Archive for the ‘Patient Navigation’ Category

Prescription: Puppies

| September 27th, 2012 | No Comments »

I checked out a link on twitter today and loved the article so much I just had to write a bit about it

Written  by an animal loving leukemia patient the article shares her experience of getting ‘prescribed’ a puppy during her recovery.  She focuses on the many benefits she has experienced in her life and I think some of her points are ones that anyone who knows a cancer patient should think about.

 The puppy has provided a positive attention draw, she is no longer identified as the ‘bald-lady with cancer’, she is now ‘the (bald) lady with the sweet puppy’ to the general public and that is freeing, she is more than her diagnosis or disease, she is not just a receiver of care, but a giver of care.  

In her more intimate relationship with her boyfriend this has provided the both of them a focus for their attentions that doesn’t have to do with treatment or symptom management.  

Taking the puppy walking and to obedience classes also get her out into the wider world regularly, providing both stimulation (mental and social) and exercise (an important part of regaining her “normal” life).  

I particularly loved the idea of the comfort and cheer listening to the  puupy’s heartbeat and feeling his warmth bring to her.  I was reminded of new Mom’s being encouraged to hold their children close to their bodies to soothe them with their warmth, scent and the sound of their hearts.  Research has demonstrated that this snuggling lowers babies heart rates, reduces their stress levels and that they fuss less often – perhaps she is enjoying similar benefits.

If you know people going through cancer treatment – especially long and/or high-risk treatments – remember that though you and they need the opportunity to talk about the illness that your relationship goes beyond that and that they may already have had lots of opportunity to talk about their treatment.  Be open to talking about their disease and treatment but remember they are not just a patient, their your friend.

Once upon a time, because of the risk of cross-infection with your pet, or your pet bringing in dirt and contaminants the ill and the elderly were not encouraged to have pets.  In recent years that has been changing.  Cats, and sometimes dogs, can now be found in nursing and retirement facilities as group pets.  These animals provide the residents with company and entertainment.  HIV/AIDS patients, with their lowered immune function, were encouraged to give up pets they had, not  just avoid adding a pet, in earlier days.  Now the emotional and social benefits of having a pet to love and care for and to be cared for by have been show to improve immune function and reduce depression in patients.

 

More reading?…..

pets in elder care

you can even go to school to learn about it…

preterm infants (another immunocompromised bunch) and touch…

 

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Do not Ressusitate.

| August 20th, 2012 | No Comments »

Talking with my friend, Pashta, a death midwife, always leads to interesting discoveries. As a death midwife Pashta is interesting in all matters around death and dying and so took particular interest in the changes around medical representative and do not ressusitate documents that occurred about 2 years ago. One of the issues that arose in her investigation didn’t directly have anything to do with the legislation or the preparation, but with the execution. An article I saw recently got me thinking about that issue again and triggered some thinking.

Let’s say you have all you paperwork in order, everything is in place, all your family is aware and supportive of you choice to allow your death to occur without “extraordinary measures”, you are a DNR (Do Not Ressusitate). Now what? If you have already been admited into the hospital, hospice, extended care facility, palliative care room or some such place you are okay. The administration of such places ask questions about this on admission and your wishes and paperwork will have been duly recorded and filed. Great. Or is it?

When you are out there, busy living your life and something goes awry (think stroke, etc) is when you are most likely to require/be given some pretty extreme emergency procedures to deal with the trauma. How does your DNR come into play? You have a high likelihood of being unconscious or unable to communicate. Most of us wouldn’t be carrying our paperwork, those that might would likely have something in a wallet or purse. Are you willing to bet your life, literally, that your EMT and/or ER doctor or nurse in going to look in you purse or wallet?

How do you let everyone know to leave you alone? Give you something so you do not suffer and leave you alone? More and more people are trying to solve this problem by tattooing their wishes on their body. Generally located over or around their sternum (breastbone) where anyone performing CPR or defibrilation would be looking, or at the wrist as a permanent medic alert bracelet. But, before you rush out to your local tattoo artist, ask yourself this -how many doctors or EMTs will honour a tattoo? A tattoo is permanent, but is it legal? All medical professionals are bound to provide all lifesaving measures in the absense of orders to the contrary. Many doctors report that they would not honour a DNR tattoo.

With this dilemma we run into the problem that is the log jam of so many death related issues. Can you decide to die? In Canada it has only been legal to take your own life since 1972, there is only one person in BC who currently has any recourse to request a doctor to assist her in ending her life. We have the right to vote, to fight for our countries, to do stupid and dangerous things and to live, whether we want to or not, but not the right to die. No matter how agonizing, hopeless or plain pitiful our life may be, just getting the right to end it is almost impossible. Ironically, the sicker we get, the more infirm and less able we are, the less likely we will be able to achieve our end.

