Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_905_Библиотеки_им_академика_М_И_Перельмана.pdf
xii
points to a combination of factors contributing to our intraoperative decisionmaking process. These factors include education, clinical know-how, mentoring, and the creativity and excellence that come with long practice and with
strict discipline.
The aim of this book is to evaluate the current literature on the subject and
to explore what is known and, more importantly, what is not known about this
process. Frankly, while the surgeon may be considered the “captain of the
ship,” there are many aspects of the surgical process that have recently
received major public interest, and these aspects are not in the hands of surgeons at all. Involvement of these other disciplines—mainly administration,
regulations, insurance, and government—has become a priority in many
cases. Often, we forget that surgery is both a science and an art, and surgeons
are the conductors of a symphony that truly needs to run perfectly. There are
other differences between surgeons and the physicians in many other clinical
disciplines. While I was a medical student at the University of Prishtina,
Kosova, Professor of Surgery, Dr. Gazmend Shaqiri would tell me and others:
“When a patient dies in a medical ward, he or she dies from the disease; however, when the patient dies in surgical ward, the patient dies from the surgery,
or more importantly, from the decisions made by the surgeon.” This may be a
decision by the surgeon to operate or not to operate. While surgical procedures are far more complex than one individual’s decisions during surgery,
there are elements to this small surgical microcosm that add additional pressure on the surgeon and how he or she copes with this decision. Over the
years, I have been reminded often of the consequences of making a decision,
both wrong and right.
When I started this book, I thought it would be a single-author book,
somewhat of a real rarity these days. However, as the months were passing by
and the project was not being completed, I saw the real reason why: I really
wanted to have other opinions on the matter.
I am hoping this book will serve as a good reference or even inspiration for
others to explore the subject further. I did not and do not envision this as a
book of algorithms and strict protocols although in a few chapters such suggestions have been made. I wanted myself and the other chapter authors to go
a bit “beyond” the surgical decision-making process and inside the surgeon as
being. I wanted to see if we can explore what makes the surgeon’s brain and
heart “buzz” and continue to work nonstop for many hours.
While at Yale University, before the regulation of working hours for residents, one of my vascular attendings and I operated basically nonstop from
Friday morning until Sunday afternoon, with a few “power naps” between
cases. I thought I was doing “ne” until I went to start my car. Now that the
adrenaline was gone, I could not even drive myself home. I was completely
exhausted and could not keep my eyes open. I had to call my wife Drita to
come pick me up and take me home. How was I able to go on for so long
while we were operating and yet I could not drive myself the 10miles home?
The anatomy and the physiology of the surgeon are addressed in Chaps. 1 and
2. We cannot forget that we are not super creatures, despite what everyone
may think of us; we are all just human.
Prologue to First Edition
Prologue to First Edition
xiii
Have you ever seen a surgeon emotionally “naked,” burnt out, exhausted,
disillusioned, and simply tired of everything? Even worse, most of us do not
talk about the matter until it becomes a real problem. Not a pretty picture by
any means. At this point, you may be thinking of friends and colleagues who
committed suicide or were on the brink of doing so. Drug and alcohol abuse,
difculties with personal relationships, multiple divorces, or simply becoming obese and not caring for oneself are not uncommon among surgeons. We
are just human, and yet, like many other professions, we still have to get up
and go to work and make some incredible decisions that will affect our
patients and their families and, of course, us, and we have to live with those
decisions.
I hope this book will explain some of those decisions and how we make
them, but, most importantly, how we live with the decisions we make and
how we improve constantly.
Valhalla, NY, USA RifatLati
Spring 2016
Prologue to Second Edition
Since the publications of the rst edition of this book, there have been signicant advancements in surgical decision-making that surgeons have embraced
and developed. Here are some noteworthy developments:
1. Minimally Invasive Surgery (MIS): Over the past decade, MIS tech-
niques have expanded to numerous surgical specialties, including general
surgery, urology, gynecology, and orthopedics. These procedures involve
smaller incisions, specialized instruments, and often the use of laparoscopes or endoscopes for visualization. Benets include reduced damage
to surrounding tissues, less postoperative pain, shorter hospital stays, and
faster recovery times for patients. Surgeons now have a broader range of
minimally invasive options to consider when planning surgeries.
