Surgical Time-Out, circa Year 2050

In the year 2050, surgical time-outs have reached a new level of safety to ensure the utmost care and risk reduction for patients.

Unlike the primitive time-outs performed in the the first decade of the 21st century (2000-2012) which involved one designated individual to confirm prior to incision (Basic9), the patient name, surgical site, performing surgeon, allergies, antibiotic administration, positioning, x-ray name confirmation, fire hazards, and fall risk, significant additional safety checklists have been implemented to create a new state-of-the-art culture of safety both in and out of the operating room.

In 2015, surgical time-outs extended to also include electrical and air quality checks (Environ2) along with separate mandatory time-outs of the Basic9 before, during, and at conclusion of surgery.  To ensure minimal air contaminants as well as maintain the highest performance of all electrical equipment in the operating room, the Environ2 requires a separate electrical and environmental engineer to certify all equipment and confirm air quality at a level of no more than one contaminant part per trillion to the 10th power in 35 separate locations within the operating theater. The Environ2 checks are double-confirmed by the circulating nurse who has been granted broad powers to cancel surgery for any reason without consequence if there are any concerns with the operating room environment that may increase infection risk for the patient as well as sub-optimal performance of any and all equipment used to perform the surgery.

In 2020, the Total5 was added to Basic9 and Environ2 which truly heralded the onset of state-of-the-art surgical time-outs. Total5, developed jointly by the Harvard School of Public Health and National Institute of Medicine, involves a comprehensive time-out of any and all individuals entering into the operating room in the knowledge that surgical outcomes are affected by personnel movement into and out of the operating room whether from contaminants on the skin or clothing of staff to infections that they may or may not be harboring. In rare cases, given the recent terrorist attacks both biological as well as chemical, the Total5 would additionally eliminate such threats.

As such, Total5 involves for each and every staff member that enters the operating room to undergo “individual time-outs”:

1) Geiger counter check

2) Body pat-down by TSA (whose duties have tremendously expanded from initial airport security)

3) Metal detector check

4) Chemical check (specifically looking for arsenic, mercury, formaldehyde, etc as well as drug screen)

5) Biohazard check (routine organisms include MRSA, VRSA, C dif, HIV, hepatitis, etc as well as more exotic organisms like Ebola, Swine Flu, Anthrax, etc).

A separate consent must be in the chart for each and every individual who is present for the patient’s surgery with their Total5 report.

The Basic9, Environ2, and Total5 surgical time-outs collectively have ensured a 360 degree safety net for the patient.

But… it is not until now in the year 2050 that the surgical time-out has reached a penultimate state with the expansion of the Total5 to Total10. In addition to the original Total5 for surgical staff, 5 additional time-out checks of surgical staff is now required. Continuing with #6…

6) Retina scan (to confirm staff identity)

7) Fingerprint scan (to double-check staff identity)

8) Malpractice insurance check (if positive, consent must be in chart to ensure patient was aware of any malpractice committed by any surgical personnel doctor or nurse)

9) EKG to ensure peak cardiac health of staff member

10) EEG to ensure a rested mind at peak performance of staff member

As with the Total5, Total10 report for each staff member must be included in the patient consent in the patient’s chart.

There was some confusion whether each staff member can undergo just one Total10 per day, but with new regulation acknowledging possibility of patient infection contaminating personnel as well as staff member fatigue that may progress throughout the day, a Total10 MUST be performed before each and every surgical case.

For any further questions on surgical time-outs, please contact your local hospital JCAHO executive liaison.

Revolutionary Camera Takes “Living” Pictures

Lytro has introduced a new type of camera that may have tremendous implications in medical photography.

It is a camera that takes a “living” picture. What does that mean?

In essence, it is a camera that takes a picture taking ALL the light information that is present such that the picture can be manipulated as if you haven’t taken the picture yet.

It sounds confusing, but practically speaking, it means that one can literally refocus any part of a picture AFTER it has been taken. We are not talking about photoshopping using the blur or sharpen filter. It is literally refocussing a picture AFTER it has been taken!!!

You need to see it to believe it…

Click here to view some sample pictures. Touch (click) to refocus any part of the picture; pinch (double-click) to zoom.

