Emergency General Surgery — dangerous and expensive

Emergency general surgery (EGS) is common in the United States.  11% of surgical admissions require emergency surgery.  The statistics on EGS seem to create more questions than they answer:

• The 11% of surgerys classified as EGS are associated with 50% of all surgical deaths.
• Poor people who have EGS have a greater risk of death than average
• Rich people who have EGS have a lower risk of death than average
• Seven surgeries (removing part of the colon, removing part of the small-bowel, removing the gallbladder, operations related to peptic ulcer disease, removing abdominal adhesions, appendectomy and other operations to open the abdomen) accounted for 80% of the deaths and hospital costs related to EGS.
• The cost of ECS in the U.S. is about 7 billion dollars per year.
• EGS patients admitted by a surgeon have lower hospital costs than those admitted by a hospitalist.
• Specific quality guidelines for ECS do not exist.

One might be tempted to say the diagnosis is so complicated nothing could improve the situation for patients.  However, this would be like the situation for pilots and passengers 30 years ago when major airliner accidents happened at least once a year.  The quality movement swept over the airline industry which is now is rated as one of the safest of complex human endeavors.  Those same measures need to be applied to EGS.

When an airplane has an emergency the crew pulls together and acts as a team.  They follow a procedure practiced many times.  They have simulators and tests.  If an engine fails, if there is a fire, if a landing gear fails there’s a procedure to follow.  Each pilot does not invent a procedure just because they are the pilot that day. Likewise, every surgeon should not invent a procedure just because they are the surgeon that day.

It would be easy to blame surgeons or the patients themselves for such dismal outcomes.  But, as people in the quality improvement department say:

IT’S NOT THE PEOPLE, IT’S THE PROCESS.

The first step is to acknowledge EGS is a process.  When a patient arrives in the emergency room with abdominal pain, low blood pressure, free air in the abdomen and a high white blood count there should be no barriers to evaluation an treatment.

1. The goal is to have the patient in the operating room within 90 minutes from  crossing the ER threshold (T).
2. Blood tests and CT scan of the abdomen are done by T+ 20 minutes.
3. Surgeon is in the ER to evaluate the patient by T + 30 minutes
4. A decision for operation is made by T + 45 minutes.
5. Pre-op antibiotics, fluids, and pressors are started as needed.
6. Anesthesiologist begins care of the patient in the ER by T + 60 minutes.
7. Central line is inserted, operating room is notified, ICU is notified, critical care team is notified by T+75 minutes.
8. Patient is transported to the operating room.  The opening incision is made by T + 90 minutes.

Such a process is obviously difficult.  First, the ambulance crew can not transport a patient with an abdominal emergency to a facility unable to deal with the problem, like a small rural hospital or an urban community ER.  This will require training of the ambulance crews and communication with a high level ER.

General surgeons and back-up general surgeons must be available within 30 minutes.  It’s a difficult life to be immediately available — the hospital is responsible to either pay surgeons to be on-call or to hire surgeons to stay in the facility.  Hospitalists are not an appropriate substitute to deal with an acute abdomen or even severe abdominal pain of uncertain cause.  A helicopter ride to a higher level facility is the best solution for patients with severe abdominal pain entering a facility not capable of following the above protocol.  The crazy practice of having a night-time hospitalist admit a critical surgical patient for a surgeon to see “in the morning” must come to an end.

Since the mortality rate of EGS patients is quite high the intensive care unit is the place they should go after surgery even if they seem stable in the operating room.  Complications are very common so early recognition and treatment is essential.  Returning to the operating room later may be needed and should not delayed.  Critical care consultation should be strongly considered.  Multidisciplinary rounding with critical care specialists, nurses, pharmacists, dietitians, and social workers is strongly advised.  Rushing to get the patient out of the hospital to a secondary level of care is a mistake since re-admission is fairly common.  The patient needs to be as stable as possible before discharge.  Hospitalization for 1 – 2 weeks is not uncommon.

The difference in outcome of EGS between rich and poor is not uncommon for many things in medicine and surgery.  Several factors are at play but probably the biggest is fear of big medical bills — if you can’t pay one would wait till the last moment.  Second, medical literacy — always a bigger problem for lower socioeconomic groups — if you think Tums or Rolaids will fix anything you might wait too long to go for help.  Finally, a negative bias toward Medicaid or “cash” patients — sometimes the finances determine whether a hospital will keep or transfer patients.  At midnight many cases seem to be too “hard” and must be sent to a referral hospital which wastes valuable time.

