Archive for July, 2011

Asthma News: Parents Underestimate Children’s Symptoms, Placebos Effective in Improving Patient’s Subjective Improvement but Not Objective Health

Monday, July 25th, 2011

image from consumerreports.org

A couple of months ago, one of my colleagues, Jon Stefanuca, wrote a post for Eye Opener entitled Four Tips For Getting the Medical Care You Need When You Are Having An Asthma Problem. In that article, he explained the importance of patients proactively knowing and explaining their asthma symptoms to healthcare providers. He focused on some of the key features of asthma and the unique symptoms that each individual may experience. If you have not already read that article, I highly recommend it as a great way to become a better advocate for yourself or someone in your life that suffers from asthma.

Over the last few months, I have been thinking about Jon’s advice in relation to some work I have been doing. It makes good sense and hopefully will help people receive better care when they are having exacerbations of their asthma. However, I was disheartened to read a recent article from Reuters about how frequently parents underestimate their children’s asthma symptoms.

Parents Underestimate Their Children’s Asthma Symptoms

I am always a little leery of studies that are drugmaker-funded, particularly when the study suggests that perhaps more medications are needed to combat a problem. However, taken at face value, this is a pretty frightening idea given how many children now suffer from asthma and how serious a condition it can be for those children and families. The article points to a disconnect between the parents’ description of their child’s asthma and whether the asthma was actually being adequately treated:

While more than seven out of every 10 parents interviewed described their child’s asthma as “mild” or “intermittent,” the disease was adequately treated in only six in 10 kids.

A doctor who was not involved in the study explained it this way:

“Parents are only aware of asthma when the child is more severely ill,” Dr. Gordon Bloomberg…

“Physicians cannot just ask the parent ‘how is your child doing?’ The physician will get a global answer that doesn’t reflect the child’s quality of life,” said Bloomberg, of Washington University in St. Louis.

Poor treatment may influence asthmatic children’s quality of life, as well as that of their families.

In the survey, more than four in 10 parents reported missing work because of their child’s asthma, and similar numbers of parents regularly lost sleep for the same reason.

Children are Better Reporters Than Their Parents of Symptoms

Interestingly, “[t]he study also found children tended to be better than their parents at determining how well their asthma was being treated.” So, clearly, doctors must take the time to discuss the asthma symptoms and treatments not only with parents but also in a sensitive and appropriate way with the children patients themselves in order to receive a better indication of the disease status. The doctors interviewed for the Reuter’s article had different opinions on what this means for asthma treatment:

According to a new report, this suggests parents need more education about asthma medications.

But one expert said more medication is not the be-all and end-all for children.

“The idea of total control…is not where we should be putting our energy,” Dr. Barbara Yawn from Olmstead Medical Center in Rochester, Minnesota, told Reuters Health in an email.

Instead of just giving children with stubborn breathing problems more medication, she said better communication is needed to determine how children’s lives are affected, and what it will take to prevent their symptoms.

New Study Shows Receiving Treatment, Even with Placebo, Important for Asthma Patients – But Does not Improve Objective Health

image from 123rf.com

In another recent study, reported in the New England Journal of Medicine, researchers looked at how asthma patients responded to a medication (bronchodilator), two different types of placebos (fake inhaler or fake acupuncture), or no intervention at all. An objective measure was taken of the patient’s ability to exhale after each intervention (or lack of intervention) and the patient’s own rating of improvement was noted. What was so interesting about this study were the different outcomes between the objective (spirometry) and subjective (patient’s self-reporting) measurements of improvement.

The bronchodilator provided markedly better objective treatment over the placebos or no treatment – a 20% improvement rather than 7% for the placebos or no treatment. However, the subjective measure of improvement found that patients were almost the same, 45-50% improvement, whether the patients received the actual bronchodilator (50%), the placebo inhaler (45%) or the sham acupuncture (46%).  All of which were higher than the 21% improvement reported by those who did not receive intervention.

An article about the study in medicalnewstoday.com explains the outcome this way:

Now a study of asthma patients examining the impact of two different placebo treatments versus standard medical treatment with an albuterol bronchodilator has reached two important conclusions: while placebos had no effect on lung function (one of the key objective measures that physicians depend on in treating asthma patients) when it came to patient-reported outcomes, placebos were equally as effective as albuterol in helping to relieve patients’ discomfort and their self-described asthma symptoms.

The study’s senior author, Ted Kaptchuk, Director of the Program in Placebo Studies at Beth Israel Deaconess Medical Center and Associate Professor of Medicine at Harvard Medical School explained it this way in the article:

“It’s clear that for the patient, the ritual of treatment can be very powerful…This study suggests that in addition to active therapies for fixing diseases, the idea of receiving care is a critical component of what patients value in health care. In a climate of patient dissatisfaction, this may be an important lesson.”

However, I wonder if it cannot also be understood another way – which is that patients are likely to feel like their symptoms have been improved after a visit to a doctor, even if objectively their airway is still compromised.

How Should this Impact Asthma Treatment?

So what can be done with this new information? I think that Jon’s advice about patient’s knowing their own symptoms and expressing them clearly to their doctors is critical. I also agree completely with his advice that patients should ask for an objective measure of their respiratory improvement before leaving a health care facility. These two steps seem key to making sure that patients objective health is being improved – not just their subjective opinion of improvement. Finally, I think that it is critical that parents act as the best advocates possible for their children – which may include making sure that the children are heard on their own symptoms since parents are not the most reliable reporters.

