Monday, May 30, 2005

SWIMBO and the Surglings Drag Me Away

No posting for a little while...taking SWIMBO and the Aggravated Surglings off to the tropics. No, no, don't worry about me, flying thousands of feet above thousands of miles of open ocean. I'm sure I'll (barely) make it there, with just enough energy left over to slurp down some of those drinks spiked with an umbrella.

While I'm away, I certainly encourage any and all interested to spend some time lying on Dr. Sanity's therapy couch to catch Grand Rounds XXXVI on Tuesday. Once she has put you back in the proper frame of mind, catch Grand Rounds XXXVII over at Medgadget --- maybe since he's such a techno whiz, he can figure a way for us to move to a more modern method of numbering (Grand Rounds v37.0, perhaps?)

Saturday, May 28, 2005

Canadian Health Savings Accounts?

Health savings accounts are interesting vehicles that have the purported benefit of encouraging more accountability on the part of patients when accessing the health care system. There are certainly pros and cons to these, but as a whole I feel they are probably beneficial. They clearly eliminate the "$10 copay and I can see anybody I want" attitude that crowds our EDs and primary care offices with patients who really don't need to see a physician. However, HSAs have really not taken off well in the US (yet), and they have been attacked by our more liberal politicians as being bad for the system.

Now it seems that Canada is toying with the idea of allowing HSAs. This is an interesting turn of events, and illustrates that the utopian idea of unfettered, free universal access to health care is not panning out to be financially viable. Most American physicians do not want a Canadian style system here, and clearly those who practice close to the Canadian border see many patients who do not want to wait for their delayed care to the north. This public development should give pause to those who advocate a government run system in the USA --- are you listening, AMA?

Friday, May 27, 2005

Music to My Ears

This Washinton Times article (registration required) reviews the recent study from Yale that found music playing in the operating room decreased patients' needs for sedation during surgery. The newspaper article isn't specific, but the study looked at sedation needs in patients undergoing spinal anesthesia, and found less sedation was needed for patients exposed to music in the OR. What's not spelled out is what kind of music was playing --- Sinatra, AC/DC, Muzak? As both a surgeon and a person who has been the recipient of several lovely incisions, I think music helps everybody in the OR, including the patient. I have had one operation done under spinal anesthesia, and I don't think I'd have enjoyed it much without the distraction of a few tunes playing in the background.

We have a stereo in the main OR my group uses, and when I'm there we are pretty much always listening to something. The only rules I have are :

  1. No rap
  2. No opera
  3. No country (except maybe a little Lyle Lovett or Willie Nelson)
  4. Nothing too "loud" for patients having a spinal or local anesthetic with sedation
  5. Absolutely, positively, no radio --- I can't stand to hear the "chatter" from the morning radio hosts!
Unfortunately, there is no way to get XM or Sirius reception, as this room is in the center of the building. We listen to Norah Jones, Crowded House, The Boneshakers, Stevie (Ray Vaughn and Wonder), Holst, Diana Krall, George Winston, pre-terrorist-worries Cat Stevens (what can I say; I'm a product of my youth), and even a little Pink Floyd in the wee hours of the morning. I have zero musical talent, but cannot imagine working in an environment where music wasn't allowed!

Hat tip to Kitty for the note!

What Would Crocodile Dundee Think?

By and large, American physicians tend to take a rather dim view of the medical literature generated in Europe (we tend to quibble about things that seem statistically impossible). However, the British medical literature tends to be more credible, and I have found, for example, the British Journal of Surgery to often contain articles of merit. This editorial from the British Medical Journal, however, is making me rethink that approach.

Violent crime in the United Kingdom is increasing; figures from London show a 17.9% increase from 2003 to 2004, and one easily accessible weapon used in many incidents is the kitchen knife...To tackle this increasing problem, various measures are being considered by the government, particularly targeting the adolescent age group. These include raising the minimum age for purchasing a knife from 16 to 18 years and allowing head teachers the power to search pupils for knives...Many assaults are impulsive, often triggered by alcohol or misuse of other drugs, and the long pointed kitchen knife is an easily available potentially lethal weapon particularly in the domestic setting. Government action to ban the sale of such knives would drastically reduce their availability over the course of a few years. In addition, such legislation would make it harder to justify carrying such knives and prosecution easier....The Home Office is looking for ways to reduce knife crime. We suggest that banning the sale of long pointed knives is a sensible and practical measure that would have this effect. (emphasis is mine)
Oh. My. God. Just exactly what are we thinking? How can we continue to have these instruments of murder and mayhem in the kitchen, of all places? It would seem that we are all just a few drinks shy of the shower scene in Psycho.

But wait just a minute. Isn't England that utopian place that banned handguns in 1997 in order to curb violence? Unfortunately, violent criminals just didn't follow the playbook :
Crime rates in England have skyrocketed since the ban was enacted. According to economist John Lott of the American Enterprise Institute, the violent crime rate has risen 69 percent since 1996, with robbery rising 45 percent and murders rising 54 percent. This is even more alarming when you consider that from 1993 to 1997 armed robberies had fallen by 50 percent.
Well, isn't that special? Now that we know that the handgun ban is working so well, why not move on to that other menace to society, the kitchen knife! Well, you can have my Ginsu only when you can pry it from my cold, dead hands!

Hat tip to Sondra K!

Wednesday, May 25, 2005

The abdomen is like a box of chocolates....

