Cookbook medicine...PODay 344

Copied from a news article:

")The U.S. Department of Health and Human Services (HHS) on Thursday announced a new payment model that aims to prevent one million strokes and heart attacks by 2017. Speaking at the White House Conference on Aging regional forum in Boston, HHS Secretary Sylvia Mathews Burwell announced the "Million Hearts" model, which seeks to reduce the nation's 610,000 deaths a year from strokes or heart attacks, as well as the $315.4 billion annual cost, according to the announcement. Research last year also found that cardiovascular events are the leading cause of death worldwide. Under the current model, the Centers for Medicare & Medicaid Services (CMS) pays providers based on specific goals relating to patient cholesterol, blood pressure or other factors. The new model rethinks this one-size-fits-all approach, opting instead for a data-driven predictive model that creates personalized risk scores for individual patients. Providers that participate in the initiative will collaborate with beneficiaries to determine a percentage that represents their heart attack or stroke risk within the next 10 years. Providers also will identify risk reduction steps that work best for an individual patient, such as taking cholesterol-lowering drugs, reducing blood pressure or quitting smoking, to create a personalized plan. CMS will pay participants that cut their high-risk patients' absolute risk of stroke or heart disease, according to the announcement." I understand the trend toward tying payment to results in the new afforable  health care paradigm. But I guess I am a bit of a fatalist in that I don't believe that a financial incentive can solve all the medical problems in the world. Is it really that simple...that paying the doctor or the hospital better or  penalizing them less will  incentivize the patient to  follow  the diet, loose weight, exercise more, all to make them healthier? Aren't there just people who are going to be sick, going to have high blood pressure, going to suffer a stroke or a heart attack in spite of sincere attempts to follow doctor orders? Is it the doctor's fault that the patient doesn't want to take a statin drug for his cholesterol? Should the doctor be penalized if the patient just cannot  stop smoking? It is said to be more addictive than heroin! If the doctor is going to paid less (or not at all?) for patients who are unable or unwilling to turn their medical situation around, won't that result in practices being unwilling to enroll chronically ill or unhealthy persons? Perhaps there is something that I don't get.

I did it!...PODay 343

Wow! This would not be what you or your doctor would like to see on an x-Ray. I copied this photo from a great resource on line. The article detailed possible "things that can go wrong."  According to the author,

"The risk of humeral fracture is increased in revision surgery, by falls and when the humeral component fixation results in an abrupt transition between a cemented or press fit diaphyseal stem tip and osteopenic bone distal to the prosthetic tip These fractures deserve a trial at closed management."

I believe what the author is saying is that when the surgeon goes back in a second time, revision surgery, the risk of fracturing the existing humerus is high. Also, a fall, as my surgeon has advised against :), can result in a break like this. And finally, an abrupt transition between the titanium shaft and the real bone is at risk if the bone shows osteopenic issues.

Obviously a fall is the easiest to understand and the most difficult to avoid. Since my initial injury was due to a fall I am absolutely paranoid about falling again. One day, feeling a little unsteady, I almost bought a walker at a garage sale! Me, a walker? Never! Unless it would save me from another disastrous fall. When I walk for exercise, as I have for several years now, I use two European style hiking poles. The good reason?  It increases the cardio- vascular workout and is good for toning your arms. The real reason? It adds stability which I am grateful for.

And if I encounter an angry raccoon I am armed!

Things can go wrong...PODay342

This is a perfect example of why I have to start a new blog...I have a great photo that I want to post but I haven't done it in a while so I can't remember exactly how. No problem, just read the directions. Well, I wish I could. But remember? My blog became corrupted some few months ago and everything written is just "0"s. Everything except what I write which appears in regular text.

Blogspot is a free service of Google. Google created the program but does not provide tech support. There are user established help sites which is a great service to us. But from what I have read the few suggested "fixes" don't work and the solution is to abandon the corrupted blog and start anew.

On top of that I try to limit my posts to reverse total shoulder arthroplasty AND medical news in general. It's true, I do stray frequently. And then there is a night like last night and I just didn't have anything to say. Oh, I could have talked about my latest sewing project or the over abundance of republican presidential candidates or how I figured out how to clean the floor of the freezer compartment in our french door fridge. But that's not what readers are looking for when they somehow stumble onto my blog.

So in just about 23 days I am going to open a new blog and start anew. I'm not going to delete this site...I don't even know if that is possible. But leaving it open preserves any useful information for any new folks who might stumble into it and benefit from some of the information.

So what was my photo? It's an X-ray of an arm with a rTSA implant and the humerus BELOW the implanted titanium shaft has fractured! Not a good day. I suppose this could be one reason my surgeon told me not to fall again. 

Hospital as insurer...PODay 341

"In a growing response to changes brought by the Affordable Care Act and the move to value-based payments rather than the traditional fee-for-service model, many hospital systems opt for a new strategy: launching their own health insurance plans.
In fact, a 2013 survey by the Advisory Board found 28 percent of hospitals hope to launch their own insurance plan within five years.
It's a dramatic shift, with health systems not just seeking reimbursement from insurance companies for services they provide, but also receiving and paying those insurance claims."

As I drive along I-95 I've been noticing billboard signs touting medical care plans sold by our local hospital. The plan replaces ones medicare and medicare supplement at a great savings..there are some limitations, of course. You have to use their staff physicians only, for instance. I think the deductible situation is different. Your primary care doctor is kind of a gate keeper, limiting visits to specialists, I believe.

It's so hard to really grasp the details of different insurance coverage. Until you have it and use it you don't really know how it works. Kind of like what Nancy Pellosi said about the Affordable Care Act. The House had to pass it before they would know what was in it. I continue to be confused by my medicare and medicare supplement. The "other shoe" dropped a few days ago when I received the supplement's denial of all those huge charges Medicare denied recently. I still don't know why it took almost a year for those bills to show up. And I choose to believe the EOB (explanation of benefits) that says I am not responsible for the exorbinate fees..

At any rate, I don't plan to change horses in the middle of the stream, or change insurers in the middle of a medical crises. Of course, that probably means I'll never change as it seems anymore life is just one health issue after another.

