July 8th, 2008 by Dr. Val Jones in Expert Interviews
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With the recent news about the high prevalence of Post Traumatic Stress Disorder (PTSD) in military veterans returning from Iraq and Afghanistan, I decided to interview Revolution Health’s expert psychiatrist, Dr. Ned Hallowell, to find out more about PTSD and what to do about it.
*Listen To The Podcast*
Dr. Val: What is post traumatic stress disorder (PTSD)?
Dr. Hallowell: As the name implies, it is the response a person has to any traumatic experience or event. The brain really changes in response to trauma, and people can be quite crippled by it. Some will actively avoid people and situations that remind them of the event, others experience “triggers” that set them off into a panicky or dissociated state. PTSD can cause “flashbacks” where people feel as if they’re right back at the scene of the incident, they may also have nightmares or problems with relationships, job function, substance abuse, major anxiety or depression and even suicide.
PTSD exists on a spectrum. You can get fired from your job and experience mild trauma, but if the firing was really unfair and unexpected it can change you fundamentally for years to come. It isn’t the actual event that determines whether or not a person develops PTSD, it’s how you –given your particular neurochemistry and genetics – are able or not able to assimilate, accommodate, and deal with the traumatic event.
Dr. Val: How does a person know if they have PTSD?
Dr. Hallowell: If something terrible has happened to you and you’re not able to calm down, put things into perspective or get back to your old self – then you may have PTSD. Instead of getting your equilibrium back you’re rattled, anxious, and sleeping poorly. Fear builds on fear and you can even become afraid of life itself and begin withdrawing, avoiding, and shutting down, and self-medicating.
What you want to do is “name it” – in other words allow yourself to consider that you may have PTSD, and then get professional help. A mental health professional who specializes in PTSD is ideal. Dr. Bessel van der Kolk has written several excellent books on the subject.
It’s also worth noting that people can get vicarious PTSD. There have been cases where practitioners have developed PTSD simply by listening to accounts of trauma.
Dr. Val: Is early intervention important?
Dr. Hallowell: This is controversial. Some people believe that it’s important to talk about the event right away, but I’m of the belief that people should remain connected to others but not be required to talk about it until they’re ready. I could see someone after a mugging or car accident and never talk about the event – my role is just to create a “safe place” for them to be. Later on we might talk about it, or we might not. Discussing the details of a traumatic event can retraumatize you – and in a funny way you can develop a habit of reliving the trauma, almost the way that people become addicted to worry. However if the patient wants to talk about the trauma, that suggests to me that they need to – and I let them be the guide.
Dr. Val: What happens if PTSD is not treated?
Dr. Hallowell: It can wreak havoc on people. “Avoidance” as a lifestyle is very incapacitating. If you can’t go places and do things, you’re feeling anxious all the time, and having nightmares and flashbacks, you can’t enjoy life.
Dr. Val: Can PTSD be prevented? In the case of soldiers, for example, who are likely to experience horrible things in times of war – can they be mentally prepared for this kind of thing?
Dr. Hallowell: Part of what makes trauma traumatizing is that it’s unexpected. So it makes intuitive sense to me that if you’re prepared for what you’re going to see or experience that you will find it less traumatic when it happens. The surprise and lack of control are what’s overpowering about trauma. Having a plan (knowing what to do in case of a traumatic event) and knowing what to expect afterwards (and how to get help) will go a long way in reducing the damage of trauma. You can still be traumatized, however, even if you’re “ready” for it.
Dr. Val: Tell me a little bit about kids and PTSD. Do they express PTSD differently?
Dr. Hallowell: In children, the dissociative state is pretty common – they become vacant and unreachable. Sometimes the opposite happens and they are inconsolable, experiencing night terrors, crying, and temper tantrums. However, kids are remarkably resilient and I’ve seen play therapy work wonders for them after traumatic events.
For example, four-year-olds might sit on the floor and not talk to me at all about the trauma they’ve been through, and the next thing you know they’re reenacting the scene with their toys and dolls. They have no idea that they’re replaying the event this way (a form of “displacement”) – and may do it over and over again for a period of six weeks… and the next thing you know they’re over it. It’s remarkable. They use their imagination to heal themselves. It’s the greatest therapy in the world. No medication is used, and it’s a permanent fix. It’s almost like doing psychoanalysis at the point of the childhood trauma. When you’re 40 you try to relive these experiences in analysis to resolve the conflict – but as a child you’re actually doing the work near the time of the incident.
