Death is not an option!

 The stories contained in this book are the stories of those who probably died prematurely through no fault of their own. They were simply human beings who were not afforded access to health care. They had no health insurance. They were either not offered health insurance through their jobs or the premiums were too expensive. The premise the uninsured have to choose between paying a premium and putting food on the table for their family is real and very self evident in this country. Many feared losing all of their worldly possessions due to accruing a large set of medical bills. When asked why they waited so long to seek care, many said the care offered in the Clinic was for "other people, those who deserved it more". Those words cut like a knife. In reality those same words probably helped to place a nail in their own coffins. Those words are often spoken by many of the patients, not just those mentioned here. Many say that pride keeps them from seeking "free" care since they take extreme pride in working and providing for their families. On a daily basis, it is written and spoken that this country, the United States of America, has the best health care in the world. For many that "best" health care is untouchable. For the health systems that are for profit entities, many patients cannot enter those doors without first having some type of coverage. For instance, a woman who wanted a specific surgeon to perform her mastectomy was required to bring one-thousand dollars to the hospital before she was allowed to have her breast removed. The surgeon was going to perform the surgery in a for-profit hospital. The hospital admission personnel minced no words when they told her if she didn't have the money, the surgery would not be done. Another patient facing bladder surgery to remove the cancer that was growing inside her bladder was told she would need twenty-five hundred dollars before she could have that surgery. Neither of these two ladies had the means to provide the hospital with these sums of money. It wasn't until phone calls were made to the CEO of the hospital explaining the life or death situation they were in was it determined that they could bring less. For the mastectomy patient, one hundred dollars; and the bladder cancer patient, two hundred fifty dollars. These two scenarios play out all over the country and most people have no knowledge how to even navigate the system. For many they have few options. They either borrow the money from family or friends or charge it to their credit cards, not the best idea. But when you are facing death in the face, charging may well be the ONLY option and if not, then there is a resignation that death is really the only option. Other countries provide all of their citizens with health care access and do it quite well. Their citizens are well and live without fear of suffering a catastrophic event. Wellness and prevention become the center of that country's health system, whereas in America, we still continue to focus on the illness rather than the wellness of our citizens. The number of dollars that could be saved simply by allowing everyone access would be immense. For many patients who know that they may be heading toward a lifelong and possibly a lethal chronic disease such as diabetes, hypertension, and COPD access to healthcare could provide the patient with the incentive to begin to pay attention their lifestyle. Quitting smoking earlier has proven to stave off the effects of COPD; better nutrition has led to a decrease in borderline diabetics; and decreasing sodium in a diet can only improve a patient's blood pressure numbers. The view from a free medical clinic is not only eye-opening but is also agonizing. As a medical professional to stand and watch as patient's unfold their stories of why they haven't had

'lau medical care in months and years, is heart wrenching. For free clinics across the country, people every day tell their stories. Lack of access is one of the largest travesties this country faces everyday. Unfortunately, there does not seem to be a compromise from those who are in power. Keeping their constituents alive and well takes a back seat to many other non-essential things. The statement that we should be provided "life, liberty, and the pursuit of happiness" becomes softer and softer, as more and more people die. Folks who work in the trenches, dishwashers, laborers, waitresses, truck drivers, etc. are in my estimation expendable. Corporations have no responsibility to the same people who make their corporations thrive. For many corporations to offer all of their employees with health insurance truly cuts into their sacred profit margins. Several companies use the "part time" label to not have to provide their workers with health insurance, although many of those same workers work almost "full time". The corporations provide the hours but for some it is only one hour difference between being "full time" and "part time". At a time when this country is plagued by unemployment and for many of those unemployed it is not just a seasonal layoff but rather a permanent one meaning it lingers on for a year or more, COBRA is not within their reach either. Food and shelter needs trump health insurance. We have been involved in a war that has stretched on for more years than needed. As we send our troops into the battlefield

