Applying the minimally invasive concept to patient management

Every time you subject the patient to an invasive procedure you take the risk of causing complication. I have done hundreds if not thousands of procedures which makes me even more aware of the risk I take every time I stick a needle or cut into the patient. We can do everything possible to enhance the safety, yet we cannot completely eradicate the risk of adverse events.

With the recent progress in the imaging technology more and more patients opt for a virtual procedure or study with no needles involved. Nowadays, you can undergo virtual colonoscopy (see image above) without the discomfort of the bowel prep and the procedure itself. The risk of complications is also greatly reduced. The sensitivity of the virtual test, of course, is not as good as that of a real colonoscopy. The technology keeps getting better and it is only a matter of time until it becomes the standard of care.

Some medical centers currently offer virtual coronary angiography to diagnose coronary artery disease. No doubt, that it has its limitations and disadvantages but it is also safer than conventional coronary angiography. Once again, the technology has a long way to go, but it’s a start.

In surgery, performing procedures with a minimally invasive approach is nothing new. If you can take a gallbladder out with a laparoscopic approach and avoid making a big incision in the abdomen, this will facilitate healing and minimize complications. Even cardiac surgery could be done minimally invasive if appropriate.

The minimally invasive concept could be applied not only to surgeries and procedures but to the overall patient management approach. A study published in the June of 2008 issue of the Annals of Internal Medicine indicated that ICU patients managed primarily by critical care physicians might, actually, do worse than the patients treated without an intensivist’s involvement.

This article delivered quite a shock to the critical care medicine community. Multiple editorials followed to dismiss the results of this study. One of the possible explanations offered by the authors of this publication was the possible harmful effects of the increased intensity of care.

Invasive procedures like central lines, arterial lines and intubations are considered to be fundamental to the practice of critical care. The authors suggested that critical care physicians simply “overdo” it. Performing more invasive procedures on the patients will, invariably, increase the risk of adverse events.

I will not try to refute the conclusions of that study, but try to learn from it. In many cases you can effectively treat and resuscitate the patient without performing risky procedures. Patients with gastrointestinal bleeding, for example, could often be supported by using a peripheral IVs rather than central line.

In conclusion, many future patients will opt for needle-free, risk-free procedures and treatments. As far as physicians go, taking the “don’t just do anything, stand there” approach might be the right thing to do for the patient in some circumstances.

Ralph Gordon is a critical care physician who blogs at realICU.

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  • RetiredRN/ED

    I thought the standard bowel prep was still required for a virtual colonoscopy. What is used in its place?

  • Doc99

    No bowel prep for virtual colonoscopy?

    “…The biggest limitation of virtual colonoscopy is bowel preparation. As with other techniques that attempt to image and visualize the colon surface, the colon needs to be cleansed of residual fecal material. Many patients find this the worst part of the examination. ”

    http://www.med.nyu.edu/virtualcolonoscopy/virtualcolon/bowelprep.html

  • Michael F. Mirochna, MD

    Is it possible that newer technology overdoes it too?

    I would assert that radiation is still a risk, especially on a population level. I imagine the CT calcium score for women will be the red dress vs. the pink ribbon.

  • http://dinosaurmusings.blogspot.com/ #1 Dinosaur

    Almost everything in that paragraph about virtual colonoscopy is wrong. Yes, it still requires a prep, and no, it is not less sensitive than actual colonoscopy. In fact, the sensitivity is markedly higher. Approximately one in three patients who undergo virtual colonoscopy will have a suspicious finding, necessitating followup with actual colonoscopy — and another prep, which, as has been said, is considered the worst part of the procedure by many patients. Imagine a one in three chance of having to do it twice.

  • http://dinosaurmusings.blogspot.com/ #1 Dinosaur

    It is the specificity of virtual colonoscopy that is not as good as the real thing.