Big vs Small...PO Day 340

Exerpted from an article

By Zack Budryk

"The Centers for Medicare & Medicaid Services' patient satisfaction rating system puts large urban hospitals at a distinct disadvantage compared to their smaller urban/suburban counterparts, according to research published in the Journal of Hospital Medicine. CMS regards improving patient satisfaction scores as a major step in the transition from fee-for-service healthcare to a value-based model, and post-Affordable Care Act, scores are more heavily weighted in the formula the agency uses to determine reimbursements. Despite this, a recent report indicates overall patient satisfaction is nearing a 10-year low even as demand for services increases. Researchers, led by Randall Holcombe, M.D., chief medical officer for cancer at Mount Sinai Health System in New York City, studied survey data from 934,800 patients at 3,907 hospitals, and found that regardless of the organization's location, English as primary language and hospital size were major predictors of patient satisfaction. Overall, patients gave the lowest scores in densely populated regions such as the District of Columbia, California, New Jersey and Maryland. Conversely, more sparsely populated areas such as South Dakota, Maine, Vermont and Louisiana had higher scores, according to Holcomb." And yet...In Post 335 I reported how some of the big, well known hospitals are wanting to establish volume requirements for CMS to pay for the top ten most difficult surgical procedures. Their opinion is that large facilities where high volume surgeons prevail have better outcomes. And that may be true but it obviously does not translate to patient satisfaction. And patient satisfaction is a large factor in rating hospitals. Of course, being able to communicate is always an issue but can you imagine being sick or injured and not able to talk to the doctors or nurses? But how would that be different at a smaller rural facility than at a large urban hospital? I would think the large hospital would be more likely to have an interpreter available or even staff members who speak the same language. It has to be the size and imtimacy of the smaller hospital that tips the scale in their favor. I like my small local hospital. It has the advantage of being part of a large hospital system but is in the just fewer than 100 beds category. I know my particular procedure is probably not done there with the frequency at thelarge  city hospital 75 miles from here. I could have sought care there. But the proof is in the pudding, all's well that ends well, and I hope the Affordable Care Act and the need to  limit services does not put the small, community hospital out of buisness.

Should I worry...PO Day 339

I just read an article about rTSA that makes me concerned. The author said that if you were too active the implant would not last as long. The  patient who asked was into exercise and even suggested weight lifting was part of his athletic program. The doctor's reply was based on that kind of activity, I suppose.

But now that I am doing so well, now that my shoulder seems finally fully healed and functional, I am using my right arm in all the normal ways. The only things I can't do involve reaching behind my back.Lifting, stretching, pulling, pushing, all those activities are pretty much back to normal. I wouldn't claim to be more active than the average woman, just maybe more active than the average woman of a certain age.

The last time I saw my surgeon was my six month checkup. When I asked if there was anything I should not do he only said "don't fall." He didn't say "don't use a hand drill and a screw driver to install a shelf." He did not mention staying off a ladder to reach the glass flower frog collection. Trying to scrape up whatever it was that melted and refroze on the floor of the freezer under the pull out drawer didn't come up in conversation.   At six months post op I could not imagine ever doing any of those things again.

But now I can imagine and do it. So asking about those kind of activities will be at the top of my list when I see him in June for my one year post op visit. Now the question will be, if he says you are doing too much, cut back...am I willing? After almost two years (first year post fracture - second year post surgery) of such limited use, I am reveling in being able to use my arm again and don't want to play the invalid any more than I have to.

By the way, I am breaking my rule of no middle of the night posts. I hope this does not turn into a page full of gibberish.   

Meaning to say...PO Day 338

I've been noticing, just in the last couple weeks, somethng new and good about my operated shoulder. So I thought I should share it instead of always complaining about this or that.

I can reach out and very slightly back to pick up an object. For instance, to write my daily post I use a wireless keyboard with my ipad. I can just type better on a traditional keyboard. Anyway, it is awkward to try to balance a keyboard on one's lap and arrange the ipad so you can see it or touch it as you often have to do. So I have kind of a wooden desk box that lets the keyboard lay flat in front of the ipad which is standing upright. Dear Husband made it years ago as part of a project and has not used it in ages so I took possession of it. It is just perfect for my purposes.

It sets on the floor beside a chair beside my bed. With keyboard and ipad in place it probably weighs five pounds.Anyway, as I sit in the chair I can reach out and back slightly and grasp the tall back of the wooden box and pick it p and sling it around infront of me. I know it doesn't sound like much.. It's not like fighting tigers or anything. But it is quite a plus for me in my shoulder evolution.

I do still have to be careful going through a heavy door. I can't let the weight of the door grab my arm on its way back. So I am not all the way healed but doing very well. I think. I doubt I will ever have full use of my arm behind my back. I can live with that. The only time my arm hurts is when I try to do something behind my back, like tie an apron. Would not even think of hooking up a bra behind my back.

Nothing else to report. All is well.

HAI...P O Day 337

When a medical complication has its own abbreviation you know it is too common. HAI stands for Hospital Associated  Infection. According to the Center for Diseasae Control one in 25 hospital patients will be a victim of a hospital associated infection. In 2011 there were an estimated 722,000 HAIs in acute care hospitals in the United States. About 75,000 patients with HAIs died during their hospitalizations. More than half of all HAIs occured outside of the intensive care unit.

The increase in reporting statistics for hospitals has made it much easier for the general public to know what is going on with their local hospital. Information is readily available on line and accessible to the ordinary individual. Infection statistics, death rates, readmission stats, reviews by patients, and more is reported now. The old "fee for service" system of paying for a patient's care was oblivious to infections but the new value-based payment program penalizes hospitals for complications such as infection, readmission or, heaven forbid, death.

Faced with superbugs of every different ilk, hospitals are under terrific pressure to find ways to prevent hospital caused problems with their patients. The hospitals are definitely taking the problem seriously. Hand washing remains the single most effective thing a person can do to prevent infection. And that doesn't mean that just the patient is washing their hands frequently...it extends to everyone who walks into your  room - visitors, doctors, nurses and aides, ministers, volunteers,  and food service.

Also, hospitals know that the longer you are in the hospital, the greater your chance of contracting the bug of the day. Hence the pressure to get you up and out. Who can argue with that? Your own bed without a plastic mattress pad, enough salt in your grits, no one waking you every hour on the hour, no one whispering in the hall outside your bedroom. Ah, home sweet home.

