Friday, September 22, 2006

Friends don't let friends help Hugo


I couldn't have said it any better --- a tip of the hat to GOP and the City.

Wednesday, September 20, 2006

Ye Olde Can o' Worms

Talk about opening a can of worms! The Travis County (Texas) county commisioners are planning to fund a pilot program to pay for a few of their employees to undergo weight loss surgery:

The Travis County commissioners approved using county tax dollars to pay for a weight loss surgery for county employees. County Commissioners will pay for up to 15 bariatric surgeries per year during a five-year trial.

This is a very radical concept. The whole idea of this came about because the county was looking at a way to control health care costs, and 400 Travis County employees are classified as obese.

"We think that surgery costs anywhere from $25,000 to $30,000 a year, but these employees right now probably cost us that much anyway. If you look at this in five or six years, that cost will cover itself," Travis County Judge Sam Biscoe said.
Travis County is big --- it basically is the Austin area, and I'm sure has a large number of employees. I would assume, as the article does not specify the particulars, that Travis County is self-insured and it currently does not include bariatric surgery as a covered benefit for its employees. Each corporation or public entity makes choices about what they want covered for their insurance dollars --- breast augmentation, for example, is never covered, but many other things that are considered experimental or less than effective are not covered either --- and a fairly substantial number of them do not cover bariatric surgery.

Why do this? What is the benefit to the county? To the employee? To the taxpayer? As Judge Biscoe states, the idea is that if the employees lose enough weight that their immediate and long-term medical costs substantially decrease, the end result will be an overall reduction in the amount of money the county will spend in health costs. In theory, then, everybody wins --- the county saves money in the long run (and gets healthier, more productive employees to boot), the employee is healthier and has a big decrease in out-of-pocket medical expenses, and the taxpayers end up with a slightly smaller tax burden for this component of government expense.

That's the theory.

There are some cold, hard realities that need to be addressed, as well. Most importantly, although they may have 400 employees that are classified as obese, many will simply not be a candidate for surgery ---- for one, simple, critical, reason: motivation. This is not an operation for the person who feels it would be a "quick fix." There are substantial changes that they need to make in order to be successful, and only the well-motivated patient who has carefully considered this option for some time and understands its ramifications will be successful (in other words, compliant) over the long haul. For this reason, this is not an operation that will work well for the patient who is told by his/her physician (or, possibly, by his/her employer) to "go get this operation -- period."

To their credit, the county commisioners have implemented a rule that will in all likelihood screen for the most motivated employees:
To qualify, county employees would have to be diagnosed with morbid obesity and go through one year of monitored unsuccessful dieting and exercise....Employees identified as possible candidates would be required to complete exercise and nutrition programs and submit to thorough health exams one year prior to the surgery. It would still cost them a $1,000 deposit along with whatever their deductible is.
OK. That's a long-winded introduction to what I found to be the most interesting part of the article: the reader responses (scroll to the bottom of the article)!! Regardless of what I, or other physicians who may or may not feel that weight reduction surgery is beneficial, it is very instructive to read the comments of many (well, let's be honest --- most) readers. Here's just a sampling (warning, it's not very pretty):
Certifiably nuts. Why on Earth should the taxpayers pay for this?

Hell no!!! That makes no sense at all!! I agree with Glenda! There is a whloe lot more useful ways to use that money, and that is not one of them, OBESE OR NOT!!

You gotta be kidding me!@#*& Morons!! Good for you Hill Country! I'm not obese, but if I were I wouldn't expect the tax payers to pay for an operation. Just like I don't expect the tax payers to pay for anything for me!!! LUDICROUS!!!

Absolutely NOT! NO WAY!!!! Don't the County EE have Health Insurance? If it is medically necessary,then Health insurance has to pay for it. They should pay for it with the corresponding deductibles and co-insurance.

