Monday, August 29, 2016
Saturday, May 28, 2016
Hype and conflict of interest are both dangerous in 2016
I love progress. Doing things safer, more effectively, more efficiently is always a goal. But our desire for progress is exploited every day by overblown or unproven assertions about all sorts of things - products, procedures, services.
Unreasonable expectations actually get in the way of progress. I am trying to be more moderate, and try the new with caution, but faith that some of these overhyped trends still have real value - just in the appropriate place (not everywhere, all the time)
Not to be too cryptic - specifically robotic/endoluminal/image guided surgery is awesome, but the revolution may be mixed! Also - as a Mindfulness advocate and practitioner, I do not believe it will (or needs to) change every aspect of my being... or cure asthma!
Self driving cars are gonna change the world in unbelievable ways - all that free time is gonna make us less sleepy and more connected and maybe even better educated! So there's some hype from me ;-)
maybe I'll leave conflict of interest for another day...
Sunday, May 22, 2016
Trying something new - very short posts
I have always tried to write in essay form. That may cause my writer's block. I have plenty to say - just not very polished.
The world really is getting more complicated, and many (most) of us really are getting more stressed. I overextend myself regularly, and have to "declare failure" and back off a bit. FOMO - fear of missing out - is the millennial term for it.
One of my awesome attending in residency gave me a TWO WORD evaluation when I first worked for him! I was ashamed, but came to realize that he was truly insightful, and his stern eval also had a decent number score with it (at least 3 out of 5...) so it wasn't a condemnation.
Thank you, Dr Lowell Bursch - for those two true and useful words. --- "Easily Overwhelmed"
The world really is getting more complicated, and many (most) of us really are getting more stressed. I overextend myself regularly, and have to "declare failure" and back off a bit. FOMO - fear of missing out - is the millennial term for it.
One of my awesome attending in residency gave me a TWO WORD evaluation when I first worked for him! I was ashamed, but came to realize that he was truly insightful, and his stern eval also had a decent number score with it (at least 3 out of 5...) so it wasn't a condemnation.
Thank you, Dr Lowell Bursch - for those two true and useful words. --- "Easily Overwhelmed"
Monday, January 25, 2016
Saturday, January 23, 2016
Saturday, December 05, 2015
Bariatric Post-Operative Discharge Instructions Supplement
HERE IS THE THING TO WATCH BEFORE DISCHARGE!!!
Wednesday, October 07, 2015
Wednesday, June 03, 2015
Thanks KTVX, Nadia Crow for wonderful interview, chance to share!
Note the Obesity Action Coalition Button!
Wednesday, May 27, 2015
Thanks to Commissioner Todd Kiser, Asst Comm Tanji Northrup #Utah @asmbs @ObesityAction #diabetes #wls #ACA #obesity pic.twitter.com/50u7c6D8L8
— Walter Medlin MD (@bonuslife) May 28, 2015This was a nice day - you would be surprised at how nice and accessible our Utah public servants are. They are dedicated, good listeners. They cannot always make everything turn on a dime, but with citizen input, can help move policy and make our state healthier!
Your advocates today (MANY others who work every month could not get to todays meeting) Attorney Kimball Christensen, Businessman/Patient/Advocate/Councilman Jeff Haaga, Surgeon Dr Anna Ibele from University of Utah, BMI manager Darren Cluff.
Many thanks to Insurance Commissioner Todd Kiser and Assistant Commissioner Tanji Northrup for our second visit as an ASMBS and OAC group... We are looking forward to bringing grassroots to the Utah Legislature in the Interim - every third Wednesday this year! Come join us.
Sunday, May 10, 2015
Packlist for going home after surgery Pain, Nausea, Wounds, Dehydration, Constipation, Fatigue---"Normal" is weeks away!
FRET, Don't FREAK!
90% of what you and your loved ones worry about is not going to happen.
Most problems are not life threatening, and even those that are life threatening rarely actually kill... Relax just a tiny bit!
THE FIRST MONTH AFTER SURGERY IS FINE TO BE SCARED AND EXTRA CAREFUL. EXPECT SEVERAL "BUMPS" IN THE ROAD (and don't panic)-
BUT..... GO TO THE EMERGENCY DEPARTMENT OR CALL 911 IF YOU TRULY FEEL LIKE YOU ARE DYING. It is better to be wrong and get checked out, than to play it cool and be dead at home. If you call a doc and say you are terribly ill, they are going to get you in to be seen in person, and have tests.
