Don’t miss your loved one whispering sweet nothings into your ear

Don't miss your loved one whispering sweet nothings into your ear

Check out this month’s newsletter: Facts About Hearing Loss

Sinus and asthma

No question, my patient’s asthma is much better when sinuses fixed. Great op today -endoscopic, image guided, total ethmoids, maxillaries.

Independent, non hospital owned practice

From the Institute of Healthcare Improvement:
“Increasingly, health care systems, health plans, public health departments, social service agencies, and regional coalitions are organizing their most strategic initiatives to move toward the Triple Aim of better health, better health care, and lower per capita costs. In the US, new models of financing and payment, such as accountable care, are deeply informed by the Triple Aim framework. In health systems around the world, the pursuit of better health, better care, and lower cost  has been adopted as a societal and fiscal imperative.
The Triple Aim focuses on serving populations while generating ever increasing value. Whether your focus is global payments or other value-based financing models, Accountable Care Organizations, the medical home, employee health, or responding effectively to assessments of community health needs, the Institute for Healthcare Improvement (IHI), which pioneered the Triple Aim concept, change strategies, and system measures, can help you master the basics and map your strategy to get real traction in producing Triple Aim results.”
and then read this from the N&O:

from this story: 
“North Carolina patients are likely to pay more for services ranging from heart tests to routine office visits if their doctors are employed by a hospital, a newspaper investigation has found.”

Unfortunately my colleagues and one of our leading hospitals have succumbed to the pressure of the dollar and security to inflate the cost of health care in our area without increasing quality or value one iota.

When and if you need and seek health care, make sure your physician is not owned by a hospital or you will be paying far and beyond what you would pay at an independent, private practice like ours.
“All value, no ripoff”

Allergies, sinus makes asthma much worse

Douglas Holmes, MD‏@drdougholmes

Got asthma? Control much better if sinusitis treated, allergy eliminated. We can do both.

Hearing aids

I was recently fitted with two hearing aids, actually communication devices. Not only do they immensely improve my hearing, they are blue toothed into my cell phone and TV/DVD. What a difference hands free communication via my cell phone directly into my hearing aids has made, and music and TV directly into my hearing aids is better than surround sound. If you have any type of hearing loss, we can now make you hear and function better than when you had ‘normal’ hearing. Check it out for yourself!!

An International City

Raleigh has quickly become an international city. Over the last several years, our practice has seen an influx of patients from Nepal, Eritrea, South America, and the Middle East. Many looking simply for a better way of life. As a physician, I am challenged to keep in mind disease processes that are not common in indigenous North Carolinians, and I also now see our common problems that are much more advanced due to lack of medical care. Not to mention cultural and language barriers … All this is challenging and oh so interesting.

Thyroid surgery – the evolution

Few areas of my medical practice have undergone the evolution that has the surgery of thyroid disorders.  No other area has benefited from such extensive experience over the last 20 yrs, and no other area demonstrates the competency that procedure after procedure has brought to me today.

My initial experience in the OR with thyroid was during my surgical intership.  An endocrine surgeon at Iowa in the general surgery division first captivated me with the detail and precision that this neck procedure requires.  Professor Dr Gurl was meticulous in surgery, and even more meticulous in drawing and documenting his operative findings.  As a benefit of his attending status, he could have allowed the resident on the case to dictate the operative report, but oh no!, Dr Gurl sat down after each and every case and very carefully described the operative findings and his intervention.  My young, learning eyes were watching and soaking up every detail and lesson.

When I had finished residency and fellowship, I had the great fortune in the USAF to be stationed at Travis AFB, California, a tertiary care center for the military.   Again I scrubbed with very experienced and talented thyroid surgeons.  Dr. Lisa Boyle taught me among other things her very successful technique in the presentation and preservation of the parathyroids and the staff endocrinologists shared their nuances of the subsequent post op calcium management.  An environment like this of shared learning without the issues of turf wars is seldom found, but I like to think it was due to our interest in patient care and our military dedication to a higher good that created these possibilities.

So when I started the UNC ENT division at WakeMed and then transitioned to my own private practice, thyroid surgery was firmly in my cache of abilities.  But there is nothing like experience, one after another, to make a capability a specialty.  Such has been the opportunity of being the head and neck consultant for Butner Federal Medical Center and developing laisons with endocrinologists here in Raleigh.  I have had the honor and opportunity to help hundreds of  patients with their goiters and thyroid nodules.  Every case involves the meticulous dissection of the recurrent laryngeal nerve which controls the movements of the vocal cords.  If hurt, the patient would be quite hoarse with a dysfunctional voice (one of my patients was the public address specialist at Seymour Johnson AFB, a damaged voice would have ruined her USAF career, he did more than fine).  This nerve runs right next to the gland, and is mere milimeters away.  The other vital structure to maintain is the parathyroids, which control calcium levels in the bloodstream.  Low post op calcium levels will lead to heart and nerve irregularities that can be fatal.  It is not unusual to require calcium supplements post op in even the best operation.  Fortunately, in my patients, no one has suffered  voice issues or need for prolonged calium supplements post op. 

