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.

150423sambydisease
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
Advertisements

Suprascapular blocks

Trends are evolving in decreasing intraoperative and postoperative opioid use.  Therefore, anesthesiologists are constantly learning new regional techniques to help with postoperative pain.  For shoulder surgeries, I’ve moved away from interscalene blocks toward supraclavicular blocks.  I think the interscalene block provides a better block of a total shoulder surgery, however, certain patient comorbidities often make the supraclavicular block a better choice.

Nice paper from Anesthesiology, Dec 2017: Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology 12 2017, Vol.127, 998-1013.

Nowadays, it seems that suprascapular blocks are gaining in popularity (I’d probably use it to supplement the supraclavicular block.

Supplies and Technique (from USRA):

Suprascapular Nerve

ssn1

How to position the ultrasound probe:

ssn5
From USRA

05_1_a_shoulder-suprascapular-artery-and-nerve_dsc_5085_copy

Ultrasound Image

ssn4
From USRA.  SSM = supraspinatus muscle
SSA = suprascapular artery
SSN = suprascapular nerve
TZM = trapezius muscle
STSL = superior transverse scapular ligament

05_1_c_shoulder-suprascapular-artery-and-nerve_labels

Useful Links

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

failed-rsi-gd

Enhanced Recovery After Surgery (ERAS)

Enhanced recovery after surgery #ERAS #anesthesia #pain #recovery

srv160008f1

Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011 Oct; 5(5): 342–348.

Dario Bugada, Valentina Bellini, Andrea Fanelli, et al., “Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach,” Surgery Research and Practice, vol. 2016, Article ID 3561249, 6 pages, 2016. doi:10.1155/2016/3561249

Enhanced Recovery After Surgery: If You Are Not Implementing it, Why Not? PRACTICAL GASTROENTEROLOGY • APRIL 2016.

A Systematic Review of Enhanced Recovery After Surgery Pathways: How Are We Measuring ‘Recovery?’  Session: Poster Presentation. Program Number: P613

46210

Sturm L and Cameron AL. Fast-track surgery and enhanced recovery after surgery (ERAS) programs. ASERNIP-S Report No. 74. Adelaide, South Australia: ASERNIP-S, March 2009.

Summary of Enhanced Recovery after Surgery Guideline Recommendations. Canada.

Patients Benefit From Enhanced Recovery Programs: Are Better Prepared for Surgery, Have Less Pain, Studies Show. Oct 2016. American Society of Anesthesiologists.

Enhanced Recovery after Surgery Guideline: Perioperative Pain Management in Patients Having Elective Colorectal Surgery: A Quality Initiative of the Best Practice in General Surgery Part of CAHO’s ARTIC program. April 2013.

Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy. Regional Anesthesia & Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 451–457.

Regional Anesthesia for surgery and other comparative studies. Sweden.

ERAS: Role of Anesthesiologist. UTSW.

Stanford Anesthesia ERAS pathway website

13012_2017_597_fig6_html

Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Anesthesia & Analgesia: May 2014 – Volume 118 – Issue 5 – p 901–902

The Role of Regional Anesthesia in ERAS pathways. Sept 2015. UCSF.

ERAS Pathway Improves Analgesia, Opioid Use and PONV Following Total Mastectomy. Anesthesiology News. May 2016.

Anesthesia Practice and ERAS. Cooper University Hospital. 2017.

ERAS: Anesthesia Tutorial of the Week. Number 204. Nov 2010.

ERAS and Anesthesia. Anesthesia Business Consultants. May 2015.

All about ERAS: Why anesthesiologists need to understand this concept. Becker’s ASC Review. June 2015.

hqdefault

 

I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.

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

h9991523_001
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)

This slideshow requires JavaScript.

My other OB blog links:

OB Anesthesia

Birth plans

Reflections

Fun on the job

Mitraclip and TEE for MR

IMG_0056

 

European Heart Journal – Cardiovascular Imaging (2013) 14, 935–949.  Peri-interventional echo assessment for the MitraClip procedure. 

Everest Clinical Trial results PPT

Open Heart 2014;1:e000056. Two-year outcomes after percutaneous mitral valve repair with the MitraClip system: durability of the procedure and predictors of outcome.

ASE Echo 2016: Percutaneous approaches to MR. UofMichigan PPT.

2015: The role of 3D TEE in the MitraClip procedure – UofColorado PPT

Abbott TTE checklist for MitraClip

EuroValve Congress 2015: MR in the MitraClip Era

2012: Echo in mitral valve intervention. 

IMG_0057

Abbott MitraClip device and delivery system package insert

Neth Heart J (2017) 25:125–130. MitraClip step by step; how to simplify the procedure.

IMG_0059

IMG_0060

Transseptal Puncture technique with TEE

JACC Cardiovascular Imaging: July 2012. Role of echo in percutaneous mitral valve interventions. 

MitraClip Cases with TEE: Mayo Clinic.

 

General anaesthesia vs. conscious sedation for transfemoral aortic valve implantation: a single UK centre before-and-after study – Miles – 2016 – Anaesthesia – Wiley Online Library

http://onlinelibrary.wiley.com/doi/10.1111/anae.13522/full?platform=hootsuite
Updated: Feb 24, 2017: http://apsf.org/newsletters/html/2017/Feb/10_TAVRsafety.htm