Tuesday, December 31, 2013

A lawyer tries (unsuccessfully) to take down Skeptical Scalpel

A trial lawyer named Max Kennerly has taken issue with a piece I wrote called "Can defensive medicine ever be stopped?" It appeared last week on KevinMD.

On his blog, he he says defensive medicine is a "myth" and accuses me of many wrongs, too numerous to detail here.

I will address a few of them.

He read my post but apparently did so selectively. He failed to note that I agreed with him that tort reform did not reduce the cost of medical care in states that have enacted it. This was documented by a paper from the National Center for Policy Analysis which I cited.

He went on to criticize three brief examples of defensive medicine that I mentioned in my post—about abdominal pain, a wound infection after colon surgery, and chest pain.

Mr. Kennerly writes, "a young girl with lower abdominal pain gets an ultrasound for appendicitis (among the least invasive, least expensive, and most helpful tests in history — remember this funny GE ad for their portable ultrasound?)."

Thursday, December 26, 2013

Why do misconceptions about brain death persist?

On December 9, 2013, 13-year-old Jahi McMath underwent a tonsillectomy at a children's hospital in Oakland, California. She suffered postoperative hemorrhage and became comatose. She was declared brain-dead by doctors at that hospital on December 12th. This was later confirmed by a court-appointed outside consultant.

There are many issues surrounding this case. Was the tonsillectomy indicated? Some stories reported that it was done to improve her obstructive sleep apnea. Why wasn't she successfully rescued from her complication of bleeding? I can find no discussion about how she could have bled so much without intervention in any article about the case.

But one of the most distressing aspects of this poor child's demise is that despite many years of experience with brain death, it is still misunderstood by laypeople, the courts, and even some medical providers.

As of December 26th, 14 days after the brain death declaration, the child remains on a mechanical ventilator with apparently stable vital signs.

A lawyer for the family had petitioned the court for the outside expert's consultation and to prevent the hospital from disconnecting the child's life-support.

After all this time, a judge has finally ruled that the hospital may remove the life-support but not until December 30th to give the family time to appeal to a higher court.

What a shame. It is bad enough that this girl has died. But to realize that in 2013, society still cannot deal with the concept that brain death is "death" makes it sadder.

It may be a problem of terminology. When we say "brain-death," it somehow does not sound like real death.

The problem is compounded by other words used in this post such as "life-support" and "vital signs." These terms perpetuate the mistaken notion that life is still present.

The Harvard Criteria for brain death were written in 1968. That is 45 years ago. Why are we still debating this in court?

The answer is, we have failed to properly educate the public about this relatively straightforward fact.

It must be extremely difficult for this child's family to accept that the girl is dead after what many have called "routine" surgery. I feel very bad for them.

Something that has not been mentioned in any report about this case is another issue that society has trouble handling—organ donation. Perhaps the family should consider this. Those who have been in similar situations say that donating organs gives them some comfort in that part of their loved one lives on and that someone else has been helped.

I hope the higher court does the right thing and declines to review the case and that the family can eventually find peace.

UPDATE: December 27, 2013

According to the San Jose Mercury-News, the family says it has found a facility willing to provide long-term care for the girl. They want doctors at the Children's Hospital to perform a tracheostomy and a gastrostomy (semi-permanent feeding tube), which they have declined to do because it is futile.

The child's uncle is quoted, "It looks like we may have found a miracle to keep Jahi alive and to give her another fighting chance to wake up." I'm sorry to say that is not going to happen.

Also, the original surgery was much more than just a tonsillectomy. The girl underwent a full obstructive sleep apnea operation consisting of the following: adenoidectomy, tonsillectomy,  uvulopalatopharyngloplasty (UPPP), and submucous resection of bilateral inferior turbinates of the nose.

Tuesday, December 24, 2013

Did a "botched" vasectomy cause a man to shoot his doctors?"

Last week, I blogged about a Forbes post criticizing surgeons for making too many errors. I pointed out that all complications are not caused by errors, and some complications cannot be prevented. My plea was that if one is going to criticize, at least one should get the facts straight.

The day after I posted that on Physician's Weekly, a man with a shotgun walked into a urology office in Reno, Nevada fatally shooting one doctor and critically wounded another before taking his own life.

Nearly every tweet and media headline about this incident stated that the shooter was upset about "botched" surgery that had been performed on him three years before.

