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Posts Tagged ‘patient education’

Haven’t had time to sit down and write about my trip to the operating room with Dr. Horacio Ham and Dr. Rafael Abril until now, but that’s okay because I am going back again on Saturday for a longer case at a different facility.  Nice surprise to find out that Dr. Octavio Campa was scheduled for anesthesia.  Both Dr. Ham and Dr. Abril told me that Dr. Campa is one their ‘short list’ of three or four preferred anesthesiologists.  That confirms my own impressions and observations and what several other surgeons have told me.

campa

Dr. Campa (left) and another anesthesiologist at Hispano Americano

That evening we were at Hispano – Americano which is a private hospital that happens to be located across the street from the private clinic offices of several of the doctors I have interviewed.  It was just a quick short case (like most laparoscopy cases) – but everything went beautifully.

As I’ve said before, Dr. Campa is an excellent anesthesiologist so he doesn’t tolerate any hemodynamic instability, or any of the other conditions that make me concerned about patients during surgery.

Dr. Ham  and Dr. Abril work well together – everything was according to protocols – patient sterilely prepped and draped, etc..

laparoscopy

laparoscopy with Dr. Ham & Dr. Abril

I really enjoy talking with the docs, who are both fluent in English – but I won’t get more of an interview with Dr. Abril until Saturday.

w/ Dr. Ham

with Dr. Horacio Ham in the operating room after the conclusion of a successful case

Then – on Wednesday night – I got to see another side of the Doctors Ham & Abril on the set of their radio show, Los Doctores.  They were interviewing the ‘good doctor’ on sympathetectomies for hyperhidrosis – so he invited me to come along.

Los Doctores invited me to participate in the show – but with my Spanish (everyone remembers the ‘pajina’ mispronunciation episode in Bogotá, right?)  I thought it was better if I stay on the sidelines instead of risking offending all of Mexicali..

Los Doctores

on the set of Los Doctores; left to right: Dr. Rafael Abril, Dr. Carlos Ochoa, Dr. Mario Bojorquez and Dr. Horacio Ham

It really wasn’t much like I expected; maybe because all of the doctors know each other pretty well, so it was a lot more relaxed, and fun than I expected.  Dr. Abril is the main host of the show, and he’s definitely got the pattern down; charming, witty and relaxed, but interesting and involved too.. (my Spanish surprises me at times – I understood most of his jokes…)  It’s an audience participation type show – so listeners email / text their questions during the show, which makes it interesting but prevents any break in the format, which is nice.  (Though I suppose a few crazy callers now and then would be entertaining.)

Dr. Ochoa did a great talk about sympathectomy and how life changing it can be for patients after surgery, and took several questions.  After meeting several patients pre and post-operatively for hyperhidrosis, I’d have to say that it’s true.  It’s one of those conditions (excessive palmar and underarm sweating) that you don’t think about if you don’t have – but certainly negatively affects sufferers.  I remember an English speaking patient in Colombia telling me about how embarrassing it was to shake hands -(she was a salesperson) and how offended people would get as she wiped off her hands before doing so.  She also had to wear old-fashioned dress shields so she wouldn’t have big underarm stains all the time..  This was in Bogota (not steamy hot Cartagena), which is known for it’s year-round fall like temperatures and incredibly stylish women so you can imagine a degree of her embarrassment.

It (bilateral sympathectomy) is also one of those procedures that hasn’t really caught on in the USA – I knew a couple people in Flagstaff who told me they had to travel to Houston (or was it Dallas?) to find a surgeon who performed the procedure..  So expect a more detailed article in the future for readers who want to know more.

Tomorrow, (technically later today) I head back to San Luis with the good doctor in the morning to see a couple of patients – then back to the hospital.. and then an interview with a general surgeon.. So it should be an interesting and fun day.

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As my loyal readers know, I do my best to try to give fair and balanced depictions of surgical procedures, as well as reviews of medical and surgical news and research.  Over at Medscape.com – there is a new video discussion by Dr. Anne Peters, MD.  Dr. Peters is an endocrinologist and a certified diabetic education.  In this video – she talks about the realities of bariatric surgery, and these are things I think that people need to hear.

For more on Bariatric surgery – see my other posts

One of the points that she makes, is (in my opinion) critical.  While bariatric surgery has been shown to cure diabetes in many individuals – there is no medical/ surgical or other treatment to cure much of the pathology related to the development of obesity in the first place.  Obesity is more than poor dietary and exercise habits – it is a psycho-social and cultural phenomenon as well.

