Venom at the NY Times Book Review

You must read a piece entitled “The Problem with Memoirs” in the January 30, 2011 New York Times Book Review. Neil Genzlinger, a Times staff editor, turns gunslinger and assassinates three of the four memoirs he reviews. The first book is skewered with the comment that with the exception of one anecdote involving Amy Carter, “The rest belongs on a blog.” [Obviously, he has never read my blog.]

The second book is pilloried with passages such as this one, “…the reader will need a hug after choking down this orgy of self-congratulation and self-pity.” And the author is chastised as “immature.” The gunslinger calls the third memoir an “…appalling example of coattail grabbing.”

Mean-spirited to say the least, but I feel compelled to take gunslinger to task for what I would say is a major mixing of metaphors at the end of his fourth paragraph. It reads as follows: “Three of the four did not need to be written, a ratio that probably applies to all memoirs published over the last two decades. Sorry to be so harsh, but this flood just has to be stopped. We don’t have that many trees left.”

Yikes!

My First Book

The New York Times Hardcover Nonfiction Best Seller List has the following two books at numbers 11 and 12.



They have been on the list for 11 and 38 weeks respectively.

I am writing a book and have been so far somewhat blocked at the title stage. But as I scanned the Times, the lights came on. My book will be called “______ ____ ____________.”

Please look for it soon on Amazon and Kindle.

Now that I am unblocked, I can share an excerpt with you.

Here is the start of Chapter I:

___ ______ the ___ ________? “____________ to a ___ _ ______,” ___ ____ an ________ ___ _ ____. _________ ____ ___ for ___________ _____; ______ __ ___’_ a ______ ____...

Voodoo Weather Forecast

The folks over at Accuweather.com have outdone themselves this time. How? Well, on one page of their website, they are predicting a major storm for February 2 with the headline “Groundhog Day Storm May Affect More than 100 Million People.” As you can see from the map, heavy snow is predicted for the entire Northeast, including New York City.



Just for fun I then clicked on the Accuweather.com extended forecast for New York City and guess what? The forecast is “Mostly cloudy, snow possible.”



Now if you had plans to fly to Florida from New York on February 2 at 8:00 a.m. as I do, what would you do?

As I said in my previous blog on weathermen, I’d like to be reincarnated as one. No accountability, no penalty for errors, no one seems to care if you are right or wrong. Some science, meteorology, eh?

I Want To Be Reincarnated as a Weatherman

As I sat here yesterday morning, two inches of snow were on the ground and the snow was showing no sign of letting up. The forecast was “Snow showers with no accumulation.” Once again, the forecast was wrong.

Just how accurate are weather forecasts? A New York Times article described in detail a study that was done in Missouri. It showed that television meteorologists were remarkably bad at predicting the weather and the further out the forecast went, the worse they did.

A website called “Forecast Advisor” tracks the accuracy of forecasts for any area of the country. The first screen shot shows three different forecasts for yesterday. The first was posted yesterday and the other two are revisions. None was correct as it is snowing heavily when the site was accessed. The second screen shot lists cumulative accuracy statistics for the New York City area.

At first glance, the accuracy for last year looks pretty good. But here’s an interesting thought. According to the New York Times article if you predicted it would not rain every day, you were right 86% of the time.

The website Weather Report Card gave “D” grades to all five major weather services that it follows regarding both temperature and precipitation forecasts for Monday, January 24, 2011.

Now contrast this with my current profession, general surgery. How would you feel about me if I told you I made the correct diagnosis of appendicitis 76% of the time last month? Or say I told you that you needed hernia surgery but at surgery I only found a hernia 86% of the time? I think I would very soon be out of business.

Not so the weathermen. It seems that they are immune to criticism or accountability. In fact, the Times report stated, “When station managers were asked about this [accountability], one said, ‘There’s not an evaluation of accuracy in hiring meteorologists. Presentation takes precedence over accuracy.’”