What do you think? Are there other tips for asthma patients and their parents out there? How do respond to these new studies?

Related Videos:

Videos about Asthma

Related Articles:

Four Tips For Getting the Medical Care You Need When You Are Having An Asthma Problem

Asthma – How to Protect Your Child When the Steroid Inhaler Fails

Use Of Acetaminophen In Pregnancy Associated With Increased Asthma Symptoms In Children

Service dogs in school — a fresh look

Friday, July 22nd, 2011
Service Dog and Boy

service dogs

A while back I wrote a piece on the topic of service dogs for kids and mentioned the use of service dogs in schools. A regular reader of our blog then wrote in with a number of comments and questions about the propriety of dogs in schools. To help answer her questions, I recently spoke with Nancy Fierer, who is the Director at Susquehanna Service Dogs in Harrisburg, Pennsylvania, which is an organization that trains and places service dogs. Susquehanna is the organization that placed two of the dogs mentioned in this NPR story.

The ADA and dogs in school

I also did a little more research on the Americans with Disabilities Act (“ADA”) and its impact on the issue. The ADA requires that all public facilities allow a disabled person and his or her service dog (not pets) to enter the premises just the same as a non-disabled person. So is a school considered a public facility? It’s an interesting question. On the one hand it is accessible to the public in the sense that parents and students can freely enter a school. However, if you’re not the parent of a child at the school, can you just walk into a school and roam the halls like you might roam around a mall? I think if you tried that, you would get stopped pretty quickly and asked to leave if you had no valid business there. However, the law appears to be settled that schools are considered public facilities at least for those areas that are open to the public such as administrative offices, gymnasiums during sporting events, and auditoriums during public events. Therefore, schools must be accessible to service dogs in these public areas. For class rooms, however, it’s not so clear. While the law appears to favor allowing service dogs in class rooms, it is being decided on a case-by-case basis because there are other considerations as well – the age of the child, the disability at issue, the ability to control the dog, etc.

How much school assistance is necessary?

I have to admit that when I first wrote on this topic, I had envisioned that the dog and child were a self-contained unit that required little in the way of adult assistance. Ms. Fierer indicated that that is usually not the case. Depending on the age of the child and the level of disability, the child may be able to care for the dog independently. However, in most instances an adult (teacher’s aide or nurse perhaps) is required to pitch in with help giving the dog water and taking it out for bathroom breaks. Ms. Fierer indicated that the dog does need water breaks during the day (feeding can be done at home before and after school). This is usually accomplished by keeping a water bowl in a nearby room – perhaps a nurse’s office or a counselor’s office. Several times a day, either the child (if he/she is old enough) or an adult can take the dog for a drink. The same is true for bathroom breaks (pee only; No. 2 is usually taken care of at home). Again, service dogs do require assistance from the school but from what Ms. Fierer told me, the disruption is fairly minimal and can be worked out with proper planning.

Controlling a service dog

A larger issue is the child’s ability to control the dog. Even though service dogs are highly trained, the owner (in this case a child) must still be able to control the dog before being permitted to take a dog into school. These include such basic commands as making the dog sit, stay, come, leave it, and walk on loose leash. These are some of the common commands that all service dogs must know. In addition, a service dog also receives additional training in a particular disability and learns specific commands unique to that disability, e.g., retrieving specific items, pulling a wheelchair, responding to seizures, search and rescue. These commands must be mastered as well. For example, if an autistic child is in need of the dog to put its head in the child’s lap to help calm him/her down, the child (or a trained adult) has to be able to give the dog that command. If the child cannot give that command to the dog, then it undermines the usefulness of the dog in school.

Because of the demands that service dogs place on the child, very young children usually do not take dogs to school unescorted. Ms. Fierer said she would be surprised to see a six-year-old, for example, taking a dog to school alone. Older children can, with proper training, be permitted to take a dog to school alone. To ensure that the child is capable of caring for the dog, Susquehanna utilizes the Assistance Dogs International Public Access Test. This test requires the owner and the dog to perform multiple tests in a variety of settings to ensure that the dog is well-trained and that the owner can properly control the dog. For children, Ms. Fierer indicated that the testing is usually administered with the parent and child because she uses the team approach – the parent, child and dog are a team. For a child taking the dog to school, however, the parent is usually not there so the child must be able to control the dog independently. Only when a child is adept at controlling the dog should the child be permitted to take the dog to school. Even then, parents have to work closely with the child’s teacher and other school staff to coordinate the details of how the dog will be cared for.

Other concerns

Our reader also asked questions about whether service dogs are a distraction in school and whether they can pose a danger to other children. After talking to Ms. Fierer, it’s my opinion that these are not major concerns. As for being a distraction, Ms. Fierer said that is usually not the case. Service dogs are generally introduced into the school gradually, starting with maybe a half-hour per day and building from there. The children get accustomed to the dog and the novelty soon wears off. Also, the other children need to be educated that this is a service dog and not a pet to be played with. Children can easily learn this lesson. As for being a danger to other children, Ms. Fierer said she has never heard of a dangerous incident happening at school such as a dog biting a child. These dogs are amazingly well-trained and the trainers allow zero tolerance for aggressive behavior. If a dog shows any aggression, that dog does not make the cut for being a service dog. Therefore, I don’t believe this concern is a valid reason for denying a child a service dog.

