What else is there to say about work? The amazing storm of OR cases continues. I feel bad because they’re two-person cases, which means the medical student is lucky to scrub, and certainly gets to do nothing whatsoever during the case. I remember how frustrating that was, especially going to the OR, haunting the holding area, waiting and hoping that the resident wouldn’t show up, and how crushing it was when they would blithely wander in and take over everything. That doesn’t prevent me from – wandering blithely in and taking everything, though.
I read Bongi’s post about assisting the surgeon yesterday, and consequently thought very carefully about my actions today. I think I did fairly well, not that it was a complex case. But even after just a week at this, I’m getting better at telling what the attending wants to do, and what direction the tension, or suction, or light, needs to go to help that happen. I read a fascinating article somewhere once about how the human brain can calculate what another person is going to do next. Apparently, when one watches another person’s motions, one’s own motor cortex lights up as if performing that action. So you can almost feel what’s going to happen next, because you can tell what your body would do next, if it were in that position. For example, someone holds a glass, and you can tell if they’re going to put it down, or drink from it, from just a split second of movement. You can watch someone walk down a hallway, and tell where they’re going to turn before they actually pivot. Similarly, with more experience, I can start to see where the surgeon’s hands are going next, or what part of the field they’re heading towards, before it actually happens. Fun.
I love AAPS. For one thing, Ron Paul is a member. For another thing, they send out delightfully informative, heretical, subversive pieces of news like this one: A major study shows that Zetia has no preventive effect on heart disease or heart attacks. This article also reviews the fact that most of the statistics showing benefit for statin drugs (and also for many other famous medications) are only impressive when given as relative risk reduction. The absolute risk reduction for many medications is not at all persuasive. This is the difference: if 100 people take a pill, and 100 take a placebo, and in the placebo group two people die, or have a heart attack, or develop angina, and the medication group only one person has that bad outcome, the relative risk reduction is 50%: half as many people died when they took the medication. The absolute risk reduction is 1%: 1 out of 100 was significantly affected by having taken the medication. Now if the effect you’re measuring is death, 1 in 100 may be a good cost/benefit ratio. But if the effect you’re measuring is just reduction in cholesterol, or slower development of coronary artery disease, and you can’t even show a survival benefit, it starts to look worse. Also bear in mind that the side effect rate is probably at least 2-3%, and probably higher, depending on what you count as significant side effects. This is why I can’t stand medicines.
(And yes, to be fair, I’ll apply this to surgery too: We say that you will get very sick if you have appendicitis, and don’t let us take it out. Similarly with gallbladder disease, and sigmoid diverticuli, and so on. But I suspect that the mortality/morbidity rate for these diseases untreated, or treated only with antibiotics and never with surgery, is not as high as we give patients the impression it would be. Or perhaps I’m underestimating the amount that surgical diseases contributed to the low life expectancy prior to this century. At any rate, it would now be impossible to do any kind of study of what happens to appendicitis if not surgically treated. And, the mortality can indeed get quite significant if you add in a few other medical problems. So I’ll keep doing these surgeries. But I’ll feel quite happy about not reording zocor and the rest for my patients who are hospitalized for a couple of days. If I get their blood pressure within reasonable limits, that’s enough.)
(On the other hand, I’m disgusted with myself for losing interest in general medical problems. I used to swear I would try to maintain some knowledge about overall medicine: thyroid disease, basic cardiac issues, diabetes – all that. For the first few months here, I did try to handle that stuff as much as my seniors would let me. Now, I’m beginning to care as little as the next surgeon. Diabetes? Sure, consult endocrine. Bad COPD? Sure, consult pulmonary. (Not that the consult does much good. Pulmonary always recommends nebulizers and pulmonary toilet, things we order reflexively in smokers and asthmatics. Endocrine puts the patient on insulin, and adjusts based on fingerstick results, which is really fairly basic math: addition and subtraction. And then they do their usual battery of tests (pulmonary function, or TSH/T4/ionized calcium/HgbA1c/microalbuminuria), which by this time I can predict, but admittedly have little interest in interpreting. I’ll quote you a cardiology consult I got the other day: “Recommend decreasing iv fluids when appropriate per surgery service.” Do tell. Usually when the patient has been resuscitated after surgery, we tend to turn the fluids down the next day or two, of our own accord. Thanks for that scintillating insight.) I’m studying for Step 3 right now, and am having great difficulty mustering any interest in the subject whatsoever. The review book has no chapter on general surgery. I looked three times. No wonder we get urgent consults for asymptomatic gallstones.)
(Ok, I’ll stop there, and get ready to duck the comments.)
February 13, 2008 at 12:34 pm
Wow. You really are becoming a surgeon. Something worth bearing in mind though is that almost nothing medicine has done since 1910 has added more than a few years to life expectancy. Clean water and air have done more than any number of stents, statins, and surgeries. So a one percent ARR is actually pretty good, because we’ve reached the point of diminishing returns in medical research and practice. (Which is also incidentally a rather strong argument against nationalized health care)
But seriously, you aren’t controlling patient’s blood pressures? Statins are controversial, certainly, but HCTZ? Probably the two best drugs out there are ASA and HCTZ, and they are certainly the cheapest.
February 13, 2008 at 7:09 pm
Hey, I said I do try to control blood pressure :), although taking 140 as a goal, not the drug-company-funded new numbers of 120-130 (since in a post-op patient I wouldn’t be comfortable forcing the pressure too low, in case they become hypotensive, and we have to consider whether it’s a surgical emergency vs. medication maladjustment).
I completely agree that hydrochlorothiazide is indicated as firstline therapy for outpatients with hypertension, not the brand-name drugs, and that aspirin works just as well as plavix. However, I would hate to have to explain to my attending why I’m diuresing a patient the night after surgery, rather than repleting their fluids, or why I’m giving aspirin to a patient whose JP drain we’re still observing with concern for bloody output (let alone why I’m giving pills to a patient who’s supposed to be strictly npo). So for me blood pressure control is a matter of adding on enough iv beta blockers or ace inhibitors to keep things at a reasonable number. I still remember the JNC guidelines, but I doubt that our referring PCPs would appreciate us putting all their patients back on the “indicated” drugs rather than the regimen they’ve worked out, for whatever reason.
February 14, 2008 at 10:31 am
I can see that. Even in my field we let stroke patients have pressures up to the 180s without worrying too much.
And I guess I wasn’t clear about when you would give these drugs, my point was mostly that despite all the studies and research, HCTZ is still the best anti-hypertensive. A lot of people see adalat as first line, and it is a good drug, but it doesn’t work nearly as well as the original. And despite all the research on ACE-Is and beta blockers and GPIIa/IIIb inhibitors, the very best thing you can do (in terms of ARR) for an MI patient is give him 325mg of ASA. That and stent his artery, of course ;)