A Chance to Cut is a Chance to Cure

Fidel Castro himself told surgeons not to perform a colostomy, opting instead for a course of surgery that produced a complication that left the Cuban leader in far worse condition, according to a newspaper report Wednesday.

After removing an inflamed piece of Castro's large intestine in an operation last year, the doctors connected the remainder directly to his rectum, rather than attaching a colostomy bag, El Pais said, quoting two medical sources at Madrid's Gregorio Maranon hospital. The operation failed when a suture burst.

"The Cuban dictator and his advisers are the ones who decided on the surgical technique that has led to the complications," the paper said.

SURGEON #1: El Presidente, we must remove your colon due to the inflammation. The safest way to do so would be to remove the diseased portion and leave a colostomy.

CASTRO: No. No colostomy. Chicks don't dig the bag.

SURGEON #1: But Maximum Leader.....

CASTRO: Take him away. (Surgeon #1 take out of room, never to be seen again.)

CASTRO (to surgeon #2): What do you think?

SURGEON#2: No colostomy, understood Jefe!!!

El Pais said that in December, when Garcia Sabrido visited, Castro had an abdominal wound that was leaking more than a pint of fluids a day, causing "a severe loss of nutrients." The Cuban leader was being fed intravenously, the report said.

“In the summer, the Cuban leader bled abundantly in the intestine,” El Pais reported. “This adversity led him to the operating table, according to the medical sources. His condition, moreover, was aggravated because the infection spread and caused peritonitis, the inflammation of the membrane that covers the digestive organs.”

The recovery from the first operation, in which part of his large intestine was extracted and the colon was connected to the rectum, did not go well. The link broke and he released feces into the abdomen that caused another peritonitis, the report said.

A second operation to clean and drain the infected area also failed, the paper said. He was then hit with inflammation of the bile duct, an illness which has a 80 percent mortality rate, el Pais said. A prosthesis made in South Korea was implanted and failed and later was replaced with one made in Spain.

Labels: celeberty medicine, colon, Fidel Castro, surgical complications

The push is on to find new sources of revenue to improve the state's trauma network, and it may lead to big new fines for speeders.

Gov. Sonny Perdue has announced a plan to tack on "additional, substantial fines" for so-called "superspeeders," Perdue press secretary Bert Brantley said. That money would be used to improve emergency care in rural Georgia and give a boost to hospitals that lose money caring for severely injured people.

Other ideas to fund improvements are also percolating at the Capitol, and a finished bill - or bills - may be weeks away from debate. The governor's office hasn't set the amount of the new fine, but Brantley said it would be "potentially in the hundreds of dollars."

Two midstate lawmakers are heavily involved in the process, having co-chaired a study group on trauma-care issues this summer.

State Sen. Cecil Staton, R-Macon, and state Rep. Larry O'Neal, R-Warner Robins, said Perdue's plan will have to be discussed. Both men are working on bills to create a permanent commission to manage funds set aside for improvements and keep an eye on the issue after it fades from the limelight of this General Assembly session.

The problem is the need to quickly treat severely injured people - and the high cost of doing so. Surgeons must be kept on call, expensive equipment must be on hand, and the injured person must be transported quickly.

That's difficult, particularly in rural Georgia, where there are large gaps in the state's network of hospitals equipped to handle the most serious injuries. In fact, the study group found that Georgia's trauma death rate is 20 percent above the national average - a difference of about 700 lives a year.

Money is a big part of the reason. Of the state's 152 acute-care hospitals, 15 are designated trauma centers. And four - in Macon, Atlanta, Augusta and Savannah - offer the highest level of care, the report states. Many hospitals don't offer these services, in part, because of a high level of uninsured patients seeking care, the report states.

Doctors, hospitals and EMS services lose about $250 million a year on trauma care, the report states. The Medical Center of Central Georgia in Macon has complained of this in the past, saying shortfalls could lead the hospital to drop its level of care.