2. Robotic-Assisted Surgery: Robotic surgical systems, such as the da
Vinci Surgical System, have made signicant strides in the last decade.
These systems offer enhanced visualization, improved dexterity, and
tremor reduction for surgeons. The robotic arms mimic the surgeon’s
movements while scaling them down, providing precise control during
complex operations. Surgeons have embraced robotic assistance for procedures like prostatectomies, hysterectomies, and colorectal surgeries,
resulting in potentially decreased blood loss, shorter hospital stays, and
improved patient outcomes.
3. Decision Support Systems (DSS): Technological advancements and the
advent of electronic health records have paved the way for digital DSS in
surgery. These systems leverage algorithms, data analytics, and articial
intelligence to analyze patient-specic information and provide evidencebased recommendations. DSS can assist surgeons in preoperative planning, predicting surgical outcomes, selecting treatment options, and
assessing risks. By integrating clinical data and evidence-based guidelines, DSS programs help surgeons make well-informed decisions tailored
to individual patients.
4. Personalized Medicine: Genomic research and molecular proling have
enabled personalized surgical approaches. Genetic testing can identify
specic genetic markers or mutations that inuence a patient’s response to
surgery, anesthesia, or drug therapies. This knowledge can guide surgical
decision-making by identifying patients who might benet from particular procedures, predicting the likelihood of complications, optimizing
drug selection, or identifying potential risks. Personalized medicine
xv
xvi
allows surgeons to customize treatment plans to individual patients,
improving outcomes and reducing risks.
5. Enhanced Imaging Modalities: Advanced imaging technologies have
had a profound impact on surgical decision-making. Magnetic resonance
imaging (MRI), computed tomography (CT), and intraoperative ultrasound provide surgeons with detailed anatomical information, facilitating
precise surgical planning and execution. These modalities help identify
vital structures, vessels, and tumor margins, reducing the risk of complications and enabling more accurate and minimally invasive procedures.
Additionally, intraoperative imaging systems provide real-time feedback,
enabling surgeons to adapt their strategies during surgery.
6. Risk Stratication Models: Predictive models and risk stratication
tools have emerged to estimate surgical risks and outcomes. These models
use patient characteristics, clinical data, comorbidities, and sometimes
genetic information to predict the probability of complications, length of
hospital stay, or mortality rates. Surgeons can utilize this information to
discuss risks and benets with patients, set realistic expectations, and
adapt surgical plans or interventions accordingly. Risk stratication models aid in shared decision-making, allowing patients to make informed
choices about their surgical options.
7. Multidisciplinary Approach: Collaboration among multiple healthcare
professionals has become integral to surgical decision-making. Surgeons
now work closely with radiologists, pathologists, anesthesiologists, and
other specialists to ensure comprehensive patient evaluation and optimize
treatment plans. This multidisciplinary approach enables a holistic assessment of patients, incorporating expertise from various domains to develop
the most appropriate surgical strategies. Collaborative discussions and
input from different perspectives enhance surgical decision-making and
contribute to improved patient outcomes.
Prologue to Second Edition
These advancements collectively pave the way for more precise, individualized, and optimal surgical decision-making, improving patient outcomes
and quality of care. Ongoing research, innovations in articial intelligence,
and further advancements in technology will likely continue to shape and
rene surgical decision-making approaches in the coming years.
But let’s get down to what really matters. While the new technological
advances are very important, in the center of all the above advances is the
surgeon and what constitute the decision-making. Despite the most conscientious preoperative preparations, surprising events may still occur. If the operation takes an unplanned turn, the surgeon has to make difcult decisions.
Depending on the procedure, continuous knowledge and awareness of the
patient’s physiologic status—including uid status, urine output, use of blood
and blood products, bleeding, current medications (such as vasopressors),
and biochemical endpoints of resuscitation, frailty index and how the patients
look and feel, are cornerstone of surgical decision-making. Even when the
operation is going well, the biochemical prole of the patient may not be
optimal, or even satisfactory, which may directly affect the outcome. In addi-
Prologue to Second Edition
xvii
tion, the surgeon must recognize his or her own physiologic status; if tired,
for example, cutting corners and making major errors are much more likely.
