The Trouble with Using the Local Hospital

I have been fortunate in that I have not had to hospitalize any patients the past four weeks.  This means I have an extra 60 minutes or more to prepare for the workday in my office. The streak ended this weekend when my associate, taking his rotation of being on call, hospitalized one of my patients with pneumonia.

In many cases pneumonia is treated as an outpatient. You receive an antibiotic and cough medicine and stay at home, rest, hydrate and recuperate.  In this case, the patient has had multiple lung surgeries to save her life from cancer and she is left with much less pulmonary reserve than most.  She was coughing with a productive cough for several days as she moved from one home to her future residence while her husband, who usually watches after her, was away. By Sunday morning it hurt to breathe and she was exhausted. She called and spoke to my associate who suggested she meet him in the hospital emergency room.

Being an anxious and nervous individual, she called her cardiologist next, repeated the story and he wholeheartedly concurred with the decision.  In the ER her x-ray showed multiple areas of pneumonia and her elevated white blood cell count and temperature (which she was not aware of) confirmed the problem.  Blood and sputum cultures were obtained; antibiotics guided by an infectious disease specialist were begun.  Surprisingly and fortunately she was not wheezing, her lungs sounded better than on many visits and she did not feel particularly ill compared to past encounters of this nature

She was moved to a private isolation room where hospital routines and protocols took over and created nothing but anxiety and concern.  She had been on a low dose of corticosteroids as an outpatient and because her body was stressed she needed a higher stress dosage short term.  It was ordered on the computer system to be given all at once after a meal, but the pharmacy protocol called for multiple dosages and this conflict resulted in her getting half the dosage ordered.

When the patient noticed the difference in administration, she complained to her nurse.  However, no one had been notified.  The infectious disease specialist ordered an extra dosage of intravenous antibiotics for the evening of her arrival. The pharmacist noted that a dosage of this long acting medication had been administered earlier in the day and cancelled the order for the evening dosage without anyone calling the ID doctor or me as the attending physician. The patient objected but was overruled by nursing.

The patient was receiving a respiratory treatment with a medication that speeds up her heart rate greatly.  She normally takes a drug to prevent rapid heartbeats called a beta blocker. This was ordered for her but not given because the patient’s blood pressure was considered “too low.”  The problem is that the patient is a small thin woman and her blood pressure is always this low. She has taken this medication for years at this dosage with no ill effects.

When the covering physician placed the order for these medications the parameters for withholding the drug due to slow pulse or low blood pressure were not presented for his consideration. Once again, a medication was held, the patient was aware of it and no one called her attending physician or cardiologist to discuss it. This made the patient even more anxious and upset.

Since early spring 2019 the physicians’ parking lot has been closed while the facility builds a new parking lot. They have the doctors parking in a much more distant location about 2500 steps away from the main entrance.  It takes an extra 10 minutes to reach the entrance in and 10 minutes leaving now to get to your car and then leave. On a hot humid South Florida summer-like day you need to shower by the time you reach the air-conditioned main entrance.

Upon entering the building with our new corporate ID cards it takes another five minutes or longer to reach the patient floor if the elevator is free. From there you walk to the nursing station and try and find an open and functioning computer terminal.  In past years, when I entered the nursing and administrative section of the patient floors, the nurses and aides would say good morning and greet me by name. The patient’s paper chart was handed to me and a nurse would accompany me to the bedside to discuss the day’s plan, review the patient’s progress and reconcile the medications.

In today’s hospital no one looks up from their screen, rarely does someone say hello and I would not be surprised if I showed up in a Halloween Costume of Freddy Kruger if anyone would even notice.

Every item of information is now on the computer. Once you obtain an open workstation it takes several minutes to log in using multiple security rituals to finally find the patient’s chart.   If by chance your patient ran a fever and you have to complete the “sepsis protocol”, or if you decided not to start the  patient on a drug to prevent blood clots from developing, you can add another five minutes just to  remove these from your screen and actually get to your patient’ data.