It is always best to be seen in your surgeon's "regular" hospital for abdominal problems if time allows. Your local ER can do many things (especially chest pain, shortness of breath, wound problems, or clot treatment)- but do not be surprised if you end up transferred for certain problems. Not all hospitals have the same areas of knowledge, and you need to be a careful consumer.
PAIN is a normal part of healing. It is not always a sign of trouble. Every day will get a bit better for most patients, and by 3 or 4 days after surgery, many can have good relief with plain Tylenol for most of the day.
The most common problem I see is not keeping a steady level of medication. Most pills or Elixirs only give 4 to 5 hours of effect - so make sure you don't go more than 6 hours between doses (ESPECIALLY OVER NIGHT! Set the alarm so you don't wake up in pain with all of your medication worn off.) If you don't like the "fuzzy" feeling that narcotic gives you, then cut the dose of that part down, but keep getting the full dose of Acetaminophen (Tylenol). Do NOT take more than 3,300 mg per day or more than 1000 mg in any one dose, though.
Everyone has nausea to some extent. It cannot be eliminated with medications. The stomach is going to cramp. Vomiting once or twice a day is not unusual, but should be reported to your team if ongoing.
Most people are anxious about how long it will take to tolerate regular food - or some particular food. BE PATIENT!!! Everything is going to be there eventually.
Every wound is a worry. The only ones we do much about have severe redness more than an inch in all directions. Redness of just a quarter inch (4-5mm) is usually part of the healing process. Wounds often "gape" open for a quarter of an inch, and often go down a quarter of an inch with scab or even white fibrous goo. This is not usually "pus" but normal protein coagulum from tissue and plasma.
DEHYDRATION is the most common reason for being put back in the hospital, and it is usually avoidable! Don't panic at how things cramp a bit - keep taking small swallows of liquid, and do not try to go too fast or too big. If you try to eat regular food too fast, then you may feel too sick to drink - then you are stuck back in a hospital bed with IV fluids, a scared family, and maybe a big bill. If you can get some fluids down, but just are not quite keeping up, many offices can give extra IV fluids during the day, without having to use the hospital (and for a lot cheaper).
Constipation is usually just much slower bowels from less food, narcotic effects, minimal exercise, and dehydration. Expect that you may only have a Bolwel Movement once or twice in the first week after surgery. If you really feel stuck, a dose or two of Milk of Magnesia or similar can help, but if you are truly pooping hard rocks, a Fleet's enema is the only real help. Not many people like this, and not many have to do it - but don't be afraid to do one at home, before resorting to the ER.
Most people notice their energy is not 100% for 3 months after any major surgery, but usually it is 85% by 4 weeks out. Do not try to "push" beyond this - just take care of the important stuff first, and punt on the stuff that can wait. BE VERY CAREFUL WITH THE CAR! If you find you are "wiped out" after a day at work (or whatever) - do not make a long drive assuming you will be ok. If you have a crash, we cannot take that back!!!
It is OK if your weight is UP after surgery - fluid retention is very common. Just keep following it, and you will be happy by the end of a week or two. We are mostly just looking for an average of 1 or 2 pounds per week over the first year - do not try to push beyond this. Many people will lose more in the first 30 days, but it is probably more important to be consistent, and keep strong muscles and bones for the long term... Expect occasional "plateaus" where your weight stays the same for a few weeks, or even goes up a pound or two.
Did I say not to panic? :-)
Any care needs to be individualized by your doc, pharmacist, or their team - this is only for general information.
Find the quiet inside the chaos. Take a breath and listen.
90% of what you and your loved ones worry about is not going to happen.
Most problems are not life threatening, and even those that are life threatening rarely actually kill... Relax just a tiny bit!
THE FIRST MONTH AFTER SURGERY IS FINE TO BE SCARED AND EXTRA CAREFUL. EXPECT SEVERAL "BUMPS" IN THE ROAD (and don't panic)-
BUT..... GO TO THE EMERGENCY DEPARTMENT OR CALL 911 IF YOU TRULY FEEL LIKE YOU ARE DYING. It is better to be wrong and get checked out, than to play it cool and be dead at home. If you call a doc and say you are terribly ill, they are going to get you in to be seen in person, and have tests.
