October 20th, 2009 by Paul Auerbach, M.D. in Better Health Network, News
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Every one in a while, an inventor comes up with something remarkable, not only in its ingenuity, but in its simplicity and applicability. Whenever I see something like that, I usually mutter or marvel, “I wish I had thought of that.” Such is the case with the original ski pole Slishman Splint, invented by my friend Dr. Sam Slishman.
Wilderness medical types are familiar with the difficulties managing long bone fractures in the backcountry. A femur fracture can be a devastating, and even life-threatening, injury. It’s common knowledge that realigning the bony fragments and stabilizing the femur are important to control blood loss and pain, and to facilitate victim extrication and transport. There are numerous traction splints for this purpose on the market, but many of them are heavy, bulky and unwieldy in a remote setting. Sam intended to solve that problem. Read more »
This post, Leg Splints Made From Ski Poles, was originally published on
Healthine.com by Paul Auerbach, M.D..
October 11th, 2009 by Dr. Val Jones in True Stories
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Well, indirectly that is. I was spending a nice Sunday afternoon biking around the Potomac with my husband when Obama’s Marine One helicopter flew low over us and took a sudden left turn. The maneuver was eye-catching, and hubby took his eyes off the road to watch. His front wheel slipped off the pavement and got wedged between the grass and bike path. He took a pretty bad spill, and I jumped off my bike to check him out. (I had given him a lecture about not wearing a helmet only a few hours prior). Luckily, he did not hit his head… unluckily, he got a pretty nice abrasion on his left elbow and hip (right through his clothing) as well as this lovely developing bursitis. See photo on next page… Read more »
September 21st, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips
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This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was about trauma and orthopedics. It was delivered by Douglass Weiss, MD of Teton Orthopaedics in Jackson Hole, Wyoming.
Utilizing some fabulous images, including those of Lanny Johnson, Dr. Weiss made some important points. Many of these are familiar to seasoned medical practitioners, but they merit repeating. First, when approaching a victim, always attend to the “ABCs” first – airway, breathing, and circulation (including bleeding) – so that a life can be saved. Then, if possible, take into account other injuries, including those of bones – save the limb, save the joint, and restore function.
Here are two good pointers. First, your field evaluation of the victim may be the only complete one, so do your best to examine the entire victim, and also to document in writing what you discover. Examine and establish the airway, listen for breath sounds, observe chest movements, feel for pulses and observe skin color, etc. Within the constraints of the situation and environment, “expose” the victim in order to evaluate bony and other injuries. The, move on to the “secondary” survey, which will include examination of the neck, back, pelvis, arms and legs, looking for swelling, bruises, scrapes, cuts, bleeding and deformities. If you feel inappropriate motion (e.g., broken or dislocated bones or joints), be prepared to apply splints.
Always try to roll the patient (using a logroll technique if necessary) to examine the victim’s back.
For the benefit of doctors reading this post, remember that if a fracture is identified, suspect an injury to the joint above and below the fracture, and be sure to splint these for the comfort and protection of the victim.
The application of splints is an art form, so should be practiced prior to your expedition. Any limb that is obviously deformed or that demonstrates excess motion (where there should be none) should be immobilized immediately. If a helper(s) is available, use assistance. Be sure to pad all splints very well to avoid pressure injuries to the tissue underneath. Depending on the rescue, the splint may be in place longer than you anticipate.
If a broken bone (fracture) is “open” (the bone has poked through the skin), then apply a wet (preferably normal saline or disinfected water) dressing and apply a splint. If you have an all-purpose antibiotic (e.g., cephalexin, amoxicillin or ciprofloxacin) and the victim is capable of purposeful swallowing, administer a dose.
Fractures of the pelvis generally imply that a very significant force was applied, so they carry a high risk for associated life threatening injuries. The victim should be evacuated as soon as possible. It is commonly taught that a broken femur (the long bone of the thigh) can cause bleeding in excess of a liter into the limb. This can be dangerous, so these injuries should be promptly splinted, preferably with a pre-fashioned or improvised traction splint.
Compartment syndrome occurs when tissue pressures within inelastic soft tissue compartments of the limbs (commonly the forearm or lower leg exceed perfusion pressure, that is, the pressure necessary to allow blood to circulate freely through the tissues and provide energy and remove waste products. Symptoms include extreme pain, loss of pulses, pale skin color, weakness or paralysis of the muscle, and numbness and tingling. If the pain is severe and the skin feels tight, a compartment syndrome may be developing. If a compartment syndrome is felt to be impending or present, keep the limb elevated and seek immediate medical attention, because an operation may be required to open the compartment and release the pressure before the onset of permanent tissue damage.