After completing this I walk to the patient’s room to find my teary-eyed patient complaining about being awakened for blood drawing and how rough and inconsiderate the phlebotomist was. She is upset about the missed medications and alterations of her home medication schedule and her fears about how this would affect her and the plan to get her home.   The examination takes a few minutes and confirms that she is improving and moving towards going home soon.   I explain to the patient what I think should occur and get her input and approval and then search for her nurse to review it verbally. Its then back to the workstation to find a free computer so I may enter the orders I just reviewed with nursing.  A bedside computer station with a nurse present would cut 10 -15 minutes off the process but they are not available yet.  My iPad has access to the system at the bedside but the smaller screen makes entering orders difficult and offsets the convenience of a bedside computer.

As I enter my patient’s room, I see her face covered in tears.  She brightens up with a smile as I walk in and then begins to tell me about everything troubling her. Initially, most of my time is just spent listening and observing.  I listen intently to her concerns and fears and assure her she is moving towards a morning discharge.  I then phone her husband with a progress report.

It’s five flights of stairs down to the main floor. I notice that a helium balloon bouncing against the ceiling above my reach is still present for the third day.  When I leave the building after using my identification card once more to open the exit door, I trudge 2500 feet through the outdoor construction area back to the car to begin the now 20-minute ride to the office to see my morning patients.

I now understand why many of my colleagues only see patients in their offices. The sheer bureaucratic, protocol-driven nature of the hospital process makes caring for a patient infinitely more dangerous, more time consuming and more inefficient.   I cannot wait for this patient to be well enough to be discharged before another hospital protocol disrupts her recovery and makes her ill.

The inconvenience of coming to the hospital is exhausting.  Although, the look on a sick patient’s face when a familiar caregiver arrives to take charge and help them through the rough spots is still worth the trouble.

Influenza Vaccination in Adults

It is time once again to be thinking about taking your flu shot.   A recently published study by the National Foundation for Infectious Diseases (NFID) estimated that only 52% of US adults plan to take the flu shot.  Reasons for not being vaccinated include:

  • I do not believe it works (51%)
  • Concern it would cause an adverse effect (34%)
  • Concern that the vaccine would give them the flu (22%)

Health and Human Services Secretary Alex M. Azar II said, “Each season, flu vaccination prevents several million illnesses, tens of thousands of hospitalizations and thousands of deaths.  Over recent years, on average, flu vaccination has reduced the average adult’s chance of going to the doctor by between 30 – 60%.

A recent study performed by the northern California Kaiser Permanente Group, using seven years of flu season data, shows the immunity from the shot is near perfect for the first six weeks and then begins to wane. They estimate your post-vaccination chance of getting the flu, even if immunized, increases by 16% every 28 days after the shot but is near perfect for the first 42 days.

It is believed the Center for Disease Control (CDC) will recommend in future years that adults receive two flu shots each season. One will be administered at the beginning of the season and one six weeks later.  For the moment, the CDC acknowledges the flu season begins at different times in different regions of the country and suggests you receive your vaccination about two weeks before it arrives.

In South Florida, we typically see the arrival of the Influenza A virus after Thanksgiving. It peaks the last two weeks in January and first two weeks in February. For this reason, we suggest taking the shot later in the fall.

Vaccines are inactivated meaning they are not live and cannot give anyone the flu!

Who Is Addressing the Availability, Safety & Efficacy of our Medications?

I watched all three presidential debates this summer with health care being a time-consuming topic for all. Universal health care and Medicare-for-All, with or without an option for private insurance, were debated and discussed at length.

At the same time NBC Nightly News presented a story documenting that all our antibiotics come from production in China. With globalization policies, which promote moving production to lower cost overseas factories, there is no longer any production of antibiotics in the USA. A former member of the Joint Chief of Staffs, citing the current trade conflicts and China’s aggressive military stance in the Pacific, considers this a security issue. I have heard not one question or comment on this topic in the debates?

This week, once again, the blood pressure medicines losartan and valsartan were recalled because they contained potential carcinogens. These generics were produced in India, Asia and Israel. These same drugs have been recalled multiple times in the last few years for similar problems.

