I turned the corner and there it was. The Death Star, as locals call it, because it’s star-shaped, imposing, and has a helipad on the roof. Also known as the Queen Elizabeth University Hospital in Glasgow—a state-of-the-art, 14-floor hospital completely interlinked, part of the National Health Service in Scotland—it was the site of the Non-technical Skills for Surgeons (NOTSS) Master Course I was invited to join.
In my exploration of what makes a good surgical team, I came across “Teamwork Assessment Tools in Modern Surgical Practice.” That article inspired me to write Can Surgery Teamwork Save Your Life?, describing one of the best assessments, Non-technical Skills for Surgeons (NOTSS).
Any excuse to travel is all right with me. The Royal College of Surgeons-Edinburgh offered a NOTSS Master course on a day I was available. So I headed to Glasgow for a few days of Scottish music, single malt scotch, and museums before the course.
NOTSS is a program to train surgical residents (and more senior physicians) in non-technical skills. They are specifically referring to the behavioral elements of optimal surgical performance.
UK surgeons who are accepted into the Royal College are called Mr, Miss, Ms, or Mrs rather than doctor. Mr. Simon Paterson-Brown and Mr. Simon Gibson kicked off the day with the usual medical statistics about using checklists in the operating room, or theatre, as it’s known in the UK. Routine use of checklists halves surgical mortality, from 1.5% to 0.8%
Using a checklist might have prevented Sheila Hynes death in March 2017, after her new heart valve was put in upside down. The two Simons asked us, “What goes wrong in your theatre?” Reasons for errors include the following:
Human factors, leadership, and communication, all included in non-technical skills, are the top three contributors to Sentinel Events. These are unexpected events in a healthcare setting that kill or harm patients and that are unrelated to the patients’ illness.
As I learned, NOTSS is not about:
And there is no single vaccination for immunity.
NOTSS is about normal people, places, organizations, and systems. It’s about recognizing complexity and optimizing performance.
Other stories by this author: A Fatal Medical Error: Lack of Care or Lack of Caring?
High on the list of necessary skills for effective surgeons is situational awareness. This is the state of being aware of what’s around you even as you focus on the task of surgery.
Check out this video to test your own situational awareness.
Here are some ways to enhance situational awareness:
I’M SAFE is the mnemonic for a self-check list at the beginning of the day and when starting new or major procedures. Are you having any negative effects from the following?
While observing surgeons, use CUSS for graded assertiveness:
In 1977, KLM Flight 4805 and Pan Am Flight 1736 collided on the runway in Tenerife. This was the deadliest airplane accident in history at that time, killing 583 people.
The pilot was Captain Veldhuyzen van Zanten, KLM’s chief of flight training and one of their most senior pilots. He took off without clearance, smashing into the other 747 on the runway.
In 2009, Captain Chesley “Sully” Sullender landed a crippled airplane on the Hudson River, with no loss of life. In the former, other crew members were reluctant to question the captain. They died. In the latter, the team concentrated on doing the right thing at the right time. They lived.
According to TeamSTEPPS, they
Good quality operating room leadership leads to decreased errors, reduced costs, improved safety, and increased compliance with standard operating procedures (SOPs).
Despite that, 47% of surgeons believe the decisions of the “leader” should not be questioned. So did the crew members of Captain van Zanten. And, contrast that with the present time where only 7% of pilots have that belief, a smaller percentage after changes were implemented following the Tenerife crash.
One solution is to send your surgeons abroad for NOTSS training. Another is for them to take the course at the annual American College of Surgeons meeting. This is where there is often a workshop on this topic.
The book, Enhancing Surgical Performance: A Primer in Non-technical Skills,* offers a detailed road map for “structuring observation, rating, and feedback of surgeons’ behaviors in the operating theatre.”
Anyone involved in surgery—surgeons, nurses, residents, students—will learn what to look for and how to perform to increase staff well-being and decrease patients’ deaths and errors in the surgical suite.
I use this assessment with my surgeon coaching clients as I observe them in the operating room with their teams. The experience changes how they approach the surgery process. Becoming adept at non-technical skills literally changes lives for the better—patients’ lives.
As the great sage, Yoda said,
“Do. Or do not. There is no try.”
*Indicate an affiliate link. We may make a small commission if you purchase this book using this link. It will not affect your price, but it does help us do our work.
Published 6/3/17. Reviewed and updated 12/3/20.
America’s opioid addiction problem began, in my opinion, over 30 years ago in what many consider an unlikely place: America’s medical schools. Prolonged anxiety, grief, isolation, and financial worries stemming from COVID-19 have only exacerbated an already growing problem.
There’s been a dramatic surge in opioid-related deaths during the past six months. In fact, just this month, the American Medical Association issued a statement citing rising cases of opioid-related mortality in more than 40 states, urging those governors and legislatures to take swift action to help curb the deadly tide.
In four years of medical school plus a five-year surgical residency, I had no formal instruction in substance use or addiction. In fact, it was mostly treated as an annoyance—doctors were tasked to “deal with the junkie in Room 208.”
I found this ironic, considering that as surgeons, we were frequently the cause of a patient’s pain—the result of a procedure to treat their primary affliction. Afterward, prescribing opioids for post-surgical pain was the standard operating procedure. Percocet, Vicodin, Oxycontin, and Dilaudid were all top of the list.
Pain was even viewed as a “5th vital sign.” It was seen as such a detriment to healing and survival that doctors were encouraged by specialty societies and medical boards to treat it aggressively for the overall recovery and well-being of the patient.
Unfortunately, physicians lacked training in the risks of opioid use. They also had limited understanding of how certain medications work (or don’t work) for acute injuries versus chronic conditions.
This opened a flood gate of excess opioid prescriptions. This, in turn, resulted in the growing consumer demand for more powerful drugs, creating an entire class of addiction patients.
Now, of course, things are much different. We know the dangers of opioids. And, we’ve come light-years in drug research and alternative pain therapies to minimize the risk of addiction. But we now face the daunting task of undoing years of damage.
The good news is that we have made some progress, including
However, more than 90% of patients who need treatment for addiction still can’t get the help they need.
Societal attitudes and the stigma and shame associated with addiction play a large role in creating those hurdles, but one of the biggest obstacles lies within the treatment community itself.
One of the largest hurdles in getting more treatment for more people is the lack of access to the right kind of care, specifically addiction medicine. Most people are familiar with the different types of clinical treatments known to be effective, including
But they may not be familiar with the medical specialty of addiction medicine which deals specifically with the physical aspects of drug addiction treatment.
It encompasses a full range of medical needs, including detoxification, vital patient care, and medication therapies to treat co-occurring diagnoses that must be managed simultaneously, including but not limited to:
A myriad of treatments can help with these needs, including medications that can minimize the damage and discomfort of detox and prevent co-occurring issues from undermining clinical therapy. These therapies must dovetail perfectly within a comprehensive treatment program to ensure the best possible outcome and avoid unintended consequences.
Unfortunately, 98% of addiction treatment providers are untrained in addiction medicine. This creates a huge shortage of specialists that have the expertise that is desperately needed in order to effectively tackle the opioid addiction epidemic from a holistic approach.
To address the addiction medicine shortage, River Oaks Treatment Center, an American Addiction Centers facility, has partnered with the Brandon Regional Hospital to launch a new Addiction Medicine Fellowship. HCA Healthcare/USF Morsani College of Medicine GME Programs is a sponsor of the program.
Led by Brandon Regional’s Dr. Abbas Sina and River Oaks’ Dr. Michael Murphy, the fellowship aims to provide in-depth, hands-on experience for two clinicians in direct addiction medicine treatment.
Through this ambitious program, two medical fellows, myself included, will partake in clinical rotations at both Brandon Regional and the River Oaks Treatment Center. We will receive a full and intimate view of the entire addiction treatment process, including
As part of the one-year program, the fellows will gain experience in managing co-occurring conditions as part of a high-volume comprehensive care center,. This will allow them to follow patients’ progress throughout the addiction treatment journey.
The program also includes a unique introduction to addiction treatment within pediatric populations. It will include taking care of neonates born to addicted mothers and going through withdrawal.
Addiction has truly become one of the most vexing medical conditions of our time. It’s the only disease in which even getting patients to accept that they have the problem that needs treatment is a formidable challenge.
There’s no denying colon cancer or a coronary artery blockage—almost no one refuses surgery to fix those. But, with an estimated 10.3 million people misusing opioids a year, and overdoses up nearly 20% since the COVID-19 pandemic began, it clearly remains a public health crisis of epic proportions.