On call today, and the old aphorism is true -- it's always bad to be an "interesting patient." A 64 year old obese, hypertensive lady is brought to the ED with 3 days of terrible abdominal pain, nausea, and vomiting. This was described as excruciating, and eventually was bad enough for her to pass out while at the blackjack table at a local casino (she must have been winning to not have come sooner). Denies ETOH use. Heavy NSAID user. On proton pump inhibitors for "years," but denies ever having an upper endoscopy. On iron for recent discovery of anemia, but no other workup to date.

She arrives in the ED with a BP of 70/40, heart rate of 130, diaphoretic, and in pretty obvious distress. Her abdomen is rigid. A quick ultrasound was performed in the ED to rule out a ruptured aneurysm. Blood work showed evidence of somebody who has been sick for at least 24-48 hours --- hemoconcentrated with hemoglobin of 18.5, creatinine of 3.2, liver enzymes in the 200 range, bilirubin 4, lipase 3,000, INR 1.8, myoglobin 1600, white count 10 with a big left shift (and likely on its way down). Almost no urine in her bladder when the foley is placed.

Her BP comes up to the mid 90s with 3 liters of crystalloid. Her CT was done without contrast due to acute renal insufficiency -- the images are therefore harder to interpret. Hope you can make out the arrows:

The first thing I see is a lot of gas in the portal region --- not typical for portal venous air, which tends to be peripheral. On subsequent cuts, this does not appear to be in the biliary tree either.

[1] A few cuts lower, there is extensive air around the duodenal sweep, and the pancreas looks boggy, especially proximally. There is also air in the falciform ligament.

[2] There is extensive air surrounding the head of the pancreas.

[3] The gallbladder wall is indistinct, but it appears normal. As there is no contrast, delineation of the biliary tree is difficult, but there does not appear to be biliary dilatation. Her portal venous system looks reasonable given the constraints of this exam.

By this time, while she is mildly better hemodynamically, this lady is quite sick. Given her history (NSAIDS, recent diagnosis of anemia) her exam (rigid abdomen), and after reviewing the CT with 3 radiologists, we all suspected she had a perforated posterior duodenal ulcer burrowing into the pancreas, with worsening sepsis due to delay in presentation. This would explain to some degree the lack of typical extensive free air on CT, and her sepsis secondary to delay would cause renal failure, hepatic injury, etc.

I was wrong. In the OR, she had a gallbladder that was as green-black as a mile wide tornado, bile tinged fluid throughout the abdomen, necrotic and gas filled fat in the porta hepatis, and evidence of pancreatitis in the head of the pancreas --- but no perforated ulcer. Out came the dead gallbladder, but because of the emphysematous changes around the common bile duct, we opened it as well; it was normal in caliber, and not filled with pus. By this point, the poor anesthesiologist is having conniptions with an unstable patient, so when the cholangiogram shows an impacted distal common duct stone, I decided to simply drain the biliary tree with a T-tube and settle that another day. Two big drains, G-tube, J-tube, and we're off to the ICU.

I have seen emphysematous cholecystitis before, as well as plenty of cholangitis and biliary pancreatitis, but this patient's presentation was certainly unusual. Essentially all of the soft tissue gas was surrounding the common bile duct, duodenum, and pancreas, mimicking a perforated ulcer. Patients with cholangitis do better when treated with ERCP, rather than common duct exploration, but there was no way to stay out of the OR here. She's at least making urine and on less pressor support at this point, but we'll have to see how the next few days go.

UPDATE: I just realized that many of my pictures weren't showing up -- now they're too large! Still struggling with how to put multiple photos in one post using Blogger and Picassa/Hello.

UPDATE: Trying again with photos linked. No surprise -- blood cultures grew Clostridium perfringens within hours of their collection.

Tuesday, May 24, 2005

Grand Rounds

Dr. Chaplin is hosting Grand Rounds this week -- head on over to see what the internet savvy medical crowd is thinking!

Stopping the Shipwreck?

Galen's interesting post about specialty hospitals, as well as thoughts from Symtym, got my motor running the other day. Basically, these facilities have been shown to provide, in the words of CMS Administrator Mark McClellan, M.D. :

"high patient satisfaction, high quality of care and patient outcomes in some important dimensions, greater predictability in scheduling and services, and significant tax contributions to the community."
Sounds good, but in the shipwreck of medicine, politics, and money, nothing is ever quite that simple. Specialty hospitals have been good investments for certain types of physicians -- squeezed by ever-shrinking reimbursement for their primary purpose in life (caring for patients), they invest in specialty hospitals to get the facility fees these places generate. Certain types of care (i.e., procedures) generate higher facility fees than other types of care (non-procedural medicine). That is why you will never see a "specialty hospital" for pneumonia, or congestive heart failure, or any of the hundreds of other disease processes regular hospitals must provide care for. So, when a specialty hospital opens its doors, it generally pulls better-paying patients away from a neighboring general hospital, significantly impacting its bottom line. Additionally, physicians investing in these facilities are far less likely to care for uninsured or Medicaid patients at their own place, shifting that burden once again onto the general hospital.

The essence of this really lies in the DRG system of payments to hospitals, and the way that CMS has manipulated payment over the years to encourage certain behaviors on the part of hospitals and physicians. Hospitals are pushing for legislation that pushes back at specialty hospital growth; there is already a moratorium on building new ones. To that end, Sens. Grassley and Baucus have introduced the Hospital Fair Competition Act of 2005. There are four main CMS plans touted in this legislation (from AAMC):
  1. Reform payment rates for inpatient hospital services through changes to the DRG system
  2. Reform payment rates for ambulatory surgical centers
  3. Scrutinize whether facilities meet the definition of a hospital (Medicare specifies that to be defined as a hospital, a facility must provide the majority of care to inpatients; the percentage is unclear)
  4. Review hospital procedures for participating in Medicare (Medicare compliance, EMTALA, etc.)
Per Sen. Grassley, "Congress needs to take additional steps to address these issues. Physician-owned specialty hospitals treat the most profitable patients and services, leaving community hospitals to treat a disproportionate share of less profitable cases."