It is always best to be seen in your surgeon's "regular" hospital for abdominal problems if time allows. Your local ER can do many things (especially chest pain, shortness of breath, wound problems, or clot treatment)- but do not be surprised if you end up transferred for certain problems. Not all hospitals have the same areas of knowledge, and you need to be a careful consumer.
PAIN is a normal part of healing. It is not always a sign of trouble. Every day will get a bit better for most patients, and by 3 or 4 days after surgery, many can have good relief with plain Tylenol for most of the day.
The most common problem I see is not keeping a steady level of medication. Most pills or Elixirs only give 4 to 5 hours of effect - so make sure you don't go more than 6 hours between doses (ESPECIALLY OVER NIGHT! Set the alarm so you don't wake up in pain with all of your medication worn off.) If you don't like the "fuzzy" feeling that narcotic gives you, then cut the dose of that part down, but keep getting the full dose of Acetaminophen (Tylenol). Do NOT take more than 3,300 mg per day or more than 1000 mg in any one dose, though.
Everyone has nausea to some extent. It cannot be eliminated with medications. The stomach is going to cramp. Vomiting once or twice a day is not unusual, but should be reported to your team if ongoing.
Most people are anxious about how long it will take to tolerate regular food - or some particular food. BE PATIENT!!! Everything is going to be there eventually.
Every wound is a worry. The only ones we do much about have severe redness more than an inch in all directions. Redness of just a quarter inch (4-5mm) is usually part of the healing process. Wounds often "gape" open for a quarter of an inch, and often go down a quarter of an inch with scab or even white fibrous goo. This is not usually "pus" but normal protein coagulum from tissue and plasma.
DEHYDRATION is the most common reason for being put back in the hospital, and it is usually avoidable! Don't panic at how things cramp a bit - keep taking small swallows of liquid, and do not try to go too fast or too big. If you try to eat regular food too fast, then you may feel too sick to drink - then you are stuck back in a hospital bed with IV fluids, a scared family, and maybe a big bill. If you can get some fluids down, but just are not quite keeping up, many offices can give extra IV fluids during the day, without having to use the hospital (and for a lot cheaper).
Constipation is usually just much slower bowels from less food, narcotic effects, minimal exercise, and dehydration. Expect that you may only have a Bolwel Movement once or twice in the first week after surgery. If you really feel stuck, a dose or two of Milk of Magnesia or similar can help, but if you are truly pooping hard rocks, a Fleet's enema is the only real help. Not many people like this, and not many have to do it - but don't be afraid to do one at home, before resorting to the ER.
Most people notice their energy is not 100% for 3 months after any major surgery, but usually it is 85% by 4 weeks out. Do not try to "push" beyond this - just take care of the important stuff first, and punt on the stuff that can wait. BE VERY CAREFUL WITH THE CAR! If you find you are "wiped out" after a day at work (or whatever) - do not make a long drive assuming you will be ok. If you have a crash, we cannot take that back!!!
It is OK if your weight is UP after surgery - fluid retention is very common. Just keep following it, and you will be happy by the end of a week or two. We are mostly just looking for an average of 1 or 2 pounds per week over the first year - do not try to push beyond this. Many people will lose more in the first 30 days, but it is probably more important to be consistent, and keep strong muscles and bones for the long term... Expect occasional "plateaus" where your weight stays the same for a few weeks, or even goes up a pound or two.
Did I say not to panic? :-)
Any care needs to be individualized by your doc, pharmacist, or their team - this is only for general information.
Find the quiet inside the chaos. Take a breath and listen.
Monday, January 12, 2015
Big News for Utah Medicaid WLS Patients! Coverage of Sleeve Gastrectomy, and no more "6 month" penalty lap
Wow - thanks so much to advocates from all sides. Patients, caregivers, public servants, companies, and the Obesity Action Coalition and ASMBS are all working to obtain equal access to care for obesity.
