Can patients shower immediately after surgery

Here’s what a recent paper published ahead of print in Annals of Surgery says:

Between May 2013 and March 2014, 222 patients were randomized to the group allowed remove their dressings and shower at 48 hours and 222 to the group permitted to shower only after the original dressing and the sutures were removed in clinic. There were 4 (1.8%) superficial surgical site infections in the early shower group and 6 (2.7%) in the late shower group, an insignificant difference with p = 0.751.

The authors concluded that clean and clean-contaminated wounds can be safely showered 48 hours after surgery, and early postoperative showering may increase patient satisfaction.

I have always been an advocate of early showering after surgery. Wounds properly closed will be bridged by epithelium within 48 hours. Tap water is relatively sterile or we couldnt drink it. Many studies have shown that even irrigating open wounds with tap water instead of sterile saline does not lead to more infections. [Links here and here.]

Much as I would like to believe the Annals study, I can’t because it is probably underpowered to show a difference between the two groups.

Here is a nice definition of statistical power from a website called effectsizeFAQ.com:

“In plain English, statistical power is the likelihood that a study will detect an effect when there is an effect there to be detected. If statistical power is high, the probability of making a Type II error, or concluding there is no effect when, in fact, there is one, goes down.”

To their credit, the authors did try to estimate the sample sizes they would need by doing a power calculation. They knew that the wound infection rate for the cases they intended to enroll was about 1%. The problem is they estimated that showering at 48 hours would result in a wound infection rate of 5%. That seems very high to me for the types of cases included in their investigation—thyroid, lung, inguinal hernia and skin tumors.

If they had hypothesized that early showering would merely triple the rate of wound infections from 1% to 3%, they would have needed at least 1536 patients in each arm of the study. Then if there was no difference, one could conclude that early showering truly does not cause more wound infections.

Even if the known incidence of wound infection was much larger, say 5%, and the rate of infection with showering was presumed to be doubled (10%), to have enough power a study would need 434 patients in each arm.

Many websites provide calculators for determining the appropriate sample sizes to detect with a reasonable degree of certainty whether one intervention is better than another. Anyone thinking about doing a prospective randomized trial should realistically estimate the expected difference and calculate the power.

Whenever you read a negative study, the first question to ask is, “Was the study adequately powered to avoid a type II error?”

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Patients can chew gum immediately before surgery I guess

A study presented at the American Society of Anesthesiologists (ASA) meeting in October of this year found that patients who chew gum in the immediate preoperative period may safely undergo surgery.

The authors, based at the University of Pennsylvania, found that gum chewing increases saliva production and the volume of fluid in the stomach, but stomach acidity was equivalent to that of non-gum chewers. An article about the study said The mean gastric volume, or total amount of liquid in the stomach, was statistically higher in patients who chewed gum before their procedure (13ml) versus those who did not (6ml). A 7 mL difference might be statistically significant, but surely is not clinically important.

The research differed from previous studies because it involved patients who underwent upper gastrointestinal endoscopy, which enabled the investigators to recover all of the fluid in the stomach for testing. Prior studies had been done using nasogastric tubes, and it was impossible to determine whether all gastric fluid was recovered when the tubes were suctioned.

The study involved 34 gum chewers who were allowed to chew any type or any amount of gum compared to 33 patients who did not chew gum.

Another article quoted its lead author.

"We found that although chewing gum before surgery increases the production of saliva and therefore the volume of stomach liquids, it does not affect the level of stomach acidity in a way that would elevate complication risks," explains Dr. Goudra.

He says patients shouldnt be encouraged to chew gum before procedures involving anesthesia, but the habit shouldnt necessitate the cancellation or delay of scheduled cases if other aspiration risk factors arent present.

There has been long-standing debate about the subject of whether using gum and hard candy should be treated the same as ingesting a regular meal.

I wrote about this on my blog back in January 2014 and pointed out that the ASA guidelines do not address the issue.

In an effort to do due diligence, I was able to locate the abstract of this paper on the ASA website. Im glad I did because the abstract came to the opposite conclusion.

When the abstract was submitted, it included fewer patients—24 who chewed gum and 23 who did not.

The average gastric volumes were 9.78 mL for the gum chewers and 24.08 mL for the non-gum chewers (p = 0.027), and pH values were not significantly different (p = 0.094). It looks like regression to the mean occurred as the number of subjects increased.

