Blame the patient

The other day some cardiologists on Twitter were discussing whether a patient should be blamed if a permanent pacemaker lead became displaced. The consensus seemed to be that it was probably poor placement (i.e., operator error), rather than patient behavior that caused leads to dislodge.

The discussion reminded me of an attending plastic surgeon of mine during my resident days. He was one of the most obsessive-compulsive people I ever met. When he applied a dressing, he always cut the tape with scissors instead of tearing it. He felt that torn tape looked sloppy, and that if a patient saw a ragged edged of torn tape, she might think that the surgical procedure itself had been done without meticulous care too.

When he wrapped a hand, he used a very bulky dressing with yards and yards of carefully cut, not torn, tape over the ace bandage to prevent from slipping or unraveling.

But my favorite eccentricity was what he told patients who had any sort of facial surgery. He had a thing about the role of movement of skin possibly causing scars to separate and permanently widen.

So he gave this written instruction to every patient who had so little as a facial mole removed, "Do not talk or chew for 10 days."

Think about it. Could any patient possibly comply with that? Some of us more cynical types figured that should a scar not have turned out perfectly, the conversation might have gone like this.

Surgeon: "About your scar, you must have talked or chewed during the first 10 days after surgery."
Patient (sheepishly): "Well doc, I must admit I did say a few words, and I had to eat something."

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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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Is the surgeon still captain of the ship

A Kentucky appeals court ruled that a surgeon was not responsible for a burn caused by an instrument that had been removed from an autoclave and placed on an anesthetized patients abdomen.

According to an article in Outpatient Surgery, the surgeon was not in the room when the injury occurred and only discovered it when he was about to begin the procedure.

An insufflator valve had been sterilized and was apparently still hot when an unknown hospital staff member put it down on the patients exposed skin. [An insufflator is a machine that is used to pump CO2 through tubing into the abdomen for laparoscopic surgery.] When the doctor saw the mild second-degree burn, he asked what happened, but "but no one in the OR claimed any knowledge or responsibility."

The hospital had settled the suit on behalf of its staff, but the surgeon, who as a private practitioner had his own malpractice insurance, held out. The original lower court ruling dismissing the suit against him had been based on the plaintiffs lawyers failure to prove that the surgeon was responsible for the actions of the hospital staff.

In December 2012, I wrote a post stating my opinion that activities such as counting the sponges during an operation were not the responsibility of the surgeon. Many who commented on the post were highly indignant that I could suggest such a thing.

I wrote another post last year on the subject in response to another surgeons blog entitled "Everythings my fault: How a surgeon says Im sorry." I felt that many things that happened to patients were beyond the control of the surgeon. Most of the comments agreed with me.

I keep hearing that medical care has become a team sport. If thats true, then the surgeon, like everyone else, is simply a member of the team. People on teams have different roles and must execute properly for the team to succeed.

One of the most interesting things about the case in question was that none of the OR team members had any idea how that hot insufflator valve found its way to the patients abdomen.

One thing we know for sure, at least in Kentucky, is that a surgeon is not legally responsible for everything that happens to a patient in the operating room, particularly when he is not even present.

Is this decision the first nail in the coffin of the "captain of the ship" doctrine?

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An intraoperative leak test should not be done or should it

Here is an abstract recently published ahead of print in the American Journal of Surgery. Please read it because a one-question test follows.

Introduction: Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 0-8%. Many surgeons routinely test the staple line with an intraoperative leak test, but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak.

Methods: Retrospective review of all SG performed over a 7-year period. Cases were grouped by whether an intraoperative leak test (IOLT) was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed.

Results: 542 SG were performed between 2007-2014. 13 patients (2.4%) developed a postop staple line leak. The majority of patients (N=494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. There was a trend, although not significant, to increased leak rates when a routine IOLT was performed versus no routine IOLT (2.6% vs. 0%, p=0.6).

Conclusions: The performance of routine IOLT after sleeve gastrectomy provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.

Do you agree with the authors that the routine use of the IOLT was associated with a higher leak rate after sleeve gastrectomy?

I dont, and heres why.

As I tend to do whenever I criticize a paper, I begin with a confession that I have written a lot of marginal papers in my time. Its one of the reasons I maintain my anonymity.

A "trend" has no scientific validity. A comparison is either statistically significant or it is not. Many scientists and statisticians have rightfully criticized our blind faith in p values, but they remain a standard way of comparing research results. That discussion is for another time. Let’s face it—p values will be around for a long time.

The claim that there was a trend toward an increased leak rate with IOLT was based on a difference of 2.6% among 542 subjects. Even if one believed in trends, the p value of 0.6 clearly indicates that there is no difference between the two percentages. Many authors get away with stating that trends exist when p values are 0.051 or 0.06. Thats still debatable, but at least close to the magic p of < 0.05.

I was never a big fan of intraoperative leak testing and agree with the authors finding that postoperative leaks can occur when the IOLT was negative. As they mention in their discussion, leaks often present long after the date of the operation and may be caused by ischemia, cautery injury, or other factors not readily identifiable by an IOLT.

