Post-Op Care 101

When my patients are ready to begin their recovery after they have had surgery, I generally tell everyone the same things regarding this process of recovery:

The human body is smart and knows how to heal itself. Supporting that process is the best plan for quick healing.

Each person is different, but in general, the healing process is consistent.

Resume diet slowly and pay attention to cravings. This is your body’s way of telling you what will feel and taste good. Try small amounts of food and drink and slowly increase as your appetite improves.

Activity: slowly increase activity level while paying attention

A former patient, Patty T., who wrote about her surgery experience for Winds of Change magazine.

to pain level.

  • Activities that are strenuous or remind you of the day you had your surgery are likely causing potential problems, such as surgical site hernias.
  • If you’re sore, but can continue activity without distraction, it’s probably okay.
  • If it doesn’t occur to you until hours later that you did an activity, then this is the ideal amount of activity for you.

Work: if you can perform your work duties without getting overly tired or having pain, then you can return without restriction.

Bathing: most of my patients can shower or bathe immediately as per their usual routine. (I usually tailor these instructions to the incision, but since I do mostly minimally invasive surgery, these are usually small incisions with no suture or specific care required.)

The following are warning signs that you should call me or come in for a post-operative evaluation:

High fevers

Excessive pain not controlled by prescribed medication

Excessive drainage or redness near the incision(s)

Inability to urinate

Inability to eat or drink or for unremitting emesis (vomiting)

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Fewer Uninsured: Update on the Affordable Care Act

Recently, I spent two weeks working at a rural hospital in northern Nevada. Despite the variety of patient populations, including homelessness, I did not have a single uninsured patient.  I credit the hospital case workers with efficiently and effectively helping people get enrolled in appropriate coverage.

The Affordable Care Act continues to expand access to health care to millions of people. Here are a few updates on the “Obamacare” front.

Enrollments: During the open enrollment period just concluded, 12.7 million people signed up for health insurance on the federal and state exchanges. According to Health and Human Services Secretary Sylvia Burwell,

“We enrolled 4 million new people in the HealthCare.gov states, and this does not include new plan selections in the State-based Marketplaces. It’s clear that Marketplace coverage is a product people want and need. And as the Affordable Care Act has taken effect, more than 17.6 million Americans gained coverage through late last summer. More than 90 percent of Americans are insured. That’s the first time this has ever been true.”

Health care coverage for Hispanic children: Hispanic children (the fastest growing segment of the American population) are not yet as well insured as non-Hispanic children, but their numbers continue to improve, according to a study co-authored by the Georgetown University Health Policy Institute’s Center for Children and Families and the National Council of La Raza, a civil rights and advocacy group for Hispanic Americans.

In 2014 alone (2015 numbers are not available yet), the uninsured rate for Hispanic kids fell two full percentage points to 9.7% uninsured, the lowest ever for this group. The authors of the study point to the Affordable Care Act as one reason for the decreasing uninsured rate: “When parents enrolled, they generally signed up their children, too.”

Medicaid expansion now in majority of states: One of the provisions of the Affordable Care Act is to provide funds for the states to expand Medicaid for low-income citizens. Today, 31 states and the District of Columbia have expanded their Medicaid coverage, either directly through the ACA or through another plan approved by the federal government.

Look for your state on this map of Medicaid expansion:  https://www.statereforum.org/Medicaid-Expansion-Decisions-Map?gclid=CObh0eKl38oCFZSGfgodyXwMBQ

Read Secretary Burwell’s complete press release here: http://www.hhs.gov/about/leadership/secretary/speeches/2016/success-by-the-numbers-2016-open-enrollment.html

Read more in this Huffington Post article:  http://www.huffingtonpost.com/entry/uninsured-kids_us_569e881be4b0cd99679b8d44?utm_hp_ref=obamacare

 

 

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Risks for Readmission

No one likes to be readmitted to the hospital with complications following surgery, and health care professionals would like to reduce the readmission rate as much as possible.

A recent study published by the American Medical Association in JAMA Surgery sought to better understand the hospital readmission rate for emergency general surgery (EGS) patients. The authors of the study write,

“Reducing readmissions is a noble cost-saving goal with benefits not only to the hospitals, but also to the patients. However, it is critical to understand the underlying factors associated with readmission to appropriately identify measures that address the true problem.”

Emergency_room

Picture of the artwork “Emergency Room” by French-Danish artist Thierry Geoffroy.