In the original abstract, the authors concluded the following: Chewing gum in the preoperative fasting period leads to significant increase in the residual gastric volumes, with no difference in pH. We recommend that patients who have inadvertently chewed gum in the fasting period should be treated as full stomach and management modified accordingly. [Emphasis added]

So what is going on here? This would not be the first time that an abstract differed from the final paper. Actually, this sort of thing happens quite frequently. However in this case, the conclusions of the two versions are diametrically opposed to each other.

The study was presented at a meeting. Lets see what happens when it is submitted to a journal for peer review.

The correct way to have done the study would have been to calculate the number of patients needed to be studied (power analysis) beforehand.

Since this was not done, I recommend we go with the conclusion of the larger number of patients studied because it agrees with my bias that chewing gum is not potentially harmful.

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Do surgeons still do postop care

Heres an email I received the other day (edited and posted with the authors permission):

I am a recently retired internist. I have noticed some evolving trends over time and had an interesting experience that illustrates this issue.

A 77-year-old friend went for check up due to urinary incontinence. He was found to have a large prostate and a PSA of only 2 so was given Flomax . This helped somewhat.

At the time, an asymptomatic hernia was found. He was immediately scheduled for surgery which went well. His Foley was removed, and he was sent home.

At home he could not void, called the surgeon, and was told to go to the ER, There the Foley was replaced, and he was to see his urologist in 2 days. The urologist removed the Foley. Later he was in agony and walked the floor all night. He called the urologist and the service said that the office was closed. He was told to drive to the other office in the next town only 15 miles away. They replaced his Foley again.

Two days later he went to the surgeon who did the hernia repair and explained his postop adventures. The surgeon said, "Those things have nothing to do with the surgery. Your wound looks fine."

Things have changed. IN THE OLD DAYS:

• After surgery, patients were not sent home until they could eat, void, and walk. Those days are history. 
• Surgeons took care of their patients post op. Those days are gone.
• Urinary retention was a recognized complication of hernia repair, especially in someone with known BPH. Are those days gone too?
• If you sent someone home after pulling the Foley, you waited till the patent had voided being aware that massive urinary retention has the potential to induce damage to the bladder muscle itself (He had retained over a liter of urine) as well as cause great pain and distress.

I am aware that surgeons are not paid for postop care, but the global fee includes the surgery and the postop care (Follow the money). Hospitals need beds for new patients (Follow the money). [Dont forget that third-party payers wont fund any extra time in hospital.]

Are surgeons no longer trained in post op care? Are surgeons not exposed to the concept of surgical complications? Isnt it interesting how things change for the worse and nobody notices?

I wondered if the friend had really needed the herniorrhaphy. The writer replied:

I looked up that question and found that only 1% of hernias need surgery by becoming symptomatic. I mentioned this to my friend, but he had been "seduced" by the authority of the surgeon who acted as though not operating was inconceivable.

I once had an echocardiogram for occasional PVCs (probably not indicated). The tech discovered gallstones. Within an hour, a surgeon stopped me in the hall and wanted to remove my GB. (So much for privacy!) As luck would have it, I had had the experience of caring for patients who had had GB surgery and had terrible results involving damage to the hepatic duct resulting in liver failure and jaundice. I looked it up and found that asymptomatic gallstones may not need surgery. I have done fine for 30 years. (Knock on wood.)

I think no postop care by the surgeon is "THE NEW NORM."

As a hospitalist, I was assigned to care for surgeons postop patients—one reason I finally retired. This was challenging at times. For example, one day a lady had a tummy tuck by a plastic surgeon. I was "consulted" to follow her and noticed her Hct had dropped. After investigating, I concluded that she must be bleeding into her wound. The surgeon never saw the patient post op. A nurse practitioner saw her but was clueless. I called the surgeon but no response came. When her Hct got down to 25, I gave her some blood and she stabilized and went home. A month later the surgeon stopped me in the hall and said when he had taken out her stitches, a huge amount of black gook plopped out. "She had a wound hematoma," he said. "Thanks for taking care of it." He was not embarrassed at all. I guess my caring for this was the new norm.

Stuff like this happened too often. If I called another surgeon for help they always refused. There was nowhere to turn.

In my fairly extensive experience, postop care by the surgeon is now seen as optional. Hospital employed surgeons are expected to operate, and NPs and/or hospitalists [Dont forget the PAs.] are assigned to do the postop care. This permits more surgeries (revenue).