The answer, according to several legislators, is to develop a new pool of money to establish new trauma centers, keep the current ones solvent and purchase more helicopters to quickly transport accident victims, who would receive free transport.

Increasing speeding fines would require a constitutional amendment, which in turn would require a statewide referendum, O'Neal said. O'Neal said he would probably support increased fines for "superspeeders," but to expect intense debate over just what that means.

For the moment, the governor's office has defined a "superspeeder" as anyone who drives faster than 85 mph, or 75 mph on a two-lane road, Brantley said. The governor's proposal also targets habitual violators who lose their driver's license and would pay a heavier fine when they reapply for the license, Brantley said.

Staton said he's glad to have the governor on board, but both he and the governor's office agree that new fines might not raise enough money. Projections have put the initial cost of the trauma network need at $85 million, with a lower cost recurring each year.

The study group's report also listed several funding options besides new traffic fines, including:

• Diverting a portion of the Georgia insurance premium tax.

• A $5 surcharge on motor vehicle registrations.

• A $1.16 monthly surcharge on cell phones.

• Surcharges on rental and leased cars.

• An option on Georgia tax forms allowing people to donate a portion of their tax refund to the trauma care fund.

Because the changes would also help prepare the state for a large-scale disaster, O'Neal said he's hoping federal money will be available through homeland security grants.

The ball is rolling on the issue, and there seems to be enough support to make significant changes, Staton said.

The question is "what the numbers will ultimately be," he said.

Labels: Georgia, Trauma System Development

Labels: Grand Rounds

A popular trend to increase the operative potential of the trauma service is to add nontrauma emergency surgery responsibilities. Although this appears to improve the trauma surgeon's operative experience and job satisfaction, reports thus far have focused on providing general surgery emergency services with limited coverage of vascular and thoracic nontrauma emergencies. Initial enthusiasm for this solution has the potential to be short lived because the majority of these surgical emergencies consist of draining soft tissue infections and excising necrotic gastrointestinal structures. Indeed, it can be argued that the trauma surgeon coverage of these surgical emergencies has a greater effect on the job satisfaction of the somnolent elective surgeon that is relieved of these responsibilities.

Labels: Future of Surgery

Forty medical school students will begin attending a joint University of Georgia and Medical College of Georgia campus in Athens in 2009, paving the way for a new health science complex at the state's flagship university, UGA president Michael Adams said this week.

Adams, who gave a State of the University address Thursday, said Friday the collaboration could eventually put as many as 200 medical students in Athens, but he stopped short of saying UGA planned to develop its own medical college.

"What we proposed was a joint trial period," working with Medical College of Georgia, he said. "Nobody has committed to anything beyond that."

Faculty members from both UGA and MCG will teach at the medical school, which MCG President Daniel Rahn described as a regional campus for the Augusta-based college.

In the past year, MCG has increased enrollment of first-year students from 180 to 190. Adding another 40 students a year in Athens beyond that number will help combat statewide and national physician shortages, he said.

The Association of American Medical Colleges has called for increasing enrollment of medical students by 30 percent by the year 2015 through expanding existing schools and creating new ones. After 20 years of no growth in the number of medical schools, several states, including Florida and Texas, are now building new ones.

Rahn said the Athens campus will be accredited and will use MCG's existing curriculum.

While no one is speculating publicly on whether the project could morph into a full-scale UGA medical school, the university has been placing an increasing emphasis on healthcare and research. In 2005, UGA opened a College of Public Health and a major center for biomedical and health sciences, and it has been ramping up
the university has been placing an increasing emphasis on healthcare and research. In 2005, UGA opened a College of Public Health and a major center for biomedical and health sciences, and it has been ramping up bids for national research dollars. UGA and MCG already have partnerships in nursing and pharmacy programs.

Adams said, of the 10 largest states, Georgia is the only one without three public medical colleges. Currently, Medical College of Georgia is the state's only public medical school. Emory University, Mercer University and Morehouse College run private medical schools.