With the right kind of treatment and resources in place—which includes a much-needed expansion in the number of qualified addiction medicine providers—we can close this critical gap in medical care and get more Americans the help they need to overcome opioid use disorder.
Here is the link to learn more about the addiction medicine fellowship at River Oaks and Brandon Regional Hospital.
[Editors note: We have not received compensation for publishing this article. But we have included links to commercial entities because they add to the strength of the story.]
Have you been wondering how much money US doctors made in 2020? It was, after all, a year marked by one of the worst health crises in modern history – the COVID-19 pandemic. The impact on our healthcare system has been profound, including impacts on physician compensation.
Not only were hospitals inundated with extremely ill patients in certain parts of the country but their most lucrative source of income, elective surgeries, evaporated overnight.[mfn]1[/mfn] This affected everyone who works in hospitals, including surgeons, radiologists, and other hospital-based-physicians.
Furthermore, visits to primary care doctors dropped precipitously as we were confined to our homes.[mfn]2[/mfn] And, the fear of catching COVID at our doctor’s office scared the bejeezus out of many. Even oncologists and other specialists experienced patients staying away even when they urgently needed the care.[mfn]3[/mfn]
Doctors and other healthcare workers found themselves in an unexpected situation with drastic declines in income and even work furloughs.[mfn]4[/mfn]
Interestingly, but not surprisingly, the healthcare sector responded to these threats with innovations that helped turn the financial calamity around. Telemedicine was rapidly instituted.[mfn]5[/mfn] And, strict procedures were implemented to make surgeries and visits to the doctor’s office safer.[mfn]6[/mfn] Patients were reassured to see their providers wearing masks and face shields.
So, what has been the net effect of all of this on doctor’s incomes year-to-date? Let’s take a look.
Doximity is the largest professional network in the US having more than 70% of all U.S. doctors as members. They have been collecting data from survey responses from 135,000 licensed US physicians over the past six years. This is the fourth year that they have published a Physician Compensation Report.
According to one of the lead authors of the story, Peter Alperin, M.D., a practicing internist and the Vice President of Product at Doximity, this survey differs from other physician compensation reports in two important ways:
Compensation growth was only 1.5% according to this year’s report. This is quite modest compared to increases of up to 4% in previous years. Further, because the 2019 inflation rate was 2.3% (as measured by the Consumer Price Index)[mfn]7[/mfn], it suggests that physicians overall had a decline in real income.
There is more than a $100,000 difference between the metro area with the highest compensation (Milwaukee – $430,274) and the area with the lowest (San Antonio – $329,475). But it’s hard to know what this really means because there are many factors that contribute to the calculation of “average” compensation, including:
The report provides some detail on another important factor impacting compensation: employment type.
It is interesting to note that metro areas with the highest cost of living [mfn]8[/mfn] do not appear on the list of places with the highest compensation.
That speaks to the fact that there are other considerations besides compensation and the cost of living that physicians may take into account before they pack their bags and move to Milwaukee. These include:
I could go on and on, but you get the picture. Compensation is important, but it isn’ everything.
Providence, Rhode Island tops the list with an 8.9% growth rate followed by Portland, Oregon with 8.6%. Again this is hard to interpret because so many different factors contribute to how rapidly compensation increases (shortages of physicians, insurance status of patients (and more). So I will just leave it at that.
The single most important decision a medical student makes is what specialty training to pursue. You have to start applying for residencies in your 4th year. However, you may have had to arrange rotation opportunities to position yourself to get a coveted residency long before that.
There is no question that potential future earnings may play a role in some of those decisions, luring soon to be newly minted doctors into highly compensated specialties. It may also discourage some medical students from choosing the lower-paying specialties, particularly if they are staring a $100,000 or more in student loan debt.
So what did the report show about who makes how much?
Sadly, the report documented a 28% wage gap between male and female physicians. This is up from 25.2% last year. We have been arguing about why there is a wage gap ever since I got into medical school as a result of the women’s movement that swept the country in the 70s. This is what I have heard about this topic my whole career:
But this year’s increase in the wage gap may also reflect gender differences in the impact of the pandemic on the ability to continue working at the same intensity as prior to the shutdowns.
Schools closed down so daytime “childcare” evaporated. Kids were now home all day and many required help with online learning and even full-time homeschooling when online options were not adequate.
Doximity’s Dr. Alperin, says that “women are usually the ones to called upon to make the sacrifice” if one parent must stay home to care for the children. In addition, because male physicians make more money than women physicians, they may feel that it makes sense for the family unit if the higher wage earner is the one to return to work
No matter that “we have come a long way, baby”, the bulk of these duties still fall to the moms of the house – even if she has a medical degree.
In fact, the widening of the wage gap between men and women has been reported in other industry sectors as well.[mfn]9[/mfn]
The report shows that there are no medical specialties in which women physicians earned the same or more than men. So even if women enter the higher-paying specialties, they still make less than their male colleagues.
Like many other people in the US, physicians took a financial hit because of the coronavirus pandemic. However, their compensation is still quite generous, placing many of them in the Top 10%. The most troubling finding in the report is the increase in the persistent gender wage gap in physician compensation. It will be interesting to see if this returns to “normal” once the pandemic is under control and life goes back to more or less normal.
1. ITIJ, US hospitals losing around $50 billion a month due to Covid-19. May 4, 2020. https://www.itij.com/latest/news/us-hospitals-losing-around-50-billion-month-due-covid-19
2. Rubin R. COVID-19’s Crushing Effects on Medical Practices, Some of Which Might Not Survive.
3. Papautsky E, Hamlish T. Patient-reported treatment delays in breast cancer care during the COVID-19 pandemic. Breast Cancer Res Treat 2020 Nov;184(1):249-254. doi: 10.1007/s10549-020-05828-7. Epub 2020 Aug 9.
5. Salber P. Doximity’s New Telehealth Application Makes It Easy to Connect, The Doctor Weighs In, June 3, 2020. https://thedoctorweighsin.com/doximity-telehealth/
6. Salber P. Clinical Care of Cancer Patients in the Age of COVID, The Doctor Weighs In, Aug 8, 2020. https://thedoctorweighsin.com/clinical-care-cancer-patients-covid/
7. U.S. Bureau of Labor Statistics, Consumer Price Index: 2019 in review. January 16, 2020. https://www.bls.gov/opub/ted/2020/consumer-price-index-2019-in-review.htm
8. Eastman S, Vazquez-Soto A. What is the Real Value of $100 in Metropolitan Areas, Tax Foundation 2020: https://taxfoundation.org/real-value-100-metro-2019/
9. New York Times, Pandemic Will ‘Take Our Women 10 Years Back’ in the Workplace. September 26, 2020. https://www.nytimes.com/2020/09/26/world/covid-women-childcare-equality.html
Methodology: Doximity used self-reported compensation survey data from 2019. and 2020 from ~44,000 full-time, licensed U.S. physicians who practice at least 40 hours/week. Responses were mapped across metropolitan statistical areas (MSAs). For more details, please refer to Doximity’s 2020 Physician Compensation Report.
Original article published in 2015. Updated 2/2/17. Updated 11/8/20.
One big crashing sound, the front of a truck beside me, broken glass in my lap, a big metal vee coming in over my lap, I remember thinking I am glad I am not fat or I would be cut in half. I knew what this was all about. There was never a moment that I didn’t know. I got hit by a truck. Seriously. I got hit by a truck. And, I survived to talk about it. Those few moments changed my life forever. It taught me the power of love.
You may think that I am going to tell you there was a lot of pain. There was. You may think that I am going to rail against the unfairness of it. I will not. You may wait for a wave of angry words. There won’t be any.
What I am going to tell you is that the power of love and goodness from strangers changed my life that day. It’s not that I meant to focus on it. It is something that happened automatically. I don’t know why. Here is what I do know. I saw a young man sobbing and crying out,
“I am so sorry I did this to you.”
A big burly EMT came into my front seat with me and held me in a loving embrace. He stroked my arm and said,
“You’ll be ok, baby girl. You’ll be ok.”
He held me as they put a big plastic sheet over us so that the Jaws of Life could give me a chance to live by pulling me out of the crushed metal.
I remember a policeman asking me who he could go and get for me. He took my purse, got in his car, and brought my neighbor.
My neighbor crawled into the car with me, kissed my cheek, and told me that she would take care of things. She said she would take care of my little dog, Jackpot. She said not to worry and I didn’t.
