Pre-operative fasting: let them eat … anything?

It is routine for patients to be fasted before an anaesthetic, usually for six hours, but for morning lists patients are usually fasted from midnight. The fasting is meant to reduce the risk of aspirating (vomit and have gastric contents enter the lungs) during the induction of anaesthesia, which can damage the lungs and be very harmful. But does fasting decrease the risk of this complication occurring? Once again, the benefits of fasting have been overestimated and the harms have been underestimated. And once again, when faced with a difficult decision, doctors have chosen the (seemingly) cautious path, and in doing so have not provided any proven benefit, and have possibly harmed patients. It may not seem like a big deal, but with over 200 million surgical procedures performed in the world each year, it can add up.

Book review: The Medicalization of Society

Title: The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders (2007)

Author: Peter Conrad

Publisher: The Johns Hopkins University Press

Continuing the work of pioneers in medicalization such as Irving Zola and Ivan Illich, this veteran but intermittent author on medicalization gives us a sociologist’s perspective on medicalization. Conrad provides us with examples, but also gives us some causes (such as direct-to-consumer advertising, managed care, changing definitions and ‘domain expansion’) and consequences of medicalization.

Book review: How Much is Enough: Money and the Good Life

Title: How Much is Enough: Money and the Good Life (2012)

Authors: Robert and Edward Skidelsky

Publisher: Other Press, New York

This book is not about health, although it does touch on health in that our measurements of general health are intertwined with well-being and happiness. That is one justification for squeezing it into this series of book reviews. The real reason I included this book is because the authors challenge our current (economic) thinking; questioning our goals and the prevailing wisdom that guides current practice. In other words, they are skeptical.

Patient care overlooked in the concern over patient privacy

A recent journal article (paywall) had the lead-in line of:

“Patient privacy and confidentiality are being overlooked in the burgeoning use of smartphones to take medical photos”.

I argue the opposite: that ease of access to medical images has been overlooked in the concerns over privacy and confidentiality.

Cruciate ligament reconstruction: wait and see

The anterior cruciate ligament (ACL) is a major ligament deep inside the knee. It is commonly torn during sport and once torn, it usually does not heal. An ACL deficient knee is often unstable, leading to “giving way” on certain movements. Previous attempts (1960’s and 70’s) to repair the ligament did not lead to good results. Later, attempts to repair the ligament were abandoned in favour of a reconstruction in which the torn ligament is replaced with some normal tissue (part of the patella ligament or some hamstring tendons). It is a very common injury and reconstruction is a common procedure for orthopaedic surgeons. If you only want information about the procedure, there are thousands of websites that will help you. If you want to know whether the surgery is necessary, read on.

Does CPR save lives?

In TV land, most people not only survive CPR (cardiopulmonary resuscitation), but they go home from hospital and function normally afterwards (yes, they actually studied this). In reality, less than 10% survive, and for many that do, it’s not a good life. The low number of people that survive and function well after CPR (as low as 2% in some studies) leads to a question: if the results with CPR are so dismal, what would the results be if we did not do CPR? In other words: does CPR itself do anything; were those that survived going to survive anyway?

Book review: Effectiveness and Efficiency, by A Cochrane

Effectiveness and Efficiency: Random Reflections on Health Services (1972)

Author: Archibald Cochrane

Publisher: The Royal Society of Medicine Press.

Cochrane was a physician and epidemiologist whose request for an organised summary of all randomised clinical trails in medicine was answered in the form of the Cochrane Collaboration (www.cochrane.org). This classic book, written as an invited lecture, is essential reading for anyone interested in of the evolution evidence based medicine, and anyone sceptical about modern medicine. Archie Cochrane pushed for evidence based medicine before the phrase was coined.  He questioned the effectiveness of much of the (then) current medical practice (such as prolonged bed rest for heart attack patients, oral therapy for diabetes, iron for anaemia, ergotamine for migraine, and my favourite, antidepressants) and was proved right.

Reasons to operate: the ‘wobbly tripod’ of evidence

"When good evidence is lacking, the best and most dedicated of us do wrong in the utter conviction of being right"

(L. Eisenberg 1977, NEJM, 297, 1230-2)

When surgical practice varies between doctors, hospitals, regions and countries (and it does), there are many possible reasons, apart from variations in the disease or the population. Some reasons that have been given for practice variation in surgery are:

Is back fusion surgery just a placebo?

It is possible that spine fusion surgery for back pain achieves its effectiveness through the placebo effect. I would like to make the case that it is not only possible, but also probable.

Achilles tendon ruptures: let the patient decide

As we age, our collagen loses its elasticity and our tendons weaken. A ruptured Achilles tendon (TA) is often the result. This is a common injury; patients are usually aged 30 – 50 and it normally occurs with a sudden push-off during sport. Now, the initial reaction when anything is torn is to repair it, and while this holds true for inanimate objects, living things are different – 4 billion years of evolution has made some headway in that regard. Many people do not appreciate that as surgeons, when something is broken, cut or torn, all we do is put the ends roughly together and it is nature that does all the healing; we just take the credit. Placing the torn ends of a ruptured TA together is easy: you just flex the ankle. And it turns out that if you do this, and gradually bring the ankle back to normal position over a few weeks, it heals fine – without surgery, and without the complications associated with surgery.

