[HSF] witchcraft

Wed Mar 17 16:52:46 EDT 2010

Tea

We do not need randomized trials to disprove or prove most things we do. There are other methods which are equally valid means of scientific evaluation. Even sometimes the N of 1 approach is itself valid, for example when you are choosing an antihypertensive for a particular patient, it doe not matter what randomized trials show but which of the several drugs or combinations one tries that yields physiologic effect. We do not need a randomized trial to show heparin is better than placebo in patients undergoing cardiopulmonary bypass. It is certainly scientific to give heparin. The controlled experiment is not the sole means of biologic study - indeed it is not the principal means either.

I would not say though that trials are invalid because of the heterogeneity of humans, of biology or of helath care providers. Provided such heterogenity is random and study sufficiently powered, randomized trials still give useful information and can prove or disprove a hypothesis. While most questions in surgery cannot be usefully be answered by the randomized trial it certainly has its role, particularly as regards drug or device therapeutics. By defintion in a trial though, as you say, one is limited to the options (often two) tested in that trial (either/or) in the manner they were applied, something health providers often neglect when we extrapolate from trials to practice. The results do not apply to the (sometimes majority) of patients that do not fit in the contruct of the absolute either/or question posed by the clinical experiment. However, we can still derive general principals to guide us (e.g. warfarin is superior to no warfarin for atrial fibrillation), but that does not imply there is never a role for the inferior treatment, or that the inferior treatment is never superior to the superior treatment (i.e. for some patients no warfarin will be superior to warfarin for atrial fibrillation). That is where the art - aka witchcraft - comes in; deciding what pieces of 'evidence' to apply to a given patient.

Research concerns populations and not individuals - except if you are performing (N of 1) research on the individual in front of you, which is generally difficult in surgical practice as things we do are irreversible. So it may well be an art of witchcraft to decide what we do, but at least we have some 'science' to guide us.

Some of us though are very versed in this witchcraft - such that it yields positive effect - the more positive and reproducible our craft is then the more it transcends from witchcraft to orthodox and to science. It is all a continuum but we have to be honest to ourselves as to which stage in the continuum our thoughts or actions lie.

Aniu

> Date: Mon, 15 Mar 2010 21:28:57 -0700
> From: tacuff at swbell.net
> Subject: Re: [HSF] witchcraft
> To: OpenHeart-L at lists.hsforum.com
> CC: 
> 
> The problem with Ani's analysis of witchcraft surgery is not that it is wrong, but that he implies that there is an alternative. Every critque that he levels at witchcraft surgery or witchdoctors is also appropriate, as we have discussed at length before, for randomized trials and scientific medicine. We might analogously call this orthodoxy religious medicine and its practioners, priests. Is there a difference between witches and priests?
> 
> A trial is not "valid" in any mathematical sense other than it separates groups into disparate populations. It is therefore TOTALLY population dependant. It does not verify any logic or represent any truth. Yet orthodoxy immediately demands deification of its logic and this logics extension to other populations, nay ultimately the rest of the world, no matter all the qualifiers with which we hypocritically deride the witches.
> 
> Further many if not most questions in surgery are not addressable by trials as to date the only "Ockham" razor for truth in a trial is dependant on naive or first level thinking: only "either/ or" is allowed. Sounds like fundamental religion to me. "Both", "and", "sequentially", "serially", and "many drops a river make" are not testable or at least devolve into incomprehensible math before we leave the counting fingers of one hand.
> 
> So our choice is not between witchcraft or science, but which witch or whose witch shall we throw into the river to see if she drowns. This seems self "evident".
> 
> tea
> 
> 
> 
> 
> 
> ________________________________
> From: Prasanna Simha M <prasannasimha at gmail.com>
> To: OpenHeart-L <OpenHeart-L at lists.hsforum.com>
> Sent: Mon, March 15, 2010 2:13:05 PM
> Subject: Re: [HSF] witchcraft
> 
> Maybe I will record the data but one blessed problem, patients don't bleed
> using this method and I otherwise sit out patients unless emergent so how am
> I going to "prove it' unless I were to consciously go ahead and operate on
> the oozers in a comparative trial ?. My patients  generally bleed less than
> 100-150 ml (and well people dont believe it but one HSF member visited us
> recently and I did physically show the bleeding we had in an another wise
> 'Bleeder" type of case (Tetrad) (since people vehemently believe it is
> impossible to do so). The patients that day bled 70 and 90 ml so whatever
> method (and I refer to it as multimodal rather than a single method) it
> works for me in my institute when all components are there and fallen in
> place whereas I cannot replicate it in another place that I operate
> precisely because some components of the strategy are missing.