In my recent complex release of adhesion in patient with complete mechanical bowel obstruction from adhesions (grade 3 and 4), I noticed oozing from
the raw surfaces. When I asked the anesthesia team, what was the patient’s
temperature, I was told 35.5°C.He became cold and coagulopathic after 3h
of intense lysis of adhesions. I decided to stop the procedure, pack his abdomen, and performed a temporary abdominal closure. The next day, after
resuscitation and warming him up, I worked on him for three more hours and
he recovered ne. The decision was a result of observation and communication. In order to assist in surgical decision-making, and reduce errors and
bias, among others, we suggest the use of articial intelligence (AI) models
that are continuously fed real-time data from electronic health records through
mobile devices. By streamlining the data collection process and leveraging
AI algorithms, the authors suggest that this approach may improve the accuracy and efciency of surgical decision-making. However, implementing this
approach successfully would require overcoming certain obstacles. These
include standardizing the data, ensuring the interpretability of AI models,
implementing and monitoring the system carefully, addressing ethical concerns related to algorithm bias, being accountable for errors, and maintaining
the importance of bedside assessments and human intuition in the decisionmaking process (Debas 2002). Irrespective of how helpful, and fast AI can
potentially be, the missing link between AI and the patient will be trust and
bond between the patient and the surgeon that needs to be established and
maintained. This bond and trust between the patient and the surgeon is most
important element and can only be established with a “hand shake”, a straight
look in the eye of the patient, detailed explanations, even the regrets when we
have, happiness when things go well, and sadness seen on the surgeon’s face
when things do not go as planned, or when there is not much that he or she
can do. These are the most difcult conversations that we surgeons have with
patients and their families. AI cannot do that. It can summarize the literature
quickly, so it will be useful for some of us who are not up to date on every
clinical issue.
In this book, as in the rst edition, we address these and other elements
that are important for the perioperative decision-making process. For the
majority of elective surgeries, the general checklist for surgery that includes
some common steps and considerations include the preoperative evaluation,
anesthesia consultation, preoperative instructions for the patient, surgical
consent and discussion, preoperative preparation, preoperative medications
and precautions, and time-out before the procedure starts, sufces, and it is
designed to reduce surgical errors.
But, the question that has not been answered yet is, how do we as surgeons
make intraoperative decisions? When a patient is dying in our hands from
bleeding that we cannot control, when irreversible metabolic shock does not
respond to anything that we do, when new problems emerge out of the blue,
when things go alarmingly wrong—in such dire moments during a carefully
planned operation, how do we decide what to do next, and how should we
xviii
Prologue to Second Edition
overcome our own fears? Many of us make decisions that later on we cannot
explain why we did things a certain way. Usually these are decisions made on
the basis of a “gut feeling,” or “intuition,” or the “gray hair effect,” among
other attributes. Yet, the anatomy of such decisions is of great importance to
all surgeons, patients, and those who work with surgeons. In this book, we
will review theoretical as well as any objective data that we as surgeons use
to make perioperative decisions. The decision we make, often with very limited amount of information, will decide between someone living or dying.
How do we make decisions in split seconds to take someone to the operating
room now, as opposed to, let’s say “a bit later”? How do we decide to operate
on a dying patient, without a CT scan, no laboratory data, just based on the
fact that he or she is in shock, just to nd liters of blood in the abdomen, a torn
vena cava, grade 4–5 liver injury, spleen, or some major blood vessel?
When the patient is dying in the operating room from massive bleeding,
everyone panics, but the surgeon reaches in the open abdomen and compresses the aorta between his or her ngers, or puts a clamp on to let the
anesthesia team catch up. Personally, when things get “tight,” I lower my
voice and give deliberate commands. Is there a molecular explanation for
this? Our collective rsthand experience as surgeons’ points to a combination
of factors contributing to our intraoperative decision-making process, including education, clinical know-how, mentoring, and the creativity and excellence that come with long practice and with strict discipline.
Frankly, while the surgeon is the “captain of the ship,” there are many
aspects of the surgical process that have recently received major public interest, which are not in the hands of surgeons at all. Involvement of administration, regulations by varies agencies, insurance, and governmental involvement,
may affect how surgeons make potential decisions. Recently, my decision to
use a certain medical product was questioned by administration. Direct interference in my surgical decision making. The majority of private and independent surgical groups are no longer private, and no longer independent. They
have been swallowed by the corporate world.