The study examined California surgery patients who were older than 18 to identity risk factors associated with being readmitted to the hospital within 30 days of their initial EGS procedure. These factors included “patient demographics [gender, race/ethnicity, age, etc.], insurance type, Charlson Comorbidity Index score (taking into account co-existing illnesses), length of stay, complications, and discharge disposition.”

The findings of the study included:

“Out of the 177,511 patients included in the study, 5.91% was readmitted to the hospital within 30 days and 16.8% of those were readmitted at a different hospital than their original.”

“The most common reasons for readmission were surgical site infections, gastrointestinal complications, and pulmonary complications.”

“[S]ignificantly higher readmission rates were seen in patients older than 65 years, who were black, and who had high Charlson Comorbidity Index scores.”

“Significantly lower readmission rates were seen in patients who stayed in hospital less than 4 days, and in those who were discharged home.”

“Gender had no effect in readmission likelihood.”

“Independent risk factors for readmission included having a Charlson Comorbidity Index score over 2, being discharged against medical advice, staying in hospital more than 7 days, and having public insurance.”

According to the American Journal of Managed Care, these findings indicate that “readmission after EGS procedures is far too common, and that identifying these specific risk factors and targeting patients who exhibit them is the step in the right direction in reducing readmissions.”

Adds  Dr. O. Joe Hines of the David Geffen School of Medicine at UCLA, the information gathered in this and other studies provides “a great opportunity to intervene on behalf of our patients and improve their outcomes.”

Next time, I’ll expand on what patients can do to help prevent readmission and what to do if you aren’t doing well after surgery.

Be well.

http://www.ajmc.com/newsroom/readmission-after-emergency-general-surgery-far-too-common-study-finds

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2015 Website Review

WordPress.com stats helpers prepared an annual report for my website.  I found it interesting, I hope you do too.  Review my most popular articles as well as learn a little about my readers. (For example, they came from 61 different countries!)

Here’s an excerpt:

A San Francisco cable car holds 60 people. This website was viewed about 2,000 times in 2015. If it were a cable car, it would take about 33 trips to carry that many people.

Click here to see the complete report.

Thank you for reading and sharing!

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Trend Alert: Coloring for Adults

Adult coloring is a trend that is sticking around. There is no shortage of coloring books marketed for adults.  In fact, a quick search on amazon.com for “adult coloring books” returned over 8,000 results.

Why is coloring so popular?

  • Repetitive tasks with predictable results are calming and lower both heart rate and stress.
  • Using fine motor skills stimulates the brain.
  • Colors and the creative process are uplifting.

netterscoloringbookColoring also helps reinforce concepts you are trying to learn.  I used a coloring book (similar to the one pictured) in medical school to help learn anatomical structures.

As an aside, medical illustration has a history as long as the field of medicine itself.  Illustrators in this field even have a professional association.

Regarding the benefits of coloring for adults, clinical psychologist Dr. Ben Michaelis says,

“Because it’s a centering activity, the amygdala, which is the part of the brain that is involved with our fear response, actually gets a… bit of a rest, and it ultimately has a really calming effect over time.”

DavisGeneralSurgeryColoringPage(Read more here.) By lowering heart rate and stress, making time for coloring or similar activities may improve your health.  It most certainly will improve your mood.

To that end, please enjoy this First Edition, Davis General Surgery Coloring Book.

Be well.

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Diverticulitis – Symptoms, Diagnosis, and Treatment

Yes, I treat diverticulitis.  Diverticulitis is defined as the inflammation and infection of “pouches” (diverticula) in the wall of the colon.  Studies have shown that general surgeons, such as myself, who specialize in the treatment of diverticulitis, have as good or better outcomes than colorectal surgeons.

Infected pouches along the colon. (University of Virginia Health Systems)

Infected pouches along the colon. (University of Virginia Health Systems)

Many people who are diagnosed with diverticulitis have never heard of it.  Here are some of the basics you should know.

Symptoms: Symptoms of diverticulitis, lasting between hours and weeks, may include:

  • Abdominal pain and tenderness, usually in the lower left side, that is sometimes worse when moving.
  • Chills and fever.
  • Bloating and gas.
  • Constipation or, less commonly, diarrhea.
  • Nausea and possibly vomiting.

Risk factors: You may find that you do not fit into all risk categories.  However, these risk factors have been associated with diverticulitis.

  • Low-fiber diet.  This diet has an abundance of processed foods (food from a box) and is lacking in whole plant-based food (food from the produce section).
  • Advanced age.  The incidence of diverticulitis increases with age.
  • Obesity.  Being medically overweight increases your odds of developing diverticulitis, with morbid obesity increasing your risk of needing more-invasive treatments for diverticulitis.
  • Lack of exercise. Vigorous exercise appears to lower your risk of diverticulitis.
  • Certain medications. Several drugs are associated with an increased risk of diverticulitis, including steroids, opiates and nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve).