Best and Worst...P O Day 336

I'm going to copy and paste the US News article summary about rating hospitals. I mentioned this in yesterday's blog. I think it is espeially interesitng and follows the time pressure felt in the white house.

Naturally the big medical centers support this idea. They have the surgical volunn to benefit from the chanages. Small hospitals will be in big trouble.

1. New ratings evaluate hospitals' delivery of 'common care'

By Leslie Small

Comment | Forward | Twitter | Facebook | LinkedIn

Amid an already crowded--and sometimes controversial--field of hospital rankings, U.S. News & World Report has added a new form of evaluation that rates hospitals based on how well they handle five common medical conditions and procedures. The Best Hospitals for Common Care ratings use 25 quality measures culled from Medicare data to rank about 4,000 hospitals in regard to how they perform heart bypass, hip replacement and knee replacement surgeries as well as treat congestive heart failure and chronic obstructive pulmonary disease, according to U.S. News. For each procedure or condition, hospitals received ratings of high performing, average or below average. "The good news for patients is that the majority of hospitals performed average or better," on these common procedures, Ben Harder, chief of health analysis for U.S. News, said in an announcement. Only 10 percent of hospitals who received ratings in each category were high performing, and another 10 percent were below average. The ratings exclude, however, more than 1,700 hospitals that perform too few procedures of the common procedures. Those exclusions themselves may be a cause for concern, as hospitals that don't commonly perform certain procedures produce considerably poorer outcomes for these surgeries, according to a recent U.S. News analysis, a finding that spurred some teaching hospitals to restrict low-volume surgeries. U.S. News' latest hospital rankings also take into account patients' health conditions, age, sex and socioeconomic status, the latter a factor that hospitals have complained can unfairly skew key quality metrics such as readmissions. Further, in a frequently asked questions document, U.S. News says it uses "a broader array of quality indicators" to determine its new common care rankings compared to other popular hospital-evaluation systems, including Leapfrog, Healthgrades, Consumer Reports, the Joint Commission and the Centers for Medicare & Medicaid's Hospital Compare websites. Hospital ratings have come under fire recently when a report noted their findings often sharply conflict with one another, FierceHealthcare has reported.

Imposed limits on surgery. PODay 335

The way it has always worked was that doctors and their patients made the decision for surgery and what surgery and the hospital agreed and everyone was happy and, unless the procedure was considered cosmetic or experimental, Medicare and other insurances covered it. No one considered the wisdom of the procedure or the expertise of the surgeon or mortality risk of the operation. If the risk was high, hopefully the doctor discussed this with the patient.

But a change is in the air. Three well known teaching hospitals in the US are planning to limit surgeries that are infrequently performed, have high mortality rates, and doctors who have limited experienc will be denied approval. Dartmouth, U of Michigan and Johns Hopkins will impose the voluntary guidelines by the end of 2015. Other hospitals around the country are considering joiniing the coalition but I suspect that if it is not done voluntarily, it will soon be done by coersion.

These three hospitals created a list of ten procedures that research has shown have the highest negative results. They include  joint replacement, bariatric surgery, lung cancer surgery, esophagus surgeries. The article in US News did not specify what the other procedures on tthe list were. This move is accompanied by an analysis that found patients were at greater risk of death from undergoing common provedures at hospitals that seldom performed them. This  reinforces the position that the "industry" should place some restrictions on who and where and on whom certain operations are performed.

Other major medical centers are reviewing the plan and considering taking similar action.

I can pretty much guarantee that my hospital where I was operated and my surgeon who performed my surgery would not be among the approved group. My hospital is a small branch of a large hospital chain and my surgeon, while very  well trained, is rather ypung. When I went for the required pre-surgery class for joint replacement patients, I was the only patient there who was scheduled for rTSA and the only patient  scheduled for TSA (total shoulder arthroplasty). Even though I asked a time or two I never learned how many such procedures had been performed there previously. I can understand no one wanted to say "we've done five" or "you are the first." But haven't we all, as young people looking for a job, been faced with the quandry of the employer who wants someone with experience but how do we get experience if no one will hire us? So how does the young orthopedic surgeon gain the necessary experience if the rules restrict certain procedures to only the older surgeons? Is this actually a move to  restrict the volume of certain operations? Certainly limiting access to receiving certain levels of care by requiring travel to major medical centers would have that result.

As we say in our family "There's the good reason and there's the real reason."

Be realistic...P O Day 334

I encountered a neighbor today who tore his rotator cuff about two and a half months ago. He chose to be treated conservatively which meant no surgery, just physical therapy. He said he has gained good range of motion but still has a lot of pain.

As you can imagine I began extoling the virtues of rTSA. But tonight I am feeling uncomfortable. Yes, it's true that rTSA is now considered the best surgical choice for a badly torn rotator cuff with glenorhumeral arthritis pain. But I certainly don't know how badly his cuff was torn which makes a huge difference in the course of treatment. The protocal suggests limited use of the arm and chronic pain should be present. Time and the opportunity for other conservative treament should have taken place. The patient should not be involved in heavy lifting or exterme physical activity. This is still considered a surgery for someone 65 or more although the recommended age is going down.

I was more than a year post shoulder fracture when I finally saw Dr. Kai (pseudonym), who tunred out to be my surgeon. I don't think he would have considered, let alone recommended, rTSA had less time passed since my accident. I had the feeling that he wanted the patient (me) to have come to end of their rope.Well, I certainly had! I just felt I had nothing to lose.

An objective and reasonable goal of the surgery would include less pain, more range of motion, better strength and improved function. So he was not promising the moon and the stars, just less pain and more use, if possible

I have had an excellent outcome and got all of the that and more. My sewing table project involved drilling holes and installing L-brackets. I used one of those little hand operated drills. So lots of drilling and more standing and watching and finally success. But I just knew something, like my prosthetic shoulder, would hurt. Nope, I am well on my way to the next arm wrestling contest. Or maybe not.

Middle of the night posts...PODay 333

No, I wasn't drinking, I didn't have a stroke and the only drug I took was an ibuprofen for a sore elbow. But I have sworn off of middle of the night posting. That's the only explanation for the error ridden post 332. I can only hope that the subject matter was so boring that everyone stopped reading before they got to the end. Even Dear Husband who acts as editor in chief must have drifted off about half way through as he has said nothing.