Prof Haile Debas, on his presidential address titled “Surgery: A Noble
Profession in a Changing World” given to the American Surgical Association,
called surgery noble and quoted Webster’s Third New International Dictionary
that denes the wordnoble as: (1) possessing outstanding qualities such as
eminence, dignity; (2) having power of transmitting by inheritance; (3) indicating superiority or commanding excellence of mind, character, or high ideals or morals. Further, Prof Debas continued: “These three attributes bet the
profession of surgery. Over centuries, the surgical profession has set the standards of ethical and humane practice. Surgeons have made magnicent contributions in education, clinical care, and science. Their landmark
accomplishments in surgical science and innovations in operative technique
have revolutionized surgical care, saved countless lives, and signicantly
improved longevity and the quality of human life. Generations of surgeons
have developed their craft and passed it on to succeeding generations, as they
have to me and to each one of you, to take into the future.”
Practice of surgery has changed signicantly and dramatically, and surgeons have become a replaceable workforce of major corporations, and worse
Prologue to Second Edition
xix
we have become “shift doctors” managed by several VPs in expensive suites
that often have just come out of MBA schools and have no clue how surgery
or department of surgery is run. Furthermore, as Prof Debas writes in the
above-cited paper: “Financial control and control of access to healthcare
were taken over by HMOs and insurance companies. As for-prot medicine
proliferated, the health of our patients has come to be treated as a commodity
traded daily on Wall Street. History will record that the medical profession
was sidelined and watched haplessly as MBAs and business executives
dened the fate of healthcare.” He calls these effects of HMO “deplorable.”
While director and chairman of a major medical center and academic
department, I witnessed senior academic surgeons, deans, and other major
academicians being “walked out” of the hospital or their ofces without any
cause or explanation. They wanted to “move in a new direction.” The academic surgeons and surgery itself once the “crème de la crème” of the hospital have become under major corporate attacks in the last 2 to 3 decades.
Unfortunately, this is not happening only in America. However, this hijacking
of the surgical world by the corporate world should not cloud our thoughts
and our surgical decisions, and we should make the best decision possible for
every single patient that we evaluate and care for, by being trained well, being
ready to care for every surgical disease. Surgeons as true leaders, should own
the care of the patient, lead the multidisciplinary and complex care with passion, love, and respect for everyone, and these affect people’s lives, save lives,
and prevent morbidity.
The consequences may be because the surgeon decided to operate, or
when the surgeon makes a decision not to operate, or not to operate in a
timely fashion. As my former Professor of Surgery, Gazmend Shaqiri, a true
(general, vascular, cardiothoracic) surgeon used to tell us students at the
University of Prishtina, Kosova, “When a patient dies in a medical ward, he
or she dies from the disease; however, when the patient dies in surgical ward,
the patient dies from the surgery, or more importantly, of the decisions made
by the surgeon.”
Every surgical decision that we make as surgeons may have consequences,
and regrets that have been reported in about 1in 7 surgical patients (Loftus
etal. 2020), both patient related and procedure related. Yet, despite this surgery was, and remains, the best clinical discipline, and represents both a science and art, and surgeons are the conductors of a symphony that truly needs
to play perfectly. There are other somewhat more silent consequences of surgical decision-making.
In a study of almost 8 million patients, analyzed from the National
Inpatient Sample data base, we found that delaying the operation and not
performing in the optimal time was the most common cause of mortality
(Smiley and Lati n.d). While we were unable to discern why the decision to
operate was delayed, the decision to operate or not is the surgeon’s, and it is
the decision not to operate that had major consequences. While surgical procedures are far more complex than one individual’s decisions during surgery,
there are elements to this small surgical microcosm that add additional pressure on the surgeon and how he or she copes with this decision. Over the
xx
years, I have been reminded often of the consequences of making a decision,
both wrong and right.
