‘Complaining’ now an Official Vital Sign in Patient Care

❝ After extensive deliberation, the American Medical Association (AMA) has decided to make complaining a vital sign…According to Merriam-Webster, to complain is “to say or write that you are unhappy, sick, uncomfortable, etc., or that you just don’t like something.”

The research that led to the AMA’s change demonstrated that 100% of patients (within a margin of error of 0%) meet the criteria for complaining. “The prevalence is astounding,” said lead researcher Mike Weber, PhD. “It’s amazing we didn’t add complaining to the vital sign lexicon before.”…

❝ Healthcare providers report hearing complaining even when they can’t assess other vital signs. “Sometime I can’t hear any reparations or a heartbeat, but I don’t even need a stethoscope to hear the complaining,” explained Jodie Marcus, RN.

Complaining is even more prevalent than the controversial former fifth vital sign, pain. The data reflect that patients often forget they’re in pain, but they never forget to complain.

Patients are thrilled with the recent designation.

Of course.

Action asthma plans tested on teens — there’s an app for that

Adolescents were able to keep track of their cell phone-based asthma action plans with greater ease compared with paper diary plans, according to a small trial…

And among the 15 patients with asthma control test scores of 19 or below (categorized as uncontrolled asthma) who were in the mobile-based group, most showed substantial improvement, while patients in the paper diary group had little to no change from baseline…

Benefits from the mobile technology were mostly concentrated in the participants with poorly controlled asthma at baseline…

“We asked them to mail a paper diary into us at the end of each month for 6 months, and hardly anyone returned them — and only one participant mailed the diary all 6 months,” Dr. Tamara Perry said. “We go months between seeing patients. If they don’t bring a paper diary to the appointment, patients only remember the last 2 weeks of symptoms.”

The mobile app had a web portal with clinician access to the logs, peak flows, symptoms, medication use, etc., Perry added.

❝ “The good thing about this is in the adolescents who really needed more timely interventions, there was demonstration that they improved with the use of the mobile app,” Mark Dykewicz, MD…said in an interview with MedPage Today.

“When it comes down to the final common denominator, the kids who needed it the most, did improve,” Dykewicz said…

Only 65% of the adolescent patients had their own phone. Others used a smartphone belonging to a family member. A good reason to come up with a burner or a loaner for similar studies.

None of this should be a surprise. Relying on what are improved communications modes makes all the sense in the world. Making communications possible makes it possible for an expanded range of contexts.

Designing better apps ain’t the toughest problem in the world, either.

Psychotherapists are starting to ‘see’ their patients online

The event reminder on Melissa Weinblatt’s iPhone buzzed: 15 minutes till her shrink appointment.

She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend’s pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist’s computer monitor; he smiled back on her phone’s screen.

She took a sip of her cocktail. The session began.

Ms. Weinblatt, a 30-year-old high school teacher in Oregon, used to be in treatment the conventional way — with face-to-face office appointments. Now, with her new doctor, she said: “I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session. I took my doctor with me through three states this summer..!”

Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans’ health care facilities and rural clinics — all supervised sites.

But today Skype, and encrypted digital software through third-party sites like CaliforniaLiveVisit.com, have made online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly…

Still, opportunities for exploitation, especially by those with sketchy credentials, are rife. Solo providers who hang out virtual shingles are a growing phenomenon…

Other questions abound. How should insurance reimburse online therapy? Is the therapist complying with licensing laws that govern practice in different states? Are videoconferencing sessions recorded? Hack-proof?

Another draw and danger of online therapy: anonymity. Many people avoid treatment for reasons of shame or privacy. Some online therapists do not require patients to fully identify themselves. What if those patients have breakdowns? How can the therapist get emergency help to an anonymous patient? “A lot of patients start therapy and feel worse before they feel better,” noted Marlene M. Maheu, founder of the TeleMental Health Institute, which trains providers and who has served on task forces to address these questions. “It’s more complex than people imagine. A provider’s Web site may say, ‘I won’t deal with patients who are feeling suicidal.’ But it’s our job to assess patients, not to ask them to self-diagnose.” She practices online therapy, but advocates consumer protections and rigorous training of therapists.

