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).