Mike Goodkind, (415) 725-5376 or 723-6911
Email: [email protected]
Health Tips from Stanford University Medical Center
March, 1997
ASK FRANK QUESTIONS BEFORE RECEIVING MINIMAL-ACCESS SURGERY
Many kinds of surgery are now being performed using tiny incisions and fiber-optic scopes linked to video monitors to view the operation, often sending the patient home with "Band-Aids" instead of stitches.
These new "minimal-access surgeries" are becoming almost universal for some procedures, such as gallbladder removal, and are even being used in a limited fashion for major surgeries, such as heart valve replacement.
The minimal-access technique, often called videolaparoscopy, results in shorter hospitalizations or, in some cases, outpatient procedures that once required hospital stays. Most patients experience far less pain because they don't have to endure a lengthy recovery of a surgical wound, says Dr. Camran Nezhat, who pioneered videolaparoscopy and who serves as clinical professor of gynecology/obstetrics and of surgery at Stanford University Medical Center.
But how do you find out if such an operation is right for you? And equally important, how do you determine who should perform it?
"More and more procedures are becoming amenable to minimal-access approaches, so there is a good chance that you might be a candidate," says Nezhat.
"Have a long talk with your primary care doctor who has recommended the surgeon or gynecologist/obstetrician for the procedure you need; then ask the physician who would perform the surgery some frank questions," says Nezhat.
First, these new techniques require a special set of skills, so you want someone who has performed the technique for a long time and has handled a large number of cases with a minimum number of complications. Ask the following questions: How often have you had to complete this type of operation using standard surgical techniques because of difficulties? Have you published the results of your surgery in a scientific journal?
Many young doctors are learning these techniques during their training years, and older doctors are returning to major medical centers for advanced training, "so appropriate laparoscopic surgeons are available in more geographic locations every day," Nezhat says.
For patients who would have the operation performed by a qualified physician who is a newcomer to the technology, Nezhat has a suggestion:
"Encourage your physician to sign up for a program at a major medical center where there is a training program available, and have your operation performed by your hometown doctor under the supervision and guidance of an experienced faculty member from the program. Then you'll get the best of both worlds: You will receive your operation under the guidance of a top expert, and your hometown doctor will be there to provide you with support and knowledgeable feedback afterward and when you return home. Also, he or she will be gaining the experience to perform the operation in your locality in the future."
HEIMLICH MANEUVER CAN BE A LIFESAVER, BUT DON'T USE IT ON BABIES OR COUGHING ADULTS
A first-aid technique called the Heimlich maneuver saves lives by dislodging food or other objects from the windpipe, but it can be dangerous if the person is still breathing or very young, says a Stanford emergency medicine specialist.
"Someone who is coughing is still breathing, so if you start the Heimlich maneuver too soon, you run the risk of forcing the food into a position that will block breathing," says Dr. Rebecca Smith-Coggins, assistant professor of surgery (emergency medicine) at Stanford University Medical Center.
"And it can also do more harm than good for babies, even if they've stopped breathing," she says.
Here's how to do the Heimlich maneuver in adults and children older than 1 year who are conscious and standing or sitting:
1. Stand behind the victim and wrap your arms around the waist.
2. Make a fist with one hand.
3. Place the thumb-side of your fist in the middle of the victim's abdomen, just above the navel and well below the tip of the breastbone.
4. Grasp the fist with your other hand.
5. Keeping your elbows out, press your fist into the victim's abdomen inward and upward with five quick thrusts.
6. Continue thrusts until the object is dislodged from the windpipe, help arrives, or the victim loses consciousness.
If the victim is already unconscious, you'll need to modify the technique: Place the victim on his or her back and apply upward thrusts to the abdomen, slightly above the navel and just below the tip of the breastbone, with the heel of the palm.
If the Heimlich maneuver does not clear the victim's airway, look for a foreign body in the mouth and remove it with a finger. If you suspect a foreign body but cannot see it, and the victim is an adult, pass your finger to the back of the throat.
Don't try any of the above procedures in an infant, however.
"If a baby stops breathing, don't do the Heimlich," warns Smith-Coggins. "You run too great a risk of causing permanent injury without even dislodging the cause of the problem."
The American Heart Association recommends an alternative maneuver to help infants under 1 year start breathing again:
Hold the infant head down, straddled over your arm. Then, with the heel of the hand, deliver four blows to the infant's back between the shoulder blades. If the infant doesn't resume breathing, lay the infant on his or her back in your lap, with the head lower than the trunk. Then apply finger pressure to the sternum four times.
"Also don't make a 'blind sweep' in an infant or child's mouth; you run a greater risk of pushing something farther into the airway," Smith-Coggins says. "An exception is if you see food or an object in the mouth, then do pull it out to help clear the victim's airway."
TAX TIME IS A GOOD TIME TO BECOME A FOOD ACCOUNTANT: KEEP A CALORIE LEDGER INSTEAD OF JUST SAYING NO
As millions of Americans turn to computing their taxes, a Stanford nutritionist advises those concerned about their weight to apply some accounting principles to their diets.
"Your diet is a balance sheet," says JoAnn Hattner, a clinical dietitian at Stanford University Medical Center and a spokesperson for the American Dietetics Association.
"Instead of being a Scrooge when you sit down for that special dinner, worrying about each item in front of you, you might think of each item as either on the plus side or the minus side of the ledger sheet," says Hattner. "Have some fun and improve your diet by looking at it in a new way. Be a food accountant."
As with making a cash budget, knowing the worth of items is invaluable in making choices. You have to know the cost - - in calories -- and you have to decide how much a given indulgence would be worth to you:
Set a budget target for a meal, say, 500 calories. As you eat, you add and subtract, and by the time the dinner is finished, if you come close to that number, you've achieved a balanced budget.
For example, when someone passes that basket of fresh steaming bread, don't automatically just grab a piece or wave off the basket. "Stop and think: Each piece is worth about 60 or 70 calories," Hattner says. "If you pass up three pieces, you've just banked 200 calories. If you've thought about putting butter on those slices-- say, three pats -- that's another 135 calories.
"In a few minutes pasta with marinara sauce is passed around. Typically a portion is about 350 calories. Now that's a pretty reasonable sum for a main course. But can you afford to add a scoop of parmesan cheese at 110 calories? Yes, if you trade it for the bread you were thinking about having. The parmesan cheese is worth two pieces of bread. But you're pushing up to that 500-calorie limit. Would you really rather have that parmesan cheese instead of a small dessert?"
"A bonus from being a good food accountant is that you'll probably be a more pleasant dinner companion. You're acting positively, making choices, enjoying what you really want, instead of simply saying no to everything and then giving in more often than not," Hattner says.
"Even more important, the more you know about calories and food and how to spend them, the more empowered you become -- it's just like balancing your budget at the grocery store," she adds.
"There's no need to count calories exactly unless you really do have an accountant's style and interest," says Hattner. "But by now you get the idea. Make choices for those things you really want, and save some calories on the rest."
WORK WITH YOUR PHYSICIAN TO GET THE MOST OUT OF CHOLESTEROL-LOWERING DRUGS
A new generation of cholesterol-lowering drugs, called statins, are more effective and generally more comfortable to take than those used even a decade ago, but patients should be aware of how to make such treatment work best for them, says a Stanford University cardiologist.
High cholesterol level in the blood causes a buildup of fatty deposits that can block arteries and cause heart disease. "A diet high in saturated fat is the number one cause of this dangerous high blood cholesterol, so before you even think about taking cholesterol-lowering drugs, try to reduce saturated fat intake to 25 grams per day or less," says Dr. John Schroeder, professor of medicine (cardiovascular) at Stanford University Medical Center.
If, after a few months of diligent effort, your total blood cholesterol remains above about 200 and your LDL ("bad") cholesterol level is above 100, it's time to talk to your doctor about drug therapy, Schroeder advises -- particularly if you have coronary artery disease or are at risk for it because of hypertension or a family history of heart disease.
Statins work at the source by preventing the liver from turning fatty foods into potentially harmful cholesterol. Earlier drugs worked in the digestive system to prevent fatty foods from getting to the liver, Schroeder explains.
"Statins are an improvement not only in efficiency and effectiveness but also in comfort, since the older drugs tended to cause constipation or other digestive discomfort," he says.
"But the statins pose a very small -- less than 1 percent -- risk of causing damage in the liver, and in any case they shouldn't be taken by someone with liver disease," Schroeder says. "It's important when you start these drugs that your physician monitor your liver function by blood tests during the first year and periodically after that," he explains. Usually, liver-test abnormalities are reversible when the drug is stopped, he says.
Schroeder suggests two other things to keep in mind when taking a statin:
* Work with your doctor to ensure that you are taking the maximum effective dose. Patients who start taking these drugs usually start at a very low dose to make sure their liver is okay. But if there are no side effects, it's important to increase that to a level that will reduce cholesterol most efficiently. That's why those follow-up visits scheduled by your physician when you start a program are crucial.
* Take the drug after dinner or just before bedtime, when your body's cholesterol-producing mechanisms are most active.
Common statins include lovastatin (Mevacor), simvastatin (Zocor), fluvastatin (Lescol) and pravastatin (Pravachol). "These drugs all work in the same way," says Schroeder. "Some are more powerful than others, so work with your doctor to make sure your therapy is as effective as it can be," Schroeder says.
People may be candidates for one of the older, albeit less efficient drugs, such as cholestyramin, if they have liver disease or certain other conditions that can cause problems if a statin is taken, he says.
Are statins a license to eat all the fatty food you crave?
"Unfortunately, no," Schroeder says. "While the drugs may be successful in lowering cholesterol, there are all sorts of health reasons --including weight control, possible protection against colon and breast cancer, and a general feeling of well-being -- to strive for a low-fat, high-fiber diet."
March 1997 -- 30 -- HT03/97
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