Due to reduction in funding for FDA inspections, many of these foreign plants have not been inspected for years. We can add recalls of generics to drug shortages. We suffered a shortage of intravenous fluids for hydration because the primary production site in Puerto Rico was destroyed in a hurricane. We had shortages of morphine and its derivatives for treatment of orthopedic trauma and post-surgical pain. They substituted foreign-produced short acting fentanyl. I saw pediatric ER physicians unable to administer the most effective treatments for sickle cell crisis in children because it required the use of a narcotic drip to offset the dramatic pain the treatments induce as they stop the crisis.

Then there are the psychiatric patients on antidepressant generics who are paying hundreds of dollars per month for products that wear off in 16 hours rather than 24 as the brand product did. Their symptoms creep back in allowing them to tell time based on the reduced efficacy of these products. By law, generics are required to provide 80% of the “bioavailability” of the brand product but what does that mean and who is testing?

This all began when the Reagan Administration closed the FDA research lab. Prior to that, all new products were sent to that lab for approval prior to being released in America. On their watch, a pharmaceutical product never had to be recalled. Big Pharma complained they took too long as did some consumer groups. This resulted in the defunding and closing of the lab. Products are now outsourced to private reference labs and their reports are sent to the FDA for review. The frequent drug recalls contrast to the success of promoting safety when the FDA did it themselves.

Isn’t it time for the health care debate, especially the presidential debates, to discuss the safety, efficacy, supply and cost of pharmaceutical products? I am all for bringing production home to the USA, restoring the FDA funding for the reopening of their lab as an impartial test site and putting the cost of repeatedly testing the generics for efficacy even after approval and release on the backs of Big Pharma. Let’s see these topics introduced to the health care debate too.

Sodium Chloride Salt Substitution Works in a Community Trial

At a meeting of the European Society of Cardiology, J. Jaime Miranda, M.D. PhD, of the University of Peruan Cayetano Heredia in Lima, Peru reported that substituting artificial salt substitute potassium chloride for table salt lowered the blood pressure of participants, reduced the number of new cases of hypertension and ultimately reduced stroke and heart disease mortality

For this study, researchers enlisted the assistance of six semi-rural agricultural fishing villages in the Tumbes region of Peru. All adults 18 and older were approached and over 91% of the 2,605 potential enrollees agreed to participate. Patients with chronic kidney disease, known heart disease or digoxin use were excluded because of the use of potassium and potential cumulative effects of this element.

The study area and residents historically have very little high blood pressure. In Peru, 140 systolic blood pressure and 90 diastolic blood pressure are considered the upper limits of normal.

The researchers replaced the sodium chloride used in food preparation with potassium chloride salt distributing it free to all families, shops, restaurants and bakeries over a three-year period. The results revealed a very small reduction in systolic blood pressure which still reduced the risk of stroke by 10% and ischemic heart disease by 7 %. The drop in blood pressure was more definitive in the 18% having hypertension at the time they entered the study and those 60 years of age or older.

This study raised the possibility of researchers approaching food manufacturers around the world to substitute potassium chloride artificial salt for sodium chloride as a means of lowering blood pressure and its stroke, cardiac, renal and vascular complications. It reinforced the suggestions to stop adding sodium chloride salt at the table or in food preparation if you wish to keep your blood pressure under control.

Antibiotic Use – Independent of Physician Prescribing

A recent article in the Annals of Internal Medicine looked at individuals who took antibiotics without them being prescribed by physicians at a visit.  The authors looked at 31 published studies between January 2000 and March 2019.  The medications came from family and friends, online distribution sites, drugs prescribed for their animals by their veterinary doctors and those stored after a previous indicated use.   When asked about it, and the reasons why these patients took these medications, the main factors cited were lack of health insurance or lack of healthcare access, cost of physician visits or medications, long waiting times in clinics, embarrassment for needing antibiotics, lack of transportation and/or easy availability of antibiotics  from other sources.

We are currently going through an antibiotic resistance crisis in the world.  Most of the fault lays with agricultural industry feeding livestock tons of antibiotics to fatten them up. Patterns of resistance develop on the farms and are passed species to species.

