Friday, June 28, 2013

Blakemore tubes. Should an inexperienced surgeon use them?

In response to a comment mentioning Blakemore tubes on my post about what surgery was like in the 1970s, I said they were instruments of the devil.

This sparked the interest of surgeon who works in a rural hospital with minimal endoscopy services. He emailed me and asked if I thought he should have Blakemore tubes available for use because he might have to transfer a patient with bleeding esophageal varices over a long distance for definitive treatment.

He trained in the early 21st century and admitted that he did not remember ever having seen a Blakemore tube. He wondered why I didn't like it.

I have witnessed all of its major complications such as tube dislodgement, necrosis of the nose and lips, aspiration, esophageal perforation, airway occlusion and death.

Without any hands-on experience, he probably should not try to use the device. In addition, the average nurse would likely also not be familiar with caring for a patient with the tube.

On the other hand, maybe as a last resort he could try it.

I had planned to write a post about the Blakemore tube, its insertion, maintenance and complications. But while researching it, I found that others had done so, and better than I.

Read this excellent article on Medscape. Registration is required, but it is free. It covers everything you need to know about Blakemore tubes.

And here is a link to a nice video from the Yale GI service that demonstrates the steps required to safely insert and manage them.

What do you think? After reading the Medscape piece and watching the video, should this rural surgeon, who has never personally seen a Blakemore tube, use it ?

Thursday, June 27, 2013

Are millennials cut out to be surgical residents?

When you hear this story, you may wonder.

Recently in a surgical residency program somewhere in the United States, the residents requested a meeting with their program director and surgical department chairman to discuss a concern they had.

A few of them were upset because during a 31-day month, one resident on a three-person rotation ended up working an extra night of call.

6/28/13 ADDENDUM#1: The residents who complained included some non-designated PGY-1s who were hoping to be converted into categorical residents if any such positions became available. This would not be perceived as favorable by those in charge.

I know that old guys like me aren't supposed to say things like this, but if residents had approached my chairman with a complaint like this, he would have thrown them all out of his office immediately.

Residents were summarily fired for lesser offenses than that too.

Despite my previous post about a Harvard Symposium that suggested we should train residents like Navy SEALs, I know we can't turn back the clock.

But people, there is something really wrong when residents start haggling about the number of days worked.

What's next? Requesting an extra hour off because you worked the Saturday to Sunday overnight when Daylight Savings Time ended?

I didn't see anyone volunteering to work an extra hour to compensate for the night the DST begins.

OK, tell me I don't understand this generation of residents. Tell me I'm out of touch.

But you won't convince me that there isn't something wrong with complaining about an extra day of call.

6/28/13 ADDENDUM#2 As pointed out to me in comments on Twitter, my post does not pertain to all millennials. I acknowledge that such a generalization was unfair.

Tuesday, June 25, 2013

What was surgery like in the 1970s?

When I first started my residency in the early 1970s, things were remarkably primitive by today's standards.

There were no ultrasound machines. Believe it or not, we would diagnose acute cholecystitis by history and physical examination alone. The only diagnostic tests we had were oral cholecystogram (OCG) and intravenous cholangiogram (IVC). For OCG, pills were taken the night before the test. If the cystic duct was patent, iodinated contrast would appear in the gallbladder and stones could be seen. Non-visualization of the gallbladder meant either the cystic duct was blocked or the pills were not absorbed (presumably due to inflammation, not necessarily of the GB) or the patient forgot to take the pills. The test was useless in acutely presenting patients. IVC was similar except the contrast was given intravenously. The common bile duct could be seen faintly unless the patient was jaundiced. It rarely showed stones in the GB.

There were no CT scans. We had to make the diagnosis of appendicitis by, you guessed it, history and physical examination alone. And since laparoscopic general surgery did not become common in the US until 1990, all appendectomies and cholecystectomies were done as open procedures.

There were no computers in any clinical departments or nursing units. Everything was on paper. The good news? There was no way to "copy and paste" progress notes. We had different colored paper for different sections of the chart, which made things easy to find. The bad news? Charts often went missing. Handwriting analysis rivaled that of archeologists deciphering hieroglyphics in Egypt. But paper charting was faster to do and easier to "leaf" through.

When submitting a research paper, drafts had to be prepared on a typewriter (an ancient kind of word processor that put the words directly on paper). If you needed to change a paragraph on page 1, the entire manuscript had to be retyped from the beginning. And making slides for presentations involved cameras with 35 mm film, taking the film to be developed and hoping the slides came out OK. Find a typo? Take the picture over and have the film processed again.

Now we use PowerPoint. It's easier, but I'm not totally convinced that it's real progress.

Maybe the biggest change has been the advent of the Internet. In the palm of my hand, I can instantly access huge amounts of information formerly available only in print books and journals. To look up a paper, we had to use Index Medicus, an encyclopedic series of books listing every article by subject in most journals.

There were far fewer journals back then. You had to know the correct heading or keyword to search or you could miss something important. Cross-referencing was not easy because it was in print and there was a different set of volumes for every year. And libraries kept many years' worth of volumes of journals.

