Can This Treatment Help Me? There’s a Statistic for That – NYTimes.com

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Can This Treatment Help Me? There’s a Statistic for That – NYTimes.com

Who over the age of 65 doesn’t take an aspirin a day? For every medical intervention practitioners look at a cost/benefit analysis. Sometimes it’s a big deal–we surgically remove the tumor on your spine at great risk to your life and mobility, but there is a strong possibility of removing and curing your cancer–that benefit outweighs the risk. Sometimes it’s not. Take some calcium supplements. They might help but they probably won’t hurt. Just whatever!

Practitioners make recommendations based on studies and evidence which are analyzed using statistical methods. We know that the average person has no concept of what statistical chance actually means. We’re just hairless apes, y’all. The same is true for docs. And this nurse.

This article illustrates beautifully what we are talking about when we talk about the metric commonly used in analyzing efficacy of treatment: N.N.T. or number to treat. Eat it up. I feel like I learned a thing today.

Health Policy Quiz

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So I’m working up the guts to post a statement of benefits that will help show the calculus that goes into medical billing. As I’m finding the courage, take these two super-fun health policy quizzes! It’s like Jeopardy but the only category is health policy! IS THIS HEAVEN?!

International health policy quiz

Medicaid quiz

Final Jeopardy: The Medicare program was signed into law by this president. (Hint: to answer this question you must know the difference between Medicare and Medicaid, study up!).

You are so welcome.

<3

In the ICU, where we keep you from dying. (Whether you might want to or not)

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I am back in the clinical setting, and boy howdy has there been some moral distress on the unit in the past days. When a patient is extremely frail or ill and does not respond to all available therapy, when they’ve reached the end of their rope, the limits of modern medicine, further curative care (which often is invasive and painful) becomes futile. The medical team calls a conference with loved ones to decide the course of action. Read below from the Jecker article and bear with me.


From Medical Futility, Nancy S. Jecker, PhD, University of Washington School of Medicine.
What is “medical futility”?
“Medical futility” refers to interventions that are unlikely to produce any significant benefit for the patient…Futility does not apply to treatments globally, to a patient, or to a general medical situation. Instead, it refers to a particular intervention at a particular time, for a specific patient. For example, rather than stating, “It is futile to continue to treat this patient,” one would state, “CPR would be medically futile for this patient.”

Why is medical futility controversial?
While medical futility is a well-established basis for withdrawing and withholding treatment, it has also been the source of ongoing debate. One source of controversy centers on the exact definition of medical futility, which continues to be debated in the scholarly literature. Second, an appeal to medical futility is sometimes understood as giving unilateral decision-making authority to physicians at the bedside. Proponents of medical futility reject this interpretation, and argue that properly understood futility should reflect a professional consensus, which ultimately is accepted by the wider society that physicians serve. Third, in the clinical setting, an appeal to “futility” can sometimes function as a conversation stopper. Thus, some clinicians find that even when the concept applies, the language of “futility” is best avoided in discussions with patients and families. Likewise, some professionals have dispensed with the term “medical futility” and replaced it with other language, such as “medically inappropriate.” Finally, an appeal to medical futility can create the false impression that medical decisions are value-neutral and based solely on the physician’s scientific expertise. Yet clearly this is not the case. The physician’s goal of helping the sick is itself a value stance, and all medical decision making incorporates values.

This paternalistic bend on discussion with patients and caregivers–that whether or not an intervention is futile is a call to be made by a medical or inter-professional team–well I’m not a fan. She suggests that the use of the words “medically futile” might disrupt the discussion. In my experience doctors and nurses may tailor language to be more or less jargon-y based on a patient/family member’s experience and education, but there is no reason be opaque when if comes to describing that an intervention will not, in the HCP’s opinion, be of benefit. And it may cause pain and harm. “Medically inappropriate” sounds snobby and skirts the issue–what are we doing here? What would your loved one want? Here is what we can offer (palliative options, less invasive options, what have you). And most importantly the decision is in the hands of the patient or their proxy. For better or worse. (This exempts surgeries, etc, where a level of medical stability is required).

We owe it to them to paint the full picture then allow them the right to choose. In my experience people can handle a lot more than we give them credit for.

