Less is more. Conventional wisdom challenged in two NEJM articles

Classical views on fluid resuscitation and nutrition in critically ill patients were questioned in two papers published today in the New England Journal of Medicine.

A large study involving febrile, under-perfused children in Africa reveals that those aggressively resuscitated with fluid boluses of either saline or albumin had higher mortality rates than a control group who were not given boluses of fluid. The study was stopped earlier than planned when the research group’s data and safety monitoring committee performed an interim analysis. This paper adds to a growing body of research that shows that large-volume fluid resuscitation may be harmful in many situations.

A second article demonstrated that in some 4600 critically ill patients given enteral nutrition, late (day 8 of ICU admission) initiation of parenteral nutrition to supplement the enteral nutrition and achieve caloric goals leads to fewer complications and faster discharge from the ICU than patients whose parenteral nutrition was started within 48 hours of their ICU stay.

The papers are accompanied by editorials (here and here) that provide perspective and as usual caution against overly interpreting the results.

Although the messages seem quite clear (especially regarding large-volume fluid resuscitation), clinicians should read both papers and decide for themselves.

Harvard Says: Train Residents and Medical Students Like Navy SEALS

Harvard Medical School recently held a symposium on learning. The topic of the meeting was “Resiliency and Learning: Implications for Teaching Medical Students and Residents.”

Chronic stress, as experienced by physicians, affects the endocrine and other systems causing immune suppression and metabolic disorders leading to depression, cognitive dysfunction and a lot of other bad things. Similar stress follows in the wake of natural disasters, war and severe abuse (again, pertinent to the practice of medicine).

The researchers found that these problems can be avoided or reversed by training as that undergone by so-called “stress-hardy groups” like the Navy SEALS. The qualities that help make Navy SEALS resilient are “a social support network, [o]ptimism (including faith in a higher cause or power), perseverance (work ethic), responsibility and integrity…”

Medical students and physicians can be taught to be resilient resulting in decreased rates of depression and burnout.

Makes sense to me. Let’s train doctors in the manner of Navy SEALS.

But wait. Not mentioned in the Harvard Medical School Focus article is an important feature of the Navy SEAL culture—Navy SEALS do not work 16 hours per day or 80 hours per week. A major part of their training is centered on performing at a high level even when sleep-deprived.

Navy SEAL Hell Week is described as follows: “In this grueling five-and-a-half day stretch, each candidate sleeps only four total hours but runs more than 200 miles and does physical training for more than 20 hours per day. Hell Week finds those candidates who have the commitment and dedication required of a SEAL. Hell Week is the ultimate test of a man's will and the class's teamwork.” It sounds a lot like a surgical residency training program circa 1972.

Although often skeptical when it comes to research from Harvard, I am all for this. We need to institute Navy SEAL style training for all residents and medical students. Let’s start by making them more resilient. No  going home the day after call. No limits on work hours. Let’s do some cases! “OOHRAH!”

[Thanks to Bill Cadigan of the blog “Doctor Parking Only” for tweeting a link to the story.]

Resident Work Hours: Let's Get Real

Today Reuters featured yet another paper that concluded that residents work hours are too long and although first-year trainees are now limited to 16 hour shifts, that may not be “… enough to prevent an alarming number of medical errors.”

The paper, which is a 39-page summary of a conference held in June of 2010, appears in the June 2011 issue of the journal Nature and Science of Sleep. The conference was held at Harvard Medical School so its conclusions must be correct. Or are they?

Let’s look at some facts.

1. The Reuters article states, “The group cited U.S. government statistics that show as many as 180,000 patients each year die due to harm resulting from their medical care.” However, the article does not cite any proof that sleep-deprived residents are causing any of these errors. There is a growing body of research [here's some] that actually shows that resident work hour reform has not had any effect on the rate of medical errors.

2. According to the European Sleep Research Society, the journal Nature and Science of Sleep has an impact factor of 0.0. That means it has no influence and is not widely read.

3. Nature and Science of Sleep is an “open-access” journal. Although its author instructions page says that it is peer-reviewed, authors must pay a fee to have their papers published. This is similar to vanity publishing.

