I Agree --- In Spades

For those general surgeons out there who receive General Surgery News, I hope you took the time to read this article by Dr. David Cossman --- he redefines the term "rant," and in the process pokes a stick in the eye of the of those who push "quality improvement" initiatives upon us that have no proven quality nor any hope for improvement. Here are a few excerpts:

This time, the blood on my hands was my own. And it was from a self-inflicted wound. Unintentional, not wholly unexpected, but surprisingly painless for a cut down to bone from a 10 blade through a latex glove. For those of you who have watched me operate lately and suspect a demyelinating disease as the root cause of this vicious digital attack, you’ll have to wait a little longer before I hang up the needle holder. I’m neurologically intact, but apparently incapable of operating the new “safety sleeves” on our scalpels without what must have appeared to have been an earnest attempt at autoamputation.

After the tetanus shot, six stitches, Ancef and washing off the “yes” in magic marker on the bleeding finger, I did what every red-blooded injured American would do—I called the manufacturer of this stupid thing and threatened to sue.

Silly me; I missed the point again. It seems that this protective device had been added for everyone’s protection except the one using it. .... The safety sheath was not there to protect me or my patients. It was there to protect the manufacturer, the distributor and the hospital that handed me the knife against lawsuits charging malfeasance, negligence and disregard for the user’s safety. There it was, a bloodstained inch-and-a-half piece of half-penny plastic, the symbolic refinement of modern day risk management at its best.

.....Sound familiar? Is it still a surprise when laws, policies and programs not only don’t work but too often are 180 degrees off target? No, it’s not surprising, because too often these instruments of public policy are little more than an opportunity to articulate a point of view instead of well-thought-out solutions to problems. It’s not surprising that policies and laws that are nothing more than ornamental expressions of political correctness not only fail to achieve a stated goal but may, paradoxically, almost comically, produce exactly the wrong results. Part of the problem is that they frequently address problems that don’t exist or might not exist.

.....failed social policies long on good intentions but short on results enjoy near-immortality because to criticize them exposes one to a veritable thesaurus of epithets. It seems that society saves rigorous outcome analysis and expectations of perfection only for projects where profits are involved. If you’re spending money instead of making it, you get a free pass if the cause is right. That’s why the drug companies take such a beating, even though there isn’t a single reader of this column whose life won’t be prolonged because of their products.

.......The moral equivalent of the carpool lane hit our profession big time with the brilliant introduction of the 80-hour workweek. I have to chuckle each time I read a “study” that attempts to quantify the effect the 80-hour workweek has had on patients, residents and surgical outcomes, as if anything would convince the perpetrators of this foolishness to retract the policy if it wasn’t working.

....Of all that has been written about the 80-hour workweek there is only one irrefutable fact: It is here to stay but not because it contributes even an imaginary sliver to patient safety. It is here to stay because it is the public’s warning shot fired across the bow of the medical profession to warn us that we’re in the crosshairs of public scrutiny. It really is hard to imagine that the policy could serve any other purpose. After all, you have to admit it’s a stretch to believe that a “postcall” resident asleep on the end of a retractor somewhere in the right upper quadrant is a danger to anyone. Oh I forgot, they’re going to go home, get some rest, and then read, read, read Schwartz’s Textbook of Surgery so they’re going to be better and smarter doctors in the future. Or better yet, they’re going to read Proust and Voltaire so they’ll be better, more cultured and more humane doctors so they won’t wind up jaded and cynical and write columns like this.

...On the other hand, the purpose isn’t really to solve the problem, is it? No, what we’re witnessing here is as primitive (and futile) as an ancient animal sacrifice, hoping that the gods (media, lawyers, politicians and patient advocacy groups) will sate themselves with the scent of the entrails laid at their feet.

....Remember the law of unintended consequences. Even if you could squeeze surgical education into a shorter workweek, even if you could prove to the Resident Review Committee that your residents are actually doing as many cases as they used to, even if you can make up numbers to show that no one has died in a hospital since the enactment of this absurd offering to the gods, we would still have the unintended consequence of what punching a clock has done and will do to a surgical culture molded by a century’s obsession with tireless adherence to dedication, detail and discipline. To defend that culture against the ululations of the compliance jackals and the medical error junkies is to get tarred as the anachronistic defender of an outdated order.

