tag:blogger.com,1999:blog-4968787219619380438.post248757120710382644..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: Sleep deprivation, surgeons, operations, and outcomesSkeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger25125tag:blogger.com,1999:blog-4968787219619380438.post-16540688208116529792013-11-22T07:00:13.826-05:002013-11-22T07:00:13.826-05:00Doctor Which, thanks for the comments. Good points...Doctor Which, thanks for the comments. Good points about sleep and care. Yes the Scottish personnel who let the patient fall of the OR table weren't sleepy, just careless. That post is here http://skepticalscalpel.blogspot.com/2013/11/patient-falls-off-or-table-system-error.html.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-5107367834224626502013-11-21T22:55:37.217-05:002013-11-21T22:55:37.217-05:00Studies with small amounts of alcohol show that th...Studies with small amounts of alcohol show that the person is aware of minor impairment and is more careful in risk taking. It has been shown to improve overall safety.<br />I believe all this has been hyped, something to do with junior doctors hours and the Geneva Convention. Nobody ever considers the cultural loss. The medical ethic of selflessness used to be indoctrinated as a part of absolute vocation. Oh, it was brainwashed into the subconscious. It was dehumanising....<br />Or was it superhumanising in terms of ethics.<br /><br />We'll miss them as in the case of the scottish hospital. The errors are a lack of self discipline caused by putting their petty little selves before the patientDoctor Whichhttps://www.blogger.com/profile/17413082449192133443noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-55867463970203816502013-11-19T08:53:08.929-05:002013-11-19T08:53:08.929-05:00I rest my case. Thank you.I rest my case. Thank you.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-7342470416223076352013-11-18T17:47:45.461-05:002013-11-18T17:47:45.461-05:00Agree.
Just ordered a Perc Cholecystostomy on a 95...Agree.<br />Just ordered a Perc Cholecystostomy on a 95 y/o with STEMIRuggerMDnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-4149937258801826652013-11-18T16:15:10.905-05:002013-11-18T16:15:10.905-05:00Rugger, I agree with you. I also think it is still...Rugger, I agree with you. I also think it is still ok to do a cholecystostomy occasionally.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-66740575444630952712013-11-18T14:34:38.086-05:002013-11-18T14:34:38.086-05:00I agree, conversion to open is not a complication,...I agree, conversion to open is not a complication, it is good judgement.<br />A complication is spending 8 hrs trying to do it laparoscopically or worse yet not converting and causing an injury.<br />IMO 99.9% of complications from lap chole are CAUSED by us.<br />The anatomy is usually straight forward with of course all the variations you can find in Netter's. If you don't know the anatomy then don't cut it.<br />If you can't see the anatomy from body habitus, inflammation, scarring or whatever, then open.<br />If you still can't find the cystic duct secondary to scarring then ligate at base of infundibulum and oversew it.<br />You don't always have to be right on the cystic duct. Some times as we say "the enemy of good is better".<br />But that is just what I do. <br />RuggerMDnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-35360789557379161462013-11-11T09:37:49.875-05:002013-11-11T09:37:49.875-05:00Medaholic, We are in complete agreement.
