Pithy Loquacity

Category: surgery

  • End (Edge) of life issues –

    icu-bed
    Sometime back, when I was a trainee, we used to get patients at the end of their life. They would come to us tired and dejected (and angry) after  treatment from premier hospitals all over the country; having tried various form of alternative therapies and charlatans. And we would evaluate them and send them back to their homes. Some saw the futility and accepted while some fought to be admitted and die in the ICU. Overall there was (is) singular lack of knowledge and guidelines for the patients, their relatives and also among the physicians and health care workers.

    I looked around and found there were no institute or place for such people and their families for guidance. The few places that existed were religion affiliated and their outlook was not what was needed. After so many years; even today no such places exist.

    In recent time this area of end of life issues and hospice care has seen advancement especially in United States. A great series of articles was published in the Dallas News which I would recommend to everybody. Excerpts

    Nobody wants to die a slow, lingering death. But many Texans do. Half die in hospitals. One in five passes away in intensive care. Often, their last months of life are expensive, painful exercises in medical futility.

    Health care reformers in Dallas and around the nation are pushing for a better way to help people at the edge of life.

    Practitioners of “palliative care” combine traditional medicine with pain relief, spiritual counseling, and practical advice for patients and families.

    These articles derive from the experiences of palliative care team at the Baylor University Medical Center in Texas.

    Unlike hospice, palliative care can continue alongside aggressive, life-sustaining treatments. Palliative doctors, nurses and other clinicians guide patients and families through searingly painful choices, including decisions to avoid overly invasive care. They aim to help patients live as well as possible for as long as possible, and to help grieving families prepare for the inevitable.

    Research indicates that such “comfort care” sometimes can prolong life more effectively than aggressive surgical, chemical or radiation therapies. It also can reduce medical expenses; Medicare spends 28 percent of its annual budget on care given in the last year of life.

    She describes the families and their emotions so well, highly recommended reading includes video clips.

    Mr. Bourque tried telling Michelle that her mom might not make it. The little girl set stuffed animals and a purple-and-orange squirt gun on her mother’s emergency-room gurney like talismans.

    The Bourques were medical people. Mr. Bourque, 44, was a pediatric ICU technician starting nursing school; Mrs. Bourque, 45, was a pediatric respiratory therapist. They couldn’t kid themselves, but it wasn’t clear how much their daughter understood.

    They’d tried to spare her, and sensed that Michelle was trying to protect them, too. They all needed help to get through what was coming. But nothing else could happen as long as Mrs. Bourque was trapped in agonizing pain.

    In this era when nothing is ever enough and the machines can breathe for you; pump your heart; feed you forever; but cannot think for you: read here the series by Lee Hancock.Technorati Tags: ,

  • Patients Overcrowding in ER? Lets hangout in Hallways!! few are in cafeteria-


    (Image from dailylife .com)

    I came across this article while surfing which made me read it again carefully. The health blog in the wall street journal describes a novel way of managing Emergency overcrowding

    Here’s one way to ease overcrowding in the emergency room: Move patients to the hallway.

    Some hospitals are giving it a try, putting patients in hallways when they’re ready to be admitted, the Associated Press reports

    The bizarre ideas germinating in managerial cubicles would put Dilbert’s Pointy headed Boss in throes of delight. The practice was justified by

    Peter Viccellio, clinical director of the emergency department at Stony Brook University Medical Center in Stony Brook, N.Y., was involved with a study that found that the practice didn’t do any harm. And before the hospital went this route, on busy days “things would grind to a halt and people would wait to be seen,” he told the AP. Worse, infectious patients would wait in the ER hallways for isolation rooms to open up elsewhere.

    I wonder if the said observations were deduced from the hopelessness of the situation. The statement which struck me the most came from one of the proponents of the idea

    Nurses, meanwhile, tend not to like the practice. But Carolyn Santora, who heads patient safety efforts at Stony Brook, told the AP that’s fine with her. “I want them to hate it,” she said. “I want them to do everything to expedite flow to get the patient out of the hallway.”

    This attitude is typical of the adversarial roles the clinicians (including doctors, nurses, paramedics,cleaners etc as a team) have to face as a team from the managers and the public in general as ‘the problem‘. It is like shooting the messenger-

    The reason the nurses are uncomfortable is because they know how dangerous the practice is; they know the enormous stupidity of the move and because they care about the patients despite perceptions otherwise.

    Just give them time to accept and acclimatize to the new rules and they will no longer be so uncomfortable!! After all they are powerless and the strings are in someone else’s hands.

    The rules and circumstances are so different in India but the end result is all the same. I used to send people with minor lacerations for tea just to have space to deal with the real sick.

    Photocredit: Dailylife.com taken out of context here.

  • Lessons from Sharks on reducing infections.

    Interesting article in the Wall street journal health blog

    The ocean is full of slow-swimming creatures covered with algae and barnacles. But some slow-swimming sharks stay pretty clean.

    A University of Florida researcher thinks that has to do, at least in part, with the microscopic pattern of shark skin, which makes an inhospitable environment for the critters that want to make a home there.

    The researcher, Anthony Brennan, hopes to make products whose surfaces mimic that property, and he’s working with a couple of Denver businessmen on a company called Sharklet Technologies. This morning’s Denver Post has a story on the business.

    The company says it’s already figured out how to make silicone surfaces with a sharklike pattern that’s resistant to the growth of bacterial films. Sharklet hopes to sell the technology for use on things like catheters, a common source of hospital-acquired infections.

