Joint Surgeons of Sacramento

Joint Effort Newsletter
Blood Supply HMO Glossary Inez Willet Passes Away Risks: DVT in TJR Support Groups Medicare HMOs Dear Doctor Staff Profile Volume 1, Issue 1 Volume 2, Issue 1 Volume 2, Issue 2 Volume 6, Issue 1 Volume 7, Issue 1 JOINT SURGEONS OF SACRAMENTO 1020 29th Street Suite 450 Sacramento, CA 95816 Ph: (916) 733-5066 Fx: (916) 733-8705 RELATED ITEMS Meet Our Doctors Map and Directions Take a Tour of Our Office HIP & KNEE INFO Total Hip Replacement Total Knee Replacement NEWSLETTER Sign Up Now!		Volume VI, Issue 1 Winter 1994/95 Just How Safe Is The Community Blood Supply? Provided by the Sacramento Blood Bank It’s rush hour traffic in downtown Sacramento. The talk show host on the radio is asking callers of they are afraid that they might get AIDS. A happily married man calls in saying he is not worried. The host then asks “What if you had an accident on your way home and you needed blood? You might get AIDS.” Sadly, this statement sums up the fear and misconceptions that many people have about the safety of our nation’s blood supply. Fear of getting AIDS, fear of getting some other life-threatening disease, fear of “bad” blood. Although the blood supply is safer than it has ever been, the fear persists. Recent media stories highlighting problems with the Food and Drug Administration (FDA), Red Cross, and other blood centers across the country only serve to perpetuate the fear. “We give blood transfusions to help people, not to hurt people. Thus, we want the blood supply to be as safe as it can possibly be,” explains Paul Holland, M.D., Sacramento Medical Foundation (SMF) Blood Center Medical Dir/CEO. Since HIV testing became available in 1985, there has not been a single case of transfusion-associated HIV infection or AIDS reported from any blood drawn and tested by the Sacramento Medical Foundation and its blood centers. According to the national Centers for Disease Control (CDC), only 29 cases of transfusion-related AIDS have been reported from tested blood. During this period, approximately 150 million transfusions of tested blood and blood components have taken place. Current CDC estimates place the risk of contracting AIDS from a blood transfusion at no more than one in 225,000, which is less than the risk of being hit by lightning. It is also less than the risk of death during a normal pregnancy, which is one in 10,000: less than the risk of total reaction to penicillin, which is one in 30,000. Because blood is a biological product, it will never be 100 percent safe. Testing is not absolutely perfect, and there is a small chance that a donor may be in the “window” period following exposure to a disease – from a few days to several months – when routine laboratory tests may miss an infection. “A person’s body needs time to respond to an infection of any kind,” explains Holland. “Laboratory tests are often designed to detect the immune system’s response to the disease rather than the disease itself.” There are multiple layers of protection in place to help ensure that people giving blood are healthy and are not giving during the “window” period of infection. First and foremost of these layers is the fact that the SMF and its blood centers rely on an all-volunteer (unpaid) donor base. People are giving blood out of the goodness of their hearts; there is no monetary incentive to donate. Potential donors are asked to read detailed information pertaining to risk factors associated with AIDS and other potentially harmful diseases; they are asked not to donate blood if they have participated in any activity placing them at risk. Medical evaluators conduct a highly personal, extensive medical history interview and mini-physical to ensure that nothing would put them or the patients receiving their blood at risk. After passing these steps, donors are informed of a confidential hotline phone number that they can call if for any reason they do not want their blood to be used. After the blood is donated, thorough testing in the laboratory backs up all these pre-donation safeguards. Currently, each unit of blood donated at SMF blood centers undergoes a number of tests for infectious diseases including: • HIV-1 & HIV-2 antibody testing – screens for the viruses known to cause AIDS • Elevated ALT level – testing for a liver enzyme that could signify the presence of viral hepatitis. • Hepatitis Anti-HBc (CORE) test – screens for possible carriers of viral as well as type B hepatitis. • Hepatitis B Surface antigen test – screens for carriers of the hepatitis B virus. • Syphilis antibody test • Cytomegalovirus (CMV) – virus present in about 50 percent of the population – could adversely affect premature newborn infants and certain transplant recipients. • HTLV-1 antibody test – screens for the presence of a rare leukemia virus. • Hepatitis C antibody test – screen for the presence of the hepatitis C virus. Adding to these layers of safety are stringent quality assurance steps and regulations mandated by the Food and Drug Administration (FDA), state and local agencies, as well as by the American Association of Blood Banks. “If I were in an accident on my way home this evening and needed a blood transfusion, I would not hesitate to use blood from our community blood supply,” declares Holland. “I think it is a shame that people have been alarmed to the point of refusing