May 17th, 2009 by Dr. Val Jones in True Stories
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Tragically, land mines injure between 15,000 to 20,000 people each year. Some civilians see a metal object sticking out of the ground and attempt to pick it up and inspect it – the result is often loss of both hands and eyes.
The goal of rehabilitation after trauma is to restore as much independence as possible to patients. With loss of vision and no hands, self care, feeding, and donning/doffing arm prostheses can be very challenging. There is a procedure, known as the Krukenberg operation (named after Hermann Von Krukenberg, who first described it in 1917), that allows the forearm bones to be separated, using the muscle rotators that exist between them to create a pincer grasp. This procedure is not uncommonly used in India and Pakistan and does indeed return some degree of functional use to the arms.
At a recent Physical Medicine and Rehabilitation conference, this photograph was used to illustrate arm function after the Krukenberg operation.
Photo Credit: Dr. Heikki Uustal
It certainly presents a conundrum – should function trump aesthetics in all cases?
I’m not sure that I’d want this procedure, even if I lost my vision and both hands.
Would you?
May 17th, 2009 by Paul Auerbach, M.D. in Better Health Network
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When a healthcare provider takes care of a patient, he or she usually completes the episode by explaining something to the patient. For instance, if I treat a wound, before I leave the patient, I explain how to change the dressing, take care of the wounds, signs and symptoms of infection, how to take any suggested medications, when to return for a recheck, etc. But in thinking about how I make the communication, I don’t always write everything down for the patient, or even quiz the patient to determine if they comprehend what I have told them. Undoubtedly, some do not.
A recent study performed in the emergency department setting indicates that at least three quarters of patients do not fully understand the care that they have been given, or even comprehend when they do not understand their discharge instructions. Dr. Kirsten Engel and colleagues (Annals of Emergency Medicine 2009; 53:454-461) found that, “not only do the patients not understand the care instructions from their doctors, but the vast majority are also unaware that they have not fully understood what the doctor has told them.” One can always be critical of any study’s methodology – in this case it might have been more effective to include more patients and caregivers in the analysis – but even if the findings were not so dramatic, there is an important message in the results.
There are many reasons why a patient might not understand what has been accomplished for him. These include lack of an explanation, an explanation that exceeds the patient’s educational level (comprehension), language barrier, and distraction of the patient (by being ill, in pain, having altered consciousness, or other medical/social situation). Doctors are sometimes poor communicators, and are even caricatured as such. During a rescue situation, or when there are multiple victims, there may not be time to be a superb communicator. However, whenever possible, at least the basics should be covered, and this certainly applies to situations of medicine in the outdoors.
If the situation allows, take the time to explain what you are doing for/to your patient while you are doing it. This begins with preparing him or her for the event, particularly if it will be painful, like wound cleansing, manipulating an injured body part, realigning and splinting a broken bone, etc. After you have accomplished your medical intervention, if you need for the patient or anyone else to be responsible for assessing/monitoring the patient, then be very precise about what it is that is to be observed, how frequently to check on the patient, and whom to tell if there is a problem. Explain all medications, including purpose, doses, frequency of administration, and common side effects. To the extent possible, write everything down, so that the patient and other caregivers have a record of what they are supposed to do. If time allows and you have the patience for it, ask the patient and caregivers if they understand what you have told them, and ask them to repeat your advice and instructions. Do not assume that because you have told someone something one time in an awkward and rushed moment, that they heard and understood everything you said. “Medical speak” can be complicated or confusing, and what seems simple and logical to you may require more than a quick run-through. The time that you take to be clear, straightforward, and understood will pay large rewards later in terms of better patient outcomes and fewer problems down the road.
Preview the Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 24-29, 2009.
Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.
This post, Understanding Instructions, was originally published on
Healthine.com by Paul Auerbach, M.D..
May 16th, 2009 by EvanFalchukJD in Better Health Network
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Why paying for health care is so difficult:
a gigantic, complex raft of billing codes which are seemingly designed to haunt you in your sleep. With thousands of codes, and with frequent revisions to the fee schedule, it’s difficult to imagine a bureaucratic system. . . more challenging to decipher.
American health care? No, Canadian.
Some problems are inherent to health care, regardless of who pays for it.
*This blog post was originally published at See First Blog*
May 15th, 2009 by DrRich in Health Policy
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DrRich’s valued colleague R. W. Donnell, who writes Notes From Dr. RW, has responded to a recent post in which DrRich bravely came out in favor of Comparative Effectiveness Research, even at the cost (DrRich asserted) of alienating the majority of the more conservative-leaning components of his readership.