Make your plans, get your tattoo, but you better start making some noise too, if you want to be sure the papers will be found, the tattoo honoured and your wishes granted. There will have to be some profound alteration in the thinking of our lawmakers, our medical caregivers, and in our society before we can expect that effort will be made to find out our wishes before action is taken. Meanwhile, make sure people – doctors, your family, and friends – know that you know what you want, and that you are counting on them to make sure you get it.

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m-Medicine – the future of your doctor’s smartphone?

| January 23rd, 2012 | No Comments »

This weekend I was reading an article in the Globe and Mail regarding the impact of technology on health care, specifically mobile technology.  The article referenced several areas in which mobile technologies can improve health care with remote monitoring, to i-tunes credit for diabetic teens who comply with their insulin regimes.  The focus, and one of the most exciting parts, for me was an improvement in post-surgical care monitoring.  

Dr. Semple, the surgeon-in-chief of Women’s College Hospital in Toronto, is running a pilot project to monitor the ambulatory surgery (in hospital less than 23 hours) patients under his care.  Dr. Semple and his research team have developed an app that allows patients with a smart phone or tablet to be in regular touch with him post-operatively.  This app allows patients to photograph their surgical incisions and send them to Dr. Semple along with text regarding how they are feeling.  From this information Dr. Semple can very accurately assess the progress of their recovery and make decisions regarding any need they may have to return to the hospital for follow-up care prior to their scheduled appointment.  

This seems simple, wouldn’t a phone call do the same?  I see this new evolution addressing several weaknesses in the call-in follow-up.  One, for time pressed surgeons – and patients – there is no need to mesh schedules.  Patients send in their information when they can and the doctor can pick up the information whenever he chooses.  Yes, this sounds a bit like answering machine tag, but there are other factors.  When the doctor picks up that message he is not just listening to a voice trying to squeeze their information into a brief window before the beep – he is reading a summary that the patient has been able to compile at their leisure.  He is also able to pick up that piece of information anywhere.  The other highly valuable piece of information he is getting is the visual.  They say a picture is worth a thousand words, and with this technology it may very well be so,  it may even be worth a life.  The article talks about a scenario where Dr. Semple is able to save himself, his patient and the system, time and money by preventing an unneeded hospital visit from the other side of the globe, but lets look at the other possibility.  What if his patient’s bruising wasn’t benign?

Using the app the doctor could have gotten that patient into the hospital as soon as he saw cause for concern.  Post-surgical care costs can escalate through to means – unneeded return, and delay of needed return.  The later being more costly in the end for all concerned as it would be associated with re-hospitalization, care for the complication that would be more extensive than a promptly dealt with one, and, perhaps, long term health issues or death if an infection was not dealt with for a prolonged period.  Close monitoring has always had benefits in terms of preventing complication but earlier discharge offers huge savings, higher numbers of patients processed and, frankly, more comfort for the patient.  Anyone who has spent time in hospital knows it is not very restful or healing.  The food is awful, it is noisy and people are disturbing you at all hours to check your temperature.  Who wouldn’t prefer the privacy of their own room, in their own home with undisturbed nights?  When those things can be accompanied by closer monitoring we have a winning solution both for the patient, for their health and for the system.

This week there is a conference in Toronto that offers doctor’s the opportunity to explore the options of mobile health technologies and hear from leaders in the field.  I hope my doctor is on her way there! 

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Misssing the obvious…

| January 19th, 2012 | No Comments »

As a health and wellness professional I think of myself as well informed and a good clinician.  I encourage people to be thoughtful with their wellness and think about all aspects of a situation when making decisions.  I even offer my services as a wellness consultant to help other with this process.  This morning I had a moment when I was reminded that no one does it right all the time – especially when dealing with family.

One of my stepsons has eczema.  Until this fall he had been symptom-free for about two years.  Then he had a flare up  Since that time we have been struggling to bring the symptoms back under control.  They have abated at times and are in a moderate level of irritation right now.  We have tired some corticosteroid cream with not great results – for either the itching or the state of the eczema itself.  He is oatmeal bathing frequently which offers temporary relief.  We have got him off of dairy – mostly – as that helped in the past.  I modified some of my bare bottom bum cream with different essential oils, which has helped as much as anything.  I got him to add an Omega 3/6 supplement as that helped with some itching I had during pregnancy.  Overall, some symptom management has been our best outcome.

