Does the timing of appendectomy influence the wound infection rate?

“Yes,” says a large review of a single institution’s experience with appendectomy for acute appendicitis.

The study looked at over 4500 patients who underwent appendectomies over the 8-year period between 2003 and 2011. The main findings of the study were that patients who developed surgical site infection (SSI) had a significantly longer delay in going to the operating room. Time to appendectomy was defined as the time the patients were admitted to the surgery service until they reached the operating room (OR).

Patients who developed infections were taken to the OR after a mean of 14 1/2 hours compared to 11 hours and 45 minutes for those who did not, which was a statistically significant difference, p = 0.013.

The delay in taking patients to the operating room did not lead to more perforations. However, the rate of perforation in this series was rather high at 23%.

The abstract concluded, "prompt surgical intervention is warranted to avoid additional morbidity in this population."

Since this paper supports my bias about performing appendectomies as soon as the diagnosis is made (as I have previously blogged), I was hoping that its findings would be valid. Unfortunately, that is not the case. The paper is not as convincing as the abstract.

The authors state that surgeons and operating room personnel are in the hospital 24 hours a day. It is not clear why patients’ operations were delayed so long. There is no mention of whether the patients received antibiotics while they were waiting. If more patients who did not suffer SSI's had received antibiotics, the paper’s results could be misleading. If you look at the mean difference between times to the operating room for non-infected versus the infected patients, you will note that it is a little less than 3 hours, which really is not that long.

Another issue is that only 41% of the patients underwent laparoscopic appendectomy. In my practice and that of most other surgeons, 90%-95% of patients with appendicitis are operated on via the laparoscopic approach. Laparoscopic appendectomy is known to have a lower wound infection rate than open.

The mean hospital length of stay for the non-perforated patients was 3.4 days, highlighting the outdated nature of the information. Most patients with non-perforated appendicitis are discharged within 24 hours of surgery in 2012.

However the most important problem with the paper has to do with the key factor that the paper emphasized; that is time. Not only was the duration of the patients’ symptoms prior to arrival at the hospital unknown, the authors also did not account for the length of time that the patients spent in the emergency department. If diagnostic CT scans, which are done about 90% of the time for appendicitis, were performed, the patients probably spent at least 6 hours in the ED.

It does not stand to reason that a less than 3-hour average difference in taking patients to the operating room when the preop duration of symptoms is unknown could possibly be significant. And 11 hours and 45 minutes to get a patient to the OR does not define “prompt” for me.

Bottom line: As I have said before (here and here), you have to read the entire paper and not just the abstract.

Some signs of the impending apocalypse

Here are some examples of why I believe the apocalypse is near.

The eighth annual "Pregnant Bikini Contest" was recently held in Houston. Before you click the link, I must warn you that what has been seen cannot be unseen. Notice of the first seven contests somehow escaped my attention.

A dispute at a bar in Calgary, Canada erupted in violence resulting in the death of a man. The disagreement was about the pitching staff of baseball’s Toronto Blue Jays.

Harvard University is investigating 125 students who may have plagiarized their test answers for a course ironically entitled "Introduction to Congress." After looking at some examples of the course material, I wonder why it would be necessary to cheat. An article in Salon magazines states, "The student source said Professor Platt was a fun lecturer who presented with accessible slides. In just one lecture he used ‘Sesame Street,’ ‘The Simpsons’ and the singer Bobby Brown to explain the origins of modern Congressional careers and committees." The same article quotes a student as saying Harvard is “out for blood” for daring to look into the matter. At least the students will be well-prepared for futures as politicians.

Also in Boston, a federal judge ruled that the state of Massachusetts must pay for a sex change operation for a prisoner serving a life sentence for murdering his wife. The Wall Street Journal reports that this prisoner has been receiving female hormones since his diagnosis of gender identity disorder in 2003. The judge noted that the murderer may receive better care for his problem than many law-abiding Americans.

A judge in England has let a burglar off without jail time while praising him. According to the BBC, the judge said, "It takes a huge amount of courage, as far as I can see, for somebody to burgle somebody's house. I wouldn't have the nerve." Prime Minister David Cameron had a dim view of the judge’s remarks.

As a charity fundraiser, donors in Japan were offered the opportunity to squeeze the naked breasts of young women, described as "adult video actresses." For an unspecified amount of money, one was allowed two squeezes per hand.

Whatever happened to personal contact?

Not long ago, I attended a retirement party for a former colleague. He had been a surgeon for 43 years at a hospital where I was once chairman of surgery. A number of old friends and colleagues whom I hadn’t seen for a long time were there. The event was so enjoyable that I said to the guest of honor, “This is a great party. You should retire more often.”

Later that evening, my wife, who is noted for profound observations, remarked that it is too bad that we don’t see people in the same way anymore. She pointed out that although we interact electronically in so many ways, we aren’t as personally connected to many of our friends and acquaintances as we once were.

