The Art of Setting Up Success

What makes a great surgeon? Do they have long fingers? Or steady hands? Or the heart of a lion?

I think it is the preparation they do right before they make the incision.

In VMH, I would be assisting various surgeons, especially Dr MR Seetharam in orthopedic surgeries. MRS is very methodical in preparation for a surgery. Every surgery is different. One might require an expensive equipment, or a team of skilled surgeons. The patient might have severe comorbidities that make post-surgical management difficult. The economics might not work out. Functional recovery maybe more important. There are many factors that go into choosing the right kind of surgery for the right kind of patient. MRS will be thinking of all these as soon as becoming aware of someone who has an issue. But that's not the preparation I'm talking about.

Inside the operation theater, with the patient and others eagerly waiting, there's a final and crucial step of preparation that MRS does. The X-rays are put on the viewer where it can be seen from the operating table. Another look is given at the X-ray to review the approach and the location of the fracture fragments. The fractured part is positioned with great attention to allow the views and manipulations that would be required later during the surgery. Extra tables are brought in if so required. The position of each assistant is decided. All the props are set up exactly where they have to be. The C-arm (A C-shaped X-ray machine that can be rotated around the patient during the surgery to see the bones and the implants near real-time) is brought in and out of the field to ensure there are no hurdles. A shoot is made in each position that the part would be during the surgery to be sure there is no obstruction in the C-arm's view. All the implants and instruments are reviewed to make sure they're right. The assistants are warmed up on the procedure and the tools that'll be used. The success of a surgery is decided before the incision is put.

That last sentence might sound like this speech by Harsha Bhogle. Or the saying "The more you sweat in practice, the less you bleed in battle". But I am not talking about the years of dedication one puts in before one becomes a fine surgeon.

I am specifically talking about the setup. Take this example of a setup for arterial blood draw.

Depends I think. If you're crammed between the wall and the ICU bed on an obese hypovolemic patient whose diaper you cannot remove completely and you're drawing the femoral artery with a plastic syringe not meant for it, should be sufficiently difficult.

— Akshay S Dinesh (@asdofindia) December 31, 2020

That is a setup for failure. If one compromises on the setup, they would often have to compromise on the result as well.

* * *

What I realized as I was writing this is that I tend to compromise a lot. I don't know whether I do it as a way to challenge myself so that I feel good about myself if I luckily succeed. Or because I've not learned how to negotiate better. Or maybe I don't know what I need. Or maybe I don't think. Or maybe I think being accommodating is a virtue.

Perhaps accommodation isn't a virtue. Perhaps if you don't ask for the right working conditions, you're going to end up being ineffective and lowering the standard all over.

But you're never going to have all that you need. "You're going to have to compromise" is the folk wisdom. It's difficult to imagine having everything I need. That's a contradiction.

Perhaps then my core premise is wrong. It is probably not about the setup. Or maybe it's a bit of everything. Maybe I'm partly right.

Maybe you can compromise on the setup if you can compensate with your skill (or luck). Or maybe that's too much strain on you.

I don't know. Maybe I'll have clarity later.

PS: I was wondering whether to make the latter section "PS". But maybe that's the script. It's a blog, after all.

Science is Broken Because Scientists Can't Think Rationally

Scihub is being sued in Indian courts by the journal industry. There are some people worried about it. But it is funny how our knowledge system works. Take this tweet for example:

Scientific publishing sure is rigged & broken. But hoping that the very bandicoots that are getting fat from the status quo will take hints and improve the system is beyond naive. The telling lack of collective resistance from scientists too enables this perverse model to thrive. https://t.co/ye9SuxlYQM

— M D Madhusudan (@mdmadhusudan) December 24, 2020

The reason why journals charge exorbitantly and still get away with it is because almost all academicians publish only in those journals. And why do academicians publish in those journals? Here comes the greatest hypocrisy/logical fallacy of academicians.

They think that publishing in "prestigious" journals bring "prestige". They even have a way of measuring prestige without making it sound like it's an emotional thing - impact factor. It is all part of the same logical fallacy - argument from authority. A cognitive bias that makes humans think that "authority" is right.

The only purpose of journals in the internet age is to exude authority.

The same purpose of universities.