Did you ever see the Seinfeld episode where Jerry awakes in the night and writes down a really funny joke? The next day he hasn't a clue what he wrote or what he thought was so funny.  He spends the day trying to figure out what he was thinking. Well, I feel like Jerry. What was I thinking?

 On top of everything I was busy all day and didn't read my yesterday post to see all the errors. I had a little sewing desk project which turned out great, the cable guy came to figure out why the cable in the guest bedroom wasn't working, I started a new apron-smock (really cute), there was a little laundry to do, and a small amount of ironing. I am working on a little art project that took a good bit of time at the copier. And I promised Dear Husband I would open a new puzzle and sort out the edge pieces. Oh dear, puzzles absolutely consume my free time. I can't walk past a table strewn with puzzle pieces  without sitting down for an hour or two. I guess there will be nothing productive accomplished around here for the next week or two.

But in keeping with my new policy, I am writing my post tonight at 8:04 PM. I am feeling a certain post supper lethargy but my brain is still engaged so I am hopeful this post will redeem me with my readers. If I wake in the middle of the night I will troll ebay looking for an unfortunate auction that ends at 3:00 AM (seller's error) while all potential bidders are asleep. Or I can cruise the virtual aisles of Macy's or Wal-Mart's big box. But no more posting on my blog in the wee small hours!

Sugar vs sugar...PO Day 332

Nutritionists have been telling us for years that sugars are not all the same but no one could explain how or why, Now they know.

Glucose and fructose are both  simple sugars. both found in fruit. While they have the same number of calories, the way they are processed by the body is different. Glucose is absorbd directly into the blood steram and produces energy. The body reacts to glucose in the blood stream by producing insulin which makes the person feel full. Fructose is processed by the liver. Fructose does not stimulate insulin production and without it we do not feel satisfied or full. Fructose  also stimulates certain areas of the brain associated with reward processing. That's why we crave high calorie  foods like candy, cookies or pizzza.

And the worst part of the story is that manufacturers use fructose to sweeten commerical products, in particular soft drinks  and many  convenience foods. Should we just give up and stop trying? It seems as if the system is agaisnt us.  Unfortunately researchers suggest we limit fruit and other sources of  dietary  sucrose. Dr. Kathleen Page,  lead researacher, explained all of this to The Week who just ran a long article dealing with sucrose, another sugar form.
                             
(This is a summary of the Week article.)

ERs saving money...PO Day 331

Last year a local hospital (Halifax Hospital in Daytona Beach) had 39 million dollars in ED (Emergency Department) charges that were unreimbursed. A large part of this expense is incurred by "frequent flyers" or patients with chronic conditions who are repeat visitors to the Emergency Departments because they do not have a regular doctor. Changes in Medicaid due to the Affordable Care Act have forced hospitals to look at these patients in a new and better way.

Instead of repeatedly treating the immediate problem as has happened in the past, hospitals are now looking at the situation with the goal of reducing ED visits. Creating a clinic for Medicaid patients with congesive heart failure is one step the hospital has taken. Where previously those patients had only the ED as a resource, now they are able to by-pass the more expensive emegency care for routine follow up in a clinic setting. Patients suffering from diabetes, substance abuve, skin infections, mental illness and chronic obstructive pulmonary disease are also referred to the clinic.

A team of nurses, social workers, dieticians, counselors, and student health coaches coordinate care for patients with limited financial resources. The goal is to  provide health care guidance to patients outside of the emergency room setting which remains the most expensive provider of medical care.

"Other hospitals in Florida are doing the same. University of Florida Health Hospital's Care One Clinic in Gainesville implemented a clinic-based multidisciplinary team, after which ED visits fell from 4.9 to 3.8 per Care One "frequent flyer" patient, hospitalizations dropped from 3 to 2.1 and days spent in the hospital fell from 3.8 to 2.9, compared to the six months before the program."

It is not just the financial savings that makes this a worthwhile attempt at reducing costs. Targeting these "super-users" and creating clinic style resources where they are able to receive medical care and education about their disease provides a holistic approach that promises to improve their lives. Counseling does not just address their immediate medical need, but also housing, food, and lifestyle, things that are impossible to separate out from their general health.

Tracking your implant...PO Day 330

I'ver been wondering why these joint implants don't have serial numbers. Don't the manufacturerers watch police shows on TV where that is the only way they are able to identify the victim?

But now, for different reasons, Mercy health care in the midwest is experimenting with tracking the devices but not for the TV drama reason.

Hospitals are under tremendous pressure to improve outcomes and reduce costs. Mercy has come up with an administtative plan to help achieve that goal. They have developed the UDI ayatem, Unique Device Identifier. Implants are given an identifying ID number. The information is used to  keep up with inventory, coordinate care between specialists and alert patients  if there were to be a device recall (!).

"In 2012, Mercy, a high-performing healthcare system in the Midwest, began a pilot program that incorporated the UDIs of coronary artery stents into its inventory management, supply chain, billing and electronic health record systems. The codes allowed Mercy to reduce its inventory in one cardiac catheterization lab from $1.9 million to $1.4 million worth of equipment in just a few months by providing staff with real-time data on how many products were in stock. Clinicians electronically recorded the exact type of coronary artery stent implanted in each patient so they would be able to easily identify the device and take action if complications arose. Finally, researchers at Mercy were able to analyze their data and better understand differences in patient outcomes based on the type of stent implanted—a finding that will help doctors make more informed decisions on what product is most appropriate for each individual."

I can see where this system would benefit a high volune progran. I'm not so sure about my facility and situation. I'm pretty sure the Device Manufacturer sales rep keeps track of "inventory" and brings what is needed to the surgical arena the day of the procedure at my facility. I haven't asked but I definitely have the impression that rTSA is a rare, if ever donee, surgery here. So I suspect they can keep track of we few patients by name.     But the UDT number could have some value if I'm ever the unfortunate player in a television police drama.

Grip strength...PO Day 329

I can't open a new bottle of catsup. I can't tear apart a bag of potato chips. The bag inside the box of Cereal defeats me. I can't break that little plastic string that connects tags to new articles of clothing. If I pull really hard I can manage to pull the wide end through the shirt leaving a disfiguring hole.

