Jeffery “Buckeye Surgeon” Parks is a board certified general surgeon working in Cleveland.
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This isn’t something we get to see every day. I saw an elderly gentlemen in the ER recently who complained of 24 hours of right sided abdominal pain. Other than a history of mild HTN, he was a pretty healthy old dude. No diabetes. Nothing in his history to suggest an immunocompromised state. He was certainly tender on exam, exquisitely and rather diffusely so. His WBC count came back over 30k and I was actually initially worried about ischemic bowel. But we sent him for a CT scan and the above image is the money shot.
What you see is a pathognomonic picture of emphysematous cholecystitis. (Notice the air in the wall of the gallbladder). This is a very severe form of acute cholecystitis where anaerobic bacteria, such as clostridial species, invade the gallbladder wall and produce gas. It’s rather rare (only about 1% of cases of cholecystitis) but it can be lethal, carrying mortality rates of 15-25%.
Emphysematous cholecystitis depends on one or both of following: vascular compromise of the gallbladder and systemic immunosuppression. Anaerobic bacteria don’t exactly thrive in tissues that are well oxygenated with good blood flow. Advanced cholecystitis, where the perfusion pressure of the capillaries is overcome by the edema of the inflammatory process, can lead to cystic artery occlusion and hence, a dead gallbag. Enter your anaerobic species, stage left. Immunocompromised patients (diabetics/transplant patients/HIV) are also susceptible to this virulent form of cholecystitis (for obvious reasons).
The treatment is surgical. Call the OR. Book the case. I took this one out laparoscopically, but sometimes you have to open because the wall of the gallbladder can often be about as sturdy as wet toilet paper (single-ply, like in bus terminal restrooms) and everything tears and spills and it’s just a horrible mess.
Merrill Goozner is an award winning journalist and author of “The $800
Million Pill: The Truth Behind the Cost of New Drugs” who write regularly at
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Medicare this morning proposed rejecting coverage of CT scans to detect colorectal cancer — sometimes known as virtual colonoscopy. In a companion cost-effectiveness analysis, agency researchers found that virtual colonoscopy every five years saved fewer lives than traditional colonoscopy given every ten years.
Moreover, for virtual colonoscopy to be cost-effective, its price of $488 per test would have to fall to $108 to $205 per scan, and for it to be even comparable to all other forms of colorectal cancer screening, its price would have to be cut in half.
However, the report did offer one wild card. If people were more willing to slip into the CT scanning machine for a virtual colonoscopy compared to undergoing the more comprehensive bowel-cleansing needed for a real colonoscopy, then “CT colonography screening could be included among the efficient strategies.”
Of course, a virtual colonoscopy that spotted polyps would require a second procedure — a regular colonoscopy — to get them out. So a large percentage of patients (about 25 percent of men and 15 percent of women over 50 are expected to have pre-cancerous polyps during routine colonoscopies) would have to undergo the second procedure anyway.
Dr. John D. Halamka is chief information officer and dean for technology at Harvard Medical School who writes at Life as a Healthcare CIO.
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As readers of my blog know, I’m a great fan of the Japanese culture, lifestyle, and people. I’m on a speaking tour of the country this week, meeting with government, academia, and industry leaders in Tokyo, Nagoya and Kyoto. Every time I visit Japan I learn more about the language, the arts, and tradition. The trip thus far has been remarkable with many insights into the challenges of their healthcare system, their plans for EHRs and their emerging interest in PHRs. I’ve met many friends and colleagues, had great vegetarian meals, and mastered the Tokyo subway system.
One of the most interesting experiences was having lunch with Dr. Shigeaki Hinohara, the most famous physician in Japan. He’s 97 years old and loved by everyone – the Japanese version of Dr. Koop. He has published over 150 books since his 75th birthday, including one “Living Long, Living Good” that has sold more than 1.2 million copies. As the founder of the New Elderly Movement, Hinohara encourages others to live a long and happy life, a quest in which no role model is better than the doctor himself.
I asked Doctor Hinohara to describe the secrets of his exemplary physical health and sharp mental acuity.
His response was simple – sleep little, eat modestly, and work hard.
Every night he goes to bed at midnight and wakes at 5:30am. His breakfast is coffee, a glass of milk and orange juice with a tablespoon of olive oil in it. (He notes that olive oil is great for the arteries and keeps his skin healthy). Lunch is milk and a few cookies, or nothing when he is too busy to eat (we ate Soba noodles together). Dinner is mostly vegetables with a bit of fish and rice, and, twice a week, 100 grams of lean meat. His total intake is about 1800 calories a day.
He always takes the stairs and walks everywhere. He volunteers at St. Luke’s Hospital in Tokyo (he’s the Chairman of the Board) 18 hours a day, 7 days a week.
If I have half his energy at 97, I’ll be happy!