After the initial incision in the neck, the skin flaps are dissected up and down, and the muscles of the neck are seperated in the midline.  Directly beneath lies the thyroid, with its extensive blood suppy.  The operation requires increment by increment removal and cautery of feeding veins, arteries, and connective tissue, all the while ;ulling the gland over in sponges toward the midline while retracting on skin and muscles laterally by an assistant to gain exposure to the promised land of recurrent laryngeal nerve and parathyroid glands.  Each movement takes only 3 to 4 mm of tissue away, so it is not unusual to spend 2 or more hours per thyroid lobe to successfully complete.

When the gland or lobe (1/2 of the thyroid removed to evaluate a suspicious nodule) is  removed, then full hemostasis (stoppage of bleeding) is assured, and the wound is closed with a only a fine line of incision and therefore scar left.  It is my goal to make it hard to see 6 months later that an operation was ever done.

Few operations require such concentration and surgical skill for hour after hour.  I love it.

bone anchored hearing aid

What a great case!!! Helping someone’s hearing by placing an implantable metal post??
It’s true. It’s called a bone anchored hearing aid, and very few Raleigh area ENT’s or audiologists offer this really neat advancement in hearing rehab. It’s designed for ears that can’t be helped with conventional hearing aids, or for ears that have lost all their hearing and need sound transmitted via the skull to the other ear. So cool!! Involves surgically placing a metal post that integrates into the bone, and when healed and stable is connected to a receiver that vibrates with sound input. Can’t wait for the another two months or so when we connect up this patient, our first. Just another example of being on the cutting edge and offering the very best and latest for our patients!

Alternative to Risky Sinus Surgery

Sinus surgery for chronic infections can be risky, as explained in this WRAL TV video by Dr. Doug Holmes. Dr. Holmes, as you’ll see, recommends a simple same day procedure called Balloon Sinuplasty, which is far less invasive and less risky than past standard surgical approaches.

Rex Health “Beat Sinusitis”

Do you suffer from chronic sinus discomfort with no relief using medication? This video describes a new procedure available at Rex Hospital called Balloon Sinuplasty; a less invasive outpatient procedure that avoids the need to pack the sinuses as in traditional surgery.

One Sinusitis Sufferers Story

Sinusitis affects some 37 million people annually and is more prevalent than heart disease and asthma.  There are medications to help with symptoms but 20% of patients do not respond favorably to them.  In this video, one chronic sinus infection sufferer tells her story of ongoing attempts and failures to cure her ongoing affliction until she found a remarkable new treatment that is far less invasive and risky than the standard recommended treatments for this condition.

Collaborative Healthcare Solutions, an alternative to medical malpractice lawsuits

Very little is more contentious in medicine than the topic of medical malpractice, lawsuits, and tort reform. The large number of stakeholders with financial and emotional capital are immense. There is little need for me to further describe our current state of ‘deny and defend’, with fear of malpractice cases by healthcare workers, limited to no discussion after a bad outcome, defensive medicine, and assertions by plaintiff’s attorneys that they alone represent the interests of an injured patient.

Until now, when all the rhetoric and verbiage can be called to the carpet, and real justice and communication and responsibility and learning and growth and apology and forgiveness and justice can come among us. Sound too good to be true? Well, it is good, and it is true, and it is here now (not just pie in the sky), but it is not everywhere. Thanks to a few hard working pioneers, it will be in North Carolina soon. It all comes under the umbrella of collaborative law.

So, a patient is under medical care and a poor result happens. With total transparency, the ‘poor result’ is investigated and a determination is made if the standard of care was met. If care fell below the standard, then all parties are brought to the table, records and relevant data are open, apologies are made, discussions are held concerning injury and further care, and a settlement is reached. Just like that. Perhaps not in one meeting, and perhaps not at all, but that is the goal.
Now this is the simplistic description, as many meetings and discussions and proposals may be involved. If the patient is still not happy, then the traditional tort reform system can be entered.

But the beauty of this approach is that real communication occurs, the patient is heard, physicians can explain their actions and if appropriate, apologize, and healing can begin. Healing for the patient, and healing for the doctor. Bad outcomes, as catastrophic for the patient as they can be, also take their toll for the medical professional in the form of stress, doubts, sorrow, remorse, and guilt. Collaborative solutions allow the doctor and the patient to heal.

If care was appropriate and there was no error, then this is disclosed and empathy about the patient’s condition is still expressed. If there is still no resolution and a case is brought, then the case is vigorously defended.