Dr. RW, noting DrRich’s claim that conservatives have laid out a formal policy of opposition to CER, says:
“OK, stop. Where are these people, conservatives or those of any ilk, who have taken a position against CER? Dr. Rich cites groups who are skeptical and very concerned about the new political agenda for CER, not CER itself.”
Dr. RW is, of course, correct. Research that compares the relative effectiveness of medical procedures or treatments is not only inherently a very good thing, but also is a form of research that has a long and proud history. Healthcare would be an even more dire activity than it is today without the large body of research that guides physicians in making recommendations to their patients when more than one option is available. So yes, comparative effectiveness research is obviously a valuable and time-honored endeavor, and for anyone (conservatives or anyone else) to come out against it would be akin to coming out against babies, or bunnies. (Though, as one whose effort to grow vegetables has been severely challenged each year by a pride of aggressive rabbits, DrRich, as it happens, is indeed against bunnies.)
So, to reiterate, neither conservatives nor anyone else are really against comparative effectiveness research, just as Dr. RW asserts.
What they are against is Comparative Effectiveness Research. They are against a new government bureaucracy that sets the CER agenda, whose stated goal is to create a more efficient and less expensive healthcare system, and that will have the authority to determine what gets reimbursed and what doesn’t.
Dr. RW has made it plain that he is not confused about the following point, but many are: There is a difference between comparative effectiveness research (whose unambiguous goal is to compare the clinical effectiveness among different treatment options, so as to offer physicians objective guidance in making clinical decisions, and which is as unassailable as babies and bunnies), and Comparative Effectiveness Research (which is to be operated by a new government bureaucracy, whose agenda regarding what kind of effectiveness is actually to be compared is intentionally ambiguous).
The ambiguity of CER (as compared to cer) was made clear recently when Peter Orszag testified on behalf of the administration before the Senate Finance Committee. When queried by skeptical Republicans on the ultimate goal of the proposed CER board, Mr. Orszag was evasive. Specifically, when asked by Senator Kyle (R-Arizona) whether the CER board would be empowered to make decisions on which medical services will be reimbursed, Mr. Orszag finally replied, “Not at this point,” a reply which did not alleviate the suspicions of the minority party.
To state the ambiguity more plainly, it is clear that while the CER board will mainly be concerned about comparing “cost effectiveness” (which is the only way they can potentially achieve their main goal of reducing healthcare costs), the only kind of effectiveness they are willing to discuss publicly is “clinical effectiveness.”
This studied ambiguity allows proponents of the new government plan to paint opponents of the CER board as being against the “babies and bunnies” form of comparative effectiveness research, and thus reveal those nay-sayers as being beneath contempt, unworthy of anyone’s attention. Meanwhile they will be free to advance their real “cost effectiveness” agenda.
DrRich agrees with conservatives that this kind of deceptive ambiguity is indeed contemptible. But really, it is no more contemptible than the thousands of other forms of covert healthcare rationing we see all around us. (Covert rationing inherently relies on ambiguity – saying we’re doing one thing while all the time we’re doing another.)
Having tried to clarify this distinction between cer and CER, DrRich will now repeat that his prior post was not merely to express support for the “babies and bunnies” variety. As Dr. RW points out, everybody is in favor of that kind of comparative effectiveness research.
Rather – and this is where he further jeopardizes his continued tolerance by his conservative readers – DrRich is offering his support to the other kind of CER, the kind described in the stimulus bill, which (though the administration will not say it publicly) will undoubtedly use comparative effectiveness research to perform cost effectiveness calculations, then coerce physicians, through one form of federal subterfuge and intimidation or another, to employ the least expensive therapies. The government bureaucrats, just as they are doing today but with less muscle, will shout “quality” while enforcing “cost.”
DrRich supports this kind of CER not because it is a good thing – it decidedly is not. He supports it because here is a form of covert rationing that will at last effect everyone, and will be so blatant that after a time even us Americans will no longer be able to ignore it, try as we might. DrRich believes that relatively soon, we would notice that here is a cadre of unelected bureaucrats rationing our healthcare – determining which of us lives and dies – through some opaque process, and lying to us about it the whole time. He believes this to be the pathway most likely to get the American people to finally face the fact of healthcare rationing, and to goad them into an open debate on the best and least harmful way to accomplish it.
Go ahead. Call him a cock-eyed optimist.
*This blog post was originally published at The Covert Rationing Blog*
