Category Archives: surgery

Complication-free ops total 4,000 in one day

Screen Shot 2016-04-16 at 20.35.05That, Dalrymple points out, is not news. Nor is

Cured patients discharged from hospital numbered 5,000 yesterday.

The lack of such reports in the newspapers naturally, he says, puts him on the

qui vive for deficiencies in the care of an old and close friend of mine who was admitted to a provincial hospital with a very serious illness.

People, Dalrymple observes,

often talk as if they believed that there could be a world without untoward events.

  • There is a terrorist outrage: the security services have failed.
  • There is a miscarriage of justice: the judges are fools.
  • A patient dies: the doctors are incompetent and the nurses cruel.

It is almost as if there were a giant conspiracy afoot to subvert the ideal normal in which we should otherwise live.

The right day for your operation

Screen Shot 2016-04-09 at 12.04.19Dalrymple draws attention to a UK statistical study that examined 30-day death rates after non-emergency operations in 2008-11 (except day cases) according to the day on which the procedure was performed. There were 27,582 deaths after 4,133,345 operations, a raw rate of 6.7 per 1,000.

  • Those who underwent an operation on Friday had a death rate 44% higher than those who underwent an operation on Monday
  • Those who underwent an operation at the weekend had a death rate 82% higher

Screen Shot 2016-04-09 at 12.10.15The death rate

increased steadily as the week progressed.

Perhaps, says Dalrymple,

hospital staff, especially surgeons and nurses, grow steadily more tired or careless as the week progresses.

Not everyone who needs surgery can have it done on Monday. Therefore,

so long as the information is not known by everyone, the wise patient would be well-advised to keep it to himself. A small number of patients, but not many, can ask for their operations on Monday and have their wishes respected.

May my surgeon be human-hearted

Screen Shot 2016-04-04 at 08.49.19Dalrymple points out that the media’s attitude towards medicine

swings between lauding a miracle cure and excoriating the murderous incompetence of doctors, leading to a dialectic between unfounded hopes and hostile suspicion.

Yet very occasionally it perhaps ought to be acknowledged that medicine,

for all its deficiencies and the carping of its critics, is a noble enterprise.

Doctors must act

in the absence of definitive knowledge. Sometimes this leads to tragedy, sometimes to triumph.

Screen Shot 2016-04-04 at 08.20.47A paradox

Everyone who comes under the knife

wants his surgeon to be as highly trained and as experienced as possible: but how is the surgeon to come by that training and experience unless he practises on people while he is untrained and inexperienced? Someone has to be operated on by tyros, even if they are under the supervision of more experienced surgeons. In practice, for compelling practical reasons, that supervision may be light: senior surgeons cannot be everywhere at once. What is true of surgery is true of other specialities: decisions of vital importance to individuals are taken by people who are still learning.

In the old days,

Thomas Rowlandson, 1793

Thomas Rowlandson, 1793

perhaps explanations of treatment options were less elaborate or full than they are today, but they were still given and consent to such treatments was still sought.

Patient autonomy as the single most important guiding principle of medical ethics has drawbacks.

Patients who are very ill are often in great pain, or severely weakened. Their concentration is poor, they may be irritable or in a state of panic. This is not generally the best moment to ask them for a reasoned assessment between two or more alternatives, each with its own advantages, side-effects and chances of failure. The insistence that they do so is often a form of disguised cruelty.

Dalrymple says that when he has been seriously ill or injured,

I have wanted my doctors just to get on with it as best they could, without any interference from me. So far, at any rate, my confidence in them has not been misplaced; and the paradox in the doctrine of autonomy is that the person may — in fact, often does — wish to abrogate it.

Surgeons

need human as well as technical understanding, and kindness is at least as important as respect for patient autonomy.

Economics of sham operations

Dalrymple comes across a paper in the New England Journal of Medicine comparing physical therapy with surgery for meniscal tears in the knees of people with osteoarthritis.

There was no difference in outcome, an important finding since 465,000 people undergo operations for this situation every year in the USA alone.

