Wednesday, May 27, 2015

Duke Docs Who Attached Intestine to Vagina Must Stand Trial

Catchy headline, isn't it?

That headline appeared two years ago on the Outpatient Surgery website. Too bad it wasn't accurate.

This case has been a topic on the Internet off and on for a few years. Although the patient's surgery took place in 2008, the malpractice trial did not occur until earlier this month.

Like nearly every news media article about malpractice incidents, details were sketchy and sensationalism was featured.

Also common in cases like this that although many stories appeared about the case before the trial, but few reported the verdict. That is because after deliberations lasting less than one day, the doctors were not found guilty of negligence.

According to a story on the only media outlet reporting the verdict—Courtroom View Network, here's what happened.

The patient underwent surgery for debilitating chronic constipation at Duke University Medical Center in 2008. Postoperatively, she developed a recto-vaginal fistula [a tract or tunnel from the rectum to the vagina] due to a portion of vaginal wall being caught in the surgical staple line when the intestine was reconnected. The problem was corrected by a second operative procedure.

Prior to the first case, the patient had been informed that secondary procedures might be necessary if complications arose.

The malpractice suit was originally denied by a lower court because the plaintiff could not find an expert witness to testify that negligence had occurred, but an appeals court ruled that an expert was not necessary because "even a layperson would be able to determine whether or not negligence occurred," and "It is common knowledge and experience that intestines are meant to connect with the anus, not the vagina, even following a surgical procedure to correct a bowel problem."

Although the second operation solved the patient's problem, she claimed that she had suffered a conversion disorder causing slurred speech, tremors, and weakness. However, subsequent treating physicians felt that her symptoms were inconsistent and that she was "trying to appear disabled."

This case illustrates several important principles about medical malpractice cases.

They often take a long time—an average of 4 to 5 years—to be resolved.

Every less-than-perfect outcome is not necessarily due to negligence. Recto-vaginal fistula is a known complication of this type of surgery.

Stories from 2013, when the appeals court said the case could go to trial and from this year just before the trial started, implied that the surgeons had mistakenly attached the intestine to the vagina which many of us found hard to believe. But without knowing the details, we could only speculate.

The jury did not believe the alleged damage—a conversion reaction—was real.

This lawsuit, which cost both the plaintiff's attorney and the defendants' insurance company a lot of money and dragged two highly competent and respected surgeons through the mud for 7 years, should never have gotten off the ground.

There was a reason that plaintiff couldn't find an expert to testify that negligence occurred. The intestine was never mistakenly "attached to the vagina."

Wednesday, May 20, 2015

Effects of acupuncture on pain and inflammation in pediatric appendicitis

A paper [full text here] from The Journal of Alternative and Complementary Medicine says that "acupuncture may be a feasible and effective treatment modality for decreasing subjective pain and inflammation" in pediatric patients with appendicitis.

They studied six adolescents with appendicitis and administered acupuncture for pain control prior to surgery. Pain was assessed using three analog scales, and inflammation was measured using serial white blood cell (WBC) counts and C-reactive protein levels (CRP). CRP is a nonspecific indicator of inflammation in the body.

Figure 2 from the paper summarizes the results.

You can see that after 20 minutes of acupuncture, all three pain scores and WBCs declined. However, CRP continued to rise. Conspicuously absent from the figure and the text of the paper are any statistical analyses. This is due to the lack of a significant difference in any of these values because of the limited number of subjects studied.

Monday, May 18, 2015

A new surgeon confronts self-doubt

A chief resident about to graduate wrote the following to me:

I just read—twice—The New Yorker's review of Henry's Marsh's [a renowned UK neurosurgeon] memoir you tweeted about. Wow.

It seems like he is grappling with so many of the things I'm feeling now, as I'm trying to sort out if I'm trained "enough" to head out into the world. Of course, Marsh is at the other end of his career. So fascinating how the same anxieties can flourish and grow in entirely different soil.

I want to read the book, but I wonder if now is the right time. Seriously! Might be better to wait a few years.

Only 38 more days to go until I complete residency.

Congratulations on finishing your training and becoming self-aware.

When I was a program director I used to laugh at residents who felt that they were so stressed. I would say to them, "If you think you're stressed now, wait until you're on your own and have to make a life-and-death decision in the middle of the night with no attending surgeon backup."