Training a service dog

In terms of the actual training given to the dogs, Ms. Fierer said that when a puppy is eight weeks old, it starts living with a dedicated puppy handler who is responsible for teaching the dog basic manners.  This time includes classes at Susquehanna twice per month.  This arrangement goes on till the dog is 18 months old, at which time the dog receives about six months of intense training.  About 50-60 percent of training is the same for all service dogs. The rest is devoted to the unique needs of each disability. Before a dog is placed, Susquehanna spends about 2 and ½ weeks training the family that is receiving the dog. Even after placement, Susquehanna continues to do follow-up training – at first on a weekly basis and then gradually declining over the next six months. It even does annual re-testing.

I hope this follow-up addresses our readers’ concerns. Ms. Fierer emphasized that service dogs are not the solution for every child. Susquehanna actually does therapy sessions with families before even agreeing to place a dog to ensure that the dog and the family are a good fit. She indicated that it is a big responsibility to own a service dog and it is not a decision that is made lightly by the dog trainers. However, for the right child and the right family, a service dog can be an amazing asset.

Related Nash and Associates Links:

Service Dogs for Kids

 

photo from servicedogtraining.wordpress.com

 

 

 

 

 

 

 

 

 

 

 

Coming Soon? Restored Breathing for Spinal Cord Injury Patients

Wednesday, July 20th, 2011

image from msstrength.com

The online version of the journal Nature publishes an article today about a potential breakthrough in the treatment of spinal cord patients. While I do not have access to the full article, medicalnewstoday.com provides an overview of the research work. The highlight is that the researchers from Case Western Reserve University School of Medicine were able to restore breathing in rodents with spinal cord injuries.

This research provides optimism for similar success in humans (clinical trials with humans are hopefully forthcoming). In the recently released studies, the scientists combined “…an old technology a peripheral nerve graft, and a new technology an enzyme” to be able to restore 80-100% of breathing function in the rodents.

Using a graft from the sciatic nerve, surgeons have been able to restore function to damaged peripheral nerves in the arms or legs for 100 years. But, they’ve had little or no success in using a graft on the spinal cord. Nearly 20 years ago, [Jerry Silver, professor of neurosciences at Case Western Reserve and senior author,] found that after a spinal injury, a structural component of cartilage, called chondroitin sulfate proteoglycans, was present and involved in the scarring that prevents axons from regenerating and reconnecting. Silver knew that the bacteria Proteus vulgaris produced an enzyme called Chondroitinase ABC, which could break down such structures. In previous testing, he found that the enzyme clips the inhibitory sugary branches of proteoglycans, essentially opening routes for nerves to grow through.

In this study, the researchers used a section of peripheral nerve to bridge a spinal cord injury at the second cervical level, which had paralyzed one-half of the diaphragm. They then injected Chondroitinase ABC. The enzyme opens passageways through scar tissue formed at the insertion site and promotes neuron growth and plasticity. Within the graft, Schwann cells, which provide structural support and protection to peripheral nerves, guide and support the long-distance regeneration of the severed spinal nerves. Nearly 3,000 severed nerves entered the bridge and 400 to 500 nerves grew out the other side, near disconnected motor neurons that control the diaphragm. There, Chondroitinase ABC prevented scarring from blocking continued growth and reinnervation.

“All the nerves hook up with interneurons and somehow unwanted activities are filtered out but signals for breathing come through,” Silver said. “The spinal cord is smart.”

Three months after the procedure, tests recording nerve and muscle activity showed that 80 to more than 100 percent of breathing function was restored. Breathing function was maintained at the same levels six months after treatment”

From medicalnewstoday.com

This could be life-changing for those spinal cord injury patients who currently need ventilators to survive. If human studies prove the efficacy of such treatment, patients would have the hope of being able to breath on their own again. Not only would this dramatically improve these patients’ quality of life, but it would also provide a dramatically improved outcome for these patients. Currently, “[r]estoration of breathing is the top desire of people with upper spinal cord injuries. Respiratory infections, which attack through the ventilators they rely on, are their top killer.”

The BBC is reporting that “[r]esearchers hope to begin trials in humans. They are also investigating whether bladder function can be restored, which can be lost when the lower spine is damaged.”

The CDC’s most recent statistics, which are a few years old, suggest that there are currently about 200,000 people in the United States who are living with spinal cord injuries. This number increases by approximately 12,000-20,000 new patients annually. If some portion of these individuals could be provided hope for breathing on their own and or regaining bladder function, their lives could be dramatically improved.

Related Articles:

Spinal Cord Injury Updates: More Reasons for Optimism?

