Instrument toss: I claim the Guinness record for distance

A recent exchange on Twitter reminded me of an incident that occurred when I was a resident.

There are many stories about surgeons throwing instruments. I was never a habitual instrument thrower but I had my moments.

I was doing a cutdown (a minor surgical procedure to gain intravenous access) on a newborn in the neonatal ICU. This was in the early 1970s, and the section of the hospital that contained the unit was not air-conditioned.

It was the middle of August. I was having some trouble finding a suitable vein. The instruments on the cutdown tray were all discards from the operating room. They were stiff and didn't work well.

At a critical point in the process, I put a clamp on a tie around a flimsy vein. Because the jaws of the instrument were not aligned, it slipped and the tie was lost.

My patience, still to this day not one of my strong points, was also lost.

I threw the clamp toward the open door of the unit. It skidded along the floor out the door across the hall and through the open doors of an elevator. The doors closed and the clamp was never seen again.

I somehow managed to finish the procedure.

Other than occasionally into a garbage can, I haven't thrown an instrument since.

Non-US citizen at a Caribbean med school wonders what his chances are for getting a surgical residency

On "Ask Skeptical Scalpel," a non-US citizen at an offshore medical school asks what I think his chances of obtaining a residency position in general surgery are.

Here's a link to that post.

Law school applications are way down; could it happen to med schools?

The number of people applying to law schools is in steep decline. So says a recent post on a website called “The National Jurist.”

The post cited some remarkable statistics from the American Bar Association. In 2012, law school applicant numbers were down 14% from 2011 and 23% from 2010.

For the fall of 2012, there were 44,481 first-year law students enrolled, a drop of about 4,000 from 2010.

Many schools have decreased enrollments with more than 90 cutting class sizes by more than 10%.

On January 2, 2013, the Wall Street Journal said, “The Bureau of Labor Statistics estimates that the economy will provide 21,880 new jobs for lawyers annually between 2010 and 2020; law schools since 2010, however, have produced more than 44,000 graduates each year.”

For the non-math majors, that’s a ratio of more than two graduates for every job.

There are way too many lawyers around anyway.

Could something like this happen in medicine? It might not be exactly the same, but an interesting dilemma is looming. A 2011 paper in the New England Journal of Medicine expressed concern that in a couple of years, the number of US medical school graduates will exceed the number of first-year residency training positions available.

In response to projected physician shortages, many medical schools have expanded their class sizes, and several new medical schools have opened or are soon to open.

But the problem is that many years ago, the federal government established a cap on the number of residency training positions in this country. And there are persistent rumors that spending on graduate medical education (GME) will be among the many future budget cuts. It is also not a “given” that existing residency programs could be expanded or more programs could be established even if funding became available.

Here is what Dr. Thomas Nasca, CEO of the Accreditation Council for Graduate Medical Education, had to say in that NEJM article. “We estimate that … domestic production of medical school graduates [will] functionally surpass our current total number of GME postgraduate year-one pipeline positions (posts that lead to initial specialty certification) by 2015 or sooner.” This excludes 10,000 non–US citizen international medical graduates (IMGs) and 3700 US citizen IMGs who seek GME posts in U.S. teaching hospitals.

In other words, not only will there not be enough residency training positions for graduates of US medical schools, there will be no positions at all for IMGs and US graduates of offshore schools.

Then there’s this. The other day, I heard an advertisement on the radio extolling the virtues of one of the new US medical schools and soliciting applicants for its “charter class of 2013.”

I have been a doctor for over 40 years. I’ve never heard of a US medical school advertising for applicants.

The rumor is that the school that is advertising may not be happy with many of its applicants so far.

Could this be a harbinger of things to come? What do you think?

OR staff hair and patient infections

A reader asks Skeptical Scalpel about covering OR staff chest & arm hair to prevent patient infections. To view this post click here.

Breaking news! Operations take longer when residents are involved

Yes, you heard it here first. A new study shows that for six common laparoscopic procedures, resident participation resulted in the surgery lasting from 20% to 47% longer.

The six laparoscopic operations were appendectomy, cholecystectomy, gastric bypass, fundoplication, colectomy, and inguinal hernia.

The paper, published in the Journal of the American College of Surgeons, culled the frequently mined NSQIP database for information on 89,720 operations. The database receives input from a large number of US hospitals, both teaching and non-teaching.

The key results were as follows:

All of the time differences are statistically and clinically significant.

