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Rationale for Testing Anticoagulants Against COVID-19

By ETHAN WEISS, MD

We have seen and heard about the classic symptoms of COVID-19 at UCSF Medical Center, where I work as a cardiologist. Patients keep coming in with pulmonary distress, pneumonia, and ultimately, Acute Respiratory Distress Syndrome (ARDS) – the life-and-death situation that requires ventilators.

However, I’m beginning to learn about other symptoms that some doctors are noticing. There are numerous reports of other complications, especially in advanced disease.

One of the most interesting involves disruption of the blood’s coagulation system. New anecdotal reports have described clotting in test tubes and lines, derangements of clinical clotting assays, pulmonary embolilarge clots in the heart, as well as microvascular thrombosis.

Elevation in D-Dimer, (a biomarker of coagulation system activation) has been associated with dramatically increased risk of death from COVID-19. This has led some to speculate that empiric treatment with anticoagulants might improve outcomes in these critically ill patients. Indeed, there was this recent publication of a retrospective analysis of anticoagulation with heparin or low molecular weight heparin showing an association with improved outcomes in COVID-19 patients in China.

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This Treatment Could Save Your Life – COVID-19 and Convalescent Plasma Therapy

Ajay Kohli
Vinay Kohli
Chitra Chhabra Kohli

By CHITRA CHHABRA KOHLI MD, AJAY KOHLI MD, and VINAY KOHLI MD, MBA

With a doubling time of cases estimated between 3 days within the U.S. and about 6 days globally (at the time of this writing) COVID-19 is demonstrating its terrifying virulence as it spreads across the world.

What’s perhaps equally terrifying, if not more, is the absence of a known cure or treatment plan for COVID-19. While there has been a lot of attention focused on Hydroxychloroquine and Azithromycin, there has been debate on the scientific validity of these treatment options, either as therapy or as prophylaxis. The impact of a solution certainly has far reaching potential, the scope of the challenge is overwhelmingly large. The editor-in-chief of Science recently wrote that the efforts to find a cure are not just ”fixing a plane while it’s flying — it’s fixing a plane that’s flying while its blueprints are still being drawn.”

There is a promising therapy that may help us weather the COVID-19 storm and, perhaps, flatten the curve. It’s based around science that defines immunology and has already been used in many different diseases, going as far back as the 1918 flu pandemic. This potential treatment is convalescent plasma therapy — using antibodies from patients who have recovered from COVID-19 and then transfusing them into patients who are currently mounting an immune response against the rapidly rising viral loads of COVID-19.

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How Concerned Should Patients Be About An Irregular Heartbeat?

By KOUSIK KRISHNAN, MD

As many industries and individuals are struggling publicly with burnout, a new study from the European Journal of Preventative Cardiology links the “burnout syndrome” with atrial fibrillation (afib). The findings are both interesting and valuable. In general, the public benefits from anything that can raise awareness of heart disease, because early intervention directly impacts improved patient outcomes.

However, headlines that describe afib as a “deadly irregular heartbeat” go too far in the name of public awareness. The truth is, afib is not a sudden killer like a heart attack, cardiac arrest, or stroke. While afib is undeniably serious, it can often be identified in advance and managed with evaluation and treatment. 

Afib is a very common arrhythmia that has numerous risk factors, including hypertension, diabetes, obesity, and sleep apnea, to name just a few. When the heart goes into atrial fibrillation, the upper chambers go into a fast, chaotic and irregular rhythm that often makes the pulse race and feel irregular. Other symptoms can include palpitations, shortness of breath, and dizziness. Some people may not have any symptoms at all. Stroke is the most devastating consequence of atrial fibrillation, but is rarely the first manifestation of the disease.

It is also important to note that afib may not always be present. For this reason, often the arrhythmia is gone by the time someone seeks medical attention, making the arrhythmia harder to diagnose. Fortunately, consumer devices, such as the new Apple Watch, have algorithms to help detect atrial fibrillation. These technologies hold immense promise. They are already helping many people manage their health, and even potentially diagnose some people who never knew they had afib.

