Responsibility for your own health

I was shocked to see that the NHS could ban surgery for the obese and smokers.  That’s socialized medicine.  You take a conglomerate group of people (the UK) on a limited budget for healthcare… and basically find the cheapest most cost-effective way to deliver healthcare.  But in a way, it’s empowering patients to take responsibility for their own health.  Smoking, for sure — I agree 100% that surgery should be banned for this population.  Obesity is a bit trickier — there’s genetics and environmental factors at play in this one.  I don’t think anyone chooses to be obese.  But, people do have the power to change their eating and exercise habits.  Despite these efforts, there are some people who are still obese…. and these people should not be faulted.

Why single out the obese and smokers?

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From SlideShare
obesity-and-cv-disease-1ppt-43-728
From SlideShare
tobacco-health-statistics
From TobaccoFreeLife.org

Smokers and the obese have elevated surgical risk and mortality, which means more cost to treat and hospitalize and provide ongoing care.

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From HealthStats

I think the NHS is on to something here.  They’re opening doors to moving the liability and responsibility away from physicians and towards patients.  This is a plus.  Outsiders may see it as separatism and elitist to only provide care for people who are healthy.  But look at the facts and the data…. obesity has a lot of co-morbidities associated.  Smoking has a lot of co-morbidities associated as well.  Why should physicians be penalized for re-admissions, poor wound healing, longer hospitalizations when the underlying conditions themselves are already challenging enough?  In fact, I would urge insurance companies to provide incentives to patients/the insured with discounted rates for good and maintained health and wellness.  With all the technologies, medications, and information out there, it’s time patients take responsibility for their own health.  I take responsibility for mine — watching my diet, exercising, working on getting enough rest, maintaining activities to keep my mind and body engaged, meditating for rest and relaxation.  It’s not easy, but my health is 100% my responsibility.  I refuse to pass the buck to my husband, my family, my physician, etc.  I do what I can to optimize my health and future — and if that doesn’t work… I call for backup.

Patients need to change their mindset re: health.  It is not your spouse’s responsibility to track your meds.  It is your responsibility to know your medical conditions and surgical history.  The single most important (and thoughtful) thing a patient can do is keep an up-to-date list of medications, past/current medical history, surgical history, and allergies to bring to every doctor’s appointment and surgery.  This helps streamline and bring to the forefront your conditions and how these will interplay with your medical and surgical plan and postoperative care.  Please do not forget recreational drugs, smoking habit, and drinking habit in this list.  It is very important to know all of these things.  Also, your emotional history is very important.  Depression, anxiety, failure to cope, etc.  This all helps tie in your current living situation with stressors and your medical history.

Links for educating yourself in taking responsibility for your health:

obesity
From SilverStarUK.org
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Emergency Checklists

It seems like in today’s day and age, emergencies are occurring everywhere.  From hurricanes to shooters to earthquakes and fires… I think it’s always important to know what to do.  Here are some fabulous checklists I’ve found for getting through those emergencies.  These are not substitutions for knowledge and training.  Clinical judgement warranted.

Emergency Manual from Stanford — Printable PDF

Ariadne Labs OR Crisis Checklist

Ariadne Labs Safe Surgery Checklist Template

Ariadne Labs Ambulatory Safe Surgery Checklist Template

Project Check

Newton-Wellesley’s L&D Checklists

WHO Safe Childbirth Checklist

Checklist for Trauma Anesthesia

ASRA checklist for Local Anesthetic Systemic Toxicity

WHO Surgical Safety Checklist

WHO H1N1 Checklist

Johns Hopkins Central Line Checklist

STS Adult Cardiac Surgery Checklist

Ariadne Labs Cardiac Surgery Checklist

STS General Thoracic Surgery Checklist

STS Congenital Heart Surgery Checklist

University of Kansas Daily ICU Quality Checklist

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Walking labor epidurals

What is an epidural?

What is a “walking” epidural?

Anesthesiology 2 2000, Vol.92, 387. Walking with Labor Epidural Analgesia: The Impact of Bupivacaine Concentration and a Lidocaine–Epinephrine Test Dose.

MJAFI, Vol. 63, No. 1, 2007. Walking Epidural : An Effective Method of Labour Pain Relief. 