....In the final analysis, I’m not far from lying in my hospital bed looking up at my surgeon who is fixing to rummage around in my chest, brain or abdomen. I don’t want to look up and see a time clock puncher in my hour of need. I don’t want someone who went weeping to the program director because some attending looked at him or her cross-eyed. I don’t want someone who was given six chances to pass the boards. I don’t want someone who had the time to wait 30 minutes in the Starbucks line to get a double decaf vente latte. I want someone whose training has steeled him or her to handle whatever it is he or she is about to find inside. I’ll take such a person, even when she’s tired. I know he or she will wake up and do the right thing when the time comes.

One day, I'll find a way to match the voices of frustration whispering inbetween my ears with the words I write the way Dr. Cossman does. And, I'd like to add, there is not one single word in this column I could even remotely disagree with.

Cultural Competence? Incompetent

So, there I was, awake and alert with a Glasgow Coma Score of 15, freshly infused with a huge cup of coffee as black as murder, and ready to gain the insight of the finest minds in all of surgicaldom. I picked up my registration materials and program and began to plan out the first morning of the American College of Surgeons meeting. I was pleased to quickly spot a few lectures given the group heading of "Evidence-Based Perioperative Risk Reduction." Productive, for sure, and a worthwhile update for dealing with the elderly, sick patient population in my tertiary care center. As outlined below, it was a good use of my time.

But then I made a mistake. The kind of mistake that caused that aromatic coffee to scald my nasopharynx as it was forcibly transported out of my nose. The kind of mistake that made my arms twitch and twist so uncontrollably that I looked like I was auditioning for the remake of Dr. Strangelove. The kind of mistake that gave me heartburn --- no, not heartburn. Angina!

What did I do? I simply perused the other offerings on the slate for Monday's Clinical Congress. Let's see --

1. Laparoscopic Colectomy: Beyond the Basics (been there, done that)
2. Breast Cancer Update: What Every Surgeon Needs to Know (not much new news this year for anyone that keeps up)
3. New Prevention and Treatment Strategies for Male Sexual Dysfunction (why do we let urologists come to these meetings?!)
4. Open vs. Endovascular Approaches for Vascular Disease: What Are the Outcomes? (interesting, but I don't do vascular surgery)
5. Postoperative Pneumonia: Strategies for Prevention, Diagnosis, and Treatment (I'd like to hear some of this, but can't be in two places)
6. Pancreatic Pseudocysts and Chronic Pancreatitis: Evidence-Bases Management (difficult patients, but the treatment is really not that difficult)
7. Inguinal Hernia Repair: An Evidence-Based Approach (old controversy, but the data to be presented is somewhat new --- and has been touted in every surgical journal for about 2 years)
   
8. Information Systems: How the Information Explosion Will Change How We Educate Surgeons and Treat Patients (I've heard variations on this theme for years)
9. Update on Blood Transfusion (boooooooring)
10. Cultural Competency: Does It FacilitateBetter Delivery of Health Care (WTF?!?!?)

(Deep breath. Must. Get. Nitroglycerin!)

I hardly know where to begin. Well, yes I do. This kind of absurdity, this rubbish, this preposterous lunacy, this AB-SO-LUTE SOCIAL ENGINEERING BULLSHIT should be presented in front of surgeons only to initiate a program to COMBAT IT!