Thanks to Dr. Weiss for his contribution to wilderness medicine education.
This post, Tips For Evaluating Injured People In The Outdoors, was originally published on
Healthine.com by Paul Auerbach, M.D..
July 1st, 2009 by James Herndon, M.D. in Health Policy, Opinion
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[Dr. Jim Herndon is a past president of the American Academy of Orthopaedic Surgeons, and chair emeritus of the department of orthopaedic surgery at Partners Healthcare]
***
The challenges of health care reform are enormous. To expect that the vast array of problems that exist today will be corrected or solved in a couple of months is totally unrealistic. Witness the moving target of announced changes and options occurring daily in the press and media in general. And add to the confusion…these changes are being developed at the top (Congress and the White House)…not from the bottom up (from doctors, nurses and other health care providers, and importantly, patients). In their place are the powerful lobbyists…the health insurance industry, the hospital industry, the drug industry and even organized medicine (AMA)…who wield their influence over our policy makers by all sorts of tangible (financial donations) and intangible (spouses of leaders on corporate boards) pressures.
I must admit, although occasionally said without real meaning…I don’t hear an outburst of support for the essential mission/purpose of health care…the health of our citizens…”the patient comes first”. Where is the patient…who is supposed to come first…in this national debate?
Everyone knows that health care is expensive. In 1970 health care spending consumed 7% of the Gross Domestic Product. In 2009 health care spending is consuming 16% or more of our Gross Domestic Product. It is increasing more rapidly than inflation. Yet, as a nation, we have not…in all these years…had a serious conversation about Americans’ health. Where is it in our list of priorities? I don’t think we know. From recent events we do know it is lower than the need to remove Saddam Hussein from power…it is lower than bailing out investment companies and banks…it is lower than stabilizing the mortgage market…and it is lower than bailing out two automobile manufacturers. I am not knowledgeable enough to question the priority of the bailouts of banks and financial institutions or the mortgage companies…but I do question the priority of removing another country’s dictator or bailing out two automobile manufacturers instead of allowing them to proceed through bankruptcy in our court system…over health care reform.
Too often in my lifetime I have seen the importance of health care reform pushed down the list of priorities over other needed programs…to wait for another day. How important is the patient, the health of Americans today? How far are we going to push the profession of medicine from “a calling”…a profession, as President Obama states to “a business”. It is known that patients trust their doctors, but not our health care system. When will patients begin to trust their own doctors less? It will happen if and when they believe doctors are more “concerned with the pulse of commerce” rather than the “pulse of their patients”. I submit we are getting very close to this tipping point…in losing the trust of our patients and society in general.
There is no unanimity of opinion regarding the health care reform debate…amongst Democrats, amongst Republication…amongst the public…amongst physicians in general…and orthopaedic surgeons specifically. I asked a few young physicians in an orthopaedic residency program their opinions about the health care reform debate. All believed that every American should have basic health care insurance coverage. Obvious to them, it would include coverage for care of patients with acute fractures or patients with severe pain or loss of function. They admit not knowing much about the “public option” and the swirling politics going on. They also were not comfortable with defining what situations or problems would not be covered by insurance…although they agreed that some restrictions above “basic care” would have to be implemented.
Their responses reminded me that in 1990, when I was in graduate school for an MBA…we had a class debate about whether health care was a right or not of all citizens? Although the discussion was lively and some felt health care was a privilege, the class conceded that health care was a right of all citizens…admitting historically it was considered a privilege for the few who could afford it, but then (1990 or earlier?) health care had become a right for all in the US. I then asked a few of my colleagues who enjoy leadership positions in the field of orthopaedic surgery their opinions regarding health care reform. They also could not agree on the issues of this debate.
One area where they did agree was that academic medical centers are not well positioned for the future…especially those that depend on state funding. We have already witnessed this in Massachusetts where apparently the state has decreased funding to some teaching hospitals that traditionally have cared for a large number of uninsured. Now that most citizens have insurance, they are seeking their care in other hospital emergency departments. My colleagues also agree that physicians will receive lower payments for specific treatments or participate in “bundled” payments to the entire healthcare team/facility for comprehensive care of the patient.