RTFA. Some of it is hilarious. Yes, I realize we’re discussing mostly legitimate needs and mostly legitimate practices designed to sort them.

I have a clear picture of the range of phonies and hustlers practicing therapeutic crafts — and how most states are easy as pie to tippy-toe around what passes for regulation and oversight. Cripes, I live in Santa Fe. I know people who channel stock tips!

Aside from the seriously disturbed, oftimes those with chemical and biological factors affecting their ability to function in society at all – a great deal of what people really need is conversation with someone who cares about listening. Maybe provide a tad of redirection towards solving problems on their own.

If I didn’t have so much fun blogging I might wander into the shrink-wrapped Skype therapy trade. Though I’d hate the record-keeping required to keep the IRS and insurance companies happy. 🙂

Pediatrician gets life in the slammer for molesting patients

A Delaware pediatrician accused of molesting more than 100 of his patients was sentenced Friday to serve his lifetime in prison.

Earl Bradley, whose practice was in Lewes, was given the maximum sentence of 14 life terms, plus 164 years in prison without the possibility of parole, according to a statement from the office of state Attorney General Beau Biden.

He originally had faced 529 counts of rape, sexual exploitation of a child, unlawful sexual contact and other charges. In June, he was found guilty of 24 counts.

The charges include first-degree rape, forcing girls to perform oral sex on him and filming dozens of children engaging in sex acts.

Police officers and detectives, but none of the alleged victims, testified in June at a bench trial, which is held before a judge without a jury. Bradley’s attorneys did not call any witnesses, nor did they make closing arguments.

The evidence against Bradley is based on video seized from his home and office, Biden has said. Public defenders in April challenged the scope of a search warrant used to acquire these tapes, but the judge ruled against them.

Throwing away the key is an unnecessary suggestion, I guess. But, I have to wonder if any of those kids complained to mom and dad and were ignored because the doctor must know best?

This went on, after all, for eleven years.

End-of-life care for advanced dementia patients

It’s hard for physicians to determine with much precision how long anyone with a terminal disease can expect to live, but it’s particularly challenging when the disease is advanced dementia.

“People with dementia get sicker inch by inch,” said Lin Simon, director of quality at Gilchrist Hospice in Baltimore, the largest hospice organization in Maryland. “Trying to say, ‘Now, she’s ready for hospice’ is much harder.”

Yet doctors serve as the gateway to hospice, which provides palliative care for the dying and support for their families. Medicare regulations require a physician to certify that a patient entering hospice is likely to die of his or her disease within six months. Doctors are more likely to do so when the disease is cancer or heart failure, which have more predictable trajectories.

That’s the major reason that dementia patients — who can benefit from the better pain control, fewer hospitalizations (so often associated with aggressive treatments that confer no measurable benefit) and greater family satisfaction that hospice has been shown to provide — are under-enrolled in hospice programs…

A 2004 study in The Journal of General Internal Medicine estimated that fewer than one in 10 people dying of dementia receives hospice services. A study of Michigan patients with advanced dementia, conducted about a decade ago, found that just 5.7 percent of nursing home residents and 10.7 percent of those receiving home care died with hospice care.

Nationally, by way of comparison, more than 40 percent of Americans who die each year are in hospice care.

When people with advanced dementia do get a hospice referral, “they’re enrolled quite late, within a few weeks or even days of death,” said Dr. Susan Mitchell, a senior scientist at the Hebrew Senior Life Institute for Aging Research in Boston.

Better prognoses might mean less suffering.


Less bureaucratic fiddling with paperwork instead of solutions – might mean less suffering, as well. Less regulation designed by beancounters instead of physicians might help, too.

