“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.

Why I don’t watch medical TV shows

A new dramatic television show called “Do No Harm” debuted last night on NBC. It is touted as a modern version of Dr. Jekyll and Mr. Hyde. Its surgeon-hero is described in the network’s public relations material as “He’s twice the man you think he is.”

The pilot apparently aired a couple of weeks ago, and NBC posted it on line as a sample of what the series will be like. Against my better judgment, I decided to see what it was all about.

If the opening scene of the pilot is representative of the rest of the episodes, viewers are not only in for some drama, they might get a few laughs too.

In first three minutes, which was all I could take, the following events occurred:

Two doctors were scrubbing for surgery with their masks off.

When they entered the operating room, the masks had magically appeared in their correct positions.

The surgeon, who apparently had never met the patient, asked another doctor what the patient’s problem was.

The other doctor said the patient had a massive brain hemorrhage and had an ICP (intracranial pressure) of 40. Normal is less than 20. The blood pressure was 160/100 and dropping, which is the opposite of what usually occurs; with elevations of ICP, the blood pressure goes up.

The surgeon ordered a unit of blood to be transfused and two more to be typed and cross-matched. Patients don’t bleed out from cerebral aneurysms. They die from brain damage due to the fact that blood fills the closed space of the skull which compresses the brain tissue. They rarely if ever need a transfusion.

The surgeon introduced himself to the patient who expressed concern that he was about to die. Not only was the patient perfectly lucid (an impossibility with an ICP of 40), but there was no sign of the ICP monitor.

After gowning and gloving, the surgeon walked over to a small machine and ran a blood sugar on himself by pressing a button WITH HIS STERILELY GLOVED HAND. It's not clear what would have happened to the patient in the OR if the surgeon's blood sugar had prevented him from starting the case. He did not don a new glove.

During the surgery, which was clipping of a cerebral arterio-venous malformation, the blood pressure falls to alarming low levels, presumably due to bleeding. However, the fake surgical field showed only some dribbling blood. This was about the only realistic part of the entire scene.

There were some tense moments and some sardonic wisecracks but the heroic surgeon managed to get a clip on the vessel just in time. The blood pressure shot up immediately.

All of this happened within the first three minutes of the show. See for yourself here.

As far as I can tell, there was no informed consent discussion and even worse, there was NO “TIME OUT.”

It turns out that the surgeon has 12-hour blackouts or something every night starting at 8:25 which can only be controlled by a powerful new sedative that a colleague gives him. People in administration know about this but still the guy is allowed to operate. There is no mention of who covers for him if a patient has a complication while the doctor is "out."

Here’s what the San Francisco Chronicle had to say: “NBC has had some problems launching new comedies, but at last it has a show guaranteed to have you falling on the floor in hysterics. Unfortunately, ‘Do No Harm’ purports to be a dramatic series.”

And that review doesn’t even mention all of the medical faux pas.

Here are my thoughts from two years ago about Grey’s Anatomy.

Note: This post was updated on February 1, 2013.

Patient Safety Summit Breaks New Ground

The first annual Patient Safety Science and Technology Summit (PSSTS) was held in Dana Point, California on January 13 and 14, 2013. The two days were filled with presentations and panel discussions on several areas of patient safety.

Unlike many such conferences, this one expected a commitment from its more than 300 attendees to actually do something about increasing patient safety when they returned to their respective institutions.

The keynote address was given by former president Bill Clinton, who challenged those in attendance to follow through on their promises to actively promote patient safety in their institutions and achieve the summit’s goal of no preventable patient deaths by the year 2020.

Noted patient safety experts from around the world covered topics ranging from medical and nursing leadership to specific safety issues such as neonatal monitoring, medication errors, failure to rescue and inappropriate use of blood transfusions.

Family members of patients who died after medical errors presented their moving stories on video and in person.

The event was sponsored by the Masimo Foundation, the philanthropic arm of the Masimo Corporation, makers of medical monitoring equipment. Masimo’s CEO, Joe Kiani, teamed with patient safety guru, Dr. Peter Pronovost of Johns Hopkins to assemble the distinguished faculty.

A significant problem that the PSSTS identified is that most medical devices cannot communicate with each other because of interface issues. Nine major medical device manufacturers have pledged correct this and work on other areas of patient safety improvement in the future. In addition to Masimo, they include Dräger, GE Healthcare, Cerner, Zoll, Smiths Medical, Cercacor, SonoSite Fujifilm and Surgicount Medical.