> I think the greatest error in these "research" methods is to focus only on
> one method or one specific technique (for eg RAP or isovolemic hemodilution
> (or finger prick for recent clopidogrel  ;)) in isolation and then say it
> doenst "work"effectively. of course it wont in isolation. As my teacher Dr
> Tendolkar  used to say.(equivalent in Hindi) Little drops of water make the
> mighty ocean and so in any of these efforts the conglomeration of multiple
> methods becomes a greater than than the individual  parts.
> Prasanna
> 
> On Mon, Mar 15, 2010 at 9:12 AM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:
> >
> > Prasanna
> >
> >
> >
> > Hey we dont have to all practice all variants of witchcraft to proof they
> dont work! Besides I practice enough witchcraft of my own to devote time to
> investigating yours (that said I used your peroxide the other day :) )
> >
> >
> >
> > You do often make a lot of categorical statements, and some (or who knows
> even all) may be true; however, why dont you publish or present your data so
> all may learn? Show us that this test done in a standardized manner
> correlates with anything we can see or measure objectively. Show us it is
> indeed reproducible in your hands. Provide us sufficient details so that
> others can reproduce it. Provide us with a biogically plausible basis of the
> test - explain its scientific or logical basis. Explain to us the
> sensitivity and specificity of the test for whatever it is we are trying to
> measure. Show us how it changes practice or outcome. You dont have to do
> this. We dont have to explain or justify everything we do. That is fine but
> then  they remain witchcraft, gimmick or fad till proven otherwise.
> Witchcraft does not though mean what is said or believed  is wrong: some
> witchcraft either by design or chance is real; however, for others (who dont
> believe in witches) to believe then they need more than just faith.
> >
> >
> >
> > While your bleeding test may work for you it will still go down as another
> one of many witchcrafts surgeons have practiced over the generations.
> Likely, no one will be doing this in 10 years: indeed maybe you are the only
> one doing it now! Your colleagues or juniors or nurses may probably even
> laugh that you place so much faith in it. Indeed many surgeons in the 1980s
> through 1990s always had a bleeding time done (using the standard technique,
> not yours) on all patients and swore the relevance. I wonder how many
> surgeons do now. The problem is not those who have an unexpectedly prolonged
> time (which is very rare) but the many who have normal times who still go on
> to bleed (hence the lack of utility of such a test). Maybe what you do adds
> specificity to standard bleeding time, but then what? Your test will
> unfortunately be irrelevant to most because your aspirations are different
> from others. You go into cardiac surgery not wanting patients to bleed,
> literally at all if possible (certainly a laudable goal), but most surgeons
> just would be happy if the patient does not bleed excessively and some are
> even okay with excessive but just dont want them to bleed to death. This
> difference is clear in how you perform your bleeding time as even after the
> bleeding stops you try and torture more blood to come out! That is a high
> bar you are setting (for the coagulation system) and way above what many
> peers would be satisfied with.
> >
> >
> >
> > There is another thing about surgical witchcraft  - we and others around
> us reenforce it by things we do and the explanations we give for things we
> see (as in Galen's quote).  This is partly why Bradford Hill introduced the
> randomized trial, as it is startling how biased our observations and
> statements are depending on our beliefs.  For example Don, explained how
> statins killed his arterial grafts, or how retrograde clot or selective clot
> killed guiseppe's vein graft but spared the arterial graft, or ligating the
> IMA for stenosis that never was - these are all ways Don reinforces his
> believe that arterial grafts are the holy grail, but explanations that
> sounded bizarre to others who did not hold the same religion so steadfastly.