Since prospective research is difficult and time consuming (taking years or decades) a local and national registry should be utilized.  The diagnosis, the surgical approach and the outcome must be tracked to find the best combinations for the best outcome.  As best practices are identified surgeons and hospitals must quickly change protocols and surgical techniques.  U.S. healthcare can not stand the usual 15 years needed to implement new practices.

References:

• Washington Post
• JAMA Surgery
• J Trauma Acute Care Surg.
• The Joint Commission
• J Trauma Acute Care Surgery
• J Trauma Acute Care Surgery
• J Am Coll Surgery

If any nurse out there has a standard order-set for EGS please share it.

Incompetence — caused by medical conditions

One of the most frustrating problems for families and care providers is the intransigent patient.  The patient who does not eat well, has poor judgement, stays at home, says they just plan to die at home, and have no intention of following family or healthcare provider advice.  Like it or not, ethically and legally the patient gets to do what they want and only heartache and frustration will result from efforts to the contrary.  What to do:  maintain contact, don’t blame, help where possible, support, be a friend and call a social worker.

HOWEVER, the situation described might have been avoided.  Might have been happier.  Might be different with healthcare provider and family input at an earlier stage, by simply asking, “what do you want to happen at the end of life?”  Listen carefully to the answer.  Because, at that point, many people are receptive to the idea of making some plans and formalizing their wishes.  Hopefully, the following documents can be completed:

1. A living will or similar document.
2. A financial durable power of attorney.
3. A medical durable power of attorney.
4. A last will and testament or a trust.

TidyForms and LegalZoom are reasonable places to get free online forms, there are probably other websites as well.  Lawyers are clearly the experts here.  But, for uncontested situations like severe dementia the free forms are usually adequate and a lot less expensive.

Why does this help?

• Because when the person is able to think clearly about options they can express their wishes for end-of-life care.  Both family and healthcare providers will be inclined to follow the wishes of the patient knowing it truly is the patient’s desire, not just some obstructionism or retaliation against the wishes of others.
• Because management of finances and health care decisions will be assumed by someone who the patient trusts.
• And, if such documents exist the barrier to intervention is much lower.  Generally no legal involvement is needed.  Most healthcare providers and banks will follow the instructions of the power of attorney if the situation is logical (like the patient has a medical diagnosis of dementia).
•   If a bank or care center requires documentation a person is indeed incompetent, a certification statement from two medical providers (a short statement — see below) is usually sufficient to invoke the powers of attorney without going to court.  However, if contested, those signed documents go a long way to getting a favorable court ruling for the power of attorney to act as the patient’s agent.

According to Legal Zoom:

“Mental competence is defined as the ability to understand the terms of a contract and the capacity to enter into an agreement. Mental competence can be temporarily compromised, for instance, by intoxication. Permanent mental incompetence can result from severe head or brain injury, mental illness, retardation or a degenerative mental condition such as dementia. The law does not allow a principal who is mentally incompetent to designate power of attorney. A mentally incompetent principal is also prohibited from revoking a power of attorney that was properly drawn up. In fact, a durable power of attorney is designed to allow an agent to act in place of a principal who becomes incompetent, either due to illness, injury or some other reason.”

Competence is a difficult concept.  That’s because competence depends on the question:  competence to do what?  There is a vast difference in the competence to decide what to eat and the competence to enter into a legal contract.  So, a person can be competent to do lots of things but not competent to do other things — it’s not a monolithic term.

Judgment is something different.  People may have poor judgment and be fully competent — if a bad decision means incompetence then we all would be in that boat at one time or another.

Mental retardation and mental illness pose huge financial and legal problems.  Professional help from lawyers, psychologists, psychiatrists and social workers is essential.

Physicians statement of mental capacity — competence or incompetence.   Requests for this type of evaluation are becoming more frequent as the population ages and dementia is more common.  Primary care MDs should not shy away from a dementia evaluation, but there are elements that need to be addressed.  A note on a prescription pad, “OK for nursing home, poor memory.” is not adequate.

It is surprising how many primary care providers base the diagnosis of dementia only on what the family reports — they never do a simple mental status exam or take the time to train a nurse to do it for them.   A Mini Mental State Exam would be great — it is excellent documentation for the medical record.  But, at a minimum, a check of orientation (person, place and time) is required.  It’s not difficult:

• Please tell me your name.
• Where are we right now?
• Could you tell me what time it is now?  [do you remember what day of the week it is today?]  [what year is it?] [is it 1949, 2016 or 1975?]

