Item — HN Reader

One of my best friends is a corneal surgeon at a university hospital, and does cataract surgery when there are other special complications. This is in Western Europe.

He told me about a work trip to India he did and how amazed he was by the routine, efficiency and lack of waste there was over there in regular cataract surgery. Literally one doctor would handle 5x to 10x as many surgeries per day as their western counterparts. Where each surgery here requires full sterilization from scratch, there they kept their wrapping etc between surgeries, and had two beds side by side. The surgeon would do one surgery while the other patient would be changed. Then he turned around and did the next cataract surgery.

We have a lot of waste in our medical practices.

7 comments

This sounds a bit like the Sunrise Hospital Emergency Room treating patients from the Mandalay Bay shooting in 2017

> I said, “Bring all your patients together.” They brought them all towards me, and I was at the head of multiple beds, spiraling out like flower petals around its center. We pushed drugs on all of them, and they all got intubated, transfused, chest tubed, and then shuffled to Station 1.

> the respiratory therapist, said, “Menes, we don’t have any more ventilators.” I said, “It’s fine,” and requested some Y tubing. Dr. Greg Neyman, a resident a year ahead of me in residency, had done a study on the use of ventilators in a mass casualty situation. What he came up with was that if you have two people who are roughly the same size and tidal volume, you can just double the tidal volume and stick them on Y tubing on one ventilator.

Groovy in an emergency scenario, but I, a humble non-doctor, like the idea of fewer compromises of sterility as the de rigueur way of doing things for non emergency surgeries.

https://epmonthly.com/article/not-heroes-wear-capes-one-las-...

That's a really awesome article. It shows the power of just thinking about the what if scenario comes in very handy, because you begin to note information that might be useful.

I have written a few disaster/emergency plans and they are often forgotten about almost immediately, to the point they forget they even had them after a year.

At my old gig the on-call rota involved doing a randomized fire drill at the start of your on call week. Think "the site is slow" or "users are seeing 500 errors." This included a TUI program to walk you through the fire drill with your partner. That same TUI was the tool to walk you through debugging a real fire, including alerting the right slack channels. It was very much inspired by how commercial pilots handle failures using checklists, allowing you to do as much of the problem solving as possible before the problem.

It feels gross to compare it to ER docs saving lives in a mass casualty scenario but, well, I have a boring life but can relate to one aspect of theirs.

That's a really good plan.

Its not the same but when your business is dead because one of the sysadmins accidentally deleted all the users from the system, its not all that different because many people's lives are on the line but the choices are different but some can become fatal.

>> What he came up with was that if you have two people who are roughly the same size and tidal volume, you can just double the tidal volume and stick them on Y tubing on one ventilator.

That is seriously cool!

As a patient, I'm not sure if I'd be comfortable with the doctor operating on me doing a speedrun.

Full sterilization before each surgery is a good thing. Better safe than sorry. Same for only having one patient in the operating room - reduced risk of contamination and human error.

It's not a binary choice between a civil war surgeon's saw and an immaculate cleanroom, safety exists on a spectrum. Better safe enough than so incomprehensibly safe that the procedure is unaffordable and the doctor has 1/10th the experience and 100x as much paperwork!

Imagine, for a minute, that there's a physical lever at the FDA that controls the amount of cost, bureaucracy, and triple-checks that occur in hospitals. Think one of those steam engine throttles, with the big pawl release lever, it's set in front of an angle gauge with colors from red to green. One side is marked "Anarchy" and the other is marked "Better safe than sorry". Right now, that lever (or the metaphorical regulatory lever, the physical lever doesn't actually exist AFAIK) is as far over to the "safe" side as I can imagine it possibly being. The US lags behind on many modern medications and procedures, health care is unaffordable for somewhere between many and most, it's so miserably difficult to enter the field that we're not educating and training enough people, and the people that we do have trained are spending too much of their time doing paperwork and fighting the insurance system to take care of people. If you or a loved one have ever gotten a refusal of treatment or needed to wait for your disease to get worse before you can get care, you know how real this lever is.

If you ever get access to that lever, please, bring it at least one click back off the limiter. Maybe two. The potential harms that you imagine could caused by contamination and human error, at the moment, are less than the actual harms that are happening right now due to lack of affordable access.