For people who don’t want to go to the Medscape site – I have re-posted a transcript of the video from Medscape.com below.

Bariatric Surgery a ‘Magic Bullet’ for Diabetes?

Anne L. Peters, MD, CDE

Transcript
Hi. I’m Dr. Anne Peters from the University of Southern California. Today I’m going to talk about the role of bariatric surgery in the treatment of type 2 diabetes.

There have been a number of recent studies that show just how good bariatric surgery can be for patients with type 2 diabetes.[1,2] In many cases, it seems to cure type 2 diabetes (at least for now), and I think it is an important tool for treating patients with obesity and diabetes.

However, I also have concerns about bariatric surgery, concerns that go back for years as I watched its increased use. When I was a Fellow, I developed a sense of the benefit of extreme caloric restriction for the treatment of type 2 diabetes. I will never forget the first patient I had, an extremely obese man with type 2 diabetes who was on 200 units of insulin per day. His blood sugar levels remained high no matter what we did. He was a significant challenge in terms of management.

One day, he got sick. I don’t remember how or why he got sick, but he ended up in the hospital and I thought that his management would continue to be incredibly difficult. In fact, it was miraculously easy. Within 2 days, he was completely off of insulin and his blood glucose levels remained normal for the entire time he was in the hospital.

This was only a short-lived benefit, however. After he was discharged, he went back to his old habits. He started eating normally, regained the weight, and went back on several hundred units of insulin per day. But it really impressed me how acute severe caloric restriction could, in essence, treat type 2 diabetes.

I have seen many overweight and obese patients with diabetes over the years, and I have seen the frustration as patients go on drugs (such as insulin) that are weight-gain drugs, and they keep gaining more weight. Although I am a big advocate for lifestyle change, many patients can’t do much better. They can’t lose appropriate amounts of weight by their own will or through weight loss programs, or increase their exercise. Therefore, bariatric surgery remains a reasonable option.

For many of my patients who have a body mass index > 35 and type 2 diabetes, I recommend that they at least consider bariatric surgery. Interestingly, very few of my patients actually go for the procedure and I ponder why this is. In part, I think it’s because of the initial evaluation, when you are told what bariatric surgery is like and how much you have to change your habits after the procedure. Before surgery, you are eating however you want to eat and, although you may be trying to diet, there is no enforcement of that diet. After surgery, you have to change how you eat, the portions you eat, and when you eat. I know that people feel fuller, and this is a lot more than just changing one’s anatomy. I think there are significant changes in gut hormones that regulate appetite and satiety. Nonetheless, it is a big change, and many people don’t want to change their habits that much. I know I would be somewhat leery if I were to undergo a surgical procedure that would change my whole way of being. For lots of people, food has many different associations. It’s not just caloric intake; it’s festival, it’s party, it’s joy, it’s sadness. It’s something people like to do, and it hasn’t a lot to do with just maintaining a positive or neutral caloric balance.

I find that people are reluctant to change, and that is understandable. We also don’t know the long-term complications of the procedure. As an endocrinologist, I see 2 things. First, I tend to get sicker patients, so my patients who are on insulin when they undergo bariatric surgery may not get off insulin entirely. They become very disappointed because they think that bariatric surgery will cure them of their diabetes. I also see patients who are too thin, who are nutritionally deficient, who have severe hypoglycemia, or who have significant issues from the surgery itself. In some cases, these patients have needed a takedown of the surgical procedure, restoring them back to their native anatomy.

I think of bariatric surgery as a tool. It is one of many ways to treat our patients with type 2 diabetes. I am a little concerned because we don’t have long-term follow-up data. I think that all bariatric surgery programs, in addition to doing a very thorough preoperative evaluation and counseling, need to do long-term, lifelong follow-up of these patients to see how they do, to see if their obesity returns. In many cases, this does happen. [Patients need to be followed up] to see what happens to their lipids, their blood pressure, and their blood sugar levels over time, and to monitor for other complications.

I think [bariatric surgery] is something that we need to recommend to our patients, and for those in whom it’s appropriate, it is a reasonable step. This has been Dr. Anne Peters for Medscape.

 References
  1. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012 Mar 26. [Epub ahead of print]
  2. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012; Mar 26. [Epub ahead of print]

Life after Bariatric Surgery

There is also an excellent article by two nurse practitioners about the long-term interventions and health monitoring needed for wellness promotion and health maintenance after bariatric surgery.  While this article is written for other health care providers – it gives an excellent look at life after bariatric surgery, as well as an overview of the surgical techniques, pre-operative evaluation and anticipated post-operative outcomes.