Without a doubt, a person who does not know who they are can not enter into an agreement — they probably can not even sign their name!  And, a person who does not know the city where they are or the correct year certainly does not have the ability to understand the terms of a contract.   Those two things mean the patient is not legally competent.  Those two things mean the power of attorney documents could be activated.

After an MD does an assessment which demonstrates a lack of competence the following are key elements for the statement:

Name and address of MD Date and time of exam Name and birth date of the patient with the medical record number. Medical diagnosis related to mental capacity (e.g. brain injury, dementia, stroke etc.) Whether the diagnosis is permanent or temporary.  If temporary when the next evaluation should be performed. Patient age, sex, general condition and over what period of time the diagnosis came into being. Brief findings of the interview and examination (especially orientation).  Other helpful comments include ability to perform activities of daily living (ADLs), ability to manage finances, the need for care givers and potential hazards such as falling or getting lost.  Conclusion:  [Name] has severe mental incapacity which is a permanent/temporary condition.  He/she is not able to manage financial affairs or make health care decisions for himself/herself or others.  In my opinion his/her power-of-attorney documents for both property and health care should now be in effect.  Specifically, by reason of mental incapacity he/she is unable to do the following: Manage his/her own estate. Enter into a binding agreement. Understand that a contract is being made and its general nature. All the facts and opinions in this statement are true and correct to the best of my knowledge and belief. [Signature of MD]

Most states require statements from two physicians.  Other practitioners may be allowed to make statements about competence but the rules are variable.

Guardianship (conservatorship) is the alternative of last resort.  This is an action by a court when a person can no longer make or communicate safe or sound decisions about his/her person and/or property or has become susceptible to fraud or undue influence.  A judge appoints a qualified guardian — family or friends have no rights in this matter (the judge makes decisions based on the person’s best interest).  The guardian does not own the assets of the ward but manages the assets and makes decisions solely for the benefit of the ward.  Depending on the person’s specific competence (or lack thereof) the guardian may be directed to make decisions for the ward in these matters:

• Determine residence
• Consent to medical treatment.
• Make end-of-life decisions.
• Possess a driver’s license.
• Manage, buy, or sell property.
• Own or possess a firearm or weapon.
• Contract or file lawsuits.
• Marry.
• Vote.

Guardianship removes rights from a person and the person’s family so it is not something to be taken lightly.  But, there are times when it is essential. A guardian may be a family member or friend or a public or private entity appointed by the court.  They must follow the instructions from a judge and make periodic reports to the court.

 

Hip Replacement — the engineer as a patient

People from all walks of life undergo hip replacement surgery.  Some of those people are engineers — people who design things, build things, and worry about the materials for manufacturing.  Those pesky engineers want information about hip surgery the average person might find boring but the engineer finds comforting.  So this guide is for the engineer who needs to have a hip replaced, not the engineer who actually makes the parts.

Original Equipment Failure.  The original specifications for the hip joint were not provided.  It seems there is a lot of variation from person to person.  Some hips last a lifetime, others do not.  The cause of hip failure mostly seems to be the result of gradual wear of the cartilage bearing surfaces within the large ball and socket joint that is our hip.  When the cartilage is so worn the underlying bone is exposed the joint fails with pain, inflammation and restriction of motion.  The time-course of joint failure can be sudden, but usually it is prolonged over many years with increasing symptoms of pain and loss of function.

Timing of Replacement:  The joint should be replaced when the joint function is causing unacceptable limitation of activity.  The time from initial symptoms until replacement is variable ranging from a couple of years to a decade.  There can be complications of surgery (including death) so jumping into surgery before it’s needed is a bad idea.

Expert Advice:  Orthopedic surgeons who specialize in large joint replacement are the experts.  They use a combination of examination and x-rays to give an assessment of the joint.  A good surgeon will never say you must have surgery — they always leave the decision to the patient.  Sometimes that attitude is disconcerting but actually is very reasonable.  After surgery, neither you or the surgeon want to say “I wish I had waited.”

