December 1st, 2007 by Dr. Val Jones in Expert Interviews
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I recently spent some time with Dr. Kevin Means, Chairman of the Department of Physical Medicine and Rehabilitation at the University of Arkansas in Little Rock. I asked Dr. Means about his life, how he chose his specialty, and how he came to Little Rock from New York City. This is his story:
Kevin Means grew up on Long Island and attended college in Binghamton, NY. The summer after his first year of college he began looking for work to help him pay his way through school. Jobs were few and far between, and only “undesireable” work remained for college students. Kevin heard about a position as a physical therapy assistant at a facility for the disabled. They were having a difficult time recruiting and retaining candidates due to the strenuous work requirements – heavy lifting, assisting patients with exercises, and moving imobile (and sometimes obese) individuals around was not feasible for many people. But Kevin was a tall, strong, African American man – undaunted by the challenges.
The first few days filled him with sadness – young men with spinal cord injuries, elderly people recovering from severe strokes, amputees with traumatic brain injuries – all doing what they could in the gymnasium. Kevin surveyed the patients and took to heart the individual tragedies that had brought each of them there. He observed the physical therapists as they encouraged movement in the imobile, taught people how to use shriveled limbs, and helped amputees use new prostheses to walk again. Over time, he began to see that each life was a beautiful story of triumph over adversity, and his initial sadness melted as he witnessed the daily victories of recovery.
Slowly, Kevin began taking on more responsibility at the facility. He would sometimes offer additional therapy sessions to patients and stayed late in the evening to make sure that everyone had a full day of exercise. Although he had no formal training as a physical therapist, he grew to understand and practice their techniques, and was dearly loved by the patients.
One day Kevin was offered an office job that paid substantially more than the PTA position. He accepted it gladly, but in the afternoons found himself thinking about his friends at the rehab facility. He wondered if the patients were being cared for correctly, if they were recovering well, and if the nurses were strong enough to help the therapists transfer the patients safely. These nagging questions burned in his mind as he filed paperwork and made phone calls. He just couldn’t stop worrying about them.
A few days later, Kevin returned to his position as a PTA in the rehab facility. He had learned that working with disabled men and women was more fulfilling to him than an office job. He spent the next 3 years working there part-time, and developed long lasting friendships with the patients and staff.
When it came time to go to medical school, Kevin promised his friends that he would do all he could to sharpen his therapy skills and research new ways to help them become independent in their daily lives. For this reason, he chose PM&R as his specialty and attended residency at the top-ranked Rehabilitation Institute of Chicago (RIC). When I asked Kevin why he didn’t stay on at RIC after his residency, he simply said that they didn’t need him. They had plenty of bright, talented physicians who could help to advance the field. Kevin wanted to go where needs were greater, and where his work might bring new hope to those who had very little.
And so Kevin went to Little Rock, Arkansas in the mid ’80’s – to help to build a PM&R program there. He was single – a fact that his friends in Chicago and New York must have called to his attention. But he forged ahead on faith, assuming that he would meet his wife in good time.
Over the past two decades, Kevin has worked tirelessly to grow and establish the PM&R department at UAMS as a center of excellence in rehabilitation medicine. He met his (now) wife while she was working a second job as a clerk at a department store in Little Rock (she is a teacher), and they have 2 lovely children. Kevin took me on a tour of the UAMS facilities which span 3 modern buildings equiped with 2 large swimming pools, beautiful gardens and multiple gymnasiums.
I watched his face as he looked out onto a team of 30+ therapists assisting disabled adults with their goals in a gym. He smiled at the physical therapists and PTAs and I had to wonder if the scene reminded him of his days in Binghamton, and the friendships that gave him the first glimpse of his calling as a physician.