blood transfusions in life and death situations.” “Furthermore, you cannot get AIDS by donating blood. Sterile, disposable needles are used only once and then discarded. The only blood a donor is exposed to is his or her own,” says Holland. The goal of the SMF is to provide the safest possible blood and blood components to the communities we serve. If you have questions or concerns regarding the safety of the blood supply, please call the Sacramento Blood Bank at (916) 456-1500 or 1-800-995-4420. Return to top HMO Glossary You may have noticed that we have started asking all patients to show their insurance cards at each visit. This is due to the growing popularity of the Health Maintenance Organizations (HMO) insurance plans. We are members of many of these plans, however, they require special attention and billing procedures. The following is a glossary of terms regarding HMOs you may want to keep for your reference: HMO – A health plan which contracts with groups of providers to manage health care to its members. These organizations restrict you access to specialist. All referrals must go through your primary care physician (see below) Approved Provider – A doctor, hospital or other provider who has a contract with the HMO and is eligible to care for its member. Approved providers are found on the HMO’s list of approved providers. Primary Physician – The doctor, usually family practice or internal medicine physicians, from which a plan member receives most of his or her care. The professional also is the only individual who can refer a patient to a specialist. Specialist – A physician who practices medicine in a certain area, such as orthopedist or cardiologist. In an HMO only a primary care physician can refer a member to a specialist. Both Dr. Bargar and Dr. Taylor are specialists in orthopaedic joint reconstruction surgery. Referral – In an HMO plan members must have a referral from their primary care physician before they may access other services from a specialist. It is the patient’s responsibility to obtain the proper referral. Co-Payment – The amount of money a member must pay at the time service is rendered, such as an office visit. A co-payment is usually required at each office visit whether it is with the primary care doctor or a specialist. HMOs require special attention from you as the patient and from the doctor’s office. All of your healthcare is directed by your Primary Care Physician (PCP). You are unable to self-refer to the specialist of your choice. Another option is a PPO plan, or Preferred Provider Organization. These plans are less restrictive than HMO plans. However, if you choose to see a physician outside of your PPO plan, you may be required to pay a higher co-payment. The final, and best option is the Indemnity Plan. This plan has no restrictions. You may see any physician you like without a penalty. Return to top Inez Willet Passes Away Inez Willet, former office nurse for our practice, 20-year veteran of orthopaedic nursing at UC Davis Medical Center, and friend passed away on December 5th. She had a prior history of colon cancer diagnosed five years ago and had survived two difficult surgeries. Despite, and perhaps because of her bout with cancer she had a full and active lifestyle. She and her friend Jane Bislend, who took over for Inez when her cancer was discovered traveled frequently and thoroughly enjoyed it. Inez was recently diagnosed with a second new colon cancer and was recovering from a successful colon resection when she suddenly died of an acute pulmonary embolism. Many remember Inez for her kindness and caring, as well as her British efficiency. She came to the United States from England in 1948 and initially worked at Mercy General Hospital as a licensed vocational nurse. In 1968 she returned to school and received her RN. Inez was responsible for the professionalism in which we all take pride in this office. We will all miss her as a friend and colleague. She is survived by her two daughters Suzanne and son-in-law Andy Davis, granddaughter Lauren Davis, Lisa and son-in-law Don Dickinson and grandson Samuel Dickenson. She also had relatives in England, Australia and South America. Donations can be sent to: UC Davis Cancer Center, c/o James Goodnight, M.D., Ph.D., 4501 X Street, Room 3003, Sacramento CA 95817. Return to top Risks: DVT in Total Joint Replacement By Dr. Tushar Doshi A well recognized complication following total hip and total knee replacement surgery is the formation of blood clots in the veins of the leg and pelvis (“Deep Vein Thrombosis” or DVT”). Without any preventative measure, the incidence of patients forming blood clots of the legs and pelvis is approximately 50 to 60%. In and of themselves the blood clots are not a threat. They can be treated with blood thinners and usually resolve, although there can be some residual circulation problems. The big concerns, however, is that a portion of the blood clot may break-off and go to the lung (“Pulmonary Embolism”). If that occurs it can be life threatening. While some degree of pulmonary embolism may occur without preventative measures in as many as 17% of the cases, most cause no symptoms. They are clinically significant in only 2% of the patients, and fatal complications are very rare (less than 1 in 1000). The reasons for the incidence of clot formations following lower limb reconstructive