A patient wants to know when to speak up

A reader asked if I could discuss how to question a doctor without being a nuisance.

Read the question and answer on "Ask Skeptical Scalpel."

Monday Mornings: The second episode

Since my review of the first episode of the new medical drama “Monday Mornings” generated quite a few comments, some of which thought the show had promise, I thought I’d give it another chance.

Although I have started to like a couple of the characters, particularly Dr. Sung and the sassy Dr. Napur, the medical portions of the show continue to disappoint. Dr. Sung said his evolving catch-phrase “Not do—dead” at least four times and hit a milestone as he uttered a complete sentence during the show.

Dr. Villanueva, the trauma surgeon, managed to diagnose trichinosis after a brief (and I do mean brief) laying on of hands and two questions. Trichinosis is a roundworm disease caused by eating raw or undercooked pork. The CDC says there are fewer than 20 cases of trichinosis reported in the US yearly and most of those come from eating game such as wild boar. The domestic pork supply is virtually free of the problem. I am familiar with the trauma surgeon community. I doubt that many of them could have picked out that zebra.

Dr. Tina Ridgeway, the female neurosurgeon who is destined to hook up with the hunky neurosurgeon with nightmares (another Dr. Jekyll? See “Do No Harm”), presented a case at M&M conference. The patient, a chef, suffered olfactory nerve damage during a craniotomy for a meningioma. She acknowledged that she relied on the resident to obtain informed consent. This is not permitted in most hospitals. The chief of surgery then castigates her for allowing the resident to do the case. When I was a chief of surgery, I usually was faced with the opposite problem. Some of the attending staff were not letting the residents do enough.

By the way, Dr. Hooten calls himself “Chief of Staff” and he never takes care of any patients. While it is true to life that many administrators don’t actually treat patients, I know of no surgery department in which the chief does not operate. It is very easy to criticize others if you don’t ever have to get in the line of fire yourself.

The transplant scenes lacked realism. The doctor who wants the organs cannot go around and ask for them. Ethically, he must refrain from any hint of solicitation. When organs are donated, they are distributed by a network of organ banks. They rarely would stay at the procuring hospital. There are waiting lists and priorities. Donor families and recipient families would never be in the close proximity that was depicted in the show.

I liked it at M&M when the chief said to the evil transplant surgeon, “Tell us how you’ve been bad.” I wish I had thought of that one when I was running those conferences.

The story line about the girl with the brain tumor was good except for the part where the trauma surgeon helps talk her into agreeing to the operation. He’s a versatile guy. But really, a grand piano in the lounge?

Why is everything so dark at the hospital? Is there a problem with the power grid? I’m waiting for someone to ask for a flashlight.

The show is better at character development than medicine. Maybe they should stick to the former.

“Do No Harm” is “Down the Drain.”

Late yesterday, NBC canceled the series “Do No Harm” after just two episodes.

You may recall that I blogged on January 31^st about the comically inept medicine portrayed in the first three minutes of the show’s pilot. The show’s premise that a modern day Dr. Jekyll and Mr. Hyde who had nightly 12-hour blackouts could be a practicing neurosurgeon with what appeared to be the open knowledge and support of his colleagues and the hospital administration was far-fetched, to say the least.

The viewers voted with their feet—making “Do No Harm” the lowest rated debuting series in the history of the big four (NBC, CBS, ABC, Fox) networks.

The second episode, which I’m told featured the neurosurgeon drilling a burr hole (to alleviate pressure in the skull) on a man pinned in a car at the scene of an accident, drew even lower ratings than the first.

Perhaps having an inkling of what was to come, Steve Pasquale, the show’s leading man, told the Huffington Post before the premier “Ultimately in this scenario, I'm just the actor who's saying the words."

My question is who thought this was a good idea? I can try to imagine the meetings where the idea of a modern day Dr. Jekyll who had to be home by 8:25 every night and did medically impossible things during the day was pitched. People with money and experience in television apparently sat there and said “What a great premise.”

Are those who make TV shows and movies so far out of touch with reality?

H. L. Mencken said, “Nobody ever went broke underestimating the taste of the American public.” In this case, he may have been wrong. The American public apparently has its limits.

Why supplemental oxygen is not considered a performance-enhancing drug

You often see a football player on the sidelines breathing oxygen after running a long distance or having worked hard during a long series of plays.

