Surgery: the worthy produce of heaven
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7359.0/i (Published 10 August 2002) Cite this as: BMJ 2002;325:iAll rapid responses
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I was trained at Groote Schuur to not worry about subcutaneous
bleeders and to tie big vessels with non-absorbable suture material and
to close all abdominal wounds in layers starting with the peritoneum. I
was also trained to close wounds in many cases around a wound drain and
sometimes two wound drains, one in the muscle sheath and one above it, if
it was a contaminated as opposed to a clean-contaminated or clean wound. A
paramedian was the preferred incision because it was thought to be
stronger than a midline. Drains were shortened over a number of days wound
care being mostly delegated to the nurses under the direction of the ward
sister who attended working rounds twice a day. Dressing were kept on the
wound for days especially when they contained drains. The net result was
infected wounds and dehiscences were regular occurrences, but wounds were
also invariably closed by registrars without a consultant being present.
Upon arriving in Michigan I rejected their laborious practice of
using transverse incisions (Michigan smile) and closing all abdominal
wounds with layers of interrupted wire sutures. I used almost
exclusively midline incisions and closed just sheath and skin even in very
obese patients. I avoided non-absorbable suture material in the peritoneal
cavity like the plague, especially in the pelvis, and adopted my Harvard
professor’s practice of meticulous haemostasis including all subcutaneous
bleeders and avoiding drains to prevent what he claimed was the cause of
what he called “drain fever”. On rare occasions when there was a large
subcutaneous dead space, usually after redo-redos, I left a closed suction
drain in until it stopped draining. I removed the drain completely never
shortening it. age In those cases that were contaminated I left the wound
open and packed it with gauze soaked in saline. Rarely did I leave the
case until the sheath had been closed usually with my assisting a
resident. These wounds were dressed a regular intervals by the residents
and not by the nurses, who never joined us on ward rounds and were rarely
actively involved in patient care other than to give medications and tend
to their personal needs. The wounds healed remarkably quickly when left
open even in obese patients and left a scar invariably indistinguishable
from a sutured wound. The net result was that I cannot recall having had
a dehiscence and almost never saw a wound infection in my very busy
practice. (In the uncommon seriously contaminated cases I invariably
closed with deep interrupted tension sutures only).
The difference in outcome in Groote Schuur and Michigan cannot be
attributed to differences in protoplasm, obesity being much more common in
Michigan and severe malnutrition in the Cape Town population being
uncommon. Instead of being painted as they were in Groote Schuur wounds in
Michigan were scrubbed for five to ten minutes with Betadine sponges and
then painted with Betadine. The UK literature does not support this
laborious practice but from my recollection of my Groote Schuur days many
of the patients from the Cape flats could definitely have benefited from
it.
Looking at the UK literature it would seem that wound care in the NHS
could benefit greatly from the adoption of Michigan practices. In the
absence of my records and numbers my anecdotal accounting of the two
different practices cannot be accepted as fact. I would, however, never go
back to doing what I had been taught to do as a registrar at Groote
Schuur. I would urge surgeons in the NHS to reconsider their practices. A
prospective randomised study comparing the two practices would be
appropriate.
Competing interests: No competing interests
Cause AND effect
The question of causality is one that plagues all correlational
studies, such as the one in question. There are at least three possible
explanations for the findings discussed, and they are not mutually
exclusive:
1) As suggested, adopting an unsympathetic tone when communicating
may lead to heightened patient dissatisfaction, which may, in turn,
influence a patient's decision to sue.
2) The disinterest and lack of compassion identified in some
surgeons' communicative style may reflect coincident deficiencies in
practice style and personality that may also influence judgment and
decision-making in other areas. These co-existing deficiencies would
therefore be responsible for the increased risk of litigation, but not the
communicative style directly.
3) The experience of being sued by a patient in the past may leave
the surgeon with difficulties in communicating with subsequent patients,
and may diminish the ability to empathize and feel compassion towards
those patients. In this case, causality runs in a counter-intuitive
direction (i.e., litigation causes poor communication between surgeon and
patient).
Explanation (1) is suggested in the review by Mr. Dobson, and our
research suggests that both (2) and (3) occur as well. The most likely
explanation is that all three factors are in play, and it can be very
difficult to sort them out clearly.
Competing interests: No competing interests