bb Albert Provocateur: February 2011

Albert Provocateur

Tuesday, February 08, 2011

Hospital-ity

There you have it! Go in with something, come out with something else, or not at all. The game of Russian roulette has begun, in a casino called a hospital, with dealers dressed in white, all in the name of “hospital-ity.” This game is different, however. Lives are at stake, and you, the crap shooter, not the house, are in control of your own destiny. With 98,000 people dying each year in hospitals due to medical mistakes, the stakes are quite high. The cards are stacked against you, and unless you play with something up your sleeve, namely, the trump card of information, you are destined to see your pile of chips dwindle, as the lack of hospital electronic medical records, the longer working hours of physicians and nurses, and the lack of simple precautionary measures like handwashing all contribute to a nasty stay or your ultimate demise. Even in a best case scenario and in topnotch hospitals, hospital-ity is at a premium, with 18 percent of patients hurt as a result of a medical procedure, medication, infection, or other cause, a euphemism for “blunder.” While counting cards is prohibited, some numbers simply cannot be overlooked. The lion’s share of hospital harm, over 63 percent by some estimates, can be prevented, and the name of the game, pure and simple, to do this is getting educated. Whether a patient is hospitalized for diabetes or surgery, the rules for maximum patient satisfaction and pay-out are similar, as are the consequences for failure to abide by them. How many times have we heard horror stories about wrong limbs being amputated, wrong operations being performed, patients going into hypoglycemic shock, and antibiotic-resistant strains of bacteria having free reign in hospital wards? In most cases, a throw of the dice is just that, when an ounce of prevention would have most certainly yielded a seven or eleven. And you say you’re not a gambler?

So, what can be done to turn the tide on the house, and stack the deck in favor of the bird to be plucked, namely, the patient? First of all, stay informed. Don’t be intimidated by your surroundings or by the air of importance generated by your health dealers in white. They are there to serve you, and not vice versa. The more questions you ask and the more informed you are, the smoother your treatment will be. You can take that to the bank! Secondly, don’t hide cards up your sleeve, when it comes to allergies, alcohol use, sexual activity, medications and supplements, and any other piece of relevant medical information that you consider too personal or too embarrassing to reveal. Remember, anything your doctor or nurse doesn’t know can kill you! Another bit of information to carry with you to the cash-out cage or discharge desk is a full understanding of any prescription your physician has written for you. Doctor’s scrawl is akin to hieroglyphics, and don’t expect your friendly neighborhood pharmacist to possess the Rosetta Stone or read your physician’s mind. Whether it be the name of a drug, the dose, its frequency, side effects, the availability of a generic version over a brand name, or any special instructions, make sure you cut the cards openly and cut your losses, too, by holding both your doctor and your pharmacist to the letter of the label. Pills, capsules, and tablets are like colored poker chips. Sometimes they get lost in the heat of the shuffle or the intensity of play. So, be sure on that score.

It goes without saying that you should move around the hospital as if it were a casino, and as if you were looking for just the right slot machine. Bedsores, blood clots, and infections have a tendency to make losers of the immobile. It is a no-brainer, therefore, to at least take that walk down the hall once a day. Don’t be afraid to speak up either, if you happen to run into your doctor or nurse, and wish to ask a question, get something off your chest, or obtain clarification on some aspect of your care. That’s what they’re there for, and the worst they can do is ban you from the casino for life, in which case you’ll choose a future hospital with better health care providers, management teams, educators, dietitians, and ancillary staff. You hold the four aces as a consumer, and it is up to the pit boss and hospital administration to retain your health care dollar and your health care business. Something as apparently inconsequential as a caregiver failing to wash his or her hands, and then subsequently not complying with your gentle germophobic reproach and reminder to them to do so, is a serious matter and grounds for changing the table you are playing at.

Taking your personal health matters into your own hands will not only cut down on iatrogenic errors and unintentional cheating by the “whitecoats,” but will guarantee a pay-out measured in numerous disease-free years and improved quality of life. Don’t get taken to the cleaners by failing to do so!