surgery are many. In essence immobility following the surgery causes stasis, or a diminished blood flow within the vein. Also, the blood is in a hypercoagulable state following surgery. Both of these conditions tend to increase the chance of coagulation within the vessel. The clinical signs that a blood clot of a leg vein may be developing is swelling of the calf, pain in the calf, especially with the movement of the foot upward. If the physician suspects a blood clot to be present, an ultrasound of the veins (“Dopler Venogram”) is usually ordered. In 98% of the cases this either confirms or rules out a diagnosis of a clot in the leg veins. If a blood clot is detected, then treatment is conducted in consultation with the patient’s internist. This usually involves placing the patient on a different blood thinner (“heparin”) which is given intravenously to decrease the chance of further clot formation and promote resolving of the clot. This procedure requires hospitalization. Various preventative measures are undertaken in joint replacement surgery to decrease the risk of any blood clots forming. Patients are normally given a blood thinner, coumadin (also called warafin) for 4 weeks after surgery. This helps to prevent blood clot formation. It acts by interfering with the coagulation process within the body systems. There is, however, a possibility of bleeding complications. Therefore, the dose of coumadin has to be monitored carefully so as to prevent bleeding. Coumadin is started the night before surgery and is then continued daily until 4 weeks after surgery. Anti-inflamatories can also predispose patients to bleeding. Therefore, we advise that no anti-inflamatories should be taken for at least 4 weeks following surgery while on coumadin. The coumadin levels are monitored with the help of blood tests (“ Prothrombin Times” and “Ratios”). The data obtained from these tests together with other factors such as age, weight, sex, activity level, and previous history are fed into a computer located at Sutter General Hospital and an optimum coumadin dosing schedule is obtained from that computer. While in the hospital, the blood is drawn daily to ascertain the optimum level of coumadin which should be given. Coumadin is usually continued for four weeks after surgery. At the time of discharge the pharmacy technician explains the routines of administering coumadin at home, including the schedule of two blood draws a week for the first two weeks, and then one blood draw per week for the next two weeks by the visiting nurse. The results of these blood draws are relayed back to the pharmacy at Sutter General Hospital which then determines the optimum dose of coumadin to be administered. If the patient is from out of state arrangements can usually be made for the patient’s internist to follow the coumadin dosage appropriately. Other preventative measures utilized along with coumadin are: pneumatic compression stockings, early mobilization beginning the first or second day after surgery, and active in bed exercises such as ankle pumps. These measures have decreased the chance of blood clots forming to less than 10%, the chance of pulmonary embolus to less than 3% and the chance of a fatal pulmonary embolus to less than 1 in 5000. 1-800-847-9031. Return to top Free Support Groups for Patients… Arthritis – Held monthly, every third Monday, 6:30-8:30 p.m. at Sutter Health Administration Building, 2800 L Street in the 1st Floor Classroom. Call 1-800=847-9031. Back Pain – Held monthly, every third Thursday from 6-7:30 p.m. at SCH in Conference Room C. Phone 1-800-847-9031 Joint Replacement – Meets monthly, every fourth Monday, from 9:30-11 a.m. at Alhambra Medical Plaza, 1201 Alhambra Blvd., in the TQM Classroom. Phone 1-800-847-9031 Pre-Joint Replacement Class – Meets monthly every second and four Tuesday from 2-3 p.m. at SGH Conference Room A. Call 1-800-847-9031. Return to top Risks in Medicare HMOs Reprint of a letter to the editor from The Business Journal 11/14/1994 Dear Editor: Thank you for the insightful article by Rebecca Kuzins (“Medicare and HMO’s,” Oct. 24) regarding the growing enrollment in Medicare risk HMOs. Medicare risk HMOs offer many attractive features to those who want to make the switch. Perhaps the most immediate benefit is the savings achieved by no longer carrying a Medicare supplemental policy which can cost as much as $400 a quarter. Many individuals covered by Medicare risk HMOs choose to disenroll from these programs within a short period of time. According to a 1993 report from the Medicare Advocacy Project of Los Angeles, disenrollment can run as high as 40 percent in some plans. When disenrollment occurs, it is often due to the realization that the patient no longer maintains the physician/patient relationship he/she enjoyed under traditional Medicare coverage. Many elderly patients fail to understand that their choice of physicians is limited until they have gone back to those physicians for services. While marketing agents of the plans are required to make this fact clear to patients at the time of enrollment, the message does not always sink in until after the fact. In addition, marketing agents are often very persistent in their efforts to sign up new enrollees. Frequent phone calls to the prospect and repeated visits to the prospect’s home may cause some Medicare patient to