Anon, he...Medaholic, We are in complete agreement.<br /><br />Anon, here's a post I wrote a while ago about surgical hospitalist work (http://skepticalscalpel.blogspot.com/2011/03/general-surgery-acute-care-surgery-and.html). Yes, it's not an ideal job for a fussy surgeon.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-57370946220532583152013-11-10T23:09:15.094-05:002013-11-10T23:09:15.094-05:00SS,
OT, but can you comment on your experiences a...SS,<br /><br />OT, but can you comment on your experiences as a hospitalist. It sounds like you can fit in anywhere, but I assume that surgeons who insist on such-and-such or I quit may not do as well.<br /><br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-40123017624975003462013-11-10T20:45:31.931-05:002013-11-10T20:45:31.931-05:00I was similarly surprised by my colleagues who int...I was similarly surprised by my colleagues who interpreted this study as same conversion rates means same amount of complications. Complications and harm are already so hard to define and measure, that it's a gross oversimplification to say open chole's are complications. <br /><br />The problem is the retrospective study design of elective (low risk) choles. I definitely would not want a sleep-deprived surgeon doing a big casemedaholichttp://www.medaholic.comnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-82877391499938218642013-11-10T19:42:38.887-05:002013-11-10T19:42:38.887-05:00Anon, you are absolutely right. There aren't e...Anon, you are absolutely right. There aren't enough surgeons to cover especially in rural areas. and yes, surgical hospitalists can work several 24-hour shifts in a row. But when I was doing that, I was able to nap in the daytime after a bad night because I didn't have a long elective schedule or an office full of patients the next day.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-2294778804686194072013-11-10T16:03:00.107-05:002013-11-10T16:03:00.107-05:00Even if sleep deprivation worsens outcome, what is...Even if sleep deprivation worsens outcome, what is the solution?<br /><br />If you are practicing in a small group in a moderately busy community hospital, you have a good chance of being wakened at night when you are on call. It is not feasible to cancel your next-day elective OR schedule or your office even if you had worked all night.<br /><br />A growing number of larger hospitals now use surgical hospitalists, including orthopedic and obstetric hospitalists. Of course, since most of them cover a week or 2 at a time, they are still at risk of operating after little sleep. <br /><br /><br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-86195668362873522482013-11-10T12:06:38.112-05:002013-11-10T12:06:38.112-05:00Ray, I'm sure that you can find research to su...Ray, I'm sure that you can find research to support both sides of the issue.<br /><br />Anon, everyone reacts differently to lack of sleep. If sleep deprivation bother you that much, you probably shouldn't be a general surgeon.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-23179118204810023472013-11-09T13:26:23.706-05:002013-11-09T13:26:23.706-05:00Even if sleep deprivation does not cause more comp...Even if sleep deprivation does not cause more complications it doesn't mean it is OK. When I'm sleep deprived I'm unhappy, irritable, and unpleasant. Sleep deprivation affects my mood and family life. It is unhealthy also.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-87311777389423952422013-11-09T08:46:52.934-05:002013-11-09T08:46:52.934-05:00Surgeon, "worse after a holiday" has bee...Surgeon, "worse after a holiday" has been studied at various times and places. The first I recall from past decades is the air force wondering why their jet fighter pilots crashed their planes more often on Monday.Ray Collinshttps://www.blogger.com/profile/11379062185065522466noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-29540964784003598202013-11-08T18:28:37.912-05:002013-11-08T18:28:37.912-05:00Anon, good questions. Regarding the difference bet...Anon, good questions. Regarding the difference between statistical and clinical significance--they are not necessarily equivalent. In your example, a 2 mm difference in BP might be statistically significant but not clinically important. I wrote about this 2 years ago. It's the most read post I've ever written. Here's the link http://skepticalscalpel.blogspot.com/2011/08/statistical-vs-clinical-significance.html.<br /><br />Statistics don't mean much to an individual patient. The woman who suffers a common bile duct injury during a lap chole doesn't care that her odds of having that happen were less than 1%. But stats help us explain risks to patients and make policy decisions as a society.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-87846179097540793522013-11-08T16:48:39.164-05:002013-11-08T16:48:39.164-05:00SS,