Method of Replacement:  Special tools and jigs are provided by each manufacturer of  artificial hip systems.  Often, a hospital will limit the options to one manufacturer for obvious cost and storage reasons.  A sterile four-part hip replacement is selected:  1) the acetabular cup  2) the liner for the cup  2) the ball and 3) the femoral stem.  When the parts are ready the surgeon must cut into the thigh, visualize the hip joint, remove (with a saw) the ball from the top of the femur bone, ream out the inside of the femur and press fit a stem into the femur.  Then, the natural socket is removed (with a grinder) and the metal cup is inserted (often fastened with screws).  The liner is snapped into the cup (the socket of the joint).  The ball is pressed on top of the stem. Finally the ball is eased into the liner.  The surgeon sutures the various layers of the incision closed.  The final layer, the skin, is closed with staples.  A sterile dressing is applied over the incision.

Options:

Surgical Incision: Each surgeon has their favorite: anterior (in front of the joint), lateral (the side of the joint) or the posterior-lateral (the side of the joint toward the back).   The lateral incision technique was developed first so many surgeons use that method.  Surgeons trained within the past 10 years may have experience with the anterior approach.  The anterior approach seems to result in a quicker recovery and less discomfort.

Metal parts:  Stainless steel was used in the past but fell out of favor because tiny amounts the cobalt and chromium in the steel could be absorbed by the body and cause undesirable side-effects.  Now, metal parts are constructed with either titanium or zirconium.  Also, the newer materials are slightly more flexible than steel, spreading stress to the bones more evenly.

Acetabular cup:  A metal part that fits into the pelvic bone where the natural joint socket was located.  The side that touches the bone is rough.  There are holes through the cup for screws to attach it to the bone.  The other side is where the liner snaps into position.  

Liner for the cup:  This is one of the bearing surfaces in the joint.  Older liners were made of simple polyethylene plastic.  Excessive wear was a problem for some patients.  Now, the most popular liner is a special polyethylene treated with radiation to result in a highly cross-linked material that is much more durable.  Polyethylene also provides some shock resistance.  Some companies make a ceramic liner, but because of the concave geometry (fracture risk), the brittle nature of the material and the tendency to squeak it is not requested as often, but it is very wear resistant.  People in their 40’s and 50’s might want the extreme wear resistance of the ceramic liner just to avoid a repeat surgery 20 or 30 years later.

Ball: The most wear-resistant material is ceramic.  Because of the spherical shape of the ball a fracture of this ceramic part is less likely than for a ceramic liner.  Ceramic balls are becoming a standard.  Nitride coated zirconium is also an option for the ball but it not as wear resistant as the ceramic.

Stem:  This is the part that is wedge-fit into the thigh bone called the femur.  It is tapered and has a rough finish.  The tool kit for the system includes several test-fit rods to make sure the reaming of the femur is exactly the size needed.  Once the fit is adequate the stem is seated in the bone with a tap from a malet.  The ball is press fit on the other end of the stem.  The ball may be an integral part of the stem in some systems.

Attachment:  Metal parts pressed against bone need to stay in position for a long time.  If a patient has healthy bone the most desirable solution is a special coating on the metal that provides a rough surface for the bone to grow into.  Titanium parts can be plasma sprayed with pure titanium as one method to obtain a rough surface.  Another method is to bind a bony material called hydroxyapatite to the metal surface.  The alternative method, for people with weak bones, is polymethyl methacrylate glue.

Anesthesia:  A short stay in the hospital is desirable to reduce exposure to germs that are resistant to antibiotics.  Effective anesthesia with good pain control after surgery make shorter stays possible.  A favorite is spinal anesthesia (makes the body numb below the waist for a couple of hours) along with a sedative, like propofol which has few side-effects.  Of course, a few injections of pain medication and pain pills are needed.  For reasonably healthy people just an overnight stay is all that is needed.

Prevention of Complications:  The surgical technique, the anesthesia, and the materials in the artificial hip all are designed to minimize complications.  Two feared complications are infection and blood clots — both of which can be fatal in extreme cases.  An infusion of an antibiotic within two hours of surgery helps to reduce infection.  Pneumatic compression stockings or “boots” help to reduce blood clots during surgery.  After surgery, maintaining activity with frequent walking reduces the risk of clots.  Some surgeons add a low-dose aspirin to reduce the chances of heart attack and stroke.  Constipation is a common complication easily prevented with prunes, stool softener or a mild laxative.

Comment:  If you are an engineer or just someone who wanted additional detail hopefully this summary is helpful.  There is a lot of information available on the Internet but it is always difficult to understand medical jargon.  Out-of-date information can be really confusing.  Of course, your surgeon is always happy to answer questions — write down the questions and take them with you to your appointment.