Otherwise my colleagues disagreed. On the one side some support the public option and universal coverage…although “the devil is in the details”. For this group they have become tired…like so many American physicians…with the convoluted way we finance health care and the associated paper trail/documentation overload. The system has made some patient conditions profitable and others not profitable…described by one as “perverted incentives”. These physicians (me included) are angry at the loss of our professionalism as hospitals and physicians chase dollars and not the health needs of each patient and the public. On the other side (against public option), my colleagues have some agreements…most orthopaedic surgeons are supportive of care of the uninsured and underinsured, especially for patients presenting with acute problems to hospitals’ emergency departments. Most also agree that there needs to be a serious realignment of incentives and improved collaboration of hospitals and doctors.
But they have many disagreements…including the provision of elective care. They argue…with good reasons…that with continued rising costs to practice medicine (rent, electronic records, employee wages and benefits, malpractice insurance, increased personnel requirements for the administration/paperwork overload) and continued reductions in reimbursement (Medicare, for example, pays an orthopaedic surgeon today approximately 50% of the reimbursement it paid for a total hip replacement in 1990)…it is becoming increasingly problematic to provide elective care for the underinsured and uninsured. They commonly ask…”How can you provide care that costs more than any receipts”?
Other disagreements include: the single payor system…they don’t believe it will work; although well-intended, they believe these reforms will result in overall lower quality of care for patients; that emergency departments will still be used by those with insurance because patients can see a physician at the patients’ convenience and avoid long delays to see a doctor in his/her office…for example there is a 40-day wait to see an orthopaedist in his/her office in Boston; the continued tremendous demands by American patients to have the latest technology, the latest treatment…even if evidence for its use is unknown; skepticism about the prevention of disorders that have a genetic basis, i.e. osteoarthritis…in the foreseeable future; the simple fact that to reduce errors and overuse/misuse of tests by an electronic medical record and computer physician-order system will cost enormous amounts of increased spending in the short term…before cost savings are eventually realized… and to draw attention to one specific unsolved problem area…Workers’ Compensation…where orthopaedists, daily, see ineffective treatments being used and large numbers of patients on disability.
Briefly, the follow are factors that have led to increased and inefficient health care in the US: high administrative costs; overuse of services and new technology; an increased prevalence of chronic disease; tremendous geographic variations in care; increased payments not resulting in improved quality; a continually high number of medical errors and complications; a broken professional liability system; a shift in costs from the uninsured to the insured; a predominant third-party payer system; overuse and misuse of care; focus changing from the patient to the pocketbook; insurance company abuses (cherry-picking healthy patients, denying care of patients with chronic disease, deliberately lowering the normal of “usual and customary” fees…to name a few); and continued issues of fraud and abuse, especially in the Medicare and Medicaid programs.
Finally I would like to close with the official position of the American Academy of Orthopaedic Surgeons (AAOS) on health care reform: “Any changes to the health care financing and delivery system…the well-being of the patient must be the highest priority. The AAOS strongly supports reform measures…that provide individuals with patient-centered, timely, unencumbered, affordable and appropriate health care and universal coverage while maintaining physicians as an integral component to providing the highest quality treatment”.
The AAOS is opposed to a single-payer health system or even a federal health care authority. The AAOS suggests “a number of tax initiatives…that will level the playing field and make health care coverage more affordable”. There should be “adoption of policies that restore equity and enhance market competition”. The AAOS also “strongly believes that patient empowerment and individual responsibility are necessary components of health care reform. Health choices should be recognized and preventive care should be promoted”.
March 17th, 2009 by Dr. Val Jones in Humor, True Stories
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As some of my Twitter friends already know, I had a bit of a scare a few days ago with my cat. I know that I more-or-less promised not to let this blog degenerate into cat talk (and for the record I love dogs too), but please indulge me because I think there’s a larger lesson to be learned.
A few days ago I was emailing away on my computer when I heard an odd thud behind me. I turned around to find my cat lying on her back with one leg fully extended, her pupils dilated, and a fine tremor in all four legs. This lasted for about 10 seconds and then she jumped back onto her feet and walked away as if nothing had happened.
My husband denied giving her any catnip, and since I hadn’t seen this odd behavior in her before I decided to keep a close eye on her. About an hour later she was walking across the floor when she suddenly raised her back rear leg, hopped a few steps, flopped onto her back and did the same weird leg extension, trembling, and let out a bizarre yowl.