Placebo surgery #4: Knee arthroscopy in arthritis

An arthroscopy (key hole surgery to wash out, trim or clean up) in the knee joint is one of the most common procedures in orthopaedics, and one of the most common surgical procedures overall, with over one million performed in the USA each year. An overview of arthroscopy for knee osteoarthritis can be found in a previous blog; this post covers the sham surgery trial as part of a series on that topic.

Lessons from history #3: From railway spine to whiplash

‘Railway spine’ was the name given to the widespread finding of chronic back pain and disability associated with railway injuries, and reaching near epidemic proportions in mid and late nineteenth century England. It has many similarities with other post-traumatic conditions and provides lessons about chasing physical diagnoses, and the role of psychosocial factors (in particular, the role of compensation). Lessons that we never seem to learn.

Financial incentives and surgery rates

Recently, a reader asked me if financial incentives could be responsible for the findings referred to in previous posts, like practice variations and the persistence of some surgical procedures despite evidence of their ineffectiveness. We know that you can change physician behaviour by altering financial incentives (Cochrane review), but anyone who believes in Homo Economicus will tell you that. And there is also evidence that financial incentives lead to increased health care usage amongst primary care doctors (here), but what about the evidence for financial incentives influencing surgery rates?

I'm not sick but I'm not well

This phrase got me thinking: what happens to people who do not have an identifiable disease, but still feel unwell; when the tests do not reveal any pathology, but they still have symptoms? They get a label, that’s what, because doctors cannot say: “Your tests are normal and you do not have any evidence of an underlying disease process. Further opinions and investigations are unlikely to help, and may lead to unnecessary and potentially harmful treatments”.

I don’t have time for a discourse on medicalisation, but I wanted to ask: What label do these people get? It turns out that it depends on the specialty training of the doctor that sees them.

Placebo surgery #3: Meniere's disease

Meniere’s disease is a disorder of balance (dizziness) and hearing (ringing or hearing loss). The underlying cause is not understood (idiopathic), the symptoms often fluctuate, there is crossover with other symptoms (vertigo, migraine), and there are many other conditions that cause “Meniere’s-like” symptoms. This makes the condition ripe for any treatment to look good if we think it works, due to the subjective nature of the symptoms, symptomatology that is open to misinterpretation, and the lack of any objective pathological test. Therefore, for such conditions, reporting good results from a series of patients is not enough; a more scientific (unbiased) assessment is necessary. Fortunately, somebody did just that. Unfortunately, despite the results of that study, surgery (now in many different forms) is still being used for this condition.

Stop the bleeding: questioning emergency trauma care

When trauma patients arrive at hospital with multiple injuries and haemodynamic instability (significant blood loss, low blood pressure, increased risk of dying), apart from resuscitating them (usually by giving blood and other things like clotting factors) the treatment is summed up by the phrase: “Stop the bleeding”.

“Stopping bleeding” is a biologically plausible mechanism for saving life that I will accept on face value. My question is: do our noble attempts to stop the bleeding actually influence the chance of dying? Looking at previous treatments that have fallen out of favour, I would say not. And the treatments currently in vogue are supported by as little evidence as those they replaced.

Anti-depressants make me sad

Anti-depressants have been around since the 1950’s, but it wasn’t until SSRIs (Selective Serotonin Reuptake Inhibitors), the first being Prozac, came on the market in the 1980’s that things really took off. The safer profile meant that primary care physicians could start prescribing, and Prozac itself became a blockbuster drug (over $US1 billion in annual sales) and a household name. Others followed and by 2005, anti-depressants were the most prescribed drugs in the USA. For most patients, however, they are no better than placebo. That doesn’t mean that they don’t’ work, they just don’t work any better than placebo.

Book review: Between the Lines

Prostatectomy: doctors just don’t get it.

The results from the latest randomised trial comparing prostatectomy to non-operative treatment for prostate cancer are all over the news, but what caught my eye was the response from a senior clinician in my country. I will address his comment, and a related comment, below.

The study (here) recruited 731 men less than 75 years of age and found that the overall mortality after 10 years was 47% in the surgical group and 50% in the non-operative group. The difference was not statistically different. If it were, you would have to weigh that benefit against the 88% erectile dysfunction and 17% incontinence rates in the surgical group (2 -3 times higher than the non-operative group).

“The whole problem is selecting the ones which need to be operated on”

Manual handling techniques and back pain

Walking from the change rooms to the operating theatres, I go past a series of posters using drawings of animals in funny positions, extolling the virtues of manual handling techniques. Lifting with your knees, bending with your hips, twisting with your elbows, or whatever. And when I arrive in the operating rooms, I am regularly fascinated by the addition of yet another ingenious device to move a patient less than one metre from their bed to the operating table. Last week we used something that was basically a fully functioning hovercraft (here).

There are countless well-meaning guidelines (and rules) on how we should be moving objects (like this, and this) but do they help? I lift a lot of heavy things in awkward positions when I am working in the yard, but really only get back pain when I lie on my back for too long. I see Olympic weight lifters putting a fair bit of weight through their back without much back pain, and I know that the biggest predictors of back pain in the workplace are not physical factors (try this, this and this) but things like job satisfaction. What is the evidence that this advice, or these devices, actually work?