Absolutely not!. Their insurance premiums should be used to pay for it.
The last two commenters obviously don't know that they are already paying for the health benefits of these workers.
Next thing you know we'll be paying for them to have all that extra skin removed!!! UNBELIEVABLE!!!!!!!!!!! How about implementing SAFETY meetings that teach PORTION CONTROL!!!!

I think its time for new personnel to make decisions for the people of Travis county. This is the most idiotic, imbicilic and moronitic thing i have ever heard of. Simple solution: PUSH YOUR FAT A***S AWAY FROM THE TABLE>
Interesting, and instructive, don't you think? BTW, you gotta love the grammar and spelling!

Friday, September 15, 2006

Time out. I'm having one of my turns......

Is it just me, or does everybody out there stay up all night dealing with a folks who willingly participate in a dance with death? Car surfers, drunken jaywalkers, street lugers, and middle-aged men who have the desperate need to ride their sparkling new Harleys at 80 mph leave me with a pounding headache and a new appreciation for Roger Waters:

Run to the bedroom,
In the suitcase on the left,
Youll find my favorite axe.
Dont look so frightened,
This is just a passing phase,
One of my bad days.



ARRRRGGGHHHHH!

OK, I feel better now. We'll return to the previously scheduled program after these brief messages.....

Monday, September 11, 2006

9/11


Never forget. Never surrender.

Thursday, September 07, 2006

Stuff That Works

There's a humorous blog that I read frequently that occasionally posts about "stuff that works" -- things that seem to be worth the money and get the job done. Well, I'm not too proud to copy that concept, and will occasionally highlight a few things that make my life easier in (and sometimes out of) the operating room.

During the Dark Ages, while I was in medical school, the surgery rotation was exciting, interesting, challenging --- and frequently the source of sore muscles. Why? Well, in big operations, the challenge of making sure the operating surgeons had enough exposure to the operating field was left to the medical student. I spent many hours "holding hooks," basically pulling on various retractors to open the abdominal wall and allow good visualization. But, let's be honest, my arms got tired! And there was not a student among us who were not regularly admonished to "pull harder!" or "toe in!" by a sharp-tongued attending or senior resident.

When I started the first day of my residency, I knew that there would be many hours spent working on my biceps in the OR, watching and learning on the "bigger" cases or when there were not enough medical students around to hold hooks. But very quickly I encountered a vision straight out of the heavens: the Upper Hand Retractor! Here was a "self-retaining" retractor that would hold its position once set and make the experience of participating in, say, an open cholecystectomy an actual learning process, rather than a muscle bulking one!

While the Upper Hand was nice, over the next few years I enjoyed the use of a variety of other retractors, starting with the one that still has the best name: the Iron Intern.
This baby seems strong enough to hold back a raging bull, is elegantly designed, and works well in the upper abdomen. I haven't seen one in use since I left residency, I supect because it had at the time one flaw --- it did not provide retraction beyond it's two arms.



Once I entered practice, the two retractors I used the most were the Thompson and the Bookwalter --- the latter most frequently. The Thompson retractor is quite stout, wears well, and "works every time." It is adaptable for use around the abdomen by adding lengths of metal bars, sort of like a Tinkertoy, to allow retraction in all directions.







The Bookwalter is a retractor based upon a circular or oval ring, to which retractor arms are attached to once again allow 360 retraction. Over the past several years, I have found it to be the easiest to set up and use for routine cases.





These days, however, I have been making use of the Omni-Tract retractor more frequently. It is easily attached to the operating table, is easy to set up and adjust, and just plain works well. It is particularly useful in retracting the upper abdomen in large patients --- it seems to hold a bit better in my experience.

I suspect that a few very innovative, engineering-minded surgeons were behind the development of these instruments. I also suspect that they didn't make huge amounts of money from them, because once purchased, they last a long time and don't need to be replaced often. I know for a fact, however, that my arms, shoulders, and eyes are eternally grateful!

Saturday, September 02, 2006

Aggravated DocSurg Public Service Announcement #2

Jus' fer example....