Fox News: "Neighbors say Nevada gunman had botched vasectomy"
CBS News: "Neighbors: Hospital shooter in pain from botched vasectomy"
Huffington Post: "Botched vasectomy might have prompted shooting in Nevada urologist's office"
The Australian: "Gunman had botched vasectomy: Neighbors"

Even after I tried to correct people, they continued to tweet these headlines for a week.

USAToday reported that the shooter's friend said "complications from a vasectomy left the man so sick and weak that he could barely move" and that he "was dying from this."

The last paragraph of the story quoted a professor of urology from the University of California, San Francisco, who said that "many very large studies … show that a vasectomy is not a risk factor for any longer-term health problems, and that's very clear."

The American Urologic Association says that 1 to 2% of vasectomy patients may have chronic pain.

There is no evidence whatsoever that symptoms like being weak and sick were the result of a vasectomy, botched or not. Since chronic pain can occur after surgery that was done correctly, the use of the term "botched" in this case is inappropriate.

And only a couple of stories mentioned the fact that the shooter had a history of depression since the 1990s for which he had been taking Prozac on and off and had also been talked out of committing suicide well before before he had the vasectomy.

Not only are the headlines misleading, but they insult the competence of both of the unfortunate urologists who were victims of a senseless crime.

But I guess the article gets more clicks if "botched" surgery is involved.

As Mark Twain said, "Never let the truth get in the way of a good story."

Monday, December 23, 2013

My top 7 most-viewed posts of 2013

Here they are in order from the most read.

An MD's thoughts on medical education A surgeon who became an anatomy teacher at a medical school has some controversial views on the role of PhDs as teachers of medical students. As of 12/23, this one has had 9,771 page views.

Is this the most bizarre bad doctor of all? A California cosmetic surgeon with many complications and other issues.

On the horrific story of a Texas neurosurgeon and why it could happen again A surgeon who had some spectacularly bad outcomes.

Pregnant woman dies after ovary removed instead of appendix Tragic story of a patient with appendicitis who had the wrong operation.

School or scam? St. Augustine School of Medical Assistants A persistent spammer annoys me so much that I retaliate.

Patient falls off OR table: System error or human error? How does a patient fall off an OR table during a case? It's hard to explain.

Surgeons behaving badly Three stories about surgeons who lost their way.

Thanks for reading.

Friday, December 20, 2013

A woman asks, "Should I be a nurse practitioner or a doctor?"

On the "Ask Skeptical Scalpel" blog, a young woman asks if she should go to med school or become a nurse practitioner.

Here's the link http://bit.ly/1l1y6LP.

If you agree or disagree with my response, feel free to comment.


Wednesday, December 18, 2013

"Stealing" the thyroid gland

Here's a story about a technique of thyroid surgery that is no longer being done

During one summer of my college years in the mid-1960s, I worked as an orderly at a community hospital in my hometown. There are no orderlies anymore. I guess the closest thing would be a "patient care technician." Orderlies used to push patients around on gurneys, help the nurses change beds, clean up poop, run errands, and do whatever no one else wanted to do. It was common for premed students to do at least one summer of orderly work to demonstrate their commitment to becoming a doctor. I suppose it's analogous to today's premed students' doing a summer of research cleaning test tubes.

Anyway, back to the story. A woman was admitted with thyrotoxicosis, a hyperactive thyroid gland resistant to whatever medications were being used to suppress thyroid function at the time.

She was scheduled for a total thyroidectomy, but the stress of anesthesia and surgery was known to induce a potentially fatal condition called a "thyroid storm." A thyroid storm can still occasionally occur in patients with untreated hyperthyroidism. Some symptoms of thyroid storm are fever, rapid heart rate, agitation, delirium, tremor, and low blood pressure, among others.

In the early 1900s, the threat of this problem prompted a famous early thyroid surgeon, George Crile, to devise a plan for "stealing" the gland.

Following Crile's script, what we did with our hyperthyroid lady was to visit her every day dressed in our surgical scrubs. The anesthesiologist would fiddle with her IV and talk to her. The OR nurse and I would chat with her too. All of this was done so that she could become accustomed to our presence. The idea was to one day anesthetize the patient in her bed and take her to the operating room for her thyroidectomy. Since the patient did not know on which day her surgery would occur, she was not so anxious.

A few days went by. One day we were told, "Today's the day." When we went into the room, the anesthesiologist, instead of just fiddling with the IV, injected some sodium pentothal, and the patient fell asleep. Off we went to the OR, and the operation was done.

These days, it's a good thing that hyperthyroidism can be treated with more effective medication. I doubt that insurance companies would pay for a three or four day preoperative hospital stay so that the thyroid gland could be stolen.