Hospital Manager

The obese are more likely to have health issues, and, subsequently require more frequent trips to the hospital. Ambulance workers say that patients weighing over 350 pounds present additional challenges to transport, and require specialized equipment and additional workers.

Where should the money come from to cover the costs of transporting extremely obese patients?

The ambulance industry wants to be able to pass on the expenses to insurance companies. It can cost 2½ times more to transport extremely heavy patients to the hospital than it costs to move non-obese patients. Customizing an ambulance with lifts and heavy-duty equipment can run up to $10,000, and it may require 3 or 4 health care workers.

In the absence of specialized equipment, ambulance crews have moved extremely overweight patients with forklifts and flat-bed trucks — which probably did the patient’s dignity no favors.

Some states already charge more for extremely overweight patients. But there are critics who argue levying additional charges on obese patients is discrimination, and passing these costs to insurers ultimately raises costs for everybody.

This issue highlights another way obesity contributes to spiraling health costs. Resources would be better spent preventing obesity in the first place — before patients reach the point of needing more costly, oversized ambulance equipment.

Although the pandemic H1N1 flu tends to strike younger people, it can be life-threatening when older people are infected, California researchers said.

Whos dying from the H1N1 flu pandemic? In the first four months of the pandemic, 1,088 people in the state needed inpatient care or died of the pandemic flu strain, according to Janice Louie, MD, of the California Department of Public Health and colleagues.

The median age of the victims was 27 — younger than is usually seen with the seasonal flu — but the highest case fatality rate was seen among those 50 and older, Louie and colleagues reported in the Nov. 4 issue of the Journal of the American Medical Association.

Those findings are based on statewide enhanced public health surveillance between April 23 and Aug. 11, the researchers said. The first cases of the pandemic flu in the U.S. were reported in Southern California on April 17.

There is plenty to criticize in our bungling trek toward health reform. Leaders on the right, left and at 1600 Pennsylvania Avenue have sidestepped the crucial conversation of controlling the cost of care, in favor of partisan rhetoric about “death panels” and “rationing care.” Worse, the entire focus of reform has centered on spending billions of dollars on technology solutions that will only make marginal changes in the cost and quality of care Americans get.

I want to refocus the debate on what matters most: relationships. Let’s reinvest in the sitting down with, listening to, empathizing with and touching patients.

America has the most advanced healthcare system in the world. But in our haste to research, develop and invest in high-tech medicine, we have lost sight of the very basics of good doctoring. The first things we learn in medical school are: ask, listen and touch. Doctors do not do enough of this any more.

As has been made painfully clear, most doctors are rewarded for doing all manner of procedures. This is true from the earliest moments of our career . As a resident, even when faced with the most basic medical problems, I was grilled by my attending when I didn’t order the full battery of tests, or contact all the specialists available to consult on a patient. Thus, over-testing and over-treating becomes a knee-jerk response from the get go.

This is how doctors practice medicine today. Some of us do it this way because it’s how we get paid. Some of us refer our patients to specialists because we don’t have time to sit down with them ourselves. Some of us rely on tests and procedures because we’re fearful of malpractice lawsuits. And most of us have just lost sight of the most powerful tools in the doctor’s arsenal: our hands and our minds.

Twice a year, physicians come together for an exhibit of democracy at its best through the AMA House of Delegates meeting. Since 1901, physicians and medical student from every state and every qualifying medical specialty debate and vote on behalf of their peers during discussions that shape the AMA’s health care agenda. The work they do is intense, the opinions and debate are passionate. This representational-style system makes the AMA, without question, the umbrella organization of American medicine.

This week, the AMA House of Delegates met in Houston and again demonstrated its unique ability to bring together voices from across the profession to create a national consensus of physicians and medical students on health reform. I was honored to be a part of the civil debate on health reform at the nation’s broadest, most inclusive assembly of physicians and medical students.