4. Nature and Science of Sleep is not listed by any of the major medical search engines.

5. The authors of the paper estimate that curtailing resident work hours further and delegating some resident work to others would cost $1.7 billion. Who is going to pay for it?

6. Here is a little known fact that many people conveniently overlook when discussing resident working conditions. A resident who is on call for 28 consecutive hours may not necessarily be awake for all of that time. Some nights are not busy. There can be time for napping. This type of work is not analogous to long-distance bus driving or piloting an airliner both of which require long hours of uninterrupted, monotonous work.

7. I confess that I downloaded the 39-page article but couldn’t finish it due to its sleep-inducing properties. [And I wasn't even on call last night.] You are welcome to read it as I provided the link above.

Ultrasound-Guided Central Venous Catheter Insertion

Despite the large amount of published evidence (here, here, and here) that ultrasound guidance reduces the failure rate of central venous catheterization, especially for cannulation of the internal jugular vein, some physicians still claim that there is no difference between the success rate of ultrasound guidance and the landmark method. This was the subject of a brief discussion regarding the safety of central venous catheter insertion in coagulopathic patients on Twitter. 

I have a couple of anecdotes to share. I was called to insert a line in an obese patient with idiopathic thrombocytopenic purpura (also called immune/autoimmune thrombocytopenic purpura or ITP). The patient’s platelet count was 2,000. Despite the short, bulky neck, a physician assistant (PA) who had done only 20 previous internal jugular sticks, accessed the vein on the first attempt using ultrasound guidance and there were no complications.

We were called to insert a central line in a morbidly obese man (see photos) who was hypotensive. A PA who had done fewer than 10 previous central line insertions successfully cannulated his right internal jugular vein on the first try using ultrasound.

I would not have attempted to cannulate the first patient without ultrasound guidance. The second patient would have probably had a subclavian approach which would have been difficult.

I was skeptical regarding ultrasound for vascular access for years. Now I would not insert a central venous catheter without using it.

Hints for New Residents

I was a general surgery residency program director for 24 years. I’ve seen them come and go. Here is some advice for those of you who are beginning residency training.

Never be afraid to say "I don't know."

Never be afraid to ask for help. Some of the worst disasters I have ever seen were because a resident didn't want to bother a more senior resident or an attending and blundered badly.

Respect your colleagues and your patients.

Until you gain a great deal of confidence, do not manage things over the telephone.

A patient who is restless or anxious may be hypoxic. Make liberal use of the pulse oximeter. Do not sedate a restless patient without personally seeing him.

Sometimes postoperative abdominal pain is due to urinary bladder distension. Learn how to use the bladder scanner yourself. 50 mL of urine output could be overflow incontinence.

Trust, but verify. [Or better yet, at first trust no one.] For example if someone tells you a lab result, say thanks and look at all the lab results in the computer yourself. Many times the nurse will say, “The labs are normal” and later you will find that the serum CO2 was 15.

Listen to the nurses (if they seem to know their stuff). They can really help you if you let them.

Be good to the nurses. If you are a jerk, they can make your life miserable.

If a nurse you trust calls and says a patient “doesn’t look good,” get to the floor as fast as you can.

You will get busy. Learn to prioritize. Learn what can wait and what needs to be done immediately.

Look at all your patients’ imaging studies yourself. Don’t just rely on reports. One, you will learn how to read them. Two, radiologists are not infallible. One of my PAs recently picked up abdominal free air that was missed by a radiologist. When in doubt, review the studies with a radiologist in person. I do it all the time.

Read, read, read. This isn't like school. You can't cram for your boards. You can’t learn 4 or 5 years’ worth of material in a one-week review course. You have to learn it as you go along.

Don’t embarrass your peers on attending rounds or at a conference. If you are asked a question and you know the answer fine. But if your chief resident is presenting a case to the chairman and says the patient’s hemoglobin was 7.2 gm/dL, don’t raise your hand and say, "Oh, no. it was 7.6.”

In the “Information Age,” there is no excuse for not obtaining old records on a patient. I have had op notes and path reports faxed from Ecuador. Surely you can get them from the hospital across town.