Because the authors didnt find a single leak by doing the IOLT in 494 cases, they suggest that an IOLT is not necessary. But what if they had found one leak and fixed it. Would that have changed their conclusion?

I wonder if everyone at their institution has stopped doing IOLTs.

PS: Don’t just read the abstract; read the whole paper.

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Basketball is still an awful sport to watch

From the current issue of Sports Illustrated:

So why do I care about this?

Four years ago, I said the same thing in a blog post called "Basketball is an awful sport. Heres why." If you dont want to read the whole thing, I will summarize.

Basketball is the only sport I can think of where a team can be rewarded for breaking the rules. Specifically, by deliberately fouling and opponents weaker free-throw shooters, a team that is losing can catch up when the weak free-throw shooter misses and the team that is losing gets the rebound.

All of the fouls and free throws plus the seemingly unlimited number of timeouts that each team has result in the last two minutes of the game taking 20 or more minutes.

To me, its unwatchable.

Pertinent to Van Gundys comments is that Detroit Pistons center Andre Drummond, who will play in the All-Star game, set an NBA record by missing 23 free throws in a single game on January 20.

This was part of a deliberate strategy by the Houston Rockets who were losing the game by nine points at the start of the third quarter. Houstons K.J. McDaniels fouled Drummond five times within nine seconds and the team fouled Drummond on seven straight Piston possessions. During that stretch, Drummond made 5 of his 16 free-throw attempts.

It must have been quite an exciting couple of minutes of play.

The All-Star Drummond had to be taken out of the game in the fourth quarter so that Detroit could hold on and win the game.

Yahoo Sports reporter Eric Freeman said: "While its a little inexact to say that sending a player to the line over and over again isnt basketball given that the rules allow it, its downright enervating to watch and not an ideal product for a league that ultimately sells entertainment above all else. Intentional fouling is also increasingly common, with seemingly each team having at least one player who gets sent to the line in opportune moments."

He suggested that NBA commissioner Adam Silver is going to have to do something about the issue.

Heres what Ive done about it. For the last few years, I havent watched basketball.

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Should I become a general surgeon

One of the rewarding things about blogging is receiving many emails from high school, college, and medical students asking about general surgery as a career.

I try to answer every one of their specific questions and direct them to posts that Ive written on the subject.

A recent inquiry stimulated me to review all of my posts and put most of the questions about becoming a general surgeon in one place. They are about 500 words each. I hope you enjoy them. Here they are.

Is the solo general surgeon a dying breed?

What is the future of open surgery?

In what specialties can a surgeon be autonomous?

An applicant worries about the future of general surgery

Will automation affect surgeons skills?

Going to medical school and becoming a surgeon when you are older

A medical student from the UK discovers surgery and has questions

Is it possible to live a full life as a surgeon?

Choosing a medical specialty is difficult

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Real Estate in a Depression by Marc Charles

4:29 PM

Hi Gang:

Ive enclosed a question I received from an entrepreneur recently.

I thought you might like my take.


Question: Marc, whats your take on making money with real estate in the current economy?
M.F. Apple Valley MN

Answer Marc Charles:

In 2004, I mentioned more than a dozen times in my newsletter, blog, speeches and conferences real estate would end badly.

Three conference organizers did not want me back....even though I was the most popular speaker at two of the conferences (according to an attendee poll).

The reason the organizers did not want me back is because I kept talking about a "depression" and real estate collapse (in most areas of the US).

Anyway, that was yesterday....what have you done for me today!

Weve all seen the real estate fiasco...and some people have been devastated by it.

But, the real estate boom (ans BUST) was predictable. If you had eyes to see, you would have known the boom was not going to last.

When I saw a cashier from a local convenience store drive into her triple car garage, which was attached to a $400,000 home, I knew the boom was toast. This was in 2005. The boom lasted another three years, and then kaput!

Almost everyone I knew, 90%+, was bullish on real estate from 2004-2008. The reason everyone was bullish is because in most cases they were making money.

But then the market collapsed....and is still collapsing.

Most people never realize, or refuse to realize, theyre involved in hysteria. But all it takes is simple, common, horse sense. You can also seek wise counsel from someone whos already lived through hysteria or "madness of the crowd". In many cases wise counsel will be twice your age.

Ive made money on real estate. But Ive also avoided major losses. I did not lose one thin dime in real estate from 2004-2009. I was also not underwater with mortgages.

Anyway..enough with the long winded response!

Yes....you can make money on real estate in a Depression. The key is buying at super deep discounts, not being over-anxious about doing deals (or fearful), and paying cash whenever possible.

The problem with most foreclosure properties is finding a clear title, and a property with no liens. But thats another topic.

The days of Fix and Flip are over for now! This market may not recover for 10 years...if ever.

But you can still find incredible deals, offer even less, wait for your terms, and rent the property.

Drop me a note if youd to know about specific markets Im considering.

I hope that helps!

Marc Charles

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