© 2011, Albert M. Balesh, M.D. All rights reserved.

posted by Dr. Al at 2/08/2011 05:39:00 AM | 0 comments

Wednesday, February 02, 2011

Articular Attack

Like a toy in the attic, collecting dust until polished and thrown back into the mainstream of the temple’s hallowed halls, rheumatoid arthritis (RA) subtracts luster and adds exquisite pain to muscles and joints long ignored in a restful and tranquil hibernation. Dormancy breeds contentment, especially in the fairer sex, until some as yet unknown trigger unleashes a symmetric articular maelstrom that rivals a perfect storm and leaves its hapless wayfarers cursing the day they were born. In short, RA is no fun, and its countless victims, currently estimated at 0.8% of the U.S. population with three times more women than men suffering its ravages, to second that attestation. Most cases, 80% in fact, develop between the ages of 35 and 50 years of age, with the onslaught attributed to a possible infectious agent such as the measles virus or the virus causing infectious mononucleosis. Whoever or whatever the culprit initiating the skirmish, the ebb and flow of battle results in devastation of joint linings and their associated blood vessels, along with an unhealthy dose of inflammatory cell invasion and edema. The latter cells release a barrage of activated substances and destructive enzymes that are up to no good, degrading the joints even further. If that were not enough, reserves are called up from the rear to discharge a battery of antibodies, which attack self-proteins called antigens that have no other fault than being in the right articular zone of combat at the wrong time.

Hostilities begin with vague symptoms of fatigue, loss of appetite, and muscle, bone, and joint pain, that gradually progress over the course of weeks or months to a more specific chain of cataclysmic events. Several joints, especially those of the hands, wrists, knees, and feet become involved symmetrically, with no prisoners taken in that 10% of the combatants who wage an acute and losing battle against fever, enlarged lymph nodes, and a spleen that roars its resentment to its increased girth. Pain in affected joints, aggravated by movement, is the alarm sounded and call to arms, with morning stiffness of greater than an hour duration interdicting immediate obedience to the bugle’s blare. Inflamed joints are held in a flexed posture, resembling a “Z,” the neck of a swan, or a buttonhole, in order to maximize their volumes and consequently minimize the hurt. Laboratory surveillance, counterintelligence, and a sending in of skirmishers to scout the terrain and lay of the land do little to extend the beachhead, as 5% of healthy recruits demonstrate rheumatoid factor, an autoantibody whose presence is not necessarily specific enough to warrant capitulation. In fact, RA may be mimicked or camouflaged by any number of conditions harboring rheumatoid factor; those being lupus, hepatitis B, tuberculosis, leprosy, syphilis, chronic liver disease, malaria, infectious mononucleosis, bacterial endocarditis, and a host of others all to ready to swing into action.

So, what to do? What weaponry in the possession of a modern-day bombardier or rheumatologist can slow the progression of disease, while at the same time lessening its cost in blood and treasure? Obviously, exercise directed at maintaining muscle strength and joint mobility is the first line of defense and stopgap measure to halt RA invasion. When lines are overrun, bigger guns are called to bear on troop movements of autoantibodies that if left to rape, pillage, plunder, and otherwise wreak havoc on the articular landscape, will inevitably result in disabilities so grave as to compromise daily activities and quality of life. Enter the fray, low-dose anti-inflammatory steroids, and, if need be, disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate and sulfasalazine, to temper RA destructive capacity. Symptom mitigation and pain relief via nonsteroidal anti-inflammatory drugs (NSAIDs), simple analgesics, and cycloogenase (COX) inhibitors (or Coxibs) may additionally be drafted into service. Finally, when all else fails, a resort to nukes, in the form of potent biologics, is authorized to control signs and symptoms of RA, slow damage to joints, and limit disability, all at the expense of a crippled defense budget.

Make no bones about it. When the dogs of war are unleashed by RA on unsuspecting joints, their bites are inevitable, at the cost of sometimes muted barks.

ã 2011, Albert M. Balesh, M.D. All rights reserved.

posted by Dr. Al at 2/02/2011 06:27:00 AM | 0 comments