Can you think of more tips? I am open to all suggestions.

To Tweet or Not To Tweet?

Last week a very active tweeter/blogger, who just graduated medical school and is about to begin a residency, suddenly disappeared from the internet. A few of us who followed him discussed the situation on line but no one knew what had happened.

After hearing that we were concerned, he emailed me that the administration of the hospital in which he was about to start his training had announced at his orientation that tweeting and blogging were prohibited, citing fears of information leaks, HIPAA concerns and nebulous “liability” issues.

I am somewhat ambivalent about this. While I certainly support freedom of speech, I also recognize the hospital administration’s position. I believe discussing patients [even disguised] on line is potentially dangerous. In a previous blog, I mentioned that even an anonymous blogger can be unmasked if he is not careful or if someone is determined to discover the blogger’s identity. There is the famous case of a Boston blogger known as “Flea,” who was “outed” on the witness stand during a malpractice trial. [Digression: Interesting interview with “Flea” after the trial.]

Another problem is the tone of some medical tweeters/bloggers. As some have commented, the output of many medical tweeters/bloggers does not pass the “elevator test” [would you say what you just tweeted in a hospital elevator?]. In fact, a lot of it doesn’t even meet the standards of normal polite conversation. On occasion, many physicians have indulged in “gallows humor,” but when it is in writing and permanent, it may come back to haunt you.

In my previous blog, I mentioned that a clever plaintiff’s attorney could ask you if you blog or tweet. Even if you use an alias on line, you are under oath to tell the truth. Would you be willing to lie and say you don’t blog or tweet? What if you then were discovered? Your credibility would be destroyed and your lawyer would be asking for a recess to discuss settling the case.

What do you think? Should residents be banned from tweeting and blogging? What about medical students?

Legislators Gone Wild: A Bill Requiring All Operations To Be Recorded

Last month the New York State legislature threatened to pass a law banning doctors from wearing neckties. This was based on some research that showed that bacteria can be found on ties. No link to any disease caused by a tie has been reported. It appears that the proposal did not become law.

Now comes news that lawmakers in Massachusetts are considering a bill that would give patients the right to have their operations videotaped if they pay for it. The story claims that this could be done without a videographer being present in the operating room. And, get this, if a hospital refused to allow the videotaping, it could be fined $10,000.

Who thinks up this stuff? Can you think of any problems with this plan? I can.

It would not be difficult to record laparoscopic and arthroscopic procedures since they are already being performed using video equipment. There would be added expense because many hospitals have not purchased the necessary DVD recorders. However, open surgical procedures are not routinely videotaped and video equipment is not readily available to do so. Even when experienced videographers are present, it can be difficult to see what the surgeon is seeing.

Who would pay for the installation of video equipment in every operating room of every hospital in Massachusetts?

A comment on the article points out that the taping of all surgical procedures would be complicated, distracting and might cause surgeons to perform differently [possibly detrimentally] when they know they are being watched.

Sometimes things happen during a case that might seem untoward to a lay person. For example, due to magnification by the laparoscope, a few milliliters of blood can look like a hemorrhage. Occasionally, gallstones or bile may be spilled. Although this rarely results in complications, it could be construed as a “mistake” by a devious [is there any other type?] lawyer.

This would of course be a boon for plaintiffs’ attorneys. Wait, aren’t most legislators also attorneys? I wonder if there is a connection?

In summary, this plan is misguided, ill-conceived and stupid. Since it is being discussed in Massachusetts, it just might pass.

Headline: “Report: Evidence Mounts that Electronic Interference May Affect Airplane Safety”

Yahoo News via Time Magazine via ABC News is reporting the “evidence” that electronic devices may cause problems with airline navigation and control systems. However, the headline is not even remotely supported by the “evidence.” Here are some excerpts from the article [in italics] with pertinent sections underlined.

In 75 instances between 2003 and 2009, electronic interference was cited as a possible cause of airplane dysfunction, according to a report by the International Air Transport Association (IATA).

But the IATA report, obtained by ABC News, provides some evidence that heeding that last rule [turn off all electronic devices], about electronic devices, would be to everyone's benefit.