Just like that, these things happened. Just like that. I felt the goodness and love of other human beings over and over in those few minutes. I focused on it and I kept thinking about how lucky I was.
I am lucky that I can feel that love and accept it. And, lucky that I know what it means. It helped keep me alive during those moments. And still to this day, it keeps me going.
I was able to feel the power of the human spirit when I was weak and could no longer feel the strength of my own spirit.
Modern medicine is a powerful thing in our world. We are living longer than ever before. And if we pay attention and take care of our bodies, we have a chance to combine it with a healthy lifestyle.
We have more advantages than our ancestors. We are a rushed and busy society and sometimes forget that there are other things that make us unique. It is the power of others and how they affect us and strengthen us if we understand and embrace them.
People will come forward during tragedy or sorrow and offer themselves. They love and they give. They remember that they are human. And, they want to tell you that they know that you are human, too. They also want to let you know that they love you.
Friends are wonderful at giving, but a great many strangers will step forward seeking no reward or remembrance. They do it just to give something of themselves to strengthen you in your weakness. It happened to me.
Before this accident, I would have told you that I would have refused help. I would have said I was ok. But, this was serious and I was too weak to refuse help.
Instead, I opened my heart and my mind and accepted every single ray of light that shined on me that day. I believe that it helped to save my life.
After I got to the trauma center, they worked on me for four hours. Calls started coming in and word spread. Two people that I love waited for me in the waiting room.
My condition was listed as critical. Friends were told that I might not make it. I remember very little of it. But what I faintly do remember is loving hands, kind words, and encouragement.
My body was treated with respect. I was treated as if I were still there and conscious. I was barely conscious. But I focused on the goodness and not the terrible. I remember faintly thinking how lucky I was.
After it became apparent that I would live, help started pouring in. People came to me just to bring me a chapstick that I wanted. Or a candy bar.
I remember getting calls although I was just barely conscious when I took them – I remember being loved. It wasn’t love like the feeling of a feather fan. Rather, it was strength and power from others formed into the words of love and admiration. It was as if they were saying,
“Take this. I am stronger now. Take this. I love you.”
Amazingly, my own strength returned more quickly than anyone expected. There was very little the doctors could do for me because of the kinds of injuries I had. They would either heal or they would not. I had eight breaks in my ribs, a broken clavicle, a mild concussion, a collapsed lung, and a pelvis broken in four places. Within a few days, I sat up.
There were constant calls and visits with constant good wishes. There were also many tears. People willing to turn their lives upside down for me, strengthened me.
My brother shut down his life and flew to me within hours. He showed no intention of leaving. I kept thinking, “all this for ME?” I was shocked. The pain lessened. I healed at a rapid pace. The doctors scratched their heads.
I focused on my dog. I want to raise this little guy and see him into old age. When things got rough, I saw him in my mind’s eye.
Later, he was allowed in when I was in rehab. He brought happiness to a lot of defeated people as he came through the public areas into my room each day.
I thought how lucky I was to be able to bring joy to all these sad people. And, how lucky I was to have a little dog like this.
I felt love from every direction. Surprisingly, I got stronger faster than expected and I was not depressed.
The first week, I walked with a walker. The doctors scratched their heads. I am still broken but I am stronger and I never give up.
Being able to accept the outpouring of love and affection when I was injured changed me forever. It wasn’t the accident that changed me. It was seeing what the power of love can do when it is needed. And, also finding out how easily people will give it to you. I didn’t know. Or, I didn’t notice before.
Love isn’t everything. It is not a miracle drug. It is not always clear what it is. But, there are plenty of studies that indicate that if you are injured and you focus on what is being given to you by others, your chances of survival are better. You will heal faster. Your attitude will be better. I am living proof of that.
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First posted October 28, 2012, this story is being republished on 12/21/17 and again on 5/20/20 in order to share its message about the power of love with all of our readers, new and old, all around the world. Please share it widely.
During a soccer game at the age of 12, Kayla dislocated her kneecap. It was her first knee injury. She would go on to dislocate it several times again over the next few years.
Despite chronic pain, Kayla continued doing the activities she loved. However, one day her doctor told her she’d need to have surgery if she wanted to keep playing sports.
Determined to live a healthy and active lifestyle, Kayla underwent her first surgery. Unfortunately, it ultimately failed.
Six years later, Kayla found herself at a crossroad. She could continue living with her knee pain and accept that she’d no longer be able to do the activities she loved. Or, she could take another chance and undergo surgery again.
Like Kayla, many patients are faced with these kinds of critical healthcare decisions. There are so many unknowns:
These are all valid questions and ones that I hear from my patients every day.
As an orthopedic surgeon, I’ve seen far too many patients with knee pain postpone treatment or not seek treatment at all. Some people are fearful of the recovery time. Others are afraid that the treatment won’t work. And, some don’t act because they think the pain will simply go away by itself.
It’s important, however, that patients with knee pain know that seeking treatment too late or not seeking treatment at all can have serious implications. It can, unfortunately, lead to even further complications down the road. For example, patients who don’t receive treatment for knee cartilage damage can be left with limited mobility and fewer treatment options.
That is why I encourage knee pain sufferers to talk with their doctor so that they can better understand their particular knee issue as well as the treatment options available to them. Luckily, today there are many repair options that have been proven to help patients get back to the activities they love.
I believe that doctors and physical therapists can do a better job of helping patients like Kayla who are at a crossroads with their knee issues by informing them of the serious impacts of not seeking treatment. We should also discuss the repair options with them earlier in their course. That way they will have the knowledge and confidence to choose a treatment option that will let them get back to the things that they love to do.
In the United States, chronic knee pain is a prevalent issue affecting many people’s health. Knee pain is the second most common cause of chronic pain among Americans. It sends more than 12 million to the doctor’s office each year. Half of these people have damage to their knee cartilage.
Knee cartilage injuries aren’t just reserved for athletes. They can happen to anyone. And, they can occur in a number of different ways, including:
Unlike other tissue injuries, cartilage injuries do not repair themselves. This is because of a lack of blood supply to the damaged area.
Therefore, cartilage damage can often be chronic. And it can get worse over time if not treated properly. This may cause limited mobility that forces people to give up the activities they love the most.
The Harris Poll recently conducted a survey of knee pain sufferers on behalf of Vericel, the manufacturer of a knee cartilage procedure called MACI. It found that over half of knee pain sufferers experienced a decrease in their mobility since they first experienced knee pain.
As time went on, those who did not seek treatment, found themselves with even less mobility. This impacted their ability to participate in the activities they once enjoyed.
Nearly three-quarters (73%) of the knee pain sufferers who used to play team sports said they no longer played. A similar proportion (73%) of prior runners said the same. Additionally, nearly 8 in 10 (77%) said they forgot what it was like to be pain-free.
Despite living in pain and missing out on the things they love, a majority of people admit they’d rather deal with their knee pain and manage it with medication than undergo surgery.
Moreover, many admit they aren’t even actively looking for a solution to their knee pain. According to the survey, nearly 3 in 4 knee pain sufferers (74%) hope their knee pain will just resolve itself. Others cited different reasons for not pursuing treatment, including:
To help alleviate some of the reluctance and fear that knee pain sufferers have towards treatment, doctors must have conversations with their patients about the treatment options that are available to them. Even more important, they need to assure them that these treatments can work.
Today, there are many treatment options available for patients with knee cartilage injuries. Surgical options available include:
Chondroplasty is a palliative procedure where doctors use an arthroscope to assess the defect, trim the damaged cartilage and clean the area with sterile water.
Marrow stimulation repair procedures like microfracture, abrasion arthroplasty and subchondral drilling that stimulate bone marrow and its associated chondroprogenitor cells. This can result in the formation of fibrocartilaginous tissue.
Autologous or allograft osteochondral implant procedures plug healthy pieces of both cartilage and bone into damaged areas.
ACI is a reparative procedure that involves expanding a patient’s own cartilage cells in a lab and then implanting them in the damaged area to restore the tissue.
So, which treatment is right for patients with knee cartilage damage? It largely depends on the patient’s circumstance and personal preference, as well as the size of the defect.
In terms of repair assessment, ACI has demonstrated greater improvement in tissue durability, knee pain, and knee function over microfracture.
Clinical studies looked at the results of receiving either ACI or microfracture treatment of their cartilage injury at two and five years. They showed that patients treated with ACI had more durable repair tissue, as well as greater improvement in knee pain and knee function.