The alternative, the current standard, requires us physicians to build a wall between us and the patient, to deny, to withhold; in other words, to stop caring for the patient. To start caring more about us than about them. And nothing could be farther from our duties and ethics and responsibilities as medical professionals than to put up barriers and restraints and just outward remove ourselves from the responsibility of caring for our patients, even those who are angry and hurt and threatening legal retribution.

Collaborative law provides a solution for this all.

Collaborative solutions allows everyone to heal, allows everyone to benefit, and allows everyone to benefit. The lessons learned from these ‘cases’ are disseminated to the entire medical community for educational purposes so that we all are aware of what and how to avoid such a mishap in the future.

And data, good data, from the University of Michigan over the last ten years, shows that this approach lowers the number of claims and amount of payouts significantly.

Collaborative healthcare solutions is coming to Raleigh, coming to North Carolina. Pilot program grants are being written, groundwork is being laid.

Can’t wait.

by Douglas K. Holmes, MD

Nosebleeds, medical advances, medical expense

Severe nosebleeds (epistaxis in medical jargon) are a great example of the secondary, often adverse effects of medical advances which run up the bill for medical costs in the United States.

If you’re on call for ENT at Rex Hospital, the most likely reason to be called to assist the emergency physicians is for a severe nosebleed. Not the little drip, drip from a vessel up front that easily responds to a little pressure or packing, but a real life threatening gusher (life threatening from the blood loss and airway compromise) that just won’t stop despite multiple attempts at packing. By the time I’m called, the patient has just about had enough from painful packing and dealing with a constant flood of blood out the front or choking them from blood running down the back of the throat.

And most of the time the cause of this most uncomfortable, alarming condition can be traced to the advances of modern medicine.

The most typical patient is an older person (70’s or 80’s) who is on multiple medications to treat high blood pressure and some type of cardiovascular condition (atrial fibrillation, deep venous thrombosis, cardiac stents, etc) that is being treated with coumadin (commonly referred to warfarin, or in non medical speak, ‘blood thinners’), aspirin, and plavix. Plavix holds a high position in the drug world as it is commonly advertised in the evening news programs: “Ask your doctor if Plavix is right for you.” These drugs keep people alive who a generation ago would have succumbed from their underlying disease processes. They would have died from stokes, heart attacks, or pulmonary emboli. But now these drugs keep people alive, only to have them suffer the side effects of uncontrolled blood pressure and delayed blood clotting – this combo is the harbinger of a real nasal gusher.

My most recent patient was an 83 year old woman, let’s call her Ruth. Well, Ruth came to emergency center at Rex on a Saturday evening with a blood pressure of 200/100 (we all know that normal pressures historically are more like 120/80, with even more stringent numbers recently) and was on warfarin to prevent blood clots and emboli to her brain secondary to atrial fibrillation with an INR of 3, which means that her blood took three times as long to clot. The care for this type of patient requires multiple docs, me to stop the nose bleed, anesthesiologist for the operating room, intensivist for post op care with need for blood pressure monitoring with arterial line, blood products and vitamin K to reverse the warfarin, and oxygen. Not to mention the nurses, OR staff, ED (emergency department) staff, ward clerks, orderlies, blood bank specialists headed up by a laboratory pathologist. So now does anyone want to discuss the rise in the cost of medical care in the United States?

So, early on Sunday morning I took Ruth to the OR where she was intubated and asleep for nasal endoscopy, cautery of her bleeding site, and extensive packing; all intervention she could not have tolerated awake. I found the bleeder up high on the left side of her nose and cauterized it to oblivion with a special suction cautery that sucked the blood away as I ‘burned’ the offending vessel. All the while looking via a rigid fiber optic scope that magnified the area and took my eye right to the upper nose. These scopes were not available to previous generation surgeons. This was followed by a balloon packing blown up to keep pressure and tamponade on the vessel. Even after this intervention, anytime her very labile pressure got high she would ooze. Finally after 4 days of packing, with control of her blood pressure, and total reversal of her warfarin, I was able to deflate her balloon with no further bleeding. Two days later her packing was removed, two days later she went home after a total of about 8 days in the hospital, several blood transfusions, and a bill that must have been over $100,000, covered by medicare of course.

This cases represents the high tech, highly specialized care available to patients here in Raleigh. It is repeated patient after patient 365 days a year in every specialty. How to scope and cauterize and pack and care for these patients is my expertise; but how our country pays for it and how ‘medical advances’ are applied to our population is not.

As a surgeon in the trenches, I’m merely waiting for the hospital to call me with the next patient in need. Perhaps one day I’ll trade in my scrubs and operating room arena for transition into a suit and the legislative arena to address the other issues.

by Douglas K. Holmes, MD