According to the confidential study, in a survey spanning six years with respondents from 125 airlines, there were 75 documented incidents in which airline pilots and crew believed that possible electronic interference affected flight controls and navigation systems. A survey* was done. How many people were questioned? There are some 850,000 flights per month in the US alone.The IATA report covers 6 years. That’s 61,200,000 flights. And all they can come up with is 75 instances of possible electronic interference?

The report, according to ABC News, stresses that no direct correlation is being made between electronic interference from personal electronic devices and plane malfunctions.

Finally in the last paragraph: Some experts argue that these anecdotes are not enough to draw conclusions about how electronic devices affect planes.

The amount of misleading information and equivocation in this article makes me wonder if it was written by a radiologist.

The “evidence” is pretty weak. What do you think?

*See my recent blog on surveys.

Operative Mortality Rates and Sleep Deprivation

To add some spice to the never-ending debate on the effects of sleep deprivation on surgeons are two recent papers published in respected journals.

“Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures” was published ahead of print in Archives of Surgery in May. This was a prospective study of the sleep patterns of six consultant [senior attending] cardiac surgeons in Canada over a six-year period. Of the over 4000 cardiac operations performed, there was no difference in the rates of mortality or complications whether the surgeon had less than 3 hours of sleep, 3 to 6 hours of sleep or more than 6 hours of sleep.

“Association of operative time of day with outcomes after thoracic organ transplant” appeared in the Journal of the American MedicalAssociation on June 1. This was a retrospective study of over 27,000 heart or lung transplant operations divided into two groups based on whether their procedures were performed from 7 am to 7 pm (days) or 7 pm to 7 am (nights). Almost exactly 50% of the operations were performed during each time period. Mortality rates at 30 days and one year were not statistically significantly different whether the procedure was done during days or nights.

Even the most ardent crusader against “tired surgeons” would have to admit that these are well-executed studies of rather complex operative procedures. In addition, there are not enough transplant or cardiac surgeons around to allow for shift work. As shown by the data in the transplant paper, half of all such procedures occur at night. Someone has to perform these operations when the organ and the recipient are available, not the next day.

The transplant paper was the subject of a New York Times blog and it drew the usual number of ridiculous comments. I don’t know why I read them because they are so infuriating. Here are some of the more inane ones:

“This is part of the "doctors are superhuman" myth that is simply unsupported in the real world.” Never mind the data.

“Are the ‘qualified surgeons’ in the business of eliminating possible competition, for example?” In response to the fact that there are not that many transplant surgeons.

“A heart transplant in the US costs roughly $145,000. Figure the chief surgeon makes $100K and 9 "helpers" make $5K each for a 5-hour operation. That works out to be $10,000/hr for the doc and $1,000/hr. for each assistant.” And the hospital does not receive any payment?

“Surgery requires superb eye-hand coordination which deteriorates with fatigue. Airline pilots have co-pilots and extensive mechanical controls on the plane and on the ground. Transplant surgeons do not.” Never mind the data.

Feel free to add your own comments [preferably not infuriating, and ...watch your math].

Patient Satisfaction Surveys Are Bogus

Patient satisfaction surveys are flawed in many ways. Here are just a few.

Sampling is a huge problem. A description of why sampling is an issue can be found here. It’s a bit complex. To summarize, the validity of a survey is strongly related to the size of the sample and the rate of response of the survey. If you have a patient base of 1000 and elect to survey 500 of them and receive responses from 100, the sample is really only 10% [100/1000] of the population in question. This would result in an accuracy of 95% ± 20%. See chart. 

Most patient satisfaction surveys include far fewer than 50% of the population in question and have even lower response rates than 20%.

