Monday, July 31, 2017

"Move that defibrillator paddle so I can finish the case"

A plastic surgeon in Sydney was reprimanded by the New South Wales Professional Standards Committee for continuing breast augmentation surgery after a patient had been successfully resuscitated from a cardiac arrest.

According to a report, the surgeon, Dr. Niroshan Sivathasan, defended his actions two years after the incident saying he operated for another 30 minutes after an ambulance arrived because he hadn't finished inserting the left breast prosthesis or closed both wounds, and he was concerned about infection if he aborted the case.

The committee didn't buy that excuse correctly pointing out that the patient could have had another cardiac arrest and said he "demonstrated almost no insight into the nature of his conduct or how he failed his patient."

He was also told he must undergo mentoring and submit a report documenting all of his complications every three months.

Sivathasan works at The Cosmetic Institute, Australia's largest plastic surgery center, which has had some problems in the past. In 2016, the Health Care Complaints Commission found six patients had experienced potentially life-threatening complications — tachycardia, seizures, and cardiac arrest—during breast implant surgery done over a 12 month period.

The complications were thought to have been due to the use of large amounts of local anesthesia with epinephrine. In addition, the facility was licensed for administering conscious sedation only, but some patients had undergone general anesthesia without their consent.

The 21-year-old woman who survived the cardiac arrest in 2015 was interviewed back then for an article in the Sydney Morning Herald. She described waking up in the hospital and finding she had received CPR and cardiac defibrillation. She said Sivathasan told her there was a problem with the anesthetic.

Regarding her surgeon, she said, "If it wasn't for him I wouldn't be alive. That place is so prepared for whatever. Literally, they saved my life."

I don't think they have Press Ganey scores in Australia, but if they did, no doubt the surgeon and the facility would have received 5-star ratings from this patient.


Dr. Sivathasan, the surgeon involved in this case, emailed me with comments which shed some light on why he continued the operation. They are published without editing below.

I felt it important to write to you just to highlight a few things that were ‘not’ correctly reported in the press release:

1) the operation was close to being finished when the patient developed ventricular fibrillation;
2) hardly any local anaesthetic was used in this case (only 10mL of 1% ropivucaine);
3) by good fortune, there were TWO specialist anaesthetists (one being a senior cardiac anesthesiologist) who were managing the patient, and the patient responded very quickly to their efforts;
4) the ambulance service despatched two incorrectly equipped ambulances, and a THIRD ambulance was required to transfer the patient.  This entailed a delay;
5) it was UNANIMOUSLY agreed by FOUR doctors (both anaesthetists and both surgeons who were present) that we ought to use the window to give the most definitive outcome for the patient.

At the end of the day, the patient, a sizeable percentage of the public, and a considerable number of doctors supported us for our actions.  They recognized that it takes more judgement and nerve to finish a procedure under such stressful circumstances, than it does to just ‘whack in a few staples and down tools’.

Unfortunately, due to the regulatory processes in place, two doctors who were not present during the incident, were able to judge upon the actions of four doctors (all of whom were in agreement).  This is simply illogical and is, certainly, an indictment of the regulatory board’s processes.  Furthermore, neither of the two doctors that were presiding over the case is an expert in critical care – one was a retired surgeon and the other was an emergency physician.

Accordingly, what those two doctors failed to recognize, in my strong opinion, is that a patient whom has been salvaged from a nasty situation remains unstable and should not immediately be in the back of an ambulance; rather, the patient shall be better served when under the care of two anesthesiologists maintaining anaesthesia (which is relatively cardioprotective given the high catecholamine situation (which may provoke another episode of VFib)).  The VFib was ‘not’ secondary to haemorrhage or anything surgical, and therefore to capitalize on the undesirable situation by finishing an almost-finished operation appeared to be the best decision (as opposed to requiring a GA in the future, where the induction may be a lottery).  

Experienced doctors shall appreciate that medicine, and especially surgery, involves judgement calls.  This patient in question has had a positive outcome.  Unfortunately, the institution where the problem occurred has been the subject of debate due to a few suboptimal practices by the management team, and this ended-up biasing the outcome.

Wednesday, July 26, 2017

Controversies in OR infection control

Like professional athletes, Skeptical Scalpel sometimes talks about himself in the third person. A recent article in Clinical Infectious Diseases [CID] confirms what Skeptical Scalpel has said about a couple of controversial topics in infection control.