I took my car to the mechanic the other day, and he said I needed a new head gasket. So, after forking over a few hundred bucks, I got my car back with the warning to avoid speeds over 40 mph for the first 100 miles. Then I got on the interstate; I had missed driving my car and decided to let it rip at 95! What a gas! Out of the blue, dammit, the stupid car started smoking more than Bill Clinton with a box of Cohibas at a stripper convention. What gives? I just got the damn thing fixed!

Finally got home later that day and DogSurg is throwing up his toenails all over the house. When I asked SWIMBO what was going on, she said she had no idea. The only new thing that had happened that day was that the lawn guys had put fertilizer all over the yard, along with some yellow signs that say keep the dog and kids off the grass for 24 hours. Sure enough, the surglings start kneeling to the porcelain god soon thereafter. What gives? Some doggie virus? If it's that damn lawn chemical I'm gonna sue!

Next morning I get up to make a big breakfast; rooting around in the fridge I find some sausage that's only a week past it's prime. Few hours later, it's me that is chumming for land sharks. What gives? I cooked it! The stuff ought to be good long past its due date!

The appliance repair guy came a while later to fix my dishwasher; he told me to wait until tomorrow before running it. But hey, I got a sink full of dirty dishes..... I can't believe it -- he didn't fix it, there's water running everywhere!

etc.........


~ * ~

Why is it that the above facetious examples of asinine behavior are universally recognized for what they are --- pure unadulterated stupidity --- while similar actions in relation to one's healh care are not? Why do physicians and nurses stuggle with patients who would never think about not following directions to care for their hot tub, but who routinely disregard often important instructions in regards to treatment? It comes down to the idea of compliance:
COMPLIANCE
com·pli·ance (kəm-plī'əns)
Function: noun
1 a : the act or process of complying to a desire, demand, proposal, or regimen or to coercion b : conformity in fulfilling official requirements
2 : a disposition to yield to others
3 : the ability of an object to yield elastically when a force is applied : FLEXIBILITY
I guess most of us Americans have a bit of an independent streak, and don't really cotton to the idea that someone else should be giving us instructions to follow. But, let's be honest here --- when I give, for example, pre- or post-operative instructions, I'm not giving them for my own good! When patients are non-compliant, it causes me heartburn, raises my blood pressure, and frustrates me to no end, not to mention increases the patients' risk for complications. It makes the idea of designing a 25 page informed consent almost palatable. Here are a few examples of how to be non-compliant:
  1. Crawl around your dirty attic two days after undergoing hernia surgery
  2. Stop taking your blood pressure medication for a week or so before surgery --- and make sure not to tell your doctor!
  3. Don't take your bowel prep before colon surgery because you don't like how it tastes
  4. Eat breakfast on your way to the hospital on the morning of surgery --- remember, "N.P.O." is only for those with really weak stomachs anyway
  5. Keep taking your Plavix or Coumadin until the night before surgery, despite instructions
  6. Smoke --- and smoke heavily --- after a complicated vascular operation
  7. Antibiotics, shmantibiotics!
Have I seen this? Oh, yes. Where does it lead? In order: severe wound infection requiring further surgery and weeks of open wound care; oh-my-God, possibly stroke-inducing perioperative hypertenstion; wound infection and risk for anastomotic leak (yeah! with a second operation and colostomy!); aspiration pneumonia, postoperative ARDS, etc.; bleeding -- a lot of it; failure of the vascular graft, more surgery, and potential loss of limb; infection and further surgery.

On and on it goes, where it stops, nobody knows!

When I ask these folks just what were they thinking, I never get a straight answer --- but I get a lot of groans and eye rolling from their spouses, who are apparently well aware of their tendency to ignore advice and instructions. Why are otherwise normal, intelligent people so willing to do things that put them at risk for significant problems? I dunno. I blame Rumsfeld!

Maybe I need to write a book about this phenomenon and get really famous.....