New Treatment Holds Promise for Patients With Spinal Cord Injuries

New Microchip Promises to Make Life Much Easier for Paraplegic Patients

FIVE TIPS TO GETTING READY FOR YOUR FIRST CONSULTATION WITH A MEDICAL MALPRACTICE ATTORNEY

Monday, July 18th, 2011

No one ever wishes to be injured as a result of medical negligence. Nonetheless, the lives of thousands are affected every year as direct result of medical errors. How would you handle such a situation? Where would you go for answers?  How do you cope? And most of all, how do you move on with your life when your life, as you know it, has changed because of a medical mistake?  For some people, consulting with a medical malpractice attorney is a prudent choice. If you have come to this conclusion, you might want to call an attorney. Let’s say you already have a scheduled appointment. How do you prepare for this meeting? What do you need to consider before you even step foot into a lawyer’s office?  The purpose of this blog is to give you some guidance.  Here are five (5) tips to get you ready for your initial consultation:

Consider your purpose.  First and foremost, make sure that you know why you are considering an action against a health care provider. Perhaps, this determination is the most important one you will have to make in the entire litigation process.  Invariably, the reason why a person decides to sue will dictate the nature of the litigation process and even its eventual outcome. Medical malpractice cases should only involve medical negligence that results in injury.  Ask yourself: Do I have a good faith basis for contacting a lawyer?  If the answer is “yes,” you are on the right track.  You don’t have to be a medical expert or an attorney to have a gut feeling about the case.   The important thing here is to avoid litigation for the purpose of revenge or annoyance. Such cases are doomed to fail.

Do you have an injury? As you prepare for your initial meeting with a lawyer, consider if the case has some cognizable injury.  Remember – it isn’t enough that a health care provider did something wrong, the negligent act must result in injury.  All medical malpractice actions are fundamentally cases of negligence. Generally speaking, in order to prevail on a negligence claim, the plaintiff must prove that 1) the health care provider breached an applicable standard of care (i.e., a wrongful act took place), 2) the breach of the applicable standard of care directly and proximately (lawyers are still fighting about the meaning of “proximate”) caused injury to plaintiff, and 3) the plaintiff sustained a discernible and identifiable damage(s).

So, ask yourself: Do I have an injury that was caused by the action or inaction of a health care provider? If the answer is “yes,” you are on the right track. Remember, absent an injury, a Plaintiff will not be able to prevail against a health care provider even if the health care provider breached an applicable standard of care.  Here is an example, let’s say that you or a loved one needed a CT scan to confirm a ruptured appendix, which the physician failed to order. But, around the same time, another physician ordered the CT scan, which revealed the ruptured appendix. Assume further that the first physician’s failure to order the CT scan did not result in any meaningful delay in treatment. Under such circumstances, one could hardly argue that the first physician’s conduct, even if negligent, caused any injury. The lesson here is to simply make sure that you have an injury as you contemplate bringing a lawsuit against a health care provider.

Examine your damages.  Once you have determined that a tangible injury exists, be prepared to discuss the full extent of your injury(s) during the initial consultation.  Your initial consultation is not a time to be shy about your experience, your injuries, and your suffering.  I know; it is counter-intuitive. After all, there are better things to brag about than your suffering. I recommend that you come up with a complete list of all injuries suffered as a result of the medical error. As you brainstorm, keep in mind that your injuries can be both economic and non-economic. Economic damages are financial damages sustained in the past, present, and future. Such damages will generally include the cost of any medical treatment for injuries related to the alleged negligence (even if your insurance is covering these expenses). They may include further medical costs as well as other costs arising from your injuries (e.g., if you have developed a disability, you may need house modifications, a new car, nursing assistance, and assistance with household activities, among other things).  Economic damages can also include lost earnings (both past and future), loss of retirement benefits, and even loss of earning capacity among many other things. Non-economic damages will generally include damages for pain and suffering caused by the negligent conduct of the health care provider.  Make sure that you consider all of your damages thoroughly before meeting with an attorney.

What is your gut feeling? Oftentimes, your gut feeling about what went wrong, is in fact what went wrong. Medical malpractice cases will often involve very complex medical issues, spanning multiple specialties.  It can be a daunting task to get to the bottom of things in medical malpractice cases. Sometimes, it takes months of medical reviews before the negligent conduct and causation are determined. As such, clients are sometimes understandably reluctant to share what they think constituted the act(s) of negligence.   Still, even after months of investigation, the lawyer’s theory of liability will invariably  end up being the same or similar to that of the client. For this reason, it is again important to be complete and willing to share as much information as possible during your first interview. It may help the lawyer narrow down the issues in order to expedite the review and investigation of your case.  If you already have some or all of your medical records, it is a good idea to bring them with you. Any other documentation, which reflects the events surrounding your care, may be very helpful as well. Also, make sure to provide the lawyer with a chronology of any and all care rendered to you around the time of your injury and subsequently.

Rely on your loved ones. You don’t have to come to the initial interview alone.  Injuries resulting from medical negligence can be quite severe and life changing. Sometimes, it is simply easier to try to forget the events surrounding the injury. Other times, because of the medical condition (e.g., coma), the patient has little or no relevant information to convey. However, it is not uncommon to have family members or friends who may have direct or indirect familiarity with the medical care or the events surrounding your injury. Such friends and family members are an invaluable source of information. Ask them to talk to your attorney as well. Additionally, it is not easy to relive a traumatic experience alone. If you can, why not rely on someone who loves and cares about you?

I hope that these tips are helpful.  I  invite all of our lawyer friends to contribute to this discussion. What else can a perspective client do to prepare for an initial meeting with an attorney? If you are a patient, what do you expect from the attorney at the time of your initial consultation?

Acquired Brain Injuries: Hypertensive Brain Hemorrhages

Friday, July 15th, 2011

So what if my blood pressure is high, right? I’m under a lot of stress. I’ll cut back on my caffeine.  I don’t use that much salt.  It’s hot outside.  All reasons to ignore an abnormal blood pressure reading, right?  NOT!