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Pandemic Fears: What the AIDS Battle Should Teach Us About COVID-19

By ANISH KOKA, MD

As the globe faces a novel, highly transmissible, lethal virus, I am most struck by a medicine cabinet that is embarrassingly empty for doctors in this battle.  This means much of the debate centers on mitigation of spread of the virus.  Tempers flare over discussions on travel bans, social distancing, and self quarantines, yet the inescapable fact remains that the medical community can do little more than support the varying fractions of patients who progress from mild to severe and life threatening disease.  This isn’t meant to minimize the massive efforts brought to bear to keep patients alive by health care workers but those massive efforts to support failing organs in the severely ill are in large part because we lack any effective therapy to combat the virus.  It is akin to taking care of patients with bacterial infections in an era before antibiotics, or HIV/AIDS in an era before anti-retroviral therapy.  

It should be a familiar feeling for at least one of the leading physicians charged with managing the current crisis – Dr. Anthony Fauci.  Dr. Fauci started as an immunologist at the NIH in the 1960s and quickly made breakthroughs in previously fatal diseases marked by an overactive immune response.  Strange reports of a new disease that was sweeping through the gay community in the early 1980’s caused him to shift focus to join the great battle against the AIDS epidemic. 

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Time Really Can Be Money

By KIM BELLARD

If you are not an IKEA fan, or haven’t been spending any time in Dubai, you may have missed the chain’s marketing campaign to help promote its second store in the area.  Titled “Buy With Your Time,” customers got store credits for how long they spent getting to the store. 

Gosh, that’s something that should make any self-respecting critic of the U.S. healthcare system perk up.  Count me as intrigued.

The campaign involved checking the customer’s Google Maps’ Trip tab to determine how long it took them to get to the store.  IKEA benchmarked the average hourly wage in Dubai, and converted the travel time into how much credit they’d generated.  It works out to about $29/hour, or $0.48 per minute.  Spend long enough getting there and you could get a free coffee table or even a bookcase.  Prices in the store include the equivalent time currency.

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Healthcare Has a Moral Injury

By KIM BELLARD

The term “moral injury” is a term originally applied to soldiers as a way to help explain PTSD and, more recently, to physicians as a way to help explain physician burnout.  The concept is that moral injury is what can happen to people when “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”  

I think healthcare generally has a bad case of moral injury.  

How else can we explain physicians practicing surprise billinghospitals suing patientshealth plans refusing to pay for pre-authorized treatments, or pharmaceutical companies charging “skyrocketing” costs even for common, essential prescription drugs?  There are people involved in each of these, and countless more examples.  If those people haven’t suffered a moral injury as a result, it’s hard to understand why.  

Melissa Bailey, writing for Kaiser Health News, looked at moral injury from the standpoint of emergency room physicians.  One physician decried how “the real priority is speed and money and not our patients’ care.”  Another made a broader charge: “The health system is not set up to help patients. It’s set up to make money.”  He urged that physicians seek to understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”

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Patient Worries as a Central Feature of their Health Care Experiences

By JOHN JAMES, ROBERT R. SCULLY, CASEY QUINLAN, BILL ADAMS, HELEN HASKELL, and POPPY ARFORD

Political forces trying to shape and reshape American healthcare without hearing the voice of patients provided the rationale for this work. Our experiences as patients, caregivers, and users of media sources cause us to worry. The Patient Council of the Right Care Alliance developed 6 questions to form a national survey of Americans to guide policy makers. The questions and our rationale were as follows:

1) Finding a doctor I can trust. Trust in our doctors is not as high as it once was. There are stories of serious patient abuse that appear in the media; two of the more notorious examples include a neurosurgeon harming many patients before being stopped and an oncologist who was deliberately misdiagnosing cancer to sell chemotherapy. Patients perceive this as the reluctance of the physician community to effectively ‘police their own.’

2) I will be misdiagnosed. Misdiagnosis happens far too often at all levels of healthcare. The problem is so common that the National Academy of Medicine turned its attention to the problem and published Improving Diagnosis in Health Care in 2015. The solution to the misdiagnosis problem is complex and has yet to arrive at the clinician-patient interface.

