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Adapted from the blog, Surgery: Hope for the best and plan for the worst. https://peperperspective.com/2018/03/18/surgery-hope-for-the-best-but-plan-for-the-worst/
The purpose of this article is to share what I have learned from a cascade of medical errors that happen much more commonly than surgeons, hospitals, or health care providers acknowledge. My goal here is to provide a few simple recommendations to reduce these errors.
It is now two years since my own surgery – double hernia repair by laparoscopy. The recovery predicted by my surgeon, "In a week you can go swimming again," turned out to be totally incorrect.
Six weeks after the surgery, I was still lugging a Foley catheter with a leg collection bag that drained my bladder. I had swelling due to blood clots in the abdominal area around my belly button, severe abdominal cramping, and at times, overwhelming spasms. For six weeks my throat was hoarse following the intubation. Instead of swimming, hiking, walking, working, and making love with my wife, I was totally incapacitated, unable to work, travel, or exercise. I had to lie down every few hours to reduce the pain and the spasms. Instead of going to Japan for a research project, I had to cancel my trip. Rather than teaching my class at the university, I had another faculty member teach for me. I am a fairly athletic guy – I swim several times a week, bike the Berkeley hills, and hike. Yet after the surgery, I avoided even walking in order to minimize the pain. I moved about as if I were crippled. Now two years later, I finally feel healthy again.
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How come my experiences were not what the surgeon promised? All those who cared for me during this journey were compassionate individuals, committed to doing their best, including the emergency staff, the nurses, my two primary physicians, my surgeon, and my urologist. However, given the personal, professional, and economic cost to me and my family, I feel it is important to assess where things went wrong. The research literature makes it clear that my experience was by no means unique, so I have summarized some of the most important factors that contributed to these unexpected complications, following "simple arthroscopic surgery."
Underestimating the risk. Although the surgeon suggested that the operation would be very low risk with no complications, statistically, the published research data does not support his optimistic statement. Complications for laparoscopic surgery range from 15% to as high as 38% or higher, depending on the age of the patient and how well they do with general anesthesia (Vigneswaran et al, 2015; Neumayer et al, 2004; Perugini & Callery, 2001). Experienced surgeons who have done more than 250 laparoscopic surgeries have a lower complication rate. However, a 2011 Cochrane review points out that there is theoretically a higher risk that intra-abdominal organs will be injured during a laparoscopic procedure (Sauerland, 2011). My experience is not an outlier–it is more common.
Inappropriate post-operative procedures. In my case I was released directly after waking up from general anesthesia without checking to determine whether I could urinate or not. The medical staff and facility should never have released me, since older males have a 30% or higher probability that urinary retention will occur after general anesthesia. However, it was a Friday afternoon and the staff probably wanted to go home since the facility closes at 5:30 pm. This landed me that evening in the emergency room.
Medical negligence. In my case the surgeon recommended that I have my bladder emptied in the emergency room and then go home. That was not sufficient, and my body still was not working properly and still could not urinate, requiring a second visit to the ER and the insertion of a Foley catheter. Following the second ER visit, the surgeon removed the catheter in his office in the late afternoon and did not check to determine whether I could urinate or not. This resulted in a third ER visit.
Medical error. On my third visit to the emergency room, the nurse made the error of inflating the Foley catheter balloon when it was in the urethra (rather than the bladder) which caused tearing and bleeding of the urethra and possible irritation to the prostate.
Drawbacks of the ER as the primary resource for post-surgical care. Care is not scheduled for the patient's needs, but rather based on a triage system. In my case I had to wait sometimes two hours or more until a catheter could be inserted. The wait kept increasing the urine volume which expanded and irritated the bladder further.
- A medical system that does not track treatment outcomes. Without good follow-up and long-term data, no one is accountable or responsible.
- A reimbursement system that rewards lower up-front costs. The system favors quick outpatient surgeries without factoring in the long-term costs and harm of the type I experienced.
- Assuming the best and not planning for the worst.