Was it too much to ask that surgeons, for Pete's sake, the last group of physicians that one would expect to go for politically correct pablum, would try to bring some semblance of sanity to this arena. Yes --- it was too much to ask. The Clinical Congress News, the official "press" of the meeting, had a fawning page one article explaining to us insensitive rednecks that cultural competency is simply a "no-brainer." But just what is this thing called cultural competence? Here is one definition, and a Google search brings up a paltry 9,650,000 sites listing the term; however, as pointed out by this essay, it mutates depending upon the prevailing wind being blown by those windbags who espouse multiculturalism as the cure for all of our ills. New Jersey politicians have already passed a law mandating that physicians undergo "cultural competency training as a condition of obtaining or renewing their licenses to practice medicine." And you won't be able to get this type of indoctrination training like traditional CME, according to one of this law's proponents:

Like believes cultural competency training can succeed, but will not be attained through a "cookbook approach to care. We have to see this as different from other types of CME courses," he says. "It has to be a process of how we continue to learn about the diverse populations we're caring for as well as our own personal and professional biases, values, beliefs, and behaviors—I don't think taking a one- or two-hour course is going to be effective." He also argues that cultural competency training should extend to all health care workers, including nurses, dentists, physical therapists, pharmacists, psychologists, social workers, and other allied health professionals.**

**Yes --- that means you, too will get to share in this wonderful, mandated politically correct groupthink experience.

Other physician bloggers have had a few things to say about this, and it's unlikely that I'll add anything substantive in this post. But let me just blow off a little steam, so that the next time I'm faced with this crap I can try to be a bit more articulate --- if this comes up for debate in my state legislature, I'll have to carry a scalpel and not a Howitzer.

I am a surgeon. A white, male surgeon, to be "culturally identified." I was raised in Texas, but have no more "Texan" in me than an unladen African swallow. I lived in France for a few years, and --- horror of horrors --- learned the language and tried to "fit in." I have been fortunate to have visited Mexico, New Zealand, Australia, Germany, Italy, England, Belgium, The Netherlands, Switzerland, Luxembourg, Canada and the foreign country of Louisiana. But while those experiences certainly have enriched my life I am, and always will be, an American. And I intend to continue to treat patients in the best manner I know how ---- and dammit, it's just too bad that I can't speak Bantu or understand the complex courtship dances of every Pilipino tribe. I can, and do, learn about many things that are of interest to me, but don't expect me to be so "culturally aware" that I will perfectly mesh with every person who comes through my office door. And who is to say what cultures I should be appraised of? The answer would hardly be the same if I was practicing in New York City or in Bay City, Texas. And what about the diversity that is seen within our own country? Are we to be indoctrinated soaked in the social customs of the midwestern corn farmer, the southern oil magnate, the southern "belle," etc.? I kindafuckindoubtit.

The bottom line is that I cannot be everything to everybody. If I am perceived by a patient as not communicating well with them, for whatever reason, because I'm culturally insensitive or because I'm just not nice enough, they have the opportunity to seek care elsewhere. If I find that a whole lot of patients are doing just that, I will have to find a way to change my behavior or go out of business. That is the American way. I don't need a Cultural Competency Czar making me sit in seminars and sing Kumbaya in Norwegian to understand that basic priniciple of life.

I guess what really stuck in my craw was the way that this is being passed off as a self-evident, overwhelmingly important movement in surgery, without a shred of evidence that it holds any intrinsic value whatsoever. Buried at the end of the article puff piece is the indicator of the way that this "discussion" is to be held in the future:

During the question/answer session that followed, the panelists agreed that although there are no concrete data to support the claim that cultural competence is an important element of effective health care delivery, it is a given and that the need for such cultural competence in health care must be addressed.

Uh-huh. It is a given. I would say that it is a given that the more of these feel good, do-nothing policies that get forced upon busy physicians, the fewer there will be available to care for the urgently ill --- because they'll just say "screw it." It amazes me that on the one hand the ACS has finally awakened to the problems we have just covering emergency rooms, and on the other hand is wasting its time on drivel such as this.

ACS Chicago --- III

Spent most of the day in a post-graduate course --- one focusing on a procedure that I spend a considerable amount of time doing (laparoscopic colectomy; perhaps something I should write a few words about some time). Certainly there was not a lot of new information presented for those who keep up with literature and techniques, but it is nice to have one's own biases and ideas confirmed by folks in academia who focus almost solely on that one topic.

The late afternoon sessions included a nice review of dealing with medical comorbidities in the trauma patient. Given the trauma population that most often hits my ED, who are primarily the recipients of blunt trauma (auto accidents and the like), it was a nice review. Unfortunately, nobody seems to have anything to say about how to deal with the patient on Plavix except to shrug their shoulders and say "try anything you think that may work."