enroll prematurely. Problems also arise when the patient’s regular physician discovers that the patient has enrolled in a plan after services have been scheduled and delivered by that physician during that short period of time when the enrollment paperwork is still in progress. In such cases, neither the new plan, Medicare, or the canceled supplemental plan will cover charges. The society has received numerous complaints from its members and from a few patients who have made the switch and then needed help to disenroll. Usually the patient is frail and confused or may not be fluent in English. Medicare risk capitation rates are lucrative for HMOs. The rate may be two or three times higher than the adult capitation rate in a standard HMO. This fact contributes to aggressive marketing. In making a decision to enroll in such a plan, Medicare patients should fully understand which primary-care physicians are on the panel and which ones are actually accepting new patients. They should also be provided the names of the physician specialists who are on the referral panel and which hospitals are utilized. Medicare patients should know that seeing a specialist is only possible by referral from the primary-care physician. Also, before they disenroll from a plan, they should make certain that they will be able to return to their supplemental carrier and what the cost will be. When requested, disenrollment forms must be supplied by the HMO. William A. Sandberg Executive Director Sacramento-El Dorado Medical Society Return to top Dear Doctor… Q. How long do I need to use the abduction pillow? A. Ideally you should use it for the first six weeks after surgery. It is your best protection to avoid dislocations while in bed. We realize that it can be very uncomfortable so it is permissible to use a regular pillow between the legs, but you should be careful not to let it come out. After six weeks no pillow is required, but you may be more comfortable with one pillow between your leg when you lie on your side. Q. May I sleep on the same side that was operated on? A. The safest way to sleep in on your back with a pillow between your legs or on your unoperated side. However, if you find this too uncomfortable, yes you can sleep on the side we operated on. It may be uncomfortable if there is any soreness in the incision, but it will not do any damage. As above, you should use an abduction pillow or regular pillow for the first six weeks. Q. Now that I have my new joint, I feel great! I would like to start doing my daily walking again. How far am I able to walk? A. You can safely walk up to 1 mile at a time. When you are first starting out, you may consider walking a few blocks and gauge how you and your new joint are feeling. Then you can work yourself up to a mile. Long distance walking (greater than one mile) on a frequent basis is not advisable due to problems with polyethylene wear and osteolysis (see Joint Effort Volume 5, Issue 2). Q. Is it helpful to do exercises before surgery? Should I join a health club or weight loss program before surgery? A. In general, the answer is no! Pre-operative exercises have not been shown to affect the post-operative course or outcome of total hip or total knee replacements. In fact, some exercises, such as vigorous leg exercises and weight machines can cause increased pain and wear and tear. It may feel better while you’re exercising, but ultimately these exercises cause a more rapid progression of arthritis. There are some gentle exercises such as stretching and isometrics that are safe, but not necessarily helpful. Weight loss is helpful, but not just before surgery. It can result in poor nutrition, which can affect blood donations, wound healing and recovery after surgery. If you need to lose weight, do it several months before surgery, but one month before surgery go back on a regular diet. Return to top Staff Profile… Once again our office is going through some changes. Anna Amos who has been our Office Manager, will function in a new position as the Practice Administrator. She will be handling all the outside functions of the practice such as contracting and public relations. She will continue to oversee the functions of the practice from an administration level. Mary Minix, who most recently has been Dr. Taylor’s Medical Assistant will become the Office Manager. Mary has been involved with all aspects of the practice since who was hired in 1987, and has been our “number two” of many years assisting Anna and filling in for her when she is gone. Mary is looking forward to this new challenge. We are confident that she and Anna will see us through the significant changes to come in healthcare. We would like to introduce the newest member of our “family,” Kim Johnson. She is Dr. Taylor’s new Medical Assistant. Kim comes to us with 2 years of experience in the medical field and formal training at Canterbury Schools. She currently enjoys time with her family and daughter. If you haven’t seen her already, you will at your next appointment with Dr. Taylor. Another change for our office has been the receptionist. Cindy decided to retire early and spend time with her family. She has three teenagers and a child in grade school that needed her at home. We have since hired Beth Burkhardt. You soon will be talking with her on the phone and seeing her at your next appointment. Return to top