Dr. Val: What’s the most important thing for families to do for loved ones who have PTSD?
Dr. Hallowell: Connect with them. Understand them, listen to them, and don’t let them get isolated. Take their concerns seriously, and don’t judge them. Then find out what they need and get them to a mental health professional who understands PTSD.
*Listen To The Full Conversation Here*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 7th, 2008 by Dr. Val Jones in Health Policy
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This is one of the worst ideas I’ve heard of in a long time – “secret shoppers” in the ER (h/t KevinMD and Dr. Wes). In an attempt to assess hospital quality, patients with fake complaints are sent to the ER unannounced to see how they will be triaged and treated. In one case, a woman complained of stroke-like symptoms (headache, slurred speech, and difficulty moving the left side of her body). She underwent a head CT (which was normal) and then signed out of the hospital against medical advice.
Let me tell you why this “secret shopper” idea is so bad:
1. The woman was exposed to unnecessary brain radiation via the CT scan – this risk is acceptable if a patient’s life is in danger, but why would a normal person wish to be exposed to additional radiation? I smell a law suit in her future…
2. The woman’s triage experience could not possibly represent the average stroke patient experience because she could not replicate the signs of a stroke and (if she tried) any good ER doc or neurologist would know that she was faking. A patient faking the symptoms of a stroke would likely be treated differently than a patient with objective signs.
3. Wait times are dangerously high in ERs across the country. Bumping legitimate patients with “secret shoppers” is unethical and downright dangerous.
4. If hospital staff know that some of their patients will be fake, this could result in mistrust of symptoms or stories and a backlash against real patients who might be confused with secret shoppers.
The ER secret shopper movement was clearly conceived by people who don’t understand the complexity of healthcare, and are applying reductionist principles that will cause unanticipated consequences. Physical harm to the shoppers, longer wait times for real patients, further mistrust by the medical community, and inaccurate quality assessments are only the beginning. I hope the AMA voices their disapproval of this practice.
Quality is better assessed by an average of real patient experience, along with data comparing treatment protocols with medical records. Fake patients have no place in the ER.
What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 2nd, 2008 by Dr. Val Jones in Celebrity Interviews, Expert Interviews
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Would you know what to do if someone in your office collapsed in front of you and became unresponsive? Having a defibrillator handy could save their life – and it’s important for you to know how to use one. I interviewed Dr. Jon LaPook, Medical Correspondent for CBS Evening News with Katie Couric, to get his take. [Interesting factoid: Jon became passionate about cardiac defibrillators after a friend of his died while exercising at a gym in NYC. The health club did not have a defibrillator on site – which could have saved his friend’s life.]
*Listen to the podcast*
Dr. Val: What is a defibrillator?
Dr. LaPook: It’s a machine that can convert a life threatening heart rhythm (like ventricular tachycardia or ventricular fibrillation) back into a normal beating pattern. It uses a pulse of electricity to do this. These machines are potentially life-saving.
Dr. Val: Why is it important for offices to have them on hand?
Dr. LaPook: About 1.2 million people in the United States have a heart attack every year and 300,000 of those have “sudden death.” The reason why these people die is not because of the heart attack, but because of the irregular heart rhythm that accompanies it. When the heart isn’t beating in a coordinated fashion, it can’t pump blood effectively and people pass out and ultimately die if there’s no intervention.
If a defibrillator is used to administer a shock to the chest during one of these life threatening heart rhythms, there’s a much higer chance that the person’s life will be saved. For every minute of delay (from the time a person collapses) to receiving a shock to the chest, their chance of survival decreases by 7-10%. So it’s very important for people to get defibrillation quickly.
Dr. Val: How do you use a defibrillator?
Dr. LaPook: When you first see someone collapse and become unresponsive, all you have to do is get the defibrillator and press the “on” switch. It will talk you through the next steps. Remember that the first step is always to have someone call 911 so that EMS will be on its way while you continue CPR. Then you expose the victim’s chest so that you can apply two sticky pads, and the defibrillator will tell you where to put the pads. Then it will analyze the victim’s heart rhythm and decide if it requires a shock to get it beating in a coordinated way. If a shock is recommended, the machine will announce that and ask you to step away from the person. Once the shock has been received, it will then give you instructions for CPR (which includes chest compressions and rescue breaths) until EMS arrives or a pulse is able to be felt. If a person doesn’t require a shock, the machine will not give one – so there’s no risk of harm to the victim.