The ACS is a bit behind the times as far as the internet is concerned --- thier web site, for example, is not the most user-friendly place on the web. However, they have introduced this week something that I think will be helpful for many general surgeons who don't have the time or resources to put together their own practice web site with patient instructions and information. "Patients as Partners in Surgical Care" is the new patient education web site that the ACS has put together, and it looks fairly promising. It certainly duplicates some of the things my practice has made available to patients on our site, and is a nice complement in other respects.

Now, as for the aggravating part of the meeting....I am not sure I'm fully prepared to rant in a coherent fashion jsut yet, but let me give you the title of one of the first sessions of the entire meeting: "Cultural Competency: Does it Facilitate Better Delivery of Health Care?" I'll have plenty to say about this later, but it amazes me to know that the presenters' opinions were basically that yeah, we don't have one iota of data that this is meaningful, but we're gonna mandate it anyways. Arrggghhhh!

ACS Chicago - part deux

A few interesting tidbits from today's overwhelming plethora of lectures. In actual fact, I arrived not really expecting to get a whole lot of new information, but was pleasantly surprised tohave a pair of lectures, delivered back-to-back, that actually were timely, informative, and very clinically useful. The first of these was a great review of the ways in which surgeons can reduce the risk of venous thromboembolism, and its sequelae, with appropriate prophylaxis. This was hammered ito me during my training, and in some ways did not come off as "new," but this field of study is dynamic and evolving. What was particularly helpful was that the speaker has put together a great web site --- www.venousdisease.com --- with all of the information (and more) presented, along with risk stratification profiles, prophylaxis stategies, etc., all available gratis.

The second lecture carried a similar profile --- things we surgeons can do to reduce the risk of perioperative cardiac complications. Basically, he was a one-man band playing the (undersung) tune of beta blocker use to prevent cardiac complications in the patient at risk for the same. Bottom line --- beta blockers good, no beta blockers bad. And for those who can't take them, there's some good data to support using Clonidine instead. And, just as helpful as the first presenter, he has a web site to help the physician or hospital that needs to get a cardiac prophylaxis program underway --- www.betablockerprotocol.com.

Don't worry -- there were plenty of things for me to get good and Aggravated about; I'll just save those for later! Hint ---- they involve a little bit of "PC-thinking," something that I don't think fits in with surgery, not in the least!

ACS Chicago -- 1

Well, I guess that I'll steal a page from Professor Reynolds and try something new (for me). I'm here at the McCormick Center in Chicago, which is rapidly being transformed into a surgical showcase for the 92nd Clinical Congress of the American College of Surgeons. They have set up a nice "Internet Cafe" in the exhibit hall, and hopefully I can give anyone that's interested an idea of what's happening day-to-day.

I have to admit, however, that I often find the activity behind the scenes to be at least as interesting as what actually happens in the meetings. It is fascinating to see how quickly an enormous, empty room can become filled with state-of-the art exhibits. Behind me a small army of people are erecting temporary walls, laying carpet, wiring huge video screens, etc. -- all of which are designed to catch the eye of the general surgeon who is roaming the hall in a stupor after listening to a few hours of (sometimes monotonous) lectures.

We'll see what tomorrow brings in terms of the "new and exciting." For now, it's time for me to find some famous Chicago pizza....

Just Plain Wrong, or at least Wrong-Sided

So it appears that LA Lakers coach Phil Jackson is scheduled to undergo surgery today --- a total hip arthroplasty, or hip replacement, is on today's game plan instead of opening day of training camp. He seems like a nice enough guy, though a bit too "Zen masterish" for me, and I hope all goes well and he recovers nicely.

But. But. But......what if everything doesn't go well? What if he becomes one of the (fortunately reasonably rare) cases of wrong-sided surgery? What, then, will pundits say (OMINOUS TONE) went wrong?

