Should surgeons be clubbed with pilots and truck drivers or artisans?

Work hour limitation has been a topic for discussion for quite a long time including in medicine. Doctors who work long and continuous shifts are fatigued, sleep deprived and exhausted.

Fatigue causes memory and attention problems, difficulties in communicating; it also impairs judgment and understanding. Sleep deprivation is even more dangerous than working under the influence of alcohol. Being awake for at least 18 hours has been shown to be the same as someone having a blood alcohol content of 0.05%. And, being awake for at least 24 hours is equal to having a blood alcohol content of 0.10%. So, driving while drowsy is equivalent to driving after drinking too much of alcohol.

Hence, a pilot or a truck driver or a doctor who is fatigued and sleep deprived is more at risk of making errors, some potentially fatal.  

But there are checks in place as far as pilots are concerned. They are required to undergo evaluation before a flight to assess their fitness to fly and also to look for alcohol or drug abuse. Their flying hours are restricted and they have a copilot as a backup. All these measures are in place to eliminate pilot fatigue.

Would we like ourselves to be compared with pilots or artisans? Are we simply mechanics trying to repair the human body or are we skilled ‘restorers’ regarding medicine as an art but armed with special knowledge and expertise?

In the Medscapes National Physician Burnout and Depression Report for 2018, general surgeons were among the highest rankers with a burnout rate of 43%. Orthopedics and plastic surgery were lower in the list with a burnout rate of 34% vs 23%, respectively. The top rankers in this list were critical care and neurology (48%) and family medicine (47%).

Primum non cere “first do no harm” is the fundamental principle guiding the ethics of practice of medicine. The principles of non maleficence (do no harm) and beneficence (do good) are derived from this.

So why are doctors and residents allowed to overwork? There is a need to debate on this.

Should the world medical bodies look into this and come out with relevant guidelines?

Should Surgeons Work Hours Be Capped Like Pilots?

The working hours of airline pilots, train drivers and truck drivers in many countries are monitored and that these employees are subject to testing for drugs and alcohol abuse.  Then why arent the surgeons monitored and similarly prevented from overworking, questions an editorial published in June 25 in the Journal of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine.

Practitioners of general surgery have the highest ranking in Medscapes National Physician Burnout and Depression Report for 2018. This group had a 43% burnout rate, with critical care and neurology (48%) and family medicine (47%) holding the top rungs. Lower down in the rankings were orthopedics (34%) and plastic surgery (23%).

The number of hours worked by surgeons should be capped to reduce harmful mistakes caused by exhaustion and burnout, according to the editorial.

There can be financial reasons for surgeons to put in long hours, including pressure from employers and layering private practice on top of work for national health services. These demands plus on-call duty can routinely have surgeons working from morning into evening.

New drug for PPH

A revamped drug, heat-stable carbetocin, that can withstand extreme heat and stay effective for 1,000 days can prevent post-partum haemorrhage. The conventional drug oxytocin needs to be kept between two and eight degrees from the moment it is manufactured to the moment it is used.

In the trial, published in the New England Journal of Medicine, almost 30,000 women in 10 countries across the globe were randomly allocated an injection of heat-stable carbetocin or oxytocin immediately after they gave birth. In most cases, both drugs were equally good at preventing excessive bleeding after birth.

Polio virus can treat brain tumor

As per a US study genetically modified poliovirus ( one that does not cause the disease) could be used to treat glioblastoma, the most aggressive cancer that begins within the brain.

In a small clinical study, the team enrolled 61 patients with recurring glioblastoma who were treated with the modified virus. The results showed that 21 percent of patients who received the modified poliovirus treatment were still alive after three years - as compared to 4 percent of patients who received the existing standard treatment. The Duke study has been published in the leading New England Journal of Medicine.

Do you know: Half of Australian infants have received at least one course of antibiotics by their first birthday. This is one of the highest rates of antibiotic use in the world.

