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?

obesity-and-cv-disease-1ppt-44-728
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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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

Anesthesia without a trained anesthesiologist

There was an article in the Washington Post: New machine could one day replace anesthesiologists.

I don’t know about that.  The trial is done on “healthy” patients for colonoscopies — a procedure that’s commonly performed under sedation.  What happens when you get an unhealthy patient or a patient who doesn’t have a diagnosed disease (obstructive sleep apnea is pretty common and often comes without a diagnosis at time of surgery)?  What if the patient obstructs or needs an emergent intubation?  I think I’ll keep my friendly anesthesiologist.

Best Anesthesia Programs

The Old Well and McCorkle Place at the Univers...
Image via Wikipedia

Taken from a 2003 post on studentdoctors.net:

Here is a previous post from a year ago that may give you an idea regarding the so-called “best anesthesia programs”:

“Academic anesthesiologists I have spoken to generally seem to stratify the outstanding programs into 3 tiers…

1) Best of the best: JHU, MGH, UCSF

2) Considered to be Elite programs: Alabama, Brigham, Columbia, Duke, Mayo, Michigan, Penn, Stanford, Wake Forest, U. Washington

3) Other excellent academic programs: Beth Israel, Cornell, Dartmouth, MC Wisconsin, Mt. Sinai, Northwestern, Penn State, UC Irvine, UCLA, UCSD, U. Chicago, U. Colorado, U. Florida, U. Iowa, UNC Chapel Hill, U. Pittsburgh, U. Rochester, U. Texas Galveston, Utah, UVA, Vanderbilt, Wash U, Yale

I think trying to rank the excellent programs from 1-50 is fruitless. If you apply yourself at any of the above programs, you will have great fellowship and job opportunities.”

People obviously have their opinions and may disagree with this stratification, but I think that it is pretty good.

I tend to agree as well…but maybe I’m biased.  🙂

How MD anesthesiologists have become victims of their own excellence

The Doctor, by Sir Luke Fildes (1891)
Image via Wikipedia

Taken from  KevinMD.com’s blog:

How MD anesthesiologists have become victims of their own excellence

Comments below that tended to resonate with my thoughts.

Med Nerd At Large January 22, 2011 at 6:20 pm

It seems like the author is criticizing medical students and physicians for choosing certain specialties as opposed to primary care. While we do need more primary care providers, simply supplanting roles traditionally held by physicians will only compromise patient care.

To examine the author’s primary example, the CRNA vs MD debate, yes most CRNAs can provide equitable anesthesia to most patients as their MD counterparts. I can attest to this fact as I see it on a daily basis as both a medical student and an anesthesia tech. However, while the author may claim that it doesn’t matter who’s behind the curtain during your average cholecystectomy, any anesthesiologist knows that it makes a world of difference the second that patient unexpectedly goes into laryngospasm.

The moment something goes wrong, the first thing a CRNA does is call for the anesthesiologist. This may be an uncommon scenario, but completely replacing Anesthesiologists with CRNAs might make the difference in those patient’s survival. Patient care is ultimately compromised by the simple fact that they’re not getting “the best.”

This truth can be extrapolated to the rest of medicine. Yes, a tech/PA/nurse with less medical training might get the job done 80% of the time, but what about that remaining 20%? Are you as a parent comfortable taking your child to a PA who will most likely misdiagnose your child’s sudden fever and malaise as a viral syndrome, when in reality it’s Kawasaki’s resulting from a previous virus and could potentially kill them?

CRNAs are great, as are PAs, nurses, and techs. I know, love, and work with a lot of really great ones! But they should stay CRNAs, PAs, nurses etc. and not try and play doctor. They’re might be very capable in their respective professions, but they aren’t trained to be physicians and many should quit kidding themselves.

And I’ll choose whatever specialty strikes my fancy without feeling an ounce of guilt. As for primary care, I’m not busting my tail through nearly a decade of medical training, sacrificing my twenties, and taking on nearly $200,000 in debt to work a job that only pays 3/4 that yearly and forces me to keep working 80+ hours after residency. I want to have a family and a life outside of medicine too. So yeah, I’ll keep killing myself now and enjoy that ENT job later. I’ll make more money, work less hours (still 60+), have less headaches, and see my wife and children more. And I’ll be better at my job than any tech with less training. Who would you rather have doing your thyroid surgery?

James Gaulte January 22, 2011 at 7:14 pm

The Lewin Group is a subsidiary of Ingenix which is owned by UnitedHealth Group. Clearly a health insurer is interested in a less expensive way to delivery care..This study plays into that nicely but will we hear a rebuttal from the anesthesiologists ?

The anesthesiologist vs. CRNA debate ends here.

This website defines the essence of physician care in the field of anesthesiology. Want to know what separates an anesthesiologist from an anesthetist? Check out the link. Plus, it lists tips on what to ask and what to bring for your upcoming surgery.

http://www.doctorbyyourside.org/Get-The-Facts.aspx

My own thoughts on this debate