Tweet Bacon Can Stop Nosebleeds! No joke...

When I saw this research, I had to re-read it to believe it... Nasal packing with good-old fashioned bacon stops nosebleeds!!!

Yes... you heard me correctly... and it was actually published in a reputable ENT journal in Nov 2011. AND, it was conducted here in the USA (Detroit, Michigan).

"Cured salted pork crafted as a nasal tampon and packed within the nasal vaults successfully stopped nasal hemorrhage promptly, effectively, and without sequelae … To our knowledge, this represents the first description of nasal packing with strips of cured pork for treatment of life-threatening hemorrhage in a patient with Glanzmann thrombasthenia."

The current standard of care for nasal packing to treat nosebleeds is using synthetic hemostatic products that appear similar to tampons used for menstruation.

However, this publication in 2011 wasn't the first to document use of bacon for nosebleeds.

There have been reports on use of bacon since 1940 sporadically (see references below).

In this day and age of cost-cutting and finding cheaper alternatives, bacon is pretty much as cheap as one can go to address nosebleeds. Compare this to synthetic nasal packing which costs on upwards of $50 or more.

Read more about nosebleed management.

Another unusual nosebleed management includes the application of female hormone estrogen (vaginal premarin cream) to the nasal mucosa.

Traditional nosebleed treatment includes nasal emollient application, humidification, nasal cauterization, septoplasty, and eventually nasal packing.

References:
Nasal Packing With Strips of Cured Pork as Treatment for Uncontrollable Epistaxis in a Patient With Glanzmann Thrombasthenia. Ann Otol Rhinol Laryngol 2011;120:732-736.

Rendu-Osler-Weber Disease— Is Embolization Beneficial? Arch Otolaryngol. 1976;102(6):385.

GENERAL PRINCIPLES IN TREATMENT OF NASAL HEMORRHAGE. AMA Arch Otolaryngol. 1953;57(1):51-59.

USE OF SALT PORK IN CASES OF HEMORRHAGE. Arch Otolaryngol. 1940;32(5):941-946.

Tweet Sleep Apnea Surgery Malpractice Lawsuit

In November 2009, a patient underwent multi-level surgery to treat her mild-moderate obstructive sleep apnea by a Houston, TX otolaryngologist.

The surgery included:

• Uvulopalatopharyngoplasty (UPPP)
• Tonsillectomy (typically considered part of UPPP)
• Adenoidectomy
• Hyoid Myotomy
• Genioglossus Advancement

She unfortunately experienced some unspecified complications stemming from this surgery which apparently has not helped with her obstructive sleep apnea either. A malpractice lawsuit commenced and final judgement is still pending.

Let's take a closer look at the incomplete information provided.

The patient suffered from mild-moderate obstructive sleep apnea which typically means a AHI score of around 15 (< 5 is normal).

For this level of severity, simultaneous multi-level surgery is not typically performed. Rather such extensive surgery is reserved for severe obstructive sleep apnea.

Also unclear is whether any objective studies were performed prior to surgery to try and localize the levels of obstruction that required correction. Such preoperative studies include a sedated endoscopy as well as trial of CPAP usage.

Assuming patient tried and failed to use CPAP and had objective evidence for multi-level obstruction, what did each of the surgical procedures do?

UPPP, tonsillectomy, adenoidectomy address mouth-level obstruction.

Hyoid myotomy and genioglossus advancement address tongue-level obstruction (the tongue can fall backward while sleeping causing obstruction).

Complications can occur for each of these procedures mainly dealing with bleeding, hematoma, infection, or abscess formation. Swallowing problems can also occur with the hyoid myotomy and genioglossus advancement.

Read more information on obstructive sleep apnea.

Source:
Sleep apnea surgery leads to malpractice lawsuit. Southeast Texas Record. 1/23/12

Tweet Dr. Chang a Northern Virginia Top Doctor for 2012

Northern Virginia Magazine published their annual list of Top Doctors for 2012 in their February 2012 edition. Dr. Chang was listed as one of Northern Virginia's Top Doctor in the field of Otolaryngology (page 72).