Int J Women’s Health, 2009, 1: 139-154. Advances in labor analgesia.

R. Can J Anesth/J Can Anesth (2010) 57: 103. Walking epidurals for labour analgesia: do they benefit anyone?

MOBILIZATION IN LABOUR AFTER REGIONAL ANALGESIA. Euroanesthesia May 2005. Royal Free Hospital. London, UK.

Impact of first-stage ambulation on mode of delivery among women with epidural analgesia. Australian and New Zealand Journal of Obstetrics and Gynaecology 2004; 44: 489–494

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From WebMD

Walking Epidural with Low Dose Bupivacaine Plus Tramadol on Normal Labour in Primipara. Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (5): 295-298.

Clinical Guidelines: Labour Analgesia. Jan 2017. King Edward Memorial Hospital, Australia.

BJOG, Feb 2015. Neuraxial analgesia effects on labor progression: facts, fallacies, uncertainties and the future.

Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews. Feb 2017.

Ambulatory Epidural Analgesia in Obstetrics: Clinical Effectiveness, Safety, and Guidelines. Canadian Agency for Drugs and Technologies in Health. Rapid Response Reports. Nov 2010.

Contin Educ Anaesth Crit Care Pain (2004) 4 (4): 114-117. Epidural analgesia in labor.

CSE for Labour Analgesia. 

cseanatomy

From the ASA 2017 (October in Boston):

  • CSE: 1 cc 0.25% bupi + 15mcg fentanyl (good for primip)
  • 25g Dural Puncture without dosing sometimes (primips)

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My other OB blog links:

OB Anesthesia

Birth plans

Reflections

Fun on the job

2015 in review

The WordPress.com stats helper monkeys prepared a 2015 annual report for this blog.

Here’s an excerpt:

A San Francisco cable car holds 60 people. This blog 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.

OB Anesthesia

Today, I’m on call covering OB.

MGH: OB anesthesia Q&A for patients

BWH: OB anesthesia Q&A for patients

IARS 2010: OB anesthesia in the 21st century

IARS 2011: OB anesthesia update

A&A 2013: A Randomized Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural Analgesia in a Private Practice Setting: Pain Scores During First and Second Stages of Labor and at Delivery

Indian J Anesthesia 2006: Acute Pain – Labour Analgesia

Presentation on mobile epidural

2014: CONTINUOUS VERSUS PATIENT-CONTROLLED EPIDURAL ANALGESIA FOR LABOUR ANALGESIA AND THEIR EFFECTS ON MATERNAL MOTOR FUNCTION AND AMBULATION

June 2011: Update on rural OB anesthesia

Oct 2013: Presentation on Labor analgesia. Epidural vs CSE, bolus v infusions

To epidural or not to epidural. That is the question.

My Reddit Comment

A great YouTube video on what an epidural is and what it will feel like.

YouTube vid of a real epidural placement ** Needles are involved in this one**

Lately, I’ve been changing my regimen for pain control with PCEA.  It seems most of my partners use a 10ml/hr basal rate, 5ml bolus dose, 10 minute lockout, and 30 ml/hr max.

My current strategy for PCEA (0.0625% bupi + 2mcg/ml fentanyl):

  • 5ml/hr basal rate
  • 10ml bolus
  • 20 minute lockout
  • 35 ml/hr max

Anesth Analges 2007: A Comparison of a Basal Infusion with Automated Mandatory Boluses in Parturient-Controlled Epidural Analgesia During Labor.

ASA Nov 2001: PCEA during labor

Br J Anaesth 2010:Labour analgesia and obstetric outcomes.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial

Neuraxial anesthesia in the non-pregnant patient

Anesthesiology Research and Practice 2012: Recent advances in epidural analgesia.

Br J Anaesth 2012: Failed epidural: causes and management.

From my blog:

Intraoperative cystoscopy and ureteral visualization

Over the years, I’ve been asked to inject various dyes to help light up the urine for visualization of the ureters.  Now, we’ve moved to fluorescein because it “lights up” quicker than other previous dyes.  Why are we always switching?  Drug shortages.

Dosing: 0.25 – 1.0 ml of 10% preparation of sodium fluorescein

Dose: 5 ml. bolus of 10% fluorescein intravenously.