March 11th, 2008 by Dr. Val Jones in Uncategorized
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As many of my faithful readers know, Dr. Val is a big fan of Web 2.0 principles (blogging, online communities, wikis, forums, chats, podcasts, etc.) I’m even leading a weight loss group online, and there are almost 1400 members already. Although I’ve been trying hard to lead by example, I’ve had occasional hiccups in my own weight loss due to the sweet lure of fine dining. Could YOU resist silky, black sesame panna cotta with butter crunch tuile and spicy cranberry compote? Well maybe you could. For me, resistance is futile.
But I digress.
What I really wanted to point out (before my thoughts were derailed by deliciousness), is that research is now confirming what many of us bloggers have known instinctively: social networking can improve the health care experience. In the Journal of the American College of Surgeons, post operative pain and length of stay were reduced for those who had more social support. This means that the more frequent and broad your social contacts, the less likely you are to be bothered by pain, and the more likely you are to get out of the hospital faster. Let’s hear it for using CarePages, FaceBook, and other online support groups while in the hospital, and perhaps as outpatients as well.
And if feeling supported isn’t enough to get you on the right track, more research in the Archives of Internal Medicine suggests that mail reminders can improve post-heart attack medication compliance. Perhaps email reminders would work just as well (and kill fewer trees?) One thing is for sure – Health 2.0 tools can make an impact on peoples lives and I’m excited to be a part of that.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 8th, 2007 by Dr. Val Jones in True Stories
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Today a dear friend of mine told me a horror story about her recent trip to a hospital ER. She has kidney stones, with rare bouts of excruciating pain when they decide to break off from their renal resting place and scrape their way down her ureters.
My friend is a stoic person who also doesn’t like to cause trouble for others – so when she was awoken at 4am with that same familiar pain, she decided not to call an ambulance but rather drive herself to the ER. She also chose not to call her doctor out of consideration for his sleep needs.
She managed to make it to the triage desk at her local hospital and was relieved to see that the ER was quite empty. There were no ambulances in the docks, no one in the waiting area, and no sign of any trauma or resuscitations in the trauma bay. She approached the desk trembling in pain and put her health insurance card, driver’s license, and hospital card on the desk and let the clerk know that she was in incredible pain.
The clerk responded,
“Lady, I saw you walk yourself in here. There’s no way you’re in that much pain. Sit down and fill out this paper work!”
My friend replied in a soft voice,
“Please, can you help me fill out these forms? I can barely see straight and can’t concentrate well. I have a kidney stone and it’s excruciating.”
Tears fell softly from her face as the clerk rolled his eyes at her.
“Yeah, I’m sure you do. And I bet you’re allergic to everything but Demerol.”
My friend started becoming frightened, realizing that she was being pegged as a “drug seeker” and would be punished with a long wait time for pain medication. “Please let me just speak to the triage nurse.”
“Sure, sweetheart,” hissed the clerk. “I’ll get him when you’ve finished your paperwork.”
And so my friend sobbed as she tried to fill in her address, phone number, insurance information, etc. on the paper form at a hospital where she had been treated for over 7 years for ovarian cancer. All of that information was in their EMR, but the registration process would not be waived.
The triage nurse slowly emerged, still chewing a bite of his steak dinner. “What have we got?” He said to the clerk looking out into a waiting room populated only by my sobbing friend.
The clerk replied to him under his breath. The nurse rolled his eyes and sighed heavily. “Alright lady, let’s get you back to an examining room. Follow me.”
My friend followed him back to the patient rooms, doubled over in pain and was put on a stretcher with a thin curtain dangling limply from the ceiling.
She couldn’t control her tears. She couldn’t get comfortable and she moaned softly as she took short breaths to explain her past history. She handed him her business card, explaining who she was and that she was not faking her pain. The nurse made no eye contact, jotted down some notes in a binder, and prepared to leave the room.
“Listen, your crying is disturbing the other patients,” he said, yanking the curtain across the front of the room to block her visually, as if the curtain would make her disappear.
Hours passed. My friend had no recourse but to writhe on the stretcher and cry out occasionally when the pain was too intense too bear. She asked for them to order a CT scan so they could see the stones. The nurse ordered it, a physician never came to examine her.
Four hours later my friend was greeted by a physician. “You have kidney stones. One is in your right ureter, and there are others sitting in your left kidney. Do you need some Dilauded?”