years than needed. As we send our troops into the battlefield we can be rest assured some will lose their lives. And the lives lost fighting the war can be termed senseless. But when average Americans living in this country and face the fact that they have no opportunity to have access to health care, it is not only senseless but a large human tragedy. The stories found here are of folks who died needlessly. As I think atX)ut many of them every day and many more like them across the country, I keep asking myself, how have we lost our love and compassion for those around us? How is that we sleep at night knowing that in our country there are average human beings who have families and who love a part of a family, doing what families do and yet we don't offer them access to care? Everyday as we wake up in this country there is a woman who finds a breast lump and cannot get help and the man who knows yet denies that he has chest We allow that to happen. Amazingly the very same who continue to grouse and fight about access for all, they and their families have no problem getting care. They can go to the doctor for a hang nail or an ingrown toenail while the people who pay for their healthcare can in the process of losing their foot because the didn't take care of the in rown toenail or losin

because they didn't take care of the ingrown toenail or losing their finger because that hang nail was really something else. None of us can ever assume that we may not walk in the of those who cannot access healthcare—losing your job or watching as your company strips away the health benefits because the premium rates have jumped another ten to fifteen percent and the company coffers are teetering on the edge are all that it may take to join the ranks of the uninsured. The patients' names have been omitted and letters represent them. Their stories are not exact in order to protect the patients' privacy. However, no matter where you turn in America, I am convinced there may many patients with the same case scenarios. This is coincidental. Death is not an option nor should it ever be. Not one person should have to die in this country because they lack the means to access health care. Not one.

This journey began with no health insurance and fear sprinkled with hope. "EE" did not have health insurance because she wasn't offered it by her employer and she couldn't purchase it on her own since she had pre-existing conditions, obesity and high cholesterol, she could not get Medicaid while she was working, as she made fifty dollars too much. Ironically, it was Medicaid which paid for all of her medical care. Possibly if she were given the omxn•tunity to have had health insurance the severity of her cancer would have not as great. "EE" died fourteen months after her diagnosis, surrounded by her family—siblings, children and grandchildren.

“You will double over in laughter and even cry a little. If you read one medical drama, make it this one.” – Dr. Sanjay Gupta, host of Sanjay Gupta MD on CNN

 “You will double over in laughter and even cry a little. If you read one medical drama, make it this one.” – Dr. Sanjay Gupta, host of Sanjay Gupta MD on CNN 

Samuel Shem is the pen name of Stephan Bergman, a psychiatrist on the faculty of NYU School of Medicine, Rhodes Scholar, author and playwright. Shem reads from his latest work of fiction, Man’s 4th Best Hospital, a sequel to the bestselling 1978 novel House of God, a mesmerizing, heartbreaking, and hilarious exploration of how the health-care industry, and especially doctors, have evolved over the past thirty years.

 There are three major forms of renal tubular acidosis (RTA):

 distal (type 1), 

proximal (type 2), 

 hyperkalemic.

 Hyperkalemic RTAs include

 hypoaldosteronism (type 4) and voltage-dependent RTA,

 

which is sometimes considered a subtype of distal RTA. These major forms of RTA differ in their pathophysiology and clinical manifestations (table 1) (see 'Classification' above):

Characteristics of the different types of renal tubular acidosis

  Hypokalemic RTA Hyperkalemic RTA 

Type 1 RTA Type 2 RTA Hypoaldosteronism (Type 4 RTA) Distal tubule sodium transport defects 

Primary defect

 Impaired distal acidification.

 Reduced proximal HCO3 reabsorption.

 Decreased aldosterone secretion or aldosterone resistance.

 Reduced sodium reabsorption. 

Plasma HCO3 

Variable.May be below 10 mEq/L

 Usually 12 to 20 mEq/L

 Usually greater than 17 mEq/L

Usually greater than 17 mEq/L. 

Urine pH Greater than 5.3. 

Variable.

Greater than 5.3 if the serum HCO3 exceeds the proximal tubule's HCO3 reabsorptive threshold. Less than 5.3 when the serum HCO3 is reduced to levels that can be reabsorbed despite defective proximal tubule HCO3 reabsorption. 

Variable.