Have you ever wondered if it works? Does breathing a high concentration of oxygen help an athlete recover from exertion faster?

The answer is a resounding “No,” and here’s why.

In healthy people, such as college and professional football players, nearly all of the oxygen in the blood is carried by hemoglobin. Only a very small percentage is dissolved in blood. Saturation defines the oxygen that is attached to hemoglobin and partial pressure of oxygen is that which is dissolved in blood.

Definitions: SaO2 = arterial oxygen saturation, Hb = hemoglobin, 1.34 mL is the amount of oxygen a fully saturated gram of hemoglobin can carry, Pa02 = partial pressure of oxygen or the amount of oxygen dissolved in blood

If an athlete has a normal Hb level of 15 gm, a SaO2 of 100% and a PaO2 of 100 mmHg, the formula used to calculate his blood oxygen content is

[Hb X 1.34 X (SaO2/100)] + 0.003 X PaO2 or

[15 X 1.34 X 100/100] + 0.003 X 100

20.1 + 0.3 = 20.4 mL/100 mL of blood

So, only about 1.5% of the oxygen content of blood is dissolved.

If an athlete raises his PaO2 to 400 mmHg by breathing pure oxygen the calculation is

[Hb X 1.34 X (SaO2/100)] + 0.003 X PaO2 or

[15 X 1.34 X 100/100] + 0.003 X 400

20.1 + 1.2 = 21.3 mL/100 mL of blood

Even at a PaO2 of 400 mmHg, only 5.6% of the oxygen content of blood is dissolved. Note that hemoglobin cannot be more than 100% saturated with oxygen.

Very soon after the athlete stops breathing the pure oxygen, its minimal effect disappears. It’s simply not enough to affect recovery or performance.

Possibly because the basic science is well-understood, there have not been too many papers on this subject.

Here’s one from JAMA that looked at 12 soccer players given 100% oxygen or placebo after exertion. Then they had to exercise again. “The administration of enriched oxygen during the recovery period had no effect on plasma lactate levels [an objective measure of recovery] or on performance during the second period of exercise. The subjects were unable to identify which gas they received.”

A similar study of 13 athletes from Medicine & Science in Sports & Exercise concluded “These findings offer no support for the use of supplemental oxygen in athletic events requiring short intervals of submaximal or maximal exertion.”

Another from the European Journal of Applied Physiology found that giving athletes supplemental oxygen during the recovery periods of interval-based exercise improves the recovery time of SpO2 [equivalent to SaO2] but did not improve post-exercise markers of reactive oxygen species or inflammatory responses because the improvement in saturation was clinically insignificant.

The situation is explained in simple terms in an excerpt from the book Exercise Physiology: Integrating Theory and Application. It concludes that supplemental oxygen may have a placebo effect, but there is “no real physiologic benefit.”

If you Google “supplemental oxygen and athletes,” you will find a number of websites touting the supposed benefits of inhaled oxygen. They are almost all supported by companies that sell oxygen.

Bottom line: Supplemental oxygen is not considered a performance-enhancing drug because it doesn’t work.

Thanks to  Dr. Joel Topf (@kidney_boy ) for suggesting this topic.

“Monday Mornings” Review Part 2

Yesterday I posted a review of the new medical drama Monday Mornings. I based it on a 5-minute preview that was available on line.

I was very critical of the way surgical M&M conference was portrayed. Then I thought maybe 5 minutes wasn’t enough. Against my better judgment (again), I watched the whole show.

I stand by my first impression. The show is a typical medical soap opera filled with the usual array of doctors—the arrogant one, the beautiful one, the arrogant and beautiful one, the black guy, the Asian guy, the devious one, the vulnerable one, etc.

Forgetting about the acting and the heavy handed directing (extreme close-ups, focusing back and forth, quick cuts) and the funereal music, I will just point out a few errors and implausible medical situations.