Related Content: What Really Works to Reduce Osteoarthritis Pain in the Knee?
Choosing the best course of treatment can be scary for patients, but there are things patients and doctors can both do to make the decision process easier. For example, doctors can provide useful resources and guidance to help patients make an informed decision, including:
The knee is a complex joint serving as the meeting point for three major bones, with ligaments and cartilage connecting and protecting the bones at the knee joint. There are several kinds of injuries that can occur to the knee, but knee cartilage injuries are often chronic. They are, moreover, one of the most critical to treat due to the fact that cartilage does not repair itself.
There are a lot of different treatments, but ACI has proven efficacy in long-lasting pain relief and improved knee function for more than 20 years.
Hearing about others who have had success with their treatment can instill a sense of trust and confidence in patients when choosing a treatment option. Many people who have chosen repair options like MACI have gone on to live very healthy and active lifestyles – much like they did before they started experiencing knee issues.
Patients should be prepared for their doctor’s visit by compiling a list of questions to ask. Here are some they may want to ask:
Chronic knee pain due to injury of the cartilage is common, however, many people are afraid of surgery. Or they may not really understand the various treatment options. Doctors need to take the time to educate patients about the consequences of not getting treated. And they should help them understand their options. That way, patients and their doctors can feel confident about their treatment choice and begin the process of recovery.
Financial disclosure: Dr. Van Thiel is an orthopedic surgeon who is a consultant of Vericel, the manufacturer of MACI, a third-generation ACI treatment used for the repair of symptomatic cartilage damage of the adult knee. He is one of few providers offering MACI in the Northern Illinois area. His business could, therefore, benefit from this article.
Editor note: TDWI did not receive any compensation for publishing this article. Rather, we published it because of the quality of its content.
The role that innovation plays in the future of health care and medicine continues to be a hot topic across the nation. An important example of a technology innovation available today is transcatheter aortic valve replacement (TAVR). The procedure helps patients recover more quickly because it involves minimally invasive surgery instead of open-heart surgery.
Conversations about innovation in healthcare touch on a wide variety of topics, including access to health care, upskilled health workers, and overall cost. However, one thing is certain: when it comes to innovation, patients want access to lower-cost treatment options, including procedures, that offer better outcomes. TAVR does both of these things.
As physicians who are stewards of medicine, we owe it to our patients to bring new, innovative forms of care to the communities we serve. This includes:
As people age, the valves of the heart can harden, thicken and calcify. These pathologic changes can reduce blood flow to the body. This is because the diseased aortic valves don’t open correctly.
This condition, known as aortic valve stenosis, is more prevalent in people 75 years or older. Although there can be other conditions that may cause this abnormality to happen in people in their 60s and possibly younger.
Damaged aortic valves are often replaced by surgeons through open-heart surgery. This requires a surgeon to cut into the chest in order to open the ribcage to operate on the heart. This surgery was initially hailed as a breakthrough because physicians finally had the ability to improve the quality of life of patients with aortic stenosis. However, this major surgery with its large incisions increases chances of post-operative complications such as infections, stroke, longer hospital stays and in the most severe cases, death.
These complications especially affect older patients who are considered high risk. They might be frail or have other ailments, such as kidney problems or lung disease that decreases the chances that they will successfully make it through surgery. This is where the minimally invasive procedure of TAVR provides a great option for high-risk and intermediate-risk patients.
TAVR is an innovative surgical option for high-risk patients with aortic valve stenosis. It was first approved by the U.S. Food and Drug Administration in 2011.
The Mayo Clinic describes TAVR is a minimally invasive procedure to replace the aortic valve in people with aortic valve stenosis. As noted above, aortic valve stenosis – or aortic stenosis – occurs when the heart’s aortic valve narrows. This narrowing prevents the valve from opening fully. This obstructs blood from the heart into the aorta and onward to the rest of the body. Aortic stenosis can cause chest pain, fainting, fatigue, leg swelling and shortness of breath. It may also lead to heart failure and sudden cardiac death.
During TAVR, doctors usually access the heart through a blood vessel in the leg. Alternatively, doctors may conduct the procedure through a tiny incision in the chest and access the heart through a large artery or through the tip of the bottom left chamber of the heart.
A hollow tube (catheter) is inserted through the access point. The doctor uses advanced imaging techniques to guide the catheter through the blood vessel, to the heart, and into the aortic valve.
Once it is precisely positioned, a balloon is expanded to press the replacement valve into place in the aortic valve. Some valves can expand without the use of a balloon. When the doctor is certain the valve is securely in place, the catheter is withdrawn from the blood vessel or from the incision in the chest.
To date, more than 100,000 patients have successfully undergone the procedure, according to Edwards Lifesciences. The organization states that TAVR has a ninety percent success rate and only has a less than five percent complication rate.
In recent years the number of TAVR centers throughout the U.S. has grown rapidly from 156 in 2012 to 587 in August 2018. Further, there is an upward trend for more locations opening as TAVR continues to move from a high-risk procedure to a standard of care.
The reason for this growth can be attributed to the benefits that the patient receives. The TAVR procedure is minimally invasive. Therefore, patients have a quicker recovery than the alternative of open-heart surgery which can have patients hospitalized for one week and take four to six weeks to recover.
In fact, we’re typically able to discharge patients within 24 hours after surgery. This reduces the costs associated with hospitalization. And there are generally fewer complications, which is a great benefit to patients. This has encouraged patients to seek out health care systems that offer this type of specialized cardiac care.
The TAVR procedure offers a minimally-invasive, quick recovery alternative to open-heart surgery. It also highlights yet another innovative advance in patient care: a team-based approach.
TAVR cases require a surgeon, cardiologist, and anesthesiologist as well as specialized nurses, to work together to develop the best protocol for each patient. This moves physicians out of their usual siloed decision-making process into a new model where decisions are made as a group on behalf of patients. This leads to better outcomes and overall care.
As physicians, we must continue to explore ways that we can continue to improve the overall care of our patients. This means looking outside of our individual areas of expertise. We should instead embrace collaboration with other professionals who bring other specializations and perspectives to the table, including primary care physicians and general cardiologists.
At the end of the day, whether it is offering technologically advanced procedures such as TAVR or implementing a team-based approach, providing our patients access to the best and most innovative care is key to continuing our important role as stewards of medicine to usher in a new era of health care.
A hysterectomy, or the surgical removal of the uterus, is one of the most common surgeries performed on women. It is second only to the cesarean section.
Half a million of these procedures happen every year. Many different conditions may necessitate surgical intervention like a hysterectomy, whether it be full or partial. Here are some of them.
Pelvic inflammatory disease, or PID, is a bacterial infection of the uterus, fallopian tubes, and ovaries. It occurs when bacteria travels up into the reproductive tract from the vagina.
Although the classic symptom of PID is pelvic pain, in many women it may not cause any symptoms initially. In fact, you might not even realize you have PID until you have trouble conceiving or develop pelvic pain.
A hysterectomy is usually the last thing a doctor will recommend to treat PID, but for cases where the infection doesn’t respond to antibiotics or other treatments, it is an option.
Endometrial hyperplasia is an overgrowth of the cells lining the uterus. It leads to a thickening of the lining. It occurs when the uterus is exposed to estrogen without progesterone.
The most common symptoms of uterine hyperplasia are abnormal bleeding, bleeding between periods and periods that last longer than usual. Although it is usually a benign condition, it can lead to cancer in some women.
Uterine hyperplasia is most commonly treated with hormones, or with an outpatient dilation and curettage (D&C) procedure where the extra tissue is surgically removed.
In extreme cases or postmenopausal women, a hysterectomy might be an option.
Placenta accreta is a dangerous condition that occurs during pregnancy.
During a healthy pregnancy, the placenta is loosely attached to the side of the uterus and detaches naturally after the baby is born. With placenta accreta, the placenta attaches very deeply to the uterus.
It can cause severe hemorrhaging if it separates, putting both mom and baby in danger. WhenI this happen, an emergency cesarean section and hysterectomy may be performed in otder to prevent dangerous bleeding.
Uterine fibroids are noncancerous tumors that grow in the muscle of the uterine wall. No one is quite sure what causes these growths. However, they can become quite large if left untreated.
Fibroids can form without any symptoms at all. You might not know you have them if you don’t experience abnormally heavy bleeding, spotting between periods, and back or pelvic pain.