This is why I’d like to be reincarnated as a weatherman. You can be wrong as often as you like. And if you are, no one cares. In addition, you get to engage in witty banter with the news anchors and the sports guy. My really special reincarnation wish would be to come back as the guy who stands on the beach during a hurricane and tells you it’s raining hard as his hat blows away and billboards fly past. By the way, what do those guys do when there are no hurricanes? I want that job too.

Medicare Dialogue. Who’s on First?

I enrolled in Medicare and obtained a card last month. Today I received a letter from Medicare asking me to complete an Initial Enrollment Questionnaire (IEQ). A four-sided paper form was included. The letter stated that the form could be completed on-line which was preferred. I went to the website and registered. I could not find the area on the website that was said to be where the form was located. Here is the transcript of my chat with Medicare’s on-line chat support. Some of you may be old enough to remember the old Abbott and Costello routine entitled, “Who’s on First?”

Agent:
Hi, my name is Agent Doe. Do not disclose any personal data such as your Health Insurance Claim Number and/or your password to me. To start, may I have your zip code and state of residence please?
Skeptical:
00000 USA
Agent:
Thank you, Mr. Scalpel. How may I help you today?
Skeptical:
I am trying to locate the IEQ on line
Agent:
When does your Medicare go into effect, sir?
Skeptical:
Already in effect
Agent:
When did it go into effect, sir?
Skeptical:
Early December of 2010.
Agent:
Did both Part A and Part B go into effect December 1, 2010?
Skeptical:
I only enrolled in Part A.
Agent:
The IEQ form will be available to you 90 days before and 180 days after your Medicare entitlement. This only applies if you are turning age 65 and are enrolled in Medicare Part B.
Skeptical:
I received the paper IEQ in the mail today.
Agent:
Unfortunately, the form is not available for you to complete online. You will need to complete the Initial Enrollment Questionnaire manually and mail it in via Standard U.S. Mail.
Skeptical:
The letter says go to MyMedicare.gov and sign in. Then go to "My publications and tools," which I cannot find. Why would they tell me to do that if it's not available on line?
Agent:
I apologize about the inconvenience, sir. If you need a paper copy of the form, I have to refer you to the Medicare Coordination of Benefits Contractor. Please call them at 1-800-999-1118. Their hours of operation are Monday - Friday from 8 a.m. to 8 p.m. ET, except holidays.
Skeptical:
I have the paper copy.
Agent:
The letter that is sent is a standardized letter that is sent to all beneficiaries that are becoming eligible for Medicare. However, it only applies to beneficiaries who are turning age 65 and are enrolled in Medicare Part B.
Skeptical:
If I'm not enrolled in Part B, then why bother to even send in the paper form?
Agent:
The letter that was sent to you is sent to all newly eligible beneficiaries regardless if you have Part A only, Part B only or both A and B. I apologize about the inconvenience, Mr. Scalpel.
Skeptical:
OK, thanks.

Mall Fall Fallout

Yesterday a video of a woman who fell into a mall fountain while texting went viral. It was taken by security personnel whose comments can be heard since they were recording from a TV screen with a phone camera.

The woman, clearly unhurt, gets right up, grabs her phone from the water and walks away. The clip is funny and it sends a message that texting while walking can be dangerous. So let’s move on to today’s viral video.

Not so fast. Cue “The Lawyer.”

In a story in today’s Reading Eagle newspaper, the woman, who works at a store in the mall, outed herself and has hired the inevitable attorney. They are claiming that instead of laughing at her, mall security should have checked to see if she was all right. The lawyer, James M. Polyak, “…plans to conduct an investigation into what happened.” The article goes on to quote Polyak, who in his best legalese said "We are troubled by the fact that anyone at the Berkshire Mall responsible for releasing this video would find humor in an employee injured on the premises. We intend to hold the appropriate persons responsible.”

I would like to help. Here is a list of potential targets for the impending lawsuits:

1. The security personnel who did not come to her aid with towels.
2. The owners of the mall who did not screen the security guards properly and who did not post signs stating that texting while walking could be dangerous.
3. The architect who negligently placed fountain where people might walk.
4. The construction company who did not place a proper barricade around the fountain.
5. The city of Reading and Berks County for not exercising due diligence when reviewing the plans for the mall.
6. The company that supplied the construction materials.
7. The State of Pennsylvania for not foreseeing this event and enacting laws governing fountains in malls.
8. The water company for supplying water to a hazardous fountain.
9. The cellular telephone company for not advising the victim that texting while walking could be dangerous.
10. Matti Makkonen, a Finnish guy, who might have invented texting and Friedhelm Hillebrand, a German guy, who also might have invented texting.
11. The estate of Alexander Graham Bell, inventor of the telephone.
12. The victim’s friend from church who was negligently engaging the victim in a text conversation while the victim was walking.
13. The federal government because it has “deep pockets.”
14. The United Nations.

Update:
This just in. According to another story in the Reading Eagle, the Mall Fall Lady has an interesting record including unauthorized use of a co-workers credit card, theft and hit-and-run driving. You cannot make this stuff up.

Private Rooms and Infection Control

Researchers at McGill University in Montreal published a study in Archives of Internal Medicine showing a 50% reduction in ICU infections in patients placed in private rooms compared to those in multiple-bedded rooms. Many media outlets [Science Daily, Eurekalert, Reuters] distributed the story. CBC ran it but somewhat conflated the ICU bed part with general hospital beds. Also, some prominent tweeters linked to #ptsafety failed to highlight that the study involved only ICU patients. [See photo.]
I am concerned that this might encourage consumers to ask for private rooms whenever they are hospitalized. In an ideal world, I certainly agree that every patient should have his own room, not only to reduce infection risk, but for privacy and comfort.
There are two major obstacles preventing us all from having private rooms. One, insurance generally will not pay for it. Two, most hospitals have a very limited number of private rooms. I spoke with Sara Beasley, of the American Hospital Association’s Resource Center. She told me that the AHA has no data on the number of private vs. semi-private rooms in US hospitals because that information is not currently being collected by any organization or agency she is aware of. She did point out that guidelines for new hospital construction do call for all private rooms. Most ICUs in the US have all private beds. But based on my own experience, I estimate that less than 10-15% of US hospital medical-surgical beds are private.

Until all beds are private, we will have to continue our efforts to practice good infection control and limit the over-utilization of antibiotics which is rampant in the country.

Twitter: The Good & the Bad

I’ve been on Twitter for about 6 months and have a modest following. I follow a few interesting people and organizations and generally am enjoying the experience. However, there are a some things I don’t understand.

Twitter offers suggestions regarding whom to follow based, I assume, on the current list of people I follow. Today it suggested I follow @[name deleted], who notably has 297 followers despite the fact that he has not posted a single tweet. [See photo.] I am not sure what to make of this since I have posted hundreds of tweets and have only 135 followers. Does this mean that if I stop tweeting, I can increase my list of followers by more than double? And what does it say about the 297? Do they know something that no one else does, like any day now @[name deleted] is going to tweet something quite profound? A partial explanation is that at least two of his followers are friends of his and when queried, they responded that they thought he would tweet.

I suppose it also is an indirect indictment of the people I follow. In other words, the people I follow are so interesting that Twitter feels a person who has never tweeted will fit right in.

Other people suggested by Twitter don’t appeal to me because almost all of their tweets are responses to other tweets which I have neither access to or interest in. It seems to me Twitter would be more effective if people would do more direct messaging or somehow be able to direct tweets to individuals. This would significantly reduce what I call “twutter” or Twitter-clutter.

I like the idea of communicating in 140 characters or fewer. It fosters a discipline that is lacking in the blogosphere where [unreadable] blogs of thousands of words abound.

Does Fluid Resuscitation Harm Trauma Patients?

A study published on line ahead of print in Annals of Surgery has attracted attention as it purportedly shows that trauma victims who received intravenous [IV] fluids in the pre-hospital setting fared worse than those who did not. Media outlets such as USA Today, the LA Times and Bloomberg Business Week all reported the findings uncritically. In fact, one version of the HealthDay story quoted the conclusion of the paper’s abstract which definitively states that IV fluids should not be used. That is why reading only abstracts can be misleading.