A child bumps his head playing soccer and appears fine. The ED docs order an MRI “as a precaution.” (And you wonder why the cost of medical care is so high?) It shows a large brain tumor which the arrogant neurosurgeon declares is an emergency that requires surgery that same morning. The patient has uncontrollable bleeding and his blood pressure drops accompanied by blood squirting out of his head, which I have never seen happen especially since the kid was hypotensive. No code is called, but the neurosurgeon without even applying pressure or packing the bleeding area, opens the chest and does internal cardiac massage. Since there was no chance that would work, it didn’t. He is understandably upset. (More about this later)

A woman is brought in as a possible “suicide by car” because there were no skid marks. She is intubated but moving. The chief of trauma walks by, shines a flashlight in her eyes and declares that it was not a suicide, but rather a bomb went off in her head. He means she had a hemorrhage. She then undergoes surgery for a brain aneurysm. There is no way that he could have made that diagnosis with a flashlight. The patient would have had a CT scan anyway since even kids who have no signs or symptoms of brain injury get MRIs in that hospital.

There is a Korean doctor who is one of the worst stereotypes I have seen in recent memory. His command of the English language is limited to 3-word sentences and his bedside manner calls to mind Donald Trump. When asked whether a procedure he recommended was really necessary, he replied, “Not do—dead.” He was told to improve his English by the chief of surgery in a hallway conversation. He also grilled the med students without mercy. However, he is a genius at deep brain stimulation.

At the end, the neurosurgeon who lost the child on the table (I will omit the part where he has a flashback to his own childhood) has to face the music at (da-da-da-dum) M&M conference. It comes to light that the tumor was much worse than anticipated and the kid would have died anyway, but the crafty chief of surgery was holding back a card. He somehow found out that the child’s estranged father had Von Willebrand’s disease, which the neurosurgeon was unaware of. It usually is a very mild bleeding disorder and would not cause fatal hemorrhaging. The type that does cause hemorrhaging would surely have come to light with easy bruising or other issues in at 10-year-old boy. And wouldn’t the mother have known about this and told the surgeon? After all, the chief of surgery knew. The neurosurgeon was appropriately beside himself about this and refused to be consoled by the pretty one who no doubt he will hook up with in a future episode despite the fact that she is married.

In the final scene, which is one of the few believable parts of the show, the chief of trauma tells the neurosurgeon that a trauma case is on the way in and he needs to pull himself together.

As we have all been in the position of feeling terrible about a complication or death but had to go back to work the next day, that scene at least rang quite true.

More on choosing a specialty and work/life balance

Just posted on "Ask Skeptical Scalpel"

Work/life balance. A med student's wife asks how to choose a specialty that will make both her and her husband happy.

Here is a link to that question and answer.

New weapons in the war against obesity

Just when you think you’ve seen everything, along comes the AspireAssist. This device, not yet FDA-approved, consists of a tube implanted in the stomach which leads to a port which is exposed on the surface of the abdomen.

Now, I’m not making this up.

You can eat whatever you want. Then 20 minutes after your meal, you attach a pump to the port and siphon and lavage the contents of your stomach into a bucket or basin, I guess. The manufacturer says that this will remove about a third of what is eaten leading to weight loss if done after every meal.

It doesn’t tell you how to gracefully dispose of the contents of the stomach, especially if you are dining at say, McDonald’s.

The only research on this product is in the form of a poster that was shown at a meeting of the Obesity Society in October of 2011. It was a randomized prospective trial of 11 patients who received the device plus “lifestyle intervention” compared to 7 patients who had only “lifestyle intervention.” It was funded by the maker of the device.

Ten subjects completed a year with the device vs. only 4 who stuck with the lifestyle intervention. Baseline characteristics were similar for the two groups. Percent weight loss and absolute weight loss were significantly greater in the device group. The average one-year weight loss was 20 kg.

However, 10/11 patients had pain more than 4 weeks after surgery and irritation and bleeding at the stoma occurred in about half the patients. Two had infections at the site. Constipation occurred in 6 patients and anemia in 4.

If you can stomach it, there is a video at the company’s website. Thankfully, it’s an animation.

Medgadget describes the concept as “high-tech bulimia.”

If that doesn’t appeal to you, how about something more simple?

Introducing the “smart fork.”

A flashing light and vibration tells you when you are eating too fast. It monitors how long it takes you to eat your meal. It has Bluetooth and USB connectivity so you can upload data to your phone or computer. Here’s an excessively overproduced video explaining it.

But wait, there’s more—it’s dishwasher safe, as a view from inside the dishwasher shows.

As far as I know, Ron Popeil has nothing to do with this product.

At least it looks a lot less messy than washing out your stomach through your abdominal wall.

I don’t think surgeons doing gastric bypasses have anything to worry about just yet.