Pushing The Limits: Is all well that ends well?

from play.google.com

A quandary.  A conundrum. A medical riddle. A dilemma.

We had one recently, and (spoiler alert) all came out well.  But, as is often the case, by the very success we experienced, more questions were raised.

A study of one is not all that scientific in it's conclusion, but this 'one' may possibly lead to a lowered threshold to take a patient to surgery that otherwise may not get there all that soon, or maybe ever.

Enough delay -  Here's the deal...

A 29 y/o BMI 40 patient with quite poorly controlled T2DM (most recent A1C over 11), on Lantus 42 units and mealtime bolus Humalog 25 units at each meal, and Metformin 1000 BID.  She was scheduled for surgery, Gastric Bypass, but unable to be cleared by her PCP due to poor control of her Diabetes, as essentially a standard reasonable precaution for any elective surgery.

Many studies have been done in the General Surgery, as well as other surgical disciplines, demonstrating a notable increased perioperative risk, mostly due to infections.  Since there really isn't anything that can be characterized as an 'emergency' (non-elective) Bariatric surgery, the decision was to wait until better control was achieved through diet, lifestyle, and improved medical management. It was generally agreed that we didn't need a "Normal" A1C (6.5 or less), but heading in the right direction, closer to 8%, with a few weeks to months of better control as the plan.  Hopefully...

Enter Mr. Gall Bladder.  Either from weight loss from our preoperative diet, or retrospectively just because of divine 'timing', she developed RUQ abdominal pain and N/V and when we worked her up we found a normal GB U/S - that is no stones, sludge, wall thickening, or pericholecystic fluid.  However, with persistent symptoms consistent with biliary colic, we did get a PIPIDA which showed positive for significantly decreased EF.

We subsequently had hoped things would quiet down on their own as we headed toward the intended weight loss surgery, but no...

And, add to that, an altered diet (anorexia) from N/V, abdominal pain, especially post prandially.  To make matters worse, BG's were now even higher due to her difficulty knowing 'when' (and 'IF') to take her insulin, and if so how much depending on what she could eat, and what she would keep down.  It was getting messy.

So, it was crystallizing to this.  Do the Laparoscopic Gall Bladder quickly and get out, and then come back another day for the Bypass. Or, take the Gall Bladder, and add the extra 90 minutes or so and do the metabolic surgery (the Gastric Bypass) at the same time as we had originally planned, just that now it would be in a more acute setting, and with not the best antecedent BG control.

*The Benefits of doing both: Get the Gall Bladder out, and get started on a big DM2 benefit and get her started with  better glucose control with greatly reduced meds. One time exposure to anesthesia. Reduced risk of 'losing' her to continued poor DM control and perhaps not having the Bypass and therefore not getting the metabolic benefit from surgery, maybe not ever (it has happened before).

**The Risks:  The standard reasons why we usually do not do it this way, that is performing an elective surgery in the face of poorly controlled blood sugars / Diabetes -  Infection.  Electrolyte issues.  Intravascular volume contraction from glycosuria.  Metabolic issues from a relatively insulinopenic state.

We did get PCP clearance with this unusual instance clarified for this specific case, and then cardiology clearance just to be sure (history of Mom with sudden ?cardiac death in her 40s).

She came in at 289 to the day surgery area on the AM of surgery, mainly owing to a reported low BG issue at 10 PM the night before, and did not take any of her Lantus- I guess it could have been worse - at least she didn't eat after midnight. We scaled her with Novolog in the preop holding area, and got her to high 100's low 200's before, and kept her there during surgery.

Not great, but actually way better than where she had been living the preceding few months when was with us (high 200's / low 300's).

So, surgery went well, both cases done in just over 2 hours. Blood sugars rapidly regulated, after some short acting insulin (Novolog) in the PACU, and followed every 2 hours.  She actually needed very little additional insulin, and we were able to follow a moderate QID scale and she got about 8 additional units total during her two day stay, keeping her BGs in the low to mid 100's.

No Lantus needed.  No infections.  No cardiac issues or tachycardia.  No surgical complications.

Huge Win-Win.

Just seen at her 1 week followup, she remains well, no further nausea or abdominal pain as she had with her Gall Bladder, and her BGs are in the 100-130 range as she advances her diet and is just on Metformin 1000 mg BID.

Surgery truly is powerful medicine.

And while we don't have this dilemma all that often, when we did, we have always leaned toward delaying surgery until it was 'safer' by standard best practices, that is with near optimal BG control before surgery.

With our experience here, maybe our threshold to do a weight loss / metabolic surgery will be lowered, taking into account the potentially rapid benefit of glucose regulation that lifestyle and medicines had been unable to deliver up until that point.

How Low Can You Go? How High Can You Fly??

from slantmouth.com

Highs and lows.

Lows and highs.