    It’s early days still for the technology, and it’s unclear whether it will get off the ground…

    Hope that this cool idea works out! Urinary tract infection following catheter insertion is certainly a frequent complication in hospitalized patients. The concept of preventing infection by disabling bacterial adhesion and migration (biofilm formation) is gaining grounds with few other materials being tried out.

    (image from the Denver Post)

    From the Denver Post via WSJ health blog.

  • WHO issues a surgical checklist.


    A lot has been written about surgical errors during operation including incidents of left behind surgical instruments, wrong site surgery, operating on wrong patients and so on.

    The WHO has issued a checklist which it hopes will go a long way in reducing such errors by enforcing a ‘time out’ when all personnel participating in a procedure will check and mark on the checklist ensuring compliance of necessary formalities. Such checks are further made at the end of procedure.

    I agree that such checklists and timeouts will be quite helpful in reducing the number of errors but surgeons are resourceful and dogged of determination; they will find a way around this.

    As an aside if you have read books by Atul Gawande you will be aware of his fascination for idea of checklist similar to those used by the Aviation industry(very effective) to reduce medical errors. His Harvard group and folks at IHI and The International Society for Quality in Health Care have been quite active at getting this off the ground.

    WHO Safe Surgery Saves Lives ChecklistTechnorati Tags:

  • Second opinion at a distance


    There is an interesting piece of new in todays USA today about taking second opinion for health conditions online from experts. You send your medical records with or without your primary doctor’s help via internet to Experts( places providing paid service) and get their opinion after a week or so.

    Online second-opinion services offer patients consultations from specialists based on the medical records that they fax, mail or send via the Internet. The average cost, payable upfront via credit card, is $500 to $1,500, depending on the number of radiology or pathology interpretations required. Patients then receive online access to a second opinion in about two weeks.

    What I find very interesting is the amount of changes in treatment or diagnosis as per this article.

    More choices, ‘more peace of mind’

    Not all remote second-opinion services require that a patient’s local physician participate. The Cleveland Clinic, for example, delivers consultations directly to a patient, while POSC shares them with the physician first and then with the patient.

    In Harlow’s case, her physician “welcomed” the idea of a second opinion. Harlow says she opted for the whole-breast radiation treatment, based on the report from Lawrence Schulman, a leading oncologist at Dana-Farber Cancer Institute,

    “In about 5% of the cases, we actually change the diagnosis of the patient. In 85% to 90% of the cases, we alter the treatment,” says Jonathan Shaffer, managing director of e-Cleveland Clinic. “What we are able to do is give the patient more treatment options and hopefully give the patient more peace of mind,” he says.

    Shaffer says people are beginning to realize the convenience of e-health technologies. “It continues to grow every year.”

    Considering the rapid progress in internet technology and telemedicine these are bound to increase. Radiology is quite in the forefront. But is it viable in the long run?

    Quite a majority of cases are such where the diagnosis and the treatment is not in doubt and the physician is quite comfortable in following through the treatment. It may happen that the patient remains unsatisfied and may want a second opinion or alternative treatment. And why not? after all it is his money and body. He might remain dissatisfied with the second opinion as well.

    Physicians have been taking second opinion unofficially and consultations officially whenever they are unsure about management of a particular disease or presentation; but will they follow up on perceived unsolicited advise?

    Do not expect the primary physician to follow and carry out the advice given by the Case manager /Second opinion provider unless he himself (or herself) co-initiated the consult. It is quite apparent that the second opinion will also be a medical consultation with its attendant liability and responsibility unless waived off by the patient( and then that has its own consequences).

    The need for second opinion arises more in evolving fields like Oncology or where there are multiple treatment options under evaluation. For example- If the patient remained unconvinced by the doctor providing second opinion then what? back to square one..Patients need to have faith in their doctors and the doctors need to have knowledge to get that trust.

    Whatever shape it takes in future; there is money to be made and does fill in a perceived need so will catch on.

    Read the complete article from USA Today.

    Pic from http://www.flickr.com/photos/luca_eos/

  • Reversible Vasectomy

    At present Vasectomy is the only reliable method of male contraception. While it is relatively simple procedure and quite cheap besides the fact that the government pays you to get it done, yet it is not that popular. 

    The reasons for that is the irreversibility of the procedure and the perception of loss of ‘manhood’. Male desiring further children have to undergo recanalization which are not always successful and is expensive ( vas may block again, antibodies to sperm may develop etc.). So any reliable alternat e  method  is bound to be popular and in the  news. from rediff.com

    Once upon a time, a scientist, rather an engineer-cum-doctor, toyed with an idea — what if there were a male contraceptive? What if a simple injection to a male prevented unwanted pregnancy?

    His ever-active brain started thinking and years of research followed. And after 30 long years, RISUG (Reversible Inhibition of Sperm under Guidance) was born.

    The credit goes to Indian biomedical engineer Dr Sujoy K Guha and his group at the Indian Institute of Technology-Kharagpur,

    In this situation a method of reversible blockage or sperm inhibition would be a wonderful thing; increasing the usefulness and acceptance of male contraception. This is where the method of RISUG comes in. Though still in advanced trial stages it is quite promising. It consists of partial blockage of the vas deferens lumen(the conduit passing sperm from the testes to the ejaculate) using polyelectrolytic compound and can be effective upto 8-9 years. The block can be reversed when desired by flushing using solvent or local stimulation.

    The method is pioneered by Dr. Guha at IIT Kgp. In case you need to know more you can visit the Risug site or

    Reversible inhibition of sperm under guidance – Wikipedia, the free encyclopedia.

    (Pic from iitkgp )