That buys her a trip to the vet – and I started running my differential diagnosis through my head. It seemed to me that she was having some kind of focal seizures – and I wondered if she could be in renal failure (she had had a UTI earlier in the year) with metabolic encephalopathy, or perhaps a small tumor that had started to trigger some seizure activity. The episodes seemed to resolve completely in between episodes so I didn’t think she was having a stroke, she also wasn’t continuing to limp and when I pressed on her bones she didn’t flinch so I didn’t think she had broken anything. I called the vet and when asked for the “chief complaint” I was just as helpful as many ER patients:
Dr. Val: My cat’s ‘acting weird.
Receptionist: Could you be more specific?
Dr. Val: Well, she’s acting like she’s had catnip, but she hasn’t.
Receptionist: Uh huh… And what do you mean by that?
Dr. Val: She keeps falling on the floor and stiffening her rear leg. Then she gets up as if everything’s fine. This seems to be happening every hour or so.
Receptionist: I see. And is it possible that she could have eaten something toxic? Do you have poison lying around the house?
Dr. Val: Not that I’m aware of.
Receptionist: Well it sounds like you should bring her in. Can you be here in 15 minutes?
Dr. Val: Wow, that’s not much time. But I can try! I think she might be having seizures…
And so with the vet’s office being 15 minutes away, you can imagine the frenzied efforts that ensued – I managed (single handedly) to put together a cat carrier and stuff the “seizing” feline into it and hoist her onto a cart and push her down the city sidewalks, much to the amusement of onlookers, who probably fully believed that I was a cat-abuser, hearing the pitiful cries coming from inside the cage.
To make a long story short, I explained to the vet-on-call what I’d witnessed, and suggested that my cat might have a brain tumor. Luckily for me, the vet did not blindly take my diagnosis for granted, but performed her own physical exam.
The conclusion?
Vet: Dr. Jones I don’t believe your cat is having seizures. She has a subluxing patella.
Dr. Val: Um, so you’re saying that her knee cap popped out of place?
Vet: Pretty much, yes. That’s why she flops on the floor and stiffens her leg. She’s trying to get the knee cap to slide back into place. It’s a grade 3 subluxation, which means it pops out easily, but still goes back into place on its own.
Dr. Val: How do we fix it?
Vet: She’s a surgical candidate. We can create a divot in her femur to help keep the knee cap in the right groove.
Dr. Val: Wow, we don’t do that for humans. Are you sure that will work?
Vet: Well, you can try glucosamine. It will reduce the inflammation.
Dr. Val: Glucosamine doesn’t reduce inflammation in humans – and there’s no conclusive evidence that it improves joint health either. Isn’t this more of a mechanical problem that needs a mechanical solution?
Vet: [Becoming irritated] Yes, well you can see our orthopedic specialist. She’s not board certified though – but she has a lot of experience with these kinds of things.
Dr. Val: Well, is there a board-certified orthopedic veterinary surgeon that we could consult with? How much do you think that would cost?
Vet: There’s an animal hospital in Friendship Heights. I’m sure their surgeons are all equally well qualified. I guess the procedure would cost around $2000.
Dr. Val: Wow, $2000 to put a divot in a cat’s femur? Gee… I don’t know…
Vet: You should also know that your cat needs her rabies shot.
Dr. Val: She needs another one?
Vet: Yes, they need one every year.
Dr. Val: How likely is a house cat to get rabies? Are there rabid mice that could get into our condo?
Vet: [Scowling] It’s the law. All cats must get a rabies shot every year. There is one rabies shot that can be given every three years, but it’s been associated with osteosarcomas in cats. Would you like to give her that vaccine?
Dr. Val: Uh, no. But seriously, where is my cat going to catch rabies?
Vet: Maybe she’ll catch it from the other pets at the animal hospital when she goes for surgery?
Dr. Val: [Visions of Cujo dancing in her head] Well, that doesn’t sound like a very safe place to take her.
Vet: Would you like to buy some glucosamine?
Dr. Val: No thanks, I think I’ll go now.
***
I learned a few things from this amusing interaction:
1. People should try not to make diagnoses beyond their level of expertise. (Brain tumor versus subluxing patella? Yikes.)
2. Vets do not necessarily practice evidence-based medicine. (Glucosamine for a subluxing patella?)
3. There’s a lot of money in cat vaccines.
4. Cash-only practices are quite lucrative. My little visit cost $300.
What do you think I should do with/for my poor cat?
Every one in a while, an inventor comes up with something remarkable, not only in its ingenuity, but in its simplicity and applicability. Whenever I see something like that, I usually mutter or marvel, “I wish I had thought of that.” Such is the case with the original ski pole Slishman Splint, invented by my friend Dr. Sam Slishman.
