[HSF] "Patients don't want cardiopulmonary bypass" - the great con
hgrmd at aol.com
hgrmd at aol.com
Sun Dec 23 12:38:10 EST 2007
Tea,
? You unwittingly support my?argument.? Death from CABG is essentially a "10 sigma" event (whatever that is).? It's extremely difficult to prove that OPCAB patients have statistically significant superior outcomes simply because the results are so good, in the vast majority of cases, no matter what you do.
? The point I raise again is that "100%" OPCAB'ers often have an air of intellectual and technical superiority over us unwashed plebes that I find specious, and, quite frankly, annoying.? Trust me, I could do essentially 100% OPCAB on the handful of stand alone CABG's I do each year if I really thought it made that much of a difference.? OPCAB is definitely not the most technically challenging thing?I?do.
Hal?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? ----Original Message-----
From: Tea Acuff <tacuff at swbell.net>
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 23 Dec 2007 12:07 am
Subject: Re: [HSF] "Patients don't want cardiopulmonary bypass" - the great con
Ani, Hal has already confirmed that your argument is on slippy ground. He agreed
with you.
Your Dr. Sergeant argument against using the pump (or neutralizing it) may not
be what it seems. Imagine that were early in CT surgery a trial of lobectomies
on and off pump that found on pump easier to expose, had more blood loss, and
prevents the likely hood of arrest requiring CPB. There were also annedotal
reported differences in post op DVT and some suspected that more aggressive
resections could be done pump supported. Blah blah, blah, and etc. In a
different world all of this seems quite possible. Of course I may be FOS (full
of self). What would we learn from this study? The same thing that we learned
from the on/off debate. We learn a lot about our tools and a little about the
patients. Would we use CPB rountinely for lobectomies in this different world
that did not happen? Would that be proper in that world but improper in our
world?
I find these abstract questions, what is better PCI or CABG, bloodless surgery
or not, or small incision or not are, well, abstract and not reality. Surgeons
see specific patients and learn by series. We never see "populations", the so
called unbiased scientific model, from which are supposed to act. By the time we
construct guidelines, best practices, and RCT, we are as far from the actual
patient as when we get "credentialed" to do "procedures" at a hospital. The only
question is what is best for whom and by whom. If these are questions with
binary answers, it is likely because we only can think of simple questions. Our
studies can by design only ask simple questions. That is why I proposed my (what
the hell is he thinking) model of practice. We get so far away from reality in
our theories we need a guide to redirect us back to the problem(s). That does
not mean, "Would you like it with or without CPB (or robot) in that ,Sir?"
Nassim Taleb notes that when someone is describing a ten sigma event causally in
fine detail (that is, an event that based on time might happen a couple of times
in the history of the universe) likely one of two things is happening: the
author is a genius or it is very likely that the author knows nothing about what
he is describing. In mdeicine we seem to search, or can only find, therapies
that improve outcomes by a p of .01 to .001 in hundreds or thousands of
patients. These is the upside down version of the above ten sigma event. The
probabilities are less but still against us in understanding causality. I would
propose a corollary "reverse rule of universals" in medical therapy. The more
that a therapy is described as universally appropriate from large population
analysis, the less the prescription is useful. If the effect is not obvious to
any scrub tech or nurse assistant in between 10 and 100 cases, then it has
nothing to do with universal
importance but it might help (or hurt) the few. This may be appropriate
thinking for simple interactions such as long term statins or preop beta
blockers, but I am not sure it is helpful thinking for complex interactions as
in techniques of cardiac operations. We should use our tools of evidence, but i
don't see how we can rigidly apply them. Does first do no harm, translate in
modern medicine as do complex things to the many to help the few?
tea
tea
----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Saturday, December 22, 2007 9:00:05 AM
Subject: RE: [HSF] "Patients don't want cardiopulmonary bypass" - the great con
And having your heart lifted out of the chest beating upside down is
physiological? The sometimes promoted notion that off-pump surgery is
physiological is part of the great con - I would like to know one thing about
general anesthesia, or being operated upon that is physiological. Let us not
pretend there is anything normal about having one's heart operated upon - which
ever way you dress it heart surgery is a big insult to the body.
Again I say there may be benefits to avoiding CPB but let us not pretend the
patient's desire is what is driving this.
In response to comments on Dr Sergeant's excellent results - I put it to you
that if he were to adopt his entire system and change only one thing - start
using CPB - his results would be exactly the same. His results are a marker of
good surgery, sub-specialization (my understanding is that his practice is
almost entirely CABG), and good systems management and not off-pump surgery.
Ani
> Date: Sat, 22 Dec 2007 15:54:30 +0530> From: prasannasimha at gmail.com> To:
OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] "Patients don't want
cardiopulmonary bypass" - the great con> CC: > > I would like to know one thing
that is physiological wrt to cardiopulmonay> bypass ?> Prasanna> > On Dec 22,
2007 3:14 PM, <NielsB at aol.com> wrote:> > >> > This discussion is always
interesting. I must again one of the many> > excellent quotes of my great friend
and previous partner in Buffalo:> >> > "Why do people feel so safe when they
enter an airplane? Because the pilot> > goes with you, and he would probably not
go if the plane was unsafe.> > But when the cardiac surgeons say: we are going
on pump it is not exactly> > true, because the surgeons does not go on pump
himself, only the patient"> >> > Of course it does not mean that the pump is a
priori bad, sometimes we> > need> > it sometimes not, it is a tool and an
important one some times.> >> > We should
not be so fixed on this issue any more, but also not ignore the> > issues. As
the previous writer said, maybe a couple of hours on the pump> > will> >
rejuvinate the brain. Of course that is a joke as far as we know,> > because I>
> really dont find much evidence that the brain is better with than without> >
pump.> > Most sudies show that cognitive functions etc are worse or equal with>
> pump> > not better.> >> > So maybe most patients do not understand all this
things, but as> > surgeons> > maybe it is our responsibility to use the tool
when it is indicated and> > necessary, and in my opinion in CABG it is not
usually required.> >> > Jacob Bergsland> >> >> > **************************************>
> See AOL's top rated> > recipes (http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004)>
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