View Image

On the heels of Rachel Leyko’s blog about heat stroke, and in keeping with some topics I’ve been blogging about on acquired brain injuries, hypertensive brain hemorrhages seemed to be a good topic du jour!

Hypertensive brain hemorrhage is just one of the many complications of uncontrolled high blood pressure.  We are currently seeing an epidemic of hypertension, much of it caused by lifestyle and the current epidemic of obesity in the U.S. And, yes, childhood and early adulthood hypertension is on the rise!  In a recent post by MedPage Today, as many as 1 in 5 young adults may have hypertension! The article goes on to cite studies measuring and monitoring patient blood pressures over several years. It is interesting to note that most of the hypertensive individuals did not know that they had high blood pressure! In 2009, DukeHealth.org posted doctor’s advice on managing childhood hypertension, recognizing that the incidence of the condition is on the rise.

Organ Systems Affected by Hypertension

The Mayo Clinic provides an excellent overview of the effects of hypertension on the various organ systems required for bodily functions.  Uncontrolled blood pressure causes damage to the following organs and results in the following conditions:

-Arteries/blood vessels: “hardening of the arteries” and cholesterol-plaque formation leading to stroke, kidney failure, heart attacks, “poor circulation”; aneurysm formation and rupture

-Heart: coronary artery disease (heart attacks); left ventricular hypertrophy and dilated cardiomyopathy; congestive heart failure

-Brain: TIA (transient ischemic attack); stroke (hemorrhagic & ischemic); dementia; mild cognitive dysfunction

-Kidneys: renal failure; renal scarring (leading to failure); renal artery stenosis or aneurysms

I have to admit that one of my “scare tactics” for encouraging patients to treat their hypertension was elaborating on the horrors of hemodialysis; hypertension and diabetes are the two main culprits for patients requiring hemodialysis.  Imagine having to spend 3 days every week hooked up to a dialysis machine (either by a large needle in one’s arm or via a “permanent” catheter tunneled under one’s skin), having to monitor fluid intake, being at increased risk for various infections, and requiring all kinds of specialized drugs to do what the kidneys would normally do! Not fun for anyone! For some reason, this had more effect that the risk of a stroke!

Hypertensive Brain Hemorrhages

I’m going to focus on these types of strokes as opposed to ischemic strokes, knowing that uncontrolled hypertension causes both types.

According to a MedScape Reference Article,

Intracerebral hemorrhage accounts for 8-13% of all strokes and results from a wide spectrum of disorders. Intracerebral hemorrhage is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage. Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure (ICP) and potentially fatal herniation syndromes.

Apparently, over time, the high blood pressures in the arteries and arterioles of the brain causes damage to the inner lining of the walls, making them stiff, weak and less compliant to that pulsation we feel everytime our heart pumps blood throughout the body.  As the pressures inside the vessels exceed the compliance of the vessel walls, ruptures occur, leading to bleeding or hemorrhage into the brain tissue.  The blood can extend into the brain ventricles or into the subarachnoid space, or it can localize and clot within the brain tissue. Not only is the blood flow to brain cells disrupted, but there is now this increased pressure being exerted by the blood collection onto adjacent brain tissue causing even more damage. That brain tissue responds by leaking fluid, causing more brain swelling and increased pressures. It is a bad cascade of events that leads to serious brain injury, permanent neurologic problems and even death.

Watch the following You Tube Animation for both ischemic and hemorrhagic strokes:

httpv://www.youtube.com/watch?v=M_fo6ytlmD0

Some Epidemiologic Statistics

According to the same MedScape article, 350 per every 100,000 elderly individuals sustain hypertensive brain hemorrhages every year in the U.S. The overall mortality rate for general intracerebral hemorrhages is very high, with 20,000 people dying annually in the U.S., 44% of which die within 30 days, and 75% of those with pontine or brainstem hemorrhages dying within 24 hours!

From a race perspective, African Americans have a higher incidence of these brain bleeds due to the higher incidence of hypertension within the population.

Women have a higher incidence of brain aneurysms while men have an overall increased incidence of intracranial hemorrhage (general term includes trauma).

With respect to age,

Incidence of intracerebral hemorrhage increases in individuals older than 55 years and doubles with each decade until age 80 years.

Although the overall incidence of hypertensive brain hemorrhages has decreased between 1950 and 2005 with improved diagnosis and management of hypertension, this trend could change with the increasing incidence of hypertension in the young and lack of diagnosis and treatment; hypertension has historically been a disease of the “middle age” patient.

Medical Diagnosis & Treatment

Time is brain tissue when it comes to any kind of stroke, much like the American Heart Association’s motto regarding Acute Coronary Syndrome, “Time is heart muscle.” In each event, the time from onset of symptoms to diagnosis and treatment is absolutely critical.  In some cases, the severity of the injury might not be amenable to any medical interventions, but then again, a lesser injury can sometimes be treated and managed medically or surgically with a fairly good outcome.  Know the signs and symptoms of stroke (similar for ischemic & hemorrhagic) and do NOT delay in contacting “911″ for rapid transport and medical attention!

SOME RELATED POSTS:

Acquired Brain Injuries: Causes and Impact

Acquired Brain Injuries: Subdural Hematomas

Stroke Warnings:Most People Who Experience Minor Strokes Do Not Recognize Its Symptoms\

Image courtesy of “Baxters Blog”.