I spent a few minutes with Mr. Kiani, who said, “Masimo will keep track of progress and expect follow-up results to be submitted.” This will apply to both corporate and individual attendee pledges.

Videos of all of the sessions including speakers, panels and Mr. Clinton’s address can be viewed here.

In the coming days I will discuss in detail some of the major areas covered by the summit.

Disclosure: I attended the meeting thanks to a grant from Masimo who had no input into anything written here.

Choices: University residency with extra years of research or not?

In a new post on "Ask Skeptical Scalpel," a student is conflicted about choosing a university general surgery program with two years of research or not. Click here to see what I think.

Choosing antibiotics for appendectomy and cholecystectomy: Are "big guns" needed?

An emergency medicine physician asked me to comment on the use of antibiotics in patients having surgery for acute appendicitis and acute cholecystitis. He said in hospitals where he has worked in three different areas—New York, Miami and San Francisco—surgeons are using Imipenem for cholecystitis and Zoysn for appendicitis.

He wondered why those drugs were chosen and offered a few theories. They are as follows:

1) Surgeons are trying to avoid resistant bugs, so they’re using bigger guns

2) There is more pressure to reduce post-op complication numbers, so they’re using bigger guns

3) It’s easier to give one antibiotic to cover multiple bacterial types, instead of, say, cipro/flagyl or cefoxitin/flagyl

4) Patients do better with these big gun antibiotics

5) Residents are being taught incorrectly, and are just developing bad habits

Yes, it is mandated that everyone needs a dose of prophylactic antibiotics within an hour of surgery for appendicitis and cholecystitis. Of course, there are nuances.
 
Appendicitis is a disease involving an inflamed, eventually infected appendix so the use of antibiotics is possibly therapeutic and not simply prophylactic.
 
For acute cholecystitis, a similar argument can be made. The problem here is that it is often difficult to tell acute cholecystitis (with possibly infected bile) from biliary colic (pain caused by a gallstone impacted in the neck of the GB) without infection. Sometimes the GB ultrasound says acute cholecystitis, the surgeon says acute cholecystitis and the path report says chronic cholecystitis. There are many other permutations of those three observations. (e.g., US-biliary colic, surgeon-biliary colic, path-acute cholecystitis, etc.)
 
Note: I do not routinely culture peritoneal fluid in appendicitis or bile in cholecystitis because by the time the culture report comes back, most patients have been home for two or three days. There is evidence to support not culturing either fluid.
 
Honestly, I’m not so sure that people with early acute appendicitis really need antibiotics. Unless the appendix is perforated, I use only one preop dose. There are also similar differences in the imaging reports, surgeon description and path reports for this disease too.

I doubt that patients with biliary colic benefit from antibiotics either. The problem is that one may not discover that acute cholecystitis is present until one is in the abdomen. The same issue occurs with appendicitis where an unsuspected perforation may be found at surgery.

At least for now, at least one pre-op dose of an appropriate antibiotic seems reasonable.
 
Where I practiced for the last few years, we did not use Imipenem for GBs and only occasionally is Zosyn used for appys. Most of us used Unasyn for both except in the penicillin-allergic patient. For that patient, we used Levaquin and Flagyl. The problem with the latter two drugs is that they each are supposed to be infused over an hour. This is not always possible because the surgery may be started within an hour in certain circumstances, such as when an operating room happens to be vacant and the patient is ready to go. It’s a rare event, but it does happen.
 
There is no evidence that patients with either disease, who usually present from home, have resistant bacteria, and postoperative complications, especially infections, are not common with either disease. There is no evidence that patients do better with “big gun” antibiotics. In fact, most of the evidence that prophylactic antibiotics are even needed in these two operations comes from the pre-laparoscopic era. Wound infections are extremely uncommon with laparoscopic appendectomies and cholecystectomies. This is probably due to the fact that the wounds are small and in most cases, the specimen is removed in a plastic bag so the infected organ does not touch the subcutaneous tissue.
 
If residents are being taught to use “big gun” antibiotics for these two diseases, I agree it’s incorrect. There is little hope of changing this.

It is similar to the unfounded practice of giving everyone who is NPO a proton pump inhibitor, which I wrote about here. There is no scientific rationale for it. Yet everyone does it, and no amount of discussion will convince people to stop.

[Note: A version of this post appeared on General Surgery News a few weeks ago. The version above is better because I thought about it more.]