Prisoner of My Preconceptions

I soon overheard our charge nurse mention that a prisoner from a regional correctional facility was in the emergency department (ED) with “really bad sepsis.”

“Ugh,” I muttered in quiet annoyance. In my experience, these patients never fared well. Moreover, my cynical side suspected that more wasteful use of limited health care resources was on the horizon. Perhaps I would have felt differently if the patient were not a prisoner; I have no doubt a large part of my reaction was that part of me assumed that anyone who winds up in prison probably is a “bad person.”

Four heavy-set grizzly men in tan security guard uniforms accompanied the cachectic prisoner into the MICU. I immediately noticed that he was shackled to the hospital bed by numerous cuffs and full-body restraints, all of which seemed unnecessary since he was heavily sedated, intubated, and mechanically ventilated. It seemed as though the excessive correctional paraphernalia were there simply to indicate the misguided and reckless life choices that he presumably chose. They may as well have written on his forehead, “I am deplorable.”

I overheard the signing-off ED nurse say in a monotone voice, “the patient is a 53-year-old male inmate with diffuse large B-cell lymphoma being admitted for presumed septic shock from a necrotic right thigh mass.”

“53? He looks more like 83,” I thought in sheer disbelief. I considered what a grueling life this man must have led to look as feeble as he did.

Once the transfer was complete and the patient was settled in his room, it was obvious that his sepsis was due to a decaying, malodorous mass protruding from his lower extremity, along with a large left pneumonia and empyema. Standard sepsis bundles and protocols were initiated and the patient continued receiving a broad-spectrum of antibiotics, intravenous fluids, and two vasopressors. For source control, general surgery was consulted for debridement of his grossly infected, necrotic thigh mass, and he would require a chest tube to drain the empyema. I immediately cringed at the assuredly onerous process of obtaining informed consent for the invasive procedures. Consent could not be obtained directly from the patient for obvious reasons, and I was dubious that any family members would be reachable. Even if kin could be reached, I knew of the cumbersome hoops that I would need to surmount to obtain the obligatory consent. I had no time for this right now; the patient was now hemodynamically unstable and his respiratory status was deteriorating. I talked with an intern and asked him to tackle the dreaded consent quandary.

Ten minutes later, the intern said to me proudly, “Consents for the procedures are in the chart.” I was flabbergasted and perplexed by the rapidity of the process. Little did I know that the patient was a married man with three children. Also unanticipated was that, despite being incarcerated, the patient was in fairly regular contact with family, which made for an effortless phone conversation between the family and intern, who easily and appropriately obtained consent.

As I sterilized and draped the patient in anticipation of his chest tube procedure, I was instantly jolted by compassion as I gazed into his lifeless eyes.

How Not to Talk to Patients

Being a doctor is about as much of a social job as one can get. Even though computers and healthcare information technology mean that physicians are now spending a disproportionately large amount of their time staring at their computer screens, there's no getting around the importance of good old face-to-face interactions. That's also what's valued by your patients. In this time of great upheaval in healthcare, everything has changed apart from human nature.

Here are five things that doctors should never do:

1. Keep turning around and looking at your computer screen when your patient is trying to talk to you. This is consistently one of the things that annoys patients the most. Of course, it's very difficult for doctors as well, who have a high amount of bureaucratic "tick boxes" to satisfy, but try setting aside a dedicated amount of time just to sit face-to-face and talk the good old-fashioned way.

2. Make it obvious you are in a hurry. Humans are perceptive animals, and we can all sense when someone is trying desperately to get away from us! Be aware of the subtle body language clues that will give this away, including starting to walk away (in a hospital), cutting people off, or worst of all -- telling the patient how busy you are

JAMA Forum: Reforming Medicaid

We are 2 former Administrators of the Medicare and Medicaid programs, under Presidents Barack Obama and George H. W. Bush. Although we represent different political parties, we take pride in the accomplishments of these 2 programs, which collectively help millions of US residents get the health care they need.