I can’t wait to see some medical photography done with this camera which starts at $399.

Purchase through the company’s website.

Want to See a Specialist Doctor Who Does Not Take Your Insurance? There Are Options…

It is not unusual nowadays that a patient may want to see a specific medical specialist who unfortunately does NOT participate with their health insurance plan. This doctor is what is known in insurance parlance as a “non-par provider.”

In this situation, there are two options.

1) The patient pays the medical bill (self-pay) and forwards the receipt to the insurance company who hopefully will reimburse the patient.

2) The patient can request a “Letter of Medical Necessity” from the primary care doctor to submit to the health insurance company requesting temporary non-participating provider (non-par) insurance coverage.

What does such a letter of medical necessity entail?

The best way to illustrate this course of action is to provide an example. In my practice, I offer several services that many other ENT specialists do not. As such, there are a large number of patients who travel from even as far away as Florida and Arizona to be seen in our Virginia office. Needless to say, many patients have health insurance plans that I do not participate with.

One such procedure is tonsil cryptolysis.

A sample “Letter of Medical Necessity” that a patient can request from their primary care doctor to submit to their insurance company is as follows (the same concept can apply to any type of procedure or specialist evaluation):

John Smith, MDCountry Lakes Family Practice

Dear [Insurance Company]:

I am writing this letter on behalf of my patient, Mary Smith (DOB: 01/01/1965), who has a 10 year history of cryptic tonsils with production of tonsiliths (tonsil stones) on a daily basis. 

Though this problem occurred intermittently during adolescence, it has recurred during adulthood and has become a chronic problem which has affected her overall quality of life.  These stones consist of debris collected in the crypts of the tonsils together with sulfur-producing bacteria which account for the acrid odor and taste.  

I believe Mary is a candidate for a minimally-invasive procedure called tonsil cryptolysis (coblation therapy).  This procedure uses a radio-frequency energy in combination with a conductive medium to form a low temperature (40-80° C) localized plasma field which allows the precise removal of affected tissue while maintaining the integrity of surrounding, healthy tissue.  This results in decreased pain and a significantly shorter recovery time as compared with more traditional methods of treatment.  This procedure can be done in the office under local anesthesia on eligible adult patients.

After an initial evaluation for candidacy, tonsil cryptolysis can be done in an office setting under local anesthesia.  Most patients (70%) require one session for complete amelioration of symptoms. 

As there are no area specialists offering tonsil cryptolysis, I recommend that Mary be evaluated and treated by a non-par provider, Dr. Christopher Chang of Fauquier ENT Consultants located in Warrenton, VA. Please provide temporary insurance coverage in order for Mary to be seen by Dr. Chang.

Sincerely,
xxxxxxx
Dr. John Smith

That’s it!

If insurance declines coverage, than you are stuck with option #1 to self-pay if you really want to see a specific non-participating provider.

In any case, some unique services our office provides for which patients have requested non-par provider coverage include:

• Video/Audio Nasopharyngoscopy for Velopharyngeal Insufficiency
• Endoscopic Staple Diverticulostomy for Zenker’s Diverticulum
• Botox Injections for Spasmodic Dysphonia
• Chronic Cough Evaluation
• Phlegmy Throat
• Chronic Throat Clearing
• Allergy Drops

Mind Over Body Treatment

24 years old female presents with several week history of progressive stomach pains, substernal chest discomfort, heart palpitations, loss of appetite, headache, insomnia, and growing lump sensation in her throat. Physical exam was essentially normal.

Can this previously healthy female have suddenly developed reflux, globus, paroxysmal supraventricular tachycardia, brain tumor, and throat cancer with possible overlying thyroid disorder? Or perhaps has she contracted some other horrific mystery disease?

Maybe…

But maybe none of the above…

What if I told you she will be giving a doctoral dissertation for her Master’s next week for which she is ill-prepared for given a recent breakup with her boyfriend of 5 years and has a growing distaste of her school classmates who have been less than supportive.

In other words anxiety.