Thankfully, I no longer directly participate in the quarterly hysteria that occurs when Press Ganey scores are received by hospitals. Press Ganey is a company that is hired by hospitals to perform patient satisfaction surveying. They send out small numbers of questionnaires and have a very low rate of response. In addition, they use only a five point scale as a basis for their ratings and report the results as percentiles. [Note: I am not a statistician, but I don’t think it is kosher to report a five point scale in percentiles ranging from 1 to 100.] Usually there are modest up and down variations in these scores which are almost never statistically significant, especially when you consider the margin of error of well over ± 20%. Upon receipt of lower scores, task forces are established, multiple meetings are held, policies are changed and staffs are browbeaten. Many times the scores improve on the next cycle and the task force is congratulated. Lost in the euphoria is the fact that there is a three-month lag between the institution of any policy changes and the receipt of the next group of survey responses. In other words, the policy changes probably were not the cause of the uptick in the scores.

Note that the Medicare Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS] survey suffers from many of the ills of Press Ganey, such as small sample size, poor response rates and way too many questions.

Other issues with patient satisfaction scores include the following:

There is no correlation between patient satisfaction scores and complaints.

Surveys are more reliable if they are completed as close to the time of the encounter as possible. Most are not done that way.

They do not necessarily correlate with quality of care as is shown in papers involving medical patients and patients with heart attacks. Other thoughtful essays on this topic can be found here and here.

No doubt the facts will not deter the bean counters from mandating that all physicians survey patients for satisfaction no matter how meaningless the data may be. American Medical News recently reported that the AMA and Press Ganey will be happy to help you with this for a mere $65.00 per month for AMA members and $85.00 per month for non-members.

I suggest you start your own patient satisfaction surveying company. As for me, I am happy that I work for a hospital.

Does Atelectasis Cause Early Postoperative Fever?

Open any surgical textbook or ask most surgeons and you will find that fever within the first 3 or 4 days after any major operation will most commonly be ascribed to atelectasis [the partial collapse of one or both lungs, usually due to pain-induced hypoventilation].

Some authors have questioned this dogma and now a systematic literature review published ahead of print in the journal, Chest, confirms that atelectasis and fever are not associated.

The authors reviewed well over 300 papers and found 8 which addressed the issue. Nearly 1000 patients were included. Of the 8 papers, 7 reported no link between the presence of fever and atelectasis. Due to heterogeneity of the studies, a formal meta-analysis could not be done.

The authors stated, “In conclusion, there is no clinical evidence suggesting that atelectasis is a major cause of EPF [early postoperative fever]. The rather limited evidence implies that atelectasis may be not associated with fever at all.”

Fever in the early postoperative period is likely due to an inflammatory response generated by the stress and trauma of surgery and anesthesia. It is a benign, self-limiting phenomenon and does not require intervention.

Like many long-held ideas, the belief that “atelectasis causes fever” will be difficult to change. I asked the authors what measures could be taken to enhance the awareness of surgeons about this important subject. The senior author, George C. Velmahos, MD, PhD, MSEd and John F. Burke Professor of Surgery at Harvard Medical School, feels that change might be prompted by “…by giving lectures and maybe designing a prospective multi-center study.”

Meanwhile, we will spread the word one blog reader at a time.

Retractor Left in Patient’s Abdomen after Hemorrhoid Surgery [Not Likely]

NBC News in San Diego reports that five hospitals have been fined a total of $300,000 by the California Department of Public Safety for “dangerous errors.” One of the errors is described as follows:

Scripps Memorial Hospital in Encinitas, April 16, 2010: A malleable retractor was left inside a 66-year-old woman's stomach during a hemorrhoidectomy (removal of hemorrhoids).The flexible metal instrument was described as being approximately 12 inches long and 1 inch wide. Surgeons performed a second operation to remove the instrument.

I have some real news for you. Unless this was the mother of all hemorrhoids, it is very unlikely that a 12 inch long retractor was left in the stomach [obviously, they meant to say abdomen] of a patient. Hemorrhoids are located in the anorectal area. One does not need a 12 inch long retractor nor does one need to open the abdomen to perform a hemorrhoidectomy. So if this retractor was left in the abdomen during hemorrhoid surgery, it is a bigger problem than simply leaving a retractor in a patient. The surgeon had to have been completely lost or temporarily insane to have done what this report claims.

I think there is something else going on here. It could not have been a hemorrhoidectomy that resulted in this complication.

Oh well, let’s not let the facts get in the way of a sensational story.