This is a fairly broad piece of legislation that on its surface seems to favor general hospitals --- in theory, it cuts reimbursement to specialty hospitals and ambulatory surgery centers. As well, it may allow CMS to revoke Medicare provider agreements with some specialty hospitals:
(The CMS) Administrator also announced that the Agency may revoke provider agreements from some specialty hospitals that fail to satisfy a long-standing Medicare condition of participation that hospitals be predominantly engaged in furnishing services to inpatients. If CMS determines that a participating hospital is not primarily engaged in inpatient care, the hospital may have its provider agreement terminated. The Administrator gave little clue as to how CMS would measure whether a hospital is primarily engaged in inpatient care.

But there's a catch, which negatively impacts general hospitals as well --- specialty hospitals are not being singled out for decreases in DRG reimbursement. That means that payment for certain inpatient services will be cut, for all types of facilities, so the bottom line at both specialty and general hospitals will be affected:

As a long-term remedy, CMS further proposed to address perceived disparities by adjusting payment rates for certain inpatient hospital services, such as cardiac, orthopedic, and surgical services, that are alleged to be overpaid and that may create incentives for physicians to form specialty hospitals, and payment rates for ambulatory surgical centers, which are perceived to be too low, and likewise encourage physicians to form specialty hospitals to receive higher hospital reimbursements. CMS'’s proposed payment reforms, as well as similar provisions in the Grassley-Baucus legislation that also would direct Medicare inpatient service payment refinements, would apply to general and specialty hospitals alike. To the extent general acute care hospitals see these changes as cutting into their margins, their enthusiasm for the Grassley-Baucus bill may diminish.
All in all, this seems to be a mixed bag for both types of facilities. As a general principle, I am very much in favor of the free market driving what can and should be offered; due to the long-standing, overwhelming government involvement with health care, that is a hard thing to achieve. I feel that presently, general hospitals are at a significant disadvantage when ambulatory facilities and specialty hospitals are operating nearby. Unfortunately, this bill will likely come across as bad for both, rather than addressing many of the underlying disparities.

There is one, far less publicized aspect of the bill that I think may have some far-reaching benefits. Presently, it is illegal for a hospital to share the results of collaborative cost saving efforts with physicians. This "gainsharing" could be allowed, and might promote better cooperation between physicians and hospitals on "best practices," EMRs, etc.

Friday, May 20, 2005

The Pig and the Watch

People are different -- different looks, different perspectives, different personalities. I may be accused of seeing things from a skewed perspective, but it seems that the differences between people is laid out in stark fashion in the medical world. Are there two more disparate types of people than psychiatrists and cardiac surgeons? Internists and anesthesiologists? I know that I am making some generalizations, but clearly there are some personality types that gravitate towards certain types of medical practice.

Which leads me to orthopedists (tongue firmly in cheek). Every doc that reads this knows about the great brain sucking machine that is attached at the completion of surgical internship to (nearly) all of the residents heading into orthopedic surgery. Out goes all of the standard medical knowledge about how to care for patients --- drug dosages, treatment of diabetes, how to evaluate a preop patient, etc. Room must be made for the names of total joint prostheses, types of fractures, and the phone numbers of the ortho reps. Simplify, simplify, simplify!

Which brings me to my favorite (true) orthopedic story. As an intern on the ortho service, my job was to stay out of the OR and care for all of the patients --- give Coumadin and pain meds, arrange PT and rehab, do the admits and discharges. One morning, a postop total hip patient was doing poorly. Diaphoretic, mildly hypotensive, chest pain, increasing oxygen needs; she basically was going down the tubes. Being the good intern, I ordered tests!! Bloodwork, ABGs, a chest x-ray, and EKG....which showed big time ST changes.

On my way to phone the ICU and cardiologist, I run into the surgeon who had operated on her. He was the chief of the department, a real big wig and by all accounts a great surgeon. "Dr. Bones, I think Mrs. Brokenbody is having a massive MI! Here, look at her EKG." And Dr. Bones returned with one of the best lines I have ever heard: "Son, showing that to me is like showing a watch to a pig."

A truer statement has never been made!

The Politics, and Money, of Bariatric Surgery Accreditation

A while back, I received an e-mail from the American College of Surgeons outlining a proposal to credential bariatric surgery centers. The idea of credentialling has many sources, but basically revolves around the understanding that there has been an explosion of programs across the country, some perhaps without proper training and without a full-fledged "program" to complement the operation. There have been high-profile deaths in some centers, and as a result there has been a desire for some sort of oversight and credentialling for centers performing this procedure. Enter the ACS, who announced their credentialling program in an e-mail today:

We are writing in follow-up to our previous communication concerning the ACS Bariatric Surgery Center Program. The communication is intended to let you know that the College is currently inviting institutions to enroll in this new program. For many years, the ACS has led our nation's efforts to ensure safe and effective treatment of all patients requiring surgical care. For example, the Joint Commission on Accreditation of Healthcare Organizations evolved from the ACS Committee on Hospital Standards. The ACS and its Committee on Trauma verify 197 trauma centers.
Sounds great! There's just one problem --- there is already a national organization providing credentialling for bariatric surgery programs. The ASBS started this process over a year ago, and literally hundreds of programs have gone through the initial screening process. It is being administered by the Surgical Review Corporation, and the initial "Centers of Excellence" are due to be announced at the ASBS meeting in June.