Joint Effort Newsletter

Blood Supply

HMO Glossary

Inez Willet Passes Away

Risks: DVT in TJR

Support Groups

Medicare HMOs

Dear Doctor

Staff Profile

Volume 1, Issue 1

Volume 2, Issue 1

Volume 2, Issue 2

Volume 6, Issue 1

Volume 7, Issue 1

JOINT SURGEONS
OF SACRAMENTO
1020 29th Street
Suite 450
Sacramento, CA 95816
Ph: (916) 733-5066
Fx: (916) 733-8705

RELATED ITEMS
Meet Our Doctors
Map and Directions
Take a Tour of Our Office

HIP & KNEE INFO
Total Hip Replacement
Total Knee Replacement

NEWSLETTER
Sign Up Now!

Volume VI, Issue 1
Winter 1994/95

Just How Safe Is The Community Blood Supply?
Provided by the Sacramento Blood Bank
It’s rush hour traffic in downtown Sacramento. The talk show host on the radio is asking callers of they are afraid that they might get AIDS. A happily married man calls in saying he is not worried. The host then asks “What if you had an accident on your way home and you needed blood? You might get AIDS.”

Sadly, this statement sums up the fear and misconceptions that many people have about the safety of our nation’s blood supply. Fear of getting AIDS, fear of getting some other life-threatening disease, fear of “bad” blood.

Although the blood supply is safer than it has ever been, the fear persists. Recent media stories highlighting problems with the Food and Drug Administration (FDA), Red Cross, and other blood centers across the country only serve to perpetuate the fear.
“We give blood transfusions to help people, not to hurt people. Thus, we want the blood supply to be as safe as it can possibly be,” explains Paul Holland, M.D., Sacramento Medical Foundation (SMF) Blood Center Medical Dir/CEO.

Since HIV testing became available in 1985, there has not been a single case of transfusion-associated HIV infection or AIDS reported from any blood drawn and tested by the Sacramento Medical Foundation and its blood centers.

According to the national Centers for Disease Control (CDC), only 29 cases of transfusion-related AIDS have been reported from tested blood. During this period, approximately 150 million transfusions of tested blood and blood components have taken place. Current CDC estimates place the risk of contracting AIDS from a blood transfusion at no more than one in 225,000, which is less than the risk of being hit by lightning. It is also less than the risk of death during a normal pregnancy, which is one in 10,000: less than the risk of total reaction to penicillin, which is one in 30,000.

Because blood is a biological product, it will never be 100 percent safe. Testing is not absolutely perfect, and there is a small chance that a donor may be in the “window” period following exposure to a disease – from a few days to several months – when routine laboratory tests may miss an infection.

“A person’s body needs time to respond to an infection of any kind,” explains Holland. “Laboratory tests are often designed to detect the immune system’s response to the disease rather than the disease itself.”

There are multiple layers of protection in place to help ensure that people giving blood are healthy and are not giving during the “window” period of infection. First and foremost of these layers is the fact that the SMF and its blood centers rely on an all-volunteer (unpaid) donor base. People are giving blood out of the goodness of their hearts; there is no monetary incentive to donate. Potential donors are asked to read detailed information pertaining to risk factors associated with AIDS and other potentially harmful diseases; they are asked not to donate blood if they have participated in any activity placing them at risk. Medical evaluators conduct a highly personal, extensive medical history interview and mini-physical to ensure that nothing would put them or the patients receiving their blood at risk. After passing these steps, donors are informed of a confidential hotline phone number that they can call if for any reason they do not want their blood to be used.
After the blood is donated, thorough testing in the laboratory backs up all these pre-donation safeguards. Currently, each unit of blood donated at SMF blood centers undergoes a number of tests for infectious diseases including:

• HIV-1 & HIV-2 antibody testing – screens for the viruses known to cause AIDS
• Elevated ALT level – testing for a liver enzyme that could signify the presence of viral
hepatitis.
• Hepatitis Anti-HBc (CORE) test – screens for possible carriers of viral as well as type
B hepatitis.
• Hepatitis B Surface antigen test – screens for carriers of the hepatitis B virus.
• Syphilis antibody test
• Cytomegalovirus (CMV) – virus present in about 50 percent of the population – could
adversely affect premature newborn infants and certain transplant recipients.
• HTLV-1 antibody test – screens for the presence of a rare leukemia virus.
• Hepatitis C antibody test – screen for the presence of the hepatitis C virus.

Adding to these layers of safety are stringent quality assurance steps and regulations mandated by the Food and Drug Administration (FDA), state and local agencies, as well as by the American Association of Blood Banks.