People are going blind, in pain, or dying right now because it's too far towards the "better safe than sorry" side. If you were on a fixed income and found yourself unable to afford a $8000 cataract surgery as the world slowly grew dim, you'd wish you could visit an efficient practice and get it done for $150, even if that meant there was another patient on the other side of the OR.

Exactly this. 10x the experience is very valuable.

That's fair, except that sometimes there aren't enough resources (qualified surgeons, facilities, etc) for everyone to get that kind of care. I'd rather cheap care that is 95% good enough than none at all. (For things I really need - I think a majority of what the healthcare industry does is counterproductive but there is also plenty of stuff that's good like cataract surgery for example.)

You’d accept a 1 in 20 chance of acquiring a staph infection?

Depending how bad my situation was and what my alternative options are.

don't you have that just going to the hospital now a days?

This one is a tough sell, in that regime the doctors will have a significantly higher amount of practice which might translate into mastery. On the other hand I would expect post-procedure tracking and reporting be significantly better in the west.

One person's waste is another person's more comfortable routine; one person's efficiency is another person's grueling day. (Even setting aside possible complications from not re-sterilizing, in this specific example.)

Our goal should be to have a comfortable amount of capacity in the system so that we don't need to sweat the details, not to hyper-optimize everyone into human machines.

It sounds like you're implying that doctors in the West have a more relaxed work schedule and really prefer their pace over an Indian doctor.

What you may not be taking into account are:

- The massive amount of soul crushing paper work in the West.

- Having to deal with insurance companies.

- Having to deal with the demands of patients who think they know better.

What compensates for the shit job:

- How much more one can buy with USD / Euro. But, this is changing rapidly.

> - The massive amount of soul crushing paper work in the West.

This sounds like a problem in the US only.

Not sure how much worse it is in the US, but here in NL it's a huge problem for GPs too.

No "here's how these other doctors are more efficient" in-the-OR practices would change that.

Let's say you're a hospital administrator who reads about how many more surgeries a doctor in India can do per day.

You say "hey, docs! you need to up your throughput! Take these surgical-workflow steps, like two patients prepped at once!"

Now the doctor has twice as much paperwork.

No doctors ever deal with insurance companies in France

This is what makes Electron apps.

Sounds like they do something similar!

From TFA:

> Aravind uses a two-pronged approach to addressing the lack of ophthalmologists: First, it enhances the efficiency of the existing staff. The hospital has an innovative “assembly line” operating theatre that allows a single surgeon to alternate between two fully prepared tables, each supported by dedicated instrument sets and nursing teams. This approach enables six to eight cataract operations per hour compared to an industry norm of one, while delivering clinical outcomes that even surpass those achieved in the UK’s National Health Service.

6–8x throughput is very impressive.

6 an hour isn’t unusual at a dedicated center in the US.

I had early cataract surgery at a “mill” here in NJ. There are similar centers all over. In talking both with my eye doctor and my cousin who is an eye surgeon in on the other side of the country, I was told it was better to go with a doctor who specialized in this surgery at a dedicated center (common called a mill). The rate of complications is less because they have really dialed in the procedure and have seen everything. The first day I saw him, I was literally the last patient. He said he had operated on 80 eyeballs that day. I think it was a long day, with more than eight hours but he does a few of those days a week at different centers. He has a large crew of support staff and multiple rooms to achieve this throughput. He did a good job. It was not inexpensive. He was driving a nice Porsche. He didn’t have time for a pleasant bedside chat.

I still don’t know why I had to get the surgery at 50. I haven’t had any other weird health issues like that. The one odd thing is that my grandfather was the first person to do cataract surgery in Lithuania, back in the 1920s. I always wonder if there was a link.

> Where each surgery here requires full sterilization from scratch, there they kept their wrapping etc between surgeries, and had two beds side by side.

This is like the old soviet block model:

https://www.youtube.com/watch?v=Kr_wcrX0d_A

I imagine the pace in India was also borne out of necessity - there are just so many more cases to go through there, that the surgeons had no choice but to adapt.

I can't help but think that they could spread disease from one patient to the next. Even if it is a minimal chance, the statistics would add up.

and this doesn't even take into account something like prion diseases, which can be spread by equipment which might be impossible to sterilize.

I only got it through the story my friend told me, so I really don't know any details.

That being said, these people are being treated for a health issue, most of the successfully. There might be more risk, but the benefits might outweigh them.