“Yes please!” said my friend, hoping that some relief was in sight.
“Alright, the nurse will be here shortly.” Said the doctor, glancing at her chart without completing a physical exam.
The shift changed and a new nurse came in to place an IV. She was gruff and complained that my friends veins were too small. “I’ve never seen anyone with a kidney stone need this much pain medicine” she snapped with a suspicious tone.
Five hours after her arrival at a virtually empty ER my friend received pain medicine for her kidney stone. She is a cancer survivor and national spokesperson for patient advocacy. In her time of need, though, she had no advocate to help her. No, she received nothing for her years of service, for her selfless devotion to helping others, for her tenderness to patients dying of a disease with no cure.
That night, my friend did not even receive the benefit of the doubt.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
October 31st, 2007 by Dr. Val Jones in Health Tips
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Gruesome costumes abound at Revolution Health today. Characters from popular horror movies seem to be a favorite, some employees even toted plastic chainsaws and spouted red ink/blood. As I was chased down a hallway by a ghoulish colleague who pretended to amputate one of my arms, I began to think – maybe this could be the subject of an interesting blog post? [Enter awkward segue here.]
Did you know that one in every 200 people in the United States has had a limb amputation of some kind? While the majority of amputations occur due to poor circulation (usually related to diabetes), some are caused by trauma, cancer, or birth defects. Limb loss is not a fictional issue, but a real concern for more people than you think. The good news is that most folks do very well with prostheses and rehabilitation programs. But since this is Halloween, I couldn’t resist discussing a potential complication of limb loss: phantom pain.
“Phantom pain” is the term used to describe pain sensations in a missing limb. Although this may sound impossible at first (how can a person feel pain in his foot when that same leg was amputated already?) the reality is that the brain takes some time to adjust to limb loss. The human brain has entire sections devoted to sensing input from and delivering movement messages to our arms and legs. When an arm or leg is lost, that part of the brain continues to function for several months or more. And so as the local brain cells lack the usual input from the nerves in the absent limb, they fire in a spontaneous manner that is perceived as cramping, aching, or burning.
How on earth can you treat this kind of pain? As you can imagine, it’s quite tricky. Some of the more successful approaches involve helping the brain to adjust to the loss of sensory input by touching or massaging the stump and walking on a limb prosthesis. These new sensations help the brain to adjust to the body’s changes. In fact, imagining moving the lost arm or leg can result in some relief of the perceived pain. This is the one case I can think of where imaginary exercise can be of real benefit to your body!Some folks do require special pain medicines (tricyclic antidepressants, seizure meds, and beta blockers can help modestly) to cope while their brain adjusts to the new input. However, most amputees experience the sensation that their limb is still there, but without any pain or unpleasantness. Phantom sensations and phantom pain almost always resolve with time – which is a testament to the amazing flexibility (or “plasticity“) of the human brain.
That being said, I hope you each have a safe Halloween – and that your only potential injury comes from a ghoul with a plastic chain saw.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 21st, 2007 by Dr. Val Jones in News, Opinion
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An interesting meta-analysis was recently published in the Annals of Internal Medicine. It showed that acupuncture for knee arthritis can reduce pain, but its effects are likely due to the placebo effect. The placebo effect is nicely described in Wikipedia:
A so-called placebo effect occurs when a patient’s symptoms are altered
in some way (i.e., alleviated or exacerbated) by an otherwise inert
treatment, due to the individual expecting or believing
that it will work. Some people consider this to be a remarkable aspect
of human physiology; others consider it to be an illusion arising from
the way medical experiments are conducted.
Because of the mind-body connection, we humans can actually alter our experience of pain if we will ourselves to do so. We experience more intense pain when we’re depressed or particularly fixated upon it (via boredom for example). And we experience less pain when we’re happy (take women immediately after giving birth – they barely even notice the Ob as she sews up their tears).
When it comes to pain management, there are many non-medical techniques that can improve the experience of pain, even if it doesn’t affect the physiology of it. And so if we can find ways to put ourselves in a frame of mind that minimizes the pain sensations, that can be really valuable.
But as far as the physiology of acupuncture is concerned, we have not yet been able to explain exactly how it works. I’ve often wondered if it may be due to the fact that the sharp pain fibers (stimulated by acupuncture needles in different locations) travel along slightly different nerve pathways than the fibers from the actual painful area for which one is getting the acupuncture. The pain input might subconsciously distract the mind from the duller (or more chronic) pain input from the arthritic joint (or other pain generator). This might explain why sham acupuncture works (meaning, putting the needles anywhere, rather than in certain specified meridians).