Kevin never did lose sight of his first love: advocating for the needs of the disabled. His career path has taken him from Binghamton to Little Rock – as he steadfastly fulfills his calling as a nurturing healer, working in places where needs are great, and workers are few.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 13th, 2007 by Dr. Val Jones in Health Tips, News
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Diabetes is a tricky disease. Sugar build up in the blood stream can damage tiny blood vessels that supply nerve endings, resulting in skin numbness. The feet are at the highest risk for nerve damage (neuropathy) and folks with diabetes often cannot sense pain in their feet.
How many of us have gotten blisters from ill fitting shoes? Painful, right? Well imagine if you didn’t feel the pain of the blistering and kept on walking, oblivious to the injury. Eventually you’d have a pretty bad sore there. This is what happens to people with diabetes who don’t choose their shoes carefully. In addition, sores don’t heal well because of the decreased blood supply to the area (from the damaged blood vessels). And to top it off, the high sugar levels in the sores provides additional sustenance to any bacteria that might be lurking on the skin. It’s pretty easy for diabetics to develop infected wounds, which can grow larger and even require amputations of dead tissue.
A recent research study suggests that the secret to avoiding this downward spiral is in choosing shoes that fit well – though they estimate that as few as one third of people with diabetes actually wear optimal fitting shoes. This may be because there is a strange temptation for people with diabetes to choose extra small shoes due to their neuropathy. When normal sensation is lost in the feet, tight fitting shoes actually feel better because they can be sensed more readily by the brain. So even though spacious shoes that don’t cramp the toes or cause blistering are the best footwear, they don’t always feel as comfortable. However, patients with diabetes who are properly fitted for orthopedic shoes with the help of a physiatrist or podiatrist, may substantially reduce their risk of ulcers.
So the bottom line for people with diabetes: choose your footwear carefully, and get professional help to make sure that your shoes fit well. Proper shoes could help to decrease your risk for foot and leg ulcers and potential amputations.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.
August 31st, 2007 by Dr. Val Jones in Health Tips
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Have you ever had a strange cramp in your foot (between your big toe and the next one or in the ball of your foot) after wearing flip flops all day? Do you get sore calves or pain in the bottom of your feet?
Flip flops seem comfortable and easy to wear (I like them because they don’t pinch wide feet) but they actually create more work for your foot and leg muscles than regular shoes. You may not realize it, but when you wear flip flops your toes must grip them extra firmly to keep them from sliding off or sideways. So you actually contract many extra toe muscles (like the adductor hallucis and the flexor hallucis brevis) with each step you take. Wearing flip flops for long hours can give you actual cramps in these muscles and others.
In addition to muscle cramps, flip flops have no arch support so your calf muscles and Achilles tendon have to work extra hard and can become sore. And finally, the lack of support can strain your plantar fascia (a thin rubbery band on the bottom of your foot), causing pain at its point of origin on the heel bone.
So if you’re having foot pain or muscle cramps – it may be caused by too much flip flopping. Of course, the cure is simple: wear comfortable shoes with good arch support and sturdy straps. Luckily for you, summer is almost over and your feet may recover naturally as you pack up the flip flops and pull out the work shoes.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 12th, 2007 by Dr. Val Jones in True Stories
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This week’s host of medical grand rounds invited individuals to submit blog posts that feature stories about “sudden change.” As I meditated on this theme – I realized that one of my patients played a key role in my sudden career change from academic medicine to joining a healthcare revolution.
As chief resident in PM&R, I spent a few days a month at an inner city clinic in the Bronx, helping to treat children with disabilities. The clinic was dingy, overcrowded, largely windowless, and had waiting lines out the door starting at 8am. Home health attendants generally accompanied the wheelchair-bound children to the clinic as many of them were orphans living in group home environments. The kids had conditions ranging from cerebral palsy, to spinal cord injury from gun shot wounds, to severe spina bifida. They sat together in a tangled waiting room cluttered with wheelchairs, walkers, crutches, and various prosthetics and orthotics. There were no toys or even a TV for their amusement. The air conditioning didn’t work well, and a lone clock ticked its way through the day with a bold black and white face.