The point is that the mind has tremendous influence over the body and numerous physical maladies can be attributable to a patient’s mental state. People can die of a broken heart or out of extreme fear. Stress can age the body dramatically (look at a picture of a presidential candidate and than another after having served 2 terms as President of the United States).

A mind under stress CAN affect the body. Reassurance helps. Elimination of the stressor is even better. If the stresses can’t just go away, development of strong coping mechanisms will do much to help. After that, there are prescription drugs that help, but have addictive potential as the anxious patient will tend to take a pill rather than dealing with and learning coping skills.

But here’s where the power of the mind can be “manipulated” into helping rather than hurting the body.

In my last blog, I did ridicule therapeutic hands to manipulate human body energy as total bunk (or rather a 9 year old girl did)… BUT… if a person truly believes that it does help, it probably can help some individuals just from the idea/belief/faith that it can.

Faith, trust, and sharing with another human being who lends a sympathetic ear is where questionable “medical” practices and homeopathy may provide benefit… not because such quackery directly helps the individual, but more because the individual BELIEVES it can help.

I can totally make up a quack treatment like placing an ice cube over the heart and stating that this practice can “calm” the heart palpitation down by “cooling” it to a more natural state… and if the patient believes it to be true… than the mind can potentially make it so in a significant number of people. In fact, I can state with some confidence that it will help in as many as 20-40% of patients.

How can I state such a statistic knowing my treatment is total hogwash?

It’s because of the placebo affect.

Although I don’t support (and perhaps even discourage) such quack medicine, as long as it doesn’t harm the patient and there’s no danger if a patient decides to forgo more traditional and evidence-based medical treatment, than I don’t see any long-lasting harm in it.

Because as scientists and doctors know… the placebo effect is real and DOES lend improvement nearly 40% of the time! Who cares if the activation mechanism of the placebo effect is via “therapeutic hands” or “local honey” or some other “un-accepted” treatment.

After all… the patient is feeling better and that’s what really counts in the end.

AND… if it doesn’t work, than traditional medical treatments can be pursued.What is evidence-based, scientifically proven medical treatment?

It’s when the treatment helps people way more than the placebo (or in other words, way more than 40%).

Even Kids Can Spot Adult Bull^!#$& … And Publish It in a Medical Journal!

Though often adults find kids to lack intellectual rigor and devoid of rational thought, sometimes it’s the other way around.

Take Emma Rosa, age 9, who debunked the idea of therapeutic touch back in 1998. She watched a TV program about nurses who practise “Therapeutic Touch”, claiming they can detect and manipulate “human energy field” by hovering their hands above a patient. Emma recognized this adult nonsense and conducted a scientific study for a 4th grade science fair to not only prove it, but also publish her results in a peer-reviewed medical journal JAMA. She found that 21 experienced practitioners of therapeutic touch were unable to no more than chance able to detect a human hand under their right or left hand hidden by a screen (so the therapist can’t see).

There are other instances where kids have similarly debunked quack medical treatments, though not necessarily published in a scientific journal. Take Rhys Morgan, age 15, who after being diagnosed with Crohn’s disease and while internet searching on this topic to educate himself, came across Miracle Mineral Solution (MMS) that claimed to cure not only Crohn’s, but also cancer, Aids, malaria, and basically most things short of actual death. Being 15, he was able to do his own research to evaluate this “amazing” treatment through which he discovered that MMS is in essence industrial bleach. Rhys has since campaigned hard to eliminate MMS.

Beyond quackery, I often see it in my ENT clinic where elementary school-aged kids offer utterly profound observations that go way beyond their years.

In a time when potential leaders and politicians are espousing claims in the media that lack rational thought and intellectual rigor (watch the news) and even the educational system is being attacked for teaching scientific principles like evolution in favor of Biblical explanations, I sometimes wonder if we need children like Emma Rosa and Rhys Morgan to come to our rescue even if we are adults who should know better.

Reference:
A Close Look at Therapeutic Touch. JAMA. 1998;279(13):1005-1010. doi: 10.1001/jama.279.13.1005

The man who encourages the sick and dying to drink industrial bleach. Guardian.co.uk Wednesday 15 September 2010 07.30 EDT

The Four Types of Patients Seen in a Surgeon’s Clinic

Over the years, I have found that patients can be loosely grouped into 4 different types. Nothing particularly wrong with any type, but it does help me to approach patients appropriately if I can get a sense of what type they are.