When I was a child we had a new jar of pickles that no one could open. Every visitor to the home got to try their special technique. No one ever did it. I wonder what happened to those pickles.

I keep scissors handy to cut my way into and out of all kinds of packages. I have a Martha Stewart thingee that grips the cap on a new gallon of milk and helps twist it off. I have a granite slab in the kitchen where I can tap or bang the edge of a bottle cap without worrying about damaging the counter top or the other popular kitchen rapping device, the table knife handle (!).

Don't ask me to loosen a tight screw or turn on the water faucet if someone hunkered down on it when they turned it off. I find pliers and wrenches very useful. I don't understand the physics of the lever, just know it works for me.

At least I always thought of this as a minor nuisance in the mechanics of life. Or better yet, a demonstration of my true femininity, a member of the weaker sex. Nothing seems to make a man feel more needed than a recalcitrant bottle of olives. But now I learn hand strength is life's crystal ball, a prognosticator of longevity. Oh dear.

In a study just reported in The Lancet following 140,000 people in 17 different countries, researchers found "grip strength may be a good predictor of the risk for cardiovascular disease." There was a clear and consistent link between grip strength and death from any cause, but especially from heart attack or stroke.

One report suggested hand grip is a stronger forecaster of early death than systolic blood pressure.

This does not bode well for my long term future. I guess I just need to get a grip. :)

        

Life goes on...P O Day 328

Here I am writing my daily post for my blog and it is only 9:40, not 2:30 AM which is usual. Good Grief, am I back on the straight and narrow? Is life returning to nomral? I am sleeping better. That's one reason I am writing my post now. I can't assume I will wake up all bright eyed at 2:00 or 3:00 AM as I have been doing for the past year. Now if I do wake up I am appropriately befuddled and                    my words to not make sense.  I am bordering on that state right now, just tired.

I did go for an exercise  walk! Not fast, not far, but unmistakenly exercise, not a stroll. It didn't kill my enthusiasm for being an athlete but I was moving a little slower all day.

The walk made me more tired and by late afternoon I just had to lie down and rest. I was out like a light! As it turned out today was a good day for me to be where I was by 4:00. I was so sleepy I fell asleep practically in mid-motion. A medication I take warns that something like can happen but I had not experienced it before. Weird.

But, in spite of the little exercise and the need for a nap, I was still productive and got a lot done around the house. Whatever is motivating me, I would hate to lose it. Speaking of losing things...as I sat down to dinner I realized the back to one of my good pierced earrings was missing.  I had been using a shop vac earlier and thought I saw something sparkly disappear into the hose. So after dinner the contents of the shop vac had to be examined. It was full of Dear Husband's woodwork shavings and an interesting shed skin from a small snake (!) but finally, in the bottom debris was my earring back. I'm glad to have it back but I can't help wondering if there had been a small snake inside the skin when it went in to the vacuum and where was it when it got sucked up and where is it now. Oh dear, I didn't need to know about this!

What to eat?...P O Day 327

Researchers followed 447 men and women aged 55 to 80 years old for four years.They were asked to eat either a low fat diet or a Mediterranean diet that included consuming 30 grams of nuts a week and one liter of extra virgin olive oil per week.

The point of the research was to learm if and how diet could affect performance on cogntive tests. Participants were given a series of brain functioning tests at the start of the study and four years later at the end of the study.

Those on the low fat diet lost some memory and thinking skills. Those who added the nuts to their diet saw their memory skills improve, on average. Those who consuned the additional liter of olive oil had an improvement in their problem-solving and planning skills.

All this according to an article in the May JAMA Internal Medicine.

The article did not address wieght management. But it would not surprise me if the low fat diet group did poorest in managing their weight. After all the hype about low fat diets in the past thirty years it does seem that low fat is not, alone, the way to go. It may be hard for Americans to follow the Mediterranean diet however. First, serving size is a big issue. We Americans do serve and eat much larger portions than Europeans, especially Mediterraneans. And, we have a friend who claims what we buy in the US is NOT olive oil, especially not extra version olive oil. I don't know what he thinks we get in  a bottle of olive oil if it isn't oilive oil. But he is not usually given to strange ideas. Not usually.

I would like to preserve the little good brain functon that I now have. And a diet of pasta, vegetables, tomatoes, wine and nuts sounds tolerable. I'm not sure how a liter of oiive oil would go down. One extra liter a week sounds like a lot. it's hard to alter one's thinking  after years of being told to eat a low-fat diet.

        

   

Can't Explain it... P O Day 326

I can't explain why I have  had so much energy lately. It's almost as if I am manically pushing myself. I don't think I have ever been obsessive compulsive but I am certainly staying busy. This phase seems to coinside with my lack of exercise. Could that explain it? Does my usual exercise program make me tired enough that I don't have the pizazz for other projects?

I do miss exercising. Without it I just don't feel as coordinated or physically organized when I am a couch potato. It's kind of a "catch 22" situtation; exercise makes me physically tired but I have more energy for little projects if I don't exercise. If I do exercise my body seems more pulled together but I am tired.

Well, we'll see. My friend with whom I usually walk has not been available to encourage me to do it. But she's back! We plan a short walk tomorrow morning. I'm anxious to see what happens. I don't want to lose the enthusiasm for getting things around the house done. But it is a miracle I have not gained weight without the physical activity. Why can't I have it both? Have it all?

I was cleaning out a closet recently and found some material that I had bought when granddaughter was about three years old.  There were three diffierent pieces of coordinating material featuring cute litttle frogs on lilly pads. While it would have been darling on a three year old, a cool ten year old wouldn't be caught in such an outfit. What was I to do with it? I made three differnt aprons, each more fun to make than the previous. Then I started looking at old linens, tablecloths that don't fit our table or have a hole or some issue. Dear Husband asked me to make him a "bib" to wear when eating something messy. One bib turned into severeal. A trip to visit a friend who is severely handicapped turrned into a reason to make her a few stylish bibs. Once a fashionista, always a fashionista. Bibs morphed into smocks, like an art teacher would wear to protect her clothes. No, there are no art teachers in the family.  Smocks have evolved into gardening aprons...at least one that is now being "field tested." What next?  I am addicted!