The Healthcare Entrepreneur blog is published by Vantage Clinical Solutions, a health-care management consulting firm based in Denver.
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Who’s never been kicked? Maybe even knocked down for an 8-count or so?
Not many I would venture to guess.
In fact, if we’re telling the truth I would bet that not one reader of these words can honestly say that they’ve never been kicked and down — possibly nearly out.
There’s a big difference between being down and being out though, and the difference I would argue – especially within healthcare – can be found in your mission. Your mission, or your practice’s reason for being, should light the way in good times and bad, helping you make decisions that support your existence, even when the world wants to do otherwise.
When things are going well, your mission helps you to grow in the right direction, maximize opportunity, and sow the seeds that will cast deep roots for your practice’s legacy. And when things aren’t going well — you’ve lost a key member of your staff, or have come to realize that your bottom line isn’t as hefty as you had planned — your mission is equally (if not more) important.
I cannot think of another industry in which reliance on a mission is as critical as it is in healthcare. By nature of the services we provide, things will not always go well. We will have patients for which we care deeply, die. We will not always have the resources necessary to provide care in exactly the manner that we would like. We won’t always go home at the end of the day feeling refreshed and alive. Sometimes, we’ll be kicked, and sometimes we’ll be down.
I was down recently due to a transaction that didn’t unfold as well as I had planned. Whether I looked at the situation from an emotional, fiscal, or operational level, it was tough to deal with, and I felt kicked and down. And after sitting on the pity pot for just long enough to know I didn’t like it there, I went back to our mission.
We — Vantage Clinical Solutions — are here to improve healthcare through entrepreneurship. That’s all we’re about. Sure, we work to be fiscally sound, enjoy what we’re doing, and on and on…but really, we’re here to improve healthcare, and we do it by weaving entrepreneurship into the minds, practices, and lives of practice owners. As soon as this became once again my focus, I quickly lost sight of the pity, jumped back on my horse, and again felt the rush of inspiration that got me here in the first place.
Now, I would like to disclaim that it might not be that every scenario will turn as quickly around as the one I described. The key though, is that scenarios can turn around, and often times this can be achieve by relying on your core — your mission.
Dr. Ramona Bates is a plastic surgeon in Little Rock, Ark., who writes
regularly at Suture for a Living.
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Acute compartment syndrome of the hand is an emergency and requires prompt surgical decompression. This article (the first reference below) is a cadaveric study aimed at identifying the myofascial compartments of the hand.
David E. Williams is the co-founder of MedPharma Partners who writes
regularly on the Health
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Dr. Robert M. Wachter is professor and associate chairman of the Department
of Medicine at the University of California, San Francisco.
He writes regularly at Wachter’s World.
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Last month’s New England Journal included another astounding checklist study, an international extravaganza that found nearly 50% reductions in mortality and complications after implementation of pre- and post-op surgical safety checklists.
Coincidentally, I read the study, conducted by a research team led by surgeon/author extraordinaire Atul Gawande, on my way home from a meeting at the headquarters of the Agency for Healthcare Research and Quality (AHRQ). The AHRQ gathering brought together the advisors to a new rollout of the Hopkins/Michigan checklist program to prevent central line-associated bloodstream infections (CABSI) to 10 additional states. You remember that study, published in the NEJM in 2007: implementation of a simple 5-item checklist in more than 100 Michigan ICUs led to over 1000 lives saved.
(Parenthetically, this was the study, led by Genius-Award Winner Peter Pronovost, that the Feds tried to shut down over the failure to obtain informed consent, an action that caused me to blow my gasket last year. The subsequent broo-ha-ha, fueled in large part by readers of this blog, led to a change in the federal policy regarding informed consent for quality improvement programs. Accordingly, the new 10-state roll-out of the CABSI program is considered “quality improvement” and thus exempted from the need for individual consent from providers and patients, Heaven be Praised.)
Last month’s surgical checklist study, one of the first initiatives of the WHO’s World Alliance for Patient Safety (spearheaded by the UK’s indefatigable and charismatic Chief Medical Officer, Sir Liam Donaldson) is, if anything, even more amazing than the Hopkins/Michigan effort. Why? Instead of changing the behavior of intensivists and ICU nurses, this one involves surgeons. And instead of changing practices in ICUs in a single U.S. state, this one did it in hospitals in 8 different cities around the world, ranging from Seattle to Manila, and Auckland to Amman. It was an audacious effort, which makes its results all-the-more-remarkable.
(In fact, it is hard to fully explain the tremendous decrease in surgical deaths and complications based on the nature of the intervention, leading some to question whether the results owe to a Hawthorne effect and are replicable. We’ll see, but for now I think the study is impressive and the intervention is likely to work elsewhere, albeit perhaps not quite as well as reported in the NEJM. OK, that’s enough parenthetical paragraphs for one posting.)