The four types are:

Type A:  If a surgery can “fix” or “cure” me such that I won’t have to take medications every day of my life, than let’s do it.

Type B: I will never consider surgery unless it is a life-threatening situation. If a medicine can help, why do it???

Type C: I will consider surgery only as a last resort when all else fails.

Type D: They thought they were Type B or C, but over time, they realize they are Type A.

Why is this important?

Because if a patient is Type B and surgery is recommended, the patient often develops an automatic distrust of the surgeon. The patient may see the surgeon as a “gun-slinger” who likes to cut people.

If a patient is Type A and the surgeon approaches them like Type B or C, such patients may come out of a visit quite disappointed and at worst, upset that the surgeon will not do what they want.

Ultimately, for a happy clinic encounter, a mutual understanding needs to quickly happen otherwise a mutual discord may snowball ultimately leading to a second opinion with another surgeon.

Of course, there is a more complex dynamic going on, but it’s a good over-simplification.

YouTube Ranks Fauquier ENT as Most Viewed for Medical Videos

I was informed that our practice’s YouTube channel has been ranked as one of the most viewed channels related to medicine in the world!

As of Oct 6, 2011, our channel which contains 52 videos has received 198,064,840 views. We currently average over 500,000 views a day!

We far surpass other more “prestigious” medical organizations with a YouTube channel.

University of Maryland Medical Center Channel 

2,047,260 views

CDC Channel 

4,173,563 views

Massachusetts General Hospital (Harvard) Channel 

33,994 views

Children’s Medical Center Channel 

318,688 views

Duke Medical Center Channel 

1,571,694 views

Medical University of South Carolina Channel 

699,002 views

UVA Health System Channel 

29,922 views

Stanford Medical Center Channel 

132,303 views

British Medical Journal Channel 

216,331 views

Penn State Hershey Medical Center Channel 

46,688 views

Scripps Health – San Diego Channel 

212,848 views

United Kingdom Ends $17 Billion Electronic Medical Records Initiative

The Wall Street Journal on Sept 23, 2011 reported that the United Kingdom will scrap the entire electronic medical records (EMR) initiative that has been 9 years in the making with nearly 6.4 billion pounds already spent.

That action was hinted at back in August 2011 after a scathing parliamentary report stating the initiative to be wasteful and incapable of delivery.

I’m not surprised…

It’s hard enough to get a group of doctors in one hospital to agree with a treatment plan let alone agree to a medical records system. The problem is exponentially more difficult when applying it to an entire country.

Physicians practice medicine differently… just like teachers have their own unique way of teaching kids. A method that may work for one doctor or teacher will not work for another. Even the method may change depending on how “busy” things are (teacher with a class of 5 kids versus 30 kids) so a doctor in a busy inner-city emergency room will have different flows and needs from an electronic medical records than a rural family practice with a sedate pace. Furthermore, the needs of a dermatologist is very different from a pediatrician. One can’t expect a single EMR system to meet the needs of both perfectly just like one cannot expect a math teacher to use the same teaching methods as a singing teacher.

Forcing physicians to use a single standard electronic medical records without adapting to these realities is bound to fail no matter how much time, training, software, and hardware you throw at it.

A better alternative (my opinion), is to treat electronic medical records like the computers they reside on. There should be many different types of EMR systems just like there are MANY different types of computer models, speeds, makes, cost, sizes, etc.

However, unlike current EMR systems, in spite of who makes a computer and what operating system software it runs, it has standardized components… USB, Firewire, HDMI, VGA, BlueTooth, etc. as well as a universal communication medium called the “internet” that works with phones, computers, laptops, etc regardless of who makes it and what software it is on.

You would think that an EMR system given its digital essence would be able to easily communicate with other systems… but no… they don’t communicate at all… which is why paper reports still exist… which are than scanned into the EMR.

