Thursday, December 24, 2020

Not On The Surgeon's Birthday

Picture from Pinterest

It's Christmas Eve and I've just finished my day at the clinic when I happened to see this article.

The authors of this study analyzed 9,800,876 surgical procedures performed by 47,489 surgeons over four years. The surgeries were all emergency procedures to prevent selection bias (patients choosing their preferred surgeons and surgeons choosing patients based on illness severity).

Four common heart surgeries, hip, thigh fractures, lung resection, appendectomy, amputation of lower extremity were among the 17 surgeries performed by these surgeons.

0.2% (2064 surgeries) were performed by the surgeons on their birthdays. These surgeons who worked on their birthdays were on average older and more likely to be men. 

Here's the shocking news. Patients had a higher chance of dying (7%) within 30 days after surgery while operated by a surgeon on the surgeon's birthday compared to other days (5.6%).

This was after adjusting for patient characteristics and surgeon fixed effects (i.e. comparing outcomes of patients treated by the same surgeon on different days).

The authors suggest that surgeons may be distracted by other life events unrelated to work when they operated on their birthdays!

Perhaps from 2021 onwards we too should give our staff the day off on their birthdays so that they will not be distracted.

Here's hoping this post finds you resting and/ or enjoying time with your loved ones after one long, unprecedented year. Merry Christmas and happy holidays from all of us at Physio Solutions ad Sports Solutions.


Reference

Kato H, Gena AB et al (2020). Patient Mortality After Surgery On The Surgeon's Birthday. BMJ: 371: m4381. DOI : 10.1136/bmj.m4381.

Friday, December 18, 2020

Patient Waited 5 Hours For Appointment


Has this happened to you before? The patient above, mentioned that there was a waiting time of about three and five hours respectively during the last two visits to see the eye doctor.

I've had many of my friends and family tell me about the same thing happening to them. Attending a medical appointment would often take up a whole day. 

On a personal note, I remember having to accompany my mother for a doctor's visit and we had to wait for over two hours as well. Such a waste of time.

At our clinics, we promise you will never have to wait more than five minutes. We will try our utmost to see you on time. We never ever book two patients or more for the same slot. 

You will not be attended by a therapy assistant if you're seeing the physiotherapist. We do not employ any therapy assistants in our clinics. If you're seeing us for an hour, you will have our undivided attention. We will not put you on a machine and attend to another patient. 

The first session with us is longer as we take the time to ask questions and assess you thoroughly to find the cause of your problem. We treat the cause of the problem and not just treat your pain. If you get better after one session, we will not ask you to come for another session.  

Rest assured, you would never have to put aside a day to see us for physiotherapy. We respect your time.

Sunday, December 13, 2020

Be Patient So You Don't Become A Patient


Maybe the best thing to do now is nothing. To not change anything. My friend, whom I shall not name is always drawn to bright, new and shiny things. He is always after the latest fads. Especially when it comes to health and fitness.

Consider his diet. He is always following the latest 'flavour of the month'. Whether it's low carb, high fat, Atkins, South Beach, intermittent fasting etc, he's tried them all. I often tell him that his quickness in switching diets (due to not seeing results quickly enough) is probably detrimental to him losing weight.

I quoted him a study done by researchers comparing low fat and low carb diets. Participants were randomly tracked for a year. Those who lost the most weight were those who adhered to that diet. Being on either diet didn't matter as much. Slow and steady wins all the time in the long haul.

I would say this is exactly the same for fitness too. A paper published in the British Journal of Sports Medicine found that the best way to avoid getting injured is to slowly increase your training volume over time. Excessive and rapid increases in training loads are responsible for a large proportion of non-contact soft tissue injuries.

I travelled extensively with our Singapore badminton players and went to two Olympic Games with Team Singapore. The players had training camps and competitions all over the world and I've had the privilege of seeing world class badminton players like Lin Dan, Lee Chong Wei, Taufik Hidayat, Peter Gade and Singapore's own Ronald Susilo  train. (Below is a picture of him beating Lin Dan at the Athens Olympics).