Thomas, C. M. & Morritt Taub, L. F. (2011).  Monitoring and preventing the long-term sequelae of bariatric surgery.  J of the American Academy of Nurse Practitioners, 2011, 23 (9).

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New allegations of gross medicare fraud from overstenting and unnecessary interventional procedures has been filed against surgeons in Pennsylvania, including the prestigious UPMC medical center.  This story, (based on cases dating back to 2001 and onwards), comes just as the dust in settling from an outbreak of unnecessary stent cases in neighboring Maryland.

What is overstenting?

Article by Michael R’iordan from the Heart.com re-posted below:

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Erie, PA – A new whistle-blower lawsuit filed in US District Court in Erie, PA claims that five cardiologists from two medical practices defrauded Medicare by performing unnecessary cardiac and vascular surgeries and interventional procedures between 2001 and 2005.

The suit, filed under the False Claims Act (FCA) and first reported January 22, 2012 in the Erie Times-News [1], states that as a result of the fraud, Medicare overpaid for these procedures, which wasted substantial public money, and patients were placed at significant and unnecessary risk of harm.

According to a copy of the lawsuit obtained by heartwire, the physicians named are Drs Richard Petrella, Robert Ferraro, Charles Furr, Timothy Trageser, and Donald Zone. The two medical practices named in the lawsuit are Medicor Associates Inc—and its affiliate Flagship Cardiac, Vascular, and Thoracic Surgery (CVTS)—and the University of Pittsburgh Medical Center (UPMC) Hamot (formerly known as Hamot Medical Center). The Medicor practice is the full-service cardiology center affiliated with UPMC Hamot.

The lawsuit states that from June 2001 and earlier, the defendants “knowingly, systematically, routinely, and repeatedly submitted false claims to and received reimbursements from Medicare and other federal healthcare programs for medically unnecessary cardiac catheterizations and cardiac and vascular surgical procedures, including but not limited to . . . PCI.”

As result of the false claims, the physicians received money to “which they were not entitled.”

Paid directorships and kickbacks

Dr Tullio Emanuele, who worked at Medicor and Hamot Medical Center from 2001 to 2005, filed the suit and claims that Medicor engaged in illegal “kickbacks” with Hamot Medical Center and referred cardiac patients to the hospital. In the lawsuit, it is alleged that Hamot signed contracts with Medicor and Flagship CVTS, valued at $75 000 per physician and as high as $525 000 per year, and the doctors would refer patients in need of medical procedures to Hamot Medical Center.

“Specifically, Hamot identified physicians who referred a high volume of patients and/or had potential to refer a high volume of patients for special treatment and offered remuneration to them in the guise of sham contracts for medical directorships or other similar personal service arrangements,” according to the lawsuit.

The claim states the physicians and the participating hospitals violated the federal Anti-Kickback Statute and the federal Stark Act, which says that a hospital is not allowed to submit a claim for reimbursement from Medicare if the procedure has been referred by a physician with improper financial ties to the hospital.

The suit also claims that Emanuele began to grow suspicious in 2004 when he noticed higher rates of intervention among certain physicians within the group. Between 2004 and 2005, 4408 catheterizations were performed, and Petrella, Trageser, and Ferraro had a “rate of surgical intervention following catheterization of double the junior members of the group.”

Emanuele, according to the lawsuit, believes that many of the procedures were performed unnecessarily. For example, Trageser is accused of performing a cardiac catheterization in a patient with chest pain, despite the symptomology being inconsistent with angina. Ferraro is accused of implanting a stent in an artery with moderate stenosis, even though Emanuele previously recommended medical therapy. Zone performed a cardiac catheterization and overstated the severity of stenosis, sending the patient on to CABG surgery, where he/she later died.

UPMC Hamot and the named physicians received copies of the lawsuit last week, according to the Erie Times-News, and have 20 days to respond. If they are found guilty, UPMC Hamot and the Medicor physicians would be required to reimburse Medicare at triple the cost of the original procedure. Emanuele, as the whistle-blower in the case, would be entitled to 30% of the reimbursed money.

More on similar stories here at Cartagena Surgery:

The Ethics of the Syntax Trial

Stent Scandal series:

Cardiology takes another hit

Mark Midei – or the man who started it all..

This is just a sample of the articles available here at Cartagena Surgery.. For more on this topic, look under the cardiology tab..

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As many of my long time readers know, that during the last month or so, I have been reviewing studies, and data on the Syntax trial as part of a presentation at my hospital.  This has been more time-consuming and angst-wrenching than I would have ever expected; the more data I reviewed, the more conflicted I became about the ethical questions involved in a study of this kind.