Actually, says Dalrymple,

the uselessness of operation had been established before — uselessness from the patients’ point of view, that is. Two previous trials had compared real with sham operations, and with no operations at all, and found no difference in the outcome two years later. One might suppose that, in the light of these findings, the 465,000 operations still performed annually constituted something of a scandal.

Dalrymple considers the economic aspect of unnecessary operations. Granted that

unnecessary operations are more expensive than intensive physical therapy, do these operations increase or decrease gross national product? At first sight they do. As everyone knows, operations are not cheap. Without them, the GDP would fall. So would the incomes of those who perform them – orthopædic surgeons, for example, and their hangers-on such as operating room nurses. Presumably their incomes have a multiplier effect, for example on the legal profession. On the other hand, there are opportunity costs of employing money in this rather futile, indeed counterproductive, manner. But would the money in fact be better employed elsewhere? Would not something just as unproductive be done with it?

Screen Shot 2016-03-31 at 16.14.18

In the operating theatre

Screen Shot 2016-03-18 at 18.47.37Writing of his Bulawayo days as a house officer at Mpilo Hospital (‘a large building of red brick in the parsimonious British municipal style of the 50s, with metal-framed windows and no embellishments’), Dalrymple says he learnt little in the operating theatre because

I wished to learn little. Assisting at operations was, for me, a kind of slow torture. It is one thing to take infinite pains yourself, quite another to watch someone else doing it.

It is a law of surgery that

Mpilo hospital opened in 1958

Mpilo hospital: it was opened in 1958

the assistant can never satisfy the surgeon. He either pulls the retractor too hard or not hard enough, but never just right. There is an old joke about a medical student who asks the famous professor of surgery: ‘And how would you like your stitches cut today, professor? Too long or too short?’

The layman may think

of the operating theatre as a place of drama,

Screen Shot 2016-03-18 at 18.41.33and it is true, says Dalrymple, that

there are moments of drama, or rather of crisis, but for the most part there is only tedium exacerbated by the desultory conversation between the anæsthetist (if he is not wholly absorbed in his crossword) and the surgeon concerning their sailing dinghies, dogs or vegetable gardens.

Screen Shot 2016-03-18 at 18.42.27Dalrymple admires the surgeon’s

capacity for prolonged concentration, up to ten hours at a time; the concern for the welfare of patients that such an effort implies; and the coolness with which crises, when they arise, are handled.

Screen Shot 2016-03-18 at 18.41.45He remembers a surgeon accidentally cutting an artery,

and the strong instantaneous jet of crimson blood spattering his face and soaking his mask. It was enough to make even a brave man flee, but in one swift and sure movement of his finger he staunched the jet, and the crisis was over before it had properly begun.

Screen Shot 2016-03-18 at 18.45.53This

was not work I could enjoy, and I never left the theatre without feeling great relief.

Screen Shot 2016-03-18 at 18.42.01Screen Shot 2016-03-18 at 18.40.33

Is your procedure really necessary?

Screen Shot 2016-03-01 at 09.22.04Dalrymple discusses a trial that sought to establish whether endarterectomy or stenting was a better treatment for narrowing of the carotid artery.

The results showed that there was no statistically significant difference in the outcomes. 11.8 per cent of the stented group had any one (or more) of the end points against 9.9 per cent of those who had had endarterectomy. 6.9 per cent of the stented group had had strokes while 5.6 per cent of the endarterectomy had had strokes. The authors conclude that there is nothing to choose between the two types of treatment.

Why you should want to be operated upon by a three-parts-drunk imbecile of a surgeon

Screen Shot 2015-03-14 at 21.12.04You may die as a result of the procedure, indeed you may die painfully, but you will have the consolation of knowing that you are part of a society that is appalled by the discrimination suffered daily by surgeon-cretins and other downtrodden groups, such as Islamists, a society prepared to act to correct these injustices. Dalrymple puts it this way:

Social justice is social justice, and not good surgery. The achievement of such justice requires that we all be prepared to make sacrifices for it: a botched operation is a small price to pay for the satisfaction of knowing that surgeons are demographically representative of the population as a whole.