What to do when a normal looking appendix is found at surgery for appendicitis

For patients undergoing surgery with a presumptive diagnosis of appendicitis in Norway and other parts of Europe, the protocol is if the appendix looks grossly normal in the operating room, it is usually not removed.

This approach was mentioned as part of a paper on the readmission of post-appendectomy patients from Oslo University Hospital. Most of the patients underwent laparoscopy based on clinical diagnosis with only 160 having CT scans and 67 having ultrasounds.

Of the 710 patients in the Oslo series, 94% of the appendectomies were done laparoscopically, and 111 had a normal appearing appendix at laparoscopy. The appendix was not removed in 88. The other 23 patients had appendectomies for various reasons, and those appendices were normal at pathology.

The cumulative rate of operating for what turned out to be a normal appendix (88 + 23 cases) was 15.6%, which the authors attributed to “the low use of preoperative CT” due to concerns about radiation exposure. That over 100 patients had unnecessary general anesthesia and surgery was apparently not a concern.

Causes of death among residents

What is the leading cause of death among residents in all specialties?

A. Accidents
B. Neoplasms
C. Suicide
D. Miscellaneous diseases

If you answered C, you were wrong. The correct answer is B, neoplasms. Suicide was the second most common cause, followed by accidents and miscellaneous diseases.

A study in Academic Medicine looked at resident deaths over a 15 year period and found that of the 381,614 individual physicians in ACGME training programs, 66 died of suicide. For the over 1.6 million person-years studied, the suicide rate for residents was 4.07 per 100,000 person-years—well below the figure of 13.07 per 100,000 years in the general population of people aged 25-34.

Residents in age groups 35-44 and 45-54 had suicide rates higher than the 25-34 group and higher than the rates of those in comparable general population age groups.

More suicides occurred during the first and second years of training and during the months of July through September and January through March. In my opinion, the months that deaths occurred in can be explained as follows. In the first three months of the academic year, residents in the first and second years may feel overwhelmed and subject to self-doubt—the so-called "impostor syndrome." By the time January and February roll around, it is mid-winter, and it seems like the year will never end.

Residents had a much lower rate of death from accidents, including those related to automobile crashes, than the general population.

The overall death rate from all causes was also lower for residents than the rate of the general population at 16.91 per 100,000 person-years and 105.4 per 100,000 person-years, respectively.

The authors were surprised that resident rates of suicide were lower than age- and gender-matched populations especially because suicide rates for medical students and practicing physicians are higher.

They concluded that suicide was probably the only area in which prevention strategies, such as a supportive environment and medical and mental health services, could reduce the death toll.

Program directors, faculty, and residents themselves should probably show heightened vigilance in the first and third quarters of the academic year particularly for first and second year trainees.

Another chapter in “Surgical Cap Wars”

No one expected the AORN [Association of periOperative Registered Nurses] to meekly accept the conclusion of the paper which found no difference in infection rates when surgeons wore surgical skullcaps or a bouffant-style head coverings.

The AORN recently fired back with a letter to Neurosurgery, the journal that published the paper. It has not yet printed the letter or a response to it by the authors of the paper. I look forward to seeing both.

Meanwhile, Becker’s Infection Control and Clinical Quality revealed some tidbits an article entitled and “AORN experts respond to study on bouffant use and SSI rates.” [SSI = surgical site infection]

The AORN claims that it never mandated the use of bouffant headgear. It merely called for “a clean surgical headcover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn” because “hair carries bacteria that could [emphasis mine] cause an SSI.”

Lisa Spruce, the director of evidence-based practice for the AORN, said, “It’s up to the facility to determine what’s the best way to get everyone’s hair covered.” This is rather disingenuous as everyone knows the only way to cover every single hair on the head is to wear a bouffant or a hood.

The AORN did not offer any evidence that hair causes infections. Instead Spruce and the other AORN experts chose to nitpick the Neurosurgery study by pointing out a single scatter plot that showed what they said was a decrease in SSI rates after bouffants were worn.

They claim the figure below indicates fewer infections occurred late in the 13 month period of bouffant usage because it took some time for everyone to comply with bouffant use.

Blue is skullcap. Red is bouffant. Time in months

They offer no proof that adoption of the bouffant took several months. In my experience, when hospitals go from skullcaps to bouffants, the transition is abrupt. On the day the mandate takes effect, skullcaps are no longer available. And by the AORN's logic, one could argue that the plot shows a spike in bouffant-associated SSIs at months 4 and 5 of use.

What about statistical significance? The table directly above the figure they cited clearly shows that there was no significant difference in the SSI rate between the two types of headgear for all operations in the hospital, spine cases, or craniotomy/craniectomy procedures.

Click on table to enlarge it.

In fact if you believe in trends, there were slightly more infections for overall operations and spine cases in the bouffant group.