Armenian Mafia busted for $100+ million Medicare fraud

Daylife/AP Photo used by permission

Dozens of people alleged to be members of an Armenian-American crime group were charged in federal court today with what prosecutors said was the country’s largest single Medicare fraud, involving at least $100 million in false medical claims.

Authorities charged 44 people in New York, Los Angeles, Atlanta and Miami in what prosecutors described as a scheme that created 118 bogus medical clinics in 25 states and billed Medicare for imaginary treatments using identities stolen from doctors and patients.

Three of the suspects remained at large, authorities said.

Medicare, the federal health insurance plan for the elderly and disabled, identified and shut down the phony clinics within several months. But authorities said more than $35 million had already been paid out to the crime group known as the Mirzoyan-Terdjanian Organization and transferred overseas.

When it comes to making money illegally, this Armenian-American group puts the traditional Mafia to shame,” said Manhattan U.S. Attorney Preet Bharara. With “a phantom doctor, a phantom office and phantom patients, the conspirators could bill Medicare with abandon.”

Mafia-style organizations are something I grew up with. Criminality and criminals are part of the definitions of anti-social behavior.

What stands out in my mind is how easy it seems to have become to commit large-scale crimes. I wonder if the criminals have gotten smarter, the hardware and software enabling such crimes is just plain better than it ever was and that’s the reason why – or, dare I ask, is it that law enforcement just hasn’t kept up.

I know a fair number of coppers who are “on the force” for a reliable paycheck and good benefits. I wonder if they outnumber the seriously talented and dedicated fraction on most police forces.

Brain stimulation helping partially paralysed stroke patients

Stroke patients who were left partially paralysed found that their condition improved after they received a simple and non-invasive method of brain stimulation, according to research in the September issue of the European Journal of Neurology.

Researchers from the Ain Shams University in Cairo, Egypt, studied 60 patients with ischaemic stroke — where the blood supply is reduced to the brain — who had been left with mild to moderate muscle weakness down one side of their body.

Twenty of the randomly assigned treatment group received repetitive transcranial magnetic stimulation (rTMS) applied at 5-Hz over the brain hemisphere affected by the stroke and the other 20 received 1-Hz stimulation of the unaffected hemisphere. The remaining 20 formed the control group, receiving inactive placebo doses of the treatment. All patients received the same physical therapy.

“When we compared the results between the three groups, we found that both of the treatment groups showed significant motor function recovery” says co-author Anwar El Etribi, Professor of Neurology and Psychiatry at the University. “No improvements were seen in the control group who had received the placebo treatment and the same physical therapy protocol.”

The majority of the patients (95 per cent) had suffered their stroke in the last three years, having been enrolled in the study at least one month after their stroke. However, there was no difference between the level of clinical improvement and the interval since the patients’ strokes.

“Our treatment worked on the theory that increasing the activity of the hemisphere affected by the stroke and reducing the activity of the unaffected hemisphere can reduce muscle weakness and improve overall motor function.”


Looking forward to continued and wider study of the potential of this treatment.There are some old geezers in my family – even older than me – who could benefit from this treatment. Now, I’m bound to search out their physicians and see if something comparable can be tried.

Patients at serious risk after hospitals overdose CT scans

When Alain Reyes’s hair suddenly fell out in a freakish band circling his head, he was not the only one worried about his health. His co-workers at a shipping company avoided him, and his boss sent him home, fearing he had a contagious disease.

Only later would Mr. Reyes learn what had caused him so much physical and emotional grief: he had received a radiation overdose during a test for a stroke at a hospital in Glendale, Calif.

Other patients getting the procedure, called a CT brain perfusion scan, were being overdosed, too — 37 of them just up the freeway at Providence Saint Joseph Medical Center in Burbank, 269 more at the renowned Cedars-Sinai Medical Center in Los Angeles and dozens more at a hospital in Huntsville, Ala.

The overdoses, which began to emerge late last summer, set off an investigation by the Food and Drug Administration into why patients tested with this complex yet lightly regulated technology were bombarded with excessive radiation. After 10 months, the agency has yet to provide a final report on what it found.