The place to make the change is not at the ICU bedside where grief has a hold of the wheel. Encouraging end-of-life preparation for those who are sick and those who will be tapped as caregivers should be normalized in the primary care setting (which, ehem, was sacrificed to pass the ACA).

Dr. Bill Thomas, aging, and de-depressing the nursing home

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Nobody is excited to be in a nursing home. Same deal for most nurses. In a terrible turn of events, a place with exploding need for professional nursing care is the most maligned of places to work. And if you’ve spent time in one, visiting an elder or maybe a loved one enduring a long recovery, you know why. It’s dense with suffering. Everyone in their own personal purgatories. And the food is yuck.

Borrowed from a chapter in Gawande’s Being Mortal and continuing the theme of the poem “Letters from a Father,” I wanted show off the work of Dr. Bill Thomas, who has gained regard for transforming the nursing home. The man has an earth shattering philosophy: In order to thrive, humans (even sick and old humans!) need something to live for. Life needs meaning. His first nursing home experiment brought in pets of all sort: birds, a variety of house plants, some dogs and cats. The residents were given autonomy, responsibility, and credit to care for them. And the residents thrived (so did the animals and, miraculously, the houseplants) Now you see the connection with “Letters.” Now I’m weepy because it is so simple, people. The needs of humans are beautifully simple.

Dr. Thomas, hippie in the most beneficent understanding of the term, calls his program The Eden Alternative:

What are the other components, what are the other criteria of the Eden Alternative?

Number one, the organization begins to treat the staff they way they want the staff to treat the elders. Very important. Long-term care has a bad history of treating its staff one way, not so nice, and expecting the staff to treat the elders a different way.

Number two, the organization brings decision making back to the elders and to the people around the elders, so that they have a voice in their, in their daily routine and their life. Crucial, crucial to re-injecting meaning into peoples’ lives.

Third, they’ve taken real steps to make the place where people live rich in plants and animals and children. I want the people to be confused when they walk through the door. What kind of place is this? I mean, there’s kids running around and playing and there’s dogs and there’s cats and there’s birds, and there’s gardens and plants and … I want them to be confused. This can’t be a nursing home. Right. It’s an alternative to the nursing home.

And finally, there has to be a commitment to ongoing growth. We believe in the Eden Alternative that even the frailest, most demented, most feeble elder can grow. And that the young person who maybe has a difficult home life or is living on the edge of poverty, they can grow. That the organization commits itself to human growth. And those words, human growth, nursing home, they’ve never gone together before and with Eden Alternative they can.
(source)

From a resident:

“Well, if I want to make things easy and comfortable for everybody, the only thing I should do is die. And having George participate in my care and having other people do the same, calls me into life. It says, despite your losses, despite your limitations, you belong here with us and we want you to stay.” — Nancy Mairs

Poetry Friday

I spent the morning sitting in a sunny spot watching birds at my feeder. Hence this poem. Reading it again now after many years, weepy, remembering being so moved even as a 20 year old kid whose main worry was where the keg at. Before sickness and aging elders became my wheelhouse. I can draw a straight line between this poem and my life as a nurse. I got there, eventually.

Letters from a Father
Mona Van Duyn, 1921 – 2004

I

Ulcerated tooth keeps me awake, there is

such pain, would have to go to the hospital to have

it pulled or would bleed to death from the blood thinners,

but can’t leave Mother, she falls and forgets her salve

and her tranquilizers, her ankles swell so and her bowels

are so bad, she almost had a stoppage and sometimes

what she passes is green as grass.  There are big holes

in my thigh where my leg brace buckles the size of dimes.

My head pounds from the high pressure.  It is awful

not to be able to get out, and I fell in the bathroom

and the girl could hardly get me up at all.

Sure thought my back was broken, it will be next time.

Prostate is bad and heart has given out,

feel bloated after supper. Have made my peace

because am just plain done for and have no doubt

that the Lord will come any day with my release.

You say you enjoy your feeder, I don’t see why

you want to spend good money on grain for birds

and you say you have a hundred sparrows, I’d buy

poison and get rid of their diseases and turds.

II

We enjoyed your visit, it was nice of you to bring

the feeder but a terrible waste of your money

for that big bag of feed since we won’t be living

more than a few weeks long.  We can see

them good from where we sit, big ones and little ones

but you know when I farmed I used to like to hunt

and we had many a good meal from pigeons

and quail and pheasant but these birds won’t

be good for nothing and are dirty to have so near

the house.  Mother likes the redbirds though.