“If I were in an accident on my way home this evening and needed a blood transfusion, I would not hesitate to use blood from our community blood supply,” declares Holland. “I think it is a shame that people have been alarmed to the point of refusing blood transfusions in life and death situations.”

“Furthermore, you cannot get AIDS by donating blood. Sterile, disposable needles are used only once and then discarded. The only blood a donor is exposed to is his or her own,” says Holland.
The goal of the SMF is to provide the safest possible blood and blood components to the communities we serve. If you have questions or concerns regarding the safety of the blood supply, please call the Sacramento Blood Bank at (916) 456-1500 or 1-800-995-4420.

Return to top

HMO Glossary
You may have noticed that we have started asking all patients to show their insurance cards at each visit. This is due to the growing popularity of the Health Maintenance Organizations (HMO) insurance plans. We are members of many of these plans, however, they require special attention and billing procedures. The following is a glossary of terms regarding HMOs you may want to keep for your reference:

HMO – A health plan which contracts with groups of providers to manage health care to its members. These organizations restrict you access to specialist. All referrals must go through your primary care physician (see below)

Approved Provider – A doctor, hospital or other provider who has a contract with the HMO and is eligible to care for its member. Approved providers are found on the HMO’s list of approved providers.

Primary Physician – The doctor, usually family practice or internal medicine physicians, from which a plan member receives most of his or her care. The professional also is the only individual who can refer a patient to a specialist.

Specialist – A physician who practices medicine in a certain area, such as orthopedist or cardiologist. In an HMO only a primary care physician can refer a member to a specialist. Both Dr. Bargar and Dr. Taylor are specialists in orthopaedic joint reconstruction surgery.

Referral – In an HMO plan members must have a referral from their primary care physician before they may access other services from a specialist. It is the patient’s responsibility to obtain the proper referral.

Co-Payment – The amount of money a member must pay at the time service is rendered, such as an office visit. A co-payment is usually required at each office visit whether it is with the primary care doctor or a specialist.

HMOs require special attention from you as the patient and from the doctor’s office. All of your healthcare is directed by your Primary Care Physician (PCP). You are unable to self-refer to the specialist of your choice.
Another option is a PPO plan, or Preferred Provider Organization. These plans are less restrictive than HMO plans. However, if you choose to see a physician outside of your PPO plan, you may be required to pay a higher co-payment.
The final, and best option is the Indemnity Plan. This plan has no restrictions. You may see any physician you like without a penalty.

Return to top

Inez Willet Passes Away
Inez Willet, former office nurse for our practice, 20-year veteran of orthopaedic nursing at UC Davis Medical Center, and friend passed away on December 5th. She had a prior history of colon cancer diagnosed five years ago and had survived two difficult surgeries. Despite, and perhaps because of her bout with cancer she had a full and active lifestyle. She and her friend Jane Bislend, who took over for Inez when her cancer was discovered traveled frequently and thoroughly enjoyed it. Inez was recently diagnosed with a second new colon cancer and was recovering from a successful colon resection when she suddenly died of an acute pulmonary embolism.

Many remember Inez for her kindness and caring, as well as her British efficiency. She came to the United States from England in 1948 and initially worked at Mercy General Hospital as a licensed vocational nurse. In 1968 she returned to school and received her RN.

Inez was responsible for the professionalism in which we all take pride in this office. We will all miss her as a friend and colleague. She is survived by her two daughters Suzanne and son-in-law Andy Davis, granddaughter Lauren Davis, Lisa and son-in-law Don Dickinson and grandson Samuel Dickenson. She also had relatives in England, Australia and South America.

Donations can be sent to: UC Davis Cancer Center, c/o James Goodnight, M.D., Ph.D., 4501 X Street, Room 3003, Sacramento CA 95817.

Return to top

Risks: DVT in Total Joint Replacement
By Dr. Tushar Doshi
A well recognized complication following total hip and total knee replacement surgery is the formation of blood clots in the veins of the leg and pelvis (“Deep Vein Thrombosis” or DVT”). Without any preventative measure, the incidence of patients forming blood clots of the legs and pelvis is approximately 50 to 60%. In and of themselves the blood clots are not a threat. They can be treated with blood thinners and usually resolve, although there can be some residual circulation problems.

The big concerns, however, is that a portion of the blood clot may break-off and go to the lung (“Pulmonary Embolism”). If that occurs it can be life threatening. While some degree of pulmonary embolism may occur without preventative measures in as many as 17% of the cases, most cause no symptoms. They are clinically significant in only 2% of the patients, and fatal complications are very rare (less than 1 in 1000).