How does that moment I described fit into all of this?  I was putting cream on my own legs and thinking how dry they are with the colder weather, which led to thoughts of other skin drying activities, which led to thoughts of my stepson being in and out of hot baths multiple times a week.  Suddenly I wanted to kick myself.  In all the other suggestions we have tried, in all the recommendations, I couldn’t remember ever saying “moisturize after your bath”.

Such a simple concept, one anyone with dry skin will tell you is a necessity, and it never crossed our minds.  We shall see now whether it is the missing piece.  Will some intensive moisturizing help?  Post bath and – if I can convince him – overnight will be the next phase of treatment.  

Now eczema isn’t deadly, no permanent harm is likely to come of this, but as my stepson would attest, it is a pain, very distracting and not helpful to life as a whole, but why make this a blog?  I keen on reminding anyone I am imperfect, but I did want a reminder of what happens when I don’t slow down and think things through.   The other reasons are: to help others remember that lesson too, and to remind them too that when dealing with family, it is easy to forget some of the most basic things.  Dealing with family we can often be both more concerned and less careful than normal.  Not careless for their well being, but sometimes, in the rush of daily life, if you never sit down and give proper, systemic thought you can miss the obvious.  Next time you or one of your family members comes up against a wellness issue, give it the thoughtfulness it deserves.  And if the issue is a larger one be sure to give it its due and if you need too, get some support.

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Integration, hooray!

| November 23rd, 2011 | No Comments »

Yesterday I got an email from one of my clients asking if  “I would be open to communicating” with her chiropractor.  I almost swooned with joy – okay, not really, I’m not much for swooning, but I was really excited.  This type of request doesn’t come very often but I am always happy to receive them.  

Most often we allied health professionals work in a bit of a vacuum.  We have only our clients recollections to inform us of what other treatments they are receiving.  Client feedback is helpful for understanding their feelings regarding progress and how their bodies experience and respond, but not so helpful in determining what another practitioner actually did, nor what they intended by doing it.

By habit. I always ask about other practitioners my client’s are seeing.  When they are receiving concurrent treatment I will often ask when they last saw that practitioner and what they work they did.  I have often determined my approach based on this feedback.  If I know their chiropractor has gotten a good re-alignment I won’t focus on my own tools for structural alignment, I will focus on soft tissue support.  If their physiotherapist has been working on nerve mobilization in the neck and shoulder I may choose supportive back work and joint mobilization to complement.  The problem is that some clients recollections don’t provide me with those insights – or I fail to inquire – and a chance to improve the quality of care I give my clients is lost.  Even worse, we practitioners may overwork an area by compounding treatments, which is as detrimental as not working the area at all.

I believe strongly in the need for increased communication between practitioners to improve the impact of all of our work and ensure that patients receive the most efficient and effective care.  Thanks to that client and I look forward to the collaboration.  I will use this reminder to increase my initiative in communication, so that I am walking my walk, not just talking my talk.

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BC Generations – onsite visit

| October 21st, 2011 | No Comments »

The last step in the initial intake for participation in the BC Generations is to do the on site visit.  The visit was very quick, I don’t think I was even there 20 minutes.  I arrived a few minutes late (sigh) but was quickly signed in and there was the standard double checking to ensure I was who they thought I was by a young man at the front desk who had a package with my name and lots of coded stickers to put on my forms.    He gave me my blood and urine lab form and directed me to give my samples before the end of November.  He then led me to an adjacent room divided  into separate cubicles where a research nurse greeted me.

The nurse asked me a series of screening questions (pregnant – no; hand arthritis – no; pacemaker – no, etc to ensure they could do all the tests and get the right outcomes.  She then got to the tests.

First, my blood pressure and heart rate, twice, of course.  All good in the blood pressure department.  Next was a revisit of the waist and hip measures (only once) where I discovered that I had been too precise in following their waist measurement instructions – I would have like it they had used her explanation – measure at the belly button!  Then height, both standing and sitting (this will let them determine spinal shortening).  

Next – all the cool toys!  First a grip device – where I discovered that my left hand is puny and my right is super strong – enough to offset the left’s puniness in the combined total.  I guess I can now tell clients I have one strong hand when they comment on how strong my hand are!  After that, my most dreaded machine – BMI calculator.  I am not going to share the exact results of my weight, BMI and percent of fat.  I will say that I definitely have some losing to do!  And some really detailed motivational number.  I now know that my body fat is fairly evenly distributed (though my arms are the fattest – who knew!) and that my right leg and left arm are fatter and stronger than their opposites.  Finally I stuck my foot in this machine that assessed the bone density of my heel (calcaneus) bone.  Here again was some good news – very dense bones.  In part this has to do with weighing so much (the bones get denser to support your mass), and with being on my feet a fair amount for work (lots of weight-bearing). 