But an examination by The New York Times has found that radiation overdoses were larger and more widespread than previously known, that patients have reported symptoms considerably more serious than losing their hair, and that experts say they may face long-term risks of cancer and brain damage.

The review also offers insight into the way many of the overdoses occurred. While in some cases technicians did not know how to properly administer the test, interviews with hospital officials and a review of public records raise new questions about the role of manufacturers, including how well they design their software and equipment and train those who use them…

Officials there said they intentionally used high levels of radiation to get clearer images, according to an inquiry by the company that supplied the scanners, GE Healthcare.

Experts say that is unjustified and potentially dangerous

RTFA. The scary bits persist. The incompetence of hospital administrators and staff in charge of procedures is matched by the carelessness of technology firms who apparently figured that folks would RTFM. And that would be good enough.

It ain’t.

Study finds cognition in some vegetative patients

Patient answers five yes-or-no questions using his mind

Some people thought to be in a vegetative state–a persistent lack of awareness following brain injury–may be more aware than previously thought, even able to communicate, according to new research… published today in the New England Journal of Medicine (NEJM).

In 2006, Adrian Owen, a neuroscientist at the Medical Research Council (MRC) in Cambridge, England, and colleagues published a startling discovery. Functional magnetic resonance imaging, an indirect measure of brain activity, revealed that a patient who showed no outward signs of awareness several months after a car accident could mentally respond to a complex series of commands in much the same way a healthy person could….

In the current study, patients diagnosed as either vegetative or minimally conscious were asked to either imagine playing tennis–a motor task–or to imagine walking through the streets of a familiar city or their home–a spatial task. In healthy people, each of these tasks activates a characteristic part of the brain, allowing scientists to determine just from the brain scan which of the two situations the person is visualizing. The task is also cognitively complex: the patient must comprehend the command, remember it during the test, and then carry out the visualization.

The researchers found that five of 54 patients presumed to be in a vegetative state were able to willfully control their brain activity…

The team went on to show that in one patient, a 22-year-old man who had been diagnosed as vegetative after a car accident five years prior, this imagery task could be used to communicate. The patient was instructed to imagine playing tennis if the answer to a question was yes, and to imagine his house if the answer was no. He was able to answer five of six questions, and answered them all correctly. Scientists did not know the answer to the questions prior to the test, confirming them later with the patient’s mother. For the last question, rather than giving an incorrect answer, he showed no brain activity at all. Researchers say he might have fallen asleep, lapsed out of consciousness, or chosen not to answer.

Not startling, to me, but riveting, yes. It should prove so to all but those medical personnel whose curiosity ends with receipt of payment.

Feds seek monitor to protect patients in Georgia mental hospitals

Georgia’s mental health system is in trouble again with federal authorities, who say seven state psychiatric centers, including Central State Hospital in Milledgeville, remain unsafe and the state must do more to move the mentally ill into outpatient care.

The U.S. Department of Justice has slapped Georgia with a federal discrimination lawsuit accusing the state of violating the Americans with Disabilities Act by improperly segregating hundreds of Georgians with mental illness and developmental disabilities in institutions. The department’s civil rights division also filed a motion seeking the appointment of a federal monitor to protect patients “from harm to their lives, health and safety.”

Federal prosecutors listed several violent incidents — a killing, a rape and several suicides — at state mental hospitals in 2009 and 2010. They said patients confined in Georgia’s mental hospitals are still exposed to “egregious harm.”

The state’s new mental health chief disputed that, arguing the state has made huge strides in improving care at its psychiatric facilities…

The state said it would stop offering care for adult mental health patients at Central State Hospital, where some of the worst cases of abuse had been reported. In November, federal officials found so many shortcomings at Central State, with patients attacking one another and receiving poor treatment, that state officials announced the facility would no longer accept new patients.

RTFA to identify the hospitals in question. I hope you haven’t any friends or kin under treatment in one of these snake pits.

Sounds about right for a state run by a “compassionate conservative”.