3) I will get an infection while receiving treatment. Healthcare-associated infections have dropped somewhat in the past decade, yet there are still about 720,000 infections and 75,000 deaths per year from healthcare-associated infections. Many of these are becoming nearly impossible to effectively treat. The improper use of ordinary antibiotics continues to be a problem in clinical settings.

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The Social Context and Vulnerabilities that Challenge Health Care in the San Joaquin Valley of California

By ALYA AHMAD, MD

Call it what you want, white privilege and health disparity appear to be two sides of the same coin. We used to consider ethnic or genetic variants as risk factors, prognostic to health conditions. However, the social determinants of health (SDOH) have increasingly become more relevant as causes of disease prevalence and complexity in health care.

As a pediatric hospitalist in the San Joaquin Valley region, I encounter these social determinants daily. They were particularly evident as I treated a 12-year old Hispanic boy who was admitted with a ruptured appendix and developed a complicated abscess, requiring an extensive hospitalization due to his complication. Why? Did he have the genetic propensity for this adverse outcome? Was it because he was non-compliant with his antibiotic regimen? No.

Rather, circumstances due to his social context presented major hurdles to his care. He had trouble getting to a hospital or clinic. He did not want to burden his parents—migrant workers with erratic long hours—further delaying his evaluation. And his Spanish-speaking mother never wondered why, despite surgery and drainage, he was not healing per the usual expectation.

When he was first hospitalized, his mother bounced around in silent desperation from their rural clinic to the emergency room more than 20 miles from their home and back to the clinic, only to be referred again to that same emergency room. By the time he was admitted 2 days later, he was profoundly ill. The surgeon had to be called in the middle of the night for an emergency open surgical appendectomy and drainage. Even after post-operative care, while he was on broad-spectrum intravenous antibiotics, his fevers, chills and pain persisted. To avoid worrying his mother, he continued to deny his symptoms. Five days after his operation, he required another procedure for complex abscess drainage.

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Medical Records in Primary Care: Keeping the Story of Phone Calls and Medication Changes with Less than Perfect Tools

By HANS DUVEFELT, MD

I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.

Here’s another Metamedicine story:

In learning my third EMR, I am again a little disappointed. I am again, still, finding it hard to document and retrieve the thread of my patient’s life and disease story. I think many EMRs were created for episodic, rather than continued medical care.

One thing that can make working with an EMR difficult is finding the chronology in office visits (seen for sore throat and started on an antibiotic), phone calls (starting to feel itchy, is it an allergic reaction?and outside reports (emergency room visit for anaphylactic reaction).

I have never understood the logic of storing phone calls in a separate portion of the EMR, the way some systems do. In one of my systems, calls were listed separately by date without “headlines” like “?allergic reaction” in the case above.

In my new system, which I’m still learning, they seem to be stored in a bigger bucket for all kinds of “tasks” (refills, phone calls, orders and referrals made during office visits etc.)

Both these systems seem to give me the option of creating, in a more or less cumbersome way, “non-billable encounters” to document things like phone calls and ER visits, in chronological order, in the same part of the record as the office notes. That may be what IT people disparagingly call “workarounds”, but listen, I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.

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Why Healthcare Needs Designers

By TINA PARK, MFA

Designing a functional lamp is simple. Building the Mars Rover is complex. Getting a doctor to ask the right questions so that a patient feels confident about their care in a highly regulated and time constrained environment? That’s complicated.

Healthcare is filled with complicated challenges. Increasingly, healthcare companies and institutions are attacking these challenges with cross-disciplinary teams — doctors, data scientists, marketers, quality officers, financial experts, information technologists, and more. An often missing member of these teams are design leaders. Designers can provide an invaluable role in healthcare, but too often healthcare does not take advantage of all that design can offer.

Good design is invisible. Think about the last time you obtained or purchased something that was well designed. When you get a new blender, you plug it in and turn it on without looking at the user manual, and it works. You don’t necessarily think “Wow, they put that on button right where I thought it would be.” You use it and get on with your day. And every day you use that blender, putting in new mixtures of fruits and vegetables. Sometimes you get a delicious jackpot mix and think this is the best blender ever. Sometimes you get something brown and sticky and you make a mental note never to try that one again, even as you choke it down.

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