Rather than the government (whether the United Kingdom or the United States) dictating what physicians must do and mandating EMR initiatives, I believe the money would be much better spent on mandating inter-operability and communication standards. The free market will create the best EMR systems and physicians will pick the one that best meets their need.

The other more insidious side of EMR is the over-reaching health goal mandates which means well, but runs into the same problem of applying standards to all physicians. Take “meaningful use” set by the Centers of Medicare and Medicaid Services (CMS). One of the core measures of meaningful use is adult weight-screening and follow-up.

Now as an ENT specialist, I see patients specifically for earwax. Why in the world would I want to perform a weight-screening when all I want to do (and what the patient only wants me to do) is get earwax out???

Makes no sense.

Does it to you???

Reference:
U.K. Scrapping National Health IT Network. InformationWeek Healthcare. Aug 4, 2011

U.K. Ends Health-Service IT Upgrade. Wall Street Journal. Sept 23, 2011

Online Appointment Requests & Scheduling Now Available 24/7!

Our office now supports 24/7 online appointment requests and scheduling! Just go to our homepage at www.FauquierENT.net and click on the “Online Scheduling” button!

At Home Laser Hair Removal That Works

Without going into TOO much detail of how I know this… I have personally observed that the TRIA Laser Home Removal System does work after observing its use and its effects over a 6 month period of time.

And before anybody asks… no… I was not paid to write this nor did I get a free one to try. Rather, someone I am close to bought it off Amazon.com and I was a skeptic on-looker.

In any case, the caveat being that I know it works  (admittedly anecdotal) as long as the hair is dark (ideally black or brown) on very light colored skin (ideally white).

The way laser hair removal works is that the laser beam is selectively absorbed by the hair follicle causing its death and destruction while preserving other skin structures. As such, the hair follicle needs to be as “different” a color to the skin around it in order for the laser to work. Otherwise, you end up burning the skin as well as the follicle. Depending on the laser used, different colored hair can be targeted on different colored skin. Because of this, the same laser can NOT be used for everybody.

In any case… back to the TRIA. This laser system ideally works best on dark colored hair on light colored skin. The greater the difference, the better it works; the best being black hair on white skin. In fact, the TRIA can’t be used at all if you don’t have the right hair/skin color combination (TRIA requires a skin check every time before use… unless you “pass,” the device will not work).

There are only a few real differences between this laser system and that used in medical offices.

The TRIA’s head is about 1/4 inch in size. The medical-grade laser head can be one inch or larger in size. What that means practically is that if you are using the TRIA for your leg, it’ll take a long time and a lot of zaps due to the large surface area.

Also, the TRIA can only be used for about 15 minutes on the highest power before it shuts off for 2 reasons: It “overheats” and needs to cool down or runs out of battery and needs to be recharged. On that last point, you can only use it on battery power (which I suspect is due to safety reasons). After letting it cool/recharge overnight, it is ready to use again by the next day.

Medical-grade lasers do not have these limitations.

Finally, for those technically inclined, the TRIA uses a pulsed diode laser (same as a medical grade laser) with five intensity settings. The highest fluence available is 22 with a wavelength of 810nm, which is lower than what is available from a laser used in the clinic.

Regardless of medical-grade laser hair removal or TRIA, it does require repetitive sessions as the laser only kills follicles that are in the growth phase. Unfortunately, hair are in different phases at any given moment (there are 3 phases) and as such, it may take numerous sessions spaced 1-2 weeks apart over a few months before all hair follicles have entered into the growth phase and thus be able to be amenable to death by laser.

And unlike brain cells… hair follicles CAN come back from the dead and start producing hair again. Hard to say when or why this happens, but is likely due to hormonal factors.

Overall, however, the TRIA can save you a lot of money (compared to getting it done by a physician) if you have the following characteristics:

1) Dark hair

2) Light skin

3) Patience (small laser head on large surface area takes a long time as well as the fact that a single session may need to be broken up over a few days due to device needing to recharge or cool overnight after about 15 minutes of use)

4) High pain threshold (even with a small head… it does hurt. And because it is a small head, there’s a lot more zaps to cover the same surface area)

You can buy it on Amazon.com here.

http://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B0029OSN4U