A hysterectomy is an option for patients who don’t respond to treatment or have fibroids that grow back repeatedly. However, there are other options. Uterine fibroid embolization is an outpatient procedure that uses a small catheter to cut off the blood supply to the fibroid, causing the tissue to die. This procedure is done under light sedation. Usually, the incisions are so small you don’t even need stitches.
Adenomyosis is a condition that is similar to endometriosis. The lining of the uterus grows into the muscular uterine wall. This causes severe cramps, heavier periods, and pressure and bloating in the abdomen.
It occurs most commonly in women who have had children and those that have undergone uterine surgery. An MRI or transvaginal ultrasound is necessary to diagnose this condition.
You can treat the symptoms of adenomyosis with over-the-counter anti-inflammatory medications or prescribed hormone therapy. In more severe cases, endometrial ablation, which destroys the lining of the uterus, or uterine artery embolization can be useful.
If these treatments aren’t successful, or not possible for whatever reason, a hysterectomy becomes a possibility.
Endometriosis is similar to adenomyosis in that the uterine tissue grows where it isn’t supposed to be. In this case, the endometrial tissue grows outside of the uterus and onto other organs in the abdomen or throughout the body.
Some patients don’t experience any symptoms, while others may feel pain in the belly, severe menstrual cramps and pain during sex. They may also find it hard to conceive a child.
Over-the-counter anti-inflammatory medication can help treat some of the symptoms. Surgery to remove the invading endometrial tissue can reduce some of the symptoms as well. If you’re done having children, a hysterectomy can help reduce symptoms by eliminating the source of the tissue that is spreading throughout the body.
The uterus is held in place by a series of muscles. If those muscles weaken, the uterus can slip down into the vagina. This is known as uterine prolapse and can occur at any age.
Everything from pregnancy and childbirth to the lower levels of estrogen in the body after menopause to a chronic cough can cause uterine prolapse. Pregnancies that ended in a vaginal birth, obesity, pelvic surgery and family history all increase your risk of uterine prolapse.
Minor cases of uterine prolapse may not require treatment. But if the prolapse is affecting your daily life, there are treatment options. Uterine suspension is a surgery that moves the uterus back into its correct place and holds it there by either repairing the connective tissue or adding mesh that secures it. Vaginal pessaries inserted into the vagina can also provide additional support. In severe cases, a hysterectomy is necessary.
The primary treatment for endometrial cancer is a hysterectomy. Depending on the patient’s age, the doctor may also choose to perform a bilateral salpingo-oophorectomy (BSO). That is to say, removing the ovaries and fallopian tubes as well as the uterus. This is to prevent cancer from remaining in the body. BSO may not be recommended for premenopausal women.
The severity of the surgery will depend on how far cancer has spread. If it has spread outside the uterus, the surgeon may choose to perform what is called a radical hysterectomy. In addition to removing the uterus, cervix, ovaries and fallopian tubes, the tissue surrounding the uterus and the upper part of the vagina are also removed.
There are a number of conditions can result in a hysterectomy. However, most of them have other treatment options you can try before taking resorting to surgery.
The only circumstance where removing the uterus is unavoidable is when surgeons find evidence of endometrial cancer.
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At my two week checkup, the nurse and my mom noticed that I was jaundiced. The doctors quickly diagnosed me with biliary atresia (BA), a rare liver disease that occurs in newborn infants.
Infants with this disease have bile ducts that are either non-existent or blocked between the liver and the small intestines. Bile is a fluid that is produced in the liver and helps to break down fat. Because these bile ducts are blocked, bile is unable to properly flow from the liver to the small intestines; therefore, this causes bile to be trapped in the liver with nowhere to go. The buildup of bile in the liver causes liver damage, scarring (cirrhosis), and in the worst cases, liver failure.
I was, according to Cincinnati Children’s Hospital, “one in 15,000 to 20,000 babies” born with biliary atresia. My parents were very worried about my deteriorating health. And, my mom was very emotional because she thought she had done something wrong in her pregnancy that caused me to be increasingly sick. The doctors assured her that her pregnancy was completely normal and that it was not her fault. Nobody, not even doctors, have determined the cause of the disorder.
The cause of biliary atresia is unknown, but it is not genetically inherited from the mother or any other family members. Researchers at the University of California San Francisco have hypothesized that a prenatal or early postnatal event such as “infection with a virus or bacterium, a problem with the immune system, an abnormal bile component, or an error in the development of the liver and bile ducts” could trigger the disease.
One of the main symptoms of BA is jaundice. Jaundice is a yellow discoloration of the infant’s skin or the whites of his/her eyes. Jaundice is caused by a buildup of bile, a yellow colored substance produced by the liver that helps with the digestion of fat.
Bile also helps with the removal of waste products from the liver. Ordinarily, bile is moved from the liver by the biliary system of channels and ducts to the gallbladder and eventually from the gallbladder to the small intestine. Infants with biliary atresia are unable to do that which leads to significant jaundice. Jaundice generally occurs in the infant in the first couple of weeks after birth and continues to worsen as time goes by.
Five weeks after birth, on December 19, 1997, I underwent the Kasai procedure at Lutheran General Children’s Hospital to help restore my bile flow from my liver to my small intestines.
I did not find out until a couple of years ago that my Kasai procedure, as performed by my surgeons, was a cutting-edge surgery in 1997.
There are a couple of different ways to perform the Kasai procedure. The way my surgeons performed the surgery was very innovative, especially since few surgeries had been performed that way during this year. I am thankful my surgeons performed the innovative Kasai surgery. If they had not, then this surgery might not have been as successful as it continues to be, and I probably would have had to receive a liver transplant by now.
The Kasai Procedure is a major surgery that ultimately attaches the infant’s small intestines to his liver to replace the bile ducts. The small intestines act as the new bile ducts to release the bile from the liver.
The Kasai procedure is only a treatment. It is not a cure. There can be complications with this surgery that make it unsuccessful. The younger the infant is when the Kasai is performed, the more successful it is.
If the Kasai procedure is not successful, then a liver transplant is needed. During a liver transplant, the surgeon removes the damaged liver and replaces it with a new one from either a living or deceased organ donor. A living organ donor, with the same blood type, can give an infant with BA part of his liver. The donated liver regenerates in the infant as well as in the living donor. A deceased organ donor would give a small portion of his liver to the affected infant. A liver transplant is the most successful treatment for biliary atresia.
During the summer of 2017, I walked for the first time in the American Liver Foundation’s Liver Walk in Chicago.
Within the following weeks, I became very sick. Every time that I ate, I was in severe pain. When my pain became unbearable, I went to the emergency room at Mercy Hospital in Aurora, Illinois only to be diagnosed with constipation. Little did the doctors know that there was a more serious issue that was causing my pain.
Two days after my visit to the ER, I woke up in the middle of the night with excruciating pain. This pain was the worst pain I had ever experienced. I ranked the pain level as a ten out of ten.
Unfortunately, at that point in time, I was not at home because I was working a softball tournament in Milwaukee, Wisconsin. I called my parents at 5:00 A.M. to come and get me and take me to the emergency room.
My parents rushed from Batavia, Illinois to Milwaukee, Wisconsin to pick me up. As we were driving from Milwaukee, to Mercy Hospital, in Aurora, Illinois I started throwing up in the car. After we arrived at the hospital, the doctors ran several tests, and they determined that my liver was very sick and that there was a blockage. They did not know exactly what was causing the blockage between my liver and small intestines. I was transported, by ambulance, to Lutheran General Hospital where my specialists were.
I was there less than 24 hours. They discovered that I had a biliary stone the size of a golf ball near my liver that had developed over a period of 10 years. This stone blocked the passageway for digestion.
At this point, I knew I was going to have surgery. Lutheran General could not operate on my liver because it would have been too risky and I could have gone into liver failure. Only a liver transplant unit could handle my case and only liver transplant doctors could do the surgery.
I was then transported, by ambulance, to Northwestern Hospital. After I arrived there, I knew I was in the right hospital because every doctor knew my disease and they were confident that they could operate on me.
Northwestern’s liver transplant doctors performed surgery and removed the golf ball sized stone near my liver to restore digestion flow. Luckily, they were able to use the same incision from my Kasai procedure when I was five weeks old.
My second surgery was performed on June 26, 2017. I was in the hospital for about a week.
The unfortunate part of my hospitalization was that I had to miss being the maid of honor at my sister’s wedding. After surgery, I had four months of physical therapy to help me get stronger and to prepare me for my return to college softball. I am currently doing well, and I am thankful I had the doctors that I did to make me better! I would not be as healthy as I am today if it were not for their expertise.