The reasons for the incidence of clot formations following lower limb reconstructive surgery are many. In essence immobility following the surgery causes stasis, or a diminished blood flow within the vein. Also, the blood is in a hypercoagulable state following surgery. Both of these conditions tend to increase the chance of coagulation within the vessel.

The clinical signs that a blood clot of a leg vein may be developing is swelling of the calf, pain in the calf, especially with the movement of the foot upward. If the physician suspects a blood clot to be present, an ultrasound of the veins (“Dopler Venogram”) is usually ordered. In 98% of the cases this either confirms or rules out a diagnosis of a clot in the leg veins. If a blood clot is detected, then treatment is conducted in consultation with the patient’s internist. This usually involves placing the patient on a different blood thinner (“heparin”) which is given intravenously to decrease the chance of further clot formation and promote resolving of the clot. This procedure requires hospitalization.
Various preventative measures are undertaken in joint replacement surgery to decrease the risk of any blood clots forming. Patients are normally given a blood thinner, coumadin (also called warafin) for 4 weeks after surgery. This helps to prevent blood clot formation. It acts by interfering with the coagulation process within the body systems. There is, however, a possibility of bleeding complications. Therefore, the dose of coumadin has to be monitored carefully so as to prevent bleeding. Coumadin is started the night before surgery and is then continued daily until 4 weeks after surgery. Anti-inflamatories can also predispose patients to bleeding. Therefore, we advise that no anti-inflamatories should be taken for at least 4 weeks following surgery while on coumadin.

The coumadin levels are monitored with the help of blood tests (“ Prothrombin Times” and “Ratios”). The data obtained from these tests together with other factors such as age, weight, sex, activity level, and previous history are fed into a computer located at Sutter General Hospital and an optimum coumadin dosing schedule is obtained from that computer. While in the hospital, the blood is drawn daily to ascertain the optimum level of coumadin which should be given. Coumadin is usually continued for four weeks after surgery. At the time of discharge the pharmacy technician explains the routines of administering coumadin at home, including the schedule of two blood draws a week for the first two weeks, and then one blood draw per week for the next two weeks by the visiting nurse. The results of these blood draws are relayed back to the pharmacy at Sutter General Hospital which then determines the optimum dose of coumadin to be administered. If the patient is from out of state arrangements can usually be made for the patient’s internist to follow the coumadin dosage appropriately.
Other preventative measures utilized along with coumadin are: pneumatic compression stockings, early mobilization beginning the first or second day after surgery, and active in bed exercises such as ankle pumps. These measures have decreased the chance of blood clots forming to less than 10%, the chance of pulmonary embolus to less than 3% and the chance of a fatal pulmonary embolus to less than 1 in 5000.
1-800-847-9031.

Return to top

Free Support Groups for Patients…
Arthritis – Held monthly, every third Monday, 6:30-8:30 p.m. at Sutter Health Administration Building, 2800 L Street in the 1st Floor Classroom. Call 1-800=847-9031.

Back Pain – Held monthly, every third Thursday from 6-7:30 p.m. at SCH in Conference Room C. Phone 1-800-847-9031

Joint Replacement – Meets monthly, every fourth Monday, from 9:30-11 a.m. at Alhambra Medical Plaza, 1201 Alhambra Blvd., in the TQM Classroom. Phone 1-800-847-9031

Pre-Joint Replacement Class – Meets monthly every second and four Tuesday from 2-3 p.m. at SGH Conference Room A. Call 1-800-847-9031.

Return to top

Risks in Medicare HMOs
Reprint of a letter to the editor from The Business Journal 11/14/1994
Dear Editor:
Thank you for the insightful article by Rebecca Kuzins (“Medicare and HMO’s,” Oct. 24) regarding the growing enrollment in Medicare risk HMOs.

Medicare risk HMOs offer many attractive features to those who want to make the switch. Perhaps the most immediate benefit is the savings achieved by no longer carrying a Medicare supplemental policy which can cost as much as $400 a quarter.
Many individuals covered by Medicare risk HMOs choose to disenroll from these programs within a short period of time. According to a 1993 report from the Medicare Advocacy Project of Los Angeles, disenrollment can run as high as 40 percent in some plans.