See below for their quote,
"Utah Medicaid follows McKesson InterQual 2014 criteria for surgical procedures. Within this product, the supervised weight loss criteria point is no longer there. It has been reworded now to be "documented history of weight management attempts" and "unable to maintain sustained weight loss." With that said, we would not require a "medically supervised" diet for any length of time. Utah Medicaid would only require documentation of weight management attempts and failure to maintain sustained weight loss. In conclusion, this places the responsibility on the provider to make sure they document these weight loss attempts. It also allows for them to use their own discretion for the appropriate length of time a patient should attempt these weight management programs. "
Anyone feel like writing letters to Intermountain Healthcare or PEHP to make their coverage as good as Medicaid and Medicare? The time for discriminatory plan design is OVER! (but not without careful monitoring of how things are implemented...)
See below for their quote,
"Utah Medicaid follows McKesson InterQual 2014 criteria for surgical procedures. Within this product, the supervised weight loss criteria point is no longer there. It has been reworded now to be "documented history of weight management attempts" and "unable to maintain sustained weight loss." With that said, we would not require a "medically supervised" diet for any length of time. Utah Medicaid would only require documentation of weight management attempts and failure to maintain sustained weight loss. In conclusion, this places the responsibility on the provider to make sure they document these weight loss attempts. It also allows for them to use their own discretion for the appropriate length of time a patient should attempt these weight management programs. "
Anyone feel like writing letters to Intermountain Healthcare or PEHP to make their coverage as good as Medicaid and Medicare? The time for discriminatory plan design is OVER! (but not without careful monitoring of how things are implemented...)
Thursday, December 18, 2014
Friday, December 12, 2014
Weight Loss Surgery SELF PAY - available for Sleeve Gastrectomy $12,000 in Salt Lake City, Utah
I hate being crass, but the world needs more transparency, and nowhere more than in medicine. Many people feel that their only option is to pay over $20,000 at home, or to go far away to Mexico for surgery.
We routinely do Hospital cases for Laparoscopic Sleeve Gastrectomy for less around $16,000 (including stop-loss insurance coverage), and Surgery Center for $12,000.
We are getting started with telemedicine also, to make travel easier, while still having a good relationship and getting more value from the trips patients do make.
For January, I will do telemedicine visits for free for initial patients. We do have limited slots, so call Kim to schedule. 801-746-2885
The program we use is free to you, but has more privacy protection than Skype or FaceTime. It is an easy download app to your smartphone, tablet, or computer (Android or Apple) It is called VSee, and I will be posting a simple video on how to set up. No special equipment required, as long as your device has a camera!
December is now here, and if you don't have good insurance coverage for 2015 - despite overwhelming medical evidence, why not find out about your other options? We often do get people approved, even when they have been denied fair access, but you won't know until we try!!!
Happy Holidays!
We routinely do Hospital cases for Laparoscopic Sleeve Gastrectomy for less around $16,000 (including stop-loss insurance coverage), and Surgery Center for $12,000.
We are getting started with telemedicine also, to make travel easier, while still having a good relationship and getting more value from the trips patients do make.
For January, I will do telemedicine visits for free for initial patients. We do have limited slots, so call Kim to schedule. 801-746-2885
The program we use is free to you, but has more privacy protection than Skype or FaceTime. It is an easy download app to your smartphone, tablet, or computer (Android or Apple) It is called VSee, and I will be posting a simple video on how to set up. No special equipment required, as long as your device has a camera!
December is now here, and if you don't have good insurance coverage for 2015 - despite overwhelming medical evidence, why not find out about your other options? We often do get people approved, even when they have been denied fair access, but you won't know until we try!!!
Happy Holidays!
Saturday, October 18, 2014
Fall Update - Blog neglected for Twitter and Facebook lately - and now YouTube, too!
Well, I'm not so good at "embedding" video, so here is the link to the visit I had this week to Fox 13 and great talk with Big Budah regarding surgical effectiveness for Diabetes, and the suitability of most 55-75 year olds for surgery. You would be surprised how many think they are too old or too sick - rarely the case in this group.
Fox 13 Health Fix Segment
So while I am blogging - I need to make up some ground from summer.
1-I am really excited about being in a practice (Bariatric Medicine Institute) that is so focused on Obesity, Diabetes and GERD care. What a wonderful team. Everything works together in a way I have not experienced before. Unity of purpose clarifies and strengthens our effectiveness.