The AORN wants all hair covered. What about the eyebrows? As I mentioned in a post back in May, an outbreak of SSIs that occurred after some plastic surgery operations in Israel was traced to an organism found in the surgeon’s eyebrows.

Bottom line: If the AORN cannot cite evidence proving that scalp or facial hair causes infections, its experts should do their own research and publish it—otherwise stop damaging the organization’s already marginal credibility.

Thanks to Artiger, a loyal reader of my blog posts, for sending me the link to the Becker's article.

Controversies in OR infection control

Like professional athletes, Skeptical Scalpel sometimes talks about himself in the third person. A recent article in Clinical Infectious Diseases [CID] confirms what Skeptical Scalpel has said about a couple of controversial topics in infection control.

The article by surgeons from the University of Washington was published online in late May of this year and gives historical context to some of the standard operating room practices we currently argue about.

Regarding operating room headgear, the authors dissect and refute the positions endorsed by the Association of periOperative Nurses (AORN) that hair and airborne bacteria cause infections. In fact, they say wearing of any kind of hat in the OR may actually disperse more bacteria due to the effect of the hat rubbing against the hair and causing an increase in bacterial shedding.

They conclude “there is little reason to support the AORN recommendations regarding head covering.”

What were attrition rates in surgical residency programs 25 years ago?

Last month I blogged about the 20% attrition rate of general surgery resident over the last 25 years, and a recent paper presented at a national meeting that found after following the general surgery resident class of 2007, 20% had dropped out for one reason or another.

A reader who calls himself Artiger commented on that piece asking, “Is there any data on resident attrition prior to 1992? Just curious if this has been a problem for more than the past 25 years.”

I responded that I wasn’t aware of any such studies but I would try to find out.

Most of the few papers written about attrition back in the day focused on one residency program or one medical school’s graduates.

Until the middle of the 1990s, many surgical residency programs were pyramidal—that is, they took more categorical first-year residents than they had chief residency positions. For example, when I began my training in 1971, my program had 12 first-year residents, decreasing to 8 in the second-year and only 4 chiefs.

Parathyroids Anonymous

A One Act Play by Leo Gordon, MD

Dedicated to Parathyroid Surgeons

------------------ 

All proceeds from the production of this play go to Parathyroids Anonymous--An international organization dedicated to the well-being of those who perform parathyroid surgery

Scene: A sparsely furnished church basement. Rain is beating against the window panes. Folding chairs are arranged in a semi-circle. Participants are drinking from plastic cups. Some are in scrub suits. All appear tired.

Don: Hello. My name is Don and I’m a parathyroid surgeon.

All: Hello Don

Don: I will be your facilitator tonight. We have a new member so let me set the ground rules. All of us in this room are parathyroid surgeons. We maintain our anonymity as we discuss the mental and physical distress that parathyroid surgery engenders. There are no boundaries at our meetings. We speak openly and freely. Use your first name only. And of course, no patient names. Who wants to begin?

Miriam: (Nervously) Hello. My name is Miriam and I am a parathyroid surgeon.

All: Hello Miriam

Miriam: I’ve been here a few times but I’m a little bit nervous.

Don: Don’t be nervous Miriam. We all share the same problems.

Miriam: Well… last week. (Begins sobbing)

Don: Now Miriam, just relax. Please continue.

Miriam: I had a 56 year old woman referred to me with hypercalcemia. She had had elegant localizing studies at our hospital. Both studies – nuclear and sonographic - stated with metaphysical certainty that there was an adenoma of the right lower gland. Yet (sobbing) when we explored the area, there was no adenoma present. All we found was a normal sized parathyroid gland!

Al: (Hands Miriam a handkerchief)

Don: Go on, Miriam

The problem of “copy and paste” in electronic records

As opposed to text that is copied and pasted or imported from another part of the electronic record, the average amount of manually entered information in a progress note is

a. 18%
b. 29%
c. 43%
d. 55%
e. 70 %

A study of 23,630 internal medicine progress notes written by 460 different hospitalists, residents, and medical students found that a mean of only 18% of the text was created by hand with 46% copied and pasted from previous note or somewhere else and 36% imported from another part of the record such as a medication list.

The analysis, done at the University of California San Francisco*, was possible because the Epic electronic medical record used there can provide the provenance of every character entered in a progress note.

Medical students had the highest percentage of manually entered text and wrote longest notes—averaging 7053 characters, but even the shortest notes, by hospitalists, averaged 5006 characters. For reference, this post contains 1189 characters.

Manual entry comprised 11.8% of resident notes with 51.4% of the remaining information copied and pasted and 36.8% imported.

Think about it. For all groups, less than one-fifth of every progress note they wrote was original material. For resident notes, it was closer to 10%.

The authors cautioned that their study was limited to a single service at a single institution, but I suspect the results would be fairly similar in many if not most hospitals.

*Location of the study corrected on 7/7/17.