Diagnosis: Doctors will do an examination and may run several tests to diagnose diverticulitis or rule it out, including blood and urine tests, X-rays and CT scans, and liver function and stool tests. In women, doctors also need to check for pregnancy or pelvic infections as the possible source of pain.

Treatment: Treatment depends on the severity of symptoms and the results of the tests. Milder cases of “uncomplicated” diverticulitis may be treated with antibiotics, rest, pain medicine, and a liquid diet for a while, with possible dietary changes later.

“Complicated” or severe diverticulitis, especially when combined with other health problems, may require hospitalization and/or surgery.

According to the Mayo Clinic, you’ll likely need surgery to treat diverticulitis if:

You have a complication, such as perforation, abscess, fistula or bowel obstruction.

You have had multiple episodes of uncomplicated diverticulitis.

You are immune compromised.

There are two main types of surgery:

  • Primary bowel resection, which can be done through traditional open surgery or laparoscopically, depending on the circumstances. The surgeon removes diseased segments of your intestine and then reconnects the healthy segments (anastomosis).
  • Bowel resection with colostomy, a more extreme surgical procedure, is done if it is not possible to rejoin your colon and rectum at the time of surgery. Waste passes into a colostomy bag on the outside of the body. In most cases, a colostomy may be reversed and the bowel reconnected after it heals.
Patty got

Patty got “glamour shots” taken with her colostomy bag for her article on her experience with diverticulitis.

It is common for many patients, when first diagnosed with diverticulitis, to become overwhelmed by the likelihood of surgery.  They have particular concerns about receiving a colostomy bag.  There is no doubt, this is a life-changing event.

Patients who have undergone treatment confirm that it was indeed a life-changing event… but for the better.  The removal of chronic pain and other symptoms frees them up to enjoy life, return to work,  and even enjoy eating again.

One specific patient of mine was moved to write an article about her experience.  Soon, she is running another half marathon, a hobby she was unable to enjoy before treatment.  You can read about her experience here: “Balancing Risk”

More information:

http://www.mayoclinic.org/diseases-conditions/diverticulitis/basics/definition/con-20033495

http://www.webmd.com/digestive-disorders/tc/diverticulitis-topic-overview

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Don’t Panic: Tips for managing when an out-of-state loved one is hospitalized

Last week I received a nice card from the daughter of a patient.  The daughter lives on the East Coast and communicated with the nurses to keep up-to-date and coordinate care.  I met her post-op when rounding on my patient. I helped her plan her return trip around the expected post-op course.

A nice thank you.

A nice thank you.

She wrote,

Thank you for taking such great care of my mother.  You tremendously helped a very stressful situation to become manageable.  Your skills and care are superb.  Mom is doing well in rehab and is looking forward to going home.

In this age, it is commonplace for me to field inquiries from out-of-town family members.

So, you get the call that your loved one has been hospitalized.  Now what?

I offer these tips to help you get the information you need.

  1. Do not panic. For most hospitalizations, time is on your side.  The initial assessment, related medical tests, and the admission itself all take time.  Take a few deeps breaths, head to an appropriate and quiet spot, then prepare to call the hospital.
  2. Have a notebook handy to keep notes. Write down the following each time you call.
    1. Date and time
    2. Name of person to whom you spoke
    3. A summary of what was discussed and any decisions that were made
  3. Be prepared to identify yourself and even provide proof of your identity. Your loved one’s healthcare is federally protected by HIPAA laws and you must not expect a facility or individual to “take your word” that’s it is ok to share information.
  4. creative commons 2015

    creative commons 2015

    Ask to speak to the nurse who is in charge of caring for your loved one. It may seem important to ask to speak with a doctor but the nurse is better for these reasons:

    1. They are on-site when you call (although be patient if they need time before talking with you).
    2. Your loved one may have multiple doctors of different specialties, but the nurse can give you the “big picture”.
    3. The nurse will let you know if a question or concern is best answered by a doctor and will have the doctor call you.
  5. Likewise, speak to the nurse in charge of your loved one in addition to speaking to him or her.
    1. Hospitalization is stressful and bombarding your relative with questions can add to that stress.
    2. You may not get the correct answers or complete picture.
  6. When following up with either the nurse or doctor, write your questions down in advance (use that notebook you’re keeping handy). Healthcare professionals do not have time to “chat”.  Sticking to your questions will ensure efficiency that will keep the conservation successful and pleasant.