2-Drs. Richards and Cottam are an amazing team in the OR. There has been news in the world of surgery about improving technique by reviewing "tape" the way athletes do. My residency colleagues in the Michigan Surgical Collaborative are key players in this. Even the best trained surgeon can grow and refine technique, and learn from others. I think my partners have had 6-7 years of coaching each other, just by working together on every case. This is no longer common - probably 90% of the work most surgeons do is without another surgeon in the room. Dr Atul Gawande wrote a great article about it last year in the New Yorker, with his own experience getting a formal "coach".
I have been blessed with many surgical mentors - and got to catch up with two of them recently. Dr James "Butch" Rosser is my Jedi master. He is my "Top Gun" program teacher (6 weeks in 2003) who made me what I am as a minimally invasive surgeon. Got to spend time at SAGES in SLC this spring and at his current hospital in Florida - always inspiring.
Got to go to Florida, and to California, and to Virginia to learn more advanced robotic techniques with Intuitive. We are already seeing benefits in hernia patients and in Sleeve Gastrectomy. Many thanks to those surgeons for opening their OR to educate!
The mentor who I have spent the most time with has never been in an OR with me. Dr Kelvin Higa was a "telesurgery" mentor during Top Gun training from his OR in Fresno, CA to our lab in NYC. He made several DVD's of entire operations - and these DVD's have been my touchstone - literally hundreds of complete viewing before ALL my first 100 cases, and with every surgical assistant, and before most revision cases. This is what it is supposed to look like! FINALLY this year I made my pilgrimage to his OR in Fresno - a THRILL! He is warm and caring, and skilled beyond belief. Not just gifted, he put in years of dedicated training to make it look so easy...
3-Endoluminal, incisionless techniques... I am a bit reluctant to talk much about this, because of FDA trial rules that I could accidentally break. Sorry if this is vague, but the GI Dynamics EndoBarrier trial has been fun to be involved in as an investigator, and now as a proctor-in-training. The engineers are expert, and the science is amazing.
4-The Salt Lake surgical community has been so welcoming, and there is a real vibrancy with all the research and teaching at every hospital, including our Salt Lake Regional home base. I have always been a bit intimidated with "urban, academic" medicine, and this is an unexpected delight!
5-Telemedicine. I got a nice taste of this in Billings, and am ever more convinced that these tools are ready to be used for care. We have to work out how, but we will! Look up VSee if you want a good start. It has privacy safeguards that Skype will not offer, and is pretty easy to download and run.
6-Both Sarah and Dudley (our Corgi) have had to take it easy last few months for orthopedic stuff - now comes a winter of rehab and training to get out and enjoy Utah next year! We will get out in the snow, too. The Kiteboarding community in Utah has been great, from the Spring gathering and online presence of Utah Windriders, to the Kiter's With Attitude Facebook group, and mostly just the folks at the water! I have gotten to ride at Utah Lake, Deer Creek, Rush, Sulphur reservoirs, and scoped out Willard and Pineview also. Rob Umstead gave a very nice boat supported lesson, too.
7-Last and most awesome - the Obesity Action Coalition and ASMBS have been really making a difference in every state. We are getting people mobilized and organized for Access to Care for all... You really should join OAC if the issue touches you in any way. The convention in Orlando was incredible, and I would put it at the top of anyone's list to come to San Antonio in August with us - it will change you! Drs Morton and English among many others in ASMBS are relentless advocates also - amazing to watch and try to pitch in.
Look for videos on YouTube - will try to post here, but get behind, and overwhelmed sometimes with the tech side.
Sunday, July 27, 2014
ORLANDO!!! ALWAYS A TREAT.
I am so ready to see everyone at #YWM2014 in Orlando.
This group is so positive, so enthusiastic - and so wise. The feeling is community - we have all been touched, one way or another, by a disease that is so poorly understood, and so often isolating. There are so many different individual journeys and perspectives. It is a welcoming place, a sincere place, a safe place... OAC is truly a membership based organization - and YWM2014 is the best chance of the year to get the most out of it, and the best place to give forward if you can. Hope to see you all there!
Monday, July 07, 2014
You Gotta Read This - Walter Lindstrom's 20 year Wisdom
I don't like to gush... but this is as important as any post I have ever read in the obesity world.
Walter Lindstrom puts a book's worth of wisdom into a single post
Partly I am posting this so I don't ever lose it... Thanks Walter, from "the other Walter" Much respect.
Walter Lindstrom puts a book's worth of wisdom into a single post
Partly I am posting this so I don't ever lose it... Thanks Walter, from "the other Walter" Much respect.
Importance of Body Composition - rechecking over time (a cautionary tale)
I was lucky a few months ago to start using Sarah's trainer in Billings. Riley Stephenson is at Granite Health and Fitness - wonderful guy and very knowledgable... So we do body composition as part of my orientation. Remember that I am a mild but frequent lifter - but know that my intensity is low. Good shape but not great shape.
Out of work - doing job search while I do 10 steady weeks of 2-3 30 minute lifting sessions per week with Riley. HARD lifting, at least 5 times more effort and time than my normal. Get a lot stronger, and balance training as a bonus!
However, this was a stressful time, and I had more TIME TO EAT... My weight ran 202-205 pounds mostly, but got down to 199 pounds the week I left Billings Clinic - devastated. Well, by mid-may my weight is UP to 212 pounds or more. -figure I am just losing my grip, and start to think all the horrible stuff we WLS patients do when "failing".
As we get set to move to SLC, I ask Riley to recheck my body composition - mainly to know how bad my damage is from all this extra eating (tried to do mostly protein, but definitely made a dent in protein bars,hummus,cheese, yogurt, smoked salmon more than I should have)
Long story short - GAINED OVER 10 POUNDS of MUSCLE!!! Actually lost 2 pounds of fat. Please remember this lesson (we say it all the time, but I still doubted) - your weight is not the only measure of your progress or health.
I plan to do body comps at least twice a year now and forever - what a motivation, and humbling lesson for me as an "expert" - ha!
Hope this inspires, or at least stimulates you on your journey - peace.
PS - look out for videos - Dr Cottam is really committed to supporting YouTube content, and I intend to contribute!
Saturday, April 05, 2014
Announcement - move to Salt Lake City, Utah - Bariatric Medicine Institute!!!
Dudley is ready!
Web page for BMI Utah
Facebook Page BMIUT
Hello to all. I am very happy to announce that I will be joining Drs. Christina Richards and Dan Cottam at the Bariatric Medicine Institute in Salt Lake City. The office is right across the street from Salt Lake Regional Medical Center, where the majority of surgery is performed, and where they have an Intuitive Da Vinci SI top of the line surgical robot, as well as High Resolution Manometry and all the Center of Excellence equipment, staff, and pathways for GREAT patient care!!!
Dr Cottam was my "hands-on" trainer 11 years ago when he was in his advanced fellowship with Dr Phillip Schauer at UPMC. He continues to be a surgical leader, and is widely published and internationally recognized.
Sarah and I are personally thrilled at the opportunities for professional and personal growth in such a vibrant metropolis. As for recreation - you literally couldn't put the mountains and water any closer!
I am excited also to explore the creation of an advanced Hernia Center at Salt Lake Regional - look for progress updates.
I hope also to have a Montana outreach clinic, and to keep up with all available advancements for telemedicine and convenient, value added follow up for post surgical patients. Look for lots more video on the Website soon (see link above).
THANK YOU so very much to all who have made this a joyous transition. It is never easy to move, and my most sincere wish is to maintain care for those who need it, regardless of the location. This is definitely a challenge that medicine continues to address.
This week, SAGES (the leading Minimally Invasive Surgery association) has been meeting in SLC, and is worthy of a dozen blog posts!!! If you are curious, they have many tweets with the hashtag #SAGES2014 or their homepage www.SAGES.org
MUCH LOVE! Also, thanks especially to all of you who took the time to post such wonderful comments to my last blog post, or who have reached out through social media or personally…
Oh - my cell phone will be changing in a few weeks, so here is our office contact info (also on links above)
Bariatric Medicine Institute
1046 East 100 South
Salt Lake City, Utah 84012
801-746-2885
Sunday, February 23, 2014
No easy way to put it - lost my job, as Billings Clinic decided not to renew my associate contract, due to conflict with management. I am no longer practicing in Billings. Started job search immediately. VERY sorry to disappoint patients… Dr Murray is an able and compassionate surgeon, and will cover the program well.
I am very thankful for the opportunity to serve Yellowstone region, and will keep working for access to nondiscriminatory, evidence based care.
Much love to all! Will keep you posted on progress - onward and upward...
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