cancer is 98%) and we can reduce her risk to one percent with Tamoxifen, with the side effects described above. Not as dramatic as made out by the relative risk, is it? Tamoxifen isn't cheap either with a months supply running about $60.

In my own practice I offer Tamoxifen to patients with LCIS or atypical ductal hyperplasia. I discuss the risks and benefits and give them some literature to review. They return in a few weeks and we discuss it some more. About 1/3 of the patients start on Tamoxifen. Studies comparing Tamoxifen with other agents, such as the STAR trial are ongoing.

Friday, April 02, 2004

It's a shame when the day job gets in the way of blogging......

The gentleman mentioned in this post has made two more trips back to the OR, one Wednesday and one today. Wednesday I removed the packs and he has mobilized his third space somewhat with the assistance of some Lasix. I was able to get is abdomen about halfway closed today.

The Georgia Senate passed an amended version of HB 1028, which according to MAG:

Emergency Department Relief: Plaintiff may not recover non-economic damages for negligence occurring in an emergency situation;

Abolish Joint & Several Liability: requiring apportionment of damages between defendants;

Venue: location of trial moved to county of remaining defendant if one defendant is dismissed from a suit and venue was based on that defendant;

Apparent Agency: relieving hospital from liability for negligence of non-employed physicians;

Expert Witness Reform: indicating who is qualified to testify as an expert at trial;

Standard of care for ER doctors;

Non-economic damages: judge authorized to reduce non-economic damages if such award exceeds by 25% the award in similar cases in other jurisdictions;

Mandatory non-binding mediation of medical malpractice claims.

No cap limit though...

I am really beat. Time to turn in
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