I often get this question from out-of-town loved ones:

“Do I need to come now?”

This question is usually a masked version of “Is my loved one going to make it?”  I make it a point to answer as honestly as possible, given the current set of facts.  However, is it ultimately you who will have to make that decision.  If you do choose to travel, please let the hospital know your travel plans so they can make arrangements.  They will know when you are unavailable during a flight, for example, as well as know when you plan to be at the bedside.

I, myself, have been in the situation of having an out-of-state loved one hospitalized.  Making arrangements and decisions long-distance was very stressful.  Clear communication can help alleviate some of that stress and I hope my tips help you if are ever in a similar situation.

Be well.

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In the Age of Patent Medicines

I’m taking another opportunity to discuss the history of medicine. I have a curiosity about old medical practices and am continuously amazed at how far we’ve come. For example, I have book in my office called the “Medical Uses of Soap” (published in 1945), which has an entire section dedicated to the health benefits of washing one’s hair.

This week, I reflected on the use of “patent medicines”, those elixirs and such which were sold directly to the public and promised cures for all kinds of ailments.

Patent medicine ad found in 1901 newspaper.

Patent medicine ad found in 1901 newspaper.

Many ailments and conditions are so easily and routinely treated nowadays with some sort of surgery that we forget how few medical choices people had in the not-so-distant past. Appendicitis, gall bladder disease, and hemorrhoids (sometimes called “piles”), for example, have plagued people for millennia, but safe surgical techniques to treat these problems are a recent phenomenon.

During the patent medicine era of the late 1800s and early 1900s, desperate people turned to all manner of concoctions to find relief for the above conditions and many others, including sexually-transmitted diseases, male virility problems, and “female complaints.” These medicines often contained many dangerous ingredients, including alcohol, cocaine, laudanum, and mercury.

The advertising of patent medicines promised miraculous cures for almost anything that ails humanity.

A product made by Kellogg promised to “drive gloom from your brain and vitalize every nerve in your body.” An “oil of gladness” would cure all aches and pains.

A well-known medicine called Chlorodyne promised to cure influenza, colds, coughs, asthma, bronchitis, neuralgia, toothache, gout, diarrhea, and several other things — a miracle drug, indeed. Patent medicines even promised to cure truly life-threatening diseases like cholera, cancer, malaria, and tuberculosis.

A diverse condition called “biliousness” was believed to result from a malfunctioning gall bladder or liver, so there were many medicines offered to treat these organs and digestive problems in general. “Liver pills” were widely available, whether or not the liver was really the culprit. Various treatments for hemorrhoids included ingredients like sulfur, camphor, carbolic acid, opium, and wax.

Today, a general surgery practice covers many of these maladies, and without the toxins listed above.  While I wish there was an actual “oil of gladness”, I encourage my patients to look beyond their present condition to an improved quality of life.  Seeing this come true does indeed produce “gladness”.

Be well.

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Your Barber Will No Longer Do Blood-letting or Surgery

I was recently interviewed about robotic surgery for an insert on the history of surgery in the Las Vegas Sun. During the interview, I described how robotics evolved from laparoscopic surgery, in which a tiny camera is inserted into the patient along with surgical instruments. I told the Sun that as in laparoscopic procedures, the robotic method “lets us complete complex surgeries on the inside of the body, but from the outside, it’s just a series of small incisions.”

While “laparoscopic is a great technique, it can be limiting. The two main problems are that the image during surgery is only 2-D, so depth perception is an issue, and the instruments aren’t as mobile. They can only move side to side, and up and down.”

Use of equipment like the da Vinci Surgical System improves on the laparoscopic technique in that it creates a 3-D image for the surgeon that emulates their experience during open surgery. The da Vinci robot also provides a full 360-degree range of motion. The movements of the surgeon’s hands are replicated exactly.

 “Open abdominal surgeries can leave patients with a four-to-six week healing time, but with robotic surgery, many patients are able to walk out of the hospital that day.”

Las Vegas Sun Insert July 2015Each patient’s surgery is unique and the best procedure is the one that affords the best possible outcome, be it open, laparoscopic, or robot-assisted.  What is impressive about the da Vinci Surgical System is that even complex surgeries are resulting in good outcomes.

