Evidence-Based Papyrus

In our modern medical world, evidence-based practice has reached buzzword status. The phrase, its three-letter acronym, and its discipline-based variants appear everywhere, giving the impression that evidence-based practice is a modern phenomenon.

Now, thanks to the efforts of collectors, curators, and translators, we have access to an Egyptian medical treatise from at least 1,600 B.C. View the Edwin Smith Surgical Papyrus [requires Adobe Flash player]. After the page loads, use your mouse to drag the scroll open. With the zoom icon at the bottom of the page you can magnify the hieroglyphic script. With the text icon, you can highlight the cases within the scroll. Selecting a case scroll brings up an overlay page that transliterates the text.

The scroll, as it currently exists, presents 48 trauma and wound cases. Each case has a description, diagnosis, prognosis, treatment, and further explanations specific to the case. The prognosis seems to include one of these three phrases:

• An ailment I will handle
• An ailment I will fight with
• An ailment for which nothing is done

These prognoses seem to be based on the existing evidence, resulting in an ancient system of triage. A serious perforation of the temple is "an ailment I will handle"; a split temple is "an ailment I will fight with"; and a fracture of the temporal bone is "an ailment for which nothing is done". It must have taken time to determine which injuries fell into which category. This papyrus likely sought to pass down that experience.

Among the treatments, a dressing with oil and honey is listed frequently. At first glance, this might seem far from evidence-based, but these substances address two of the four items that comprise the TIME acronym of modern wound healing: Tissue, Infection, Moisture control, and Epidermal margin.

Honey is a well-known wound dressing. View PUBMED search results for english language articles on honey and wound healing. In recent years, the Food and Drug Administration has approved a wound dressing called MEDIHONEY™.

While health care has certainly advanced in the last 3,600 years; but let's not assume the ancient Egyptians were not also asking themselves: is this injury treatable? and what treatment produces the best outcome? And clearly, they must have had a medical librarian to index and store their papyrus documents ;-)

2 comments - Posted by Steve Rauch at 10:28 AM - Categories:

Adjustable Eye Glasses

The next time you are in a crowd of people, look around at how many of them are wearing glasses. Consider that some also have contact lenses or have had refractive eye surgery. Now dig out some issues of National Geographic and look at a story on Sub-Saharan Africa. How many of them are wearing glasses? Ever wonder why?

In the UK, there is an optometrist for every 8,000 residents. In Sub-Saharan Africa, the ratio balloons to 1 for every 1 million residents. For these people, the cost of a pair of glasses can cost months of income. Poor eyesight is more than a health and safety problem; it affects education, income, and quality of life.

Josh Silver, a retired physicist from Oxford, turned his humanitarian eye to this problem. He developed a pair of glasses that can be adjusted by the wearer to their needs. There is a single lens in front, a strong flexible piece of plastic behind, and a clear fluid in between. The amount of fluid can be adjusted by a screw syringe mounted to the eyeglasses frame. Mouse over Professor Silver's picture to see his invention.

Several web sites are associated with Professor Silver's work. The Centre for Vision in the Developing World at Oxford researches issues and solutions. Adlens is the technology company developing this product. Adaptive Eyewear is the not-for-profit company that distributes the glasses around the world. They have partnered with organizations to distribute 30,000 pairs of glasses. They hope to reach 1 billion by the year 2020.

When I go to the eye doctor, I sit behind a phoropter and the ophthalmologist tries different combinations of lenses to determine my eyeglass prescription which is then sent to a lab to grind lenses to my specifications. The beauty of Professor Silver's solution is to have a single set of glasses that can be fitted to any user's needs.

The glasses will not fix astigmatism and the shortage of eye doctors means that some eye diseases will go undiagnosed, but this is a solution for the many people who have basic refractive eye problems. Imagine the joy of a tailor who can continue his livelihood again, or an older person seeing their grandchildren in focus for the first time.

A colleague of mine, when I shared this story with her, called it a "day brightener". True, in so many ways.

2 comments - Posted by Steve Rauch at 9:40 AM - Categories:

Ride Like a Kid

I’m not sure at what point I started wearing a helmet while riding my bicycle, but I do know that it was some point after turning18. I never wore one as a kid riding my bike for fun, for my paper route, or for getting to and from school. Now, as a father and two-time bike-wreck concussion-survivor, I don’t ride without one, nor do I allow my four-year old to ride her bike without her Dora the Explorer helmet.