Of course, many more changes have occurred. Can any of my older colleagues comment?

Monday, June 17, 2013

Two new posts up today

On Physican's Weekly, I explain why elderly patients don't get up and walk when hospitalized. Here's the link

On General Surgery News, I ask the question "How many authors does it take ...?" Here's the link

Wednesday, June 12, 2013

Vacation Notice

I will be out of the country for the next 10 days. I'm speaking at an international conference on surgical education and also visiting some friends.

On June 17, new posts will appear on General Surgery News and Physician's Weekly.

If you haven't been a regular reader, may I recommend some of my more popular recent posts?

School or scam?

Law school applications are way down. Could it happen to medical schools?

Why I don't watch medical TV shows

Thousands of errors are made by surgeons. Lots of comments.

Is normal saline bad for the kidneys?

Pregnant woman dies after ovary removed instead of appendix

On June 10, 2013 a 32-year-old "heavily" pregnant woman was reported to have died after having an ovary removed instead of her inflamed appendix. As the infected appendix festered, she became septic and succumbed to multiple organ failure. This tragedy occurred in the UK in late 2011, but has just come to light.

How could this have happened?

Let me count the ways.

The surgery was performed by two trainee surgeons. Their level of experience was not stated.

The senior staff, called consultants in the UK, had gone home for the day.

The operation to remove the appendix was apparently done as an open procedure, not laparoscopic, which is acceptable if done correctly. The articles say that the surgeons had to take out the organ by feel and not under direct vision, which is not proper.

Although an ovary can be enlarged during pregnancy, under no circumstances does an ovary look or feel like an appendix. As in another case described below, inflammation can cause confusion at times, but not to this degree.

The woman was discharged a week after the initial surgery but returned with pain some 10 days after the removal of the wrong organ. During that time period, no one had checked the pathology report. The mistake was discovered by a doctor reviewing the patient's records during the readmission.

An abscess was drained but the she died on the operating table during a futile attempt to at last remove the appendix.

Last week, the CEO of the hospital sent a written apology to the family promising to correct the dreaded "system errors." Too little, too late.

Yes, there were system errors.

But what about human errors?

Trainees were allowed to undertake a supposedly routine operation without supervision. However, as this case shows, an appendectomy during pregnancy can be very difficult. The uterus is in the way, and its increasing size may displace the appendix from its normal position. This type of surgery cannot be done by "feel" alone.

Commentary from UK physicians on Twitter suggests that all the facts of the case, such as what communications took place between the trainees and their supervisor, have not been made public. They also point out that it is not mandatory for a consultant to be present in the operating room for every case as is true of the resident-attending surgeon relationship in the US.

But I doubt that many US surgeons would allow residents to operate independently on a pregnant patient with appendicitis. At the very least, the attending would have been in the OR, if not scrubbed.

Did the trainees ask the consultant for help when they found themselves doing an appendectomy by feel?

The surgeons did not look at the pathology report, a major omission. But what about the pathologist? If a pathologist receives a specimen labeled "appendix," and he finds only an ovary, wouldn't the prudent pathologist pick up the phone and call the surgeon?

There is also "failure to rescue." When the patient was readmitted, earlier recognition of sepsis and more timely intervention might have saved her life.

I am aware of a similar case in which an inflamed piece of fat was removed by two unsupervised trainees who mistook it for the inflamed appendix. On the following day, the pathologist called the attending surgeon to tell her that the appendix was not present in the specimen. The patient was promptly taken back to surgery. He wasn't too happy, but he was alive.

The hospital's investigation of this case should have taken a few days at most. If the media reports are true, disciplinary measures and remediation should have been promptly instituted. An apology should have been offered far sooner than it was.

“An extensive trust-wide action plan was drawn up following Mrs De Jesus’ death in 2011 to ensure that such a tragic incident will not happen again" and "… to improve systems and patient safety," said the hospital's CEO.

As I have blogged before, system changes can be instituted, but can be defeated easily by carelessness, inattention and lapses of common sense by one or more individuals.

Stories about this from the UK media here and here. Search this blog for "system error" to view other posts on system errors.

ADDENDUM April 15, 2014
For some follow-up on this sad story, click here.

Wednesday, June 5, 2013

A med student with issues wants to be a general surgeon

A medical student with some major issues wants to be a general surgeon.

Check out the question and answer on the Ask Skeptical Scalpel blog.

Tuesday, June 4, 2013

Comments you haven't seen on my blog

A while ago, I wrote about an alleged school for medical assistants that had unleashed a massive spam attack on my blog. For a while, the spam kept coming even after I posted my investigative report blog about the inadequacies of the school.

They finally gave up, but other spammers persist. I have noticed a common thread which is that spammers are either illiterate, careless or maybe both.

I thought you might enjoy some of the spam that I've blocked from appearing in the comments section of my posts. I have omitted the many links to their websites, but otherwise have not altered the text at all.

Here goes. Some must be read aloud for maximum effect. The comments are in italics. [My thoughts are in brackets.]

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