Liver cancer treatment guidelines

ICMR has issued a draft consensus document for treating of hepatocellular carcinoma. The cancer accounts for 90% of cancers of the liver worldwide. Globally, hepatocellular cancer is the fifth most common cancer (7.5 lakh new cases annually) and is the third leading cause of annual deaths due to cancer (7 lakh deaths each year) after lung and stomach cancer.

FDA may soon approve a one-day flu pill

A one-and-done flu pill, baloxavir marboxil, already available in Japan, could soon be marketed in USA. The drug shortens influenza infection with a single dose. It has earned a "priority review" from the FDA and, if approved, has the chance of hitting the market in 2019.

Marijuana-Based Epilepsy Drug

On Monday, the US FDA recommended for approval the first marijuana-based drug, called Epidiolex, to treat two types of severe epilepsy. Epidiolex is an oil containing cannabidiol (CBD)— a component of cannabis that does not cause the psychoactive high typically associated with marijuana. The drug was formally approved to treat Lennox-Gastaut syndrome and Dravet syndrome, which are particularly rare. Both cause daily seizures, are associated with developmental delays, and often don’t respond to standard anti-seizure medications. In three randomized, controlled trials, which included over 500 patients with one of the two syndromes, Epidiolex reduced seizure frequency compared to placebo when it was added on to patient’s normal treatment regimens.

One died of leptospirosis in Mumbai

A 15-year-old boy from suburban Kurla fell prey to leptospirosis on June 25. Leptospirosis is a bacterial infection which is spread through infected urine of rodent animals.

Kale was admitted to the civic-run hospital on June 24 with high fever and chills, and his medical reports confirmed leptospirosis infection. He died within 24 hours of admission. A total of 16 people had died of leptospirosis in the last two years.

Nuts can lower diabetes risk

Lenore Arab from the University of California, Los Angeles (UCLA)  has written that consuming walnuts -- rich in antioxidants -- may nearly halve the risk of developing Type-2 diabetes compared to those who do not eat nuts, finds a study representing more than 34,000 adults. The findings showed doubling walnut consumption (or eating 3 tablespoons) was associated with a 47 per cent lower prevalence of Type-2 diabetes. 

Waist circumference to assess abdominal obesity

A waist circumference of ≥40 in (102 cm) for men and ≥35 in (88 cm) for women is considered elevated and indicative of increased cardiometabolic risk. For Indians the values are 90 cm for men and 80 cm for women.

Waist circumference measurement is unnecessary in patients with BMI ≥35 kg/m² as almost all individuals with this BMI also have an abnormal waist circumference and are already at a high risk from their adiposity.

Waist circumference is a measurement of abdominal obesity and provides risk information that is not accounted for by BMI.

Patients with abdominal obesity (also called central adiposity, visceral, android, or male-type obesity) are at increased risk for heart disease, diabetes, hypertension, dyslipidemia, and non-alcoholic fatty liver disease.

Waist to hip ratio

Measurement of the waist-to-hip ratio provides no advantage over waist circumference alone, is infrequently used by clinicians, and is not currently recommended as part of the routine obesity evaluation by the American Heart Association (AHA)/American College of Cardiology (ACC)/The Obesity Society (TOS) guideline, although it was in the previous version.

Weight history

The age of onset of obesity is of some importance in determining risk. Children with a low birth weight and those whose weight rises more rapidly in the first 10 years are at high risk for diabetes as adults.

The risk for any given degree of obesity seems to be greater in patients whose obesity begins before the age of 40 years, probably because of the longer time period over which comorbid conditions, such as diabetes mellitus and hypertension, can develop.

Weight gain after age 18 years is also important. Even very modest weight gain (≥5 kg) after age 18 years in women and after age 20 years in men increases the risk of CHD and type 2 diabetes at all levels of initial BMI.

Happy Reading on Saturday

Dr KK Aggarwal

President HCFI

Padma Shri Awardee

Group Editor in Chief Medtalks