Being an Etch-A-Sketch Is Not So Bad After All
The Etch-A-Sketch has been highlighted during this presidential political cycle as Governor Mitt Romney’s Republican platform has been dissected like a frog in a high school biology class! For those not tuned-in to CNN, the idea is that Governor Romney has a history of “flip-flopping” on several social issues i.e. bending to the conservative right as the GOP nominee for President – distinctly away from his history as a “Moderate Republican” as the Governor of Massachusetts.
Reflecting on this, I have been drawn to the conclusion that I too am an Etch-A-Sketch! Several key tenants of my practice have undergone gradual improvement over that last several years and, upon review, could be construed as “flip flopping”!
Top Ten Dr. Massey Flip Flops!
10.The Compression Girdle
Historically, I did not use the compression girdle for Stage 1 DIEP flaps (only for GAP’s). I transitioned to home-use of the compression girdle for DIEP flaps in 2007, started doing immediate compression in 2009, and now, in 2012, am using it again only after patients return home in the form of SpanxTM or MarenaTM garments specifically reserving the “dominatrix” for Stage 2 compression.
9.Home Blood Thinner Injections for Deep Vein Thrombosis (DVT) Prophylaxis
||LovenoxTM on a selective basis (active cancer, Body Mass Index (BMI) over 32, personal history of Deep Vein Thrombosis (DVT), strong family history of Pulmonary Embolism (PE)
||ArixtraTM for all
||LovenoxTM for all
8.Post-Operative Flap Monitoring
||Implantable Venous Doppler
||External Skin Island Doppler
||Implantable Venous and Arterial Doppler
7.Betadine Swabbing of Incisions
I have “flip flopped” on this issue so many times that I can’t even recite the history!!! It’s a day-by-day, or more likely a city-by-city decision! I really can’t tell if it makes any difference what so ever!
6.Breast Cancer Surveillance after Natural Breast Reconstruction
From 2002 – 2011, mimicking my preceptors, I recommended no form of breast cancer surveillance after flap reconstruction other than self examination. In January of 2012, I transitioned to an annual MRI surveillance recommendation given the preponderance of locally advanced patients with lymphedema that now dominate my office.
Up until 2008, I never believed that lymphedema education, prevention and care was a part of my role as a reconstructive surgeon. Given our advances in lymphatic reconstruction, we now lead this aspect of breast cancer care in the US. Enough said.
4.NIL Patient “Bags” for Post Operative Wound and Education Supplies
In 2010, the National Institute of LymphologyTM (NIL) was established as a consortium of health care providers dedicated to the advancement of clinical care for individuals not only suffering the ill effects of lymphedema, but for the proactive education of patients at risk for developing lymphedema after cancer care. In this mission, a lymphedema education program was introduced in our clinical practice and integrated to include our Clinical Trials focused on the outcomes of perforator flap breast reconstruction and lymph node transfers. A component of this program included providing patients a tote bag in which to carry their compression bandages and educational materials. Currently, we are on Version 3 of the NIL Patient Bags within 2 years – a fast evolution!
Version 1 of the NIL Patient Bag was an open tote bag designed to carry only lymphedema bandages to and from therapy. It was limited as its contents could easily fall out in the airplane – it did not have a zippered central compartment and could not be checked. So, it had to be hand carried on-board and kept up-right.
Version 2 of the NIL Patient Bag was a multi-pouched, zippered duffle bag type with room, not only for bandages and LymphodermTM, but for post operative wound supplies, discharge instructions and our lymphedema education booklets. The issue with Version 2 of the NIL Patient Bag was that it was a bit “masculine” like a nylon gym bag and it was large enough that patients would pack it so full of goodies from the hospital that it would exceed the weight lifting restrictions set for Stage 1 patients.
