Winter 2021

PMH STORY

The patient’s daughter called from California. Said she was worried about her mother and that she was afraid her dad would not call. Dr. Kelly knew that her mother was not well. After talking to the daughter, it seemed better to address the patient’s needs at the hospital.

We are working more often with a hospital team. This means that other hospital doctors may be assigned to the case and help direct care. Dr. Kelly continues to visit, contribute to care, and play a role in the planning during hospitalization. This PMH story shows how the important role we play has not changed.

Visiting with the patient in the ER that first night, there was possible pneumonia on chest x- ray. Decision was made to proceed with admission and treatment. CT scan of the chest raised greater probability of viral infection. COVID testing was positive. Dr. Kelly returned the next morning around 7:00 to visit. The patient was stable. Plans were underway for admission and recommendations were left for modifications in care.

As Dr. Kelly was walking out of the emergency room, he pulled up the patient’s husband’s number on his iPhone and dialed it. Out of the corner of his eye, behind his mask and face shield, Dr. Kelly saw the back of a man in a sports jacket in the waiting section of the emergency room. Dr. Kelly recognized the figure and realized that the man he saw was the person whose phone he was dialing.

Dr. Kelly went into the emergency room waiting area and visited with the patient’s husband, then returned to see the patient to give her the details of this conversation and her husband’s proximity and involvement. Hospital policy forbade the husband to visit her. Dr. Kelly asked the patient if she had any instructions. She told him to tell her husband to go home and to eat something. She worried about him as he is somewhat frail himself. Dr. Kelly passed the instructions on to her husband.

The patient’s care progressed, and her needs were met. This would likely be true even if Dr. Kelly did not visit. What is important and what the hospital cannot provide is recognition out of the corner of the eye and the intuitive understanding of a patient’s condition. PMH has its pros and cons, we recognize that. This episode is an example of how PMH helps.

Robert H. Kelly, MD, FACP

APPENDICITIS

Doctors in Finland continue studying antibiotic only (no surgery!) treatment of appendicitis. Laparoscopic removal of the appendix with short duration antibiotics causes little morbidity or mortality. It is hard to imagine how we can improve on the current surgical management of appendicitis. But over the past 10 years, researchers in Finland have shown that the overall complication rate is decreased in randomized trials where patients are randomized to medical treatment initially and not surgical treatment. If the patient did not recover quickly, surgery was performed. In their initial experiments, they used intravenous antibiotics, but in experiments reported this month in JAMA, surgical teams randomized patients to treatment with either IV or oral antibiotics, and surgery only if antibiotics failed.

In this recent trial, successful treatment without surgery was achieved in 70% of those treated with oral antibiotics, and 74% of those treated with IV antibiotics. There was no statistically significant difference between the oral and IV treatments. The possibility of treating appendicitis patients as outpatients without surgery is still not mainstream. But simplifying treatment and having less invasive options available for our patients and their families is progress.

This research was done by departments of surgery in Finland. Appendicitis is still a disease managed by surgeons. Even well established, standardized treatments can be challenged with new ideas.

Allan R. Kelly, MD, FACP

KNEE ARTHRITIS

Knee arthritis is a common problem. After age 60, approximately 37% of persons will complain of significant knee arthritis in surveys. As age increases, so does the incidence of arthritic knee pain. There has been a significant change in our approach to alleviating the pain and discomfort and limitations of knee osteoarthritis.

In the past, doctors would recommend steroid injections to the knee and oral medication such as Motrin, Aleve and even narcotics. The American Rheumatologic Association now identify the primary option for treatment to be topical nonsteroidal anti-inflammatory drugs. This option, like Voltaren gel, became available 14 years ago. In 2020, Voltaren gel, also called diclofenac, became available over the counter. Topical nonsteroidal drugs are equal to the effect of the oral nonsteroidal drugs. In other words, applying a topical nonsteroidal to the knee gives the same results as an oral nonsteroidal in randomized trials. But the oral nonsteroidals risk adverse effects, including ulcers, kidney disease, and increased cardiovascular risk. The new treatment with topical nonsteroidals is the better choice.

There are other interventions that we know will help. Exercise and weight loss are at the heart of making things better. Any type of exercise can work: Strengthening exercise, aerobic exercise, tai chi, physical therapy: All will statistically reduce the degree of pain.

Joint injections with steroids now are reported to have uncertain benefit. A single injection for a life event, such as a wedding or a trip, may make sense. But repeated injections increasingly are seen as more risk than benefit.

The most reliable nonsurgical interventions for knee arthritis are available without a doctor’s prescription: Topical diclofenac gel, daily exercise, weight loss, and tai chi. For those people who cannot get good results, and who are increasingly impaired, surgical treatment typically results in significant pain relief and increased mobility.

