Thursday, December 24, 2009

Christmas Coronary

There is an interesting term I came across called "Christmas Coronary". Emergency rooms report an increased number of cardiac cases on the day after Christmas. No one is sure why but there are a few opinions.

First and most obvious is that symptoms may be present but not addressed until after Christmas. Sometimes a patient may have atypical chest pain and attribute symptoms to indigestion. Over-indulgence in rich foods,salt, alcohol, and caffeinated beverages may also account for ER visits due to heart rhythm problems and congestive heart failure. Decrease activity and prolonged sitting in the car or at the table may also contribute.

At the risk of being called Scrooge, here are my recommendations. First, don't over eat to the point where you feel uncomfortable. Eat slowly. Avoid excessive sodium intake. "Calorie saving" where you starve yourself so you can eat more on Christmas is not a good idea. Take a baby aspirin (if not contraindicated) in the morning...especially if you are traveling. Go for a walk after your meal and avoid prolonged sitting. If you have a cardiac problem it's best to avoid caffeine and alcohol.

And finally, if you develop symptoms of seek medical attention. Waiting may make things worse.

Wishing you a Merry Christmas and Happy and Healthy New Year.

Sunday, December 20, 2009

Dementia Misdiagnosis

Mary,a 92 year old woman who sustained a hip fracture, was admitted to a nursing home from a local hospital. The medical record was littered with the words dementia and alzheimers disease. I learned from staff that she was managing her affairs and caring for herself in an apartment prior to her fall. This was a red flag. The very first notation in the hospital record indicates severe dementia. But if she was so demented how could she have been taking care of herself so well. Was there a stroke or delerium that would have caused such a change?

On my initial interview I learned that she was not demented at all. She was hearing impaired. When I took the time, spoke to her clearly and gave her an opportunity to answer, I discovered she was cognitively more advanced than the staff. Once her hearing was corrected by a cerumen disimpation and a battery change in her hearing aids, we learned that she in fact she was a retired nurse and was well versed with health care.

There are lessons to be learned. First, don't rely on previous assessments. Mistakes like this tend to be repeated. Second, take a few moments to allow communication. Don't prejudge because of initial lack of response. And finally, all patients with a diagnosis with dementia should be tested for hearing loss. What you think is dementia may actually be in part or entirely due to a hearing problem.

Saturday, December 19, 2009

"If you knew where your food came from, you wouldn't eat"

In my Italian immigrant household everyone worked hard all day and somehow found the time for a multi-course sit down dinner. I now see the logic of staying home for an excellent meal but as a child I wanted to go out eat. My dad would say "If you knew where your food came from, you wouldn't eat".

I watched a documentary about the industrial food complex called Food Inc. I cannot recommend it enough. Let's be real. When someone serves up a big juicy hamburger or steak, any fleeting moment of wondering where it came from is quickly suppressed. Maybe on a subconscious level we don't want to know how our food is processed. Yet, this is the kind of movie that keeps you thinking and it may help you make better food choices.

One in three Americans born after 2000 diabetes (one in two for minorities). There is a reason for this. Children die from e coli infections and we propagate a food industrial complex that does not value the quality of food, their workers, the environment and least of all the consumer.

I'm sure we realize we are carnivores. And we know that indirectly we have to kill in order to eat. But this movie is about much more. It shows you how our meals are produced and all its political, health, environmental and moral consequences.

Food inc trailer

A movie trailer about obesity called "Killer at large" is another must see film.

Friday, December 18, 2009

Can Caffeine Be Good For You?

Coffee and tea may reduce the risk of serious liver damage in people who drink too much alcohol, are overweight or have too much iron in the blood.

The study of nearly 10,000 people showed that those who drank more than two cups of coffee or tea per day developed chronic liver disease at half the rate of those who drank less than one cup each day.

A daily dose of coffee, decaf or tea can reduce the risk of getting Type 2 diabetes by 25 to 35 percent, according to a new study published in the Archives of Internal Medicine.
Specifically, four cups of coffee or tea a day can lead to the 25 to 35 percent decrease in chances of getting diabetes -- or a 7 percent lowering of risk for every cup.

The study reviewed past research between 1966 and 2009, encompassing more than 450,000 patients, and also involved original research. It found that coffee and tea protect against metabolic syndrome.

But.... Caffeine stimulates you nervous system, increases heart rate and transiently increases BP. The Framingham study failed to show caffeine to be a risk factor for cardiac disease. Still its hard to imagine a high stress state caused by excess caffeine can be beneficial. My best advice would be moderation.

Sunday, December 6, 2009

So you or someone you love needs nursing home care

So you or someone you love needs nursing home care. You are struggling at home and it's become physically or emotionally impossible to remain at home. You are asked to pay 11,000 hard earned dollars per month for nursing home placement. But you are now desperate. The home care you expected consists of a nurse coming to check a BP once a week. Surprise! Medicare only covers a very limited service. Here are the insights of one who has worked in the industry for many years.
If you were to hire someone to care for you at home, you would choose someone who has the necessary skills and is also caring. Not so easy to find. If you find someone good don't let them go.
Going to a facility is culture shock. Institutional care is exactly the opposite of what you would look for at home. This is best demonstrated by the bathing process. Basically you are pulled out of a warm bed at the facility's convenience, not yours, and thrown into a hard plastic chair. You are stripped naked and hosed down like a car in your back yard. The water temperature depends on the mood of your aide. Maybe she thinks you need to wake up a little so the water will be colder. You are now cold, wet, and most likely combative. An alternate way is to use a bed bath system that employs lotions, massage, and moist warm towels proven to be hygienically equal or better that the traditional bath. So why doesn't the facility use this system.
Toileting is another issue. It is done on a schedule so you better be on the same timeline. If you have visitors and it's the "wrong time to go", you may have to suffer the indignity of sitting in your urine and or stool for a while. Imaging what your aide must be thinking. Probably that job at Walmart that doesn't look so bad any more.
After being involved with nursing homes as medical director for 25 years, I've come understand the problem. Facilities and their staffs are under great financial and regulatory pressure. Everyone seems to have a distorted reality. This includes administrators, staff, government, and families. The truth is nursing homes at the present configuration will not work.
When you visit the nursing home as a prospective client, don't be misled by the new carpet or the fancy conference room. The approach should be the same as if you were at home. Who is the person who will be caring for you directly. Are they well paid.? Do they have enough help? Are they well trained and how is that ensured? What is the philosophy on dignity, independence and meeting client preferences? The further you move away from the client caretaker relationship the less important it becomes.
The government underpays and over-regulates . Their oversight is well intentioned but misguided and self serving. Facility administrators spend most of their time at meetings talking about their financial hardships. Facility Boards are great people who are leaders in their own fields but easily misled by bells and whistles played by management. The dollar pyramid is inverted and ready to topple. Most money is spend at the top ; far away from the client-caretaker relationship.
There is much talk about culture change and moving toward a more homelike environment. But that's all it is- talk.... and I've heard it for many years. Facilities should de-institutionalize and spend their resources on the points of contact. When they realized that the need to reconfigure their thinking and not their physical plant, they will win the battle. Congress needs to realize that home care dollars spent will save them from extended hospital and nursing home stays. We seem to be heading in the wrong direction.

Wednesday, December 2, 2009

Who Should Receive H1N1 Vaccine

Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;
Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants younger than 6 months old might help protect infants by “cocooning” them from the virus;
Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;
All people from 6 months through 24 years of age
Children from 6 months through 18 years of age because cases of 2009 H1N1 influenza have been seen in children who are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and
Young adults 19 through 24 years of age because many cases of 2009 H1N1 influenza have been seen in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,
Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.