Tuesday, June 25, 2013

What was surgery like in the 1970s?

When I first started my residency in the early 1970s, things were remarkably primitive by today's standards.

There were no ultrasound machines. Believe it or not, we would diagnose acute cholecystitis by history and physical examination alone. The only diagnostic tests we had were oral cholecystogram (OCG) and intravenous cholangiogram (IVC). For OCG, pills were taken the night before the test. If the cystic duct was patent, iodinated contrast would appear in the gallbladder and stones could be seen. Non-visualization of the gallbladder meant either the cystic duct was blocked or the pills were not absorbed (presumably due to inflammation, not necessarily of the GB) or the patient forgot to take the pills. The test was useless in acutely presenting patients. IVC was similar except the contrast was given intravenously. The common bile duct could be seen faintly unless the patient was jaundiced. It rarely showed stones in the GB.

There were no CT scans. We had to make the diagnosis of appendicitis by, you guessed it, history and physical examination alone. And since laparoscopic general surgery did not become common in the US until 1990, all appendectomies and cholecystectomies were done as open procedures.

There were no computers in any clinical departments or nursing units. Everything was on paper. The good news? There was no way to "copy and paste" progress notes. We had different colored paper for different sections of the chart, which made things easy to find. The bad news? Charts often went missing. Handwriting analysis rivaled that of archeologists deciphering hieroglyphics in Egypt. But paper charting was faster to do and easier to "leaf" through.

When submitting a research paper, drafts had to be prepared on a typewriter (an ancient kind of word processor that put the words directly on paper). If you needed to change a paragraph on page 1, the entire manuscript had to be retyped from the beginning. And making slides for presentations involved cameras with 35 mm film, taking the film to be developed and hoping the slides came out OK. Find a typo? Take the picture over and have the film processed again.

Now we use PowerPoint. It's easier, but I'm not totally convinced that it's real progress.

Maybe the biggest change has been the advent of the Internet. In the palm of my hand, I can instantly access huge amounts of information formerly available only in print books and journals. To look up a paper, we had to use Index Medicus, an encyclopedic series of books listing every article by subject in most journals.

There were far fewer journals back then. You had to know the correct heading or keyword to search or you could miss something important. Cross-referencing was not easy because it was in print and there was a different set of volumes for every year. And libraries kept many years' worth of volumes of journals.

Of course, many more changes have occurred. Can any of my older colleagues comment?


Chris Porter MD said...

While I recognize the inefficiency, I miss the collegial ritual of going to radiology every day, or twice, sometimes three times a day. We'd look at the films of every patient on our service and discuss them with the radiologists. Now I look at the images wherever I am just after they're shot and only discuss with the residents when there is something important to see. The closest I come to a discussion with a radiologist is occasionally reading his/her report long after decision making is done.

Skeptical Scalpel said...

Until I retired I made a point of looking at images with the radiologists as often as I could, nearly every day. Even in the age of PACS, I felt it was worth the effort to discuss the case, verify the reading and get other opinions if necessary.

CholeraJoe said...

No CT so used V/Q scans to dx PTE. Not very accurate. Sent lots of folks for thoracotomy for pulm nodules. Abd aneurysm repair was all open, long and bloody.

Blakemore tubes for bleeding varices, not endo banding.

Skeptical Scalpel said...

Cholera Joe, yes, those are all very good points. I used to hate V/Q scans. And Blakemore tubes? Instruments of the devil.

Anonymous said...

No pulse oximetry. Patient looks kind of blue? Umm, maybe. Or not.

I would rate routine availability of CT, pulse oximetry, and laparoscopy as the biggest peri-op innovations in the past 25 years.

Skeptical Scalpel said...

It's hard to argue with those choices, although you left out robotic surgery.

RuggerMD said...

Hate to say it, but I suspect there were quite a bit more complications and deaths back then as well.
I still remember the dogma of having to get the belly closed.
I'm sure lots of trauma patients and general surgery patients died from abdominal compartment syndrome.

Skeptical Scalpel said...

I'm not so sure about that. True we closed some abdomens that maybe we shouldn't have, but today there are probably far too many being left open to develop fistulas and large hernias.

RuggerMD said...

Not if you do it right. You leave it open and washout 2 or 3 times and get them closed when inflammation/edema settles down and if you cant you can put in a biologic and do a component separation to close.
Should be part of every acute care surgeons repertoire.
We have but one or two bellies get stuck open in last five years and only one fistula.
In fact, are going to be writing it up soon.

Skeptical Scalpel said...

Those are excellent results. How many open abdomens does your group do per year?

artiger said...

Rugger, I hope you'll post here when you get everything put together.

Anonymous said...

CT was just coming into use when I was an intern/resident. We had to beg/flirt with the booking secretary to get an "elective" scan on the only scanner in the city.

If I have to pick the biggest impact on all medical (not specifically surgical)practice in the past few decades, it has to be CT.

Detection and treatment of MI would be the second on my list. When I was an intern, an evolving MI was giving morphine, lidocaine (proven useless), and sent to the ICU to monitor for v-fib.

Skeptical Scalpel said...

Yes, CT scan was a big advance. You are also right about the treatment of an MI. It has come a long way.

Anonymous said...

My straight surgical internship was at Columbia P&S in 1968-9. We were on and in-house either Tuesday, Thursday and Friday, or Monday, Wednesday and the entire weekend. By Monday evening you could pick me up with a damp washrag, but I got to follow sick people as they progressed rather than sign them out to a colleague after an 8 hour shift. The difference was remarkable.


Skeptical Scalpel said...

I had the exact same call schedule in the early 1970s. As I have pointed out in a previous post, we got more sleep when we were on call because we weren't cross covering so many patients.

JonMD said...

Great article. I'm currently a surgical resident at a busy public hospital/academic medical center and still experience some remnants of the past. While we definitely have had some amazing advancements, including the CT scan as one example from above, in my opinion we've also had some setbacks. Most troubling, I think, is the adaptation of the new work hour restrictions. I agree with you that, although being on-call occurred more often, there was less cross coverage and you actually knew your patients better. Wish we could go back to that system - it's unfortunate that the people who make the rules aren't the same people who are teaching residents.

Skeptical Scalpel said...

Jon, thanks for commenting and agreeing with me. I have said the same thing--those who make the rules are not always on the front lines.

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