While I tend to agree with the premise that IV fluid administration might raise the blood pressure and actually promote further bleeding, the paper’s conclusion that the routine use of IV fluid resuscitation for all trauma patients should be discouraged is not supported by its data.

Here are some of the problems with the paper:

1. The paper is based on data from the National Trauma Data Bank, a voluntary database contributed to by over 600 trauma centers. The data may not be entirely reliable. For example, the paper reviewed data from the years 2001-2005. Of 1,466,887 possible patients, only 776,734 (53%) had pre-hospital data to review.
2. The only mention of an IV in the raw data is whether or not an intravenous catheter was inserted. The database contained no information on the amount of IV fluid given at the scene of the trauma, during transport to the hospital or even in the emergency department. This renders the title of the paper “Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis” somewhat suspect.
3. During the years studied, scene and transport times were not collected. It is possible that the problem leading to the poorer outcomes in the patients who had IV lines placed is increased time wasted at the scene and not necessarily the IV fluid itself.
4. According to the database, more than half of the patients who had an IV started also had Military Anti-Shock Trousers [MAST] placed. This is hard to believe since the use of MAST was discredited years ago. And of the patients who did not have an IV inserted, only 0.19% had MAST applied. Perhaps the MAST is doing the damage and not the IV.

I asked the lead author of the study, Dr. Elliott R. Haut, to comment on my criticisms and he said, “I agree that our study is not perfect for some of the reasons you cite and others as well. Retrospective data studies like this are fraught with potential problems and cannot truly define causality. However, I do continue to feel strongly that our study, along with all of the other data on the subject, suggest [sic]that IV fluids are not all benefit without harm. More research needs to occur to figure out the best practices.” This is a much softer statement that that of the abstract of the paper which concluded “The harm associated with prehospital IV fluid administration is significant for victims of trauma. The routine use of prehospital IV fluid administration for all trauma patients should be discouraged."

Patients Are Not Airplanes

As promised in my post “Surgeons Are Not Pilots,” today I will address the issue of whether patients can be compared to airplanes. Honestly, I cannot think of even one thing that patients have in common with airplanes.

As alluded to yesterday, probably the most glaring difference is that, unlike an airplane, each patient is unique. If a pilot sits at the controls of any Airbus A320 aircraft, he can be reasonably sure that pulling back the stick a certain amount will result in a very consistent response from the plane. Therefore, practicing on a simulator will enable the pilot to prepare for any emergency with the knowledge that what he did on the simulator will in fact be reproducible in a real emergency.

Contrast that with a patient. Often patients with similar illnesses will behave very differently because human beings are not engineered like airplanes. For example, let’s say I am performing a difficult laparoscopic cholecystectomy (removal of the gallbladder) and I am having trouble locating the cystic artery (artery to the gallbladder). I know that the anatomy of the cystic artery is highly variable. This link illustrates 11 of the most common anatomic variations in the location of that vessel. This means that there is not a simple maneuver that will help me find the artery in every case.

A pilot can be confident that a 5% increase in power will result in a very predictable response in airspeed. Contrast that with a patient’s response to a medication. I have had patients fall asleep with an intravenous injection of only 2 mg of morphine and I’ve had other patients who loudly complain of persistent pain after receiving 10 mg of the same drug.

A word about simulators. Because all stimuli are external to a fixed object, the pilot, aircraft simulators are easy to design and are very realistic. They recreate the motion, sounds and visuals of flying very well. When I was in the Navy stationed on an aircraft carrier, I heard pilots talk about their experiences in simulators. They said the intensity of the experience was very similar to that of flying a real plane. While surgical simulators have become more sophisticated, they still lack the realism of aircraft simulators because the action is all occurring on a video screen and the surgeon is sitting in a lab somewhere. There is no way that a surgical simulator can give you the adrenaline rush and anal sphincter-puckering feeling of seeing a sudden squirt of blood that covers your laparoscope and totally obscures your vision during a tough case. And there are no realistic surgical simulators for open (non-laparoscopic) cases. Operating on a pig just doesn’t cut it. (Pun intended.)