So why reinvent the wheel? If this is an important policy goal, why doesn't the ACS get together with the ASBS to jointly administer accreditation? If one reads the SRC web site, the program goals are essentially the same as those laid out by the ACS:
(ACS e-mail)...we have reviewed the available information, consulted with experts in the field of bariatric surgery, listened to ACS leadership, developed standards, defined necessary resources, organized the means to collect data, and organized the processes for conducting site visits to accredit hospitals and outpatient facilities in an ACS Bariatric Surgery Center Network. In addition, the ACS assembled a team to manage and lead this project.
If they have consulted with experts in the field of bariatric surgery, that in essence means the ASBS and its leadership (and no, I'm not an ASBS member). Consultation should have led to cooperation....but that is too much to ask, it seems, particularly from the organization that has given us JCAHO (see above). This announcement smacks a little too much of the "town and gown" phenomenon, IMHO, along with a healthy dose of monetary incentive:
Centers will report outcome data on all bariatric surgery patients, whenever possible
using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). For centers not enrolled in the ACS NSQIP the ACS will provide an alternate data management resource.
What's not stated there is that participation in NSQIP is expensive, costing about $40 per operation to run (Khuri SF.Quality, advocacy, healthcare policy, and the surgeon. Ann Thor Surg 2002;74:641–649). In addition to the costs incurred by the hospital complying with the program (any of you involved with JCAHO, the ACS Trauma Program, and the ACS cancer center accreditation processes can relate), it costs $35,000/year to participate with NSQIP. Apparently there will be an alternative for those hospitals not participating with NSQIP. The new ACS Bariatric Surgery Program? That will set your hospital back a few more bucks:
When we receive your signed Participation Agreement and enrollment fee of $10,000, you will become a provisional member of the program...To maintain full accreditation through the ACS Bariatric Surgery Center Program, your facility will complete an annual status report (five-page document similar to the enrollment application) and undergo a site visit every three years. Your facility will be required to pay $10,000 for the tri-annual site review.
Now, imagine you are the CEO of a reasonable sized hospital, trying to make income at least match cash outflow. You have a well run, reasonably busy bariatric program, and you have spent so far about $35,000 in fees and compliance with the ASBS Centers of Excellence application process. Are you going to be interested in paying the ACS to do essentially the same thing?

Politically, it appears that the ACS and ASBS are in the same straits as the Republicans and Democrats in the Senate. Right now, there is no compromise --- the ACS says the ASBS criteria are too strict, the ASBS says the ACS wants total control of the process. In the end, I suspect there may be competing "centers of excellence" in some communities, accredited by different organizations. In the end, I fear that the American College of Surgeons will lose because of the way that this has been handled. I hope that there can be some meeting of the minds in the near future --- that precedent was set when SAGES and the ACS worked together to ensure proper credentialling for laparoscopic surgery.

Thursday, May 19, 2005

AMNews no longer online?

MedGadget writes that the online version of "The Newspaper for America's Physicians", the AMNews, is soon to be taken offline for non-AMA members. I happen to be a non-AMA member, having dropped my membership during medical school due to the overwhelmingly liberal slant of the organization. So, I really don't have any standing to complain about their services (or lack thereof) at this point.

However, I would say that at this point in time, the unprecedented ease with which people can get information should change the way that large, highly visible organizations should approach the dissemination of their facts to the public. In the response to MedGadget's post, the editor of AMNews states

American Medical News is principally designed to be a newspaper offering useful news and information for and about physicians. In meeting that commitment to our readers, we report on a wide variety of topics, certainly among them the policies and activities of the AMA. We at AMNews hope that we have a valuable offering that would be of interest to virtually every practicing physician in America.

That said, the cost of presenting AMNews online is borne almost entirely by AMA members and is offset only somewhat by ad revenue. The decision was made, therefore, that members should benefit from their support by retaining access to the site. In the same spirit of rewarding those who underwrite the publication, paid print subscribers will also be allowed online access.

This is where I have a policy difference with the AMA --- as well as the American College of Surgeons, and other groups which represent large numbers of physicians. While information is easy to find, good information is hard to come by unless you know exactly what you are looking for, and have a very discriminating eye. I feel the AMA members -- and ACS members as well -- would be well served by regular publication of medical data and policy statements that are readily available to member and non-member physicians, as well as the general public. If, for example, it is the policy of organization "X" that government run health care coverage is crazy, the organization should say that clearly, in as many forms as possible, and allow people to make up their own minds. While it doesn't make sense to discuss the latest phase I trial for melanoma in this manner, these publications generally stick to articles dealing with either policy issues or well-established therapies.

What is interesting to me is that this decision is occurring at a time that many publications are being made much more widely available online, as is pointed out here. I hope that all medical organizations take a long-term view of this, and realize that their putting on their best "public face" can generate good end results.

Dr. Parker's Most Excellent Trauma Service

Bard Parker once again provides a superb description of trauma surgery today. It sounds like his night was a difficult one, at best. Seeing a fatal liver laceration with a likely retrohepatic vena caval injury and a duodenal laceration in the same night, from the same accident, will certainly keep one working into the wee hours of the morning. After reading his post to get a feel for what trauma surgery can be like, take a minute and review an earlier post about what problems face trauma care and what the future of trauma surgery look like.

As Dr. B. Parker has stated, trauma care is in large part nonoperative for the general surgeon involved. For that reason, I feel that the best type of person to care for trauma patients is the general surgeon who operates in the abdomen with frequency. This is classically the case, so that the occasional patient who needs urgent exploration, like the two described by Dr. Parker, receives care at the hands of the most capable surgeon available. Under the "emergent general surgeon" model that is currently being pushed by academic centers, I'm not sure that will be the case.