Usually greater than 5.3. 

Variable.

Usually greater than 5.3. 

Plasma potassium Usually reduced, but hyperkalemic forms exist; hypokalemia largely corrects with alkali therapy. Normal or reduced; made worse by bicarbonaturia induced by alkali therapy. Increased; correcting the hyperkalemia alone will improve the acidosis by increasing ammonium availability. Increased; correcting the hyperkalemia alone will improve the acidosis by increasing ammonium availability. 

Urine anion gap Positive Negative Positive Positive 

Urine calcium/creatinine ratio Increased Normal Normal Normal 

Nephrolithiasis/nephrocalcinosis Yes No No No 

RTA: renal tubular acidosis; HCO3: bicarbonate.

YESTERDAY

  

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Theophylline: Drug information

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Theophylline poisoning

    

September 18, 2020

 

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Graphic: CD4:CD8 T lymphocyte ratios in diseases presenting with lymphocytic alveolitis

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Role of bronchoalveolar lavage in diagnosis of interstitial lung disease

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Foscarnet: An overview

Nasogastric and nasoenteric tubes

 Nasogastric and nasoenteric tubes are flexible double or single lumen tubes that are passed proximally from the nose or mouth distally into the stomach or small bowel. In adults, they are used for gastrointestinal decompression in the treatment of small bowel obstruction or prolonged severe ileus, administration of medications or enteral nutrition, and occasionally for gastric lavage. (See 'Introduction' above and 'Indications' above.)

●Nasogastric and nasoenteric tube placement is contraindicated in patients with esophageal stricture, and every effort should be made to avoid their use in patients with esophageal varices or a bleeding diathesis. Nasal intubation is contraindicated in patients with basilar skull fracture or facial fracture; these patients should undergo oral tube placement. (See 'Contraindications' above.)

●Do not usie prophylactic postoperative nasogastric tubes after gastrointestinal or abdominal surgery (Grade 1B). Although nasogastric or orogastric tubes are placed in the operating room for gastrointestinal decompression during surgery, the majority of these tubes should be removed once the patient is alert and recovered from anesthesia. In the past, routine postoperative gastrointestinal decompression was thought to speed the return of gastrointestinal function following thoracic or abdominal surgery. However, the time to return of bowel function was not significantly changed and could even be delayed. (See 'Prophylactic placement' above.)

●Nasogastric and nasoenteric tubes are available in multiple sizes and lengths (table 1). Dual lumen sump tubes are most commonly used for gastrointestinal decompression. Although sump tubes can be used for the administration of medications and for enteral nutrition, these tubes are stiff and irritating. Specifically designed, flexible, small-diameter enteral tubes are preferred for long-term nutrition. (See 'Types of tubes' above.)

●The majority of nasogastric and nasoenteric tubes can be placed at the bedside. For tubes that will be used only for gastrointestinal decompression, initial confirmation of the tube's position by clinical means is usually adequate. However, we always radiographically confirm the position of any tube that will be used to administer tube feeding formula or medications. (See 'Confirmation of placement' above.)

●The proper functioning of nasogastric and nasoenteric tubes should be routinely checked every four to eight hours by irrigating the tube. The drainage from tubes placed for gastrointestinal decompression should also be documented to help judge the progression or resolution of obstruction/ileus and requirements for supplemental intravenous fluid. Tubes are removed when the indication for their use is no longer present. (See 'Management' above.)

●Complications of nasogastric tubes are a consequence of tube placement (eg, perforation, pulmonary abscess), chronic irritation of the gastrointestinal tract (eg, gastritis, ulcer), or altered physiology (eg, reflux) due to the presence of the tube. Proper placement and confirmation of positioning should prevent many of these complications. When gastrointestinal reflux, gastritis, or ulcer is identified, the tube should be removed (ideally) and other treatment measures instituted as indicated. (See 'Complications' above.)

