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PRSonally Speaking

Tuesday, December 16, 2014

Best Video Discussion of 2014 Contest

Each year, PRS produces at least one expert Video Discussion per issue. We love these videos and hope you do too; they provide a dynamic way to make education fun, accessible and multimedia.
We are very thankful for each of our fabulous Video Discussants; their efforts, expertise and willingness to step in front of the camera to discuss our field. They deserve all of our respect and gratitude. Their contributions will be watched for years to come. We could simply not provide the same level of interactivity and multimedia content without them.

While we are asking you to vote for your favorites, and will ultimately crown a "Best Video Discussion of 2014," this title will simply represent the culmination of your opinons. All of the video discussions from 2014 are important, well-done and represent a major time commitment from the surgeons you see on screen. They are all fabulous, interesting and should all be watched!
This contest will only include our regular issue video discussions from calendar 2014. So, to view ALL video discussions please visit our Video Discussion Collection.
In the spirit of having a little fun, though, you will choose- by popular vote- the Best Video Discussion of 2014. In order to decide which one to vote for, we encourage you to watch all of them as they each represent hours of research and effort.
A subscription to PRS is not needed to become a registered user, or to watch the Video Discussions.
So, watch all of the great video discussions from 2014 for free and start voting today!

Wednesday, December 10, 2014

by Jinesh Shah, BS, Samuel Lin, MD
Civilian drones are beginning to have applications in numerous fields, ranging from delivering shipped goods, to aerial surveillance, mapping topography, disaster relief, and even natural resource exploration. Increasingly, drones are available in different shapes and sizes, and their varied abilities have garnered popularity with civilian customers and media alike, and governments are debating legislation defining the scope of their use(1).

Commercial drones afford special benefits applicable to the practice of medicine, including being equipped with advanced cameras and the ability to carry heavy loads. Companies like Amazon and Google are already pushing the envelope on how to deliver small packages quickly, safely, and efficiently using drones. It is not difficult to envision this model being adopted and improvised to deliver medications, medical supplies, even custom made 3D printed implants and biomedical devices to remote locations, over relatively long distances, and in resource constrained settings. In fact, American company Matternet is trying to do just that. In partnership with Médecins Sans Frontières in Papua New Guinea and Haiti (2), they are developing autonomous drones to help transport medicines, food, and water to areas afflicted by natural disasters. In other countries like Bhutan, where there are 0.3 physicians per 1,000 people, they are teaming up with the World Health Organization to deliver medications through inclement weather and mountainous terrain, and connect roadless rural communities to healthcare providers (3).  By using drones, providers in these environments are able to save precious time and money without needing extensive infrastructure development. In addition, autonomous drones require minimal oversight, allowing providers to multiply their effects and further save on costs. Other shipping companies like DHL are already testing their “parcelcopter” to deliver medications and emergency goods daily to the island of Juist (4),  and universities in England and Malaysia are utilizing drones to monitor spread of pathogens, research disease epidemiology, and track land-use changes and disease incidence in real time(5).

As we continue to find novel ways to utilize autonomous aerial drones, future applications include use by the military to carry supplies for wounded soldiers in areas of active conflict or over hazardous terrain. The lightweight and rapid maneuverability of drones combined with sophisticated cameras may someday equip physicians with tools to remotely diagnose and triage in real time to determine which patients needed medical intervention and what services would be most beneficial. In doing so, drones would not only improve efficiency in resource allocation, but also potentially save costs and valuable time.

Wednesday, November 12, 2014

by John Ver Halen, MD

Instead of waiting for the next technological “quantum leap” to improve patient care, what can we do better with the tools at hand? Fayezizadeh, et al, describe their impressive (but unsurprising) results using a multimodality pain control program in patients undergoing transversalis abdominis release, and find that time to resumption of oral diet was significantly shorter (versus historical controls)(1). In contrast, when pain management is viewed as a simple direct feedback system (i.e., patients are administered narcotics according to a linear pain scale), the incidence of postoperative nausea and vomiting, ileus, and length of stay goes up considerably.

As we are all aware, patients (and thus, medicine) are far from simple, and require a complex approach. Modern management strategies (e.g., Lean, six-sigma, PDSA cycles) advise us to make small, incremental changes, measure our results, and change accordingly. To quote Winston Churchill (and Frank Underwood): “To improve is to change; to perfect is to change often.” Numerous small changes have resulted in the end product of decreased length of stay, decreased narcotic use, and accelerated recovery in patients in enhanced recovery after surgery (ERAS) protocols. The authors’ results are representative of the global experience with these protocols.

Since my hospital system has initiated an ERAS protocol for abdominal surgery, we have noted a similar decrease in the utilization of narcotics, incidence of postoperative ileus, and hospital length of stay. This has been in the absence of an increase in readmissions, or added morbidity. We have subsequently started using it for our complex abdominal wall reconstruction (hernias, fistulas, component separation) with similar results. We have also changed our mesh repair technique from an inlay, to an onlay technique fixated with fibrin glue to remove trans-fascial suture pain. Like so many hospital systems, mine is undergoing a transition from “quantity” to “quality”. Some of our measures are objective, while others are patient-centered (e.g., Press-Ganey scores). Undoubtedly, instituting an ERAS system is initially more resource-intensive, and requires significant provider training … but how much does it save? And what are the gains, from a patient perspective? Will these changes be requisite, in the future, for providers and hospitals to survive in the changing environment? Finally, in an era of widespread narcotic abuse, is there a positive impact on society at large?

The immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice. Once again, this will be a situation where we will be either “flying ahead of the plane”, or “behind the plane” (to borrow project management jargon). Many plastic surgeons are already using Exparel with abdominoplasty and breast augmenation patients, with convincing results in most cases. But I feel as though we are still behind other specialties in utilizing these techniques. My orthopedic colleagues are using complex pre-surgical, intraoperative, and postoperative cocktails that have permitted outpatient knee arthroplasties for years. What will it take, and what will be the result, when we apply these protocols to our patients?

1. Enhanced Recover After Surgery Pathway for Abdominal Wall Reconstruction: Pilot Study and Preliminary Outcomes.
Plast Reconstr Surg. 134:151S, 2014.

Thursday, October 9, 2014

by Henry C. Hsia, MD, FACS
With Breast Reconstruction Awareness Day ( approaching this month, a timely article appears in the October 2014 issue entitled “Helping Patients Make Choices about Breast Reconstruction: A Decision Analysis Approach” by Sun et al.  The authors adapt techniques which originated in business management, and which have been increasingly applied in medical decision making, to the purpose of helping a breast cancer patient decide whether and how to undergo reconstruction.
"... a Google maps-like personalized reconstruction decision guide would be returned..."
In my practice, the initial patient visit (IPV) for a patient contemplating breast reconstruction is by far the most time-consuming type of patient encounter, often extending an hour or longer.  And with the inexorable pressure to cram more patients into my office hours, I have long sought the “holy grail” of time management solutions to make these visits somehow happen more efficiently through brochures, websites, adjunct counseling by staff members… you name it.  And while these measures are helpful in educating patients about breast reconstruction, in the end they haven’t significantly reduced the amount of time I spend talking to a patient, and my office staff knows never to schedule a “breast reconstruction IPV” for only 15 minutes.
Perhaps the approach offered by Sun et al will change that.  Although the authors never explicitly state this, their approach, with its need for computation-intensive analysis of probabilistic outcomes and use of equations with values weighted based on individual circumstances and preferences, does lay the basic groundwork for a future computerized application where patient-specific information could be entered and a Google maps-like personalized reconstruction decision guide would be returned, telling patient and surgeon the best way to get from the present office visit to the future goal of a restored breast with a minimum of complication.
"...the initial consultation is to help the patient understand my role in her recovery and to get her to see me as not only a surgeon but also a guide for her healing process. "
Yet I spend much of the visit time not in outlining probabilities but in reassuring patients, an especially difficult task given that these patients often come in already scared and anxious, still in the process of coming to terms with the reality of their recent diagnosis.  And as we go over the various alternatives for reconstruction and the potential pitfalls, it can take a great deal of effort and time to help my patient keep her anxiety level in check, while also being forthright about potential complications and managing her expectations appropriately.  It’s a delicate balance, and I often find that the information I say matters much less than the manner in which I say it, as well as the patience with which I listen, often at length, to my patient’s fears and concerns.
I’ve learned over time that the most productive use of the initial consultation is to help the patient understand my role in her recovery and to get her to see me as not only a surgeon but also a guide for her healing process.  I try to get her to understand that proper healing requires not just my technical proficiency but also her cooperative efforts (and that of her support network) to help her body to heal well.  That my technical skills as a surgeon cannot “make” her body heal and become whole again any more than a gardener can “make” a plant grow and bloom or bear fruit.  Restoring a garden ravaged by disease and drought requires not just the gardener’s technical expertise but also an effort, often collaborative, to get the environment and conditions just right to promote the proper growth.  To restore a women’s body requires not just my skill but also substantial efforts on her part.  And I find that getting a patient to understand and buy in to this, especially if she is already afraid and anxious, takes time.  And so while I welcome efforts like Sun et al, I don’t think I’ll be telling my office staff any time soon that I will be squeezing my breast reconstruction IPV’s into a crisp 15-minute encounter.