Tuesday, May 17, 2005

Anecdotes are not evidence.....

Take a deep breath and then dive in to Jane Galt's dissection of a NY Times article about disparities in health between the rich and poor. Being the NY Times, this article harbors the usual, expected biases; what bothers me, and obviously Ms. Galt, is how anecdotal information is tossed around as real data ---- there are no supporting studies cited for many of the most important assertions made by the author.

The mantra found in the comments section bears repeating: Anecdotes are not evidence.

UPDATE: Thanks to Kitty and Lifelike Pundits for the plug!

Grand Rounds -- In Session

Grand Rounds is in session at Galen's Log. Time to get your CME credits!

Monday, May 16, 2005

One Lap Band, and a Margarita to Go

Good, bad, or indifferent. That pretty much sums up the opinions about surgery for morbid obesity. I fall into the “good” category, but only for appropriately selected patients who fall into well-defined parameters. We could debate the pros and cons of bariatric surgery, and the different surgical options for hours, but I think most physicians agree that gastric bypass surgery is helpful to many patients. What is pretty well established, however, is that bariatric surgery is seen by many as a big, fat industry. There are online and print ads for bariatric surgeons, seminars, and a fair amount of press coverage, which makes the whole process seen as money driven. What gets lost is the reason to do this operation --- it is designed to eliminate the root cause of a hornet’s nest of medical problems. It seems that the Lap Band procedure, which is not covered by most insurance carriers, is associated with more of this type of advertising (I think that it may play only a limited role in bariatric surgery in this country in the long run; I’ll leave that for a future post).

Living in the intermountain west, and being a bit naïve, I was unaware that some patients are heading south of the border for weight loss surgery. Unable to get insurance approval for bariatric surgery or not interested in a more standard gastric bypass, they pay cash to have a Lap Band done in Cancun, Monterey, Mexicali, Tijuana, etc. This came to light when I received a page while on call from a patient who had just returned from Mexico after undergoing a Lap Band --- and she was having problems.

Now, it’s important to understand that weight loss surgery is a different animal in comparison to the remainder of GI tract procedures. Patients require extensive preoperative counseling and teaching, as their whole world is suddenly inverted --- they go from eating large meals to only ¼ of a Dixie cop of food at a time. They need ongoing teaching and support from their surgeon, dietician, psychologist, family, etc. It is hard to make this type of surgery into a “weekend getaway” and have success. The Lap Band, in particular, requires even more postoperative care --- patients need to see their surgeon about every two weeks, and the volume of saline in the band often needs adjustment.

The phenomenon of patients seeking “alternative” care (don’t get me started – just go to Quackwatch) in Mexico is nothing new. This situation is an extreme reach, however, and I think several factors are involved:

  1. The refusal of many insurers to cover an operation (Roux-enY gastric bypass) that has an excellent track record, good results, and the blessing of the NIH.
  2. Lap Band advertising promising that the procedure is “reversible and adjustable,” appealing to many patients.
  3. It is clearly cheaper for patients to go to Mexico to pay cash for this procedure than it would be for them to do the same here (many do pay out of pocket in the US for Lap Bands, and some for gastric bypass due to insurance exclusions).
  4. Most importantly, patients that have not been counseled about the indications for weight loss surgery, its risks, and its long term goals and outcomes can mistake this undertaking as “not that big of a deal.”
So, what to do? Besides the emergent issues involved for this patient --- potential for pulmonary embolus, a malpositioned Lap Band which may need further surgery or simply adjustment --- she needs instruction on how to eat, what to eat, what to watch for, etc. Who is to provide that for her? Who is to adjust her band if and when that needs to be done? I suspect her insurance company will not provide payment for any of this type of care here. Ultimately, she needs to decide where she wishes her medical care to be delivered.

At the risk of sounding too cheeky while talking about weight loss surgery, this is just a little “food for thought.”

Morning Rounds

It’s 7 AM, and my trauma call weekend is, over, done with, consumado, accompli, perfetto, законченный. Nothing exciting over the past few days, just the usual assortment of folks who like to mix their alcohol with internal combustion engines, and one fellow who didn’t get off the roof in time to avoid a lightning strike (he was very lucky – only a few flash burns). Monday morning brings a day in the OR for me, followed by a few carefully chosen olives spiking my favorite adult beverage.

One of my partners is out of town, so I saw his patients again on morning rounds, including one who has been here for about 4 weeks. She has been exceedingly ill (ARDS, dead bowel, etc.) but has rallied and is making a remarkable recovery. Extubated a few days ago, she is eager to talk about what the hell has gone on the past month – “Why was I so sick? When can I go home?” I had to explain to her that there was a time when many felt she would not leave the hospital with a pulse.

The next patient I saw was a cantankerous little old lady recovering from a GI bleed (Coumadin is one of my least favorite drugs); fortunately, she didn’t require surgery. When I rounded on her yesterday, she was just starting the Sunday NY Times crossword puzzle, a temptation I yield to weekly. Knowing of my crossword addiction, she blurted out “what is 68 across?” before I could even ask how she was doing! The clue was “Like electrical signals in the body [Toyota],” with the name of a Toyota vehicle as part of the answer. I told her I’d give her a clue --- Tercel --- if she’d promise to get her INR checked a wee bit more frequently.

Some time when I was in college, my closest friend’s father, a nephrologist, took us on weekend rounds, as we were both thinking about medical school. I was captivated by the ease with which he cared for patients of different ages, with different backgrounds, all with different problems. I now understand that only part of that ease came from the confidence of knowledge and training. Just as much came from the ability to talk to people in a truly defenseless position who are at the mercy of their caregivers. Sometimes, I think that skill requires more practice than anything in medicine, but it yields the most rewards.