To remedy this, the US agriculture industry, especially in chicken production, has cut back drastically on this process.  At the same time, we are requesting physicians to work with infectious disease doctors in stewardship programs to reduce their use of ineffective antibiotics and to prescribe with precision when these medications are needed.  It works. Studies are beginning to show the benefits of these programs.

Despite this, the pressure from patients to be given something when they pay for, and invest in, a medical evaluation for an infection is overwhelming. In the setting of telemedicine, as well as walk-in and urgent care centers, reviews and patient satisfaction survey results are tied to whether the patient was given an antibiotic whether it was indicated or not.

As bacteria become resistant to common and inexpensive antibiotics, pharmaceutical manufacturers are not being incentivized to produce newer more efficacious medications.  At the same time, older useful antibiotics which do not generate much of a profit are not even being ordered and stored by chain pharmacies that lose money each time the older generics are prescribed.

To begin solving this problem, an improvement of our health literacy is required. Education in schools and in public health announcements, both in print and social media, need to realistically address the issue. This education will not replace the need for access to health care and health, but it is a beginning to make individuals understand how, when and why these “miraculous” medications can and should be used.

Heartburn, Indigestion & Protein Pump Inhibitors

I have seen multiple adult patients with intractable heartburn, reflux, indigestion and chest pressure all related to food and digestive enzymes kicking back up the esophagus from the stomach through a lax group of muscles known as the lower esophageal sphincter.  All these patients receive a fiber optic upper endoscopy (EGD) at some point and are observed and biopsied to eliminate the possibility of ulcers, cancer, gastric polyps, esophageal cancer, potential esophageal cancer and Helicobacter Pylori bacteria as the cause.

They are all treated with weight control suggestions, avoiding a host of foods, most of which are quite healthy from a cardiovascular standpoint plus limits on alcohol, elimination of tobacco and other indulgences of adults. We ask these patients to wear loose clothing at the waistline, avoid reclining for three hours after eating and take a host of medicines including proton pump inhibitors (PPI) such as Nexium, Protonix, Prilosec.  Drugs like Tagamet, Zantac (H2 Receptor Blockers), Tums, Rolaids are far less effective.

In recent years, numerous articles have appeared in medical journals stating that protein pump inhibitors, when taken regularly, can predispose to increased and early death, pneumonia and dementia.  A large review article from a prominent GI group in Boston, and published in the New England Journal of Medicine, tried to eloquently refute these claims but the doubt about long term safety lingers buoyed by numerous lay periodicals and online internet sites sensationalizing the down sides of these medicines.

To allay the patients fears, doctors and patients work together to try and stop the PPIs and substitute the older standbys like Tagamet and Zantac but they just don’t provide the symptom relief that the PPI’s do. Patient’s face the dilemma of taking the medicine that works best and incurring the potential risks or suffering.

In a recent edition of the journal Gastroenterology, Paul Moayyedi, MB ChB, PhD from McMaster University in Canada followed 17,000 patients for three years with half the group taking PPI’s. Those taking a PPI (Protonix) for three years had no more illness or adverse effects than those taking a placebo.  L. Cohen, MD, a reviewer at Mount Sinai School of Medicine in NY, concluded that the study provided strong evidence of the safety of PPIs for patients taking the drug for three consecutive years.

The controversy will continue. I am sure next week someone will produce data revealing some additional horrible consequences of taking these medications to relieve heartburn. It will ultimately come down to individual decisions about quality of life versus potential risks because the lifestyle changes necessary to control this problem are difficult for human beings to sustain over a long period of time.

Hurricane Dorian: Staying Focused as the Storm Moves In

As Hurricane Dorian moves through the Atlantic Ocean towards the United States and the Florida peninsula, there is no respite or escape from the constant barrage of news updates and suggestions being offered on TV, radio, print news, internet news outlets and social media.  The fierce image of the tightly curled storm is displayed everywhere.