I was intoxicated with the idea of being of being a surgeon

 Surgeons acted boldly and decisively. They achieved cures, opening an intestinal blockage, repairing a torn artery, draining a deep abscess, and made the patient whole again. Their art re- quired extraordinary precision and selEcontrol, a discipline of body and mind that was most evident in the operating room, because even minor mistakes—too much pressure on a scalpel, too little tension on a suture, too deep probing of a tissue— could spell disaster. In the hospital, surgeons were viewed as the emperors of the clinical staff, their every command obeyed. We students were their foot soldiers. I was intoxicated with the idea of being part of their world.

Metabolic alkalosis

 Metabolic alkalosis 

is a relatively common clinical disorder that is most often due to diuretic therapy or the loss of gastric secretions due to vomiting (which may be surreptitious) or gastric suction. (See 'Introduction' above.)

The generation and subsequent maintenance of metabolic alkalosis require two separate factors (see 'Pathogenesis' above):

Elevation of the plasma bicarbonate concentration can be generated by excessive hydrogen ion loss into the urine or from the gastrointestinal tract, hydrogen ion movement into the cells, the administration of bicarbonate salts (or other alkalinizing salts such as sodium acetate or lactate), or volume contraction around a relatively constant amount of extracellular bicarbonate (called a contraction alkalosis).

•A decrease in renal bicarbonate excretion may be due to reduced kidney function, increased renal bicarbonate reabsorption, or reduced bicarbonate secretion.

Several factors are responsible for increased net renal bicarbonate reabsorption in metabolic alkalosis. In the absence of advanced kidney failure, one or more of these factors must be present to sustain the high plasma bicarbonate concentration:

•A reduction in extracellular fluid (ECF) volume or reduced effective arterial blood volume, including reduced tissue (and renal) perfusion in edematous states such as congestive heart failure and cirrhosis. 

•Chloride depletion and hypochloremia.

•Hypokalemia. 

•Increased distal nephron delivery and reabsorption of sodium ions in exchange for hydrogen and potassium ions. 

It is impractical to perform all possible screening procedures

 Within a population, it is certainly impractical to perform all possible screening procedures for the variety of diseases that exist in that population. This approach would be overwhelming to the medical community and would not be cost-effective. Indeed, the amount of monetary and psychological stress that would occur from pursuing false-positive test results would add an additional burden on the population. When determining which procedures should be considered as screening tests, a variety of end points can be used. One of these is to determine how many individuals would need to be screened in the population to prevent or alter the outcome in one individual with disease. While this can be statistically determined, there are no recommendations for what the threshold value should be, and may change based on the invasiveness or cost of the test and the potential outcome avoided. Additionally, one should consider both the absolute and relative impact of screening on disease outcome. Another measure used in considering the utility of screening tests is the cost per life-year saved. Most measures are considered costefective if they cost <$30,000–$50,000 per year of life saved. This measure is also sometimes adjusted for the quality of life as well and presented as quality-adjusted life-years saved. A final measure that is used in determining the effectiveness of a screening test is the effect of the screening test on life expectancy of the entire population. When applying the test across the entire population, this number is surprisingly small, and a goal of about 1 month is desirable for a population-based screening strategy

LUNG-EXPANSION TECHNIQUES

 LUNG-EXPANSION TECHNIQUES A lung-expansion technique is any technique that increases lung volume or assists the patient in increasing lung volume above that reached at his or her usual unassisted or uncoached inspi- ration. Rationales for the use of various strategies to promote lung inflation include

 (a) to increase pulmonary compliance. (

b) to increase partial arterial pressure of oxygen (Pao2). (

c) to decrease work of breathing. and 

(d) to increase removal ofsecreions . 

