Never?

This study from Johns Hopkins surprised the hell out of me:

After a cautious and rigorous analysis of national malpractice claims, Johns Hopkins patient safety researchers estimate that a surgeon in the United States leaves a foreign object such as a sponge or a towel inside a patient’s body after an operation 39 times a week, performs the wrong procedure on a patient 20 times a week and operates on the wrong body site 20 times a week.
The researchers, reporting online in the journal Surgery, say they estimate that 80,000 of these so-called "never events" occurred in American hospitals between 1990 and 2010 - and believe their estimates are likely on the low side
 

The numbers seem quite high, but it's hard to argue with the methodology of using historical information from the National Practitioner Data Bank.  And one can assume that even these results underestimate the true problem; not all patients sue for retained sponges or wrong site surgeries.  It truly is mind boggling to me, a practicing general surgeon, that we are leaving foreign bodies inside patients to the extent of 39 times a week.

It's unacceptable, of course.  And in this era of the Timeout, pre-operative marking of the surgical site, and Checklists, hopefully future outcomes will not be so alarming.     

Hospital Scenes

The old man lie down sprawled in a contorted mechanical hospital bed, configured like a caterpillar scrunching its way across a sidewalk.  I had operated on him a few weeks ago; subtotal colectomy for patchy diffuse ischemia.  After an initial rocky course he stabilized, was extubated, and we were able to get him out of the ICU.  It was mid-morning on a weekend.  His head was kinked sideways into his shoulder as he dozed.  Spittle dried in the corners of his mouth. 
-Good morning Mr L, I said.  He stirred and opened his eyes.
-Morning, he murmured.  His eyes fluttered and then fell closed. 
-You've come a long way, I said, listening to his heart and lungs.
He opened his eyes again.  He looked at me like looking at someone standing too close to you on a bus or a subway. 
The TV blared from a wall mount.  There are few more depressing sounds in life than the dulled, hollowed-out sound of a telelvision playing too loud in a patient room.  It's hard to explain.  The only form of entertainment.  The recipient not even really watching it.  The way it echoes out into the main hallway. 
-What did you used to do in your younger days, sir?
-Drywall and....    He shifted to the side, stiffening in an attempt to lean forward.  His face showed gaunt and grayed under the halogen lights.  He hadn't been shaved in at least a week, sparse coarse thickets of gray splotched across face and neck. 
-Labor? Owned a business?
-Drywall...and....and....I....drywall.....I can't.....
-It's ok, I said.  It's Ok. 
-I can't talk anymore....
He relented to fatigue, let his body fall back stricken into bed.  He dozed again.  His stoma made a noise under the covers.
I stood there for a while, perhaps 3-4 minutes, not quite ready to just leave.  He was about set for transfer to a rehab facility.  I probably wouldn't see him again for weeks.  The TV was showing some old collge football game from years ago.  I turned to leave.
-Can you cover my feet? he said, suddenly reanimated.
-Of course. 
He had pulled the sheets and blankets up tight around his chest, leaving his long pale, skeletal feet bare.  The thickened toenails were yellowed and hooked around the confines of the nail beds.  I pulled one of the blankets over them, tucked it under his heels.
-Thank you. 
-No problem.
-You said your name was?
-Parks.  Dr. Parks.  I did your surgery a a couple weeks ago.
-Parks.  Parks, you say.  Ok...... 
And he drifted off again.  His chest rose and fell slowly, emphatically.    
 

Stool Sniffers

The British Journal of Medicine has published a paper about a beagle sniffing out cases of clostridium difficile (c diff) colitis in hospitals.  C diff is a certifiable plague in this era of antibiotic overuse.  I have taken out my fair share of colons in toxic patients.  Until recently, the diagnosis of c diff required a stool sample (sometimes multiple) that could sometimes take several days for results to post.  This dog, Cliff, in the paper was able to correctly identify the bug in 25/30 patients with confirmed infection.  Furthermore, he accurately indicated absence of infection in 265/270 stool samples. 

I suppose this is a nice little study.  It's the end of the year, the Holiday season.  We all like mood-elevating stories about cute animals doing amazing things.  Surprising that it would find its way into the esteemed BMJ, however. 

Anyway, the whole thing is sort of moot.  Newer PCR testing techniques for c diff have shortened diagnosis turnover time to around an hour.  It is lamentable that there is little likelihood that hospitals will commandeer packs of hounds to make olfactory rounds on inpatient toilets.  Alas. 

Enough

The events in Newtown, Connecticut yesterday will hopefully jump start a national conversation.  That's about the only solace I can take from the senseless murder of 20 schoolchildren in a classroom.  This conversation ought to transcend minutiae like the specifics of gun laws and gun show loopholes (although there will be a time for redressing these inanities).  I don't want to hear about how we "need more God in our schools", as if ol' Jesus would have sent down a thunderbolt, Zeus-like, to prevent Adam Lanza from firing wantonly at Kindergartners, if only we hadn't halted compulsory prayer in our schools.  That's all you will hear about over the coming weeks, in this highly charged partisan echo chamber of red state/blue state, FoxNews/MSNBC.  And it's all irrelevant.  The fundamental questions will get buried beneath an avalanche of op eds and monologues advocating for or against the highlighted "issue" of the moment.  The important questions will never get asked. 

