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  • Boca Raton Concierge Doc

The Blood Pressure Guidelines Dilemma

The American College of Cardiology and American Heart Association recently published blood pressure control guidelines that suggest we should be treating blood pressure in 25 year olds the same way we treat it in 79 year olds and older patients. If you have any cardiovascular disease, or a 10% cardiovascular risk assessment over the next few years, they want your systolic blood pressure to be less than 130. They present excellent data explaining that as the blood pressure elevates above 130, the risk of a heart attack, stroke, vascular disease or kidney disease and, ultimately, death increase. No one is arguing these facts.

The American College of Physicians (ACP) along with the American Academy of Family Physicians (AAFP) recognizes this one size fits all in blood pressure control creates many problems. As we age, our arteries become less compliant or elastic. Stiffer arteries are more difficult to assess for blood pressure value. After we have exhausted the lifestyle changes of smoking cessation, weight loss, salt restriction and increased activity to control blood pressure; we are forced to use medications. We try to use low doses of medicines to avoid the adverse effects of the pills that the higher dosages can bring.

These medicines are costly. The more we prescribe the more patients don’t take them due to the cost. The more we prescribe, the more patients forget to take multiple pills on multiple schedules of administration. If we get the patients to take the medication we run into the problem of blood pressure precipitously dropping when patients change positions from supine to sitting to standing. If we are lucky, and the patient is well hydrated, then we may only be dealing with a brief dizzy spell. In other cases, we are left treating the consequences of a fall and injury from the fall. The more we strive to control your blood pressure to the new levels with medications the more we must consider drug interactions with prescription medicines being prescribed for other health problems seen in older Americans.

At this point, experts from the ACP Policy Board and noted hypertensive experts at the University of Chicago have suggested we follow the more liberal guidelines of the ACP individualizing our care based on the patient’s health issues. Personalizing care with individual goals makes sense to me, especially in my chronically ill patients battling blood pressure, weight control, age related orthopedic issues, and age related visual and urological issues plus other problems. We strive to do that in our practice allowing the time for discussion, questions and evaluation at each visit.

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Emergencies and the Rational For Our Treatment Algorithm

We are a primary care medical office that tries to deliver personalized attentive care. We define emergencies as chest pain, significant breathing difficulty and loss of consciousness, uncontrolled bleeding or pain, sudden change in mental status and behavior or major trauma. In these situations, my office staff receiving a phone call interrupts me so I can speak with you and determine whether or not to advise you to call 911. We do this because we know with life threatening situations time is of the essence.

Emergency Medical Services at 911 can arrive within 5 minutes. They are all Advanced Cardiac Life Support (ACLS) trained and carry the equipment and medications to provide life sustaining care while you are transported to a hospital Emergency Department that has the staff, medications and equipment to keep you alive while we diagnose the problem and create a plan to rectify it.

The office staff is trained in Basic Cardiac Life Support. We do not have a defibrillator. We do not maintain and store medications to correct low blood pressure – cardiac arrhythmias. We do not have endotracheal tubes to intubate you and breathe for you. In the past, when we tried to maintain these supplies, they became outdated due to infrequent use and were expensive to replace. Since we do very few resuscitations day to day we are not as experienced or efficient as EMS and emergency department personnel are.

I realize the wait for care and institutional care settings are not pleasant. We sacrifice that for the best chance to keep you healthy. Trust me, it is no fun cancelling a scheduled patients to run to the ER and then return already behind. We do it for your comfort and security and safety.

In the recent past patients with chest pain resembling heart disease, trouble breathing and excessive bleeding have refused to call 911 and were upset when we did not bring them into the office. We do this for your health and safety not our convenience. If you would like to discuss this feel free to contact the office.

Globalization, Corporate Control and Shortages of Medication

One of my online medical information websites carried a letter from the head of the Food and Drug Administration (FDA) trying to explain why there is a shortage of standard intravenous fluids to administer at hospitals and medical clinics in the United States. The author cited an extremely busy influenza season causing patients to use Emergency Departments in record numbers plus a loss of manufacturing capabilities due to damage to a production facility in Puerto Rico during a seasonal hurricane. No more, no less.