But sitting at a sewing machine is doing nothing for my physical self. So tomorrow it's back on the road again.. I hope I can do it! I hope I can do it all.

Good reason-Real reason...PO Day 325

When I started this blog nearly eleven months ago my plan was to do it for one year. I thought I would be  more handicapped from my surgery than I actually was and I thought a quiet intellectual activity would get me through sedentary months. As it turns out an operated shoulder does not keep your  other arm, legs and feet from working normally so mostly life went on pretty much as ususal.

But the blog has been great fun. I've learned a lot while reading about subjects to write about. I feel so modern to be able to say "I have a blog." I never was a diary person, not even as an adolescent when every girl used to get a locking diary for her birthday. But I have always loved to write and the blog made it not ALWAYS about me. Sometimes the topic was something I was interestd in but sometimes it was a real stretch to justify the topic of the day's post with the subject of the blog

What will I do at post op day 366? Right now my plan is to let this blog stagnate and start a new blog with a new name and a new topic. The good reaon? I have beat the subject of shoulder surgery to death and more and more go off on tangents that have nothihng to do with rTSA. So  a new blog would let me go in a new direction, conversaiton wise. The real reason? Maybe you recall several months ago suiddenly in the middle of the night my blog work site was corrupted and all the directions. identifying words, everything word or letter except what I type has been replaced with a kind of rectanular 0. I can't do anything innovative because I can't read any directions. I cnn only enter my daily posts as i can remember the directions but no way can I now read them. They are just not here.

The only way to have a normal blog format again is to start a new one. blogspot is a division of Google, they host the site. Blogpsot is a free service so Google has no motivation to spend a lot of time and energy solving we freeloader's tech problems. So, for now, my plan is to let this blog lay fallow and move to a new site on PO Day 366. I do think there are some pearls of wisdom here for the potential surgery patient so I'll leave it open and refer readers to my new site if they want to follow me.

At least that's the plan. We'll see what really happens.

Mother's Day...PO Day 324

If there's a little conflict around your celebration of Mother's Day, you're in good company. How are we going to celebrate, where are we going to eat? No, Mom doesn't like Olive Garden. We can't make it to the 11:00 service. Yes, I know she'd like us to go with her.

Yes, it's hard to organize a family event.

Blame it all on Anna Jarvis of West Virginia. In 1908 she organized the first official Mothers Day church service in Grafton, West Virginia to honor her own mother who died three years earlier. Talk about conflicted, she worked to have the day officially added to them national calendar and after successful, she spent her life trying to have it removed because she hated the commercialism that came along with it.

Nonetheless, she must have been proud of establishing the day of honor since she, all her life, signed things "Anna Jarvis, founder of Mother's Day." Interestingly, she never married and had no children.

Of course the idea of honoring one's mother is as old as the Ten Commandments. Probably older than that. Have you ever noticed how the winning football quarterback always says "Hi Mom" when the TV camera catches him after the game? I've never seen one of those guys say "Hi Dad." Yes, Dad gets to give away the bride, although that tradition is falling out of favor. But everyone knows it was Mom who stayed up all night with that little girl when she was sick. Mom was the one who made sure her favorite cookie was in the lunch bag on nervous school days. And Mom figured out how to make a Halloween costume out of a terry cloth bathrobe and some aluminum foil.

So, kudos to Anna Jarvis for reminding us to stop and honor our moms. She'd probably like it if we didn't send a hallmark card or send an expensive gift or even get everyone to agree on a restaurant. Rather, I think she'd approve if we just told our moms that we love them and appreciate what they did for us.

The Keurig business's plan....PO Day 323

I had breakfast with a group of friends this morning and we were discussing the popular Keurig coffee maker. Coincidently I read an interesting article about Keurig this afternoon. Wish I had known all this at breakfast. Here's a summary.

In the business world there are several ways companies approach profitability. One successful plan is to make a basic product that requires continuous purchases to accompany the original item. One example is a man's razor that uses a special blade. The razor might be sold at a loss to ensure the ongoing purchase of the blades where the real profit lays.

A really popular item that falls in that category is the Keurig coffee maker. The real profit for the company is in the k-cups, single serving coffee pods that push the price of a pound of coffee into the range of $50.00. Frugal Keurig owners have been able to get around this by buying reusable cups designed to be filled with one's own coffee. Removing a small part of the original Keurig allowed the home coffee brewer to have the best of both worlds, the high tech coffee machine and the economical grocery store pound of coffee.

But Keurig looked at the loss of k-cup sales to all those tightwads filling their own little containers as unacceptable. So in August 2014 the coffee machine was redesigned so new models would no longer accept refillable cups. Customer response was swift and angry. Sales tanked and the stock price fell ten percent in one day. Inventory stockpiled on store shelves. In a company quarterly meeting the president admitted trying to convince the public that the changes were part of their quality control process was a bad idea. Keurig capitulated and new machines can again use the self-fillable cups.

It's a good thing the old design is back. When the time came to replace our machine Dear Husband would never have gone for the convenient, but expensive, disposable k-cup approach. But I bet this is not the end of the story. The company knows we stingy baristas are out there and, no doubt, they'll be looking for another way to bring us into the fold. 

Solutions to the ER...Po day 322

One medical industry development that has the potential to solve the use of the ER problem is the  "Retail" clinic.   CVS and Walmart are two companies that are establishing out patient care programs for individual patients and also for companies wishing to provide health care for employees but not wanting to go the traditional insurance route. In these early stages facillities are being opened in areas where there are doctor shortages or long distances betwen physical sites where people can seek care.

Walmart has opened trial facillities in North Carolina. They are staffed by nurses who use the "best practices" protocal in diagnosing and treating patients and, unlike other trial runs where the clinic is operated by a third party, these facilities are owned and run by Wal-Mart.  Clinics are open 12 hours  a day on weekdays and 8 hours a day on weekends. Office visits are $40.00 and patients are able to uodate or add onto theeir existing medical record. Employer covered patients may have only a $4.00 co-pay to meet. Clinics accept Medicare patients and, in some locations, will acccept medicaid patients as well.