There is a study that has been published in the September issue of Archives of Surgery that, like many that have preceded it, tries to address that very question. Entitled "Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events: Are They Preventable?," it is authored by a pediatrician at the University of Chicago Comer Children's Hospital and an anesthesiologist at the University of Miami School of Medicine. One of the obvious difficulties they encountered is a lack of consistent data; they tried to collect as much data as possible from sources such as

(1) the National Practitioner Data Bank (NPDB), (2) the Florida Code 15 mandatory reporting system, (3) the American Society of Anesthesiologists (ASA) Closed Claims Project database, and (4) a novel Web-based system for collecting WSPE cases (http://www.wrong-side.org).

I guess I should not be surprised by two things about this report that jump out and grab me. First of all, there is a very difficult to substantiate OMINOUS CLAIM (from the abstract; full text requires subscription):

Based on these findings, we estimate that there are 1300 to 2700 WSPEs annually in the United States. Despite a significant number of cases, reporting of WSPEs is virtually nonexistent, with reports in the lay press far more common than reports in the medical literature.

That's a pretty big number, particularly when the National Practitioner Data Bank has evidence for only 5,940 such incidences --- in 13 years. Now, I will grant the authors some latitude, as there is no consistent, mandated method for reporting such incidents. But to throw out these kinds of unsubstantiated WAG numbers is irresponsible.....why, I haven't seen such irresponsibility since, let's see, oh yeah! The Institute of Medicine's report on deaths attributable to hospital errors!

Sorry. That bit of statistical voodoo still sticks in my craw.

Now comes the second thing that may not seem so obvious but is clearly linked with the OMINOUS FINDINGS of the report. The authors of this study, Samuel Seiden, M.D., and Paul Barach, M.D., MPH, just so happen to be the guys in charge of (guessed it yet?) www.wrong-side.org! Well, isn't that special! Kind of like publishing a study that "finds" that carpet dirt can cause acne while at the same peddling a "new" vacuum cleaner.

OK. Please do not misread my aggravation. I do not think wrong-site/wrong-side surgery is over-reported, and it certainly deserves a much clearer, probably mandated, reporting system. But this type of "academic study" appears, at least to me, an attempt to get funding for one proposed solution --- the one being proposed by the study's authors ---- rather than a clear look at the problem.

For me, there are some fundamental issues that are at the heart of the wrong-side/wrong-site surgery problem, and they differ to some degree from the non-surgical wrong-treatment/wrong-procedure problem. First and foremost is the importance of a good old-fashioned doctor-patient relationship. This means in my practice not seeing the patient and scheduling them for surgery some weeks away without a preop appointment soon before the operation is to take place. That allows at least two occasions for the patient and I to interact, and the visit within a few days of surgery keeps me well aware of what I am doing to that particular patient. I think I lose a "feel" for the patient, their history, and their surgical problem if I don't see them a day or so ahead of time.

On the day of surgery, I always see the patient before they are carted off to the OR. I just have always felt that was common courtesy, at a minimum, and it gives me a chance to make sure there are no unanswered questions from the patient or their family. Because it is mandated by JCAHO, that also gives me the opportunity to mark the patient when I am doing surgery on one side or the other (such as a hernia repair). I'm also a stickler for making sure the patient is not prepped until I am in the room, so that I don't arrive with the wrong side already prepped, draped and begging for an incision.

It's not all left up to me, however. There are guidelines that have been established to ensure a multiple-step process to try to prevent the wrong procedure from being done. Everyone involved with the procedure is involved, from the preop nurses to the anesthesiologist to the scrub techs. Essentially every specialty society has policy statements about how to prevent wrong-side/site surgery --- the American College of Surgeons, the American Academy of Orthopedic Surgeons, the American Academy of Ophthalmology, etc. --- all following the basic outline of the JCAHO protocol. For example, here are the ACS guidelines:

The American College of Surgeons (ACS) recognizes patient safety as being an item of the highest priority and strongly urges individual hospitals and health organizations to develop guidelines to ensure correct patient, correct site, and correct procedure surgery. The ACS offers the following guidelines to eliminate wrong site surgery:

