- 12:18 25 June 2014 by Clare Wilson
Blood transfusions were voted one of the most common unnecessary surgical procedures in a recent poll of anaesthetists. The evidence about when they are needed has changed but doctors can get stuck in their ways. So here’s what you should know about blood transfusions – and some other medical procedures you may want to think twice about.
(Image: Kevin Curtis/Getty)
1. Don’t let your doctor… give you blood (unnecessarily, that is)
Let’s be clear, there is no doubt that blood transfusions save lives. But they have also been linked to higher death rates if they are given when not strictly necessary.
A study published this month looked at people taken to hospital with significant blood loss from physical injuries. For people judged on arrival to have more than a 50 per cent risk of dying, those who had a transfusion of red blood cells were twice as likely to survive as those given no transfusion. But in arrivals judged to have less than a 6 per cent chance of dying, those who got a transfusion were five times as likely to die as those who did not receive one.
It’s not clear why but a dose of someone else’s red stuff may mildly weaken the immune system or, more rarely, cause lung inflammation, says Lee Fleisher, an anaesthetist at the University of Pennsylvania in Philadelphia.
(Image: Niko Guido/Getty)
2. Don’t let your doctor… operate on you on a Friday
Some people don’t like Mondays, but it’s a good day for an operation.
Emergency surgery should of course be carried out whenever doctors advise it, but if you face any non-urgent surgery and are offered a choice of day, keep in mind that the earlier in the week you have it, the better things are likely to end up.
Patients tend to get worse post-operative care at weekends because hospitals have fewer staff in, and those who are around tend to be more junior. “That first 48 hours is the most critical part of a patient’s recovery from an operation,” says Paul Aylin of Imperial College London, who carried out the study.
Aylin is quick to point out, however, that most kinds of non-urgent surgery have a low risk of death to begin with – often less than 1 per cent – so a 44 per cent increase is still a small risk in absolute terms. Still, when it’s your life on the line, every little helps.
3. Don’t let your doctor… approach you brandishing a razor
Hair is dirty – so if you’re going to be cut open you’d think it would be the last thing you’d want waving around. Hence the long tradition of the pre-surgery shave for any hairy parts of the body. For some men, this can be nearly everywhere. Hair removal is often done with a disposable razor, sometimes without so much as a splash of water.
The trouble is that this approach causes the exact problem it is supposed to prevent – a wound infection. “The razor grazes the top layer of skin and you get tiny, microscopic cuts,” says Judith Tanner, a professor of nursing at De Montfort University in Leicester, UK, who has reviewed the research on the subject. “Bacteria from your skin get in and multiply.”
Official advice in the UK and the US is now that body hair should not be removed unless it will physically get in the way of surgery or dressings, in which case electric clippers should be used. But you still see cheap razors used, says Tanner. “It’s dispiriting.”
4. Don’t let your doctor… give you a new hip – get an “old” one instead
When it comes to technology, newer is usually better. That’s not necessarily true when it comes to medical devices. Unlike in the US, in Europe there is no requirement for new devices to undergo years of randomised controlled trials before they go on sale. They merely have to pass some basic safety tests.
There are over 200 different types of artificial hip available in the UK, with new designs introduced every year or so. It can take 15 years or so to see if a new model is as effective and long-lasting as existing ones. The most recent problem to come to light is with some metal hips, which can wear down too fast, releasing metal into the bloodstream.
Some people are too keen to try the newest technology, says Siôn Glyn-Jones, an orthopaedic surgeon at the Oxford University Hospitals in the UK. “They read about it in the Daily Mail. We spend most of our time saying ‘No, it’s too new’.” Neither are surgeons immune to manufacturers’ marketing spiels. “There’s a need to keep innovating but there’s a balance between that and safety,” says Glyn-Jones.
5. Don’t let your doctor… give you a general check-up
General health check-ups have long been popular in the US, where they may be carried out once a year. They have recently been introduced in the UK as a“midlife MOT” to be done every five years. The UK check-up is mainly focused on reducing people’s risk of heart and circulatory diseases. Doctors measure blood pressure, cholesterol levels and body mass index and give some general health advice.
Having a regular check-up sounds like common sense – the ultimate in preventative medicine – but they are surprisingly controversial among those who favour evidence-based medicine. That’s because they are a form of screening – in other words, looking for illness in people who have no symptoms. And screening has a nasty habit of doing more harm than good if it is brought in without large trials to back up its effectiveness.
The potential downsides of screening are that it can worry people unnecessarily, offer false reassurance, or trigger unneeded tests and treatments. That has been shown for other kinds of screening such asprostate-specific-antigen (PSA) testing, breast self-examination, and perhapsmammographies too.
Trials looking at the effectiveness of general health check-ups have been done and they have been overwhelmingly negative. The most recent, and one of the largest ever, looked at nearly 60,000 Danish people who were offered annual checks for five years. Five years after this period, there was no effect on heart attacks or overall death rates.
“The first thing we know about all screening is that it causes harms,” saysPeter Gøtzsche, who heads the Nordic Cochrane Centre in Copenhagen, Denmark. “Sometimes the benefits are bigger than the harms, and sometimes they’re not.”
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6. Don’t let your doctor… attempt to resuscitate you when it’s essentially futile
Doctors occasionally get a bad press for placing seemingly inappropriate “do not resuscitate” orders on some patients’ notes. In fact it’s more common for them to make the opposite mistake – performing inappropriate CPR on those who have little chance of surviving.
CPR is not a good way to spend your final moments, says David Newman, an emergency medicine physician at Mount Sinai Hospital in New York City. To have any chance of success, doctors have to pound on the patient’s chest so hard they usually break ribs and lacerate the heart and lungs. “It’s a very violent, invasive act,” he says.
Of course CPR can be life-saving in apparently well people who have a sudden cardiac arrest. “The problem is we have extended CPR to people who are dying as a result of processes that have been ongoing for months or years,” says Newman, such as people with terminal cancer. “Their chances of survival are close to zero.”
Of course, when you are dying you are in no position to order doctors around. You can pre-empt matters while you are still healthy, however, by making anofficial declaration if you do not want such extreme measures taken in the final moments of your life.
7. Don’t let your doctor… touch you – without washing their hands
Sometimes you would like a standoffish doctor to be a bit more touchy-feely, but did you see them wash their hands before they approached? If not, smile sweetly and politely remind them.
An estimated 1 in 15 UK hospital patients pick up an infection during their stay – if they’re unlucky it could be a potentially lethal superbug that causes blood poisoning (MRSA) or diarrhoea (Clostridium difficile). One of the biggest causes is healthcare workers failing to wash their hands between patients.
“If hand hygiene was a drug-treatment you would be queuing up to use it,” says Sheldon Stone at University College London Medical School. He has shown that for every extra millilitre of alcohol hand-rub that a hospital goes through, per patient, per day, there is a 1 per cent drop in its MRSA rates.
Stone has found that the main reasons staff don’t wash their hands are getting distracted or just forgetting. Another factor is that some don’t even know they need to in certain circumstances, such as after removing gloves – as microbes can pass through latex.
On the bright side, on-the-job training improves hand-washing rates, especially if senior members of staff give feedback to the slackers. “You can teach an old dog new tricks,” says Stone.