this is not something i thought about straight away when i was doing in my junior years and
i'm going to present to you guys some stuff it happens once in a while but i want to give you
the tools to be able to find this information out so i'm just going to ask someone now
what do you reckon jacob maloof what do you reckon the risk benefit profile is
i guess in terms of the risk benefit profile you're weighing up the potential complications
or deleterious effects of the surgery or any complications that you might think be
could be possible during the surgery yes as opposed to the benefits that the patient will
gain from having that surgery because obviously we're doing it to try and improve a syndrome or
a physical complaint that they're suffering from but it's a matter of weighing up whether or not
the actual surgery itself will have more ill effects than the cure that we're trying to provide
exactly right and what i found that what i found that when i was trying to figure out what this
risk benefit profile was back when i started there wasn't a lot of good data out there but now there
is a lot of good data and i want to show you where to find that data because i think that's really
really worthwhile for the highest risk and most complicated cases that you can do this even now
as an intern resident junior registrar or whatever so exactly what you said jacob
risks have been risk and benefit of surgery is comprised of the perioperative risk and
then the surgical risk itself and then there's the risk of doing nothing often the benefits
of the surgery are quite obvious you know lap collie take out gallbladder it's curative or
total knee replacement fix the osteoarthritis with metal wear and it's it's sorted so
in the most recent the 2014 acc aha guidelines which we'll go through in a bit of detail in
one of the next sections talks about this risk calculator which you can plug in a whole bunch
of variables to get some really concrete data so i want you guys to take a photo of that screen um
www.riskcalculator.facs.org and this has just literally just changed my life i can now plug
in data and then print out something or show my patient you know the risk of mortality
the risk of any complication the risk of a serious complication
um and even chance of discharge to nursing home or rehabilitation or whatever it is and it's a really
good way of you know showing concretely what you know what the patient might be facing afterwards
so that's the reasons i use for these very tricky cases for surgical it's quite obvious i just asked
the surgeon i asked the surgeon what's the chance of improvement what's the chance of no improvement
and what's the chance of surgical harm and finally what are the risks of doing nothing so in this
next exercise i want you to have that ability to just go to those resources to know how to
balance these risks in a very practical way which is not just words you've got you know you want to
be able to give concrete data for this as well so the risks of surgery surgical perioperative risks
to do nothing benefit of surgery is this chance of improvement obviously in this particular case
we've got a patient um with bulging disc and back pain for laminectomy these are real cases
i've had over the years i've just altered slightly when i plug this into the um risk calculator the
perioperative risk is about five percent death as well as other complications that could occur and
the chance of you know surgery having improvement is 80 but the chance of no improvement is about 19
and the chance of harm is one percent so this was a really tricky situation
with these rates who would go ahead with surgery and a lot of patients would go ahead but the next
question i had to ask was what are the risks of doing nothing so this patient was in so much pain
and they had a one percent chance of paralysis if they did nothing that that kind of balances
up i've got a one percent chance of harm with the operation but i've got a 1 chance of paralysis
and harm even without the operation so this really does favor me doing the doing the procedure maybe
maybe my pain wasn't that bad you know maybe i would go ahead or maybe if i was just really happy
with my life at the moment and you know a few more years was all i needed maybe i wouldn't go ahead
now i want you to think about this 45 year old female for a lap collie past history severe osa
bmi 60 severe pulmonary hypertension limited functional capacity so the risks of surgery
are low specifically i mean you know once you get past the bmi issue they'll get the gallbladder out
not the highest risk operation but i really i like that you ask what are the risks of doing nothing
so in this patient 30 will have a gallstone related complication in the next 12 months and
when you think about that suddenly my elective bad patient you know with high risk has now gone to
emergency potentially emergency high-risk patient so that's exactly the right question i need to ask
and when i asked the surgeon this they said yeah look it's we'd rather do this electively
than urgently next one 60 year-old male for revision total knee replacement again a whole
bunch of bad stuff bad heart failure very low ejection fraction severe copd
again what do i want to ask the surgeon i'd ask these questions and essentially again the risk of
surgery per se is low it's curative but the risk of doing nothing is pain and limited mobility
so this is where it can get pretty complicated right um so let's say imagine that patient is
the highest risk patient you can imagine um i do exactly what you just said there i do
i do a quality of life assessment and it's not something they teach in anesthesia necessarily
but i think it's the question that of often you know we don't we don't often ask the patients
to help guide them to a decision would they be you know would they rather be in their current state
than undergo the hazards of the operation are they happy how they are or they do they really you know
want to fix what they've got and you can imagine these two situations where you know say you've got
someone who isn't very active doesn't care to be active is happy you know with the amount of pain
they've got and they're happy just watching tv on the couch and that makes them joyful versus
someone who's really active really wants to go and play with their grandkids and do active stuff and
that's debilitating and they're so unhappy with their life because of it it's a very different
scenario of the same patient and it would change everything of how i perceive that situation so i
asked that question would they rather be in the current state they'll undergo the hazards and
also is their disease unlikely to progress like in that gallbladder example now generally speaking
most patients who have sought medical advice will elect to go ahead with the operation that's just
been my experience over time that very rarely is that the patient goes actually what don't
want it at all that's happened maybe a handful of times where after this discussion the patient says
actually ah too too high risk for me again um that was just a bit of an insight into how i want you
to be able to actually ask the surgeon the right questions to to get their risk for benefit profile
and plug the data into the risk calculator to have concrete the concrete ability to get this
yeah la hero i was wondering if you find that it's partly your role as well because i found
a lot of the time patients might um i guess underestimate the risks of their operation
a lot of patients might think oh man modern medicine like a urine you're out it's no big deal
but in patients where they have quite a large risk profile like that last gentleman we talked
about do you find that in doing those quality of life assessments you might have to take on a bit
of a role of educating about the risks as well so that they can then make a more informed decision
absolutely and because it's great because as a nieces i rarely see my patients after my
operation maybe not even the day after you know i've i think myself and a lot of my colleagues
have very little insight into the long-term progress of a patient and but not just the
so the fact that i can give data and presented with numbers to a patient to talk to them you know
in an informed fashion that database i'm using is of millions of cases it's a really comprehensive
database but yeah so that's really for the patient and then the extra thing is that often when i
show the surgeons the data it's news to them as well like they know their operation very well
but they don't necessarily know the medical impact of the disease and maybe they will refer to
medical management or icu for afterwards so yeah a real real twofold benefit with that knowledge
you