Medicaid has become a major focus in the debate over repealing the Affordable Care Act (ACA), because the proposed replacement bills go beyond the ACA into the underlying Medicaid program that was originally passed by Congress in 1965. As we have overseen the Medicaid program at various stages, we are familiar with its successes, its areas for improvement, its effect on state budgets, and its importance to millions of ordinary people who count on the program and will need it in the future.

That is why we are calling for Congress to separate reforms to the Medicaid program from the most pressing task at hand—stabilizing and improving the nongroup market. Given the divergent views on appropriate Medicaid changes, we recommend initiating a 12-month bipartisan review process that focuses on long-term reforms to improve care and reduce costs. Such a process would benefit from broad stakeholder involvement and expert feedback, gathered outside of the heat of the current political environment. Changes to the individual market alone have a greater chance of receiving bipartisan support while substantive work on Medicaid is under way.

The Myth of Drug Expiration Dates

The box of prescription drugs had been forgotten in a back closet of a retail pharmacy for so long that some of the pills predated the 1969 moon landing. Most were 30 to 40 years past their expiration dates — possibly toxic, probably worthless.

But to Lee Cantrell, who helps run the California Poison Control System, the cache was an opportunity to answer an enduring question about the actual shelf life of drugs: Could these drugs from the bell-bottom era still be potent?

ProPublica has been researching why the U.S. health care system is the most expensive in the world. One answer, broadly, is waste — some of it buried in practices that the medical establishment and the rest of us take for granted.  We’ve documented how hospitals often discard pricey new supplies, how nursing homes trash valuable medications after patients pass away or move out, and how drug companies create expensive combinations of cheap drugs. Experts estimate such squandering eats up about $765 billion a year — as much as a quarter of all the country’s health care spending.

The findings surprised both researchers: A dozen of the 14 compounds were still as potent as they were when they were manufactured, some at almost 100 percent of their labeled concentrations.

“Lo and behold,” Cantrell says, “The active ingredients are pretty darn stable.”

It turns out that the FDA, the agency that helps set the dates, has long known the shelf life of some drugs can be extended, sometimes by years.

 In fact, the federal government has saved a fortune by doing this.

For decades, the federal government has stockpiled massive stashes of medication, antidotes and vaccines in secure locations throughout the country. The drugs are worth tens of billions of dollars and would provide a first line of defense in case of a large-scale emergency.

2006 study of 122 drugs tested by the program showed that two-thirds of the expired medications were stable every time a lot was tested. Each of them had their expiration dates extended, on average, by more than four years, according to research published in the Journal of Pharmaceutical Sciences.

Some that failed to hold their potency include the common asthma inhalant albuterol, the topical rash spray diphenhydramine, and a local anesthetic made from lidocaine and epinephrine, the study said. But neither Cantrell nor Dr. Cathleen Clancy, associate medical director of National Capital Poison Center, a nonprofit organization affiliated with the George Washington University Medical Center, had heard of anyone being harmed by any expired drugs. Cantrell says there has been no recorded instance of such harm in medical literature.

Whole Person Care Takes Another Step Forward

Thanks and a hat tip to Dohn H.......

If you are looking for trends in the health and human services industry, California is often the place to look (see California As A Bellwether). Another great recent example of California at the forefront of industry trends is whole person care coordination – the practice of treating consumers with co-occurring health conditions and social services needs, specific to each consumer’s needs.

In July, the California Department of Health Care Services (DHCS) launched seven new Medi-Cal Whole Person Care (WPC) pilots and expanded another eight – bringing the total number of pilot programs to 25 (see California Medicaid Launches 7 New Whole Person Care Pilots, Expands 8 Others). These five-year WPC pilots are locally-based initiatives that coordinate physical health, behavioral health, and social services, including non-Medicaid services, housing, and supportive services for Medicaid beneficiaries. Also key to the initiative – the pilots rely on data sharing to identify the targeted populations, link them to services, and track the intervention impact on outcomes.