 

 

 

 

 

Dog Days of Summer Bring Pool Parties and Cookouts but Increase Your Risk for Heat-Related Injury

Monday, July 11th, 2011

The dog days of summer are upon us and with that heat and humidity comes an increased risk for injury.

Recently I ran a 7 miler race through the streets of downtown Baltimore on a hot and humid morning.  During that race, I saw at least one person suffering from what appeared to be heat exhaustion.  Luckily for that runner there was race support nearby and EMS on its way.  Had there not been race support there to cool the runner down with bottles of water he may not have survived.  Running is not the only outdoor summer activity that can result in heat exhaustion or heat stroke.  Any outdoor event in this heat can lead to an emergency situation.  It is important to know how to prevent such heat-related injury from happening but it’s also imperative to know what to do should someone suffer from heat exhaustion or heat stroke because if not properly treated death can occur.

What is Heat Exhaustion?

Heat Exhaustion usually develops after several days of exposure to high temperatures and inadequate intake of fluids. The elderly and people with high blood pressure are prone to heat exhaustion as well as people working or exercising in the heat. Heat exhaustion symptoms include heavy sweating, paleness, muscle cramps, tiredness, weakness, dizziness, headache, nausea, vomiting, and/or fainting. With heat exhaustion, a person’s skin may feel cool and moist.  Cooling off is the main treatment for heat exhaustion. Drinking cool, non-alcoholic liquids may help as well as taking a cool shower, bath, or sponge bath. Getting into an air-conditioned environment will also help. If the conditions worsen or have not subsided within an hour, seek medical attention. If heat exhaustion is not treated, it may lead to heatstroke which needs immediate emergency medical attention. Call 9-1-1.

What is Heat Stroke?

Heat Stroke is the most severe of the heat-related problems. Like heat exhaustion, it often results from exercise or heavy work in hot environments combined with inadequate fluid intake. Children, older adults, obese people, and people who do not sweat properly are at high risk of heatstroke. Other factors that increase the risk of heat stroke include dehydration, alcohol use, cardiovascular disease and certain medications. Heatstroke is life threatening because the body loses its ability to deal with heat stress. It can’t sweat or control the body’s temperature. Symptoms of heatstroke include rapid heartbeat, rapid and shallow breathing, elevated or lowered blood pressure, lack of sweating, irritability, confusion or unconsciousness, feeling dizzy or lightheaded, headache, nausea, and/or fainting.  If you suspect heatstroke, call 9-1-1 immediately. Then try to move the person out of the sun and into a shady or air-conditioned space. Cool the person down by spraying them with cool water or wrapping them in cool damp sheets. Fan the person, and if possible, get the person to drink cool water.

Tips for Prevention

An article on the Active.com website highlights 10 tips to prevent a heat-related injuries:

1.  Acclimatize – It takes your body time to adjust hot and humid weather.  Just because you can run a 10-miler at an 8-minute pace, doesn’t mean you can do the same when the dog days of summer approach.  The same goes for any outdoor exercise! The American Running and Fitness Association recommends that on your first run in the heat, you should cut your intensity by 65 to 75 percent. Then over the next 10 days, slowly build back to your previous level.

2.  Check the Index – Before you leave the comfort of your air conditioner, check the heat index and air quality index.  The Air Quality Index (AQI) is an index for reporting daily air quality. It tells you how clean or polluted your air is, and what associated health effects might be a concern for you. The Heat Index tells you what the temperature feels like when combining the air temperature and the relative humidity.  Both indexes should be checked before heading outdoors.  Your health depends on it!

3.  Hydrate! Hydrate! Hydrate! – Always remember to rehydrate after outdoor exercise! But it’s even more important to be well-hydrated BEFORE you exercise or spend time outdoors.  Hydration during your run depends on the temperature and the length of your run.  Don’t wait until you feel thirsty to drink. If you’re thirsty, that means you’re already low on fluids. Also, as you age, your thirst mechanism isn’t as efficient and your body may in the early stages of dehydration and you may not even feel thirsty. After 60 minutes of outdoor exercise, you will need to start using a sports drink or supplementing with a sports gel or a salty food such as pretzels. After 60 minutes, you begin to deplete vital electrolytes (i.e., sodium, potassium, etc.). Sodium is needed in order for your body to absorb the fluids you are ingesting and depleted potassium levels can increase your chances of experiencing muscle cramps.  Also, packing an extra bottle of water during outdoor exercise to pour over your head can help increase the evaporation-cooling effect.  Lastly, when you finished exercising, you need to replace the water you’ve lost.

4. Know the Warning Signs – Dehydration occurs when your body loses too much fluid. This can happen when you stop drinking water or lose large amounts of fluid through diarrhea, vomiting, sweating, or exercise. Not drinking enough fluids can cause muscle cramps. When you’re dehydrated, you may feel faint, experience nausea and/or vomiting, have heart palpitations, and/or experience lightheadedness. Runners also need to be aware of the signs of severe dehydration such as heat exhaustion and heatstroke, not only for yourself, but so you’ll be able to identify the symptoms if a fellow runner is experiencing heat-related problems.

5.  Buddy-Up – In the severe heat, be sure to work-out with a buddy. That way you can keep tabs on each other. Sometimes it’s hard to tell if you’re starting to suffer the effects of the heat, but a buddy may be able to spot the signs before its too late.  Plus, working out is always more fun with someone else!

6.  Work-Out Early – If at all possible, get your work outs done in the early morning.  The hottest part of the day is typically around 5p.m.  So, if you can’t work-out until after work, wait until later in the evening.