How often are you on the correct side of both in the same context?  In my experience, not that often. But, when you are, its a time to celebrate and take note!

Such an occurrence occurred in the Bariatric Surgery field recently, from an article published in the January 2015 JAMA entitled "Association between Bariatric surgery and Long term Survival".

The study of 2,500 VA patients not only showed that weight loss surgery prevents, resolves, or improves diseases such as obesity, type II DM, and certain kinds of cancer, but can lead to a longer life.

The study followed patients 5-14 years post surgery between 2000 and 2011. On average, the mean age was 52 years old, and the average BMI was 47. Mix of procedures was 74% Bypass, 15%Sleeve, and 10% Band; 1% 'other'.

As time passed in the study, the curve of those patients that had surgery clearly diverged from matched controls who did not have the surgery. As measured at both 5 years and 10 years into the study prospectively, the surgery patients showed significant all cause mortality reductions, even across different sub groups defined by diabetes, diagnosis, age, and sex.

All these 'highs' of resolving and / or improving comorbidites, and the 'low' of markedly reduced mortality for 10 years out from bariatric surgery in this study.

A win -win scenario for sure.

How many other surgical procedures can boast of such glowing attributes, that even get a fraction of the scrutiny of weight loss surgery?

We're Not in Kansas Anymore, Toto

From Kaitlinwatteron.com

I was just thinking, now that the New Year is fully upon us, how things have changed ever so 'slightly' in our practice, and likely yours over the past year.

In fact, looking back over just the past couple of years, it seems like the changes are many and significant, and there is seemingly no end in sight now that we have started down this path.  Are the changes accelerating, or is it me that is stuck in my ways, already looking back to my 'glory days' despite my age only still in my forties?

Oh, some of these changes are certainly for the best.  Some are meant to be for the best, but fall notably short. And some... I have no idea.  In fact, their very name or label for a new part of the medical practice sometimes couldn't be farther from the truth. Does the term "Meaningful use" sound familiar?

So here is a list, in no special order of a few of the changes that have entered our practice, and your as well, and are now part of the current state of Electronic Medicine as we all are well into this next generational phase.

The Electronic Medical Record. A topic of topics unto itself.

Istop.

E-Prescribing for most meds, soon to be all meds in NYS.

Sorian Clinicals (clinical platform) and Sorian Financials(billing and scheduling platform).

Computer Physician Order Entry.

HIXNY.

Patient Portals.

E-Discharge orders in addition to order entry.

Meaningful Use with regular updates of new mandates required every quarter.

This list is a bit more daunting than it may appear.  And yes, all do bring a new level of potential benefit to the general care of a patient by a provider, but the pace of the new rollouts, and the often additional skill set development required to manage each "App", and that aspect itself for me leads to instantly less user-friendliness than intended.

Add to that the often non-interactive nature of these individual Apps, that in a perfect world should work together in compatibility, and do not. Such as in our system, our Sorian Financials that didn't play nice with our EMR platform.  Or the hospital side of diagnostic tests and reports and hospital admission data that again doesn't easily flow to the EMR platform, thus requiring manual 'scanning in' to make the EMR useful and approaching the completeness and usability that I think the database was intended to provide.

And, those "Meaningful Use" criteria that appear to be progressively nickel and diming their way to more irrelevance as they additively take more and more time to process a patient visit, for often no perceptibly added gain in quality to an office visit.

But in summation, probably the most substantial negative common denominator for all these additions to our medical system in the recent past is more Time.

Time - a commodity that was short to begin with, and now so much less is available to maintain anywhere close to the productivity that was once a sense of pride and purpose in how I approached my day, every day.  Not just to maintain financial stability for an employer, but the ever-present challenge to maintain a personal standard of high quality, efficiency, and personal connectedness to each patient I see. That's much more difficult now, even that the learning curve for our EMR, for example, is nearing its 1 year mark.

What I still have hope in, is that somehow we will acclimate, and we all will be soon getting back to a sense of what it means to truly participate in the care of a patient, and that these new tools, and even those that are mandated to be used, can be put together to comprehensively offer true advantage to us as providers, and the patient-provider relationship,  actively taking advantage of newly available technological means.  That's what Meaningful Use would mean to me.

Because, what I am discovering, as I look at a printout of 2-3 pages for a follow up office visit with all sorts of "meaningful" information - is that which is often the first casualty to save time with these new modern era office visits of checking all the boxes on all the necessary components of the visit - is the connectedness that I so enjoyed with how medicine was in the past.  "Medicine" as a whole is now not the same as it once was.  Not by a long shot. I miss Kansas.  And, (Toto) I miss the Rain down in Africa...

And you know what? Even worse?  Providers aren't the only ones who are a bit taken aback by this new electronic era of medicine. Patients have noticed as well, and some of them are not too happy either with the change.

So, enough ranting already.  Back to Bariatric issues and insights soon!

Happy New Year.