[HSF] "Patients don't want cardiopulmonary bypass" - the great con

Mon Dec 24 04:50:12 EST 2007

> From: tacuff at swbell.net> 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?
But Tea, are complex interactions not an amalgamation of simple interactions and do we not make complex interactions more predictable by applying simple interactions in a logical and consistent manner as the likes of Sergeant and de Leval have demonstrated? By definition we have to do complex things to many to help the few - how many of the patients did you operate this year that you think benefitted from your surgery - hopefully the majority but no doubt a sizable minority (including for example those who died or had a stroke) did not. Unfortunately varied surgical skill, teams skills and infrastructure and logistics mean that few operations or surgical therapies can be reproduced consistently decreasing utilization of practice guidelines (such as OPCAB as recommended practice if evidence of superiority is unequivocal: despite what Hal says, we cannot all do all our CABGs off pump. I am yet to see a surgeon who is truly capable of doing 100% CABGs off-pump with good results that prefers to do them on bypass). However, even within our individual skill sets we can usually get an idea from the 'evidence' for what is best for the individual patient (even if what is best involves referring patient to a colleague).

Applying population based data to the individual patient is the closest we can get IMHO to improving the health of the population.

Ani

> Date: Sat, 22 Dec 2007 21:07:58 -0800> From: tacuff at swbell.net> Subject: Re: [HSF] "Patients don't want cardiopulmonary bypass" - the great con> To: OpenHeart-L at lists.hsforum.com> CC: > > 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)> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE,> to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> _________________________________________________________________> Get Hotmail on your mobile, text MSN to 63463!> http://mobile.uk.msn.com/pc/mail.aspx_______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and> disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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