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August 24, 2008

Surgery Past and Future

da-vinci-healthcare.jpgImagine how a single operation with a 300 percent mortality rate would appear on NHS Choices. In the 19th Century John Liston—proud of his ability to amputate the limb of an unanaesthetised patient in less than 30 seconds—accidently amputated an assistant's fingers along with the patient’s limb. Patient and assistant died of infection and an observer of shock.

Blood and Guts by Richard Hollingham is a pithy and readable history of surgery that does not hold back on the successes and the botches. One of the most amusing anecdotes became known as the “night of the pigs” and takes place in the National Heart Hospital in London in 1969.

Surgeon Donald Longmore waits for a delivery of pigs. He plans to graft a pig’s heart and lungs into a patient to keep him alive. One pig has other plans and makes its escape onto Wimpole Street, pursued by gowned, capped, masked and booted theatre staff.

The pig, now secured, is taken to the mortuary to be put to sleep, but the anaesthetist assigned to the task is Jewish. Another anaesthetist is found, but there is another problem: the patient is also Jewish and now unconscious so unable to take any decisions for himself. Mr. Longmore calls a rabbi who in fits of laughter gives the go ahead for a genuine attempt to save the patient’s life. Unfortunately, the operation fails in its final stages owing to an unforeseen reaction of pig heart to an injection of calcium.

Also described is the sad life of Ignaz Semmelweis who drastically reduces cases of puerperal fever among postnatal women in Vienna General Hospital by insisting doctors wash their hands in a chlorinated lime solution before entering the ward and with soap and water in between patients. Ironically, an embittered Semmelweis, whose findings were rejected by many experts, himself dies as a consequence of an infected wound two weeks after he is committed to a mental institution. A doctor’s touch could mean death.

In an interview on BBC Radio 4 Lord Winston debates the future use of robots in healthcare with Professor Noel Sharkey. One of Winston's main arguments is that patients need human contact and the healing touch. I wouldn’t disagree, but I do not think that precludes an increased use of medical robotics. The two go together. Certainly, as discussed before research in Cognitive Based Therapy indicates computer software is at least as effective as human practitioners.

For me one of the most noticeable aspects of the Radio 4 debate is the mismatch of the views of doctor and roboticist. In the history of surgery, robotics will not be the first innovation to have been resisted by established experts, though, as Hollingham reminds us at the end of Blood and Guts, modern surgery is based on brilliant, courageous and misguided individuals who were prepared to have a go. Sometimes they succeeded; sometimes they failed, but their efforts have helped future patients to live.

August 11, 2008

Healthcare IT: no evidence

cane.jpgGeorge’s nightmare began with a succession of illnesses. At the beginning of the year he endured agonising head pain for a week after he was discharged from hospital. He was eventually readmitted, and medical staff discovered he had a bleeding capillary in his head. After some persuasion from my Mother--they are of a generation that prefers not to disturb doctors “unnecessarily”--he had called the out-of-hours GP service, but the doctor attending said he could do little because he did not have George’s medical record, thus lengthening the agony. But they say there is little evidence to support the use of ICT in healthcare.

Last week my Mother tried unsuccessfully to call George for several days. After calling his family and even sending an acquaintance round to his house she thought she had done all she could. After all, he was the customer of a care service that checked his well being with telephone calls and that would send someone around if there was no reply—except it didn’t.

He was found on Thursday lying paralysed and unable to speak on his bathroom floor having suffered a stroke on the previous Sunday evening. Of course, the technology to monitor remotely is available, but they say there is little evidence to support the use of ICT in healthcare.

I have been reading Max Pemberton’s Trust Me I’m a Junior Doctor in which he relates his experiences of the UK’s National Health Service. I worked in the NHS for 10 years and many of his anecdotes brought on a wry smile of recognition.

When I was studying for an MBA I remember learning about corporate culture (now an overused and devalued term) and how it might be described using myths, heroes, legends, stories, jargon, rites and ritual. An NHS manager on my course suggested the consultant’s ward round as an example of a ritual. In it the medical consultant and a retinue of junior doctors progress through a ward reviewing and discussing patients. An extreme example can be seen in the film Doctor in the House (1954) when the formidable Sir Lancelot Spratt humiliates his underlings.

Max Pemberton was also at the bottom of the pecking order, because he’s packed off to get the coffee and croissants for the round. That seems poor reward for the time he spent excavating X-ray films from behind radiators and tracking down missing pathology samples and results in preparation for the ritual. He even has to transpose manually drugs charts by interpreting the glyphs of senior medical staff. But they say there is little evidence to support the use of IT in healthcare.

A rigorous scientific approach to medicine is to be applauded; but using demands for “evidence” as a way to slow down IT adoption in the face of common sense is not.