Physicians at the meeting passionately defended their positions and then voted on a course forward for the AMA. At times there was fierce debate, but ultimately there was a clear final product – a shared vision on how to help physicians help patients.

The physician prescription for reform that emerged from this meeting reaffirmed the AMA’s commitment to health system reform. As the country’s foremost organization of physicians – for physicians – the AMA must continue in its role at the center of the health reform process.

Limiting surgical residents’ work hours has compromised both surgical education and patient safety, according to an analysis concluding that an 80-hour work week isn’t enough.

Surgeons dont receive enough training when resident work hours are capped The maximum 80-work week imposed in the U.S. for residents is too little to provide mastery in surgery, Gretchen Purcell Jackson, MD, PhD, and John L. Tarpley, MD, both of Vanderbilt Children’s Hospital, wrote in online in the British Medical Journal.

Although the cap on working hours was designed to enhance patient safety by keeping exhausted residents away from operating tables and other aspects of patient care, rates of surgical complications and reinterventions actually climbed after the rules were imposed, they said.

Jackson and Tarpley recommended more flexibility in duty-hour limits for surgical residents in particular.

“Surgical disciplines are unique in that surgeons must not only acquire medical knowledge but also develop the manual dexterity and, sometimes, the strength and endurance to perform procedures,” they said. “There probably isn’t a shortcut for learning surgery.”

The 80-hour week limitation in the U.S. regulations, instituted in 2003 across medical disciplines, is already much longer than 48-hour limit imposed by the European Working Time Directive for trainees in 2009 and the 37-hour week instituted by Denmark.

But even the 80-hour U.S. limit, twice as long as the standard work week in most industries, has been met by opposition from groups including the American College of Surgeons who say it’s not tough enough.

With health reform looking more likely, it’s worth looking at the Massachusetts model to predict what’s going to happen nationwide.

I’ve written several times that the lack of primary care access will simply shift newly insured patients to already crowded emergency departments, where care is exponentially more expensive. And in the end, it is that lack of spending control that will make the costs of universal coverage unsustainable.

According to recent data, well, we’re pretty much on that path.

In an article from American Medical News, a poll of Massachusetts emergency physicians stated that, “42% of the 138 physicians surveyed said emergency care had ’somewhat increased’ since the reforms took effect, and 22% said such care had ’significantly increased.’”

Furthermore, many of those who seek emergency care already have insurance, disproving the myth that the uninsured are primarily responsible for filling up ERs.

There’s little question that providing universal coverage is a laudable goal, but it cannot be done without consequence. With little relief for ER crowding being discussed, a scenario where the majority of Americans have coverage, but cannot access care, is going to be likely possibility.

Nearly half of women who undergo surgery and other treatments for breast cancer report having persistent pain in and around the treatment area a year or more later, probably because of nerve damage, according to research published in the November 10 issue of the Journal of the American Medical Association.

Here is some information about neuropathic, or nerve, pain:

• It is a type of pain that occurs when a nerve is injured and begins sending incorrect messages to the brain
• It can feel like numbness, tingling, pins and needles, burning, stabbing, electric shocks, or just be very difficult to describe
• There are pain medications specifically designed to treat this type of pain

Researchers from the University of Copenhagen in Denmark sent questionnaires regarding persistent pain to nearly 4,000 women who underwent treatment, including surgery and possibly chemotherapy or radiation, for breast cancer in 2005.

Overall, 87% of the women responded to the questionnaire. Among the respondents, 47% reported having persistent pain an average of 26 months after their treatment. Nearly half had light pain only, but about 40% had moderate pain, and as many as 13% had severe pain. Overall, 20% of the women with pain had consulted a physician regarding the problem in the previous three months. Younger women, especially those who had undergone breast-conserving surgery rather than full breast removal, as well as women who underwent radiation therapy were more likely to report having pain. Younger women were also more likely to report having sensory disturbances in and around the treatment site.

