Thursday, December 13, 2012

Day 180 - more Unaccountable

In another demonstration of why I need to get myself back to work, I am completely unclear on what I did with my day for the most part. I visited Terry and we went out for coffee and a nice chat. Afterwards I went for a walk on the beach. It was really beautiful--all 1.5 miles of brisk stroll interspersed with stops to view various shells and other debris--and, oddly, was warmer than downtown Portsmouth. On the way home, I stopped to see Nancy at C'est Cheese and stayed a while. It was incredibly busy and they kept starting to help me and I kept letting other people go first because I was not in a hurry and I didn't want people who were busy to wait while we discussed my first post chemo hair cut. She had only the tiniest sliver of double creme brie which was a big disappointment. She was explaining how Sandy was a disaster for the food industry because it wiped out two thirds of the docks that food importers usually use. She was just getting things she had ordered for Thanksgiving so the fact that she was due to get more brie tomorrow was no comfort. I will prize the portion we got. It's funny, when people heard "first post-chemo haircut," everyone in the store congratulated me. One of the women there talked a lot about how she had a couple of friends with cancer (she appeared to be about 55 years old) and told me that she always tells her friends with cancer that we're all going to die, that they just have a better idea of when and from what. I was not sure if that was supposed to be comforting, but smiled and nodded. It is actually not true in the case of leukemia or, actually, a lot of cancers, but hopefully her friends take it in the spirit which it is offered and it at least does not make them feel worse.

Earlier this week, Ana gave me a game called Pictureka. Ellie saw it and asked to try it out. If you ever find yourself playing a game with Ellie, take this hint: if she starts an argument with "who's to say," even she does not believe it.

It's been a while since I've given you an update on "Unaccountable" which I am still enjoying. The next section of the book is devoted to stories about what happens when the public finds out things like the mortality rate from CABG at various hospitals. NY decided to publish these and he describes how one hospital lowered its mortality (sorry I don't know in what timeframe) from 26% to 7% over a three or four year period. Statewide, the death rate fell by 41%. (Relative rate, not absolute. Still, it's good stuff.) He talked about Johns Hopkins' CEO finding out that the cardiac surgical ICU (I love how these tertiary hospitals have an ICU for not just surgery, but surgery on a specific body area) was a dangerous place with a high turnover. He made a point to round there every week and talk with the staff and found out things like there were dirty lights in the operating room and the staff did not feel comfortable calling a surgery off until they got cleaned and the cleaning people wouldn't do it anyway. After fixing the root cause of these sorts of problems, things really improved there. The author also cited the Walter Reed Hospital as a place that improved after public scrutiny.

The next chapter was devoted to a story about the former Shah of Iran and how he needed his spleen removed and got it done by DeBakey (of DeBakey forceps fame). In fact, he insisted it be done by this world famous surgeon. Unfortunately, the surgeon was a world famous cardiothoracic surgeon and the spleen is not in the thorax. DeBakey did the surgery anyway and varied in technique from the usual way to do it which almost certainly caused the Shah to end up with an infection and a hugely complicated recovery. He was getting this surgery at about the same time as the hostages were taken in Iran and the author wonders how much the fact that the Shah was weakened by being sick played into that international situation. His point is that you want the person doing your surgery to have done a lot of them before. The fancy pants-est surgeon may not be the best choice for the job. We were told a similar story about the chief of anesthesia at the Mayo Clinic and a middle eastern ruler when I was in medical school.

I have had very few VIP patients in my career although once as a student I did a physical on the governor of a state of Venezuela who traveled to MN to get a yearly physical in the Spanish speaking clinic I was rotating through. No one told me he was a VIP; he was next in line so I did his physical. What he got from me (the inexperienced med student) that he hadn't gotten all these years from the (I guess) semi-famous Spanish speaking doctor he traveled all the way to the U.S. to see was advice to quit smoking. I don't know if he quit or not, but I suppose this is an example of the attending not adhering to standard of care.

Marty Makary in "Unaccountable" next talks about open vs lap surgeries and how sometimes a patient will get assigned to a doctor (for instance, it's Dr. X's night to pick up the ED patients) who doesn't do the surgery they need laprascopically and then the patient will get stuck with an open procedure and the collection of risks and complications that go with that. He talks about how much better it would be if proceduralists would refer to other proceduralists if the best procedure for the patient was one they did not perform. I can honestly say that I feel the local doctors are quite collaborative and collegial and refer patients to each other if that would result in a better procedure for the patient. Of course, I have visibility into a fairly small section of medical practice in Manchester, not any huge view. We are now about one third of the way through "Unaccountable."

For me, for tomorrow, I hope simply for a fun day. For you, I'm not sure. You may want a more substantial wish than two days of fun in a row. On the other hand, fun is good, so fun you get for tomorrow's wish.

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