I’m sure some of you will disagree with this – and it’s only a theory. But it does seem that inserting tiny sharp needles into the skin improves pain sensations in knee arthritis – no matter where the needles are put. How do we explain this placebo effect? I’m not sure – but if the treatment is quite harmless, and seems to decrease pain, how important is it to have an explanation?
And by the way, I was just about to post this when I found another interesting article about acupuncture in the journal Circulation. In this study, they found that acupuncture (when performed 3-5 times a week for 30 minutes each time) was able to reduce blood pressure by about the same amount as a low dose ACE inhibitor pill. Interestingly, though, in this case the needles placed according to Traditional Chinese Medicine (in certain meridians) rather than sham acupuncture (random placement) decreased blood pressure significantly more. I wonder if the TCM placements are activating the autonomic nervous pathways in this case?
At this point the jury’s still out on how all this works. But acupuncture does have measurable effects – even if they’re due to the placebo effect and/or stimulation of the autonomic nervous system. The real question is: would you rather pop a pill each day or travel to and from an acupuncturist’s office 3-5 times a week for 30 minute treatment sessions?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 2nd, 2007 by Dr. Val Jones in True Stories
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Continuing on with the car accident theme… A patient came to see me in the clinic. She had been run down by a bike messenger (could it have been my friend with the bleeding leg?) when attempting to step out of a bus onto a cement curb. She had a lot of pain in her shoulder and side, and was taken to the ER where a chest XRay was unremarkable. She was released with a prescription for extra strength Tylenol.
Still in pain, she made an appointment at the hospital’s orthopedic clinic for the next available time slot (she was covered by Medicaid) where she met with a young resident who suspected that she was a drug seeker and sent her away with “reassurance” and more Tylenol.
The woman, knowing that if she came back to the clinic again, she’d probably see a different physician (and could therefore get a second opinion) – made another appointment. The next orthopedic resident read her chart (where the previous resident had written that the patient exhibited drug seeking behavior) and barely listened to the woman’s story. But after the patient insisted he do something, the orthopedist did what most do with “chronic pain patients” – send them to the rehab doc.
And so, nearly 6 weeks after the accident, I met the woman in the rehab clinic. I had read the ortho notes prior to seeing the patients and was nearly convinced from their descriptions that she was a belligerent, drug-seeking nightmare.
The woman was thin and irritable. I asked her why she had come to see me, and she said she thought I was going to do some physical therapy with her. I asked if she could recount the events in her own words, and explain what exactly was troubling her. As the story unfolded, I was saddened by what she described – the endless frustration of being in pain, of being bounced around from one young physician to another in clinics overflowing with patients, and of being labeled as a drug seeker. And all this after a very painful encounter with a hit-and-run bike messenger.
I asked her to describe her pain and point to it exactly. She said it had been slowly improving, but that it hurt most when she breathed in and there was some point tenderness over her 8th, 9th, and 10th ribs. I asked her if she had had a rib series… nope just a chest XRay.
I told the woman I thought it was likely that she had fractured her ribs, and that rib fractures are often hard to see on XRays, especially chest XRays. I also told her that there wasn’t any real treatment for rib fractures, except pain management and time to heal. Her face lit up.
“So you believe me? I’m not crazy?”
“Sure I believe you,” I said. “I’ve fractured ribs in the past and I know how painful it is. When it happened to me no one believed me either. My chest XRay was normal.”
“So what did you do about it,” the patient asked, looking at me compassionately.
“The truth is, I had to sleep sitting up for a week or so, and I breathed very shallowly for a while. Eventually, though, the pain went away on its own.”
“Thank you for listening to me, doc,” she said, tears welling up in her eyes. “Even though there’s nothing I can do about the ribs, I’m glad to know what the pain is from, and that I’m not crazy.”
I wrote a short note in the chart, documenting my impressions. I did not recommend physical therapy for the patient, but to follow up if needed.
Apparently, the woman had one more clinic appointment with the orthopedic team. They read my note and ordered a rib series to confirm the diagnosis. The rib series showed healing fractures of ribs 8, 9, and 10.
I never saw the patient again, but I’m quite sure that explaining her diagnosis was the most therapeutic thing that we did for her.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
