A Comment about Transparency in Medicine

Original story about crap left in people after surgery: http://www.msnbc.msn.com/id/25120613/

My comment: http://cmolstrom.newsvine.com/

And yet more thoughts! This is not a defence of surgeons as much as an explanation for how things are from their perspective I guess.

In the OR staff joke, "how often is a final count off when the patient leaves the OR?" The answer of course is never, because a patient should never leave the room with an off count and unexplained missing item would be found. The point is that something gets left behind and the count is still correct! Human error, but there are better and better systems with built in redundancy that improve catching errors if they happen, because they will.

One example is putting a small metallic strip in every gauze pad or towel so that it will show up on xray. A normal gauze or even towel will not show up on CT or xray, which could be why some patients need to be re-opened to find the damn thing. Some people do not recover well from abdominal surgery - especially if they have other illnesses - and so a left behind towel is not the first thing to come to mind since that sort of thing is rare. In that case the corrective surgery should not be the responsibility of the patient - probably the surgeon since he or she is ultimately responsible (although the scrubs, etc., are hospital employees).

Not all cases are clear cut though. Certain specialized staple guns that use a ribbon of stables and work by zippering together two pieces of tissue usually shed some extra staples in the process. Going after all those staples would take extra time (more anesthesia risk) and expose risk to organs due to the "fishing around" - the risks are not worth the benefit. The risks theoretically are, I suppose, a perforation of something, but that never happens so I'm told. Just sitting there they will not cause infection because they are sterile just like the other staples that will remain in permanently. It is debatable whether a surgeon should tell every patient about these things that never cause a problem even if they theoretically could. Of course patients want to know everything but in reality doctors filter out information since there is little use in telling a patient about extremely rare 1 in a 100 million risks and complications that do nothing but cause anxiety. Believe it or not many people do not understand statistics. This is a frustrating aspect of the profession.

Example - Last night in the ED I saw a woman with abdominal pain and tingling in her arms and legs that got better after vomiting once. She was totally healthy, 34 years old, no history of any diseases, mother of 2 infants. She was also a very anxious woman, prone to anxiety attacks, corroborated by her husband, and had given a history very suspicious of anxiety-induced abdominal pain: her cousin's son had just been diagnosed with a brain tumor and she had visited the family earlier that day. She has two kids and has been festering on that...what about my children? To an extent this is natural maternal feeling, but the chances of her kids getting are brain tumor are really, really, rare. The chances of her having a heart attack or stroke (what she thought she had) are extremely unlikely. Can't say impossible - you never say never in medicine - but very unlikely. What do I tell her? I say it is very unlikely for reasons x, y, and z that you have a heart problem, and the tests we ran here show that. But should I also say, "but an EKG (heart tracing) is not 100% on the money for heart problems, and so there is still a chance this could be your heart" and send her home an anxious again? Reassurance involves minimizing some information and maximizing other, and some people take that as not being up front with the patient.

Leaving extra staples in is one of those things that surgeons never talk about - not because of denial but because patients are not likely to understand the very low risk of complication and will just make them worry. Hell, every veteran doctor has seen a zillion patients who start to have symptoms only after they are made aware of a disease (which they don't have, but think they might). "I'm having belly pain after my surgery (everyone does) and the doc told me about those staple...I wonder if it could be..." and so that the belly pain gets worse for no physiological reason. This is called somatization.

Another example, just last night! 20 month old girl comes in with 4 very worried family members because she is wheezing. She improves some on medicated oxygen (for asthma) but not back to 100%. Parents are very anxious because they've never seen many infants with asthma. From a physician's view in fact the girl is doing really well overall, her blood oxygen is totally normal, she does not look infected. Half of the treatment involves reassuring the parents. We get a chest x-ray to rule out a foreign body aspiration. Her lungs look great, but she has an unusually shaped aortic arch. X rays are not at all the test of choice to diagnose an aortic problem, plus she was poorly aligned in the machine, so the film is a little cock-eyed. But the shape is unusual nonetheless. We talk to radiology and they did not even feel it was necessary to comment on the aorta in their report. So, of course I am not going to tell the parents, "the xray looks normal, except we thought the aorta was a bit strange - oh, don't worry, it is probably nothing just the way the film was" Worried parents don't hear anything after "don't worry...." It would have been nuts to say anything. There was no explanation for the unusual shape, she clearly had no cardiac problems. Normal anatomic variant? Weird artifact from the film? At any rate should I worry the parents about these details?

Every doctor has their own way of talking to patients about adverse effects, risks, complications, abnormal test results -in my woman above many would just say "it's not a heart problem, don't worry" and leave it at that. I think it is important that patients know our tests and diagnostic skills are not perfect, that there's other possibilities even with someone like this woman. But at the same time I can't dwell on the other possibilities without making her totally freak out. Its a fine line, and every patient is different. The bottom line for me is: when in doubt, talk it out!