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.
August 6th, 2007 by Dr. Val Jones in Expert Interviews, Health Tips
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A new study in the Journal of the American College of Cardiology (August 14th issue by Bangalore et al.) questions the evidence behind using beta blockers as fist line therapy for high blood pressure. It seems that these medications may actually increase the risk of stroke, especially in the elderly population. The following drugs are all beta blockers:
- Atenolol (Tenormin)
- Metoprolol (Lopressor, Toprol-XL)
- Propranolol (Inderal, Inderal LA)
- Carvedilol (Coreg)
As many as 60 million Americans have high blood pressure, and many of them are currently taking beta blockers. I asked Dr. Frank Smart, chairman of the department of cardiovascular medicine at Atlantic Health in New Jersey, what he thought of this new study.
1. What is a beta
blocker?
Beta blockers are a class of drugs that exert their effects on the heart by blocking the effects of adrenaline. This results in a slower heart rate and reduced blood pressure. They can also protect you from rhythm disturbances.
2. What did this study show?
Beta blockers have a lot of important uses, but this analysis shows that they’re not as effective as (and may have more side effects than) other therapies for the treatment of high blood pressure. In the past, we physicians thought, “Well, shucks, if beta blockers are good to use after a heart attack, and people with high blood pressure are at risk for having heart attacks, then maybe we should use a beta blocker to treat the blood pressure.” This study contradicts this thinking, suggesting that the beta blockers are inferior to other therapies. In other words, we should use beta blockers for the conditions that they’re known to be good for, but we should not infer that they are best for blood pressure management when there are better drugs available.
3. Will the findings of this study
change your practice?
Yes they will. I’m one of those people who have used beta blockers on occasion to treat high blood pressure in patients whom I thought were also at high risk for heart attack. I probably won’t use beta blockers as first line treatment in those individuals anymore. I’m going to stick with diuretics or renin-angiotensin system blockers.
4. What do these findings mean for
people with high blood pressure?
It means that they should follow the guidelines indicated for the treatment of high blood pressure. It involves a step-wise approach, with diuretics being that first step. Any therapy is better than no therapy, and controlling high blood pressure is critically important, but beta blockers (as a monotherapy) are probably not as good as other treatments.
5. When would you recommend the use of
beta blockers?
Beta blockers are a very important class of drugs for many cardiovascular diseases. Anyone who’s had a heart attack needs to be on a beta blocker, anyone who has congestive heart failure (CHF) and can tolerate a beta blocker should be on one, and hypertrophic cardiomyopathy requires treatment with beta blockers. Beta blockers can control certain heart rhythm disturbances, and can reduce the risk of adverse cardiovascular events during surgery.
6. What’s the take home message from
this study?
When treating high blood pressure, we should use drugs that have been shown to have the greatest reduction in mortality. Don’t assume that the valuable effects of beta blockers (for people who’ve had heart attacks) automatically translate into benefits for people with high blood pressure.
Want to hear the full conversation? Listen to the podcast with Dr. Smart
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 5th, 2007 by Dr. Val Jones in News
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Russia has been promoting a new sport: the stiletto heels sprint. Although I’d heard of this a couple of months ago, I just noticed some video footage on Yahoo! In this particular race, over 200 women turned out to run 1 kilometer (about 2/3 of a mile) in heels that are at least 3.5 inches high.
It is well known that regularly wearing high heels can result in foot deformities such as bunions and corns. And yet women continue to wear them as they never seem to go out of fashion. If you’re unwilling to give up those heels, but would like to avoid having feet that look like this, here are some tips for you:
1. Minimize the distance you walk in heels. Carry your shoes to work with you and wear flats or sneakers during most of your walking.
2. Wear shoes that are wide in the toe box and do not squeeze your toes together.
3. Put metatarsal pads in your high heeled shoes, to keep your foot from sliding forward (especially if they are closed-toe).
4. Don’t wait too long to see a rehabilitation medicine specialist or podiatrist if you think you’re developing a bunion. Corrective action should be taken as early as possible.
5. If you’re working at your desk, remember to slip off your shoes to reduce the pressure on your toes. Every lit bit helps when it comes to reducing toe joint stress. If your relatives have bunions, you may be at higher risk for developing them too.
As for those Russian women who race in their stilettos, all I can say is that they’ll be keeping the rehab docs, orthopedists and podiatrists in business!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 23rd, 2007 by Dr. Val Jones in Opinion
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Many European countries have “presumed donor policies” where (unless otherwise stipulated) the untimely demise of one of its citizens results in potential organs for those on organ transplant waiting lists. In other words, the default assumption is that you want to be an organ donor should you die in an accident.
Britain is now undergoing internal debate over whether or not to institute a presumed donor policy. On the “no” side is Scotland and the Conservatives – suggesting that the government has no right to an individual’s remains. On the “yes” side are the Liberals and the British Medical Association – reminding the “no’s” that people are free to opt out, and that studies show that 70% of people have not formally registered to donate their organs even though they state that their wish would be to donate their organs in the event of sudden death.
Spain has been very successful with their presumed donor policy – doubling organ donations after enacting it into law. Austria quadrupled their organ donations after following suit.
I think that Europe’s presumed donor policy is a good idea and I would personally endorse a similar policy in the US, so long as next of kin had veto power. What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 19th, 2007 by Dr. Val Jones in News
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There was a very interesting case report in the New England Journal of Medicine this week. A 25 year old woman went bungee jumping and wound up with sudden decreased vision in one eye. As it turned out, the sudden yank of the bungee cord (while being upside down) caused an increase in pressure in her eye ball (kind of the way the Heimlich maneuver can), and broke one of the blood vessels in the back of her eye. Luckily she had surgery to remove the blood and recovered nearly normal vision in that eye a week later.
If I ever felt tempted to go bungee jumping, this case cured my curiosity. How about you?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