Wednesday, September 24, 2014

by Anu Bajaj, MD
Recently, I’ve had the opportunity to consider this question since I’ve experienced both personal and professional injuries.  Physicians usually apply different standards to themselves than they apply to their patients.  Everyone else I know, if they are sick or injured takes time off of work – my nurse, my scrub, my husband.  But because our job is to care for others, as physicians, we believe ourselves to be invincible.
everyone had his or her own tale of working at all costs – throwing up in the call-room bathroom, working with a high fever, or asking the nurse to start an IV on oneself.
As a resident, regardless of how bad I felt, I always dragged myself into work.  When I spoke with my fellow residents or former residents, everyone had his or her own tale of working at all costs – throwing up in the call-room bathroom, working with a high fever, or asking the nurse to start an IV on oneself.  During my training, I can recall only one instance when I left the hospital early  -- as a fourth-year medical student, I came down with Rotavirus while on my pediatrics rotation and remember having both nausea/vomiting and diarrhea.  After spending the entire morning in the bathroom, my chief resident finally sent me home.  Similarly, I can recall stories of my father (who is also a surgeon) needing to get breathing treatments between OR cases for his asthma.
In fact I started working with my father when he was injured – he had slipped on the ice and had broken his wrist.  He was in a cast for 3 months and was unable to operate during this time.  When I joined his practice, I was instantaneously busy since he was unable to work.  A year later, I broke my elbow while riding my bike -- I had a non-displaced radial head fracture.  My practice was still young so when my orthopedic surgeon advised that I keep my elbow immobilized for 10 days, I reluctantly complied for a week.  After further discussion, he conceded that I could do gentle range of motion and start operating on SMALL cases; he even specified, no breast reductions or abdominoplasties or weight bearing for 6 weeks.  I did return to work (and followed his instructions).
We were able to find the pieces in the midst of the zucchini, and my father – the hand surgeon – was able to secure them as grafts to my fingertips.
Then three months ago, as I was making zucchini spaghetti on my fancy kitchen mandolin, I sliced off the tips of my thumb and long finger (as a surgeon, I was grateful that it was the radial side of my thumb and my long finger knowing that these areas are less critical for my operating skills).  We were able to find the pieces in the midst of the zucchini, and my father – the hand surgeon – was able to secure them as grafts to my fingertips.  A typical hand patient would have been told to keep the dressing clean and dry and to elevate the hand; I was not a typical hand patient.  Since I didn’t follow instructions, I did have a little graft loss (all eventually healed well).  My father told me that I wouldn’t have lost any of the graft if I hadn’t used my hand while it was healing.  How does one do that?  I’m used to washing my hands umpteen times in a single day.
In the past, I have treated my running and athletic endeavors the same way that I have treated surgery – I have always learned to run through the pain whether it was plantar fasciitis, a strained muscle, or hip pain.  I was able to get away with this approach until a few years ago when I had my first stress fracture.  At that point, there was no way for me to continue to run through the pain, and I had to take time off from running – 4 weeks after the first stress fracture 6 weeks after the second.   I was forced to take time off again following a recent hamstring injury.  I injured my hamstring while running – the pain was so severe that initially I had difficulty walking.  Nevertheless, as soon as I started to feel better, I started running again – probably too soon and promptly reinjured it.  This time, I dutifully rehabbed the injury – took time off from running, then after the pain had disappeared started gentle stretching and cross-training with swimming.  I followed instructions so well that I didn’t run for five weeks despite having an upcoming relay race (Hood to Coast in Oregon). 
As caregivers, it is difficult to acknowledge our vulnerability – not only for ourselves but also for our patients.
So, why do I have this compulsion to keep working or running despite the effects to my well-being?  When we watch professional athletes, many of them will take time off because of an injury – OKC Thunder player Russell Westbrook was sidelined during NBA playoffs for example.  Similarly, as a physician, when I discuss upcoming procedures with patients, I routinely advise them how much time they may need to take off of work, how long before they can work out, and how long they may require someone to help them at home.  And as they recover from surgery, when they ask about resuming activities, I always urge them to listen to their bodies.  They can gradually start to increases activities but should pay attention if “something doesn’t feel right, ” and “listen to your body.”  While it may be easy for me to give advice, it is far more difficult for me to follow this advice.
The easy answer is that we are the caregivers.  As caregivers, it is difficult to acknowledge our vulnerability – not only for ourselves but also for our patients.  Telling a patient that you have to cancel surgery – even if it is because the surgeon is sick or injured still results in disappointment and frustration for the patient.  When I broke my elbow many years ago, I had to cancel a bilateral DIEP flap – despite the excellent reason for needing to reschedule, my patient’s initial response was negative.  So, I have had it ingrained in me that I don’t cancel patients, ever. 
... we are human and not invincible.
The other part of the equation is the guilt I feel for having to cancel on any commitment – whether it’s to myself or to others.  With running, I beat myself up if I skip a day – saying that I’m lazy; and I take the same approach if I have to change my work schedule for a personal reason.  I have had asthma since childhood.  Typically, when I have a severe episode, it will rapidly progress to bronchitis.  After having a particularly bad weekend, I spoke to my father on Sunday evening about our DIEP flap for the next day.  My dad said, “are you sure that you’re ok for tomorrow?”  I responded, “ Of course I am, I’ve never cancelled a surgery before for an asthma attack.”  He said, “maybe you should consider it, you don’t have to work if you’re not feeling well.”  At that point I realized that I had never had permission to think of myself and how I felt.  Now, I had permission to acknowledge that I may not be 100% upto a task. 
Usually, when I’ve had an athletic injury severe enough to keep from running, I have been told not to run; when I have a personal illness, as physicians, we rarely obtain “permission” not to work – even on days off, patients still have needs and will still call.  Struggling to take care of our patients and ourselves is a balancing act that many of us are still trying to navigate.  Nevertheless, we must all admit that we are human and not invincible.