Can I trust the health care provider's statement that the procedure is low risk and that the recovery will go smoothly? The typical outcome of a medical procedure or surgery may be significantly worse than generally reported by hospitals or medical staff. In many cases there is no systematic follow-up nor data on outcomes and complications, thus no one knows the actual risks.
In the United States medical error results in at least 98,000 unnecessary deaths each year and 1,000,000 excess injuries (Weingart et al, 2000; Kohn et al, 2000). The Institute of Medicine reported in 2012 that one-third of hospitalized patients are harmed during their stay (Ferguson, 2012; Institute of Medicine, 2012).
One should also be intelligently skeptical about positive claims for any specific study: it is important to know whether the study has been replicated with other populations and not just a particular highly selected group of patients. To quote Dr. Marcia Angell (2009), the first woman editor of the highly respected New England Journal of Medicine:
It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.
The evidence for many procedures and medications is surprisingly limited:
Research studies frequently select specific subsets of patients. They may exclude many patients who have other co-morbidities.
Clinical trials may demonstrate statistical significance without providing clinically meaningful results. For example, between 2009 and 2013 almost all cancer drugs that were approved for treatment in Europe showed upon follow-up no clear evidence that they improved survival or quality of life for patients (Davis et al, 2017; Kim & Prasad, 2015).
Pharmaceuticals are tested only against a passive placebo. In some cases, the patient's positive response may actually be the placebo effect, due to physical sensations induced by the medication or its side effects, thus inspiring hope that the drug is working (Peper and Harvey, 2017).
Negative side effects are significantly underreported. The data depend on self-report by both the patient and the health care provider.
Many published studies on the positive clinical outcome of pharmaceuticals are suspect. As Dr. Richard Horton (2015), Editor-in-Chief of The Lancet, wrote in 2015:
A lot of what is published is incorrect … much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.
Most studies, including those on surgery, lack long-term follow-up. The apparent short-term benefits may not be beneficial in the long term or may even be harmful. For example, doctors and patients are convinced that SSRIs (serotonin re-uptake inhibitors – antidepressants such as Paxil and Prozac) are beneficial, with resulting global sales in 2011 of $11.9 billion. However, when all the research data were pooled, meta-analysis showed that these drugs are no more effective than placebo for the treatment of mild to moderate depression and increase suicides significantly among young adults (Fournier et all, 2010; Kirsch, 2014).
Consider long-term follow-up in my case: the surgeon will report a successful surgery, despite the fact that it took me almost two years to recover fully. (I did not die during surgery and left in seemingly good shape.). Although I called him numerous times for medical guidance during my complications, the outpatient surgical facility will report no complications since I was not transferred from that facility during the surgery to a hospital for continuing care. My insurance carrier that paid the majority of the medical bills only recorded the invoices as separate unrelated events: one surgery/one bill, but three separate bills for the emergency room, an additional visit to my primary care physician to check my abdomen when my surgeon did not return my call, and the ongoing invoices from the urologist. They all reported success because the iatrogenic events were not linked to the initial procedure in the data base.
In my case, following surgery, I had to go to the emergency room on three separate occasions due to post-operative urinary retention, placing me at risk of permanent detrusor damage. For more than a year, I was under the care of a urologist.
Over the past two years, my symptoms have included gastro-intestinal inflammation, spasms, and abdominal bulging, which are only now disappearing. Even my posture has changed. I am now working to reverse the automatic flexing at the hips and leaning forward which I covertly learned to reduce the abdominal discomfort. This level of discomfort and dysfunction are new to me. Reading the research on laparoscopy, I realized that excessive internal bruising, large hematomas, and internal adhesions are fairly common with this type of surgery. However, soft tissue injuries are difficult to confirm with imaging techniques.
My complications were also a direct result of inappropriate post-surgical recommendations and treatment. The symptoms were further compounded by faulty patient discharge procedures performed by the outpatient surgical facility. Since this was my first general anesthesia, I had no idea that I would be one of the people whose outcome were not what the surgeon had predicted. Thus, hope for the best, but plan for the worst.