As a self-admitted bike junky, I look around at the bikes in my garage and all but one, let’s just say there’s close to a half-dozen, have a computer or speedometer of some sort, fancy pedals that require a specific shoe, rechargeable lights, soft-grip cork handle bar tape, gears from 1 to 27, and so on. However, my favorite bike is a replica of a 1948 Schwinn Heavy Duty. They were used as warehouse bikes back in those times. It has an extra strong reinforced frame, simple one-color paint scheme, kick-stand, 60-spoke wheels, and a huge industrial strength basket.

I don’t ride that bike often, but when I do it’s the most fun. I’m tempted to not wear a helmet, just doesn’t seem to fit the theme, but do anyway. I’ll ride it short distances to the grocery store or to Graff Dairy. It’s perfect for pulling my daughter in the tag-a-long. Sometimes, I ride it around the neighborhood just like I did as a kid. No particular reason, just do it to ride. I have no idea how far I’m going or how fast. Push the pedals forward you go, press backwards you stop, can’t get much simpler than that.

May is National Bike Month. So, whether you are an avid cyclist, or haven’t been on one for a while; remember you never forget how to ride a bike. I recommend taking a ride-like-a-kid ride at least once, just for the fun of it. And don’t forget the helmet. Happy riding.

2 comments - Posted by Guest at 9:04 AM - Categories:

The Checklist Manifesto

The Checklist Manifesto by Atul Gawande (author, medical school professor, and surgeon) tells the story of the development and assessment of the Safe Surgery Checklist for the World Health Organization (WHO).

Along the way, Gawande treats us to stories of near misses and failures in medicine and air flight and shows how the events led to the development of checklists. He also examines other industries that have gotten so complex as to invite checklist use: investment analysis, skyscraper construction, and even the repeated preparation of meals at a fine restaurant.

While it is hard not to picture the smile on his face when Gawande takes the captain's seat in a Boeing 777 simulator, for me the most interesting aspects of this work are not the author's ventures into these other highly complex industries; but two simple aspects of checklists:

1. They are hard to write well
2. They promote communication

When Gawande first tried to use the WHO checklist in his own operating room, flaws appeared: was it to be spoken or just filled out? Some items were ambiguous. Some were unclear. And it took so long it detracted from the patient on the operating table. Off he went to visit an expert at Boeing who had helped develop numerous checklists for pilots. This visit resulted in some checklist guidelines:

• Checklists are difficult to write well
• Be brief, time is important
• Write for the professionals who will use them
• List the critical steps, not the minutiae
• Always test in the real world!

As the WHO task force discussed the possibility of using a checklist, some people with checklist experience mentioned that using them improved communication and sense of teamwork. They said that allowing nurses to "say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions." This spoken introduction of the surgery team was incorporated into the WHO checklist. Communication seems to have been the key resolution when the building industry encountered an unplanned outcome of one of the steps in skyscraper construction.

Even a low tech program Gawande mentions suggests that communication was enhanced. Public health workers in Karachi, Pakistan, delivered bars of soap to impoverished residents and gave them instructions on how to and when to handwash. These people already had soap, but they liked receiving the gift. The main intervention, however, seems to be that this project gave the public health staff an opportunity to communicate with the people who health they were trying to improve.

Do we think that posting pictures and roles of the surgery team by the door to the operating room would have the same results as briefly speaking the same information as the procedure was about to begin? Would mailing the bars of soap with printed instructions produce the same success rate as face-to-face communication?

I come away from this book wondering if the real title is "The Communication Manifesto". Up to a point, all of health care is clinical care. Beyond that point, communication becomes significant, and often affects the patients' perceptions of their care.

I'd be delighted to hear comments on The Checklist Manifesto or on your thoughts about the role of communication in healthcare.

2 comments - Posted by Steve Rauch at 10:39 AM - Categories:

The Great People We Meet

A while back my 4-year old daughter and I were enjoying a day of skiing at Powderhorn. During lunch we were sitting at a communal table and started talking with two women. They were a mother and daughter who had moved to Grand Junction for health reasons several years ago. In true small-world, smaller-town fashion, we discovered that we live in the same neighborhood and I had seen the older woman’s sister some years ago for a diabetes education class.

They shared with me an interesting story of how they had transitioned through different physicians, clinics, and hospitals through their time in the valley. It turns out now they are both recipients of services here at our own Community Hospital. When I told them I work at Community Hospital, they became quite animated and had lots of positive things to say including a comment from the mother about how great the people are that work at Community Hospital. I agreed with her as we continued our conversation. Eventually, we went our separate ways, but her great people comment stuck with me.

Later that same evening, we attended the Moonlight Ski and Campfire event on the Mesa at the Skyway cross-country ski area. Many people on the Community Hospital wellness committee spent lots of time to organize this event. There was an excellent turnout with over 20 employees plus family and friends present.

One person that stands out in my mind is a quintessential cowboy and gentleman named Spurs. Yup, Spurs. He is the friend of a Community Hospital employee who attended the event. Spurs arrived with a flat bad pick-up truck loaded with logs; enough for a week’s worth of fires. Before long he had built a roaring fire, around which many of us huddled. During the evening, he conversed with my young daughter, deftly wielded an axe to cut firewood, and stopped an errant log from escaping the confines of the fire.

As I was leaving a bit earlier than everyone else, I asked Spurs if he would see that my camping table was returned to me. Two days later to my surprise, not only was the table returned, but a long-broken fastening strap had been repaired. What a great guy.

3 comments - Posted by Guest at 10:54 AM - Categories:

Groundhog Day

There is likely more folklore surrounding the weather than any other aspect of daily life. The width of the center band on the wooly caterpillar predicts the severity of the coming winter. A green Christmas means a white Easter. The weather of each of twelve days of Christmas predicts the weather for the corresponding month in the coming year. Surely you have your own favorites.

My grandfather was a dairy farmer, completely dependent on the weather for his livelihood. He listened to the National Weather Service forecast every day; but he also consulted the Old Farmer's Almanac.

As a Pennsylvanian, the dearest folklore has to be Punxsatawney Phil, the groundhog whose interest in his shadow attracts media coverage from around the world. If the day is sunny, Phil sees his shadow indicating six more weeks of winter. If cloudy, spring is on its way.

According to the Official Website of the Punxsutawney Groundhog Club, Phil will be texting his forecast this year.

The best thing going for Phil is that by the time spring arrives, we have long forgotten if he saw his shadow or not.

4 comments - Posted by Steve Rauch at 1:29 PM - Categories:

Reflections on Luck

Like our CEO Chris Thomas this is my first attempt delving into the blogosphere. Well sure, I’ve read some friend’s blogs but never posted anything. As it says in my intro, I am a Registered Dietitian and Diabetes Educator. I spend a good part of my professional life talking about food and its relationship to our health. As I pondered a topic for my first posting, I could not take my mind far from the tragedy in Haiti.

If we read the paper, go online, or watch the television news we are inundated with mind boggling statistics of death, destruction, and rampant human suffering. Local people, as well of the rest of the country have responded with great empathy and efforts to help the people of this impoverished island nation. The politics and history of Haiti’s existence is best left for others to discuss, however there are a few thoughts I’d like to share.

It’s said that two-thirds of Haiti’s population lives on less than 1 U.S. dollar per day. As I went through the cafeteria line here today and electronically charged my $6 meal to a payroll deduction, I thought to myself, “Wow, I am lucky!” Now I know that on-site cafeteria with payroll deduction may in itself seem like extra luxury, but the truth is for most of us, we live in a world of relative abundance in terms of food. Food advertisements often tout a value or savings menu of items for a mere $1. In Haiti, that’s a day’s work. My lunch today - 6 days work. I truly am blessed.

If we got up today brushed our teeth, took a shower and flushed the toilet we used more fresh water than a typical Haitian has access to on a normal day, pre-earthquake. With the current catastrophe it is known that thousands more will parish due to lack of access to drinking water or from diseases associated with contaminated water. Going to bed hungry is one thing, but going for days completely without water is unimaginable. As the United States and much of the world airlifts water and food to the people of Haiti, again I am reminded of my good fortune as I fill my water bottle daily.

Some things we say become cliché because they are, for the most part, true. Working in healthcare, we need not look far to find others less fortunate. I think most would agree that despite all the negatives in our lives, the truth is we have it pretty good. One thing we must never take for granted is our health. Please join me in recognizing our own personal good fortune, and if you’re so inclined, say a prayer for people suffering throughout our country and throughout the world; and especially the people of Haiti.

Be well, Ray

3 comments - Posted by Guest at 2:30 PM - Categories: