Coleman’s 11th Law of Medicine

There is no such thing as Minor Surgery

A few years ago I created 12 laws of medicine designed to help patients get the best out of doctors and hospitals. I turned the laws into a book called, rather predictably I’m afraid, Coleman’s Laws. I’ve decided to record a series of short videos describing these laws. In the end I hope to record a series of 12 videos. In this video I want to explain Coleman’s 11th Law of Medicine which states, quite simply, that there is no such thing as minor surgery. I’ve started with this law simply because it’s very simple and easy to explain.

Now, obviously, some operations are more complicated than others. Some operations take many hours to perform and involve teams of surgeons. I’ve assisted at operations where one surgeon would start an operation, another doctor would come in and take over and then a more junior surgeon would come in and sew up the patient. When an operation lasts 12 hours or more the operation will often require doctors and nurses to work in shifts – with different surgeons taking on different responsibilities.

It’s also pretty obvious that some operations are more dangerous than others. Major heart surgery can be risky – especially if the patient is already seriously ill. Even a simple operation such as the removal of an inflamed appendix can be dangerous in some circumstances. I never practised as a surgeon – removing an appendix by myself was the most complicated piece of surgery I ever performed – though as a GP I performed thousands of small procedures usually dismissed as `minor’.

The problem is that these small operations or procedures which are invasive are never really minor or insignificant and always need to be taken seriously if problems are to be avoided.

Consider, for example, the simple procedure of taking a blood sample – known as venepuncture.

This is considered by many health professionals to be such a trivial operation that it doesn’t need to be taken seriously and can be delegated to just anyone available. In some general practices these days, blood samples are taken by members of staff who are possibly no better qualified than the cleaners and probably less qualified than the staff working in the reception area. Even then patients are often told that they have to wait a week or two for an appointment to have the blood sample taken. This is unforgiveable.

All this happens partly because too many doctors and nurses consider themselves too important to perform such small tasks, partly because they work an absurdly short working week and spend much of each day filling in forms and dealing with administration and simply don’t have the time to do these things themselves. And it is partly because they have never been taught just how risky these simple procedures can be.

Neither doctors nor nurses are taught much, if anything, about iatrogenesis – doctor-induced disease – even though it is now one of the three major causes of illness and death; up there alongside cancer and circulatory disorders such as heart disease and strokes. Nor are doctors and nurses taught about the side effects of drugs or the variety of adverse events which can result from a medical intervention. They aren’t even taught anywhere near enough about the way that prescription drugs can interact when given together. And they aren’t even taught about the importance of evaluating `risk’ versus `benefit’. I used to be invited to speak to doctors and nurses about these problems but the drug companies complained that I was bad for business so I was banned.

The result of all this ignorance is, in turn, that the untrained staff who are given the responsibility of taking blood samples are not taught how to take blood properly. This is a delegation too far. Too many unskilled practitioners stab the needle down into a vein with the result that they go straight through to the other side, fail to take a sample, produce a huge bruise and possibly ruin the vein for the future. They then have to try again with another vein. When a patient needs repeated blood tests this constant botching can be a serious problem and can eventually result in blood having to be taken from a foot, which isn’t easy, or from the inside of the thigh which is even more tricky and involves something called a venous cutdown.

When taking blood from a vein in the cubital fossa, the inside of the elbow, the needle should be slid into the vein, almost horizontally to the skin but it usually isn’t. Venepuncture is probably one of the simplest and yet most under-estimated surgical procedures. When I was a medical student we had to take a dozen or two dozen blood samples every morning before lectures and ward rounds. This came in handy when I became a family doctor because we usually took our own blood samples in those distant days. The blood result would be back in a day or two at the most. These days the whole business can take weeks.

It’s easy to tell if a blood sample has been taken clumsily or incompetently.

If there is a bruise after a simple blood sample has been taken then the person who took the sample probably did things badly. If this happens more than once then the venepuncturist needs to be retrained or, perhaps, sent back to cleaning the windows. Incidentally, just pressing on the puncture site won’t do much good if the needle has gone straight through the vein and come out the other side.

So, apart from the bruising and the damage to the tissues, why do I say that taking a blood sample should not be classified as minor surgery?

And I’m not talking about bruising, though that can be extremely painful.

First, there is a risk that the needle might go into an artery by mistake. When a needle goes into a vein the blood comes out slowly. If the needle enters an artery by mistake then someone will have to clean up a good deal of blood – including the splashes on the wall and the ceiling. The patient will be in shock and may lose rather too much blood. And the person on the operating end of the needle will probably panic if they aren’t properly trained.

Second, the needle could hit a nerve. That’s something you really don’t want. You know how much it hurts when you bang your elbow? It used to be called hitting the funny bone. Well, it’ll be a lot worse than that. Apart from hurting a great deal the resultant damage can be considerable. There are some big, important nerves and indeed arteries very close to the veins which are likely to be used for blood sucking.

Third, there is a real risk of a bacterial infection at the site where the needle entered the body. And that can turn into cellulitis or sepsis. This is a very real risk. It’s avoidable but it’s happening with increasing frequency – especially in hospitals and health centres which aren’t properly cleaned and which may contain antibiotic resistant bugs. There is a tendency among too many medical staff not to bother to wash their hands because they put too much faith in antibiotics. That’s dangerous because there are a lot of bugs around which sneer and stick their tongue out when you threaten them with an antibiotic.

Fourth, there is a risk that the blood might not stop coming. This is most likely to happen in patients who have a blood clotting problem. I wonder how many people taking blood samples check to make sure that the patient isn’t taking medication that could hamper blood clotting. Something between none and hardly any at all is my guess.

Other possible problems include phlebitis, hypotension, syncope and seizures.

And, finally, if the blood isn’t taken properly, and stored properly, there is a risk that the result from the laboratory will be misleading and the patient will be treated for something they haven’t got or not treated for something they do have. Remember that one in six patients in hospital is there because they’ve been made ill by a doctor. When I mentioned this on the wireless once, a few decades ago, a doctors’ representative pointed out, with great delight, that this meant that five out of six patients were in hospital because they hadn’t been made ill by a doctor. He was very proud of that.

The bottom line, Coleman’s 11th Law, is that all surgery – even taking a blood sample - should be taken seriously and performed by someone who is properly trained. It’s not something to delegate to anyone who happens to be passing, as seems to be the fashion in some medical or health centres these days.

It is never safe to describe surgery as ‘minor’ and everyone, doctors, nurses and patients, needs to remember that. Awareness of the possible hazards is the best way to avoid them. When you perform a procedure regularly it’s easy to become blasé and careless. And the inevitable consequence of being blasé and careless can be disaster.

There isn’t much that patients can do to protect themselves from these hazards. But you could send copies of this short video to your doctor and hospital – just to remind them of the potential dangers. And it’s probably a good idea to stay alert, take an interest in what’s happening and walk away if you aren’t happy about the way things are being done. It’s always nice, for example, to see the venepuncturist wash their hands before attending to you. And a fresh pair of rubber gloves would be nice, too.

If you found this video of interest please watch out for the other Coleman’s laws. If you want to make sure you don’t miss any of them just subscribe to this channel.

This channel has not been monetised, by the way. It is a public service video in the old-fashioned style. There are no adverts, no sponsors and no requests for funds.