It’s important for people not to be intimidated about defibrillation because it’s really very simple and can save a life.
Dr. Val: What are a person’s chances of surviving a cardiac arrest?
Dr. LaPook: Nationally, your chances of survival (without intervention) are about 4-6%. If you receive CPR, your chances increase to 15% but with a defibrillator – especially if it’s used quickly – the chances are 40% or higher.
Dr. Val: What do you think about the new research suggesting that rescue breaths may not be as important for CPR as initially thought?
Dr. LaPook: I spoke to Dr. Rose Marie Robertson, who is the Chief Science Officer at the American Heart Association, and she said that in a “witnessed arrest” (when you actually see someone collapse) it doesn’t seem to make a {big} difference if you do rescue breathing (i.e. mouth-to-mouth resuscitation) or not. The reason they studied this is because one of the main reasons why people don’t perform CPR is the “ick” factor of mouth-to-mouth resuscitation. As it turns out, chest compressions alone are about as successful at saving lives as traditional CPR. However, if you’ve been trained to do the rescue breathing technique, you should definitely use it. The key to CPR is “hard and fast” chest compressions, about 100 compressions per minute. Whatever form of CPR you use, the key to success is using the defibrillator as soon as possible, ideally within several minutes.
Dr. Val: What should people working in an office environment know about first aid?
Dr. LaPook: The most important thing is for people to be trained in CPR, the Heimlich maneuver, and defibrillator use.
Dr. Val: Are there enough defibrillators out there nowadays?
Dr. LaPook: Not at all. At the very least, defibrillators should be in every single health club in America. I also think they should be installed in every office building and be widely available at schools.
A cardiologist friend of mine told me about some parents who lobbied for their daughter’s school to purchase a defibrillator. (They were in tune to cardiac issues in children because their daughter had an arhythmia called Wolff-Parkinson-White syndrome.) Two years after the school purchased the device, the girl – only 13 years old at the time – collapsed while walking past the nurse’s office at the school. The nurse saved her life with the very defibrillator that her parents fought so hard for. So defibrillators are incredibly important, and although they’re not inexpensive (about $1200), you really can’t put a price on life.
*Listen to the podcast*
*Check out Dr. LaPook’s defibrillator training video with Katie Couric*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 1st, 2008 by Dr. Val Jones in Expert Interviews
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Some 600,000 physicians are facing a 10.6% cut in Medicare payments beginning July 1.
Congress failed to pass a measure to block a steep reduction in the Medicare physician payment rate before adjourning for a weeklong July 4 recess. That failure allows a 10.6 percent cut to take effect on July 1 that could end up limiting or denying care to millions of Medicare beneficiaries. [
AAFP News Now]
I reached out to Dr. Nancy Nielsen, the President of the American Medical Association, for comment. [Listen to the podcast]
Dr. Val: How will the Medicare cuts affect seniors in this country?
Dr. Nielsen: Because the 10.6% cuts to all physicians who see Medicare patients goes into effect today, we are really on the brink of a meltdown. Physicians say that a cut of this size will force them to make terrible choices, just to keep their practices open. In a recent survey, 60% of physicians said that the cuts would cause them to limit the number of new Medicare patients that they treat. This is the last thing we need at a time when baby boomers are aging into Medicare. It’s not why any of us went into medicine – to shut doors and turn patients away. So this is really, really painful.
Dr. Val: What do you say to those who claim that doctors are simply protecting their own salaries when opposing this cut?
Dr. Nielsen: We’re really not hearing that argument because people understand that this is about whether or not payments keep up with the costs of rendering care. At least 50% – 65% of income that comes into a physician’s office is spent on overhead. That includes rent, liability insurance, staff salaries, equipment and supplies. None of the manufacturers of hospital gowns or exam table paper are cutting the cost of those supplies to us by 10%.
When you’re spending up to two thirds of your income on overhead, you simply can’t tolerate payments that haven’t kept up.