My bad knee is so sore and I can’t hardly hear

and Mother says she is hoarse from yelling but I know

it’s too late for a hearing aid.  I belch up all the time

and have a sour mouth and of course with my heart

it’s no use to go to a doctor.  Mother is the same.

Has a scab she thinks is going to turn to a wart.

III

The birds are eating and fighting, Ha! Ha!  All shapes

and colors and sizes coming out of our woods

but we don’t know what they are.  Your Mother hopes

you can send us a kind of book that tells about birds.

There is one the folks called snowbirds, they eat on the ground,

we had the girl sprinkle extra there, but say,

they eat something awful.  I sent the girl to town

to buy some more feed, she had to go anyway.

IV

Almost called you on the telephone

but it costs so much to call thought better write.

Say, the funniest thing is happening, one

day we had so many birds and they fight

and get excited at their feed you know

and it’s really something to watch and two or three

flew right at us and crashed into our window

and bang, poor little things knocked themselves silly.

They come to after while on the ground and flew away.

And they been doing that.  We felt awful

and didn’t know what to do but the other day

a lady from our Church drove out to call

and a little bird knocked itself out while she sat

and she bought it in her hands right into the house,

it looked like dead.  It had a kind of hat

of feathers sticking up on its head, kind of rose

or pinky color, don’t know what it was,

and I petted it and it come to life right there

in her hands and she took it out and it flew.  She says

they think the window is the sky on a fair

day, she feeds birds too but hasn’t got

so many.  She says to hang strips of aluminum foil

in the window so we’ll do that.  She raved about

our birds.  P.S. The book just come in the mail.

V

Say, that book is sure good, I study

in it every day and enjoy our birds.

Some of them I can’t identify

for sure, I guess they’re females, the Latin words

I just skip over.  Bet you’d never guess

the sparrow I’ve got here, House Sparrow you wrote,

but I have Fox Sparrows, Song Sparrows, Vesper Sparrows,

Pine Woods and Tree and Chipping and White Throat

and White Crowned Sparrows.  I have six Cardinals,

three pairs, they come at early morning and night,

the males at the feeder and on the ground the females.

Juncos, maybe 25, they fight

for the ground, that’s what they used to call snowbirds.  I miss

the Bluebirds since the weather warmed. Their breast

is the color of a good ripe muskmelon.  Tufted Titmouse

is sort of blue with a little tiny crest.

And I have Flicker and Red-Bellied and Red-

Headed Woodpeckers, you would die laughing

to see Red-Bellied, he hangs on with his head

flat on the board, his tail braced up under,

wing out.  And Dickcissel and Ruby Crowned Kinglet

and Nuthatch stands on his head and Veery on top

the color of a bird dog and Hermit Thrush with spot

on breast, Blue Jay so funny, he will hop

right on the backs of the other birds to get the grain.

We bought some sunflower seeds just for him.

And Purple Finch I bet you never seen,

color of a watermelon, sits on the rim

of the feeder with his streaky wife, and the squirrels,

you know, they are cute too, they sit tall

and eat with their little hands, they eat bucketfuls.

I pulled my own tooth, it didn’t bleed at all.

VI

It’s sure a surprise how well Mother is doing,

she forgets her laxative but bowels move fine.

Now that windows are open she says our birds sing

all day.  The girl took a Book of Knowledge on loan

from the library and I am reading up

on the habits of birds, did you know some males have three

wives, some migrate some don’t.  I am going to keep

feeding all spring, maybe summer, you can see

they expect it.  Will need thistle seed for Goldfinch and Pine

Siskin next winter.  Some folks are going to come see us

from Church, some bird watchers, pretty soon.

They have birds in town but nothing to equal this.

So the world woos its children back for an evening kiss.

CDC Recommends Antiviral Drugs For At-Risk Patients : NPR

CDC Recommends Antiviral Drugs For At-Risk Patients : NPR.

The flu is awful this year. I’m in the bathroom washing my child’s hands all Lady Macbeth the second he gets home from school. In this interview Tom Freiden, Director of the CDC, explains plainly why the flu is so bad right now and why people who have gotten the flu shot are still getting sick. He also talks about antiviral use in flu patients.