Granted, I have a sensitive nature, and as a nurse, patient advocacy is one of my primary goals.  But thankfully, I found that I am not alone in questioning the legitimacy of subjecting patients to a ‘non-inferiority’ trial.

“In our opinion, the Syntax study disregarded the safety of the patients, by including death and major complications of a primary end-point of a non-inferiority study.”
— Mantovani et. al (2010).
Mantovani et al. (2010) Non-inferiority randomized trials, an issue between science and ethics: the case of the Syntax study.  Scandinavian Cardiovascular Journal, 2010; 44: 321-324.  Mantovani et al. full text pdf.   They question the benefit of subjecting patients to unproven therapies using a trial design that really fails to prove much at all about the effectiveness of the proposed treatment, (in this case, PCI).  They have an excellent discussion (and definitions for the uninitiated) on trial designs and what they really mean, in real terms.
As they point out – studies with this kind of trial design – really don’t prove anything at all.  It was a methodology designed by pharmaceutical companies in order to get new drugs on the market (whether or not these newer, more expensive versions of existing drugs were an improvement over older, safer, cheaper versions or not.)
But in this case – the real results were the unintended ones! Despite a skewed set of accounting (weighing heavily in cardiology’s favor) the results were determinedly negative, showing worse patient outcomes with stents, more deaths, more serious adverse events with stents.
As I delved even further into the data,  I began to question the concept of patient ‘informed consent’ all together.  Can a patient really comprehend the risks involved and what these outcomes really mean in practical terms for something like this?  Would anyone in the study actually break it down in a honest and straight-forward (no BS) fashion to potential study participants?
And how do patients (lay public) understand all of this anyway?  Their perceptions might radically differ from what we (researchers) think we’ve presented.  And, in fact – there are some HUGE differences, as multiple studies attest.  What patients hear and understand is DRAMATICALLY different from what we might expect.
Somehow, I don’t expect that researchers said to patients (for example):
“Mr. X, you are 50 years old, with HTN, diabetes and severe CAD affecting all three major arteries.  Since your labs, and general health is otherwise unremarkable, according to experience and the STS risk calculator, your risk for death with bypass surgery is Y (pretty darn safe). However, we would like to put you in a study where you may receive anywhere from 3 to 20 stents with extensive exposure to nephrotoxic (kidney-harming) dye,  and radiation.  These stents may close either acutely (stent thrombosis) or over time, causing a potentially fatal heart attack.  Stent occlusion happens much more frequently then bypass graft occlusion.  Oh, and by the way – we aren’t doing this study to see if stents are better than bypass surgery (we already know it isn’t) – we are doing it to see how much worse it is – within acceptable margins, of course [whatever than may be].”
No, somehow – I don’t think it went down like that.
More on the Syntax Trial comparing PCI and CABG:
Syntax, part II: New guidelines for revascularization
More on PCI appropriateness  (we have an entire series on PCI here at Cartagena Surgery)

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Dying to be thin?  These patients are… A look at the Get-Thin clinics in Beverly Hills, California..

This series from LA Times writers, Michael Hiltzik and Stuart Pfiefer highlights the importance of safety and the apparent lack of regulation in much of the bariatric procedure business here in the United States.

In these reports – which follow several patient deaths from lap-band procedures, both surgeons and surgical staff alike have made numerous reports against the ‘Get Thin” clinics operating in Beverly Hills and West Hills, California.  These allegations include unsafe and unsanitary practices.  One of the former surgeons is involved in a ‘whistle-blower’ lawsuit as he describes the dangerous practices in this clinic and how they led to several deaths.

Regulators ignore complaints against Beverly Hills clinics despite patient deaths  – in the most recent installment, Hiltzik decries the lack of action from regulatory boards who have ignored the situation since complaints first arose in 2009!

House members call for probe into Lap-Band safety, marketing – California legislators call for action, but the clinics stay open. (article by Stuart Pfiefer)

Plaintiffs allege ‘gruesome conditions’ at Lap-Band clinics – mistakes and cover-ups at the popular weight loss clinics.  (article by Stuart Pfiefer)  This story detailing a patient’s death made me ill – but unfortunately reminded me of conditions I had seen at a clinic I wrote about in a previous publication..  The absolute lack of the minimum standards of patient care – is horrifying.  This woman died unnecessarily and in agony.  It proves my point that anesthesiologists need to be detailed, and focused on the case at hand.. (not iPhones, crosswords or any of the other distractions I’ve seen in multiple cases.. Now this case doesn’t specifically mention a distracted anesthesiologist – but given the situation described in the story above, he couldn’t have been paying attention, that’s for sure.