That led to a discussion of the atmosphere permeating medicine today. Back in the day, physicians used to socialize more. In most hospitals, there were doctors’ dining rooms or designated tables in the cafeteria where a rolling group of docs from many disciplines would have lunch and chat about difficult cases, the hospital administration, politics and many other topics.

There’s no longer a need for such things since no one has time for lunch nowadays and the hospitalist movement has succeeded in eliminating the primary care doctors from the hospital environment. I have been practicing at the same hospital for over three years and have never even met 95% of the local primary care docs.

Something is lacking when you aren’t able to attach a face to a name.

Are these are just the ramblings of an older doctor longing for “the good old days”? Or is this another reason why a lot of us don’t enjoy practicing medicine as much as we used to?

Reflections on retirement

As I contemplate retirement from clinical practice as a general surgeon, something I've been doing for over 41 years including residency, I've been having some unsettling thoughts.

Like many physicians, I've tried to stay somewhat emotionally detached from my patients. You must maintain some distance in order to be able to make tough decisions and to keep on doing surgery for so long.

I have written in a previous blog about the effect of complications on the psyche of a surgeon, realizing of course, the patients and their families suffer even far more than I do. I’ve always taken complications personally, but lately I’ve been more acutely aware of this issue.

As I reach the end of my career, I find myself empathizing more and more with the plight of my patients, especially since many of them have somehow become younger than I am.

 

There are things you don’t think about when you are 40 or even 50 years old. I find myself making a long mental list of diseases that I hope I never get. Lately, I've been pondering a real conundrum. Which is worse, growing old and becoming demented with a body that still has many miles left on the odometer, or having the body break down and remaining lucid enough to realize what a mess you are in?

 

I haven't settled that issue yet but I'm leaning toward dementia as long as I'm pleasant. Unfortunately having been a cranky bastard for pretty much my entire life, I think I'm more likely to be a disagreeable if dementia sets in, so maybe the sound mind/unsound body option would be a better deal for my family. Too bad they don’t get to choose. Nor do I.

I would prefer neither. In an attempt to postpone physical deterioration, I've been exercising regularly and am in the best shape I can ever recall, including when I was in high school.

If you’ve been following me, you know that for mental gymnastics, I've been blogging about three times a week for the last two years. I plan to continue writing for long as I can coherently put two sentences together.

Perhaps it is the end of summer that has made me melancholy. Or possibly it’s realizing that very soon the way I have defined myself for the last 41 years will no longer apply. Let’s look at the bright side. At cocktail parties, people who used to ask me for medical advice will probably think twice knowing that I’m retired. Instead maybe they’ll start asking when does “its” take an apostrophe.

A version of this post appeared on General Surgery News on 8/27/2012.

Hospital installs hand washing surveillance cameras

Doctors and nurses in the ICU at Long Island’s North Shore University Hospital are being watched by 39 video cameras in an effort to increase compliance with hand washing. According to a report hand washing compliance is up from less than 10% to 90% since the program started.

Cameras are positioned near the doors of patient rooms and at sinks Patients are not being videoed. The real-time feed is observed by workers in India. Staff failure to wash hands is noted, and the results are posted on electronic bulletin boards in the unit. So far, miscreants are simply talked to.

"No one's been fired, no one’s been written up but there have been one-on-ones," the news story says and, “Infections have decreased though an exact percentage was unavailable.” That raises the question of how they would know if infections have really decreased if the exact percentage is unavailable. And there’s another question, “Is the decrease statistically significant?”

This venture, while well-intended, seems like a bad idea to me. I suppose you are thinking, “Could Skeptical Scalpel really be against hand washing?” Well, I’m not. But what seems logical and correct sometimes may not be. For example, everyone knows that sinks with faucets that have electronic eye sensors are cleaner and better to use in hospitals than sinks with manual faucets, right?

A study presented at a meeting of the Society for Healthcare Epidemiology of America last year by a group from Johns Hopkins concluded the following: Electronic faucets were more likely to become contaminated with Legionella spp. (species) and other bacteria after water system disruption. Electronic faucets were less likely to be disinfected after chlorine dioxide remediation. Electronic faucet components may provide points of concentrated bacterial growth. These findings led to removal of all electronic faucets from clinical areas in our institution. [Emphasis added.]

Washing hands with soap and water may cause dryness and irritation resulting in skin breakdown. It may be that constant, obsessive hand washing and use of gels could promote the emergence of resistant organisms.

Another potential issue with the video observation is a false accusation of failure to wash. Patient rooms and patients themselves are not being watched. Let’s say a nurse went into a patient’s room to tell him something and didn’t touch anything. A person in India watching a video from a camera focused on a door or sink would not be able to tell that. If the nurse doesn’t wash her hands when she leaves the room, is she going to be cross-examined?

And what about cost? How much does it cost to install and maintain 39 video cameras, stream the video to India and pay people there to watch the monitors and feed back the information 24 hours per day? Remember, they have no proof that video surveillance reduces infections.

What does this scheme say about the relationship of the professional staff to the hospital’s administration? More problematic is the fact that even though they know they should, doctors and nurses at a major medical center apparently cannot be trusted to wash their hands unless they are spied upon. What else do they not do?

