Research-based medicine vs. ‘death panel’ rhetoric

Ever have a stomach tube in, the kind they cram through your nose? I have, and I didn’t like it very much. Mine was in a med school lab, where we’d shoved them into each other, clumsily, since we were idiots, for an experiment about stomach acid. Mysteriously, my tube started to grow, painfully, to the size of a garden hose, and I yanked it out before the experiment ended. I think I still feel it.

In surgery training, I was taught many things, stone-carved, because “that’s the way it’s done.” Had I ever questioned them, professorial and public humiliation would have rained down like bricks. One of those immutable laws was that stomach tubes were required in every patient who’d had any sort of belly surgery. For gallbladder removal or splenectomy, they remained for three days. For intestinal operations, till the cows came home. If you get my meaning.

It wasn’t until I went into practice for myself that I started wondering. I began to omit those tubes in anyone except those with stitches in their stomach or intestines and, amazingly, not only were there no adverse effects, patients recovered faster — and were a heck of a lot happier. When researchers finally did studies, they confirmed that in most circumstances the tubes were actually slowing recovery. Eventually, I hardly ever used those infernal things at all, even in stomach surgery. Take that, old professor!

Another study, amazing for its gutsiness, addressed an operation being done for patients with angina (heart pain due to coronary disease): an artery from behind the breastbone was mobilized and poked directly into the heart muscle, like sticking the end of a hose into dirt. Invented before bypass came along, it was called the Vineburg procedure, and many recipients claimed improved symptoms postoperatively. The study compared those who’d had the operation with ones who’d had their chests opened and closed with no implantation. (See? Gutsy.) Results? No difference. No more Vineburg.

Wouldn’t you want to avoid a miserable stomach tube if you knew it was safer than having it, if it meant you’d be home sooner and with less cost? Aren’t you glad no one is suggesting you undergo a useless operation like that heart procedure? Well, here’s the thing: studies that figure that stuff out are the part of Obamacare called “effectiveness research.” Or, as Sarah Palin called it, “death panels.”

Some, like the governor, see basing care on such research as government deciding who gets treatment, and what kind, holding the power of life and death over its citizens. As a political ploy to get people to reject health-care reform, its effectiveness needs no research. But it’s either an honest misunderstanding of what’s involved or a deliberate lie. Since we know politicians don’t lie, let’s assume the former, and help her to understand.

Here’s another example, and pardon me while I pat myself on the back: years ago I thought of injecting every incision I made with long-acting local anesthetic, figuring that if patients awoke pain-free, they’d do better. Plus, it’d be easier to manage pain as it approached rather than when it was in full force. It worked. As a bonus, stays in the very expensive recovery room got shorter. Returning to their rooms, patients were able to be up and around right after surgery, which has been shown to reduce complications. Soon, the nurses were suggesting to surgeons who weren’t doing it that they ought to. And now, based on confirming studies, it’s pretty standard stuff.

Was telling docs they should inject incisions a matter of interference, or was it a fact-based way to assure that patients did better, and cost someone less money? Harking back to the hose in the heart muscle, would it have been government interference if Medicare stopped paying for it?

Surgery and intensive care eat up the vast majority of hospital expenses. If we can determine which interventions work and which don’t, if it’s determined that less expensive treatments work as well as more expensive ones, wouldn’t that be useful information? And if the best way to implement the findings is to stop paying for useless or harmful care, isn’t that a proper step? Or is it death panels?

Sid Schwab is a longtime, “mostly retired” general surgeon in Everett.

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