A Visit to the Eye Doctor — do your homework

When you go to an eye doctor do you walk away not really understanding what just happened?  Do you know your diagnosis?  Do you know what the prescription means?  It should be simple but it’s not and you need to do your homework before your visit.

CAST of CHARACTERS: Ophthalmologists are MDs who do surgery and prescribe medications.  Optometrists are ODs who mostly do vision tests for glasses but depending on training and State laws they may also do some of the things Ophthalmologists do.  RNs, PAs and MAs assist eye doctors just as they might for any medical doctor.  Opticians have a high school degree plus training to fit glasses.

Ophthalmologists may have the highest IQs of any doctor group.  Ophthalmology has a reputation for a good life-style and high income.  The training programs have huge numbers of applicants and only take the best and brightest.  Ophthalmologists are so far from primary care they really don’t know what it is about and the reverse is also true.  A high IQ does not guarantee skill at explaining eye problems.

Eye doctors are obviously visually oriented.  So, one of the best questions a patient can ask is, “I don’t understand, could you draw a picture?”

The eyes alone seem to have as many things that could go wrong as the rest of the body.  But. there are a five topics most people should know about:

1. Glasses.  What is near-sighted and far-sighted.  What do the numbers on the prescription mean.
2. Aging eyes.  As we get older our eyes can’t adjust to see close things as well — the reason reading glasses were invented!
3. Ordering glasses on the Internet works well and can save a lot of money (hundreds of dollars).
4. Removal of cataracts (clouded natural lenses inside the eye) is a 20 minute painless surgery.  The old lens is removed and a plastic lens inserted in it’s place.  Most people need to wear glasses full or part time after the surgery.
5. Diabetes is becoming very common.  Diabetes hurts the eyes and may cause blindness.  Good control of blood sugar is essential.  Laser treatments can slow down some of the deterioration by cauterizing tiny damaged and leaking blood vessels in the retina.

GLASSES PRESCRIPTION:

The key numbers are under “Spherical”.  These are the strength of the lenses needed measured in diopters.  The bigger the number the stronger the lens.  A positive number here means you are far-sighted and a negative number means you are near-sighted.

The cylinder is an optical adjustment needed when the natural optics of the eye are not symmetric — the shape of the cornea is not as spherical as it should be — it is a little oblong.  The axis is the angle of the oblong abnormality.   Any cylinder numbers mean you have this non-spherical problem called astigmatism.

The ADD is the amount of power added to the basic lens strength needed for close-up vision (the lower part of bifocals).  +2.5 is typical for seeing things about 14 inches from the eyes (reading) and 1.25 is about right for seeing things about 20 inches from the eyes (computer screens).

The PD (pupilary distance) is important for centering the glasses over the eyes.  The right PD is from the bridge of the nose to the center of the right pupil and the left PD is on the opposite side.   In most people these are equal and only the sum is important (in this case the sum is 68).

AGING EYES.

As we get older the eyes can’t adjust well from far to near.  People with normal vision may find they just need reading glasses.  Near and far sighted people may need bifocals.  If you have more than about 0.50 of cylinder adjustment cheap reading glasses will likely not be comfortable and prescription glasses are the solution.

GLASSES on the INTERNET

A couple of reasonable sites are zennioptical.com and 39dollarglasses.com.  There are others if you search for them.  It’s no big deal to adjust the frames — dipping the bows in near boiling water for 15 seconds then bending them to fit is not difficult — but do not take them to an eye shop for this — they will not help you for obvious reasons.  If you have frames that fit make sure to take the measurements suggested on the website and get something similar.

REMOVAL of CATARACTS:

Cataract surgery only takes about 20 minutes and is painless.  The clouded lens is removed with a little suction blender then a rolled-up plastic lens is inserted  through a needle — it opens up inside the space of the old lens.

Although the surgeon tries to get perfect vision after the surgery it is not a perfect science so about 30% of people will need glasses for driving.  Virtually all people will need reading glasses.

 

 

DIABETIC EYES

Blindness is one of the feared complications of diabetes.  It is usually do to an overgrowth of blood vessels in the retina that tend to leak protein and sometimes leak blood — both substances that damage the retina and make holes in the vision.  People who keep the blood sugars in tight control tend to have less of this problem. The abnormal blood vessels can be cauterized with a very fine laser which slows down the progression of the condition.