I'm more excited than Ronald!
They all employ different strategies to build fitness and hone their court skills. Different coaches have different coaching styles. But all lead to the same objective, to be able on put the shuttlecock where they want to on court, be it with a smash or drop shot to win the point. To win the badminton match.

Sitting on court in Beijing 2008
And the key to success is that the players stick to the plan. There are many roads leading to Rome, and they get there only if they stick to their path.

If the training you did this week was twice as much as what you average over the past four weeks, you're 5 to 10 times more prone to getting injured compared to 10 percent increases in training volume and intensity.

This is especially true when my patients are returning from injury. I always tell them to err on the side of caution. Doing too much too soon may get them injured again. Our bodies need time to adapt to training loads after injury.

So as this strange, unprecedented year draws to a close, hang in there if your diet or fitness routine hasn't gone exactly to plan. Be patient, keep at it, remember it's slow and steady that always wins in the end. Patience is really a virtue.


References

Gabbett TJ (2016). The Training - Injury Prevention Paradox: Should Athletes Be Training Smarter And Harder? BJSM. 50(5): 273-280. DOI: 10.1136/bjsports-2015-095788.

Gardner CD, Trepanowski JF et al (2018). Effect Of Low-fat Vs Low-carbohydrate Diet On 12-month Weight Loss In Overweight Adults And the Association With Genotype Pattern Or Insulin Secretion. JAMA. 319(7): 667-679. DOI: 10.1001/jama.2018.0245.

Sunday, December 6, 2020

Patient Says She Has Sciatica

Check out her hip range
Recently, a patient came in to see me with pain down her buttocks and leg saying that she has "sciatica". The lower levels of the lumbar spine are notorious for referring pain down to the buttocks and the outside and/ or back of the leg. This is commonly known as 'sciatica' since that is the path of the sciatic nerve, the largest nerve in our bodies. 

Typically sciatica usually affects only one side of the body. She thought she must have hurt her back recently before this buttock pain started. I checked her lower back and it was fine.

Distribution of Sciatic nerve

However, I hit the jackpot when I checked her hip. It reproduced all her 'sciatica' symptoms she was complaining of. 

Femoral and Obturator nerves

How did I know to check her hip? The hip joint is also known to refer pain to the groin and to the front of the thigh, more commonly in the groin due to its nerve supply from the obturator, femoral and sciatic nerves. This is from previous anatomical studies and analysis of pain patterns in patients waiting for hip replacements.

I recall reading an article where researchers did a fluoroscopic guided injection to map out pain referral patterns from the hip. A fluoroscopic injection allows exact locations in the body to be located (under x-ray imaging). Fluoroscopy injections can be used to alleviate pain or in this study's case to identify the origin of pain.  

The researchers had 51 patients (28 female, 23 male) for their study. These patients had hip pathology as evidenced by x-ray or MRI. Pre injection, these patients marked out on a body chart where their pain was (see picture below).

Pain referred from the hip 

The patients were then given a fluoroscopically guided intra-articular (FGIA) injection. There was only local anesthesia and no oral or intravenous sedation for the patients to avoid confounding of results. Only when their pain was reduced by 90% before the FGIA injection was deemed effective. 

Long needle to reach the hip

The researchers found that referred pain to the buttock was the most common (71%). Traditionally accepted referral to the thigh (57%) and groin (55%) were less common. 22% of patients had referred pain to the legs (below the knee).

The referred pain areas in this study (from the hip joint) were similar to previously reported pain patterns observed from the lumbar spine and sacro iliac joints.

This is a very useful study for knowing referral patterns of the hip joint. When a patient complains of pain in their buttocks, groin, thigh or even in the foot, one must not rule out the hip. It is important to note that there is no lumbar spine referral in this study.

Note to self (and other physiotherapists reading this), not all radiating leg pain is 'sciatica'.

Reference

Lesher JM, Dreyfuss P, Hager N et al (2008). Hip Joint Pain Referral Patterns: A Descriptive Study. Pain Med. 9(1): 22-25. DOI: 10.1111/j.1526-4637.2006.00153.x