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Thursday, October 30, 2008

I didn't want to end up with someone else's meal: Colored name tags and hospital bracelets

Nurses at Roosevelt Hospital in New York City were caring for Tom Pineault, age 74, a former merchant seaman, who was recovering from surgery for an ulcerated foot. When they pointed out the yellow name tag on the door of his hospital room, denoting that he was at risk of a fall, he also checked the tag for his name. "I made sure that was me that was in there," he said. "I didn't want to end up with somebody else's meal."

Hospitals are using color-coded name tags and bracelets much more frequently now to avoid errors, by quietly alerting the nurses who see them. The colors differ from hospital to hospital, which may be confusing for nurses who work at different hospitals.

Advice to hospital patients and their advocates: Ask about the meaning of any colored bracelets or name tags you receive. It'll ensure that you get the right meal – and maybe the right meds.

Thanks to Anemona Hartocollis for the article in the Sept 25 issue of the New York Times.

Tuesday, October 28, 2008

Mustard and relish sandwiches: Broadening health insurance coverage

From Barack Obama's More Perfect Union speech, March 18, 2008, Philadelphia, Pennsylvania:

There is a young, twenty-three year old white woman named Ashley Baia who organized for our campaign in Florence, South Carolina. She had been working to organize a mostly African-American community since the beginning of this campaign, and one day she was at a round-table discussion where everyone went around telling their story and why they were there.

And Ashley said that when she was nine years old, her mother got cancer. And because she had to miss days of work, she was let go and lost her health care. They had to file for bankruptcy, and that's when Ashley decided that she had to do something to help her mom.

She knew that food was one of their most expensive costs, and so Ashley convinced her mother that what she really liked and really wanted to eat more than anything else was mustard and relish sandwiches. Because that was the cheapest way to eat.

She did this for a year until her mom got better, and she told everyone at the round table that the reason she joined our campaign was so that she could help the millions of other children in the country who want and need to help their parents too.

Now Ashley might have made a different choice. Perhaps somebody told her along the way that the source of her mother's problems were blacks who were on welfare and too lazy to work, or Hispanics who were coming into the country illegally. But she didn't. She sought out allies in her fight against injustice.

Anyway, Ashley finishes her story and then goes around the room and asks everyone else why they're supporting the campaign. They all have different stories and reasons. Many bring up a specific issue. And finally they come to this elderly black man who's been sitting there quietly the entire time. And Ashley asks him why he's there. And he does not bring up a specific issue. He does not say health care or the economy. He does not say education or the war. He does not say that he was there because of Barack Obama. He simply says to everyone in the room, "I am here because of Ashley."

I'm here because of Ashley." By itself, that single moment of recognition between that young white girl and that old black man is not enough. It is not enough to give health care to the sick, or jobs to the jobless, or education to our children.

But it is where we start. It is where our union grows stronger. And as so many generations have come to realize over the course of the 221 years since a band of patriots signed that document in Philadelphia, that is where the perfection begins.

Advice: Vote for, and work for, a presidential candidate who will broaden health insurance coverage.

Read another story of poor access to care.

Friday, October 24, 2008

Don't tell my wife: Stretching prescriptions

Martin Schwarzenberger, a 56-year-old accounting manager for the Boys and Girls Clubs of Greater Kansas City, s stretching out his prescriptions. Martin, who has Type 1 diabetes, is not cutting his insulin, but has started scrimping on a variety of other medications he takes, including Lipitor.

"Don't tell my wife, but if I have 30 days worth of pills, I'll usually try to stretch those out to 35 or 40 days," he said. “You're trying to keep a house over your head and use your money to pay all your bills."

Advice: Ask your doctor which of your prescriptions you can stretch with the least harm.

Read another story of access to care.

Thanks to Stephanie Saul for the source article in the Oct. 22 issue of the New York Times.

Thursday, October 23, 2008

They didn't mention it at all: Jon Lester, cancer survivor

The second game of the World Series is on as I write this, and the Red Sox aren't in it. Jon Lester pitched very well in game seven, but was out-duelled by Tampa Bay’s pitchers.

The announcers talked a lot during the game about the power and mix of Jon's pitches. They didn't mention at all that he was a cancer survivor.

Early in the season in Jon's first few victories on the baseball diamond, the headlines and the stories focused on the marvel that Jon could have returned, after cancer, to the top of his game. Now, it is a mark of how far he has come in his recovery that they don't mention it at all.

Advice: Understand that your cancer survivor friends may prefer not to talk about their cancer, that they don't want to be defined by it.

Read another story about Jon Lester.

Saturday, October 18, 2008

He still had headaches: A brain injury during a football game

Ryne Dougherty, a high school football player in Montclair, New Jersey, died on Wednesday of a brain hemorrhage he got while making a tackle during a junior varsity football game.

He had sustained a concussion on September 18, and then doctors cleared him to return to play three weeks later, even though he had told a teammate that he still had headaches – showing he had not fully recovered from the concussion.

His high school uses the ImPACT neurological testing program, a computer-based protocol that helps determine whether an athlete has recovered from a concussion. A baseline is performed before the season to gauge short-term memory and other mental functioning. Then, after a concussion, the player takes the test again, and the results are compared to the player's baseline results.

However, they had not actually given Ryne the baseline test.

Ryne was the second player in New Jersey, and at least the fourth in the U.S., this season to die from a brain injury.

Advice to parents of high school football players: Insist on a baseline test of mental function before the season.

Read another football story.

Thanks to Michael Schmidt and Dave Caldwell for the source article in Friday's issue of the New York Times.

Friday, October 17, 2008

We're not done yet: Drug court for drug abusers

At a regular session of the Seattle drug court, Jenifer Paris, 36, sounded hopeful. She was six months clean, she said, after 22 years of cocaine and heroin use and stretches of homelessness and prostitution. She is in a methadone maintenance program – acceptable to many drug courts – and in therapy.

"You guys are the first people to believe in me," she said. "I'm full of gratitude for the opportunity and for you not kicking me out," she said, eyes sweeping from Judge J. Wesley Saint Clair to the prosecutor and her public defender.

"We're not done yet," Judge Saint Clair replied with a hint of a smile.

Advice for family members of drug addicts: Drug court may help them straighten out.

Read another drug court story.

Thanks to Erik Eckholm for the source article in the Oct. 15 issue of the NY Times.

Thursday, October 16, 2008

Like the difference between black and white TV and HDTV: Misdiagnosis of an MRI scan

Jim Glanz, the Baghdad bureau chief for the New York Times, was playing touch football in New York in late 2005 when he landed hard while diving to make a catch, both elbows hitting the ground at once. The next day, his fingers and hands hurt so much he couldn't type.

But an MRI showed nothing except some bulging disks in his neck that, he was told, were common in people his age, 50. He was advised to do neck exercises, and eventually he felt better.

About a year later, he fell again while playing football. His symptoms came roaring back.

The worst was when he woke up in the morning, Jim said. The two middle fingers on each hand were so stiff they would not even bend. He would massage his fingers and loosen them, but his hands and knuckles ached all day. He tried ibuprofen, to little avail.

Finally, last spring, he sought help at the NYU Hospital for Joint Diseases, where he had another MRI. It turned out that he had a nerve impingement so serious that he was warned that he risked permanent paralysis if he did not have surgery. So this summer, he had a major operation called a French-door laminoplasty, in which his surgeon opened and widened four or five vertebrae to free the trapped nerves.

How could his MRI’s have come to such different conclusions? MRI machines vary in four ways: First, some use higher quality, more sensitive imaging coils that surround the body parts being scanned. Second, their computer programs vary in the way they form the images. Third, some technicians are much more skilled than others. Fourth, the strength of the machines' magnets varies. The difference can be like the difference between seeing a black-and-white TV versus HDTV, says Dr. John Kennedy of the Hospital for Special Surgery in New York.

Advice to people about to have an MRI: Make sure the radiology center is accredited by the American College of Radiology.

Read another MRI story.

Thanks to Gina Kolata for the source article in Tuesday's New York Times.

Friday, October 10, 2008

It’s almost unfair to my loved ones: A brain tumor support group

Jeffrey Schanz of Washington, DC is an 11-year survivor of a glioblastoma. After treatment, he was able to return to his high-pressure job with the U.S. Department of Justice as director of the Office of Policy and Planning within the Audit Division. He recently accepted a new job as inspector general of the Legal Services Corporation, which provides legal assistance to low-income people.

Jeffrey, age 56, runs a support group at the George Washington Cancer Institute in Washington, DC. Support group members share nutrition and exercise tips, information about alternative therapies, and humor.

Attending a support group helps him deal with the ups and downs of his recovery. Though his thinking is about the same as it was before the brain tumor, “not every day is a good day….There have been cases where I’ve had to be more deductive to figure out what was going on instead of just snapping my fingers and going, ‘Oh, yeah, I understand that...' In the brain-tumor world we call it a ‘new normal’ because you’re never going to be the same person," he says.

He understands the need for camaraderie. “It’s almost unfair to my loved ones,” he says, “but I’m more comfortable with brain-tumor survivors because we all know what we’ve gone through. It’s still hard to articulate how hard you have to fight.”

Advice to people with a brain tumor: Find a support group to participate in.

Read another brain tumor story.

Thanks to Stephanie Cajigal for the source story in the September/October issue of Neurology Now.

Monday, October 6, 2008

Her first one since childhood: Counselors for the uninsured

Francine Fitz, a 57-year-old Worcester widow who relied on the E.R. for routine health problems until she was diagnosed with breast cancer last year, is one of the patients helped by counselors at the UMass Memorial Medical Center. The counselor, Heather Reddick, helped her enroll in subsidized health insurance. A telemarketer paid $10 an hour, Francine could not afford her employer's health plan, she said.

The counselor also helped her find a primary care doctor, her first one since childhood. The doctor works at a UMass health center and had just opened his practice to new patients, so Francine was able to get an appointment the next day.

Now, when she feels sick, she calls her doctor first, instead of heading to the E.R.

"I have never seen a doctor who calls me at home to make sure I'm OK," she says. "He even gives my children his private cell phone number, if they have a question."

A number of medical centers have added telephone help lines, counselors and social workers in their E.R.s to answer insurance questions, enroll uninsured people, and find them a primary care doctor. UMass Memorial Medical Center has gone further, sending counselors to laundromats, barber shops, farmers' markets, and churches. Armed with BlackBerries, portable scanners and laptops, they sign people up for insurance as well as food stamps, Social Security disability coverage, and other programs.

Advice to uninsured people in the E.R.: Ask the hospital what help they can give you in addition to treating your immediate medical problem.

Read another story about the new Massachusetts health coverage law.

Thanks to Kay Lazar for the source story in today's Boston Globe.

Saturday, October 4, 2008

We can still do some good: Public learning from a fatal misdiagnosed aortic dissection

This story was the subject of a particularly popular seminar at the conference today of the American Society for Healthcare Risk Management in Boston. It was so popular that the room was filled to capacity, leaving many others outside – like me. So this story comes from Michael O’Connor of the Omaha World-Herald, rather than from the presentation by lawyer Sara Juster, Vice President of the hospital:

Watch a new video produced by Methodist Hospital and you'll see Tyler Kahle looking just like he did the weeks before he died: chiseled face, short brown hair and a big smile.

The death of the 19-year-old Omahan five years ago resulted in a lawsuit against Methodist and an out-of-court settlement that included creation of the video.

Parts of the 20-minute video are a tribute to the young man. It shows him graduating from high school, skateboarding, wave-boarding and doing the high-energy activities he loved.

Other parts carry messages that legal experts say are surprising and uncommon.

In the video, initiated by Methodist, the hospital's doctors acknowledge the mistakes that Methodist made in diagnosing the medical problem that caused his death. Legal experts say it's rare for doctors and hospitals to publicly acknowledge mistakes after a settlement.

"It's more common that they don't parade around [saying] that we made a mistake," said Craig Dallon, a professor at the Creighton University School of Law.

What's also unusual, he said, is that Methodist has posted the video, made in cooperation with Tyler's family, on its Web site and plans to distribute it as a DVD nationally to educate other hospitals and doctors about the aortic dissection that led to Tyler's death.

"It was a way to memorialize Tyler, and we hope to prevent this from happening again," said Sara Juster, a vice president for Nebraska Methodist Health System, whose duties include overseeing the hospital's legal cases.

During negotiations for the settlement with the man's family, Methodist raised the idea of the video and the family backed it, said Juster and Deb McMillan, Tyler's mother.

Deb said the video provided the justice she wanted for her son. She wanted Methodist to publicly admit its mistakes. She also wanted the hospital to help educate other health care providers and prevent deaths.

"If I can't have my son back, we [can still do] some good," she said.

During an eight-day span in fall 2002, Tyler went twice with chest pains to the Methodist emergency room and once to his family doctor at Methodist Physicians Clinic.

All three times, Methodist physicians diagnosed and treated Tyler for upper respiratory problems.

Deb repeatedly told Methodist doctors about her son's family history of aortic dissection, but he was never given a scan for the ailment. He died four days after his last trip to the Methodist emergency room.

Aortic dissection — deadly if not diagnosed quickly — is a tear in the lining of the main artery for blood leaving the heart. It can be spotted with medical imaging equipment and can be treated. The ailment, which killed actor John Ritter, runs in families, including Tyler's.

In the video, Methodist doctors say Methodist did not take into account Tyler's family history of aortic dissection and did not consider the fact that it can occur in young people.

Dr. Anton Piskac, Methodist vice president for quality improvement, said in the video: "We had multiple opportunities to do the right thing and repeatedly neglected to do so."

Dallon, the law professor, said the video may reflect the frustration some doctors and hospitals have with defense attorneys who typically advise not to acknowledge any mistakes. The "I'm sorry" laws in Nebraska and more than 25 other states are another sign, he said.

Nebraska's law, approved in the last session, makes a health care provider's expression of apology, sympathy or compassion inadmissible as evidence of liability in a lawsuit.

Juster said Methodist wanted to share its experience because hospitals across the country have lacked an understanding that young patients with a family history of aortic dissection can suffer from it.

She said Methodist did not offer to produce the video as a way to reduce the financial payment to Tyler's family that was part of the settlement. Both sides declined to reveal the amount.

Omaha attorney Jeffrey Welch, who represented Tyler's family, said money wasn't the family's priority. They wanted to keep the young man's memory alive and prevent other deaths.

Advice to parents: If you disbelieve a doctor's diagnosis, ask what else it could be. If you know an inheritable condition may be involved, ask if that can be ruled out as a diagnosis, and why.

See a short video by a survivor about an instructive medical error.

Friday, October 3, 2008

I was just starting to feel comfortable: A patient-doctor relationship

Mrs. J. looked baffled and hurt. I had just explained that I would no longer be her primary care doctor. I was leaving the field after just three years. "I have had three different primary care doctors over the past 10 years," she said. "You can't leave now. I was just starting to feel comfortable. I am getting older now. I can't keep changing doctors!"

Primary care is in crisis. Current primary care doctors are quitting, and medical students are pursuing other specialties. Primary care has lost its attractiveness as a profession because of poor compensation and plummeting job satisfaction. Primary care physicians are in short supply, and in Massachusetts, this problem has intensified in the wake of healthcare reform, as more than 300,000 previously uninsured individuals have joined in the search for available doctors.

As a former primary care physician, I am most troubled by the antagonistic state of the patient-doctor relationship. The system sets us against each other. Like many in the field, I chose primary care because I love people. I wanted to take care of the whole person, body and mind. I wanted the intimacy that comes with knowing your patients well and following them over many years. These goals are difficult to achieve in primary care today. After two years in my practice, I walked into an exam room one day and introduced myself to a patient. "We have met before," she replied, clearly aggravated. I was horrified and saddened.

Patients are angry, and rightly so. They feel frustrated by the inability to get timely appointments with their physicians, rushed by the 15-minute visits and the seemingly harried doctors, ignored when they do not receive letters with lab results or follow-up phone calls. They feel disrespected when they come to their medical appointments on time and then sit in the waiting room for 45 minutes. All of these feelings are justified. We are not offering high-quality care.

Doctors feel angry, too. We have too many patients. It is not uncommon for a full-time primary care doctor to have upwards of 3,000 patients. It is impossible to know all of these individuals well, to give adequate focus to each person's unique situation, to sift through the piles of paperwork and lab data daily. Our days are divided into 15-minute sessions, back to back. We move frantically from exam room to exam room, trying desperately not to fall behind in our schedule. We are given incentives to see patients as quickly as possible. We live in fear of litigation.

We are drowning, and in this overwhelmed state we lose our ability to take good care of people. Outwardly, we may feel resentful and burdened. Underneath, many of us feel loss, deep sadness, and personal failure.

This rift between patient and doctor is painful and destructive to the core of medicine: the therapeutic relationship. In an environment where patients and doctors don't know each other well and appointments are rushed, it is inevitable that more medical errors occur and that resources are wasted as expensive tests are substituted for communication. By contrast, research indicates that medicine practiced in the context of solid primary care relationships allows for earlier detection of chronic diseases, and, ultimately, better outcomes and monetary savings, to say nothing of patient and doctor satisfaction.

Dr. Brewster's Advice: Primary care physicians should be valued as team leaders and advocates, poised to help patients navigate the complex medical system.

Read another story on the patient-doctor relationship.

Thanks to Dr. Annie Brewster for the source OpEd in the Boston Globe of May 29.

Thursday, October 2, 2008

She kept the remaining ones: A fatal fentanyl patch drug error

After an accident several years ago, a woman got a prescription for fentanyl patches to treat her chronic pain. She didn't use all the patches, and kept the remaining ones.

Years later, her six-year-old daughter complained of neck pain late one evening. The foster mother gave her an appropriate dose of ibuprofen, and placed one of the left-over fentanyl patches on her neck to treat the pain. The next day, the girl was found unconscious in bed, and was pronounced dead by the time she arrived in the hospital’s Emergency Room.

Mike Cohen's advice to parents: Discard unused prescription medication after you're done with it. Ask your pharmacist about the safe use of fentanyl patches. Don't share fentanyl patches with anyone else.

Read another Fentanyl story.

Thanks to Michael Cohen for the source story in his ISMP Medication Error Report Analysis, published in Volume 43, Number 9 of Hospital Pharmacy.

Wednesday, October 1, 2008

It helped to save his life: Universal health insurance in Massachusetts

Tim [not his real name] was not feeling well, but didn’t see a doctor because he had no health insurance. He was uninsured for several years before he contacted Health Care for All’s HelpLine. The counselor helped him apply for benefits over the phone. Tim says, “Without Commonwealth Care, it would be nearly impossible to find an affordable health insurance plan.” Since becoming insured and seeing a doctor, Tim was diagnosed with diabetes and is being treated. It’s clear to him that getting insurance through Commonwealth Care and finally visiting a doctor helped to save his life.

The flip side of Tim's story from the files of Health Care for All is seen in a story from my aunt's life. The timely diagnosis and treatment of diabetes may well have given extra years of active life to my aunt, Anne Troutman, as well. A very high-energy woman into her 70s, she loved to travel. She didn’t treat the poor circulation in her feet, and required an amputation of her big toe late in life. That greatly reduced her ability to get around, and her quality of life. We don’t know how much she knew about her diabetes and self-care, for she died, not long afterward, of a heart attack. Clearly, a doctor could have helped her, as Tim’s doctor is helping him.

Advice: Ask your friends if they have health insurance, and refer them to the HelpLine at 800-272-4232 if not. The HelpLine answers questions about healthcare in Massachusetts, including co-payments, health insurance rules, directions, program eligibility, and much more.

Read another story about care for the uninsured.

Thanks to Amy Franz for the source story in the Fall 2008 newsletter of Health Care for All.