Archive | November 2010

President Obama’s Injury: What Does “12 Stitches” Mean?

Simple interrupted suture (scheme)

Interrupted Sutures

Yesterday, the President caught an elbow during a basketball game and suffered a lip injury.  News reports stated that he had 12 stitches applied under local.  Does that mean anything?  Sort of, but not really.  Everyone is always fascinated by the number of stitches needed to fix a cut.  You will get this question almost every time you sew somebody up in the emergency room (if you do that sort of thing).

Of course it is important for reporters to determine what the injury is, how serious it is, and so forth.  Stitch counts are not going to go away, but they are not that meaningful.  Here’s why:  the number of sutures required for a cut can vary widely, and are largely arbitrary.  Some surgeons put them in very close together, others farther apart.  This depends on the surgeon’s background, experience, habits, suturing technique, and so forth.  So a “12 stitch” cut isn’t necessarily bigger than a 6 stitch cut, or smaller than a 20 stitch cut.  (I am guessing that being the President will get you about 20% more stitches.  That doesn’t mean a better outcome).

So how should the cut be described?  I suggest length and location.   Those are better and more informative.  You can also give the depth, but that is getting overly technical.  “The President suffered a two-inch cut to his upper lip that was fixed with stitches.”  Or, “a one inch scrape to his cheek that did not need stitches.”  Note I did not use the metric centimeters (preferred in actual medical discussions but not suited to news articles).

From the AP:
The medical unit that treated Obama used a smaller filament than typically used, which increases the number of stitches but makes a tighter stitch and results in a smaller scar

Sounds reasonable, but you don’t really want the closure “tight”, and the length of the scar will be affected only minimally.  Its possible a running subcuticular (under the skin) suture was used to keep the closure short.

No word yet on what happened to the guy who elbowed him!

What’s Wrong With West Palm Beach?

West Palm Beach

Given that it is Thanksgiving week, there are plenty of travel articles flying around.  This one, “13 Things Your Flight Attendant Won’t Tell You“, covers all the usual gripes one might expect from the flight attendant perspective.  You have to sympathize with flight attendants, as they deal many travelers, some of them obnoxious and frustrating. But check out item #12:

“I hate working flights to destinations like Vail and West Palm Beach. The passengers all think they’re in first class even if they’re not. They don’t do what we ask. And the overhead bins are full of their mink coats.”

Hey!  Did they just insult my adopted home?  Yep, and also threw in a dig at a renowned ski area for good measure.

I fly quite a bit these days, and haven’t seen too many rude passengers heading to PBIA.  At least half the plane is filled with tourists heading down for a good time, and the rest with friendly snowbirds.  Keep in mind that West Palm is a regular town, its the island across the bridge that has more of  the high-end types.   But the biggest ones have their own planes! So they aren’t filling the overhead bins with mink coats.

I wonder, if a frustrated attendant curses out the passengers and pulls a Steven Slater inflatable slide move, can I follow them out?  I’ll politely ask first, then grab my mink coat out of the overhead bin.

Spiral CT Scans For Lung Cancer Screening: High Cost, Modest Benefit

Beschreibung: Kleiner Lungentumor (T1) linker ...

Image via Wikipedia

A new study has shown that  spiral CT scan screening of heavy smokers can reduce deaths from lung cancer.  The study looked at 53,000 heavy smokers aged 55-74.  Patients were screened with either chest x-rays or spiral CT scans.  There were 354 deaths in the CT group vs. 442 deaths in the x-ray group over an eight-year period.  The difference was significant, but it is not clear whether spiral CT scans should be used as a standard-of-care screening test in this population.  Concerns such as radiation risk and false positives warrant further exploration, but for now I will look at the costs.

Sources put the cost of a CT scan between $300 and $400.  Let’s split the difference and call it $350.  The study was randomized, so assume that 26,500 people had CT scans at a cost of $9,275,000.  This resulted in 88 fewer deaths, or a preventive cost of $105,397.72 each.  Does this number have meaning?  A common cost/benefit reference for costly treatments, such as cancer therapy, is $50,000 per year of life gained.  It seems likely that this test would be cost effective by this standard, since odds are good that those 88 individuals should live another 2 yrs each, many quite a few more.

The study probably represents an incremental benefit against lung cancer.  The scan does nothing to the biology of the disease, but it increases the odds of successful treatment with earlier detection.

The statistics can be looked at from another angle, one which makes the CT test seem less attractive.   To prevent 88 deaths, 26,500 people were screened, or about 300 scans per single death prevented.  Preventing 20% of the 159,000 yearly deaths from lung cancer would save 31,800 lives.  But, it would require CT scans of 9.5 million people at an annual cost of more than $3 billion.

To be fair, my analysis does not take into account the cost implications of preventing these deaths, nor does it address the costs of chasing false positive scans or several other “what if” scenarios.

These types of analyses will become necessary for many types of treatments and tests as we convert healthcare to a much more evidence-based system than we currently have.

Lung cancer is a nasty disease with nasty outcomes, and smoking is a very hard habit to break.  The question of how much to spend on smoking cessation efforts and how much to spend on detection and treatment of lung cancer is not an easy one.

The National Lung Screening Trial