The article by surgeons from the University of Washington was published online in late May of this year and gives historical context to some of the standard operating room practices we currently argue about.

Regarding operating room headgear, the authors dissect and refute the positions endorsed by the Association of periOperative Nurses (AORN) that hair and airborne bacteria cause infections. In fact, they say wearing of any kind of hat in the OR may actually disperse more bacteria due to the effect of the hat rubbing against the hair and causing an increase in bacterial shedding.

They conclude “there is little reason to support the AORN recommendations regarding head covering.”

Wednesday, July 19, 2017

What were attrition rates in surgical residency programs 25 years ago?

Last month I blogged about the 20% attrition rate of general surgery resident over the last 25 years, and a recent paper presented at a national meeting that found after following the general surgery resident class of 2007, 20% had dropped out for one reason or another.

A reader who calls himself Artiger commented on that piece asking, “Is there any data on resident attrition prior to 1992? Just curious if this has been a problem for more than the past 25 years.”

I responded that I wasn’t aware of any such studies but I would try to find out.

Most of the few papers written about attrition back in the day focused on one residency program or one medical school’s graduates.

Until the middle of the 1990s, many surgical residency programs were pyramidal—that is, they took more categorical first-year residents than they had chief residency positions. For example, when I began my training in 1971, my program had 12 first-year residents, decreasing to 8 in the second-year and only 4 chiefs.

Sunday, July 9, 2017

Parathyroids Anonymous

A One Act Play by Leo Gordon, MD

Dedicated to Parathyroid Surgeons
All proceeds from the production of this play go to Parathyroids Anonymous--An international organization dedicated to the well-being of those who perform parathyroid surgery

Scene: A sparsely furnished church basement. Rain is beating against the window panes. Folding chairs are arranged in a semi-circle. Participants are drinking from plastic cups. Some are in scrub suits. All appear tired.

Don: Hello. My name is Don and I’m a parathyroid surgeon.

All: Hello Don

Don: I will be your facilitator tonight. We have a new member so let me set the ground rules. All of us in this room are parathyroid surgeons. We maintain our anonymity as we discuss the mental and physical distress that parathyroid surgery engenders. There are no boundaries at our meetings. We speak openly and freely. Use your first name only. And of course, no patient names. Who wants to begin?

Miriam: (Nervously) Hello. My name is Miriam and I am a parathyroid surgeon.

All: Hello Miriam

Miriam: I’ve been here a few times but I’m a little bit nervous.

Don: Don’t be nervous Miriam. We all share the same problems.

Miriam: Well… last week. (Begins sobbing)

Don: Now Miriam, just relax. Please continue.

Miriam: I had a 56 year old woman referred to me with hypercalcemia. She had had elegant localizing studies at our hospital. Both studies – nuclear and sonographic - stated with metaphysical certainty that there was an adenoma of the right lower gland. Yet (sobbing) when we explored the area, there was no adenoma present. All we found was a normal sized parathyroid gland!

Al: (Hands Miriam a handkerchief)

Don: Go on, Miriam

Friday, July 7, 2017

The problem of “copy and paste” in electronic records

As opposed to text that is copied and pasted or imported from another part of the electronic record, the average amount of manually entered information in a progress note is

a. 18%
b. 29%
c. 43%
d. 55%
e. 70 %

A study of 23,630 internal medicine progress notes written by 460 different hospitalists, residents, and medical students found that a mean of only 18% of the text was created by hand with 46% copied and pasted from previous note or somewhere else and 36% imported from another part of the record such as a medication list.

The analysis, done at the University of California San Francisco*, was possible because the Epic electronic medical record used there can provide the provenance of every character entered in a progress note.

Medical students had the highest percentage of manually entered text and wrote longest notes—averaging 7053 characters, but even the shortest notes, by hospitalists, averaged 5006 characters. For reference, this post contains 1189 characters.

Manual entry comprised 11.8% of resident notes with 51.4% of the remaining information copied and pasted and 36.8% imported.

Think about it. For all groups, less than one-fifth of every progress note they wrote was original material. For resident notes, it was closer to 10%.

The authors cautioned that their study was limited to a single service at a single institution, but I suspect the results would be fairly similar in many if not most hospitals.

*Location of the study corrected on 7/7/17.