Allan R. Kelly, MD, FACP

REDUCING INFECTION RISK

Researchers from the University of Michigan tried to reduce operating room infection risk by increasing operating room sterile precautions. The basic approach for the past 100 years to reducing operating room risk is antiseptic preparation of the skin of the patient, and the OR team. The OR team puts on sterile gowns and gloves. After the patient is asleep, sterile drapes are placed over the patient to isolate the area where the incision will be made. Infection rates after a clean surgery are very low. But researchers asked whether clothing the patient in a sterile head covering and sterile gown before going into the OR would reduce infections.

The study looked at operative infection rates during three periods of time: Routine care, routine plus hair covering care, and routine plus hair covering and sterile surgical jacket. During a period of one year’s observation, there was no change in the surgical infection rate in the three groups. Commonsense, straightforward effective reduction of bacterial organisms coming into the operating room, did not improve protection provided by sterile skin preparation and aseptic precautions already in common use.

Postoperative infection is caused by bacteria on the skin of the person being operated on and bacteria on the surgical instruments and hands of the surgeon doing the operation. Preoperative head covering and sterile gowns on patients had no effect. Researchers will continue to try to find new ways to reduce our infection rate. But once you cut through the skin, bacteria are unavoidably introduced into a usually sterile part of the body.

Allan R. Kelly, MD, FACP

TELEHEALTH

Telehealth visits, both video and audio, have now been embraced by the medical community. Even Medicare is allowing visits with the doctor while you are in your own home. Availability for such visits has always been a part of PMH, but there is now a much wider acceptance of these visits. Recent reports have shown the value of these. In some ways, a telehealth visit on FaceTime, Doximity, or even just with a dedicated time for a phone call is the modern equivalent of a house call. Much of the information and knowledge that might be shared at a doctor’s office visit, or if the doctor came to the house, are shared on a telehealth visit.

A study in Boston showed 68% of patients would be satisfied with a telehealth visit. The study estimated that patient saved more than two hours of time from their schedule by using telehealth. This time would have been spent driving to and from the doctor’s office and waiting. Some of the telehealth visits were done with family providing the link. Telehealth visits with the patient and a loved one are often even more productive. Readiness of patients for telehealth visits has improved. In the Boston study, nearly half the patients had the technology to have a telehealth visit. In 2018, only 8% of eligible patients had the technology for a telehealth visit. In a separate study of patients who consented to the telehealth visit but did not complete one, only one-third actually went to the office for a face-to-face visit. The two-thirds who could not make it to the office were left without the help they wanted. Making telehealth work will help patients and their families.

Robert H. Kelly, MD, FACP

QUOTES

Doctors are only human, perhaps with more insight because from the very character of their work, they gain insight into human nature, and thus comes to understand it well and respect it highly.

-J.M.T. Finney, M.D., 1940

There are individuals – doctors and nurses, for example-whose very existence is a constant reminder of our frailties.

-William Osler, M.D., 1904

“I teach you that being a real doctor isn’t a stamp on your diploma. You can’t master it from a book…being a real doctor is being present and vulnerable. It’s blurring the lines of physician and friend. Telling them to never give up hope while helping them to let go.”

-Rana Garris, M.D., 2020.

“Live long enough and eventually the body fails. It betrays us.”

-From the book titled Elderhood by Louise Aronson

FROM THE OFFICE OF DR. ROBERT KELLY

Martha Claire Kelly-Legler, Nurse Practitioner, will join Dr. Robert Kelly’s practice on 03/22/2021.

She graduated from University of Minnesota (Master of Nursing Science), St. Olaf (BA of Russian Language) and University of Texas Medical Branch in Galveston (Nurse Practitioner). Her clinical work has been at St. Cloud Hospital in Minnesota, Harris Hospital, and rotations at various medical practices here in Fort Worth. She spent approximately six months interning with Dr. Robert Kelly.

NP Kelly-Legler understands PMH and is in a position to be a resource and expert provider for PMH subscribers. She will provide care in the months and years ahead. Many of you will undoubtedly have a preference to see NP Legler instead of Dr. Kelly. This is understandable. However, there will be times when you may find yourself seeing one or the other because of needs that arise either in or out of the office. With two providers, we can better respond to urgent care needs.

In all cases, there is open and frequent collaboration between Dr. Robert Kelly, and NP Kelly-Legler. In all difficult and complex cases, there will be immediate collaboration until problems resolve.

This is a step-up for Dr. Kelly and our PMH office. This improves the ability of our office to do the work that we promise to do. We welcome NP Legler.