Labels: Georgia, MCG, medical education, UGA

Labels: Grand Rounds, snark

Georgia’s Certificate of Need Program was codified by the Georgia legislature in 1979 in Georgia's Health Planning Statute, Title 31, Chapter 6. The purpose of the CON program is to insure the availability of adequate health care services to meet the need of all Georgians, while safeguarding against the unnecessary duplication of services that perpetuate the costs of healthcare services. The Department of Community Health was created in 1999 and the administration of the CON Program was placed within the Department.

An Ambulatory Surgery Facility that is physician owned, office-based, and single-specialty, the establishment and development of which does not exceed the limited-purpose physician-owned ambulatory surgery centers threshold.

Recommendation 14.1 (5 Agree, 1 Disagrees, 4 Abstain

Treat General Surgery in a consistent manner as all other single specialties.)

The majority of the Commission recommends that General Surgery be treated in a manner consistent with all other singe specialties, regardless of the regulatory requirement for single specialty facilities.

One member disagrees and maintains that general surgery should be treated as a multi-specialty because of the complex nature of the cases that a general surgeon may perform.

Recommendation 14.2 (5 Agree, 3 Disagree, 2 Abstain)

Abolish entirely the exemption for freestanding single specialty, office-based, physician-owned ambulatory surgery centers and require physician-owned limited purpose ambulatory surgery centers to obtain a Certificate from the Department. Upon application, such applicants would not be required to address need criteria but would be required to make indigent and charity care commitments, to accept Medicaid, to supply data to the Department of Community Health, and to verify that all its physicians are members of a hospital staff and are willing to accept emergency room coverage.

The membership of the Commission was sharply divided on the issue of physician-owned single specialty ambulatory surgery centers, which are currently exempt from Certificate of Need if the center can be established for a dollar amount less than approximately $1.6 million. One contingent of the Commission agrees with the recommendation that the current exemption be abolished and that limited-purpose, physician- owned ambulatory surgery centers (“ASC”) obtain a Certificate, although such centers would be free from an objective need methodology. Such ASCs would be required to commit to the provision of indigent and charity care at a level of 3 percent of adjusted gross revenues. In addition, this contingent recommends that these ASCs agree to accept Medicaid, if at all possible, and provide services as a minimum community standard, that such facilities agree to provide annual data to the Department, and that all physicians who perform procedures at the facility be required to hold hospital staff privileges, if possible, and to accept ER coverage. The members who agree with this recommendation do so because freestanding single-specialty ambulatory surgery centers have been shown to be high quality and low cost alternatives. These members who argue for less regulatory control contend that to artificially restrain these services raises costs reduces efficiency, and prevents physicians from billing facility fees.

Other members disagreed with this recommendation and maintain that the exemption for physician-owned ambulatory surgery centers should be abolished and that such centers should be required to obtain a Certificate of Need addressing all applicable review criteria including a determination of need. These members are concerned that if ambulatory surgery centers are allowed to proliferate significantly, hospitals will not have a financially sustainable business model. Mainly, these members maintain that ambulatory surgery centers take low acuity, paying patients, and leave hospitals to treat the complex cases and individuals without the ability to pay.
The CON Commission has been unable to reach consensus with regard to the best policy to address this difficult issue because its root causes involve complex factors relating to reimbursement and costs that are beyond the CON program’s purview. A real and sustainable solution to this dilemma will require a health policy approach that corrects the cost and payment problems for both professional services and hospital-based services, particularly with respect to the under-insured and uninsured.

Recommendation 14.3 (3 Agree, 3 Disagree, 4 Abstain)

Abolish the exemption for physician-owned, office-based, single specialty ambulatory surgery centers and require such facilities to obtain a Certificate of Need under the exact same standards as all other ambulatory surgery centers.