Instead of issuing press releases about this ill-advised program, hospital management might want to consider investigating why their staff is non-compliant.

Civility is Disappearing. Why?

A while back, USA Today reported on the declining civility on college campuses citing numerous anecdotes such as Yale women taking offense at frat boys shouting sexist slogans, the online video resulting in a Rutgers student's suicide and a UCLA student's YouTube rant against Asians.

There is a bigger issue which is the decline of civility in general. For example, political discourse is at an all time low on the civility scale.

It may not have started on the Internet, but it certainly serves as a convenient platform for incivility.

Take the USA Today story mentioned above. If you look at it on-line, you will find numerous malevolent comments, many of which have nothing to do with the story itself but rather are directed toward previous commenters, including the following:

What's it like to go through life with no IQ like you do?

Would it be asking too much to put a verb or semicolon in a sentence?

The best thing these idiotic "scholars" can do for America is volunteer to go to Afghanistan and clear minefields by walking across them. Of course, in that they're not patriotic, they won't...

These sissy-chicks (all liberals, of course) make real women look bad. Go back to your mommies and leave normal people alone.

Encourage respect and tolerance? Why is it these LEFTIST professors NEVER encourage respect and tolerance towards individuals promoting a CONSERVATIVE viewpoint. Instead, they try to CENSOR any political viewpoint that is not in LOCKSTEP with their LEFTIST AGENDA. HYPOCRITES!!!!!

WELL, IN THE NAME OF FREE SPEECH I WILL FIGHT BACK IF SOMEONE START TELLING ME UGLY OR RACIST NAMES. I HAVE PLENTY OF AMMUNITIONS SO WE'LL SEE WHO GAVE UP FIRST.

I agree with many who say it is about the anonymity that the Internet provides. As one of the more coherent commenters pointed out, many of the rants would not have been made if real names had to be used. As a by-product of the decline in civility comes a decline in grammar, spelling and punctuation.

This trend has infected Sermo, a doctors only on-line community, as well.

Here are two excerpts from comments on a post of mine on Sermo from three weeks ago:

A surgeon: Also no need for me to see the film or examine the patient, although of course I did both, you ass.

A radiologist: Well, it seems, surgeon, if you have a radiologist who cannot tell "worsening bilateral pneumonia" from atelectasis, you are working in a hospital with perhaps suboptimal radiologists. As for the "you ass" part, FUCK OFF pissant.

I doubt that exchange would have taken place in the cafeteria or the doctors' lounge.

What do you think? A version of this post appeared on Sermo yesterday and the few who commented all felt that civility is declining and most agreed that the Internet was fueling that decline.

Plastic surgeon in trouble for aggressive billing practices

There’s a big Internet dustup about a California plastic surgeon who is being sued by the state to stop her aggressive billing practices. The state medical board is investigating her for possible illegal balance billing and may remove her medical license.

The LA Times ran a story documenting the plight of a patient who cut off the tip of a finger. In the emergency department, he requested the services of a plastic surgeon. The doctor saw the patient and had him sign an agreement to pay for what she was about to do.

It is not clear exactly what was done in this case, but apparently, all the work took place in the ED. The surgeon billed the patient $12,630.00 and received $3500.00 from the patient’s insurance carrier, which she refused to accept. She billed the patient for the entire amount and sued him when he didn’t pay. She also started a process to force the patient to sell his house in order to pay her.

Some doctors are defending the surgeon. For example, the blog White Coat Call Room said, “Suing a doctor and trying to revoke her license because she wants to get paid the asking price for her services? If people don’t want to pay her price, then don’t use her. Go see another ‘professional.’”

The LA Times article was posted on Sermo [free registration required & restricted to licensed MDs] and has yielded over 280 comments, a large majority of which are sympathetic to the surgeon.

There’s a lot more to this than you think.

Some have pointed out that patients often request a plastic surgeon unnecessarily. I agree with that. But such consults are often instigated by the ED staff and no discussion of costs or fees ever takes place. I spent 24 years as a surgical department chairman fielding complaints about this sort of case from both patients and surgeons.

Although the patient may have agreed to pay the surgeon, it is not clear from the LA Times account that he was made aware of what the fee would be before signing.

Some have suggested that because the surgeon was “out of network,” she could bill whatever she wanted to. Nonsense. She was covering the ED. She had an obligation to treat emergencies. Fees must be reasonable.

The fee of over $12,000.00 is outrageous for any procedure done in an ED and particularly for what seems to have been a simple fingertip repair. The $3500.00 payment from the patient’s insurance company seems quite generous to me.

The surgeon has a pattern of this behavior having filed more than 50 breach of contract lawsuits since 2010.

Most damning of all, the LA Times notes, “She attended law school at UC Berkeley, though she is not licensed to practice law in California.” Too bad. She would be a great lawyer.

To me, the plastic surgeon is simply greedy.

These are the kinds of stories that make all doctors look bad. Is it any wonder that people resent us and don’t respect us as much as they once did?