So please, stop trying to compare patients to airplanes.

A postscript on yesterday’s “Surgeons Are Not Pilots” blog.

Captain Chesley Sullenberger, the appropriately acclaimed hero of the successful Hudson River landing of US Airways Flight 1549, is hardly a typical pilot. According to one biography, he had over 27,000 hours of flying experience with more than 19,000 of those hours in Airbus A320s or like aircraft. He also had written about air safety and worked as an NTSB investigator. The hours alone qualified him as an “expert” pilot.

Compare Sully’s background with that of the pilots of Colgan Air Flight 3407, which crashed in Buffalo two years ago, killing 50 people. The following is from the Wikipedia entry about this incident, “The crew of four was led by Captain Marvin Renslow … who was hired by Colgan in 2005 and had flown 3,379 hours. 261 of these hours were on the Dash-8 Q400 (including 109 as a captain). First Officer Rebecca Lynne Shaw … was hired by Colgan in January 2008, and had flown 2,200 hours, 772 of them on the Q400.” The cause of the fatal accident was several pilot errors and failures to follow protocols.

All the checklists in the world didn’t prevent that crash. As long as humans are going to perform surgery on other humans, bad outcomes will occur. Yes, we should endeavor to minimize errors as much as possible, but “zero defects” and Six Sigma are not possible in medicine (or even in manufacturing).

Surgeons Are Not Pilots

I am sick of hearing that surgeons can be compared to pilots. Yes, there are some similarities and some things can be learned from the aviation industry. For example, I am a big fan of checklists, having used them in both the operating room and intensive care settings. Both a GS and an FP will have occasion to multitask and both need to have what is termed “situational awareness” or an understanding of where he is and what is going on around him. But let’s look at some of the differences between specifically, general surgeons (GS) and fighter pilots (FP).

The training of surgeons and pilots is remarkably different. This table illustrates some of the differences.

Total hours of training for a GS after medical school can be broken down as follows. Five years of residency training at 80 hours/week equals 20,800 hours. Allowing for 6 hours of sleep/night (Ha!) over five years would reduce the actual training time to 15,600 hours of which some 2000 hours would be spent in the operating room (about 1000 cases performed by the average graduating chief resident at about 2 hours/case).

Total hours of training for an FP entering the US Air Force are as follows. (Note: data are from a paper by a USAF colonel who is also a surgeon.) Once accepted to flight school, the neophyte first takes 50 hours of civilian flight training and becomes certified as a private pilot. Then he goes to Phase I or preflight training which apparently involves ground training, survival, navigation etc and no actual flying. Phase II is six months of flight training with 90 hours of flight time in a jet trainer. Phase III is another 6 months of training with 120 hours of flying in the aircraft to which they have been assigned. The entire package takes about two years at let’s say 10 hours per day or 5200 hours (50 hours/week x 52 weeks x 2years) of which some 260 hours is actually spent in the air.

To illustrate this point more clearly, someone once said, “I know a lot of doctors who became recreational pilots, but I don’t know one pilot who became a recreational doctor.”

If what Malcolm Gladwell says is true that one needs to spend 10,000 hours at a task before one can be considered an “expert”, I leave it to you to decide whether surgeons and pilots are experts.

Some thoughts on this from surgeons in the UK:

“If a pilot were to undertake all the roles required by a consultant surgeon, he/she would interview separately every potential passenger for every flight that he/she was responsible for. He would then have to determine for each passenger the optimum way of reaching their destination; it may well be that rail, road or sea travel would be better for that particular individual than air travel. [T]he captain would need to obtain informed consent from every passenger to ensure that they understood what flying involved, including the risk of infection in aircraft, the risks related to the type of ventilation being used for that particular flight, the risks of deep vein thrombosis and pulmonary embolism, the risks of a major air disaster, the risks of air turbulence, etc.” It goes on.

“When was the last time you talked to your pilot? Please let the analogy end.”

Coming soon: “Patients Are Not Airplanes”