Doctors, nurses and patients are expected to believe that there is only one production center for our intravenous fluids nationally located in Puerto Rico. If it is unable to produce and ship product then health care as we know it has to change?

If this is in fact the truth, and the only reason for the lack of available IV fluids, what exactly does it have to say about our planning and leadership at the level of the FDA and CDC? Might it in fact indict the corporate model of efficiency and productivity? Is there not a Plan B and C for supplies of intravenous fluid if one source cannot supply our needs? If this is in fact the only production source then why wasn’t it a post storm FEMA national priority similar to if the NORAD intercontinental ballistic missile system had been damaged due to Hurricane Irma or Maria and we could not monitor North Korean launches?

At the same time we have a shortage of intravenous fluids, we have a shortage of injectable narcotics for pain relief. Morphine and dilaudid are in short supply. My hospital pharmacy committee and chief medical officer are now limiting injectable pain medications to immediate post-surgical cases.

Pain elsewhere in the institution should be treated with the oral pain pills we read about causing the opioid epidemic and crisis in America. There apparently is no shortage of injectable heroin on the streets of Palm Beach County, Florida. The Mexican cartels have found a way to meet the demand of its customers unlike organized healthcare which seems unable to do so.

I do not know who is responsible for insuring that we have enough materials and medications available to care for our nation. I do know they are doing a very poor job of it and would love to know who is responsible.

Primary Care Docs Outperform Hospitalists …

A study published recently in JAMA Internal Medicine looked at 650,651 Medicare patients hospitalized in 2013. It showed that when patients were cared for by their own outpatient physician they had a slightly better outcome than when the patients were attended to by full-time hospital based specialists who had not previously known them.

As an internal medicine physician who maintains hospital privileges, as well as caring for patients in an office setting, this study supports the type of medicine I have been trying to practice for the last 38 years. However, I am not naïve enough to believe it entirely.

In recent months similar studies have touted the benefit of female physicians over their male counterparts, younger physicians over older physicians and even foreign trained physicians over those trained in the USA. Based on these studies, one might conclude you should be treated by a young female outpatient physician who trained in a foreign country. While the JAMA study shows the success of the outpatient primary care physician, those in hospitalist medicine could similarly produce their own studies showing the benefit of using a hospital based physician or hospitalist.

I do believe having a familiar physician, you know and trust, adds a major level of comfort when you are ill. Having that physician consult within his or her referral network of physicians who know how that doctor expects the communication between doctors, and care to occur, is an additional benefit.

The fact that your personal physician knows what you look like in health gives them a distinct advantage in recognizing when you are ill. They know you and all about you and that helps. It especially helps patients with complex medical issues who require more time and thought. Being able to review the old records and previous specialty consultations which you were a part of seems to impart an advantage that someone just joining the care team does not yet possess.

This study does not say that outpatient primary care docs are better than hospitalists. It only points out that in a senior citizen population in 2013, patients cared for by their own primary care doctor had a better 30 day survival after a hospital stay.

On Loss, Death and Dying

As an internist with “added qualifications in geriatric medicine” I care for a great many elder individuals. In most cases these are individuals I met 20 or more years ago and have been privileged to share their lives with them as they aged.

The circle of life is relentless and unforgiving so there comes a time when these relationships end. In some cases it comes when they can no longer care for themselves and I suggest they move out of the area to be closer to a loved one who will provide support and care. In some cases the patient moves from their home into a senior assisted or skilled nursing facility out of the area.

There have been a few situations where an adult child from out of the area shows up on the scene and transfers their loved one’s care elsewhere. These are the most difficult situations because the children are stressed and put out by the responsibility and inconvenience of suddenly having to care for their loved one. They do not have the longstanding professional relationship with me that I have with the patient. They expect quick and simple answers and treatment plans in most cases when for the most part we are dealing with complex issues involving many professionals and treating one condition fully often exacerbates another.

Then of course there are the patients who pass away. As detached as you try to be, those of us who care invest a bit of our heart and soul in each patient who comes to us for care. I see that investment made in the vast majority of my colleagues across all the disciplines and specialties. When you lose someone, even an ancient senior citizen, it takes a piece of your being with it.