First and foremost, how will these pilots change the work done by provider organizations in the California market and how does this represent an opportunity? There are two elements to keep in mind:

Clinical Trial Suggests Parkinson’s Can Be Halted

It may be possible to stop the progression of Parkinson’s disease with exenatide, a drug typically used to treat Type 2 diabetes, a new U.K. clinical trial suggests. Parkinson’s gradually damages the brain as cells that produce dopamine start dying. Currently, drugs can help manage the symptoms, but they do not prevent the progression of the disease. “This is the first clinical trial in actual patients with Parkinson’s where there has been anything like this size of effect,” said Tom Foltynie, a professor who worked on the trial. “It gives us confidence exenatide is not just masking symptoms; it’s doing something to the underlying disease. We have to be excited and encouraged, but also cautious as we need to replicate these findings.”

Meta-Analysis: Tai Chi Keeps Seniors from Falling

Tai chi may reduce the rate of falls and injury-related falls during the first year by about half in older and at-risk adults, according to a new meta-analysis.

Pooled data from 10 randomized controlled trials showed a significant 43% reduction in the risk of falls compared with other interventions at 12 months or less, and a reduction in the risk of injurious falls by 50% over the short term, Rafael Lomas-Vega, PhD, from the University of Jaén in Spain, and colleagues reported online in the Journal of the American Geriatrics Society.

Welcome to Iridis

Thanks and a hat tip to Kathryn W.....

Thank you for signing up to hear about the latest news on Iridis. We are delighted that you want to be part of this cutting-edge revolution in the sharing of dementia design principles. 

The University of Stirling’s Dementia Services Development Centre (DSDC)has an international reputation for promoting best practice in design for people with dementia. We know that good design can help people with dementia stay independent for longer and improve their well-being and overall quality of life. 

Dementia Design Audit Tool
You may already be aware of DSDC’s Dementia Design Audit Tool, which has been used around the world to assist with the designing of dementia inclusive environments. Iridis will allow us to take the research based design principles, which underpin the audit tool, and translate them into a digital tool which can be accessed by those who want to improve environments for people with dementia. 


The Iridis app has been made possible through collaborating with Space Group, international design and technology specialists for property and construction.  By combining our range of knowledge and expertise we will be able to provide you with a ground-breaking app which will help to improve the lives for people with dementia and their carers. 

Centrist lawmakers plot bipartisan health care stabilization bill

A coalition of roughly 40 House Republicans and Democrats plan to unveil a slate of Obamacare fixes Monday they hope will gain traction after the Senate’s effort to repeal the law imploded.

The Problem Solvers caucus, led by Tom Reed (R-N.Y.) and Josh Gottheimer (D-N.J.), is fronting the effort to stabilize the ACA markets, according to multiple sources. But other centrist members, including Rep. Kurt Schrader (D-Ore.), and several other lawmakers from the New Democrat Coalition and the GOP’s moderate Tuesday Group are also involved.

Their plan focuses on immediately stabilizing the insurance market and then pushing for Obamacare changes that have received bipartisan backing in the past.

The most significant proposal is funding for Obamacare’s cost-sharing subsidies. Insurers rely on these payments – estimated to be $7 billion this year — to reduce out-of-pocket costs for their poorest Obamacare customers.

IL-6 Blocker Wins in Vasculitis

Among a cohort of 251 patients with biopsy or imaging-confirmed giant-cell arteritis who underwent a 26-week prednisone taper, 56% of those who received subcutaneous tocilizumab once weekly were in sustained remission at week 52, as were 53% of those who were given the interleukin-6 receptor alpha inhibitor every other week, according to John H. Stone, MD, of Massachusetts General Hospital in Boston, and colleagues.

In contrast, only 14% of patients given placebo with a 26-week prednisone taper had sustained remission after 1 year, as did 18% of those given placebo with a 52-week prednisone taper (P<0.001 for both tocilizumab groups versus placebo), the researchers reported in the New England Journal of Medicine.

However, longer-term follow-up is needed to more fully assess the safety of tocilizumab.