I’m concerned for public health and the future success of flu shot campaigns. The strain that is infecting people despite vaccination was chosen for the vaccine, but between it’s selection and the beginning of our flu season it mutated. ARGH. This wasn’t a failure on the part of the CDC but it will lose them good faith in a year where we already had our eyes set to roll at their very next press release. So now add to the giant list of reasons people won’t get their flu shot “they messed it up last year.” Which is bad for community immunity.

Below, data for health districts reporting in VA (two weeks old). The red is the sub-type of flu the vaccine does not cover.

flu data
http://www.vdh.virginia.gov/Epidemiology/flu/WklyPhysReport.pdf

Knowledge cures ignorance so here is the back story of the flu vaccine and why this year was a one-off to convince you to please get your flu shot next year, too:

How are the viruses selected to make flu vaccine?

The influenza (flu) viruses selected for inclusion in the seasonal flu vaccines are updated each year based on which influenza virus strains are circulating, how they are spreading, and how well current vaccine strains protect against newly identified strains. Currently, 141 national influenza centers in 111 countries conduct year-round surveillance for influenza and study influenza disease trends. These laboratories also send influenza viruses to the five World Health Organization (WHO) Collaborating Centers for Reference and Research on Influenza located in Atlanta, Georgia, USA (Centers for Disease Control and Prevention, CDC); London, United Kingdom (National Institute for Medical Research); Melbourne, Australia (Victoria Infectious Diseases Reference Laboratory); Tokyo, Japan (National Institute for Infectious Diseases); and Beijing, China (National Institute for Viral Disease Control and Prevention) for additional analyses.

The influenza viruses in the seasonal flu vaccine are selected each year based on surveillance-based forecasts about what viruses are most likely to cause illness in the coming season. WHO recommends specific vaccine viruses for inclusion in influenza vaccines, but then each individual country makes their own decision for which strains should be included in influenza vaccines licensed in their country. In the United States, the U.S. Food and Drug Administration (FDA) determines which vaccine viruses will be used in U.S.—licensed vaccines.

Alarm Fatigue – Recent Research About Nursing – Robert Wood Johnson Foundation

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Recent Research About Nursing, December 2014 – Robert Wood Johnson Foundation.

Alarm fatigue UNC study: 

Alarm fatigue occurs when nurses and other clinicians are exposed to a high number of physiological alarms generated by modern monitoring systems. In turn, alarms are ignored and critical alarms are missed because many alarms are false or non-actionable.

In the ICU, parameters for BPs, heart rates, respiratory rates, oxygen saturation, and the like are often outside of normal limits. It is not uncommon for every patient’s monitor to show tachycardia. Or atrial fibrillation for that matter.

Investigators analyzed a subset of 12,671 arrhythmia alarms, which are designed to alert providers to abnormal cardiac conditions, and found 88.8 percent were false positives. Most of the false alarms were caused by deficiencies in the computer’s algorithms, inappropriate user settings, technical malfunctions, and non-actionable events, such as brief spikes in heart rate, that don’t require treatment.

True story: the only alarm on the floor that makes me jump is the one that goes off when the medicine drawer attached to our computer has been open too long.

So to quiet the floor and maybe do a more precise job monitoring the status of ICU patients, smarter technology that will observe for artifact and normal abnormals would be great. For now, we can better manage the technology we have by knowing our patient’s history and tailoring care. If someone is in chronic afib with a resting rate of 110, set the monitor with an appropriate upper limit–also you might might raise the lower limit to alert you if they convert to sinus rhythm. An alarm on a heart rate of 118 on this patient would be meaningless information, but an alarm on a heart rate of 70 could help you identify a stroke risk and prompt appropriate assessments and prophylaxis.

Nurses can often determine the reason for an alarm by looking at the monitor (as of now it’s that alarm that draws them to look) A bad wave form because the O2 monitor is lose, artifact on the ECG leads, heart rate up and O2 sats down ’cause the patient is using the bathroom are common non-urgent alarms.  Rather than blow up the unit with noise, shouldn’t we have an app for that? In my pocket, a phone that vibrates, so I can check it out trouble shoot, ya know?

These are partial solutions but reasonable I’m thinking.

What we’re going to do about those distal occlusions man, I haven’t a clue (IV pump humor!).

ivpump

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