Wednesday, August 16, 2017

Fatal internal jugular vein cannulation by a misplaced NG tube

A case report published last month involves a 79-year-old man with multiple comorbidities including depression, alcohol abuse, hypertension, CHF, and COPD who was admitted because of abdominal pain and distention which was found to be a perforation of the right colon. 

He underwent a resection and did well until the seventh postoperative day when he became distended. A nasogastric tube was inserted. Its position was checked by injecting air through the tube and auscultating over the upper abdomen [a notoriously inaccurate method of locating an NG tube’s position].

A few hundred mL of dark blood came out. He was treated for a presumed upper gastrointestinal bleed. A chest x-ray showed the tube in good position but the tip was not seen.

When the patient’s vital signs deteriorated, a new NG tube was put in and drained 2 L of blood. The patient suffered a cardiac arrest and could not be resuscitated. At autopsy, the NG tube was found to have gone through the right pharyngeal wall and into the right internal jugular vein. The tip was in the superior vena cava.

Although I had never heard of this complication before, it has been reported in the literature at least one other time.

Wednesday, August 9, 2017

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.

Monday, August 7, 2017

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.

Wednesday, August 2, 2017

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.

Monday, July 31, 2017

"Move that defibrillator paddle so I can finish the case"

A plastic surgeon in Sydney was reprimanded by the New South Wales Professional Standards Committee for continuing breast augmentation surgery after a patient had been successfully resuscitated from a cardiac arrest.

According to a report, the surgeon, Dr. Niroshan Sivathasan, defended his actions two years after the incident saying he operated for another 30 minutes after an ambulance arrived because he hadn't finished inserting the left breast prosthesis or closed both wounds, and he was concerned about infection if he aborted the case.

The committee didn't buy that excuse correctly pointing out that the patient could have had another cardiac arrest and said he "demonstrated almost no insight into the nature of his conduct or how he failed his patient."

He was also told he must undergo mentoring and submit a report documenting all of his complications every three months.

Sivathasan works at The Cosmetic Institute, Australia's largest plastic surgery center, which has had some problems in the past. In 2016, the Health Care Complaints Commission found six patients had experienced potentially life-threatening complications — tachycardia, seizures, and cardiac arrest—during breast implant surgery done over a 12 month period.

The complications were thought to have been due to the use of large amounts of local anesthesia with epinephrine. In addition, the facility was licensed for administering conscious sedation only, but some patients had undergone general anesthesia without their consent.

The 21-year-old woman who survived the cardiac arrest in 2015 was interviewed back then for an article in the Sydney Morning Herald. She described waking up in the hospital and finding she had received CPR and cardiac defibrillation. She said Sivathasan told her there was a problem with the anesthetic.

Regarding her surgeon, she said, "If it wasn't for him I wouldn't be alive. That place is so prepared for whatever. Literally, they saved my life."

I don't think they have Press Ganey scores in Australia, but if they did, no doubt the surgeon and the facility would have received 5-star ratings from this patient.


Dr. Sivathasan, the surgeon involved in this case, emailed me with comments which shed some light on why he continued the operation. They are published without editing below.

I felt it important to write to you just to highlight a few things that were ‘not’ correctly reported in the press release:

1) the operation was close to being finished when the patient developed ventricular fibrillation;
2) hardly any local anaesthetic was used in this case (only 10mL of 1% ropivucaine);
3) by good fortune, there were TWO specialist anaesthetists (one being a senior cardiac anesthesiologist) who were managing the patient, and the patient responded very quickly to their efforts;
4) the ambulance service despatched two incorrectly equipped ambulances, and a THIRD ambulance was required to transfer the patient.  This entailed a delay;
5) it was UNANIMOUSLY agreed by FOUR doctors (both anaesthetists and both surgeons who were present) that we ought to use the window to give the most definitive outcome for the patient.

At the end of the day, the patient, a sizeable percentage of the public, and a considerable number of doctors supported us for our actions.  They recognized that it takes more judgement and nerve to finish a procedure under such stressful circumstances, than it does to just ‘whack in a few staples and down tools’.

Unfortunately, due to the regulatory processes in place, two doctors who were not present during the incident, were able to judge upon the actions of four doctors (all of whom were in agreement).  This is simply illogical and is, certainly, an indictment of the regulatory board’s processes.  Furthermore, neither of the two doctors that were presiding over the case is an expert in critical care – one was a retired surgeon and the other was an emergency physician.

Accordingly, what those two doctors failed to recognize, in my strong opinion, is that a patient whom has been salvaged from a nasty situation remains unstable and should not immediately be in the back of an ambulance; rather, the patient shall be better served when under the care of two anesthesiologists maintaining anaesthesia (which is relatively cardioprotective given the high catecholamine situation (which may provoke another episode of VFib)).  The VFib was ‘not’ secondary to haemorrhage or anything surgical, and therefore to capitalize on the undesirable situation by finishing an almost-finished operation appeared to be the best decision (as opposed to requiring a GA in the future, where the induction may be a lottery).  

Experienced doctors shall appreciate that medicine, and especially surgery, involves judgement calls.  This patient in question has had a positive outcome.  Unfortunately, the institution where the problem occurred has been the subject of debate due to a few suboptimal practices by the management team, and this ended-up biasing the outcome.

Wednesday, July 26, 2017

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.”

Wednesday, July 19, 2017

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.