Scheduling Medical Procedures
The following recommendations may help reduce post-surgical or medical procedure complications.
1. Schedule elective medical procedures or surgery early morning and in the middle of the week. Do not schedule procedures on Mondays, Fridays, or in the afternoon. Procedures performed in the afternoon have significant increase in complications and errors. Anesthesia complications, for example, are four times higher in the afternoon than in the morning (Wright et al, 2006). Our biological rhythms affect our (medical staff) ability to attend and focus. In the morning most people are able to concentrate better than in the afternoon (Pink, 2018).
2. Avoid weekends. Procedures performed on weekends (as compared to those done in the middle of the week) increase the risk of complications or dying. For example, babies born on the weekend have a 9.2% higher infant mortality than those born during the week, while those born on Tuesdays have the lowest death rate (Palmer et al, 2015) .
It is possible that on Mondays medical staff are recovering from weekend binging, while on Fridays they are tired and looking forward to the weekend. If elective procedures are done on a Friday and complications arise, the emergency room is the only option, as the medical staff may not be available over the weekend. In my case the procedure was done on a Friday, and I left the surgical outpatient facility at 2 pm. When complications occurred, it was after 5:30 pm – phone support from the advice nurse and the surgeon on call were my only option until the following Monday. Thus, I had to go to the emergency room late Friday evening and again the next evening because of urinary retention, with a long delay in a busy waiting room. Since, I wasn't bleeding or having a heart attack, that meant I had to wait, wait and wait, which significantly aggravated my specific problem and hyper-extended the bladder.
3. Schedule medical procedures at least one or two weeks before any holiday. Do not schedule surgery just before or during holidays. Medical staff also take holidays and may not be available. In my case, I scheduled the procedure the Friday before Thanksgiving because I thought I would have a week of recovery during my Thanksgiving break from teaching. This meant that medical staff were less available and more involved in their holiday planning.
4. Schedule procedures so that you are released early in the day. This can allow you to return to the facility in case complications arise. I was released at 2 pm and the complications did not occur until early evening. The facility was closed, so the only option was the ER. When possible, schedule medical procedures or surgery in a facility that is able to provide post-operative care after 5:30 pm.
5. Do not schedule elective procedures during the month of July in an academic teaching hospital. During this month mortality increases and efficiency of care decreases because of the end of the academic year and subsequent changeover to new personnel (Young et al, 2011). Medical school graduates with limited clinical experience begin their residencies and experienced house staff are replaced with new trainees. This is known as the July effect in the US and Killing season in the United Kingdom . During the month of July in any given year, fatal medication errors, for example, increase by 10% at teaching hospitals, but not at neighboring hospitals which do not experience this turnover in medical personnel (Phillips & Barker, 2010).
6. Have procedures performed at a medical facility in which the health care professional has no financial interest – take economics out of the equation. When health care practitioners have financial interest in a facility, they tend to order more tests and procedures than health care providers who have no financial interests (Bishop et al, 2010). In my case the surgeon had a financial interest in the outpatient surgical facility where I received surgery. Had I had the operation across the street in the hospital where the surgeon also operates, I probably would not have been released early, avoiding the problems in follow-up care.
Strategies to Optimize Outcomes and Health
Organize your support system. Assume that recovery could be more difficult then promised.
Before your procedure, ask family members, friends, and neighbors to be prepared to help. If you did not need them, thank them for their willingness to help. In my case I did not plan for complications, thus my wife was my entire support system, especially for the first three weeks when I was unable to do anything except rest and cope. I was very fortunate to have numerous family members, friends, and colleagues who offered their expertise to help me understand what was going on and who assumed my responsibilities when needed.1
1. Bring an advocate to your appointments. Have your advocate/friend keep notes and ask questions, especially if the health care provider is a respected authority and you are suffering, exhausted, and/or anxious. Record any detailed instructions you must follow at home as a video or audio file on your cell phone or write them down (be sure to ask the health provider for permission). Under stress one may not be able to fully process instructions from the health care provider.
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