1. Verify that the correct patient is being taken to the operating room. This verification can be made with the patient or the patient's designated representative if the patient is under age or unable to answer for him/herself.
2. Verify that the correct procedure is on the operating room schedule.
3. Verify with the patient or the patient's designated representative the procedure that is expected to be performed, as well as the location of the operation.
4. Confirm the consent form with the patient or the patient's designated representative.
5. In the case of a bilateral organ, limb, or anatomic site (for example, hernia), the surgeon and patient should agree and the operating surgeon should mark the site prior to giving the patient narcotics, sedation, or anesthesia.
6. If the patient is scheduled for multiple procedures that will be performed by multiple surgeons, all the items on the checklist must be verified for each procedure that is planned to be performed.
7. Conduct a final verification process with members of the surgical team to confirm the correct patient, procedure, and surgical site.
8. Ensure that all relevant records and imaging studies are in the operating room.
9. If any verification process fails to identify the correct site, all activities should be halted until verification is accurate.
10. In the event of a life- or limb-threatening situation, not all of these steps may be followed.

Call me old fashioned. Call me a curmudgeon. Call me an arrogant bastard. Just don't call me Shirley. The problem with this type of policy is that it leaves sufficient wiggle room for laziness. Most hospitals have policies that allow a physician extender to take the place of the surgeon in the steps above --- so it's the orthopedic PA that says "hi" to the patient and marks them preop (and the orthopedic PA that dictates the preop history and physical, and obtains the surgical consent,...I pick on orthopods because [1] they are responsible for most of these incidents, as they do "sided" surgery all the time; [2] they all seem to have a PA attached to their hip; and [3] because I can, and it's fun).

In fact, JCAHO guidelines even state the operating surgeon "should," rather than "must," mark the patient, and even the OR nurse --- who has never even met the patient --- is considered an adequate substitute for the surgeon in marking the patient. That's just plain wrong.

Look, I'm not full of sour milk here -- I agree with the study authors that wrong-side/site surgery is likely underreported, and I agree that we need a better system to report and monitor such events. As much as I might hate to admit it, I think that JCAHO is on the right track in trying to ensure a system-based approach to prevention of this 100% preventable problem. But I also believe that the "best defense is a good offense," and in this case, the best offense is good communication between patient and surgeon.

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.

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!

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.....

9/11

Never forget. Never surrender.

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!

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.....

No-Pay for Performance?

What would make a primary care physician say this?

Between September 22nd and October 1st, I will refuse to see Medicare patients in my office. If they need care urgently, they can go to the ER. I shall also tell them exactly why I am imposing a moratorium on caring for them. And if (when?) this happens again next year and the year after that, I'll just be that much closer to the brink of opting out of Medicare entirely.

Read all about it here. I had forgotten all about this little quirk in Medicare reimbursement, which came about as part of the bill that prevented a 5.2% decrease in payment from Medicare this year (which, incidentally, is back on the table for next year).

Why I don't practice in Florida

This is an excellent example of why I get many offers of "great" practices to join in Florida --- sort of lurid sales pitches from snake oil salesmen sitting in a snake pit.

A jury has awarded $8.25 million to a Fort Myers woman who claims a Naples-based plastic surgeon botched a breast augmentation.....Aills' lawsuit said Dr. Luciano Boemi failed to inform her surgery could result in damage to her body. During the surgery, the suit contends, Boemi failed to ensure blood continued to flow in her breasts and caused a loss in sensation.....The jury of four men and two women awarded Aills $250,000 in actual damages to cover medical expenses and personal costs. The other $8 million was for pain and suffering.

Okey-dokey. Let's say, for argument's sake, that the plaintiff was correct, and that real malpractice occurred. The article states the patient went on to have a total of 13 surgeries, with what sounds like eventual loss of both breasts, and the $250K covers those expenses. But $8 milliion for pain and suffering? How did they settle on a figure of $4 million per breast? I doubt that even any of these ladies have Lloyd's of London insurance coverage that extensive for their cleavage.

Whenever I see an award in a malpractice case that is this high, I remind myself to continuously express to patients one of the basic tenets of life: Bad things happen. Sometimes, they happen despite the best efforts of everyone involved.

Surgery, like life, offers no guarantees.