What has become of our culture?  Who are we?  Why do we glorify violence and mayhem?  Why have we embraced pre-emptive war and torture and rendition and robotic drones raining down death and destruction in far away lands?  We do we countenance the non-prosecution of Wall St fraudsters?  Why have we waged an unsuccessful 30 year Drug War (with militarized local SWAT teams) that overwhelmingly targets the poor and forlorn?  Why are video games like Call of Duty and Assassins Creed ubiquitous in the rec rooms of 12 year old boys?  Why are we the only advanced western country without a national health care system for all?  Why is the national sport a modern day gladiatorial contest, leaving its combatants wracked with the cognitive and psychiatric consequences of long term brain injury?  Why would a rational American respond to the murder of children in a school by posting a picture of this on Facebook? 

Who are we?

What is this nation of Americans?

What have we become?

A culture in the throes of decadence, one that embraces hypocrisy and degeneracy ought not to be surprised when the more disturbed elements of society act out in ways that stretch the bounds of pure unfathomable evil.  We are now inured to mere everyday evil.  The deranged psychopaths in our midst must come up with ever more creative acts of intransigence to draw our gaze.   It requires the massacre of innocent children in classrooms to get our attention.  That which was once unimaginable is now the only option left for attention-seeking deviants. 

We are all responsible for this atrocity, to some degree.  Our civilization's survival depends on a thorough reckoning with our own sins.  We must look in the mirror and acknowledge reflections of horror.  Our rotten core cannot be hidden any longer.  There is still time to salvage our souls.  Together, as a nation, we must seek our collective penance and redemption.   The words of Dostoevsky are uncomfortably appropriate at a time like this: 
"There is only one salvation for you: take yourself up, and make yourself responsible for all the sins of men. For indeed it is so, my friend, and the moment you make yourself sincerely responsible for everything and everyone, you will see at once that it is really so, that it is you who are guilty on behalf of all and for all. Whereas by shifting your own laziness and powerlessness onto others, you will end by sharing in Satan's pride and murmuring against God."

Hug your sons and daughters tight this Christmas season....

More Student Loan Bondage

Wisconsin Republican Congressman Tom Petri has introduced legislation that would allow the federal government (via the Department of Education and the IRS) to automatically deduct student loan payments from borrower's paychecks (capped at 15% of one's income).  This is being touted as a good thing because it would then obviate the need for third party collection agencies, who previously had been subcontracted by the government to help collect the $1 trillion in outstanding student loans. 

Because, you see, borrowers would much rather have actual money deducted directly from their paychecks by some all-powerful federal agency than to have to simply ignore repeated phone calls from relentless collection agencies who have no legal power to make you pay anything at all. 

Laparoscopic vs Open Ventral Hernia Repair

Dr Heniford's group down in North Carolina had a nice little paper out in the Annals of Surgery last month which prospectively studied quality of life (QoL) outcomes and complications in patients who had ventral hernias repaired either laparoscopically or at open surgery.  Both repair techniques incorporated the use of synthetic mesh. 

The conclusions are as follows:

• Laparoscopic repairs are associated with lower short-term QoL scores and higher degrees of post operative pain
• Long term recurrence and overall complication rates about the same
• Fewer infections and shorter length of hospital stay with laparoscopic approach

Pressured Giving

In line at Dick's today I overheard the cash register clerk ask the customer in front of me if she wished to donate to "St Jude Children's Research Hospital" during the checkout process.  It was asked in a very loud, matter of fact voice.  The store was crowded and all the lines were stacked five deep.  The woman sort of paused, almost blushed,  mumbled something about "having donated last week" while shaking her head, and the clerk ran her card without missing a beat. 

I loathe this on so many levels.  I hate the enforced  public display of philanthropy.  I hate the commingling of pure profit-seeking commerce with generosity.  I hate the disengaged, rote way it is asked by minimum wage-earning employees.  I hate that reluctance to donate on the spot can be perceived by others as a sign of miserliness and general sociopathy.  Typically those who are asked respond in one of several ways:

EMR Adventures

The hospitals I cover have all made the transition to electronic medical record  (EMR) documentation.  This means all our daily progress notes and H&P's have to be done using the templates in the EMR.  I'm fairly computer literate so the transition hasn't been awful.  I actually like being able to read the thoughts and recommendations of other physicians following  my patients.

The problem is my unease with some of the drop-down options for "physical exam findings".  When you click on "Cardiac", for example, a list of objective findings appears that you can choose to include in your note.  These findings include things like "S1 S2 normal, no murmurs, no rubs, no gallops, PMI location," etc.  I'll be honest--- I don't think I could reliably tell you what a rub or a gallop is.  What I can do is listen to heartsounds and determine if there is an arrhythmia or a murmur (in vague, nonspecific terms).  Beyond that, I am sort of flailing to describe what the hell I hear.  So most of the time I just opt for the blank option and manually type in my PE findings.  It's disconcerting using terminology outside one's comfort level.  It's sort of like a neophyte awkwardly trying to describe a wine to a connoisseur---this Pinot has a bold mahogany uplift with a sweet hint of, um, rosemary lingering on the palate, like a faint evocation of a youth spent in Tuscany reading Cicero...blah blah blah...pretentious vomit...  

Video Gamers

An experiment from the University of Texas at Galveston compared robotic surgical skills of three groups: high school students who played two hours a day of video games, college students who played four hours a day, and, finally, actual surgical residents.  The results indicate that moderate video gaming is predictive of superior robotic surgical skills. 

Specifically, the UTMB study measured participants' competency on more than 20 different skill parameters and 32 different teaching steps on the robotic surgery simulator – a training tool that resembles a video game booth complete with dual-hand-operated controllers a video monitor that displays real-time surgical movements. As a whole, the nine tenth graders participating in the study performed the best, followed by nine students from Texas A&M University and lastly the 11 UTMB residents; the mean age of each group was 16, 21 and 31 respectively.

12-0

Once again the Team Up North can go to hell.