If scientists step down from their pedestals and start looking at the world without bringing in their cognitive biases (like every scientist should be doing), there can be a world where knowledge is produced and consumed with lesser hurdles.

Lumbar Puncture and HIV

Lumbar puncture is a fascinating procedure. It is cheap, it can be done in relatively remote places, and it can be learnt easily given access to enough people who need it.

LP has an incredible role in the management of many complications related to HIV. I've heard stories about how there used to be 5 LPs done every day in VMH during the time when HIV was causing rampant destruction in Karnataka and India. When I was there, we would do about 5 in two weeks. Nevertheless, when a colleague asked on Twitter about CSF analysis, I thought I should write down some of the things I believe to know about Lumbar Puncture itself, especially in relation to its use in management of complications of HIV.

The first many LPs I saw were all done for spinal anesthesia in KR Hospital. Till then all I knew about spinal anaesthesia was a friend's description of the back ache he had post a "cool" hernia surgery because they had "poked many times for anaesthesia". I think I hadn't really thought about it till I was doing my anaesthesia rotation during internship. The first LP I did was also done during the same time - the "pop" and being in the space that you can learn only by doing. (If anyone thinks that all knowledge is codifiable like I do, here is what it feels like. Imagine there is a thick plastic layer laid around a piece of rusk. Imagine your needle piercing through the rusk and then splitting open the plastic layer. Now you are in the space.)

The first time I saw an LP done for diagnostic reasons was in the medical emergency ward of KR Hospital where a young patient with some sort of neurological condition was being pinned down to the bed by 4 people and the postgraduate resident was dancing with the needle along with the squirming patient. Despite the grotesqueness of the picture, I found it incredible that 20-40 drops of a particular fluid can be so valuable in diagnosis.

I learned the reasons when I was in VMH. There were many "spot" diagnoses we made using LP:

1) Perceived high opening pressure in an HIV infected patient with neurologic symptoms - we send for cryptococcal antigen and it is almost certainly positive. (Always use Cryptococcal antigen test. Indian ink looks fancy under the microscope when it is positive, but is not as sensitive)

2) High lymphocytes and proteins - you can keep your various tuberculosis diagnoses active. But even otherwise, you can't rule out TB ever.

3) RBCs and you can suspect sub-arachno... Just admit that you did a traumatic tap.

But LP was mainly used for ruling out the infections. It is very simple to miss CNS infections in HIV infected patients. For example they will come with vomiting and you will examine their mouth and see oral (and possibly oesophageal) candidiasis written all over it. But rather unknown to you, they might also be having cryptococcal meningitis.

It might be difficult to treat cryptococcal meningitis because Flucytosine is not something you find easily in India and therefore you are stuck with Fluconazole and Amphotericin B and good luck to you if you plan to give the latter in peripheral venous lines. (I'm not sure if the liposomal variety of Amphotericin B doesn't cause as much phlebitis). But cryptococcal meningitis is a diagnosis you do not have to miss, if you are doing LP.

It is a messy thing, but it is a life saving diagnosis. I've seen one patient die during the treatment, even though we were doing regular therapeutic lumbar punctures to reduce the intracranial pressure. But I've seen almost everyone else survive (including the case where I had to take PEP). I've also heard a very inspiring story from Dr Ramakrishna Prasad about a patient whom everyone else had given up on, coming back to life after switching over to the liposomal variety.

A (thankfully) much rarer thing is HIV CSF escape syndrome. Hearing about this for the first time is when I realized which peak of the Dunning-Kruger effect I was on. You see, the blood brain barrier is a real thing. And not all of the HIV drugs cross this barrier the same way (paradoxic?). And therefore there are patients who can have no virus in their plasma, but if you do a CSF viral load test you will have a real surprise waiting.

A not so uncommon thing which can be diagnosed through CSF is neurosyphilis. I always have to read the guidelines three times about when to use a VDRL test and how much to rely on it, but this is a test that we used to do as a protocol while doing an LP in HIV infected.

Things like gadolinium enhanced MRI are becoming more useful than CSF analysis in diagnosis of things like tubercular meningitis. But from what Dr Rahul Abraham once told a group of us about his experience with MSF in Bihar, lumbar puncture will remain with us till the end of the HIV pandemic.