On a more philosophical note, I am fascinated how "standards" change right before our eyes, but the process goes on unnoticed, slowly, almost invisibly. Then a few people speak up. They notice things. But it doesnt pay to agree with those people. Eventually, the process becomes obvious, and everyone says, "You know what? Health care in America really sucks. When did this happen?"

Are surgical residents being trained in postop care? Do surgeons no longer take care of their patients? I think this is true in orthopedics and plastics. Has it spread to general surgery too?

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Externships or observerships Can they help an IMG get a surgical residency slot

A woman writes [some non-essential details have been changed to preserve anonymity. Permission to post this was obtained.]:

I am a non-US citizen medical graduate from The University of The West Indies in Trinidad and am currently an intern in a Caribbean nation. Although UWI has produced great students, you may not be familiar with it.

I would like to become a surgical resident in the US. I have no US clinical experience, but my USMLE Step 1 score was >235.

What do you think about my doing a post-intern year externship (hands on clinical) as opposed to an observership (just observing) in the US? I know that an externship carries more weight as far as applications go, and the only reason I would want to do either of these would be to get recommendation letters from surgeons in the US.

However, since I have already graduated from medical school, getting into an externship will be more difficult because this will no longer be a medical school rotation. I believe that observerships will be easier to get into but are they worth it?

Do you know of any IMG-friendly programs that facilitate this? Do you think that this is a good idea? Do you feel that I will be able to get an externship?

Other than this idea for externship/observership, I am blank for ways to improve my chances of matching to a US program in surgery. Do you have any suggestions?

Thank you for writing and for reading my blog.

Your USMLE Step 1 score is excellent, but as you stated, the lack of any clinical experience in the US might be a problem.

Im afraid your plan to do externships may not work out. I do not know of any hospital in this country that supports externships for people who have already finished medical school. The issue is that once you graduate from medical school, you no longer have status as a student. There are medicolegal, educational, and funding considerations that I do not think can be overcome.

I am not sure about the availability or value of observerships. My opinion, which may not be shared by others, is that I see no value in observing. How could anyone write a meaningful letter for you if all you did was watch other people take care of patients?

I am also unable to tell you what a letter from a surgeon who works at a hospital nobody knows is worth.

I hope my readers will have some thoughts for you.

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Should radiologists tell patients their test results

Radiologists discussing test results with patients, a subject that has been lurking under the radar for a while, recently came to light because of an article in the New York Times. The idea is that patient anxiety while waiting to find out a test result could be alleviated by an immediate discussion with a radiologist.

That would be very nice, but there are potential problems, some of which are detailed in a post that appeared on the website of The Advisory Board and others in an editorial by radiologist Saurabh Jha accompanying a paper on the subject..

In the Times, Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford, said, “[T]he radiologist may be capable of transmitting the information but the obvious next question for the patient is, ‘What do I do now?’ which, as nontreating physicians, radiologists are not trained to answer.”

Both The Advisory Board and Dr. Jha speculated about the potential liability exposure of a radiologist whose advice might differ from that of the referring doctor causing concern for the patient and hostility from the doctor.

Unless the radiologist performs a history and physical examination, he will not know much about the patient. A lack of clinical context might cause a radiologist to misinform the patient.

Heres a scenario. A radiologist tells a patient she has a suspicious mass in her adrenal gland on a CT scan but cant tell the patient what should be done about it. Instead of anxiety about not knowing the test result, the patient would then have anxiety about having a mass and no plan to deal with it.

What about incidental or equivocal findings? Dr. Jha wrote, "Such findings, for example, could potentially, albeit immensely improbably, turn out to be cancer. Radiologists will find that the burden of ‘clinical correlation’ will fall upon them, and this task will be all the more challenging at a single time point."

A study found that a radiologists discussion with the patient about a CT scan took a little more than 10 minutes. Would that time be reimbursed and if so, how? Dr. Jha pointed out that the discussion would have to be documented and the decrease in radiologist productivity would have to be made up somehow.

Since they rarely, if ever, talk to patients, radiologists may be extremely uncomfortable with this new role. Ive known a few radiologists who are not even comfortable talking to other physicians. Many radiologists dont choose a career being sequestered in a dark room because they are "people persons."

The Times article described one patients interaction with a radiologist. He said the radiologist "seemed physically afraid of me."

The real solution is for radiologists to communicate more rapidly with referring physicians and for those physicians to communicate more rapidly with their patients.

Here is what needs to happen. 1) A critical or unexpected result of radiologic examination should always be immediately discussed in a telephone call from the radiologist to the doctor who ordered the test. 2) Every doctor or her staff must promptly communicate the results of any radiologic test to a patient.