Hospital length of stays for all groups did not show important differences. Cases involving residents were associated with significantly more morbidity for all procedures except inguinal herniorrhaphy and fundoplication. The authors feel that the increased morbidity seen was not clinically significant. It isn’t clear upon what they based that feeling. There was no difference in mortality rates for the two groups for any operation.

In no less than four places in the text, the statements similar to the following were made. “The presence of a resident during a surgical procedure is a surrogate marker for a learning environment in which there are likely to be other health care learners at each of the stations in the operating room.” The other health care learners might be anesthesia residents, medical students, nursing students or others.

This is a completely unfounded assumption. For example, in three hospitals I worked in over the years, we had a surgical residency training program with no anesthesia residents and no student nurses. Conversely, it is certainly possible to have no residents but have training programs for student nurses or scrub techs.

The authors rightly point out that the increased operative duration associated with resident training translates into some inefficiencies. A single operating room might not be able to process as many cases as it could when cases are done by attending surgeons. Also, longer cases might cost someone (third-party payer? patient?) more money since OR costs are tallied by the minute.

The paper concludes, “Additional work must be undertaken to identify strategies to optimize operating room efficiency and to develop alternate strategies to prepare participants for the performance of the procedure.”

And what would those “alternate strategies” be? You can pick up beads on a simulator all you want, but it’s not the same as doing an operation. And assuming open surgery is still being done somewhere, there is no simulator for open surgery.

A patient wants to know when to speak up

A reader asked if I could discuss how to question a doctor without being a nuisance.

Read the question and answer on "Ask Skeptical Scalpel."

Monday Mornings: The second episode

Since my review of the first episode of the new medical drama “Monday Mornings” generated quite a few comments, some of which thought the show had promise, I thought I’d give it another chance.

Although I have started to like a couple of the characters, particularly Dr. Sung and the sassy Dr. Napur, the medical portions of the show continue to disappoint. Dr. Sung said his evolving catch-phrase “Not do—dead” at least four times and hit a milestone as he uttered a complete sentence during the show.

Dr. Villanueva, the trauma surgeon, managed to diagnose trichinosis after a brief (and I do mean brief) laying on of hands and two questions. Trichinosis is a roundworm disease caused by eating raw or undercooked pork. The CDC says there are fewer than 20 cases of trichinosis reported in the US yearly and most of those come from eating game such as wild boar. The domestic pork supply is virtually free of the problem. I am familiar with the trauma surgeon community. I doubt that many of them could have picked out that zebra.

Dr. Tina Ridgeway, the female neurosurgeon who is destined to hook up with the hunky neurosurgeon with nightmares (another Dr. Jekyll? See “Do No Harm”), presented a case at M&M conference. The patient, a chef, suffered olfactory nerve damage during a craniotomy for a meningioma. She acknowledged that she relied on the resident to obtain informed consent. This is not permitted in most hospitals. The chief of surgery then castigates her for allowing the resident to do the case. When I was a chief of surgery, I usually was faced with the opposite problem. Some of the attending staff were not letting the residents do enough.

By the way, Dr. Hooten calls himself “Chief of Staff” and he never takes care of any patients. While it is true to life that many administrators don’t actually treat patients, I know of no surgery department in which the chief does not operate. It is very easy to criticize others if you don’t ever have to get in the line of fire yourself.

The transplant scenes lacked realism. The doctor who wants the organs cannot go around and ask for them. Ethically, he must refrain from any hint of solicitation. When organs are donated, they are distributed by a network of organ banks. They rarely would stay at the procuring hospital. There are waiting lists and priorities. Donor families and recipient families would never be in the close proximity that was depicted in the show.

I liked it at M&M when the chief said to the evil transplant surgeon, “Tell us how you’ve been bad.” I wish I had thought of that one when I was running those conferences.

The story line about the girl with the brain tumor was good except for the part where the trauma surgeon helps talk her into agreeing to the operation. He’s a versatile guy. But really, a grand piano in the lounge?

Why is everything so dark at the hospital? Is there a problem with the power grid? I’m waiting for someone to ask for a flashlight.

The show is better at character development than medicine. Maybe they should stick to the former.

“Do No Harm” is “Down the Drain.”

Late yesterday, NBC canceled the series “Do No Harm” after just two episodes.

You may recall that I blogged on January 31^st about the comically inept medicine portrayed in the first three minutes of the show’s pilot. The show’s premise that a modern day Dr. Jekyll and Mr. Hyde who had nightly 12-hour blackouts could be a practicing neurosurgeon with what appeared to be the open knowledge and support of his colleagues and the hospital administration was far-fetched, to say the least.