Of note, Dr. Chang was nominated by his doctor peers opposed to nomination by a small panel.

Tweet Northern Virginia Balloon Sinuplasty for Chronic Sinusitis

In the past month, local residents of Northern Virginia may have received a magazine newsletter from Prince William Hospital (Manassas, Virginia) that contained a feature story about sinus surgery and about balloon sinuplasty specifically.

It was a great story about how far sinus surgery has come compared to even just 5-10 years ago and the great patient experiences under otolaryngologist Dr. Gardner is not uncommon now.

A few key features of sinus surgery of the 21st century:

• Nasal packing rarely occurs

• Most patients are surprised by how little pain there is

• No facial swelling or bruising... your best friend won't be able to tell you just had sinus surgery

• Fast recovery

• No incisions on the face or in the mouth

• GPS-like image guidance to make sinus surgery even safer is available
• In select patients, can even be performed in the office without sedation using local anesthesia only

Balloon sinuplasty is a relatively new innovation that allows sinus surgery to even be performed even more comfortably in the office without any sedation (not all patients are candidates).

Such advanced sinus surgery techniques have been available at Fauquier ENT since 2005.

Read more about sinus surgery and balloon sinuplasty.

Source:

Balloon Sinuplasty. Perspectives Winter 2011 Pages 2-3.

Tweet Hospital-Based Practice Versus Physician Private Practice

The other day, an astute patient of mine asked what the difference is between a physician who works for a hospital (hospital-based practice) versus a physician run private practice.

After all, a patient still sees a physician in either case...

Is there an actual difference from a patient's perspective???

Assuming all things equal whereby a private practice physician and a hospital-based physician are equally competent and the supporting staff for each are both equally good (such assumptions are debatable in some circles, but will be ignored here), it all comes down to money.

When a patient sees a private practice physician, the fee schedule only incorporates payments to the physician.

When a patient sees a hospital-based physician, the fee schedule not only incorporates physician payments, but also additional payments to the hospital.

Now, the patient doesn't pay what insurance covers in either scenario, but typically there is a copay or coinsurance payment that the patient is responsible for that typically is 20% of the total charges.

Here's an example using the Medicare fee schedule from 2002. I elected to provide "old" 2002 data as this information can be found easily and corroborated, but rest assured, the numbers are starkly different and perhaps more lopsided today. Medicare was selected as it is the bar to which all other insurance plans are typically based on.

In a physician run private practice, the only charges that are incurred is from the "Physician Fee Schedule". In a hospital-based practice, a patient incurs not only the physician fee schedule, but also additional charges based on the "Outpatient Prospective Payment System".

As you can see, the physician fees are slightly higher in the private practice setting compared to hospital-based practice... BUT, given the additional hospital charges involved with a hospital-based practice, the patient ends up being charged more per service for a simple clinic visit ($16.48) than if they had been seen in the private practice office ($10.06).

The cost differential for the patient is far worse with any procedures ($62.62 versus $342.47).

For the same exact procedure or service, a patient automatically ends up paying more to be seen in a hospital-based practice.

This payment system is the same whether you go to a tertiary care teaching hospital like Massachusetts General Hospital or a tiny 98-bed community hospital.

As an aside... for any physicians employed by a hospital, it behooves you to consider this differential payment in terms of how a hospital determines your salary and productivity. Do they consider ONLY the physician fee schedule or do they also take into account the outpatient prospective payment system?

I should also mention that for 2012, Congress is considering abolishing the outpatient prospective payment system for clinic visits only. Click here for more info.

Source:
Elimination of Differential in Medicare Payment for Clinic E&M Services Furnished in Hospital-Based Outpatient Departments Proposed. Martinedale 12/10/11

Medicare rules for hospital-based clinics. American College of Surgeons. Vol 87, No 4

Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System. Congressional Research Service. 8/6/2010