Because my Kasai procedure was successful, I am considered unique. According to Children’s Hospital of Philadelphia, the “overall survival with a native liver (not transplanted) ranges from 30-55 percent at 5 years of age; and 30-40 percent at 10 years of age. It is thought that approximately 80 percent of patients with biliary atresia will require liver transplantation by the age of 20.”
Biliary atresia is the main reason that children receive liver transplants. I am 21 years old and I have yet to receive a liver transplant. It is a miracle that I am one of the 20% that has yet to require a liver transplant at this point in my life.
Most infants that undergo the Kasai surgery have a transplant within three months after surgery. I am the exception to the rule. The liver transplant doctors at Northwestern Hospital that performed my second surgery said that I am in uncharted territory. They have no idea what will happen to me in terms of my liver disease because there are very few individuals that have made it past the age of 20 without a liver transplant. I am a rare case and the lucky one.
Because I know there is a chance that I will have a liver transplant in my lifetime, I encourage others to become organ donors. The ratio of viable organs that are available to wait-listed individuals varies/differs greatly.
According to U.S. Government Information on Organ Donation and Transplantation, in August 2017, 114,000 men, women, and children were on the national transplant waiting list. Of those 114,000, only 34,770 transplants were performed in 2017.
As a result of only a fraction of individuals receiving liver transplants each year, an estimated average of 20 patients die each day awaiting a transplant. The reason individuals need to register to be an organ donor is that 95% of U.S. adults support organ donation, but only 54% are signed up as donors.
Every 10 minutes another person is added to the waiting list. Just one donor could save eight lives through the donation of a heart, two lungs, liver, pancreas, two kidneys, and intestines.
Individuals who choose not to become designated organ donors have three main reasons for not doing so:
Nonetheless, these theories of individuals against organ donation are not true for the following reasons.
If individuals are under 18 years old and they want to register as organ donors, they can tell their family about their wishes.
If individuals are older and not as healthy, they are still able to be organ donors. They do not rule out organs just because they are older.
Medical professions cannot determine if organs are unsuitable until they run tests to see if they meet the required standards for an organ donor. The more organs there are available, the more lives that can be saved.
Throughout my life, I was always afraid to tell my story, but freshman year of college I had a breakthrough. I started realizing that this liver disease is a part of who I am. I need to embrace it and start sharing my story.
Even though I am an exception and one of the few that has yet to receive a liver transplant, I still want to spread awareness for all of those with my disease that had a liver transplant.
It is not difficult to be an organ donor. All individuals need to do is register to be an organ donor when they obtain or renew their driver’s license. They can also register with the national Donate Life Registry which can be done through the Health App on an iPhone.
An organ could save my life in the future, so I hope that you will take the initiative, do what is right, and become an organ donor.
There I said it.
It was both cathartic and horrifying to utter those words in response to my husband’s question of why I don’t call the answering service.
It has taken me 3.5 months, 1 surgery for cancer at the time we were about to start a family, and 2 surgeries for complications from the original one for me to get to the point to utter those words.
It had been simmering for at least one month. Both my surgeon and I ignored the symptoms. I became more irritable. I had less patience with him. I was more discouraged.
He responded by trying to see the silver lining and letting me know that we were close to the finish line. Instead of cheering me up, his words had the opposite effect, further enraging me, further frustrating me.
Hindsight being 20/20, I was depressed. I was crying several times a day. This finish line that my surgeon referred to was nowhere near in sight and I felt deceived and lied to.
I was emotionally drained and I didn’t have the strength to keep going. So I chose anger and animosity to hide my fear, to hide my despair, to hide the depressive thoughts that became harder to ignore.
I was in flight or fight mode and I didn’t have the strength to fight anymore.
I didn’t need my surgeon to cheer me up. I needed him to acknowledge my feelings. I needed to be heard by my doctor.
The thing is that I didn’t know how to express to him that that was what I needed, so he tried to help me out the only way he knew how which was to see the glass as being half full. But I could only see it as half empty.
All that I wanted him to do was to tell me, “I know that this whole situation sucks, and I’m sorry that you have to go through this.” When he finally said those words, it was too late. I had lost trust in him and all surgeons.
The ironic thing about this is that I am a surgeon, and my surgeon is a friend and colleague. How can I say that I don’t trust surgeons when I am one? Does that make me a hypocrite?
How do I act toward my patients who have complications? As a surgeon, I knew that these complications were out of his hands, that he was doing everything by the book, but as a patient, I blamed him.
The next day, I spoke on a panel of cancer survivors at the medical school. All of the speakers, except for me, were 10-15 years out from their diagnoses while I was 10-15 weeks out.
As I listened to each one of them share their stories, I noticed a pattern that there was one person in the treatment team that they resented because that person just didn’t get it. Fifteen years after the incident and I could still hear the anger in their voices. I didn’t want to harbor these feelings for the rest of my life.
How do you forgive someone who doesn’t know that you feel that they wronged you? A better question is, “How do I get closure?” How do I let go of this anger or resentment so that I can move on?
I had to do the thing that terrified me the most: I had to shed my armor of anger and show my vulnerability to my surgeon. I had to reveal to him the frightened person inside.
One week later, I was readmitted to the hospital for a possible wound infection. My surgeon was out of town and came to see me when he got back.
As I sat in the chair, I said to him, “I need to tell you about my existential crisis.” My heart was pounding and I was shaking inside. I told him about not wanting to call the answering service, speaking at the medical school and the persistent resentment, and the need for closure.
Now came the scary part. I stared at my patient bracelet and played with it as I took a deep breath. I hugged my knees to my chest. I was trying to make myself as small as possible.
“I guess the person I resent most is you, and the only way I can think of to move on is to explain to you how I feel. Every time you have to reoperate on me, every time there is a complication, I feel like my life is put on pause. And I see everything else moving forward in the distance: my practice, life in general, my end goal, chemotherapy, everyone else.
When you tell me that I can resume regular activities, I run as quickly as I can to catch up to those things, but I never catch up because I have to stop again. My fear is that when I can finally start back with life, I will never be able to find those things and I will never be able to catch up with my end goal, which is having a baby.
So when I get angry with you, I am scared that I will never be able to get pregnant; I mourn that dream. I am like a porcupine: I roll myself in a little ball to protect myself and let my quills hurt whoever tries to come near me.”
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I finally looked up from my bracelet while my body is contorted in some surreal pose not unlike a porcupine. I was scared of my surgeon’s reaction knowing that this is going to be a turning point for our relationship.
He said exactly what I needed to hear: “Thank you.” He then explained to me how difficult it is to take care of a friend who has had complications and knowing that that is what is keeping me from having a child.
He coped with those feelings by distancing himself from me and ignoring my resentment and anger. I didn’t understand the emotional toll that he went through and how hard it had been for him. I realized that he had created an armor of optimism to protect himself.
We both smiled at each other. At that moment, I knew I had my closure and that he had his. All it took was being vulnerable to my surgeon and him being vulnerable to me.
My surgeon finally got it.
He regained my trust.
Surgery is one of the most stress-inducing things you might go through in your lifetime, and once it’s over, you’ll feel an incredible sense of relief. But just because the procedure is officially complete doesn’t mean the healing process is over. In fact, it’s just begun! Proper post-operative care is vital to a speedy recovery. When you equip your body with everything it needs to heal, you’ll bounce back faster and feel like yourself in no time. Heed the following post-surgery advice to kick the healing into high gear.
Surgery is a major stress both physically and mentally. Your body will expend a tremendous amount of energy healing. Therefore, it is important to rest afterward. If you push yourself too hard and do not rest, your recovery will take much longer. What does an injured animal in the wild do? It rests.
One of the risks of any surgery is the development of a blood clot in the veins. This is called a deep venous thrombosis or DVT. Surgery puts us at risk for blood clots because we are immobile after surgery, have sustained a physical injury, and our blood is more likely to clot. Physicians know these three risk factors for DVT as “Virchow’s triad” (stasis, injury, hypercoagulability). Leg elevation, if done correctly, will increase blood flow in the veins and lower the risk of blood clots.
Proper nutrition is paramount to healing. However, knowing what to eat can be challenging, as there are so many different ideas about nutrition. The one thing that all nutrition experts agree upon is that our diet should be loaded with vegetables and fruits. Plant-based foods are loaded with micronutrients and phytonutrients that your body needs to heal. Most people do not realize that plants also provide the perfect amount of protein. Keep in mind that processed food has been stripped of its nutritional value and loaded with sugar, fat, and salt. Your healing body requires protein, vitamins, and minerals; NOT sugar, salt, and red dye no. 2. A great option to get in a lot of fruits and vegetables at one time is to make a smooth with your favorite fruit, veggies, yogurt, and a plant-based milk or water.