> Others around us also help us to reinforce our beliefs. We have all
> half-heartedly done tests (like your juniors doing bleeding times for you)
> for our teachers that we did not believe in and we presented them with
> whatever we felt they wanted to hear thus reinforcing the utility ot their
> tests. We have all performed useless or non-specific clinical exams and
> presented their findingd proudly. I have been doing a bit of reading from
> literature in the 1960s and it is interesting the (diagnostic) gospel being
> proclaimed at the time by many of the greatest doctors at the time, which we
> now know in retrospect to be heresay. Without 2D echocardiography, CT and
> MRI, physicians got away with a lot of proclaimations without peers having
> means tovalidate or  invalidate them. Many wonderful observations, some
> eponymous, from clinical exam, cineangiography, pressure tracings,
> electrocardiography, phonocardiography etc which were preached as diagnostic
> gospel in that era are now realized to be all but witchcraft, some present
> in only a tiny minority of people with the 'disease'  they were used to
> diagnose, and often present in an equal number (or more) who did not have
> the disease. Witchcraft at its best those days.
> >
> >
> >
> > I do not deride you but we have to prepare ourself that anything we do or
> believe in may well be false and witchcraft. That it works for me or you
> actually does not also prove its validity. In general almost as a rule
> anything one surgeon does that a susbstantial group of surgeons do in
> numerous different ways is witchcraft and likely does not matter. There are
> exceptions and those exceptions may gradually creep in to become standard or
> desirable practice; but considering the thousands or millions of variations
> in what we do, those exceptions are very few. This is why we always have to
> question what we do and disbelief what we do - almost certainly there is
> always a better way to do things. If I live long enough, I am sure I will,
> in future be embarassed at many things I have written, said or believed in.
> The sad thing about this though is as I said some witchcraft will indeed be
> real or valid but will fall by the wayside and be scorned because it is seen
> as such - partly why witchdoctors have to do their best to subject their
> practices to scientific testing and evaluation.
> >
> >
> >
> > Ani
> >
> >
> >
> >> Date: Mon, 15 Mar 2010 07:47:59 +0530
> >> Subject: Re: [HSF] clopidogrel loaded patients
> >> From: prasannasimha at gmail.com
> >> To: OpenHeart-L at lists.hsforum.com
> >> CC:
> >>
> >> Oh Yes and the Old woman from Shropshire and that pesky mold in a
> >> petri dish did trigger of major things.
> >> Most science have to come from initial observations or chance
> >> observations which trigger further research by people.Probably your
> >> Hill and Greenwood may also be rolling over for people lacking
> >> tangential thinking !!.
> >> I clearly told that I have made an observation.Maybe it can be done
> >> and reproduced by others. If they find it useful , use it . If not
> >> trash it. Funny that someone can speak about it and deride it
> >> authoritatively with an extensive experience of N=0 patients with that
> >> particular technique.
> >> Prasanna
> >>
> >> Prasanna
> >> On Mon, Mar 15, 2010 at 7:15 AM, Ani Anyanwu <anianyanwu at hotmail.com>
> wrote:
> >> >
> >> >> tea, I am surprised you have not been able to distinguish between >
> regular sternal bleeding and platelet inhibited bleeding, the latter > being
> characterised by thin ill formed >clots and repeated bleeding > from the
> same places after diathermy application. On rare occasions it > is
> torrential after sternotomy
> >> >> Don
> >> >
> >> >
> >> > Well Tea it gets more interesting...first was the fickle finger and now
> it is the the sternum provides us with that long desired point of care test
> of platelet function...All I can say is good thing we live in the 21st
> century and not the 16th surgery or most of us would have been long burnt on
> the stick (for the practice of witchcraft). I wonder what other 'tricks' or
> wizardries are still to be declared.
> >> >
> >> > Sir Bradford Hill will turn in his grave listening to our
> interpretations of our observations, and the strength of our beliefs in our
> interpretations - indeed maybe his mentor, Major Greenwood, was not far off
> from the truth when almost 100 years ago he said that surgeons should be
> shamed out of the 'comic opera' they call statistics of operations. As a
> colleague once told me, a belief in false gods (whatever they are) is an
> essence of surgical practice (and those gods vary from surgeon to surgeon,
> sometimes referred to as surgeon preference, and frequently are very far
> from the 'truth' or reality if evver such a thing). It has to, my colleague
> argued, be that way for us to do what we do. We have to believe in
> *ourselves* and *our* ancestors (our mentors) and *our* gods (aka
> witchcraft). From time to time we are expunged of these evil spirits and
> false gods by our colleagues, by chance, by science, or by evidence; but
> many will prevail.