I am hoping this book will serve as a good reference, or even inspiration,
for others to explore the subject further and remind yourself what I teach
everyone who listens—that “surgery is easy, the decision is not.” I did not and
do not envision this as a book of a bunch of algorithms both from some great
books on the subject, or created by AI, whose computers are major polluters
of our environment, to create strict protocols, although in a couple of chapters
such suggestions have been made. I wanted this book to go a bit “beyond” the
glory of being a surgeon and at the soul of the surgical decision-making process, and inside the surgeon being, under his or her skin. I wanted to explore
what makes the surgeon’s brain and heart “buzz,” and continue to work nonstop for many hours. While at Yale University, before the regulation of working hours for residents, one of my vascular attendings and I operated basically
nonstop from Friday morning until Sunday afternoon, with few “power naps”
in the PACU or noisy operating room lounge between cases. When we nished Sunday afternoon, I thought I was doing “ne” until I went to start my
car. Now that adrenaline was gone, I could not even drive myself home. I was
completely exhausted and could not keep my eyes open. I had to call my wife
Drita to come pick me up and take me home. How was I able to go on for so
long while we were operating and yet I could not drive myself home the
10miles to Hamden?
The anatomy and the physiology of the surgeon are addressed in Chaps. 1
and 2. We cannot forget that we are not super creatures, despite what everyone may think of us; we are all just humans, like all others except we are
leaders who really care.
Have you ever seen a surgeon emotionally “naked,” helpless, lonely,
exhausted, disillusioned, and simply tired of everything? Even worse, most of
us do not talk about the matter until it becomes real problem. Not a pretty
picture by all means. At this point, you may be thinking of friends and colleagues who committed suicide or were on the brink of doing so. Drug and
alcohol abuse, difculties with personal relations, multiple divorces, or simply becoming obese and not caring for oneself are not uncommon among us
surgeons. We are just humans, and yet, like many other professions, we still
have to get up and go to work and make some incredible decisions that will
affect our patients and their families, and of course us, that we have to live
with those decisions. Hopefully, this book will explain some of those decisions, and how we make them, but most importantly how we live with the
decisions we make and how we improve constantly.
Prologue to Second Edition
Further Reading
Debas, Haile T. MD. Surgery: A Noble Profession in a Changing World.
Annals of Surgery 236(3):p 263–269, September 2002
Loftus TJ, Tighe PJ, Filiberto AC, Efron PA, Brakenridge SC, Mohr AM,
Rashidi P, Upchurch GR Jr, Bihorac A.Articial Intelligence and Surgical
Decision-making. JAMA Surg. 2020 Feb 1;155(2):148–158. https://doi.
Prologue to Second Edition
xxi
org/10.1001/jamasurg.2019.4917. PMID: 31825465; PMCID:
PMC7286802.
Abbas Smiley, Rifat Lati. The Role of Delayed Operation in Hospital
Mortality in Emergency General Surgery Admissions: A 10-year Study of
6,805,380 Patients. Unpublished data.
Wilson A, Ronnekleiv-Kelly SM, Pawlik TM.Regret in Surgical Decision
Making: A Systematic Review of Patient and Physician Perspectives.
World J Surg. 2017 Jun;41(6):1454–1465. https://doi.org/10.1007/s00268-
017- 3895- 9. PMID: 28243695.
RifatLati
Contents
Part I Changing World and the Legacy of Surgical Decision-Making
1 Surgical Decision-Making and the Changing World . . . . . . . . . . 3
Rifat Lati and Abbas Smiley
2 Professor Rao Ivatury: A Legacy of Surgical Decision-Making
in Trauma Surgery, Excellence, Compassion, and Humility . . . 9
Rifat Lati
3 Surgical Decision-Making: More Questions than Answers? . . . . 15
Rifat Lati and Abbas Smiley
Part II The Complexity of Surgical Decision: Setting the Stage
4 The Anatomy of the Surgeon’s Decision-Making . . . . . . . . . . . . . 31
Rifat Lati and Abbas Smiley
5 The Role of the Surgeon’s Physiology and the State of Mind
in the Surgical Decision-Making Process: An Update . . . . . . . . . 41
Rifat Lati and Abbas Smiley
6 Surgeons and Pilots: What Do We Have in Common? . . . . . . . . 49
Rifat Lati
7 Planning and Preparing for the Operation: The Role of
Artificial Intelligence in Modern Surgery. . . . . . . . . . . . . . . . . . 57
J. Esteban Foianini and Genna Beattie
8 Decision-Making in Critical Care Rescue for Re-operative
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Diane N. Haddad and Gary A. Bass
Part III Surgical Decision Making in Difcult Scenarios of Acute
Care Surgery
9 Surgical Decision-Making in Postinjury Multiple Organ
Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Ryan S. Ting, Kate L. King, and Zsolt J. Balogh
xxiii