When disenrollment occurs, it is often due to the realization that the patient no longer maintains the physician/patient relationship he/she enjoyed under traditional Medicare coverage. Many elderly patients fail to understand that their choice of physicians is limited until they have gone back to those physicians for services.
While marketing agents of the plans are required to make this fact clear to patients at the time of enrollment, the message does not always sink in until after the fact. In addition, marketing agents are often very persistent in their efforts to sign up new enrollees. Frequent phone calls to the prospect and repeated visits to the prospect’s home may cause some Medicare patient to enroll prematurely.

Problems also arise when the patient’s regular physician discovers that the patient has enrolled in a plan after services have been scheduled and delivered by that physician during that short period of time when the enrollment paperwork is still in progress. In such cases, neither the new plan, Medicare, or the canceled supplemental plan will cover charges.
The society has received numerous complaints from its members and from a few patients who have made the switch and then needed help to disenroll. Usually the patient is frail and confused or may not be fluent in English.
Medicare risk capitation rates are lucrative for HMOs. The rate may be two or three times higher than the adult capitation rate in a standard HMO. This fact contributes to aggressive marketing.
In making a decision to enroll in such a plan, Medicare patients should fully understand which primary-care physicians are on the panel and which ones are actually accepting new patients. They should also be provided the names of the physician specialists who are on the referral panel and which hospitals are utilized.
Medicare patients should know that seeing a specialist is only possible by referral from the primary-care physician. Also, before they disenroll from a plan, they should make certain that they will be able to return to their supplemental carrier and what the cost will be. When requested, disenrollment forms must be supplied by the HMO.

William A. Sandberg
Executive Director
Sacramento-El Dorado Medical Society

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Dear Doctor…
Q. How long do I need to use the abduction pillow?
A. Ideally you should use it for the first six weeks after surgery. It is your best protection to avoid dislocations while in bed. We realize that it can be very uncomfortable so it is permissible to use a regular pillow between the legs, but you should be careful not to let it come out. After six weeks no pillow is required, but you may be more comfortable with one pillow between your leg when you lie on your side.

Q. May I sleep on the same side that was operated on?
A. The safest way to sleep in on your back with a pillow between your legs or on your unoperated side. However, if you find this too uncomfortable, yes you can sleep on the side we operated on. It may be uncomfortable if there is any soreness in the incision, but it will not do any damage. As above, you should use an abduction pillow or regular pillow for the first six weeks.

Q. Now that I have my new joint, I feel great! I would like to start doing my daily walking again. How far am I able to walk?
A. You can safely walk up to 1 mile at a time. When you are first starting out, you may consider walking a few blocks and gauge how you and your new joint are feeling. Then you can work yourself up to a mile. Long distance walking (greater than one mile) on a frequent basis is not advisable due to problems with polyethylene wear and osteolysis (see Joint Effort Volume 5, Issue 2).

Q. Is it helpful to do exercises before surgery? Should I join a health club or weight loss program before surgery?
A. In general, the answer is no! Pre-operative exercises have not been shown to affect the post-operative course or outcome of total hip or total knee replacements. In fact, some exercises, such as vigorous leg exercises and weight machines can cause increased pain and wear and tear. It may feel better while you’re exercising, but ultimately these exercises cause a more rapid progression of arthritis. There are some gentle exercises such as stretching and isometrics that are safe, but not necessarily helpful.
Weight loss is helpful, but not just before surgery. It can result in poor nutrition, which can affect blood donations, wound healing and recovery after surgery. If you need to lose weight, do it several months before surgery, but one month before surgery go back on a regular diet.

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Staff Profile…
Once again our office is going through some changes. Anna Amos who has been our Office Manager, will function in a new position as the Practice Administrator. She will be handling all the outside functions of the practice such as contracting and public relations. She will continue to oversee the functions of the practice from an administration level. Mary Minix, who most recently has been Dr. Taylor’s Medical Assistant will become the Office Manager. Mary has been involved with all aspects of the practice since who was hired in 1987, and has been our “number two” of many years assisting Anna and filling in for her when she is gone. Mary is looking forward to this new challenge. We are confident that she and Anna will see us through the significant changes to come in healthcare.

We would like to introduce the newest member of our “family,” Kim Johnson. She is Dr. Taylor’s new Medical Assistant. Kim comes to us with 2 years of experience in the medical field and formal training at Canterbury Schools. She currently enjoys time with her family and daughter. If you haven’t seen her already, you will at your next appointment with Dr. Taylor.

Another change for our office has been the receptionist. Cindy decided to retire early and spend time with her family. She has three teenagers and a child in grade school that needed her at home. We have since hired Beth Burkhardt. You soon will be talking with her on the phone and seeing her at your next appointment.

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