Thursday, May 25, 2017

Are incentive spirometers useless?

Has this ever happened to you? You walk into a patient's room on postoperative day 1 and find the incentive spirometer still in its plastic wrap. And it's on a windowsill 10 feet from the patient's bed.

Here's another question. Does it matter?

A friend just had a 4-vessel CABG at a major academic center. Despite a lack of evidence that incentive spirometers are effective, he was told to use one in the hospital and to use it hourly at home which he has faithfully done.

That’s right. The effectiveness of incentive spirometry in postoperative cardiac and abdominal surgery patients has never been proven.

Three Cochrane Reviews (2007, 2012, 2014) have been done. In the 2014 review analyzing 12 studies with 1834 subjects who underwent abdominal surgery, the authors noted problems with study methodologies and lack of data on compliance with the use of spirometers. For preventing pulmonary complications, spirometry was not superior to deep breathing exercises or no respiratory intervention at all.

Monday, May 22, 2017

Finally, evidence clarifies the surgical caps controversy

A study of clean surgical cases found no significant difference in wound infection rates for 13 months before and 13 months after the use of bouffant surgical caps became mandatory. Infection rates for the 7513 patients operated on when surgeons were allowed to wear traditional skullcaps, was 0.77%, and for the 8446 patients who had surgery after the bouffant cap mandate, the infection rate was 0.84%. Subgroup analyses of only patients having spine or cranial operations showed similar insignificant differences in wound infection rates.

The study, from a group in Buffalo, New York, was published online in the journal Neurosurgery.

At the 2017 Americas Hernia Society meeting, Dr. Michael Rosen, director of the Cleveland Clinic Comprehensive Hernia Center, presented the results of a survey of 86 surgeon members of the society's quality collaborative.

Ventral hernia repairs were done in 6210 patients with a 4.1% incidence of wound infection. Risk factors for surgical site infection were obesity, hypertension, width of hernia, operation duration greater than two hours, and female sex. The type of cap worn was not associated with the occurrence of a wound infection or any other surgical site complication such as seroma, wound dehiscence, or enterocutaneous fistula.

Of the 79% of surgeons who responded, 48% said they wore disposable skullcaps, 9% wore cloth skullcaps, 29% wore bouffant caps with ears exposed, and 16% wore bouffant caps covering their ears.

[I know that adds up to 102%, but that's what the General Surgery News article about the paper said.]

The report mentioned a series of postoperative infections caused by a mycobacterium at an Israeli hospital in 2004. At the time, a newspaper account of the 15 breast plastic surgery patients said an investigation found the source was a surgeon whose hair and eyebrows were colonized from his home Jacuzzi.

In 2016, the surgeon published a paper about the incident. The organism had never been identified before and was christened M. jacuzzii. Several patients suffered persistent infections and required removal of implants. In the paper, the surgeon revealed he wore a standard paper cap [presumably a skullcap] and the organism was also found on his facial skin.

While some might suggest this paper justifies the use of bouffant caps, the surgeon could still have contaminated the operative field with organisms from his facial skin or eyebrows. Other than with a space helmet, complete coverage of the eyebrows and facial skin is impossible.

The paper from Buffalo had some limitations. It was from a single hospital and was not a randomized trial. However, it was sufficiently powered to detect a difference in infection rates.

The hernia study was not as scientifically rigorous as the Buffalo study, but enough procedures were analyzed to detect a difference in infection rates had one been present.

In the GSN story, the Association of periOperative Registered Nurses (AORN) response to the American College of Surgeons statement supporting the use of skullcaps was quoted. “Wearing a particular head covering based on its symbolism is not evidence-based [nor is the AORN's bouffant cap rule] and should not be a basis for a nationwide practice recommendation.”

Now that we have evidence that skullcaps are not linked to increased infection rates, will the AORN at last get over its obsession with bouffant caps?

My previous posts on this topic can be found here and here.

Friday, May 12, 2017

Can a med student who flunked Step 1 still become a surgeon?

I received these emails (italics) recently. The writer gave me permission to publish them. They have been edited for length and some details have been changed to protect his anonymity.

I'm a third year medical student at an allopathic state medical school. I've always wanted to do surgery. My problem is I failed USMLE Step 1 the first time and got a 207 on my second attempt. I hadn't failed anything else throughout first and second year, with the majority of my grades being my school's equivalent of Bs.

My surgery shelf exam was a week after I received my Step 1 score and, despite studying hard, my low score on that exam got me the equivalent of a C in surgery even with very good clinical evaluations. The rest of my third year has been good with most evaluations saying I'm well-liked and a team player.

Should I give up and go into a different specialty with better odds of matching? Apply to prelim surgery programs and categoricals? Or even apply to all of those things at once? I'm in a large pickle, paralyzed with indecisiveness, and would immensely appreciate your advice.

Disclaimer: This is my opinion. I do not presume to speak for all program directors. I'm going to be honest.

Thursday, May 4, 2017

Can surgical residents please have some autonomy?

A comparison of appendectomy outcomes for senior general surgeons and general surgery residents revealed no significant differences in early and late complication rates, use of diagnostic imaging, time from emergency department to operating room, incidence of complicated appendicitis, postop length of stay, and duration of postop antibiotic treatment.

The only parameter in which a significant difference was seen was that attending surgeons completed the procedure significantly faster by 9 minutes—39.9 vs. 48.6 minutes, but this may have been influenced by the fact that attending surgeons used laparoscopic staplers 13.5% of the time as opposed to use by the residents in only 2% of cases, also a significant difference.

This before-and-after study of more than 1600 appendectomy patients was published in JAMA Surgery. Between 2008 and 2012, residents were permitted to perform appendectomies without direct supervision by an attending surgeon. The pre-2012 group included 548 operations performed by general surgery residents alone. Because of a policy change, all of the appendectomies from 2012 to 2015 were performed by attending surgeons alone or directly supervising a resident.