Current Version 3 NIL Patient Bags are awesome! Designed exclusively for the NIL by Brit Kleinman, a RISD alumnus and designer of high-end hand bags in New York City, this canvas bag tastefully displays the NIL lymphangion logo on canvas in the setting of functional inner and outer pockets with strong leather handles and a terrific core zipper. I must admit that the size is purposefully restricted as to limit the weight of its potential contents. And, we still give patients a Version 2 duffle bag at time of discharge for wound supplies, relating that husbands can carry the more masculine bag while patients may sport the classy shoulder bag version that can be used for years to come.
Just a little side bar – The Version 3 NIL Patient Bags were manufactured in all of its parts completely in the United States and are unique to our practice. We are so proud of its design but must admit we do have one more suggestion for Version 4 in 2013! We will keep that suggestion to ourselves for now!!!
Historically, I have not been a “fan” of social media but allowed the girls in my office to have at this aspect of the practice. Now, I, with the help of Evan our Website Designer in Orlando, do have access to the Facebook and Twitter passwords! I too can be found posting on the Dr. Marga Practice Group Facebook page on occasion! Evan even coordinated the DMPG Twitter account to communicate with my personal Facebook page and the Dr. Marga website, who ever knew we could be so connected?
Best of all, we also now use our Facebook page to communicate with current patients regarding travel and weather alerts given our experience with Hurricane Isaac. Facebook was a very helpful way to reach out to our patients to share with them vital, real-time practice related information when phone lines were down. Thank God for iPhones! We also use it to remind patients to send in their post operative photos!
2.Use of Care Extenders for Discharge Instructions
This is a Big One – I historically have done most of the discharge education in my practice – even when I had Plastic Surgical Residents. As my practice became overwhelmingly large, I transitioned to care extenders for this including a Physician Assistant and Nurse Practitioner with much of the education occurring when patients were still in the hospital.
I have returned to my post as the Discharge Educator in the Spring of 2012 and focus on education after discharge. I learned, as a patient myself, that it’s hard to retain much of what is offered to you in the hospital setting. Further, fifteen minutes with me each Sunday evening fully equipped with the knowledge of your case and current photos is priceless. Weekly phone follow up with me directly allows us to explore exactly how each of you are doing once you arrive safely at home. So, keep the post op photos coming and I will keep calling!
1.Air Travel Versus Ground Travel
Believe it or not, there has been a time when I related to patients that if they could not fly, they could not come to us for care. I was a firm believer that patients needed to be able to cross large sections of the country by air.
Now that air travel has become increasingly difficult (and, I know A LOT about this), I have come to love ground travel and highly recommend it! You can stop and go on your own schedule, listen to the music of your choice or even enjoy an audio book or iPad games. You can enjoy more healthy snacks at a lower cost than airport food by packing a small cooler. You have the opportunity to see our fantastic country and meet lots of interesting people. If you get tired, you can check into a hotel of your choice and take it easy for a day or two. In fact, it can be a mini-vacation with your family that you never expected! The added bonus is that you can carry your pets with you more easily! Luke, Lucy and Lola much prefer ground travel if possible!
Right now, the girls in the office are competing to design the Mermaid Mobile. Just trying to figure out the design of the Mermaid tail on the RV! What do you think of this design?
My husband predicts that we will have an operating room on wheels before I retire!
I can’t speak for Mitt, but I want to believe my “flip flopping” stems from getting smarter from experience; however, I must admit that some of it stems from wanting to put a positive twist on the current issue of the day. In the end, it’s nice to know that there are many different and successful ways to approach a clinical, social, business or travel issue and it’s OK to alter what we do to make things better for our patients! In the big picture of things, the goals must include safety, efficacy, efficiency, cost containment and patient comfort. I choose to believe that experience brings with it an evolution of solutions – So, I encourage you to be an “Etch-A-Sketch” too!
Let’s be sure to ask Mitt about his beliefs-in-evolution as the debate season approaches!
P.S. Contrary to what Brian from Arkansas (or is it Alabama, LOL!) thinks, I’m an Independent!
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