By the way, his son got smart and decided to avoid the whole “patient contact” thing and spends his days looking at pictures in the dark.

Sunday, May 15, 2005


Krauthammer. Filibuster. Read it.
'Nuf said

Friday, May 13, 2005

Walter Reed To Close?

The BRAC base closure list had a hidden surprise for many in the medical arena -- Walter Reed Army Medical Center in Washington, D.C. is on the hit list! I have never been in the military, but I know plenty of physicians who spent at least part of their training there. It is quite an icon in our military and medical systems; founded in 1909 with a mere 80 beds, it quickly grew to 2,500 with the outbreak of World War I. Despite serving our troops for nearly a century, it is felt to be too expensive to keep open when the National Naval Medical Center in Bethesda is nearby.

"It is very expensive to run a hospital. It just did not make sense to have two tertiary facilities within seven miles of each other," Winkenwerder said in an interview yesterday afternoon.

Over 20 years, the Pentagon projects savings of $301 million. Construction at Fort Belvoir and Bethesda probably would not begin until about 2009, Winkenwerder said, and the last medical programs would have to move from Walter Reed by 2011.
Most physicians in this country are well acquainted with the facility's namesake. Dr. Reed's pioneering work in typhoid and especially yellow fever were of enormous importance to the military and to the US as a whole. Perhaps what is less well known is the method used to prove the method of transmission of yellow fever --- and the debt we owe to the volunteers involved (it's long, but worth it):
With the express permission of General Leonard Wood, Governor General of Cuba, Camp Lazear, named for their fallen comrade, was established on November 20, 1900. Moreover, General Wood authorized the Board to use and pay American and Spanish volunteers for the experiments since at this time yellow fever was thought to be a disease afflicting only humans. Dr. Carroll had exhausted the list of experimental animals, rats and the like normally used for scientific research, failing to produce any cases of the fever in them. In addition to the mosquito theory, Dr. Reed also desired to disprove the seemingly fallacious belief that yellow fever could be transmitted and induced from clothing and bedding soiled by the excrement of yellow fever sufferers. These articles were known as fomites and were commonly thought to carry the disease. Just as "everybody knew" that the mosquito theory was foolish, so "everybody knew" that fomites were dangerous.

In November, 1900, Camp Lazear was established one mile from Quemados and placed under strict quarantine. At this experimental station Private John R. Kissinger permitted himself to be bitten and promptly developed the first case of controlled experimental yellow fever. This case has been deemed as important to medical science as Robert Koch's discovery of the tubercle bacillus and the development of the diphtheria anti-toxin. Kissinger and John J. Moran had volunteered on condition that they would receive no gratuities, performing their service "solely in the interest of science and the cause of humanity."

Then, in order to prove the theory for all time and to destroy the fomite myth, two specially constructed buildings were erected in Camp Lazear. Building Number One, or the "Infected Clothing Building," was composed of one room, 14 x 20 feet heated by a stove to ninety-five degrees. For twenty nights Dr. Robert P. Cooke and Privates Folk and Jernegan hung offensive clothing and beefing around the walls. They slept on sheets and pillows befouled by the blood and vomit of yellow fever victims. Not one of the volunteers contracted the disease. On December 19, 1900, they were relieved by Privates Hanberry and England who, in turn, were finally relieved by Privates Hildebrand and Andrus. From November 30, 1900 to January 10, 1901 the experiment ran to completion, disproving the fomite theory of transmission and thereby demonstrating the uselessness of destroying the personal effects of yellow fever victims, thus saving thousands of dollars in property.

The second building was similarly constructed and was called the "Infected Mosquito Building." It was divided into two parts separated by a screen with screens on the windows as well. Mr. John Moran, a clerk in General Fitzhugh Lee's office, was bitten by fifteen infected mosquitoes, developed the fever and recovered. The other volunteers who were separated, and thereby protected by the screen, escaped infection. Ten cases were produced in this manner.

Yellow fever was produced in the bodies of twelve more American and Spanish volunteers either by direct mosquito bites or by injections of infected blood or blood serum. These injections proved that the specific agent of yellow fever is in the blood and that passage through the body of a mosquito is not necessary to its development.

The courage of the volunteers is inestimable. A unique honor helps keep alive the memory of the twenty-four gallant men who participated in this experiment. In 1929 Congress awarded a special gold medal to each man or his next of kin. Had it not been for Major Reed's fair and thoroughly scientific approach to the problem and misconceptions concerning the disease, especially the whole contagion theory, yellow fever might have continued for years.

There is one final twist to the story of Dr. Walter Reed. This major combatant against infectious disease ironically succumbed to peritonitis following an appendectomy in 1902.

Tuesday, May 10, 2005

Thanks....and, No Thanks

When I was a medical student, a simple "thank you" from a patient was a welcome gift to a worn out young man. As a surgical resident, those "thank yous" were even more cherished, coming from patients who were kind enough to recognize that my at times disheveled appearance reflected limitless hours at the hospital away from the attentive eyes of SWIMBO. Now, as a practicing surgeon for almost 11 years, I have come to cherish the times when a patient (or family) takes the time to give me a hug, say "thanks," or otherwise express their gratitude for the care I have delivered. I even keep a file in my desk of all of the cards and notes I have received over the years; they comfort me when I have had a particularly difficult week, and the ones from deceased patient's families remind me of exactly what I am unable to do.

A patient that I have operated on a few times recently died of unrelenting lymphoma. While I was providing no direct care for her, I did have the chance to speak with she and her family a few times recently in the hospital. When the eventual outcome was apparent to all, I ran into her mother and husband. Both were effusive in their thankfulness, even though I could do nothing to make her any better or more comfortable. That type of gratitude is very humbling, and really helps me keep going at times.

Recently, however, I had the opportunity to see the "dark side" of this process. A patient came to the office with the complaint of an incisional hernia. Neither I nor my partners had seen him before, but this is not unusual in this age of great mobility and frequent insurance changes. He was a rather large man -- somewhere in the 350-375 pound range -- and had the standard list of weight-related medical problems: sleep apnea, hypertension, AODM, chronic venous stasis changes, etc. All in all, a formidable surgical challenge. My visit with him quickly devolved to the issues surrounding the development of this incisional hernia:

Mr. Big Dog: This is really all Dr. Older Established Surgeon's fault.
Me: Really? How so?
Uh-oh, where is this going?
Mr. Big Dog: Yeah, he really screwed this up. First he let the thing get infected, and then... well, I really don't have any confidence in him.
Me: What was the surgery done for?
Mr. Big Dog: I had appendicitis. I tried to tough it out and sat at home for about 3 days with a burst appendix, and was pretty sick when I came into the hospital.
Me: So, Dr. Older Established Surgeon took out your appendix.
And saved your life! This guy had to have been pretty sick!
Then what happened?
Mr. Big Dog: Well, my incision got pretty infected and took a long time to heal.
Me: no surprise there
Mr. Big Dog: After a while, I got this big bulge! And Dr. Older Established Surgeon says that while it can be repaired, I might have it come back!
Me: again, no surprise there
Mr. Big Dog: I have no confidence in Dr. Older Established Surgeon. First the infection, now the hernia. What else can go wrong with him?
Me: biting my tongue
What would you like me to do?
Mr. Big Dog: I want you to fix this so that it won't ever come back, and I don't want another infection! I don't want Dr. Older Established Surgeon operating on me!
Me: no longer biting my tongue
Well, let me give you my two cents. If I had seen you that night, I can guarantee you that you would have [1] gotten a wound infection, and [2] developed an incisional hernia. At your weight and with your medical problems, those things are a given! What you don't realize is how sick you were, and how much farther down the drain you'd have gotten without Dr. Older Established Surgeon's care. As far as your hernia is concerned, I would tell you that you have such a high chance for recurrence that I'd lay good money on it at the Bellagio. Your problems did not start with Dr. Older Established Surgeon, they started with your weight; if you want to get better, that has to be your starting point. And given what he was able to accomplish, I would have nothing but confidence with Dr. Older Established Surgeon, if I were you.
Mr. Big Dog: So, you'll fix it?
Me: sigh....and it's a REALLY big hernia!
This is one of those times when I wish I could explain get a patient to understand how great his care was! The other surgeon deserved this patient's gratitude, not his scorn, and I felt powerless to change his perceptions. His attitude also worries me, as if I do operate on him and he has complications (once again, there's a reasonable chance), what does he tell the next surgeon he sees -- or his attorney? Now you know why I keep that collection of thank you notes.

Needle Disposal

I like new gizmos, especially ones that address a need. This is a neat device that renders recently used needles harmless. It may make things easier for diabetics, particularly for those with little kiddos at home.

Friday, May 06, 2005

Since nobody volunteered to foot the bill and send me to the Royal Albert Hall, I hope someone had the sense to record this!

Thursday, May 05, 2005

Now this is cool.....

I am continually awed by the scientific achievements that keep giving docs the tools to do better things, but this just takes the cake. Artificial retinas have been implanted in six patients, and early results are encouraging.

"These patients are blind because they don't have the photodetectors," said lead researcher Dr. Mark Humayun, a professor of ophthalmology and biomedical engineering at the University of Southern California. "The implant jump-starts the remaining cells. You're effectively coupling a blind person with a wearable camera."
The system is named after the Greek mythological character Argus, a giant shepherd with 100 eyes. As frequently happened in those tales, he got caught between the warring Zeus and Hera, and wound up DOA. As a consolation prize, Hera installed his eyes in the tail feathers of the peacock.

More info can be found at Second Sight's web site. This is certainly a far cry from my first introduction to Argus --- my first (and still favorite) camera, the Argus C3.

Trauma Call With a Twist

Dr. Bard Parker posts an excellent introduction to the idea of "emergency surgeons" today. Basically, this idea comes in response to a few simple realities:

  • Trauma care is poorly reimbursed and time consuming
  • Trauma care is a field in which general surgeons provide evaluation and care for patients who need primarily orthopedic and neurosurgical care
  • As a result, trauma surgeons don't operate very much
  • Sooooo, why not have the trauma surgeons also provide emergent surgical care for the hospital?
The difficulties with trauma call are no less true here; my group does provide all of the trauma call coverage here, but our primary practice is general/vascular surgery. The idea of increasing a trauma surgeon's income and operating experience by adding "emergent surgery" to his responsibilities is hardly a new one. Trauma surgery leaders, such as Dr. Ken Mattox, have for years urged us to pin hips, do emergent craniotomies, etc. I'm afraid that it would be the unusual surgical resident who would choose to pursue that type of practice. I know that if I was told at the beginning of my residency I would have to spend 5 years training to be a general surgeon, only to rarely operate as a trauma surgeon, I would have re-entered the match. I went into surgery because I like to operate; I know of no surgeon who feels differently. To be additionally offered the opportunity to provide all of the emergent surgical care for the hospital would be a bitter pill to swallow --- watching other surgeons doing nice, elective cases in the daytime (which will on average pay better and involve a healthier population) while they never have to take ER call......wait a minute! I'd want that job!