The viewers voted with their feet—making “Do No Harm” the lowest rated debuting series in the history of the big four (NBC, CBS, ABC, Fox) networks.

The second episode, which I’m told featured the neurosurgeon drilling a burr hole (to alleviate pressure in the skull) on a man pinned in a car at the scene of an accident, drew even lower ratings than the first.

Perhaps having an inkling of what was to come, Steve Pasquale, the show’s leading man, told the Huffington Post before the premier “Ultimately in this scenario, I'm just the actor who's saying the words."

My question is who thought this was a good idea? I can try to imagine the meetings where the idea of a modern day Dr. Jekyll who had to be home by 8:25 every night and did medically impossible things during the day was pitched. People with money and experience in television apparently sat there and said “What a great premise.”

Are those who make TV shows and movies so far out of touch with reality?

H. L. Mencken said, “Nobody ever went broke underestimating the taste of the American public.” In this case, he may have been wrong. The American public apparently has its limits.

Why supplemental oxygen is not considered a performance-enhancing drug

You often see a football player on the sidelines breathing oxygen after running a long distance or having worked hard during a long series of plays.

Have you ever wondered if it works? Does breathing a high concentration of oxygen help an athlete recover from exertion faster?

The answer is a resounding “No,” and here’s why.

In healthy people, such as college and professional football players, nearly all of the oxygen in the blood is carried by hemoglobin. Only a very small percentage is dissolved in blood. Saturation defines the oxygen that is attached to hemoglobin and partial pressure of oxygen is that which is dissolved in blood.

Definitions: SaO2 = arterial oxygen saturation, Hb = hemoglobin, 1.34 mL is the amount of oxygen a fully saturated gram of hemoglobin can carry, Pa02 = partial pressure of oxygen or the amount of oxygen dissolved in blood

If an athlete has a normal Hb level of 15 gm, a SaO2 of 100% and a PaO2 of 100 mmHg, the formula used to calculate his blood oxygen content is

[Hb X 1.34 X (SaO2/100)] + 0.003 X PaO2 or

[15 X 1.34 X 100/100] + 0.003 X 100

20.1 + 0.3 = 20.4 mL/100 mL of blood

So, only about 1.5% of the oxygen content of blood is dissolved.

If an athlete raises his PaO2 to 400 mmHg by breathing pure oxygen the calculation is

[Hb X 1.34 X (SaO2/100)] + 0.003 X PaO2 or

[15 X 1.34 X 100/100] + 0.003 X 400

20.1 + 1.2 = 21.3 mL/100 mL of blood

Even at a PaO2 of 400 mmHg, only 5.6% of the oxygen content of blood is dissolved. Note that hemoglobin cannot be more than 100% saturated with oxygen.

Very soon after the athlete stops breathing the pure oxygen, its minimal effect disappears. It’s simply not enough to affect recovery or performance.

Possibly because the basic science is well-understood, there have not been too many papers on this subject.

Here’s one from JAMA that looked at 12 soccer players given 100% oxygen or placebo after exertion. Then they had to exercise again. “The administration of enriched oxygen during the recovery period had no effect on plasma lactate levels [an objective measure of recovery] or on performance during the second period of exercise. The subjects were unable to identify which gas they received.”

A similar study of 13 athletes from Medicine & Science in Sports & Exercise concluded “These findings offer no support for the use of supplemental oxygen in athletic events requiring short intervals of submaximal or maximal exertion.”

Another from the European Journal of Applied Physiology found that giving athletes supplemental oxygen during the recovery periods of interval-based exercise improves the recovery time of SpO2 [equivalent to SaO2] but did not improve post-exercise markers of reactive oxygen species or inflammatory responses because the improvement in saturation was clinically insignificant.

The situation is explained in simple terms in an excerpt from the book Exercise Physiology: Integrating Theory and Application. It concludes that supplemental oxygen may have a placebo effect, but there is “no real physiologic benefit.”

If you Google “supplemental oxygen and athletes,” you will find a number of websites touting the supposed benefits of inhaled oxygen. They are almost all supported by companies that sell oxygen.

Bottom line: Supplemental oxygen is not considered a performance-enhancing drug because it doesn’t work.

Thanks to  Dr. Joel Topf (@kidney_boy ) for suggesting this topic.