If those actions occurred on a regular basis, radiologists wouldnt need to talk to patients, and litigation due to overlooked important findings could be avoided.

So what I really would like to see is pathologists talking to patients.

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More on activity restrictions after surgery

In early January, I blogged about the dearth of evidence about activity restrictions after surgery.

A number of people commented and most agreed that there is little basis for most of the activity restrictions surgeons currently use.

An anonymous reader told me about a 2008 study from Creighton University that generated some interesting data about intra-abdominal pressures associated with some common activities. Here’s a summary of the paper.

The authors managed to find 10 healthy volunteers all of whom could bench press at least 100 pounds and were willing to have nasogastric manometry catheters placed and Foley catheters inserted into their urinary bladders.

Intra-abdominal pressures were recorded as each subject coughed 10 times as hard as possible, bench pressed varying amounts of weight from 26 to 114 pounds, and vomited after receiving ipecac syrup and drinking about 500 mL of water.

Pressures in the stomach and bladder correlated fairly well. To keep things simple, let’s look at gastric pressures only.

The highest mean and maximum pressures were found during vomiting. Coughing produced similar pressures. Most interestingly, intragastric pressures during weightlifting were significantly lower with a mean of 2 mmHg and a maximum of 52 mmHg, p <0 .001.="" br="">The authors mentioned that another group had found similar intra-abdominal pressures with subjects bench pressing 25 pounds.

Another unexpected finding was that although the differences were not significant, the mean intragastric pressures were inversely proportional to the amount of weight lifted.

Maybe we should tell postoperative patients not lift less than 26 lbs.

The authors were focused on measuring pressures that would disrupt a gastric anastomosis. They calculated that an intragastric pressure of 290 mmHg generated by vomiting was about 1/50 of the 20N [Newton] force that would disrupt a gastric suture line in a porcine model as demonstrated by other investigators.

The effect of repetitive stress such as found in patients with a chronic cough were unknown, but they said “the intra-abdominal pressures generated in our study alone do not appear to be responsible for hernia formation.”

The Creighton study authors concluded, "The common postoperative lifting restriction, although logical, has little evidence to support it." They called for more research in this area.

Unfortunately, their call has not been answered.

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Readmissions Sometimes its the patients

My Twitter friend Dan Diamond (@ddiamond) posted a picture of a slide that said a hospitalized patient was taught to inject insulin using an orange to practice on. When he was readmitted to the hospital with a very high blood sugar, it turned out that instead of injecting himself at home, the patient was injecting his insulin dose into an orange, and then eating it.

Weve all heard stories about patients who took suppositories by mouth instead of the way they were intended.

Since doctors get blamed for just about everything, some would say that patients who take suppositories by mouth or eat an orange filled with insulin do so because they were not properly taught by their doctors (or nurses).

I have blogged before about the problem of who is at fault if patients do not follow up. Although I feel that much of the time its the patient who decides not to return for follow-up, it seems prevailing sentiment and possibly even the courts say its the physician who should be held responsible.

But how do you explain this? A study in Heart, a BMJ journal, found that of 208 hypertensive patients referred to a clinic for suboptimal blood pressure control, 52 (25%) were either completely or partially non-adherent [aka non-compliant] with their antihypertensive medications as determined by urine mass spectrometry.

The authors concluded that urine testing for medications or their metabolites would help doctors avoid ordering unnecessary investigations for patients whose blood pressures were not well-controlled.

The reasons for patient non-adherence were not mentioned. Could all 52 patients not have been told about the importance of taking their medications? I doubt it.

You might think the 15% who were partially non-adherent may have forgotten to take the drugs occasionally, but it turns out that most of those in this group took adequate doses of most of other their prescribed medications. This suggests that they selectively omitted some doses of one or more drugs.

The only explanation I can fathom for the 10% who had no traces of any BP meds in their urine is that they just said "to hell with it" and didnt take their meds at all.

I know someone with type 2 diabetes who doesnt watch her weight or what she eats and doesnt check her blood sugars. She says, "Youve got to die of something. Id rather live my life the way I want to."

Is it that doctors and nurses arent educating the patients or are the patients at fault?

The answer to this question has important implications because of the newly established financial penalties for hospitals with high readmission rates.

Older methods that may improve adherence are tracking prescription refills and having pharmacists or nurses specifically assigned to explain medications to patients in detail.

Heres something that might help.