I too am no spring chicken. I talk about Medicare from experience now. Morning stiffness is a shared experience, not a term in a medical textbook. Male urinary problems, once something you treated in older guys is now a way of life. My older colleagues are retiring. When making hospital rounds I notice the prevalence of younger physicians.

My beloved pets age too. For the last 16 years my Pug (Pugsly) and my mixed-breed sweetie (Chloe) greeted me at the door, took long walks with me and provided fur therapy after a stressful day. Pugsly expired a year ago. His mate Chloe left this world in November. For a clinician well versed in Elizabeth Kubler Ross’s book “On Death and Dying” and dealing with life and death daily, the loss of a beloved pet should be easier. The pain is palpable. The sadness recurs and the heaviness on the shoulders, eyelids and heart wears you down.

I have several younger patients valiantly battling against horrible malignant diseases. Their drive and courage to overcome illness and enjoy the time they have with family and friends is inspirational. They do not know it but they are my role models for how to deal with the adversity of losing loved ones, human and pet, and sharing the diminishing independence and health that my long time patients now experience.

New Non Live Shingles Vaccine Approved by FDA and ACIP

For several years the Advisory Committee on Immunization Practices (ACIP) has been encouraging adults to receive the shingles vaccine or Zostavax. Shingles is a recurrence of chicken pox which we had as children. The virus lives within the nerve endings near the spinal cord and recurs following sensory nerves at unexpected times producing a chicken pox like (herpetic) rash with pain on one side of your body. The lesions follow the pattern of the chicken pox with pustules crusting over the course of a week. During the rash, patients are contagious and can transmit the chicken pox virus to people not immunized against it or those people whose immunity is diminished. As the rash subsides, a large percentage of the patients continue to have pain along the path of that sensory nerve which can last forever in a post herpetic neuralgia.

Zostavax will prevent an outbreak of shingles in about 2/3 of those who receive the shot. It prevents the post rash pain syndrome in a much higher percentage of the recipients. It was this quality that made it easy for me to recommend the vaccine to my patients and to take it myself.

The shot’s major drawback was that it involved receiving an attenuated or modulated live virus. This prevented individuals on chemotherapy or with a weakened immune system from receiving this vaccine.

To address that issue Glaxo Smith Kline developed Shingrix which is a non-live, recombinant subunit vaccine injected into the muscle on two occasions. It is touted to prevent shingles in 90% of the recipients over a four year period. It will replace Zostavax as the shingles vaccine of choice. For those of us who already received Zostavax they are recommending that we boost our immunity by receiving this new vaccine as well.

I have always been quite conservative on recommending new pharmaceutical products until they have been on the US market for at least one year. With the decreased funding of the FDA, I will wait at least a year until I see what adverse reactions occur in the US population. In the meantime I will price the product and try and learn if private insurers and/or Medicare will pay for its administration.

Scientists Develop Rapid Susceptibility Tests for Urinary Tract Infections

In my geriatric patients, recurrent urinary tract infections and conditions mimicking them pop up frequently. Patients young and old find it inconvenient to come to the office to provide a specimen to analyze whether or not an infection has occurred and what is causing it. You often need to send the specimen off to the lab to culture the offending bacteria and then wait further for the lab to determine what antibiotic if any will work against that invader. As clinicians, if we suspect an infection and the in-office or clinic urine specimen looks infected, we treat with the antibiotics most likely to cure until we actually get the official reports back from the lab.

An esteemed panel of health care experts has recommended something different -suggesting that when symptoms of a urinary tract infection develop patients be prescribed a three day course of antibiotics without an exam or urinalysis or pre-antibiotic treatment urine for culture and sensitivity. This is all part of the 21st Century movement for less costly, less time consuming, more convenient self-diagnosis and care using your high tech apps to diagnose and treat your problem.

In my patient population many of the elderly patients use so many antibiotics so many times for presumed urine infections that we are often dealing with multi drug resistant bacteria requiring intravenous treatment with complex medications to cure the problem.

Scientists announced recently in the journal, Science Translational Medicine, that they have developed a rapid 30 minute DNA test that will allow us to determine the susceptibility of the offending organism quickly. The successful study has led to the beginning of developing a commercial variety of the test expected to be available in three years. If it works and is affordable it will make outpatient treatment of urinary tract infections far more accurate and efficient.