I have been through quite a few storms starting in 1979 when the builders in our unfinished community loaned us plywood to board up our windows with concrete anchors ruining our exterior stucco finishes forever. Fourteen hours of work with a saw and hammer and screw drivers and I was too exhausted to notice the storm gracefully curled out to sea sparing us.

For Hurricane Andrew we had no shutters or knowledge, just luck. Masking tape was on the windows since no one had shutters.  A few pillows and pool floats were over the windows in the room we were closest to as we slept on the tile in a window free hall. Post-storm I volunteered to provide medical care in Dade County and was in a Ford Van that was broadsided at a Kendall intersection killing two in the other vehicle that ran what used to be a stop sign.  The impact sent our van tumbling over and over until we ended up right side up in someone’s driveway with our seat belted volunteer medical crew mercifully just frightened and sore.

Then there was the year that, as the storm passed and a curfew was in effect, we went to bed as it got dark with the power out and the windows open. The dogs started howling and there was loud knocking on the door.  I grabbed a flashlight and baseball bat and was greeted by a police officer at the door looking for “Dr. Reznick”.   ““They need you in the ER.“ he said.   “How can that be?  We have a coverage arrangement and no one is supposed to be called during the storm or immediately after?”

The poor officer told me the new administration had cancelled the plan and called into FEMA and was given a military reserve medical unit to cover the hospital.  “You are the first doc I have been able to find on my list of 20. Don’t worry about the curfew. If they stop you just show your hospital ID or driver’s license.  You’re good to go.”

I got dressed as did my wife and we threw the dogs into the car and headed for the hospital.  Every streetlight was out. Trees were down. Traffic signals were not working so each intersection was a treacherous four way stop sign situation.

As I turned onto Meadows Road my headlights lit up a big tree across the road and, off to the side, a roadblock with two military personnel in full battle gear signaling me to stop and roll down my window.  I showed my hospital ID and they told me I needed hospital ID for my passenger to proceed.  I told them it was my wife and she and the dogs would wait in the doctor’s lounge while I attended to the ER patient.

He said they were not permitted to accompany me to enter the facility area.   I told him to step aside or shoot us or get run over but I was going forward which I did. An MP met me at the entrance to the doctors’ lounge and, in language not repeatable in mixed company, I told him what he and his CO could do.  They backed off.

When I got to the ER I learned that one of my ocean front condo commando patients, who refused to heed the evacuation order, took the elevator down from the 18th floor to the lobby to view the storm. The power went out as he toured his lobby and he was trapped there.  He called 911 and was rescued by first responders and brought to the hospital because they had nowhere else to deposit him. Turns out he was constipated so they called me in to admit him.  I handled the administrative duties, told the new administrator what I thought of his decision to suspend our decade’s long program of collegially covering the hospital and each other’s patients and trudged home.

The FEMA medical team was sent packing the next morning as the medical staff chastised the administration for their poor decision making. This was one of administration’s first decisions which changed and ruined the community feeling of our small facility forever.

Staying focused prior to the storm is the hardest part.  Patients call in anxious and harried from the preparations and endless threatening updates and news flashes. Listening to the chronic complaints of your most anxious and worried patients and trying to sort out what is new, what is pertinent, what is important while your mind tries to stray to storm survival mode is a skill you are always trying to perfect.

The remaining shutters we use for the few remaining non-impact windows are ready to go. The windows have been sprayed with wasp and hornet spray so that we don’t get stung when the shutters and noise disrupt the hornet nests that pop up daily – which happened years ago. The work gloves are ready as are the work boots.  The WD40 is in great supply to make sure the Kevlar storm screen anchors easily screw in and out of their mooring holes.  We have three weeks of water and lights and batteries and nonperishable food.  The cars are full of gas. My wife is making extra ice for reasons I am not entirely certain of – but it cannot hurt to have it. The dogs have extra food ready.  Our quick escape “go bags” are packed and by the exits. Now all we can do is wait.

I head out for the office being extra careful on the wet and windy road because every driver is paying attention but distracted. The fender benders and aggressive driving due to anxiety have begun. Focus and stay safe.  That is the goal.