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A couple of new articles over at Medscape highlight the role of Nurse Practitioners (and Physician’s Assistants) in patient care.

The Role of Nps and PAs with MDs in today’s care

A study from Loyola showed that surgical NPs reduced emergency room visits  : here’s a link to the article abstract by Robles et al. (2011).

Reducing cardiovascular risk with NPs: the Coach trial

And yet again, Nurse Practitioners trump physicians in patient satisfaction surveys.

This is just a sampling of the articles featured over at Medscape’s NP perspective.

From the free-text files: a selection of articles showing the growing use of Nurse Practitioners around the world

Nurse practitioners improve quality of care in chronic kidney disease: two-year results of a randomised study.  – a study from the Netherlands

A Parallel Thrombolysis Protocol with Nurse Practitioners As Coordinators Minimized Door-to-Needle Time for Acute Ischemic Stroke.  A taiwanese study showing the impact of nurse practitioners in reducing door-to-needle time in acute coronary syndromes.

Helping patients attain and maintain asthma control: reviewing the role of the nurse practitioner.

Type 2 diabetes, cardiovascular disease and the utilisation of primary care in urban and regional settings.  An Austrailian study discussing the impact of NPs in rural care.

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Just got back from spending a day at John Hopkins looking at ‘domestic medical tourism’. While the terminology is new, the concept isn’t. Who doesn’t know someone, a friend or family member, who has traveled outside of their own community for treatment? We all do – any many of those people have travelled to those big name facilities that we are all familiar with; the Mayo Clinic, Duke, the Cleveland Clinic and John Hopkins.

John Hopkins, is in fact – a leader in both domestic and international medical tourism. John Hopkins has also ranked #1 for US Hospitals for the last 21 years. While there is some discussion as to the real validity of these rankings, they are still impressive.  As we have discussed before on our sister site, Bogotá Surgery.org  – Hopkins has international affiliations and collaborations with facilities throughout the globe (including Santa Fe de Bogotá)**.  Hopkins directly manages several other facilities – in places such as Turkey and the Middle East.  They truly are a global healthcare organization.

I visited the International Patient Center and observed the services available for out-of-state patients.  These departments make special efforts to provide convenience and familiarity to their out-of-town patients.  As part of these, patients are escorted to appointments, and appointments are grouped (when patient needs more than one service.)

They also have translators for over twenty different languages, and special accommodations to enable respectful, culturally competent care to patients with special religious or cultural needs.

Many of these out-of-town patients stay at the McElderry House, which is a pleasant, and affordable option, located just across the street from the hospital.    I stayed there during my visit – and the staff are charming, helpful and accommodating.  The rooms are spartan, but the accommodations are homey and comforting.  With full kitchens, these townhouses are perfect for potential long-term visitors.

The story behind McElderry house is sweet and inspiring.

Theresa, the owner, is a former nurse, who worked at John Hopkins as a travel nurse twenty years ago.  During her travel assignment, her daughter was diagnosed with osteosarcoma (a particularly virulent cancer).  Instead of returning to their native Michigan – they stayed in Baltimore for treatment.

Yesterday, I met her daughter – who is doing wonderfully, thriving in fact.

Later, Theresa started McElderry House for patients and families in situations like hers.  She started small and now has multiple townhouses spread over two streets kitty-corner from John Hopkins.  She welcomes patients, families and medical / health professionals like myself.

During my visit – I also managed to interview a wonderful, inspiring surgeon, Dr. Daniela Molena.  I’ll be posting a longer article about her and her work at Hopkins soon.

Yesterday was just a quick peek at John Hopkins  – I hope to be back soon to take another look.

*For patients requiring in-patient care; John Hopkins maintains elegant, luxury upgraded accommodations at the Marburg Pavilion within the John Hopkins facility. (Read here for an article on Forbes about Marburg Pavilion, and other upscale patient facilities).   When these amenities accompany excellent medical care, such as in this case, it’s a plus.  It’s when the accommodations trump the care when it becomes a problem.

** There is some concern over the sudden increase in facility ‘branding’ since the onset of the medical tourism phenomenon and as to whether this is truly a mark of quality – or just a reflect of services (logos) ‘bought and paid for’.  As someone who previously worked in a ‘branded’ facility myself – there is some truth to the notion that it’s more of a rented logo than anything else.

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