> >> >
> >> >
> >> >
> >> > Indeed if we go further in history and we see that we are little
> different from our blood letting and leech applying forebearers. One of the
> most quoted quotes from Galen summmarizes it all
> >> >
> >> > "....All those who drink of this remedy recover in a short time, except
> those whom it does not help, who die. Therefore, it is obvious that it fails
> only in incurable cases"
> >> >
> >> > Plus ça change, plus c'est la même chose.
> >> >
> >> >
> >> >
> >> > Ani
> >> >
> >> >
> >> >
> >> >> From: donross at bigpond.com
> >> >> To: OpenHeart-L at lists.hsforum.com
> >> >> Subject: Re: [HSF] clopidogrel loaded patients
> >> >> Date: Mon, 15 Mar 2010 10:19:43 +1100
> >> >> CC:
> >> >>
> >> >> I hope you have invented a way of making the bleeding time meaningful,
> >> >> Prasanna.
> >> >> Now you need to correlate the result with operative blood loss or some
> >> >> such end point.
> >> >> With your present experience, would you postpone an operation till
> >> >> the fickle finger failed to force flooding?
> >> >>
> >> >> tea, I am surprised you have not been able to distinguish between
> >> >> regular sternal bleeding and platelet inhibited bleeding, the latter
> >> >> being characterised by thin ill formed clots and repeated bleeding
> >> >> from the same places after diathermy application. On rare occasions it
> >> >> is torrential after sternotomy and recently we had a case of OPCAB
> >> >> Lima to LAD in a patient who was just on aspirin who had three take
> >> >> backs for bleeding and eventually stopped after many platelet and
> >> >> blood product transfusions.
> >> >> If he had been closed and put off for a week perhaps the operation
> >> >> would eventually have been far less invasive.
> >> >> Don
> >> >> On 15/03/2010, at 3:33 AM, Prasanna Simha M wrote:
> >> >>
> >> >> > In fact you know how I came up with the idea, traditionally in
> Indian
> >> >> > Mythology Lord Krishna dies due to an arrow hitting his toe. He is
> >> >> > considered a clinical Tetralogy of Fallot based on mythological
> >> >> > description (and was presumably polycythemic and coagulopathic) and
> >> >> > after a particular bad bleeder it set me thinking and I poked the
> >> >> > bleeding patient with a needle and watched the time needed to stop
> >> >> > bleeding and after the basic bleeding stopped finger pressure made
> it
> >> >> > bleed for a very long time. When repeated with a non bleeder the
> clot
> >> >> > in that case stayed stuck without bleeding and after that I have
> used
> >> >> > it when taking a patient early with platelet poisons on.
> >> >> > Prasanna
> >> >> >
> >> >> > 2010/3/14 Prasanna Simha M <prasannasimha at gmail.com>:
> >> >> >> Laugh at your will but there is a difference which I have noted.I
> >> >> >> have noted that the patients who continue to bleed with finger
> >> >> >> pressure for a longer period of time are the ones which are bloody
> >> >> >> on table. Maybe related to stability of clot compared to just
> >> >> >> platelet plug formation.
> >> >> >> Prasanna
> >> >> >>
> >> >> >> On Sun, Mar 14, 2010 at 9:50 PM, Ani Anyanwu
> >> >> >> <anianyanwu at hotmail.com> wrote:
> >> >> >>>
> >> >> >>>> No, the bleeding time they do and what I refer to are different.
> >> >> >>>> They
> >> >> >>>> stop with spontaneous cessation whereas if you have a look at
> >> >> >>>> bleeding
> >> >> >>>> stopping with pressure of the finger , you see a difference.
> >> >> >>>> Prasanna
> >> >> >>>>
> >> >> >>>
> >> >> >>>
> >> >> >>>
> >> >> >>> I do the same but I rub some garlic on before applying pressure -
> >> >> >>> that way I can tell if the clot formation is more likely
> >> >> >>> intravascular or extravascular :)
> >> >> >>>
> >> >> >>>
> >> >> >>>
> >> >> >>> Ani
> >> >> >>>
> >> >> >>>
> >> >> >>>
> >> >> >>>> Date: Sun, 14 Mar 2010 17:14:34 +0530
> >> >> >>>> Subject: Re: [HSF] clopidogrel loaded patients
> >> >> >>>> From: prasannasimha at gmail.com
> >> >> >>>> To: OpenHeart-L at lists.hsforum.com
> >> >> >>>> CC:
> >> >> >>>>
> >> >> >>>> No, the bleeding time they do and what I refer to are different.