The emergency surgeon idea is certainly the flavor of the day, but I don't think it will stand up to the realities of practice outside training programs and a few urban centers. In the world outside of academia, I still believe the best trauma surgeons are those who operate with great frequency and are comfortable caring for the sickest patients in the hospital.

Wednesday, May 04, 2005

Proposals for Malpractice Reform

Ted Frank at Point of Law writes a wonderful, unfortunately tongue in cheek, article extolling the virtues of a trial lawyer-run medical malpractice company. He carefully lays waste to the ATLA's talking points about medical malpractice reform; and he's an attorney! I wish this type of article could be distributed more widely.

Another take on this issue, once again from a non-physician, comes from the deputy editor of the Wall Street Journal's editorial page, Daniel Henninger, who endorses Common Good's proposal for the creation of health courts. I think he "gets it:"

Noting that special courts already exist to handle tax disputes and patents, Henninger said, "One benefit of health courts is they would create judges who understand the nature and complexity of medicine. Yes, bad things do happen in medicine. And when they do, the arguments ought to be handled by judges who know from experience the difference between an honest mistake and malpractice."

The unreliability of the current system has serious consequences, as Henninger detailed. "Everyone knows what malpractice is about," he said. "It's about doctors leaving states like Ohio, Pennsylvania and Maryland because their premiums are through the roof. It's about doctors practicing defensive medicine, ordering lots of tests, to avoid lawsuits."

Paul Barringer, general counsel for Common Good, laid out his case for health courts in the National Law Journal on May 2nd. Part of his argument has been heard before, but bears repeating:

Of claims brought forward, 80% involve situations where experts believe the doctor did nothing wrong. A poor medical outcome, rather than negligence on the doctor's part, is often the key to the size of the award. Nor does the current malpractice system foster quality improvement. Doctors and nurses, fearful of being sued, are reluctant to admit to mistakes. Patient safety experts generally agree that most medical errors result from breakdowns in health care delivery systems rather than from individual wrongdoing. But the current system assigns liability to individual doctors, inhibiting the open communication necessary to catch errors and make improvements.
There are legislative efforts afoot to at least get a health court system established on a trial basis. Much more information can be found here, here, and here. My personal feeling is that med-mal reform has to be put into the context of overall tort reform; we seem at times to be living in a system designed by and for the benefit of trial lawyers.

Hat tips to Dr. Tony and DB.

Tuesday, May 03, 2005

We're not blowing smoke, part II

This article from Staten Island once again illustrates the difficulties in providing medical care in our current legal environment. Most folks in this country see the tort system as a non-issue (how many get excited about asbestos litigation?), and will not unless and until it directly affects them. Pregnant women on Staten Island are now directly affected; one hopes that they, and their Congressional representatives, will now get involved.

Hat tip to Ace of Trump.

Monday, May 02, 2005

Grand Rounds XXXII

Mudfud is hosting Grand Rounds, and does a great job of reminding me of why I can't remember much of what happened in medical school -- way too busy!

I Love Irony

How could I have missed this over the weekend? Jane Galt points out the ultimate irony of the week --- the AFL-CIO is contemplating layoffs. What a shocker! Do you think they are actually responding to (gasp!) market forces?

Interesting turn of events

At Kevin, M.D.'s site, I found a link to this American Medical News article. Turnabout, it seems to me, is fair play. Physicians have long been allowed to refuse non-emergent care to patients who sue them; perhaps it is time to extend the same set of rules to hospitals, clinics, surgi-centers, etc.

SWIMBO Blogging

Weekend's over, back to work, on call, and the searing pain of reentry is just about to hit full force. Over the weekend, I started to post on something from home, when my wife (who has never seen this site), asks the standard wifely question : "What in the world are you doing?" How does one explain blogging, exactly? So, the conversation with She-who-must-be-obeyed goes something like this:

SWIMBO: What in the world are you doing?
Defenseless me: Blogging!
SWIMBO: What? I know there's all sorts of weird stuff on the internet, but what the heck is "blogging?"
Little old helpless me: Uh, it's a place where I can write things down that interest me, are funny or important to me, are important to medical care; I try to direct anyone interested to other good web sites.....
SWIMBO: Why would anyone read what you are writing?
Me (now a little hurt): Actually, I'm not sure. They're bored, perhaps?
SWIMBO: How much does this cost?
Me, the cheapskate: Uh, well, see, it's free. Don't ask me why, somebody somewhere must be making a pile of money, but this part is gratis.
SWIMBO: Can anyone read this? Even my mother?!
Me, now excited: Especially your mother! Anything in particular you'd like me to write about SWIMBO the first?
SWIMBO (irritated): NO!!! Oh, Lord, don't even think about it! Shut that thing down!
Me: Yes, dear. I'll take the trash out now. By the way, is it OK if I keep my blog until your mother decides to get a computer?
"She-who-must-be-obeyed, " or SWIMBO, is how my better half is known in the operating room, as the circulating nurse often has to answer my pages whilst I operate away, unable to get to the phone. It is a marvelous turn of words, drilled into my head while watching "Rumpole of the Bailey" with my father. I only recently discovered that John Mortimer, author of the Rumpole series, had lifted the phrase from Sir H. Rider Haggard's "She." Sir Haggard (no relation to my previous post), who also wrote "King Solomon's Mines," created a character described as "the embodiment of the mythological female figure who is both monstrous and desirable, and deadlier than the male." Why do I feel like I should spend more time on call after reading that last bit?