Here is an edited timeline of important surgical milestones and procedures included in the Las Vegas Sun article (if you are using a larger screen, the PDF of the actual insert is worth viewing):

6500 B.C.: Evidence of trepanation, the first surgical procedure, dates to 6500 B.C. Trepanation was the practice of drilling or cutting a hole through the skull to expose the brain. This was thought to cure mental illness, migraines, epileptic seizures and was used as emergency surgery after a head wound.

1540: Once rivals, the Barbers Company and the Guild of Surgeons combined their expertise to create the United Barber-Surgeons Company in England. The group performed tooth extractions and blood-letting, in addition to the occasional haircut.

1846: Surgical anesthesia was demonstrated for the first time by American dentist William T. G. Morton using the inhalation of ether. Prior to this discovery, all patients had to undergo operations, including amputations, while awake.

1867: British surgeon Joseph Lister created antiseptic using carbon acid, and he published a study citing the importance of cleanliness and sterility during surgery. In the following years, the mortality rate for surgical patients fell dramatically.

1896: The first successful heart surgery was performed.

1917: The first documented plastic surgery was performed on a burn victim.

1950: The first successful organ transplant occurred.

1975: Laparoscopic surgery was performed.

1985: The first documented robotic surgery was performed.

2000: The da Vinci robot was granted FDA approval for laparoscopic surgery.

Read the entire article here: http://lasvegassun.com/native/mountainview/2015/jul/05/evolution-surgery/

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Two New Hands for Zion Harvey

Sometimes a medical story in the news is particularly compelling and really captures our attention. Such is the recent news about Zion Harvey, an 8-year-old boy who recently received the first bilateral hand transplant performed on a child.

Why this surgery is amazing:

  1. Microsurgery — the act of literally performing surgery while looking through a microscope.
  2. Multiple systems — circulatory, nervous, muscular, skeletal, immune.  Failure of one is failure of all.
  3. Teamwork.  Ditto.
  4. Tissue and organ donation.  This selfless act made the whole thing possible.
  5. Peds patient.  It’s my direct experience that kids are the most resilient, and the most optimistic of patients.  Which often makes working on them the most heartbreaking but most rewarding.

Zion suffered a massive infection at age two that resulted in amputations of both feet and hands, as well as other emergency treatments to save his internal organs. He received a new kidney from his mother at age 4. Now he has two new hands and is thus far doing well.

Double-hand transplant recipient eight-year-old Zion Harvey smiles during a news conference Tuesday, July 28, 2015, at The Children’s Hospital of Philadelphia (CHOP) in Philadelphia.  (AP Photo/Matt Rourke)

Double-hand transplant recipient eight-year-old Zion Harvey smiles during a news conference Tuesday, July 28, 2015, at The Children’s Hospital of Philadelphia (CHOP) in Philadelphia. (AP Photo/Matt Rourke)

His story illustrates the extraordinary results that modern surgery can achieve. Just the scale of the procedure is impressive. CNN reports that “the 10-hour surgery looked more like a scrubs convention than an operating room. Among the 40 medical personnel that helped with the operation were a dozen surgeons, eight nurses and a team of at least three anesthesiologists.”

The staff had to “create tags with descriptions such as ‘ulnar artery’ and attach them to the various vessels, bones, nerves and tendons that needed to be connected” (CNN) in order to keep everything straight.

Doctors point out that in Zion’s case, the procedure had to allow for future growth of his arm bones and other considerations based on his youth. It will be months before he has true sensation in his hands and he faces years of physical therapy to gain normal function (ABC news).

As you can imagine, hand transplants are a pretty new phenomenon. The first successful transplant was performed in the United States in January of 1999. The first double hand transplant occurred a year later in France, and there have since been additional hand and arm transplants in other countries, including China, Malasia, Belgium, and Italy.

Prior to the surgery, Zion was not only brave and resolute about his upcoming ordeal, he was even prepared for failure.

“When I get these hands, I will be proud of what hands I get,” he said. “And if it gets messed up . . . I don’t care because I have my family” (ABC news).

Dr. L. Scott Levin, director of the hand transplantation program at The Children’s Hospital of Philadelphia, reminds us of the other family involved, that of the donor: “I think the difference is finding a family who has the courage to relinquish the arms of a child who just died and give hope and life and quality of life to a child who’s still living.”

Read more here:

http://www.handtransplant.com/TheProcedure/HandTransplantHistory/tabid/96/Default.aspx

http://www.cnn.com/2015/07/29/us/baltimore-boy-zion-harvey-first-double-hand-transplant-recipients/

http://abcnews.go.com/Health/future-youngest-recipient-groundbreaking-dual-hand-transplant/story?id=32765236

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