> >> >> >>>> They
> >> >> >>>> stop with spontaneous cessation whereas if you have a look at
> >> >> >>>> bleeding
> >> >> >>>> stopping with pressure of the finger , you see a difference.
> >> >> >>>> Prasanna
> >> >> >>>>
> >> >> >>>> On Sun, Mar 14, 2010 at 4:52 PM, Donald Ross
> >> >> >>>> <donross at bigpond.com> wrote:
> >> >> >>>>> We used to do bleeding times and were informed by haematology
> >> >> >>>>> that it was,
> >> >> >>>>> contrary to logic, meaningless.
> >> >> >>>>> Don
> >> >> >>>>> On 14/03/2010, at 7:14 PM, Prasanna Simha M wrote:
> >> >> >>>>>
> >> >> >>>>>> Why not prick their fingers instead of slicing their chests ?
> >> >> >>>>>> In doubt
> >> >> >>>>>> I do that occasionally especially if they need to be done
> >> >> >>>>>> early. Some
> >> >> >>>>>> guys just keep dripping even with a needle prick.
> >> >> >>>>>> Prasanna
> >> >> >>>>>>
> >> >> >>>>>> On Sun, Mar 14, 2010 at 10:43 AM, Donald Ross <
> donross at bigpond.com
> >> >> >>>>>> > wrote:
> >> >> >>>>>>>
> >> >> >>>>>>> Judging from previous HSF discussions, members either wait 5
> >> >> >>>>>>> days if
> >> >> >>>>>>> possible or just go ahead anyway.
> >> >> >>>>>>> Those who don't wait, presumably, have not had seen extreme
> >> >> >>>>>>> coagulaopathic
> >> >> >>>>>>> problems with this approach.
> >> >> >>>>>>> There is no doubt, however, that even with aspirin alone some
> >> >> >>>>>>> patients
> >> >> >>>>>>> are
> >> >> >>>>>>> exquisitely responsive to anti-platelet medication and can
> >> >> >>>>>>> really have
> >> >> >>>>>>> dangerous bleeding even if the pump is avoided. Furthermore,
> >> >> >>>>>>> there does
> >> >> >>>>>>> not
> >> >> >>>>>>> appear to be any reliable lab test for this condition. Perhaps
> >> >> >>>>>>> the
> >> >> >>>>>>> "platelet
> >> >> >>>>>>> mapping" TEG offers some hope but I have not been impressed
> >> >> >>>>>>> with it's
> >> >> >>>>>>> veracity.
> >> >> >>>>>>> To get around this dilemma I have been advising such patients
> >> >> >>>>>>> of this
> >> >> >>>>>>> problem and warning them of the possibility that after opening
> >> >> >>>>>>> the chest
> >> >> >>>>>>> the
> >> >> >>>>>>> operation might have to be postponed for a week. In other
> >> >> >>>>>>> words if
> >> >> >>>>>>> serious
> >> >> >>>>>>> coagulopathy is observed clinically then just close chest and
> >> >> >>>>>>> wait for a
> >> >> >>>>>>> new
> >> >> >>>>>>> crop of clean platelets before operating on the heart.
> >> >> >>>>>>> This doesn't work for urgent surgery but avoids having so many
> >> >> >>>>>>> stable
> >> >> >>>>>>> patients unnecessarily hanging around in hospital.
> >> >> >>>>>>> Barking mad?
> >> >> >>>>>>> Don
> >> >> >>>>>>> _______________________________________________
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> >> >> >>>>>>
> >> >> >>>>>>
> >> >> >>>>>> --
> >> >> >>>>>> Prasanna Simha M
> >> >> >>>>>> _______________________________________________
> >> >> >>>>>> OpenHeart-L mailing list
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> >> >> >>>> --
> >> >> >>>> Prasanna Simha M
> >> >> >>>> _______________________________________________
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> >> >> >> --
> >> >> >> Prasanna Simha M
> >> >> >>
> >> >> >>
> >> >> >
> >> >> >
> >> >> >
> >> >> > --
> >> >> > Prasanna Simha M
> >> >> > _______________________________________________
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> >> --
> >> Prasanna Simha M
> >> _______________________________________________
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> 
> -- 
> Prasanna Simha M
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