It is also important to stay hydrated post-operatively by drinking lots of water. Most importantly, being well-hydrated makes it easier for nutrients to be delivered to your cells. It also lowers your risk of developing blood clots and keeps your bowels and kidneys functioning. Being dehydrated makes it harder for your heart to pump blood with oxygen and nutrients to your cells. Dehydration also makes it harder to get rid of cellular waste products. Keep things flowing smoothly by drinking LOTS of water. If the thought of drinking plain water doesn’t entice you to get in your 8-10 cups a day, try adding a lemon or lime wedge, or even some cucumber for a refreshing yet hydrating alternative to plain water.
Although it is important to rest after surgery, once you start to feel better, it is time to get moving. Set goals and try to gradually improve on them. Listen to your body. If you overdo it, then back off some and rest. When we are not moving, things shut down. Our joints get stiff. Blood flow slows down. When we are moving, we get our blood flowing and keep our joints moving. However, if at any point you start to develop severe pain in the area in which you had the surgery, cease immediately and call your doctor. The last thing you want to do is complicate your body’s healing process or start physical activity prematurely. Your doctor will let you know when you’re cleared to get moving.
You will likely require pain medications initially. However, keep in mind that these are just for the immediate post-operative period. Try to wean yourself off pain medications as quickly as you can. Too much pain medicine will make you tire, groggy, and keep you immobile. They will also slow down your bowel function, which can become a problem after surgery. Gradually begin tapering your pain medications as soon as you can. If you can, switch to a less intense painkiller such as ibuprofen once you feel your body starting to heal and feel better. Remember that pain medications will help control your pain, but not make it go away completely.
In order to stay positive after surgery, it is important to control your focus. When we focus on the negative after surgery, it is harder to make progress. If we are focused on the pain, we are less likely to get moving. When we focus on all that is positive, our brain and body work to bring that idea to fulfillment. It’s that simple. Stay positive. You will get through this. The operation is behind you. The pain will get a little better each day. You will feel stronger. Focus on the fact that your body has an amazing ability to heal, especially if you follow our six rules listed above. If it helps you, make sure you’re recovering in a place where you’re comfortable, and have friends and family help you with the day-to-day immediately following surgery. Being comfortable and in good company will help you think more positively which will ultimately help your body heal faster.
A few years ago, on the 22nd of February, my aunt went in for a gynecologic surgery. The surgeon had recommended a minimally invasive procedure so she could be back home quickly. She discussed it with her sister – my mom and a doctor herself – and all the indications were that this would be “routine”.
The surgery was completed as planned, and within a few hours, my mom received a call relaying that the procedure went uneventfully. Everything seemed fine and my aunt was recovering well. A couple of days later, when my aunt got up to use the restroom, she suddenly felt breathless. Before my family could fully grasp what was happening, she was in the ICU. And before long, my mom received another call, except this one had a very different tone. The message this time was that “something has happened”.
My aunt was a second mother to me. I grew up with her, spending every one of my summer breaks at her home. Because my mom had a busy clinical practice, she could never really take a summer break. My aunt ended up being the caregiver for my grandparents, other family members, and even our family dog. Somehow, she always seemed to have the energy to do it all. She was a mathematical genius and her passion for the subject was infectious. Every summer, she challenged me for many hours a day with math problems, somehow managing to make it fun. Just as my mom was our family’s primary doctor, my aunt was our family’s primary event organizer. She organized all our holidays making it enjoyable for all age groups. And she did all this so gracefully. Always ready to serve, she hesitated to bother others for her needs.
That February though, when my mom flew in, she was shocked to see the state her younger sister was in. Hadn’t it been a routine procedure on a healthy woman? How had she deteriorated so quickly? All the pre-op tests she was told were normal. And the anesthesiologist had cleared her for surgery.
The lab results now seemed unbelievable and my mom tried to seek answers to the medical questions. This surgeon had done many such surgeries safely. But from having opened up many abdomens herself, my mom was known to say, “opening an abdomen is like opening a Pandora’s box”. Had the surgeon found something in my aunt’s abdomen that wasn’t normal?
My mom’s own friend, a trusted radiologist, had personally come to the hospital to perform a thorough abdominal scan. After reading it herself, she confirmed there were no perforations or apparent technical issues with the surgery. At this point, an abdominal infection was suspected. By the time her son (my cousin) made it to the hospital, she was already on a ventilator. A couple of nights later, at around 11 pm, the nurses told the family to rush to the ICU. Running down the stairs, my cousin overheard the nurses saying that it was over – my aunt was no more.
In the wee hours of the morning, my mom could hardly make sense of all that had happened. How could her own sister be dead days after a laparoscopic surgery? How many thousands of women had she personally witnessed go through such surgeries! From her own point of view, surgery had evolved so much. Operations like this had become so much safer.
When she started her career, these surgeries were done with a six-inch incision across the abdomen. Now, as her sister had experienced, it was a minimally invasive procedure. Using laparoscopes, the surgery could be performed through only tiny poke-hole incisions with cameras to guide their work. It was much safer with minimal blood loss and an easier recovery. It was all simple; until it wasn’t.
None of us got to say goodbye to our aunt. The surgeon later surmised that the reason for death was probably a pulmonary embolism and sepsis. He then went on to say that each case was different and that the same things he had given his other patients hadn’t worked on my aunt. He said that each human body was different. Was this no longer a “routine” or “standard” case?
Universally, anyone who hears a story like this views it as tragic; what comes next varies widely based on the individual. Some will be immediately tempted to invoke the “fragility” of human biology. Others will philosophically ascribe it to the unpredictability of life. Some others feel indignant and blame the medical providers. To me, it seemed this simply should not have happened with skilled doctors and an otherwise healthy surgical candidate. I have since spent many nights trying to understand surgical complications.
Sepsis and pulmonary embolism, I learned, are “common” and surgery increases their risk. The reported crude mortality rate after major surgery is 0.5 – 5%, and complications after inpatient operations occur in up to 25% of patients. Looking at the US trend alone, hospital mortality rates were going down significantly after non-elective surgery, but no such improvements were occurring for elective surgery patients who developed sepsis. An estimated 9 million people have post-surgical sepsis annually, and the global incidence of sepsis is on the rise. Does that mean our tragedy could be re-lived by that many families every year?
On that fateful morning, my aunt was the first of many such cases that this surgeon performed in that same operating room with that same team. How was she different? Perhaps she was at a higher risk for infection and blood clots compared to the other patients? The surgical team followed a standardized evidence-based protocol; but in speaking with leading surgeons and scouring academic journals, I found published research on many specific risk factors for each type of complication after surgery.
Why wasn’t my aunt assessed for each of these known risk factors?
Because this was a “routine” procedure on a “healthy” patient, were the possible risks subconsciously minimized in the minds of well-meaning doctors? Surely, armed with specific risk information for each complication type, more tailored interventions could have been pursued at the earliest sign of a complication.
According to the World Health Organization, at least half of the cases in which surgery led to harm are considered preventable.
At least half of the cases in which surgery led to harm are considered preventable .
Why then was the hustle demonstrated after the complication dramatically more than what was demonstrated before the surgery? Could the preparations have been personalized to my aunt’s risk levels? Could some optimizations have been done before the surgery to avoid the complication? If we don’t have a “before” picture of her risk for complications, we cannot make sense of the “after” results. Without risk-adjusted outcome measurements, this surgeon, the medical community, and researchers could never truly learn from this tragic loss.
When any doctor uses the word “routine” now, I reflexively cringe. When they say a complication occurs only 5% of the time, I break into a sweat. No one wants to be in the 5%. When you are in the 5%, the complication happens to you 100% of the time. I am not bending the statistic, I am speaking only of the reality when viewed from the lens of the patient and their family. If complications can be prevented, is there not an imperative that we pursue it? Surgical utilization is rapidly accelerating worldwide. Our population, and hence the surgical candidates, are increasingly older and sicker, and we do more surgeries today on an outpatient basis than we do in the hospital.
Investments in risk management before surgery then are one of the most critical levers for any healthcare system.
After my first healthcare startup, I worked at Providence Health & Services, the 3rd largest non-profit health system in the US. I was in the health plan division, where existed an urgent and strong incentive to mitigate health risks. It was here, developing health risk assessments, personalized patient engagement, and digital health innovations, that it became increasingly clear to me that all healthcare is risk management.
All healthcare is risk management.
Whether it is preventing chronic diseases or planning acute care, proactively mitigating risk is required for consistent outcomes. No matter how many advancements are made in medicine, their application carries inherent risk. A health plan, however, looks at risk at an aggregate level. I didn’t want to reduce risk for “most 40-50 year old non-smoking females who were getting surgery”. I wanted to mitigate the risk for each patient like my aunt. Population health carries the allure of helping many, but I believe it is critical to focus on each specific surgery and each specific person. Getting it right individually adds up to getting it right at a population level. As I had learned first hand, each surgery is unique.
Today, for the first time in human history, errors of ineptitude have overtaken errors of ignorance as medicine’s key problem. Some of our society’s brightest minds become surgeons today. But they are human too and limited by the same cognitive biases and misleading heuristics all of us routinely display. I wanted to empower these surgeons to do everything they possibly can to mitigate surgical risk.
If every medical intervention is a risk we take, each time we must pair it with a rigorous risk mitigation strategy.
This is the only way we can get to 0% complications. If our medical professionals had access to all the relevant patient-specific risks at the time of their decision-making, it puts them in a position to target mitigation strategies on an individualized level to ensure better outcomes for that patient.
Why then are we still discussing standardization protocols, when we understand that each patient is so different? Today, we can garner intelligence from vast amounts of personalized data. Precision medicine means every patient gets care perfectly tailored to her, even if it’s not the “standard of care” at a population level. No longer will we simply consent to the generic “5% chance of complications”.
That is why I started Ready Surgery – an AI-Enhanced Risk Intelligence Platform built by and for surgeons & anesthesiologists to ensure that every patient will have a successful outcome through personalized risk management. Personalized Medicine may seem to some as a new buzzword; but to me, it simply means one safe surgery at a time; one young woman, like my aunt, at a time. Medical rigor means no family ever looks back after surgery and wonder if anything could have been done differently.
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After months or years of attempting to lose weight and keep it off, you may be considering bariatric surgery.
Before you can decide whether this is a good choice for you, you need to know the facts. Though bariatric surgery is safe and generally successful in achieving weight loss, to be a good candidate, you must be prepared to deal with both physical and emotional issues.
Seven years ago, I had a gastric bypass and went from being barely able to function to living a magnificent life as an authentic and productive person. (I tell my story in more depth at Medium and in my book Recovering My Life: A Personal Bariatric Story.)
To be clear, I speak as a clinician (I am a licensed Marriage and Family Therapist) and as someone who has been through weight-loss surgery and the difficult process of recovery. I am not a nutritionist or medical practitioner.
But my experience and research have taught me that successful bariatric surgery requires preparation, long-term recovery, and lifelong changes in your relationships with your body, food, and the people in your life.
Bariatric surgery is not a cosmetic procedure. We may hope to look better after losing weight, but the best reasons for undergoing this major surgery are to extend and improve our lives.
The most common procedures are lap band, with a success rate of 47%; gastric sleeve, with a success rate of 80%; and gastric bypass, which has an 85% success rate. These procedures support weight loss while requiring lifestyle changes.
There’s a common misconception that most patients who have bariatric (weight-loss) surgery regain their weight. The truth is, most bariatric surgery patients maintain successful weight loss long-term.
Patients who undergo bariatric surgery and follow all treatment guidelines can expect to lose weight and improve the quality of their lives. More than 85% of patients lose and maintain 50% of their initial weight loss.
If you’re thinking about bariatric surgery, it’s important to get all the information you need—including the physical and emotional ups and downs.
Though bariatric surgery is safe and less life-threatening than obesity, it is major surgery. You will have to deal with physical pain, medication, possible complications, and all the to-be-expected problems associated with surgery. More, you will face dietary restrictions, some of which are ongoing, like not drinking with meals.
Perhaps the greater challenge is dealing with the mental and emotional issues. For years, you have used food as a means of coping.
Changing that complicated relationship goes far beyond getting back to “normal” after surgery. The new normal will be a novel approach to and understanding of food, your body, and other people.
You must be absolutely sure that this is the best path for you because you’ll have to convince others: your family, your doctors, and your insurance carrier.
To be considered for the surgery, your doctor must recommend it. Then, you must provide at least six months of records showing your weight and your attempts to lose weight. Once you have the doctors on board, your medical insurance provider must authorize payment.
Advocating for yourself means educating yourself, planning, and learning how to speak up for yourself.
Once you’ve been approved, you need to build a support system. One of the most important decisions you’ll make is choosing your team. The family members, friends, acquaintances, and professionals on your team must respect and support your decision.
You’ll need to make plans for an extended recovery. Beyond help with childcare, household chores, and transportation during and after hospitalization, you will need help adjusting to the changes in your life and the emotions that accompany those changes.
Your surgeon is likely to require you to follow a weight-loss regimen for about six months before surgery to ensure you are committed and as healthy as possible before surgery.
You’ll need to deal with fears and frustrations. Support from a therapist or support group and family is as important now as it will be later.
Recovery from the surgery itself is just the beginning.
Your doctors will advise you about the physical challenges that may follow bariatric surgery: constipation, dumping syndrome (nausea, vomiting, and weakness caused by eating high sugar meals, sodas, and fruit juices), possible infection of the wound, and possible leaks in the new connections.
Physical changes may include body aches or fatigue (vitamin or mineral deficiency may be the cause). You may feel cold. Dry or sagging skin, hair loss or thinning, and the inability to process certain vitamins (B12 and D) and minerals (iron, folate, calcium) may cause problems.
Managing your pain medication is another challenge. The early stage of recovery can last from one to six weeks. You will need to taper off from prescription pain meds. Don’t go cold turkey!
Follow your doctor’s advice on medication. Stopping without medical approval can cause serious complications, even hospitalization.
Be aware that bariatric patients should not take NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen. NSAIDs are not safe for people who have undergone bariatric surgery. Even one use can cause “marginal ulcers”, that is, sores or holes in the stomach pouch. If it is necessary to take an NSAID, take it with a proton pump inhibitor (PPI) medication, such as Prilosec or Nexium.
Medical advice may not give you the information you need about the emotional side effects of your surgery. You may lose your appetite, or you may feel hungry. You’ll be on a liquid diet at first, and that can be stressful.
You may experience “food grief”. Food has a special meaning for people who suffer from morbid obesity, and “mourning for lost foods is a natural step in the re-birth process after weight loss surgery.”
Emotional issues like self-doubt and mood swings may arise. Weight loss will be dramatic at first, but there may be setbacks—reaching a plateau or regaining some weight.
It may take time to get used to your new body. Keep your expectations realistic. Focus on the improvement in your health.
Ask for help. Take time for self-care. Keep friends who support you close. Avoid the ones who don’t. Use your support system.
Some patients who have undergone weight-loss surgery struggle with alcohol and substance abuse. One explanation is “addiction swapping”. No longer able to use food as an addiction, the patient may be drawn to alcohol or other substances as substitutes.
Also, weight-loss surgery is known to change alcohol sensitivity because the alcohol goes through the stomach and into the small intestine more quickly. You feel even small amounts more rapidly.
Ironically, you may be at risk of developing an eating disorder after bariatric surgery. Having trouble eating because you don’t have an appetite may lead to “the type of disordered eating that can turn into bulimia or anorexia.”
After surgery, eating too quickly or not chewing thoroughly can cause vomiting. Another unhealthy habit is chewing and spitting out food, which can lead to an eating disorder.
Eating out may be a challenge after bariatric surgery. Avoid high-calorie drinks, like lattes and sodas. Select meals with a balance of protein, fiber, and healthy fats. Don’t be afraid to create your own dish, ask for a half portion, or take leftovers.
New eating habits to acquire:
Bariatric surgery, even when successful, mandates changes in many areas of life. Many of these, like better health, more energy, and better self-esteem, are positive.
But even though your body may be in better health, emotional challenges may remain.
It’s up to you to manage the physical and emotional challenges. With the help of your medical team and your support group, you can weather these storms and live the magnificent, productive life you are meant to live.
Successful bariatric surgery means making lifelong changes to your lifestyle. Taking on the physical and emotional work to make these changes requires total commitment to your health. Are you ready to meet these challenges? Then you’re ready for bariatric surgery.