Gawande articulated (a particularly apt word in the case of this gifted writer) his zeal for checklists in his New Yorker article, “The Checklist.” And Pronovost is passionate about everything – he could make you joyful about doing your laundry. But what is so impressive about both these superb leaders and the projects they spawned was something more wonky than stirring: their insistence on a rigorous measurement strategy.
Which brings me to the recent wrap-up of the 5 Million Lives Campaign, the Institute for Healthcare Improvement’s (IHI) much-touted sequel to its 100,000 Lives Campaign. As you may recall, I critiqued the earlier campaign for using fuzzy math in estimating its “lives saved,” among other things. I worried aloud that the short-term high that came from celebrating the 100,000 Lives Campaign’s achievements might prove to be as ephemeral as that achieved by crack cocaine: without measurable results, it is awfully hard to generate sustainability, and the day-after hangover can be nasty.
And so it was with the 5 Million Lives Campaign, which ended with a relative whimper, sans the press hoopla that accompanied the 100,000 Lives effort. To IHI’s credit, there was no preening this time about lives saved, or defending of largely indefensible statistics. In fact, as the Boston Globe reported in December after the campaign’s end,
[the IHI] does not have numbers to measure the effect of its efforts over the last two years, IHI vice president Joseph McCannon said… But stories of reduced infection rates, improved medication management, and better cardiac care have been flowing in from the more than 4,000 hospitals participating in the campaign, he said…
The next stage, added McCannon, was the addition of three new “planks” to the 5 Million Lives practices: linking hospitals’ patient safety efforts to cost savings, preventing nosocomial urinary tract infections, and promoting the WHO surgical checklist program described above. In addition, IHI launched a tool, known as the “Improvement Map,” to help hospitals keep track of their various quality and safety initiatives.
This is all fine, but I get the sense that the absence of results took some wind out of the IHI’s sails. (Of course, that’ll be nothing compared to the wind removed if – as has been reported in the blogosphere – IHI founder and CEO Don Berwick becomes head of the Centers for Medicare & Medicaid Services).
What is the lesson in all of this? While baking rigorous measurement into large-scale tests of quality improvement or patient safety practices costs some time and money (doubtless the reason why IHI chose a Nike-like, “Just Do It” implementation strategy), the choice to eschew such measurement comes at a high cost. When the Michigan ICU study ended in a seminal New England Journal paper, there was tremendous momentum to do more, based largely on the unassailable evidence of lives saved. Not only did AHRQ jump at the opportunity to fund a rollout to 10 more states, but two private philanthropists gave Pronovost another $2.5 million to disseminate it even more widely! We haven’t heard the upshot of the WHO surgical checklist study yet, but you can bet that it will spark more efforts to promote this and similar interventions. Not just because the premise (marrying the use of checklists with culture change) made sense or because Gawande is a wonderful writer and a great guy, but because they demonstrably worked.
At the end of the AHRQ meeting last month, all the advisory board members were asked to identify the highlight of the day. Mine was this: I was floored by the blend of passion and scientific rigor shown by Pronovost and the other members of the project team (he’s being aided by the American Hospital Association’s Educational/Research Trust, along with several leaders from the Michigan effort).
Why did I focus on this combination of passion and scientific rigor? Because too little of the former and you can’t get projects this complex and messy off the ground. And too little of the latter, you risk finishing the project and not knowing whether you’ve accomplished anything of importance.
In other words, this is a Goldilocks problem and both Gawande and Pronovost, and their superb teams and funders, have gotten it just right.
The Happy Hospitalist is a board certified internist who works in the
hospital and writes regularly on several blogs, including The Happy Hospitalist.
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If you haven’t checked out AllergyNotesTwitter feed, you are missing out (you can even get an RSS feed of it). This guy is a gold mine for great information. From his feed comes this other great find about 15 graceful ways to say no.
Some people live their lives trying to please others. For some, the thought of letting others down can eat at them for weeks at a time. In their mind, they believe that if someone asks them for help, they are obligated to help them.
While helping others is certainly a noble gesture, there must be limits and boundaries to how much you can do. Some people are incapable of finding those boundaries. They are so busy helping others, the are unable to help themselves, nor help others in a capacity that they deserve.
I learned to say no years ago. It comes quite natural to me. I have no ill will on myself when I have to decline other’s requests for help. I have established my own boundaries and feel quite comfortable picking and choosing, by my own choice, when I will say yes and when I will say no.
I know there are many folks out there that just can’t say no. The always Yes crowd have their own reasons. Some feel a desire to help everyone all the time, putting their needs last. Others have a loneliness that drives their irrational belief that helping others will make them less lonely. Some find their self esteem is tied to being there for others.
Whatever the reason, being unable to say NO is as unhealthy as never saying Yes. Finding that happy medium should be a priority for everyone