The original recommendation of the Specialized Services Sub-Committee was to abolish the current ASC exemption and require all ASCs to obtain a Certificate of Need without exception. The full Commission discussed this recommendation, but was sharply divided and no final conclusion was reached on the recommendation.

Recommendation 6.0 (4 Agree, 1 Disagrees, 5 Abstain)

Deregulate diagnostic cardiac catheterization and require therapeutic catheterizations to be performed only by providers approved to offer open heart surgery.

The members of the Commission who support the deregulation of adult diagnostic cardiac catheterization maintain that deregulating diagnostic cardiac catheterization will allow for the proliferation of these services in the market assuring access to residents in all areas of the state. Such members feel that this service is a valuable service to the citizens of the state and has been shown to save lives, particularly in states such as Georgia with high rates of coronary disease. These members feel that the regulation of the quality of this service could be managed by Licensure.

One member of the Commission disagrees. This member feels that this service should continue to be regulated by Certificate of Need. Because cardiac catheterization is such a specialized service, certain quality standards must be met to achieve the best possible outcomes. Because the American College of Cardiology recommends that minimum volumes be maintained to ensure the quality of the service, this member feels the Certificate of Need process ensures that there will not be a proliferation of low volume providers who won’t maintain the same quality as high volume providers.

Several members of the Commission report that this recommendation should only apply to hospital-based cardiac catheterization and not to freestanding cath programs.

Recommendation 7.0 (6 Agree, 1 Disagrees, 3 Abstain)

Deregulate Level I perinatal services and continue regulation of Level II and Neonatal Intensive Care.

Most members of the Commission recommend that Level I perinatal services be deregulated because these services are already provided by most hospitals in the state and do not require specialized labor. These members believe that access to perinatal and obstetrical care will be enhanced by their recommendation. The fact that federal law already requires a facility to treat a woman in active labor further supports this recommendation. The members who make this recommendation maintain that Level II and Level III services should continue to be regulated by CON because of the highly- skilled nature of these services and the workforce that is required to support them. One member of this group further believed that Level II should be deregulated in addition to Level I.
One member of the Commission made the recommendation to maintain existing CON regulation for this service. This member believes that maintaining Certificate of Need regulation of Level I perinatal services will address the problem of large fixed costs incurred by facilities that provide these services and the shortage of skilled workforce.
Several members of the Commission report that this recommendation should be limited to Level 1 perinatal services at hospitals and should not be construed as a recommendation regarding freestanding facilities.

Concerned about a possible hit to their bottom line, metro Atlanta hospitals are preparing to put a few newly proposed state health-care regulations under the knife.
.....Hospitals argue that physician-owned surgery centers siphon off their best-paying patients, leaving the burden of the uninsured for hospitals to bear.

Recent financial data just released by the state Department of Community Health, which tracks the performance of hospitals each year, shows that metro Atlanta's 25 largest hospitals spent nearly $485 million combined on uncompensated, indigent and charity care in 2005. That's up 12 percent from $435 million in 2004.

The recommendation "is just one more knife in the hospitals' back, and it's a big knife," said Michael Rovinsky, president of the health-care consulting firm Integrity Consulting Group. "General surgery accounts for a lot of profitable procedures. This is the one [recommendation] that's going to be fought the hardest."
....But the proposal to classify general surgery as a single specialty could be damaging to many hospitals, especially as they continue to fight rising costs to care for the poor and uninsured.

"It would have a financial impact," said Holly Snow, Piedmont's vice president of government and external affairs.

The commission anticipated the controversy, and in its recommendations says all outpatient surgery centers must commit to serving the indigent and uninsured.

Other possibly contentious recommendations are also included in the commission report. One permits hospitals wanting to launch general labor and delivery programs to circumvent the certificate-of-need process. The same goes for hospitals trying to start up diagnostic heart catheterization programs. The catheterization procedure involves a thin, hollow tube that is threaded through the body to examine the heart's chambers.

Labels: Georgia