7.  Go Technical – Wearing light-colored tops and shorts made of technical fabrics will keep you cool and allow moisture to evaporate more quickly.  Staying dry will also help prevent chafing.  Clothing made of Lycra, Nylon, CoolMax and Dry-Fit are some examples of technical fabrics. Be sure to hang dry your technical fabric clothes.  The fabric softener in dryer sheets can actually block up the fabric decreasing its moisture0wicking abilities.

8.  Change Your Route – If your normal running route or work-out spot is treeless, find one that provides more shade.  If this isn’t possible and you have access to a treadmill or gym, head indoors on really hot days.

9.  Lather It On – Be sure to wear sunscreen!! Use a sports sunscreen that is waterproof with an SPF of 15 or higher.  Also, be sure to wear a hat or visor.  This will help keep the sun out of your eyes as well as the sweat out of your eyes.

10.  Have a Plan – Let your family and friends know your running route or work-out location.  If you’re gone too long, they will know where to look for you.  If you are in a rural area or doing a trail work-out, you may even want to pack your cell phone.  Don’t change your plans at the last minute without letting someone know.  It’s better to be safe then sorry!

For additional information on heat related injury and illness, see the National Weather Services heat advisory information page – Heat Kills

Week in Review: (July 2 – July 9, 2011) Eye Opener Health, Law and Medicine Blog

Saturday, July 9th, 2011

Eye Opener’s Week in Review

From the guest editor:         Good morning! I was hoping that you would take a break from making your “to do” list to stop by and check in with us. As usual, we have been busy blogging. And practicing law. And getting ready for trial. And in trial! Needless to say, we have been pushing it to the limits. In truth, we wouldn’t have it any other way. Before we get back to trial preparation, lets take a step back and look at the past week.

–Jason Penn, guest editor

Litigating for the Sake of Litigating: A Temptation to Be Resisted

By Jon Stefanuca

What do you do when your opposing counsel forgets that the practice of law is a profession and not a blood sport? What do you do when the phase “zealous representation” gets confused with “obnoxious obstructionist behavior?” When faced with similar frustrations, Jon Stefanuca broke out his keyboard and explained what we litigators deal with on a day to day basis. Being a lawyer is a very rewarding profession, but like any other, it has its share of frustrations. Don’t take my word for it, read more

Can Copper Surfaces and Duct Tape Reduce Hospital Infections and Deaths?

By Sara Keogh

Germs are in your kitchen.  They are in your bathroom and your bedroom.  They are on your fingertips and even on your tongue.  And everyone knows that there are going to be germs in hospitals. Even the best hospitals have to work to keep the patients, rooms and visitors clean and safe.  Sara Keogh reported on news that may make keeping hospitals and other health care environments less germy in the future. Two simple solutions, copper and duct tape, might have a major impact on infection control.  Read more

Sneak Peak of the Week Ahead:

The Eye Opener and its writers are excited about the week ahead too!  Here’s a sneak peak of what’s in store for you:

  • Service dogs for children:  more than just a pet
  • Legal Boot Camp is back in session and Part IV of our Cerebral Palsy tutorial.
  • And more!

Images courtesy of:

www.lifehack.org

www.mountainpulse.blogspot.org

 

Can Copper Surfaces and Duct Tape Reduce Hospital Infections and Deaths?

Thursday, July 7th, 2011

Image from medgadget.com

How many times have you heard about someone entering the hospital healthy, or relatively so, and developing a dangerous infection while hospitalized? What about the number of times that you may have visited your own doctor’s office or your child’s pediatrician’s office and wondered whether the cold you got a few days later was coincidence or the result of having been in the waiting and exam rooms following other sick patients? Have you ever considered what cleaning procedures are done in hospital rooms when one patient is discharged before another takes their place?

In the past, Brian Nash and the other legal bloggers here at Eye Opener have written posts and made mention of the importance of hospital cleanliness and sterility, see the related posts below. We have been involved in cases involving the devastating results of infections. However, everyone knows that there are going to be germs in hospitals. Even the best hospitals have to work to keep the patients, rooms and visitors clean and safe.

Well, there is news that may make keeping hospitals and other health care environments less germy in the future. Two recent articles have focused on seemingly simple solutions, copper and duct tape, that may have major impacts on infection control.

Copper Surfaces Dramatically Reduce Infections by Killing Bacteria

A Reuters’ article reports that a recent study “presented at the World Health Organization’s 1st International Conference on Prevention and Infection Control (ICPIC) in Geneva, Switzerland” shows that “replacing the most heavily contaminated touch surfaces in ICUs with antimicrobial copper will control bacteria growth and cut down on infection rates.” According to the Reuters’ article:

[a]ntimicrobial copper surfaces in intensive care units (ICU) kill 97 percent of bacteria that can cause hospital-acquired infections, according to preliminary results of a multisite clinical trial in the United States. The results also showed a 40 percent reduction in the risk of acquiring an infection.

This news could have a profound impact on health-care costs, disease spread, and most importantly lives lost. If hospitals are able to replace some of their current surfaces with copper surfaces, at least in the parts of the hospital that are most frequently the source of infections, there could be a dramatic improvement in hospital-acquired infections.

Hospital-acquired infections (HAIs) are the fourth leading cause of death in the United States behind heart disease, strokes and cancer.