I am a young adult cancer patient who waited five and a half hours for the H1N1 vaccination along with 1200 other Chicagoans in a city college hallway. I do not have the trained eye of a public health analyst, yet it was easy to spy the glaring flaws that occurred in the whimsical distribution of this short supply vaccine. One of these oversights was the absence of trained workers screening citizens to determine if they actually needed a shot.

In the midst of what the government is calling a pandemic, there was a stunning lack of triage. Anyone could wait in line and receive a shot no questions asked. The public health department merely instructed citizens to use a common sense approach: If you consider yourself high-risk, get a vaccination.

I am an extremely aggressive patient with a high level of health literacy. As the author of a book on young adult cancer, I strongly advocate for patients participating in our care and knowing our bodies. However, I am not a doctor and medical practice is not common sense knowledge. Determinations of whether a patient’s underlying medical condition puts them at high-risk for complications from influenza should have been made by trained medical professionals, not by citizens making nebulous judgment calls.

Tensions ran high in the hallway of the makeshift walk-in clinic as my linemates and I vied for low cue numbers. People cut in front of each other, police mediated shouting matches, and camera crews interviewed desperate patients. My linemates and I began discussing our ailments, each defending our high-risk need for the shot. The 51-year-old man in front of me thought he was at risk due to high blood pressure that sometimes limits his use of over the counter medications. One woman in her late fifties boasted she thought she had a predisposition for bronchitis. Were these accurate self-determinations of the need for the vaccination or were my linemates pilfering from the short supply?

Dementia is a terminal illness. However, people with advanced dementias often languish in skilled nursing facilities, far from the ministrations of specialists. And, with reasonable luck, they have directives that specify that they are not to be taken to the hospital in the event of a respiratory arrest. Consequently, most of us are not privy to the mechanisms of demise in such situations.

How do people with dementia die? In the interests of demystifying this, a group of geriatrics researchers sought to prospectively study the course and concomitants of advanced dementia. They followed 323 patients, in 22 nursing homes near Boston, for 18 months. Eligible patients were identified by a variety of measures commonly already obtained on such patients. The required levels of these measures for study enrollment specify, for example, paucity or absence of speech, incontinence, and inability to walk. These were severely impaired people. The medical records were reviewed for episodes of complications such as pneumonia, eating impairment, and fevers. Other data obtained were related to “sentinel events,” evidence of distress and unpleasant interventions, and various issues regarding family members (and other “health care proxies”).

The results are instructive. The mean age of the cohort was 85.3 years old, and the median interval since dementia diagnosis was 6.0 years. 177 (54.8%) of the patients died during the 18 month study period. The median survival was 478 days, and the probability of death within 6 months was 24.7%. Probabilities for medical problems during the study period were 41.1% for pneumonia, 52.6% for an episode of fever, and an impressive 85.8% for an eating problem.

Distressing symptoms were distressingly common, and the probability increased as the patient neared death. The most common such symptoms were agitation (53.6%), dyspnea (46.0%) and pain (39.1%). The nature of sentinel events is also interesting, particularly from a neurologic perspective. 42 such events occured, of which the most common was seizure (14/42; 33.3%), followed by gastrointestinal hemorrhage (11; 26.2%) and hip fracture (3; 7.1%). Stroke also occurred in 3 patients.

During the study period, 16.7% of all patients were hospitalized and 8.0% received tube feedings. The probability of such an intervention was higher as patients neared death: Within 3 months of death, 52 (29.4%) received parenteral therapies, but fewer (12.4%) were hospitalized. In the same pre-death interval, 72 patients (40.7%) received at least one such intervention. Interventions were most common in patients with pneumonia.

Communication with family members was quite poor. At the time of the last evaluation, only 18.0% reported receiving prognostic information from a physician. Also, while 81.4% thought they understood what complications to expect, less than one third (32.5%) indicated that a physician had counseled them about this.