The home health aides were eager to be called back to the examination rooms so that they could escape the oppressive conditions of the waiting room. I opened the door to the room and called the name of one young man (we’ll call him Sam) and an aide leapt to her feet, knocking over another patient’s ankle-foot orthosis in the process. She pushed Sam’s electric wheelchair through a series of obstacles to the exit door and back towards the examining room.
Sam was a teenager with cerebral palsy and moderate cognitive deficits. His spine was curved into an S shape from the years of being unable to control his muscles, and he displayed the usual prominent teeth with thick gums of a patient who’d been on long-term anti-seizure medications. He looked up at me with trepidation, perhaps fearing that he’d receive botox injections for his spastic leg muscles during the visit. His wheelchair was battered and worn, with old food crumbs adhering to the nooks and crannies.
“What brings Sam here today?” I asked the home health aide, knowing that Sam was non-verbal. She told me that the joystick of his electric wheelchair had been broken for 10 months (the chair only moved to the left – and would spin in circles if the joystick were engaged), and Sam was unable to get around without someone pushing him. Previous petitions for a joystick part were denied by Medicare because the wheelchair was “too new” to qualify for spare parts according to their rules. They had come back to the clinic once a month for 10 months to ask a physician to fill out more paperwork to demonstrate the medical necessity of the spare part. That paperwork had been mailed each month as per instructions (there was no electronic submission process), but there had been no response to the request. Phone calls resulted in long waits on automated loops, without the ability to speak to a real person. The missing part was valued at ~$40.
I examined Sam and found that he had a large ulcer on his sacrum. The home health aid explained that Sam had been spending most of his awake time in a loaner wheelchair without the customized cushioning that his body needs to keep the pressure off his thin skin. She said that she had tried to put the electric wheelchair cushion on the manual chair, but it kept slipping off and was unsafe. Sam’s skin had been in perfect condition until the joystick malfunction. I asked if he’d been having fevers. The aide responded that he had, but she just figured it was because of the summer heat.
Sam was transferred from the clinic to the hospital for IV antibiotics, wound debridement, and a plastic surgery flap to cover the gaping ulcer hole. His ulcer was infected and had given him blood poisoning (sepsis). While in the hospital he contracted pneumonia since he had difficulty clearing his secretions. He had to go to the ICU for a period of time due to respiratory failure. Sam’s home health aide didn’t visit him in the hospital, and since he was an orphan who was unable to speak, the hospital staff had to rely on his paper medical chart from the group home for his medical history. Unfortunately, his paper record was difficult to read (due to poor handwriting) and the hospital clerk never transferred his allergy profile into the hospital EMR. Sam was violently allergic to a certain antibiotic (which he was given for his pneumonia), and he developed Stevens-Johnson Syndrome and eventually died of a combination of anaphylaxis, sepsis, and respiratory failure.
When I heard about Sam’s tragic fate, it occurred to me that the entire system had let him down. Bureaucratic red tape had prevented him from getting his wheelchair part, poor care at his group home had resulted in a severe ulcer, unreliable transfer of information at the hospital resulted in a life-threatening allergic reaction, and a lack of continuity of care ensured his fate. Sam had no voice and no advocate. He died frightened and alone, a life valued at <$40 in a downward spiral of SNAFUs beginning with denial of a wheelchair part that would give him mobility and freedom in a world where he had little to look forward to.
Sam’s story was the last straw in my long list of frustrations with the healthcare system. I began looking for a way to contribute to some large scale improvements – and felt that IT and enhanced information sharing would be the foundation of any true revolution in healthcare. And so when I learned about Revolution Health’s mission and vision, I eagerly joined the team. This is a 20 year project – creating the online medical home for America, with complete and secure interoperability between hospitals, health plans, healthcare professionals, and patients. But we’re committed to it, we’re building the foundation for it now, and we know that if successful – people like Sam will have a new chance at life. I can only hope that my “sudden change” will have long lasting effects on those who desperately need a change in healthcare.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