A recent meta-analysis showed that adherence to HIV/AIDS antiretroviral therapy was modestly improved when patients were sent reminders to take their medications by text message. Those who were more adherent had lower viral loads and better CD4 counts.

Of course, such an intervention assumes that patients have mobile phones or pagers capable of receiving texts, will check for messages, and will act upon the advice. Compared to patients with HIV/AIDS, those with hypertension might tend to be much older and possibly not as technologically savvy.

So what is the solution? I dont know, but sometimes the problem is the patients.

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Patients vs doctors

A JAMA Viewpoint article suggests that doctors should be aware that patients may be surreptitiously recording their conversations. The author, a neurosurgeon, takes a very benign view of this issue and recommends that if a doctor suspects that patient is recording a conversation, "the physician can express assent, note constructive uses of such recordings, and educate the patient about the privacy rights of other patients so as to avoid any violations."

He also says this would show that the physician was open and strengthen the relationship between the doctor and the patient. Im not so sure.

Heres a different perspective. If a patient is secretly recording a conversation, the relationship between him and the doctor is already in serious trouble. What I would do is to tell that patient to find another doctor.

If a patient asked me if it was OK to record our conversation, I would agree, but I would also want to record it to preserve a complete copy.

This comes on the heels of another privacy and trust question—should doctors google their patients? There is no consensus on this, but having read several discussions on the topic, most writers feel that googling patients should only be done for certain narrow reasons which you can read here.

Most medical societies have not weighed in on the subject, but I would guess when guidelines are published, they will discourage the practice. But of course, patients may google physicians at will.

Taking it to another level, Dr. Jeremy Brown, Director of the Office of Emergency Care Research at the National Institutes of Health, recently proposed that emergency physicians should be equipped with body cameras to record audio and video of patient encounters.

Leaving aside such questions as who owns the videos, how to store the vast amount of data, and what impact this would have on the performance of the individual physicians, body cameras would establish an adversarial relationship that is unnecessary for the overwhelming majority of doctors and patients.

A physician interaction with a patient begins on terms quite different from those of a police officer interacting with a suspect in which the adversarial relationship is already established. The increasing number of controversial and highly publicized cases involving police and suspects has resulted in a need to protect both parties. This need seems much less pressing in medicine.

Where does this end? Should all patients be equipped with body cameras too in case the physician copy "gets lost"?

It is sad to realize how far we have sunk as a profession.

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More ratings—this time its residency programs

Can you really decide which surgical residency program is right for you using Doximitys Residency Navigator?

I dont think so, and heres why.

The rankings of residency programs were obtained by surveying surgeon members of Doximity. They were asked name the five top programs for clinical surgery training. When the survey was announced in June, I predicted that most respondents would probably overlook the word "clinical" and focus on the usual famous academic institutions.

I also pointed out that anyone not intimately familiar with a program would be unable to judge whether it is good or not and suggested that reputation would be the main driver of results.

In fact, that is exactly what happened. Of the top 40 programs listed, all are based at university hospitals, as are 66 of the top 70. Back in June, I speculated about the top five programs and got the first two correct but in the wrong order.

A 2012 survey of surgical residents with over 4200 responders (an 80% response rate) found that community hospital trainees were significantly more satisfied with their operative experience and less likely to worry about practicing independently after graduation. Wouldnt you then expect a few community hospital programs to be among the top 40 hospitals for clinical surgery training?

Proof that the surveys findings are not reliable is that every one of the 253 surgical residency programs in the country was mentioned by one or more of those who responded. This included one program that has been terminated by the Residency Review Committee for Surgery. At least it appears near the bottom of the list.

The number of voters who cited the lower ranking programs must have been very few, meaning the difference between the 200th and 240th program ranks is probably not statistically significant.

Some programs that were rated are so new that very few or no residents have graduated yet. How could anyone know if they are turning out competent clinical surgeons?

Board passage rates for programs, which are available online, were omitted for some and were not clearly identified as the percentage of residents who passed both parts of the boards on the first attempt only.

The percentile rankings of alumni peer-reviewed articles, grants, and clinical trials are displayed prominently. What do those data have to do with the research question—which residency programs "offer the best clinical training"?

So whats the bottom line?

You can put the Doximity Resident Navigator in with the other misleading ratings of hospitals and doctors. Applicants considering surgical residencies should not rely on it for guidance.

It has warmed the hearts of faculty and residents at highly rated programs, but I wonder how the OR lounge discussions are going at places where programs ranked lower than expected.

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