Good point about the problem of using lap cho...SS,<br /><br />Good point about the problem of using lap choles for this study. Most surgeons can do them in their sleep (oops). <br /><br />I am puzzled about the statistical comments. I'll use Type 1 errors as an example. Say Drug A lowers blood pressure by 2 mmHg in a study of 1000 patients, and is deemed statistically insignificant. The researchers then studied 100,000 patients and got the same 2mmHg reduction, but the stats are now highly significant.<br /><br />What is the clinical relevance?<br /><br />Similarly, if you need to study 20,000 patients to avoid a Type 2 error, does that mean anything to a patient undergoing surgery?<br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-61078478889719997572013-11-08T15:32:12.510-05:002013-11-08T15:32:12.510-05:00Drew Shirley, MD put this comment on NowTalk: I re...Drew Shirley, MD put this comment on NowTalk: I really agree with this post! I was a little shocked at how others on Twitter propped this up as definitive proof that sleep deprivation doesn't effect surgical outcomes. I think a fundamental problem with the study is that it used lap chole as the procedure to prove this when even the most inexperienced surgeons could do this instinctively and they have a fairly low complication rate baseline.<br /><br />Good comments, Drew. The problem for the researchers is they needed a high volume procedure to study. But since the rates of iatrogenic injury and death are so low, they would need more than 20,000 patients in each group to avoid a Type II error.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-62306478165347429572013-11-08T15:26:02.898-05:002013-11-08T15:26:02.898-05:00Todd, I agree. there's nothing wrong with sayi...Todd, I agree. there's nothing wrong with saying that conversion rates were similar but to equate them with complications? I don't think so.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-19650299755961253712013-11-08T15:03:03.860-05:002013-11-08T15:03:03.860-05:00me too. And one of the authors seemed to be a PhD ...me too. And one of the authors seemed to be a PhD biostatistician. My biostats profs taught me to be more measured in my conclusions, and what you were hinting at is that this needs to be an equivalence study (http://learnpkpd.com/2011/01/01/trial-designs-non-inferiority-vs-superiority-vs-equivalence/). "These results do not find a significant difference between group A and group B" would have been a far more statistically honest statement than what the conclusion said. Todd J. Scarbrough, M.D.https://www.blogger.com/profile/09254631173069503684noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-73312548187621625442013-11-08T14:52:34.952-05:002013-11-08T14:52:34.952-05:00Surgeon, I don't know about that. You're g...Surgeon, I don't know about that. You're going to need a bigger series to convince people.<br /><br />Todd, I am surprised that this appeared in JAMA. An editorial about this paper by two well-known surgeons did not raise any of the points I mentioned.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-22681512859250110622013-11-08T14:49:05.917-05:002013-11-08T14:49:05.917-05:00I accidentally deleted a comment by Pamchenko (sor...I accidentally deleted a comment by Pamchenko (sorry) which said, "converting a lap to open gallbladder usually means its a really bad gallbladder. probably a male gallbladder." I agree some people think cholecystitis is worse in males. Of course, the study was about elective surgery and almost 75% of the cholecystectomies were performed on women.<br /><br />Anon, the average age of the surgeons was 48. Other than that, there was no mention of a breakdown of cases by surgeon age.<br /><br />Ray, thanks.<br /><br /><br /><br />Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-36168076340369857322013-11-08T14:47:05.048-05:002013-11-08T14:47:05.048-05:00JAMA publishes negative retrospective studies that...JAMA publishes negative retrospective studies that look at questionable surrogate measures which yield bold conclusions highly susceptible to errors of statistical inference? They do that now?<br /><br />Well OK.Todd J. Scarbrough, M.D.https://www.blogger.com/profile/09254631173069503684noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-52194760080803649932013-11-08T14:44:11.002-05:002013-11-08T14:44:11.002-05:00I am better in the OR if I am sleep deprived. I am...I am better in the OR if I am sleep deprived. I am worst just after a restful vacation. Surgeonhttps://www.blogger.com/profile/08364600923116064890noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-83760521595403898482013-11-08T13:30:37.774-05:002013-11-08T13:30:37.774-05:00Thanks for this post. I am not a surgeon, so I fou...Thanks for this post. I am not a surgeon, so I found your viewpoint useful. I referenced it in my own post today. http://eraycollins.postach.io/conversion-vs-complication-rate-as-a-sleep-deprivation-metricRay Collinshttp://eraycollins.postach.ionoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-81703653260115491002013-11-08T12:38:00.384-05:002013-11-08T12:38:00.384-05:00Were there differences due to the ages of the surg...Were there differences due to the ages of the surgeons? I know that as a 20-something resident I could get by with 2-3 hours sleep, work 10 hours next day, and then go out for a couple of beers. Now at age 50? Not so much.<br /><br />(I am not a surgeon.)Anonymousnoreply@blogger.com