Lung-expansion techniques are meant to duplicate a normal sigh maneuver . Theoretically. sighs or periodic hyperinflations to near-total lung capacity reverse microatelectasis . Lung-expansion techniques are indicated to prevent atelectasis and pneumonia in patients who cannot or will not take periodic hyperinflations (94], such as postoperative upper- abdominal and thoracic surgical patients and patients with respi- ratory disorders due to neuromuscular and chest wall diseases. Adequately performed. maximum inspirations 10 times each hour while awake significantly decrease the incidence of pul- monary complications after laparotomy (95). Whatever techniques are used postoperatively (e.g., coached sustained maximal inspiration with cough, incentive spirometry, volume oriented intermittent positive-pressure breathing, intermittent CPAP, or positive expiratory pressure (PEP) mask therapy (961 ) , it should be taught and practiced preoperatively. when properly used, coached sustained maximal inspiration with cough and incentive spirometry—the least expensive and safest techniques—are as effective as any other method [97). Of the several commer- dally available incentive spirometers, the one chosen should combine accuracy, low price, and maximum patient accessibility (981. Because there are no definitive studies comparing the relative efficacy of volume- and flow-oriented incentive spirometers,he choice Of equipment must based on empiric assessment of patient acceptance, eaq• of use, and cost. mien chest Sion with postural drainage is added to the previously mentioned expansion techniques in patients without prior lung disea«•. it has failed to affect the incidence of postoperative pulmonary complications AIRWAY CLEARANCE Efficient mucociliary clearance and effective cough are the two basic processes necessary for normal clearance of the airways. In abnormal situations, this system may be dysfunctional and lead to mucus retention [ 100). A discussion of techniques aimed at enhancing airway clearance follows. 

AUGMENTATION OF MUCOCILIARY CLEARANCE Mucociliary clearance is one of the most important defense mechanisms of the respiratory system. Mucociliary dysfunction is any defect in the ciliary and secretory elements of mucocil- iary interaction that disturbs the normal defenses of the airway epithelium [1011. Ineffective mucociliary clearance leads to re- tention of tracheobronchial secretions. Mucociliary clearance may be ineffective 'be rnecti-- anisms or over Copyfish port, or both. Mu

Communication of bad news is an inherent component of the physician–patient relationship

 Communication of bad news is an inherent component of the physician–patient relationship, 

and these conversations often occur in a hospital setting where the

treating provider is not the primary care provider for the patient. Many physicians struggle with

providing clear and effective communication to patients who are seriously ill and their family

members. In the scenario presented in this case, it is necessary to have a discussion about the

patient’s poor prognosis and determine goals of care without the input of the patient as her

mental status remains altered. Failure to provide clear communication in the appropriate

environment can lead to tension in the relationship between the physician and patient and may

lead to overly aggressive treatment. The P-SPIKES approach (Table I-49) has been advocated as a

simple framework to assist physicians in effectively communicating bad news to patients. The

components of this communication tool are:

• Preparation—Review what information needs to be communicated and plan how emotional support will be provided. • Setting of interaction—This step is often the most neglected. Ensure a quiet and private environment and attempt to minimize any interruptions. • Patient (or family) perceptions and preparation—Assess what the patient and family know about the current condition. Use open-ended questions. • Invitation and information needs—Ask the patient or family what they would like to know and also what limits they want regarding bad information. • Knowledge of the condition—Provide the patient and family with the bad news and assess understanding. • Empathy and exploration—Empathize with the patient’s and family’s feelings and offer emotional support. Allow plenty of time for questions and exploration of feelings. • Summary and planning—Outline the next steps for the patient and family. Recommend a timeline to achieve the goals of care. Setting a follow-up meeting is not a primary component of the P-SPIKES framework but may be necessary when a family or patient is not emotionally ready to discuss the next steps in the care plan.

Safety is the first part of quality

  Safety is the first part of quality 

the healthcare system must guarantee that it will deliver safe care. Improving safety and quality in healthcare relies on understanding the frequency and type of adverse events that are occurring in the healthcare system. An adverse event is defined as an injury caused by medical management rather than the underlying disease of the patient. One of the largest studies that attempted to quantify adverse events in hospitalized patients was the Harvard Medical Practice Study. In this study, the most common adverse events were adverse drug events, which occurred in 19% of hospitalizations. Other common adverse events included wound infections (14%) and technical complications of a procedure (13%). Among nonoperative events, 37% were adverse drug events, 15% were diagnostic mishaps, 14% were therapeutic mishaps, and 5% were falls.