Dr. Val: What can patients do to protect themselves from being denied access to medical care?
Dr. Nielsen: Patients need to understand that this issue is about them. We physicians embarked on careers in medicine to serve them, and we’re hoping that Medicare beneficiaries and military families will reach out to the senators who did not vote with us and tell them that this is a critical issue that needs to be fixed. The AMA has a Patient Action Network available online or by calling a toll free number: 1-888-434-6200. Individuals should contact us to take a stand against these cuts. Patient groups have been very supportive – the AARP and representatives from the disabled community and assisted living were with us pleading with the Senate to block the Medicare cuts.
Dr. Val: What is the AMA doing to protect access to healthcare?
Dr. Nielsen: The Medicare crisis is an access issue. It is the insurance that seniors depend on and that our country has promised them. We do not want a Medicare meltdown. The responsibility for this crisis lies with the Senate. We are hoping that the Senate will come back from vacation and do the right thing.
Last year the AMA embarked on an unprecedented campaign to encourage all Americans to put pressure on politicians to find a way to cover the uninsured. This is the other major access initiative that we’re promoting.
Dr. Val: What do you make of the “concierge medicine” movement where doctors — who are fed up with insurance — simply stop accepting it?
Dr. Nielsen: It’s a symptom of doctors becoming frustrated with bureaucratic red tape and payment problems. Many don’t feel that they have enough time to spend with their patients, and can’t afford to practice the kind of medicine they want to with insurance-based payments. Concierge practice is not a big movement, but there are some good physicians who have made that choice. We’re hoping that more physicians are not forced to stop taking insurance, but those who choose this route report being very happy, and so are their patients. The problem is that for patients who cannot afford concierge medicine, it’s not a solution at all.
Dr. Val: What would you like to say to the American public today about the Medicare cut crisis?
Dr. Nielsen: We need your help and we need it immediately. Please call your senators over the long weekend and plead with them to do the right thing and help us avoid a Medicare meltdown – a crisis that is not in anybody’s best interest.
[Listen to the podcast]This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 30th, 2008 by Dr. Val Jones in News
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I read a touching story at the BBC news center about a young woman with Alpert’s Syndrome. This rare syndrome is present in only 1 in 170,000 births. It results in facial disfigurement and mitten-like hands.
The physical defects of Apert’s syndrome were first described by Fredrick Apert in 1942. These characteristics include: A tower-shaped skull due to craniosynostosis (premature fusion of the sutures of the skull)—an underdeveloped mid-face leading to recessed cheekbones and prominent eyes, malocclusion (Faulty contact between the upper and lower teeth when the jaw is closed) and limb abnormalities such as webbing of the middle digits of the hands and feet.
Bones of the fingers and toes are fused in Alpert’s infants giving a “mitten-like” appearance of their hands. Children with Apert’s syndrome can have unusual speech characteristics such as hyponasal resonance due to an under-developed mid face, small nose and long soft palate and, sometimes, cleft palate.
What struck me about the girl’s story was how she described how it felt to be teased growing up, and how the worst part of the teasing was that no one stuck up for her. I’ve seen kids do this kind of thing before, and I can imagine how painful it is when no one has the courage to go to bat for you. I’ve often wondered how “doing nothing” to defend a little one might be just as bad as actively harrassing them. I’d encourage parents to teach their children not to tease others, and beyond that, to come to the defense of those being teased. I bet this will do a lot of psychological good for the victims.
The good news in this case is that the girl has had some very successful reconstructive surgery and has a fairly normal life. The teen is even thinking about boyfriends, and preparing for college. Many thanks to the surgeons who did such a wonderful job.
And coincidentally, the Happy Hospitalist brought this story to my attention: a 4 month old kitten was in a horrible accident that resulted in her losing the front half of her face. Veterinarians were able to save her life, though she remains quite deformed. I am told that the kitty is not in any pain, and is enjoying her life as a therapy pet. She brings hope to those recovering in the hospital from surgeries and serious illnesses. I suppose they see her as a loving animal who is cheerfully going about her kitty business, without giving much thought to her previous injury.
These stories of hope are made possible by the surgeons and veterinarians who devote their lives to saving face. In so doing, they provide the rest of us with valuable lessons, and new friends of exemplary courage.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