"The company's move signals yet another shift in healthcare delivery that creates more competition for traditional providers like doctors and hospitals. Public and private health insurance exchanges under the Affordable Care Act mean patients have more control over their own healthcare than ever before," Rob Lazerow, a practice manager with the Health Care Advisory Board, told Forbes Magazine. "This is a very different competitive landscape than what most executives have faced previously--and hospitals risk losing volumes at each decision point," Lazerow said.

That last statement is indicative of the conflicted attitude within the health care industry. While the Affordable Care Act discourages use of Emergency Departments, hospitals are fearful of losing the "not urgent care" patient to retail medical care.   So far the general public has not embraced retail medical care but Wal-mart may be just the entity to reach us. Just like when they introduced $4.00 prescriptions and, more recently, starting salaries at higher than minimum wage levels,  where Wal-Mart goes, so goes the country.

Dr. Watson...P O Day 321

If you are fan of Jeopardy you may have watched the program the two nights that IBM's computer, Watson, competed with Jeopardy's two biggest human winners (most money and most  episodes). The first night the human competitrs didn't stand a change. The second night they had learned to buzz in before the question had been read and hope they had a prayer of knowing the answer. They did better but Watson still was the victor. It was a fun look at a sophisticated computer but I really did not get how it would be useful in real life.

Fast forward to the present.

"The technology company is partnering with electronic health record vendor Epic and Rochester, Minnesota-based Mayo Clinic to apply cognitive computing capabilities to EHRs, according to an announcement Tuesday. Epic will also use Watson to embed cognitive computing services into its decision support offerings using open standards such as Fast Healthcare Interoperability Resources and application programming interfaces."

"In addition, IBM announced that it plans to collaborate with 14 cancer institutes across the country to create more personalized treatments for patients. This isn't a totally new endeavor for IBM; it previously worked with Memorial Sloan-Kettering and the New York Genome Center on personalized cancer treatment projects."


'In addition to these new programs, IBM also has a partnership with Apple to bring cloud services and analytics to HealthKit and ResearchKit. "

So don't expect Dr. Watson to roll into your hospital room but pretty soon he will be consulting behind the scenes, searching his data base fot statistically similar if not identical patient histories to create a personalized treatment program for you. This is just one more way the Electronic Health Record is creating a huge data base of what treatment works under what conditions in the new Value Based Purchasing health care paradigm.

ER visits...P O Day 320

One of the goals of the Afforable Care Act was to reduce the use of the Emergency Room (which we are now supposed to call the Emergency Department) as it is very much more expensive than a doctor office visit. The idea was that having regular health insurance would encourage people to have a primary care physician and seek treatment in their office setting. That hasn't happened and the use of EDs (Emergency Departments) has increased rather than decreased. Many of the patients have been referred by their doctor and a significant percentage are Medicaid patients who have been unable to find a private doctor to accept them as a patient.

At first I thought I understood. People don't make the effort to find a doctor and establish a relationship when they are healthy. As we all know, medical problems always take a a turn for the worse at night or on the weekend, certainly there is little or no warning. Trying to get in to see a physician on short notice when you have not been their patient before just isn't going to happen.

While that is all true, there is more going on. It used to be that "your" doctor had an obligation to be available to you 24/7. Some chose to take care of their own patient population personally, quite a burden as they had to be available at all times.  Most formed loose associations with other physicians of like specialities and took turns "being on call." Everyone made use of an answering service that knew the schedule. When a patient called Dr. A after hours or on the weekend with a problem, minor or major, the answering service  would call the Doctor on Call, Dr. B, who would  agree to see the patient in his office. Rarely the seriousness of the problem would require seeing the patient in the Emergency Room. Even then it was Dr. B who met the patient at the Emergency Room and took care of them.

Well, it doesn't work that way anymore. I don't know when the "On Call" system dissolved but, for me, I experienced it for the the first time about six years ago. I had had surgery and developed a post op infection. I saw my surgeon in his office early on a Friday. The problem  was handled as a serious situation, blood work was ordered to rule out a very bad infection and a very expensive antibiotic was ordered. I was shocked when, as I prepared to leave, my surgeon said "If things get worse over the weekend, go to the Emergency Room." "I don't call you," I asked. "No, go to the ER," he said.

More recently, when a radiologist scanned a routine post rTSA x-ray and realized mu breathlessness and weakness was due to a collapsed lung, I was told to go to the Emergency Room immediatley even though it was during regular business hours.My orthopedic doctor was alerted but I did not see him until the next morning after being treated in the ER and admitted to the hospital as an inpatiemt. I was in the care of the "hospitalist" and a thoracic surgeon, not my orthopedic surgeon. (He did drop
in to see me every morning at least)

So, even though it is being drilled into us to NOT use the Emergency Room as a doctor's office, even those of us who have a physician and see them routinely, the "system" is directing us to the ER.  I wonder if the healthcare administrators understand how it works in the real world.

catching up... P O Day 319

I survived the annual check up. My cholesterol was up a little but nothing like it deserved to be considering my recent diet and lack of exercise. It waas hardly mentioned. My weight was the same. That was hard to believe but what a relief.  My hurty pinkie finger might be gout. GOUT? Isn't that for old people who eat too rich food and drink too much wine? Oh. Right. A uric acid test will rule it in or out.

But what I really meant to talk about was the appearance of my operated shoulder.

The scar is pale and fairly smooth. I think of it as two parts; the lower half extends vertically down my upper arm in the front and the upper half runs diagonally from the midpoint toward the collar bone.  The lower half is exposed if I wear a sleeveless shirt; the upper half is mostly covered in any upper garment, sleeveless or whatever. The only way it would be visable would be in a strapless top.

Now, this part is hard to describe, As muscles have been repurposed to allow use of the artificial joint, I find that  I must use some chest muscles to help lift that arm. So the chest muscle midline to the upper scar has developed stronger and very slightly more prominent on the operated side. This causes the diagonal scar to look like and actually be recessed, almost as if it lays in a valley, if you can visualize that. Then, lateral to the scar, the shoulder roundly forms the upper joint and looks quite normal again.

I would say the somewhat irregulat appearance of the area is due to rearrangement of the fleshy tissue under the scar. But I am not complaining, just remarking for the benefit of someon anticipating surgery. The key to accepting how it looks is to wear clothes!   But I am sure that no one would noticee the slightly unusual topography in summer bare shoulders.

And, since this is considered surgery for older people, like at least fifty years or older, the patient is probably not going to quibble over how the wound looks.