According to estimates provided by the Centers of Disease Control and Prevention, nearly one in every 20 hospitalized U.S. patients acquires an HAI, resulting in 100,000 lives lost each year.

From Reuters

Perhaps even more infections could be prevented if these changes could be made outside of just ICUs. For instance, perhaps copper surfaces could replace highly touched surfaces on sink handles, the doors to hospital rooms, hospital bed rails, or in out-patient surgery centers and long-term care facilities that are not housed within hospitals.

Duct Tape Warnings Keep Others Far Enough Away from Infected Patients

Image from ducttapesales.com

An article from Medicalnewstoday reports that some hospitals are using plain duct tape – just colored red – to achieve a reduction in infection rates from highly infectious patients without having to deal with the hassle and expense of all visitors or hospital personnel who enter the room having to rescrub and use new gowns every time they enter the room of an infected patient. The study looked at highly infectious diseases like C. diff that require isolation of patients and very careful hand washing to avoid spreading the infection. So how does duct tape help?

The Association for Professionals in Infection Control and Epidemiology (APIC) commissioned a study to corner off a three foot perimeter around the bed of patients in isolation. Medical personnel could enter the room unprotected if they stayed outside the perimeter. Direct patient contact or presence inside the perimeter meant a redo of the cleansing process. The concept, called “Red Box” employs red duct tape, a color used as it provides a strong visual reminder to those who enter the room to be aware.

The study found that 33% of all who entered the rooms could do so without the addition of gowns and gloves, saving the environment, hospital and patient costs, and time without compromising the patient or the medical personnel.

From Medicalnewstoday

How Else Can We Reduce Infections?

What ideas do you have for the use of copper surfaces? Do you think that copper surfaces or duct tape could make a dramatic difference in the safety of hospital admission? What about the cost? Do you think that hospitals would pay the upfront costs of replacing surfaces with copper to be able to dramatically cut infection rates? What about other low cost solutions like duct-tape around the perimeter of the bed? Can you think of other low-cost solutions that could minimize infections and maximize safety?

Related Posts:

New federal study finds ‘lax infection control’ at same-day surgery centers

FDA warning to healthcare professionals: use sterile prep pads!

Litigating for the Sake of Litigating: A Temptation to Be Resisted

Tuesday, July 5th, 2011

It really grinds my gears when attorneys start litigating for the sake of litigating without context or purpose. That’s right; I bet if you are a litigator, you know exactly what I am referring to.  I am litigator, and I am absolutely convinced that we would all be better lawyers and happier individuals if we just learned how to do our job with dignity and professionalism, while avoiding absurd tactics and unnecessary drama.

Maybe I am alone on this one (and part of me really wishes that I am), but I just don’t understand why some lawyers think it is beneficial to have one gear and one gear only during the litigation process –  to object and obstruct no matter what. Is it really necessary, for example, to resist any and all discovery requests by dreaming up objections that have no merit?  In the end, is impeding the flow of information during discovery really in the client’s best interest, and frankly, is it consistent with our ethical obligations as professionals?  It is my humble impression that this kind of obstructive behavior happens more than one might expect. So, we end up writing unnecessary motions and nasty letters and emails, we go to depositions to argue some more with the opposing attorney instead of focusing on the witness, and we create so much “bad blood” that the case becomes one about lawyers and not their clients. Is this consistent with our professional obligations? I certainly think not.

Isn’t it in the client’s best interest to share as much information as possible about the merits of the case so that the opposing party can make informed decisions about settling the case early instead of dragging the parties through litigation for years? Why would a plaintiff’s lawyer not want a defendant to know the nature of his claims, the extent of his damages, and the identity and subject matter of his experts’ testimony?  Sharing this type of information is exactly the reason why a Plaintiff is in litigation in the first place.

Similarly, doesn’t it help a defense lawyer to be a straight shooter early on in the discovery process so that the plaintiff will not go on to note 100 depositions and use every discovery tool just to make sure that defense counsel isn’t hiding something? If the defense to a case is weak, isn’t better for all parties to be on the same page (yes, even when a corporate defendant is not in the mood to hear bad news) so that a case that must be settled can be settled early without making defendant incur unnecessary defense costs? Pardon my cynicism, but since I am on my soapbox, let me say this as well: the interest in having billing time should never be a substitute for the client’s best interest.  One byproduct of being evasive in discovery is that the defendant client (especially a corporate client) might end up being misinformed about the merits of the case – not a good position to be in when the lawyer finally comes to his/her senses and recommends settlement, but the client is not on the same page.

We have got to stop taking positions that have no good faith basis.  If there is no evidence of contributory negligence, don’t claim contributory negligence.  If experts are retained to testify at trial before the expert designation deadline, don’t object to their disclosure during written discovery simply because the expert designation is not due for another three months. If you can’t resist speaking objections, there are better places than a deposition to hear yourself talk.  If you have to file a motion, file one because you have to, not because you got a new crop of summer associates or first year associates doing nothing but writing motions for the sake of writing motions. I can go on, and I am sure that, if you’re a litigator, you can contribute to this list.

Life is too short and our occupations too stressful to engage in the meaningless waste of spirit. Time spent on useless litigation could be time spend with our families. What do you think? Don’t be shy, hop on the soapbox….

Related Posts:

Why early settlement is a win-win for all

Mediation of Lawsuits: The Top 5 Things that Tick Me Off!