Black Box Warning for ADHD Drugs

I don't see many children in my practice, but am often surprised at the number of kids out there that are being medically treated with stimulants for ADHD. Without getting into the debate (I'll leave it up to Flea, with whom I tend to agree), there is a new twist to the story: The FDA has slapped a "Black Box" warning on these drugs (from eMedicine; emphasis is mine):

Earlier this year, a FDA advisory panel voted 8–7 to add a black-box warning to the labeling of stimulants (eg, amphetamine mixtures, dexmethylphenidate, dextroamphetamine, methylphenidate), used to treat attention-deficit/hyperactivity disorder (ADHD) to alert prescribers about cardiovascular risks associated with use of the drugs. Sudden death has been reported in association with CNS stimulant treatment at usual doses in children and adolescents with structural cardiac abnormalities, cardiomyopathy, serious arrhythmias, or other serious cardiac problems that may be exacerbated by sympathomimetic effects. In adults, sudden death, stroke, and myocardial infarction have been reported with use of stimulants for ADHD.

The Food and Drug Administration (FDA) has received reports of more than 20 deaths associated with use of ADHD drugs, reviewers said. But, said Kate Gelperin, a medical officer in FDA's Office of Drug Safety, cardiovascular signals in ADHD adverse events reported to the agency were "not conclusive."

About 1.5 million adults and 2.5 million children take ADHD medications, FDA safety reviewers told the panel. Use of ADHD medications is on the rise, especially in adults, said Andrew Mosholder, a medical officer in FDA's Office of Drug Safety. There was a 90 percent increase in adult use of the drugs over the past three years, he told the advisers. About 10 percent of adult users of ADHD medications are over age 50, Mosholder added. ADHD medication use in children peaks around ages 9–12, and then drops off, he said.

Methylphenidate products, marketed by Novartis under the brand name Ritalin, are the most frequently prescribed ADHD medications, Mosholder said. "Over the last decade or so, we've seen an enormous rise in the use of these drugs now to the point that 10 percent of 10 year olds are getting treated" for ADHD, said Steven Nissen, director of cardiovascular medicine at the Cleveland Clinic in Ohio—the panelist who proposed the black-box vote. "I have grave concerns about the direction we are going in with the mass use of these drugs and the potential for harm," he said.

10% of 10 year-olds are getting meds for ADHD? That seems like an awfully high number, and I wonder if that was an off-the-cuff remark or reflected actual data. (Illustration above © Joanna Walsh, found here.)

A "Black Box" warning is a pretty big deal, and can seriously change prescribers' activity. My only experience with this kind of warning came when the FDA similarly labeled Droperidol, which had been in wide use since the 1970s primarily to treat perioperative nausea.

Tony Gerlach, a pharmacist and medication safety specialist for the Ohio State University Medical Center (OSUMC) in Columbus, said his health system’s medication-use improvement team, a P&T; subcommittee, decided to "phase out" droperidol use over the coming months. Gerlach said OSUMC had previously used droperidol as a first-line antiemetic drug for surgical patients "mostly as a cost-saving measure." But, he said, after the addition of the boxed warning to droperidol’s labeling, the health system’s head of anesthesiology recommended against using the drug. "He said that, although he has never seen an adverse event, the black-box warning is too hard to ignore," Gerlach said.

I was involved with our P & T committee at the time, and we felt our hand was forced to severely restrict access to the drug, even though the decision by the FDA was exceedingly controversial and based on very skimpy data. In addition to increasing overall costs for antiemetics, that particular "Black Box" warning also has prevented us from using Droperidol to calm the heavily intoxicated, agitated trauma patient to allow safe evaluation (with CTs, X-rays, etc.); now, they all have to be intubated, increasing risk and costs.

With this new warning, I wonder how many pediatricians will be willing to continue to prescribe Ritalin and its cousins. Will they screen all such patients with echocardiograms, at a considerable cost, to try to prevent a lawsuit? Or will they continue to prescribe these drugs at their current rate?

UPDATE: I know this may come as a surprise to a grand total of 3 of you, but guess what type of professionals have also noticed this black box warning?