I certainnly am not.

Dress for the Doctor...PO Day 318

Tomorrow is my primary care annual check up. Today was the day I got everything together that I need; other doctor report, list of questions to discuss, cookies, and, most important of all, what I will wear.

Like attending your husband's office Christmas party, you don't want to overdress. Nothing too long, too short, not low cut, modest but modern, casual but not like you just came from working in the garden. It mustn't be too loose as if you have lost weight recently, not too tight as if you have gained weight, for Heaven's sake.

I suppose some people might say it does not matter what one wears. So after we zipped through the afternoon chores I considered that idea. What I wear day in and day out is not worthy of much forethought. A t-shirt and shorts is the uniform of any day. Fortunately or unfortunately that uniform is pretty standard everywhere, especially beach communities..There are work in the garden shorts, go to the grocery store shorts and go out to dinner shorts. A t-shirt with a collar elevates one's ensemble  to dress up status. So, yes, in Florida, shorts can go to the doctor.

Crisp and fresh, coordinated (if you are female-guys can get away with plaids and stripes), a little color, collected...that's what I am going for. The "clean underwear" mantra isn't anough - clean has to extend to the outer layers too. Lightweight is good, remember stepping on that scale! And finally, easy to pull up or pull down or pull off...just in case.

But most important, your clothes must give the impression of good health. That's a little hard to put words to. But we know it when we see it. So does your doctor!

Exercise ...P O Day 317

I have not been exercisiing. Thats not to say I haven't been busy or doing things. I've been sewing and cleaning and working in the yard...but none of that counts as exercise. My brain has been challenged due to a new computer in the house but exercising one's brain doesn't do anything for the body.

And apparently, exercise without sweat doesn't count either. As reported in The Week (yes, my favorite magazine), a group of Australian researchers followed 200,000 people for six years. Those who exercised more vigorously, enough to break a sweat, had a mortality rate up to 13% lower than those who exercised but with less enthusiasm, shall we say.

"The benefits of vigorous activity  applied were independent of the total amount of time spent being active'" saaid Klaus Gebel, the lead author of the report.

I wonder if my fairly slow walking pace qualifies? Eleven months of the year I break a sweat. Pretty easy to do in Florida! 

Monthly summary... P O Day 316

I didn't forget, just a day late.

My shoulder is getting along fine. Since about nine months post op things have really been just about normal. I have very little discomfort. There are positions that remind me not get into them, particularly any place behind my back. I can live with that. Today I lifted a couple very heavy bags of leaves, used a weedeater, and even hammered a stake into the ground. I am a little sore tonight but within predictable ranges.

The only thing I really battle with anymore is dressing. Geting both arms in a jacket can be difficult. I think it is my long arm problem. And pulling up pants can be a little hard. Hooking and zipping side opening skirts or pants is awkward. And I cannot zip up a dress... but couldn't before rTSA sugery.

I can lift, pull, push, carry, pour, pound, hammer, and reach. Stretching to reach high items is a problem, not from shoulder trouble, because I am shorter than I used to be. Everything I wannt is on a higher shelf. I may have to rearrange kitchen stuff! I may have told you I am not walking so consequently I have tons of energy for household items that need repaired or cleaned or rearranged.

All in all, maybe an "A" grade. It took a while to get better but finally doing it! 

Medical mistakes...PO Day 315

In 1711 when Alexander Pope wrote "To err is human" he probably wasn't thinking about medical errors resulting in harm to the patient.

The commonly quoted phrase "at least do no harm" attributed to Hippocrates was really "first do no harm" and really originated in the late 18th century with English surgeon Thomas Inman.

But the issue of hurting, not helping, the patient has been around for centuries.

An oft quoted study in 1999 suggested hospital medical errors resulted in 98,000 patient deaths a year. However, that report is based on incomplete data that does not take into consideration more recent information.

A new study published in the Journal of Patient Safety says incidents of patient death due to medical error may be as high as 400,000 deaths a year. (That's the high end of the estimate to get your attention)

"The new study reveals that each year preventable adverse events (PAEs) lead to the death of 210,000-400,000 patients who seek care at a hospital. Those figures would make medical errors the third leading cause of death behind heart disease and cancer, according to Centers for Disease Control and Prevention statistics."

My first thought is that's a pretty broad range, 210,000 to 400,000, and perhaps exaggerated for shock purposes. My second thought is if you are 1 of 210,000 or 1 of 400,000, either way, it can't get much worse.

What can I, the patient, do  to prevent disastrous medical mistakes? CNN compiled the following list of ten things you can do to prevent serious medical errors.

• Treating the wrong patient. Before procedures, patients should ask hospital staff to verify their entire name and date of birth, as well as the barcode on their hospital bracelet. 

• Leaving a piece of equipment inside a patient's body during surgery. If a patient feels unexpected pain, swelling, or fever, they should ask staff whether they might have a surgical instrument in their body.

• Losing a patient with dementia. Family and friends of patients with dementia should consider using GPS tracking bracelets if the patient tends to wander frequently. There are cases of patients with dementia wandering off without the knowledge of hospital staff and later dying of hypothermia or dehydration.

• Con artists pretending to be physicians. Patients should always confirm that a physician is licensed using resources available online or elsewhere. 


• Becoming more ill while waiting in the ED. Patients in overcrowded EDs may wait hours to see a physician and must be proactive if they need immediate care. Patients should call their physician on the way to the ED and ask them to alert the hospital staff.

• Allowing air bubbles to enter the bloodstream when a chest tube is removed.Patients should ask staff about proper body positioning before having a chest tube removed. 

• Operating on the wrong body part. Charts can be incorrect or surgeons can misread them, so patients should confirm the surgical site with the nurse and surgeon before the procedure. 

• Acquiring an infection because of poor staff hygiene. Although it is an uncomfortable question, patients should ask physicians and nurses if they have properly washed their hands before being touched—even if they are wearing gloves.

• Putting medicine in the wrong tube. Patients should ask staff to trace every tube back to the point of origin when injecting substances to avoid errors.

• Failing to give a patient sufficient anesthesia. Patients may want to ask if a local anesthetic would work as efficiently as general anesthesia (Bonifield/Cohen, CNN, 11/5).