I haven't read Dr. Marsh's book, but the excerpts had an impact on me as well. I've been retired for 2½ years, and I still go over complications and mistakes in my mind. Even now, it is so real for me that sometimes I can't sleep.

Wednesday, May 13, 2015

CPR in space is possible, maybe

Last summer I wrote about the many problems associated with performing surgery in outer space. [Link here.]  Not surprisingly, I was highly skeptical about such issues as training astronauts to operate on each other and the difficulties in taking along enough supplies to deal with unexpected trauma and surgical diseases.

At least one commentor on that post felt that NASA had all the answers. But another said, “What NASA never wants to discuss publicly is the scenario: If X happens then you die.”

Not to be outdone, the European Space Agency recently released a YouTube video illustrating how cardiopulmonary resuscitation could be carried out in a weightless environment.

You can see that the technique is rather awkward and questionably effective. To my knowledge, the rescuer falling on the victim is not currently recommended in the latest CPR guidelines.

Assuming that by some miracle the victim survives CPR, what would happen to him? Would he be transferred to the intensive care unit on the spaceship? Would there be a ventilator? What about an endotracheal tube and someone to insert it? Who would monitor the patient? Would that person be subject to work hours limits?

Here’s what I think.

If you have a cardiac arrest on the way to Mars, you’re not only in deep space, you’re in deep doodoo.

Saturday, May 9, 2015

Problem with my blog. I need your help

I have a big problem.

For the last 10 days, Twitter has been blocking me from tweeting any links to my blog.

This is the message I get whenever I try to send a tweet with "" in it.

I have tried to contact Twitter through @twitter and @support four times and have received no reply, nor have they replied to numerous ticket requests through the Twitter Help Center.

I discovered a site called which compiles reports from 63 different programs that detect viruses, worms, trojans, and malware.

Originally a site called BitDefender claimed my site was malicious. The next day, BitDefender declared my site was clean, but AutoShun, which previously had no problem with my site, said it was malicious. The following day, AutoShun said my site was unrated and Clean MX said "malicious." But the day after, AutoShun went back to calling it malicious and Clean MX said my blog was clean. At no time, did more than one of the 63 detection programs identify my blogsite is being malicious.

You would think that if my blog contained any suspicious programs, more than one of the 63 virus detection organizations would have come up with a positive result on the same day.

None of the programs saying my blog was malicious gave me any clue as to what part of my site was supposedly creating the problem.

I attempted to get some help from Blogger, which hosts my blog. Although one person on a forum responded with some advice, it wasn't enough for me to solve the problem.

My blog is averaging 1600 page views per day. Not one person has contacted me to complain that I am harboring viruses or any other malicious software. That is because, to the best of my knowledge, no such malicious software exists on my blog.

Maybe it would help if you would go to the results section of the virustotal website and cast your vote in favor of my site as not being malicious. In the upper right-hand corner of the site you will see this cartoon.

 Please click on the green face to support my blog.

Meanwhile, I have discovered an interesting workaround which enables me to tweet links to my blog, but visitors to the site will still be blocked by Twitter from tweeting links.

If you consider yourself computer-savvy, maybe you can figure out how I did it. If you think you know the answer, please submit a comment.

I also would welcome any comments or suggestions that could help to resolve my problem. If anyone knows a way to contact a human at Twitter, please let me know.


Wednesday, May 6, 2015

Problems with surgical residents and continuity of care

How are we doing with residency training and continuity of care? Not too well if you believe a recent paper called "Continuity of Care in General Surgery Resident Education" appearing online in the American Journal of Surgery.

A group from Rush University in Chicago looked at the records of 228 patients who underwent commonly performed operations during the year 2012. They found that in only 21/228 (9.2%) of cases had the operating resident seen the patient preoperatively, and in 20/223 (9.0%) had the operating resident seen the patient in postoperative follow-up. In no case, did the operating resident see the same patient both pre- and postoperatively.

The table lists the type of cases and the frequency of resident participation in preoperative care or postoperative follow-up.

This is important because on page 18 of the Residency Review Committee (RRC) for Surgery Program Requirements for Graduate Medical Education in General Surgery, the following is stated: