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Sunday, May 31, 2009

We're going to put on your magic cream: Medical play

Cori Liptak on medical play [excerpted from this article about Cori Liptak’s work]:

Sometimes children aren't sedated for difficult procedures, and they need to sit still, and we help them to get through it. We can do work ahead of time to help them prepare so they understand what their job is throughout the course of the procedure. They might say, "Cori, I'm going to sit like a statue right now." Anytime you get to witness a child using something you taught and be successful as a result, that's rewarding.

For instance, when I use medical play with a child and see him stop giving the puppet lots of shots, and instead hear him say, "We're now going to put on your magic cream. It's numbing and you're not going to feel a thing. Don't be scared!" I’m watching him evolve in his ability to cope, and that transfers over into his real-life experience.

These behavioral interventions play a role in helping children master their situation medically.

Advice to parents: Role-playing a medical appointment with your child might make them less fearful.

Read about a very different kind of medical simulation.

Thanks to Cori Liptak, PhD, for the source article in the Fall/Winter 2008 issue of Paths of Progress, edited by Dawn Stapleton, and published by Dana-Farber Cancer Institute.

Wednesday, May 27, 2009

Their final act of service: Autopsies of fallen soldiers

Colonel Howard Harcke, a U.S. Army pathologist, noticed something peculiar in late 2005. The emergency treatment for a soldier's collapsed lung involves inserting a needle and tube into the chest cavity to relieve pressure and allow the lung to reinflate. But in one case, Colonel Harcke could see from a scan of an autopsied soldier that the tube had been too short to reach the chest cavity. Then he saw another case, and another, and half a dozen more. A collapsed lung can be life-threatening, so proper treatment is essential.

He pulled 100 CT scans of autopsied soldiers from the archives and calculated the average thickness of the chest wall in the American troops. He found that the standard tubing, five centimeters long, was too short for half the soldiers. If the tube were eight centimeters long, it would have been long enough for 99% of them.

The findings were presented to the Army Surgeon General, who ordered in August 2006 that the kits given to combat medics should be changed to include only the longer tubing. This allows for more effective emergency treatment of collapsed lungs.

Advice: Autopsies can teach doctors how to change medical practice to save people's lives. These fallen soldiers had a final act of service to others.

Read another story about the life-saving use of autopsies.

Thanks to Denise Grady for the source article in yesterday's New York Times.

Tuesday, May 26, 2009

Leave no veteran behind: Surviving veterans and their caregivers

On Memorial Day, we honor the soldiers who are continuing to grapple with their combat injuries, and we honor their family and professional caregivers and advocates. These are the men whose stories have appeared here in the last year:

Army Sgt. 1st Class Chris Blaxton survived the blast from an Improvised Explosive Device (IED) in Iraq. He has received help from the web site CaringBridge, his caregivers at Walter Reed Army Medical Center, and his niece, Anna Carncross.

Michael O'Neal, a veteran who served in Korea, has been cared for at the San Francisco Veterans Affairs Medical Center.

Army Staff Sergeant Brian Pearce survived in IED blast in Iraq. Dr. Kara Gagnon, director of low vision optometry at the West Haven, Connecticut veterans hospital, has been caring for him. The Blinded Veterans Association advocates on behalf of soldiers like Brian.

Sgt. Tony Wood, survivor of an explosion from an IED in Iraq, has been helped by the 10 in 10 Project, and the Warrior Transition Unit of Tripler Army Medical Center in Hawaii.

Tuesday, May 19, 2009

The Lion Still Roars: Teddy Kennedy & survival predictions

A year ago, Senator Teddy Kennedy's doctors told him he had 90 days to live. The senator pledged at the Democratic Convention in July that he would participate in Barack Obama's inauguration in January, and he did. We anticipate the arrival very soon of the Senate's universal health care bill, his long-time dream. "The lion still roars," as the Boston Herald's front-page headline of a story on Saturday by Hillary Chabot and Dave Wedge reports.

Doctors' predictions of how long a terminal patient has to live are often wrong. Indeed, these predictions only have "small associations" with survival times, according to a systematic review article that examined 24 studies. Dr. Antonio Vigano and his colleagues published their analysis of studies of terminal cancer patients in Palliative Medicine, a medical journal.

Advice to those hearing grim predictions of their survival time: Take it with a grain of salt, and savor Teddy Kennedy's example.

Read last year’s Teddy Kennedy story.

Friday, May 15, 2009

23 Employees: Farrah Fawcett and Patient Privacy, Part 2

California health regulators fined Kaiser Permanente's Bellflower hospital $250,000 Thursday for failing to keep 23 employees from snooping in the medical records of Nadya Suleman, the mother who set off a media frenzy after giving birth to octuplets in January.

The fine is the first monetary penalty imposed and largest allowed under a new state law enacted last year after widely publicized violations of privacy at UCLA Medical Center involving Farrah Fawcett, Britney Spears, California First Lady Maria Shriver and other celebrities.

The breaches involving Farrah's medical records -- first reported by The Los Angeles Times in April 2008 -- enraged California lawmakers and prompted the new law. In Farrah's case, a low-level UCLA employee accessed her records more often than her own doctors. The employee pleaded guilty last year to federal felony charges of selling the information to the National Enquirer.

Farrah said recently that she had suspected that hospital staff were leaking her records. To test that, she delayed telling her family about a specific recent diagnosis – until after it was leaked to the press – proof that an employee had been snooping.

Advice to people concerned about privacy: Ask your doctor to sign this form by the Patient Privacy Rights Foundation.

Read last year's story about Farrah.

Thanks to Charles Ornstein for the source story in the May 15 issue of the Los Angeles Times.

Wednesday, May 13, 2009

Your pet’s health is very important to us: Appointment reminder cards

Last month I received a cute postcard from our dog's veterinarian. It has a photo of a beagle puppy lying down, underneath a golden kitten, and they're looking at each other, nose to nose. Under the title, Keep your Companion Healthy, are four bullet points:

Bring them in for regular exams;
Keep their vaccinations current;
Ensure a proper diet and exercise;
Give them lots of love.

On the other side of the postcard is the vet's address and phone number, and a list of the five vaccinations that Jackson should get, with the date that each is due. The message at the bottom says: "Your pet's health is very important to us. Please call for an appointment."

Do you routinely get a friendly reminder like this from your doctor of the need to schedule an appointment? I don't. The vet's electronic medical record system must have generated the postcard, for there is no handwriting on it. The only manual step was to put the postage stamp on it.

To our friends who are doctors in medical practices: We can send a man to the moon, and we can replace hearts and lungs and livers. In addition to those heroic acts, as patients, we'd really appreciate getting a simple reminder card if we forget to schedule an appointment for our well-loved human pet.

Read another story of how our dog's electronic medical record is better than mine.

Our vet’s office: Highland Animal Hospital in Needham, Massachusetts.

Advice to those who are picking a doctor: Choose one who uses an electronic medical record system.

Thursday, May 7, 2009

It's our heads under the knife: Comparative effectiveness research on treatment outcomes

I'm in training again toward an ambitious personal fitness goal, and it feels good. That's a real change from a few months back, when I had to stop jogging, biking and rowing because of a nasal condition. Here's the story:

Feeling congested all the time, I saw my primary care doctor. He referred me to an ear-nose-throat (ENT) surgeon for a consultation. The ENT surgeon examined me, and suggested – surprise! – surgery. (Indeed, Jack Fowler of the Foundation for Informed Medical Decision Making says surgeons recommend surgery in most of their consultations.)

I found and read a book on the treatment options for this condition, written by a surgeon who has widely performed this operation. To my surprise, I learned that he has started generally advising patients against this operation. I looked on the Internet to find the comments of patients who had had the surgery, and learned that many patients needed the operation again a few years later. Others reported that their recuperation had been particularly uncomfortable.

Luckily, I learned that an alternative to surgery was available: a steroidal inhaled spray, which has eliminated the congestion. It seems that I don't need surgery.

So now it's springtime, and I can train again, and breathe deep of the fresh air. And there's the fresh air of a new presidential administration. A thousand flowers, and a thousand legislative bills, are blooming.

One big bill would fund and publicize comparative effectiveness research on treatment options. Pres. Obama said that government should serve as an honest broker in helping people assess and evaluate treatment options. As he told interviewer David Leonhardt in Sunday's New York Times Magazine, "[it's] not an attempt to micromanage the doctor-patient relationship. It is an attempt to say to patients, we've looked at some objective studies, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one. And if a provider is pushing the red one on you, then you should at least ask some important questions….You have to have some independent group that can give you guidance."

Yes. For the septoplasty et al that I was considering, it would have been helpful to know what fraction of these surgical patients would recommend the surgery to a friend, how many needed the surgery repeated, how uncomfortable the recuperation was, how they rated the long-term improvement in how they felt, and how dangerous it was. The treatment decision is about the clinical quality as patients define it – not as it's usually defined by clinical outcomes researchers.

I hope that the $1.1 billion to be spent very soon on comparative effectiveness research will be spent on outcomes as patients define them. It's our heads that are under the knife…

In buying a car, I first look at Consumer Reports. This esteemed nonprofit routinely surveys car owners and portrays their findings on key dimensions of the cars' quality. We need something similar so that we can become smart buyers of our own healthcare.

Advice: Read widely about treatment options before you make a decision.

Read another story on a treatment decision.

Tuesday, May 5, 2009

A heaven of hell: The focused life

Winifred Gallagher's story:
Attention is selection: It's either this or it’s that.

During my cancer treatment several years ago, I managed to remain relatively cheerful by keeping in mind William James' comment, "My experience is what I agree to attend to." And this line from Milton: "The mind is its own place, and in itself can make a heaven of hell, a hell of heaven."

People don't understand that attention is a finite resource, like money. Do you want to invest your cognitive cash on endless Twittering or Net surfing or couch potatoing? You're constantly making choices, and your choices determine your experience, just as William James said.

You can lead a miserable life by obsessing on problems. You can drive yourself crazy trying to multitask and answer every email instantly.

When I woke up in the morning [several years ago], I'd ask myself, Do you want to lie here paying attention to the very good chance you'll die and leave your children motherless, or do you want to get up and wash your face and pay attention to your work and your family and your friends? Hell or heaven – it's your choice.

Winifred's book, Rapt, is a guide to the science of paying attention. This post was synthesized from excerpts of her book, as reported by John Tierney in today's New York Times.

Read another story about the surprising effects of removing distractions.

Thanks to Winifred Gallagher, and John Tierney for the source article.