The sum up is that I am as fat as I thought, but I am not doing too bad in terms of strength, blood pressure and bone density.  Basically I am healthy enough that I can  lose the weight to fix the other measures with relative ease.  That is my own personal project though – not the BC Generation’s responsibility.

There you are, that is the total of my experience to date.  In future they may phone to ask me to participate in specific studies (which I can decline if I choose) or to come back in for a repeat of the on site visit I had (or perhaps some similar type of visit).  They now have my permission to check in on any testing results I get within the medical system.  Not to big an impact on my life given how much could come of it – an hour or so of my time now to provide information for studies over the next 25 years.  

 

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BC Generations – the forms

| October 20th, 2011 | No Comments »

My first step as a participant of the BC Generations project is the intake form.  This is a fairly thick bundle of papers you receive in the mail a few days after signing up.  Along with the intake you receive information about the project, its purpose, and a release for you to sign saying you understand and agree to participate. 

Going through the form probably took 20 minutes.  Most of the questions are quite easy to answer, though I found it interesting they always give you the option to say “I don’t know”.  First you give your vital statistics (name, age, gender, etc.) you answer questions about you lifestyle (servings of fruit and vegetables in a day, amounts of exercise within a week and its intensity) and other health habits like amount and type of drinking and smoking.  These are easy, you just have to think about your habits a bit – which I found a bit revealing.  For instance, I discovered that I do not eat as many fruits and vegetables as I thought.  My activity level, which I knew was low, registered even lower as so many of the things I do involve shorter spans of activity than they were looking for.

The next section if the intake is family history and make up, along with the medical stuff.  You are asked to identify you ethnic background and where your parents and grandparent were born.  A bit more thought there, but still pretty easy.  They also ask about the make up of your family of origin (who you grew up with) and your current family and relationship status (married or not, kids or not, etc).  This section finishes with the questions I expected sooner – your history of illness (or not) and that of you parents and biological siblings.  Here things get a bit more specific and you need to think a bit – for me my sister was the trickiest as I have never had been a caregiver for her.  Depending on how close you are to your siblings (who they lump together in one set of questions) you may have to ask them – or choose the “I don’t know” box.

The final section of the questionnaire is the one I have been dreading.  Having put on weight lately I was dreading taking measurements and writing down my weight numbers.  This part is a bit of a bother as they want you to do two measurements of both and I found the waist location description not great.  I made it  through this though I disliked the numbers as much as I expected.  

Overall, pretty easy.  I only had to go looking for one piece of information (the DIN of my prescription – and I am guessing most everyone would have to go reference that one) and the need to find a tape measure – and my dread – meant that the questions got answered a few days before the measurements got taken.  

 

 

Next – the on site intake….

 

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Gastric Bypass

| October 17th, 2011 | No Comments »

I have, over the last few months, gained some weight. I am very aware of the irony of being a health professional and being unhealthy on such a fundamental level. My dissatisfaction has led me to spend time thinking and exploring eating, exercise and weight loss options. All this looking around led me to the various surgical options – which I have always considered risky and extreme – to my surprise there is a high success rate and low risk factor. I believe firmly that eating habits and exercise are the best way to lose weight – have I been wrong?

In the end I think not. When it comes to weight if you burn more calories than you consume you will lose it. If food in and calories burned are the same, your weight will be steady. This equation is not in question. The questions circle how best to do this, how best to successfully lose weight. How do weight loss surgeries have such success? Simply put, the success of weight loss surgery comes from reducing stomach size to force you to eat less. Yes, eat less, reduce the size and frequency of meals, you know, a diet. Basically you are having someone put you a surgically induced diet. Ultimately this means that reducing your eating works.

A recent study actually shows that the family members living with gastric bypass patients lose weight in concert with the patient, believed to be due to the diet and exercise programs they have participated in with the patient. In fact the more I read the more it became clear that the surgery is just the first step in the process of weight reduction. The surgery is a step that is followed by nutritional and personal counselling, personal training and life changes. It turns out I am right – diet and exercise are keys. Whether you get a surgical boost or not, it is how you eat, and how much you move, that determine your weight.

The medical community is coming out more and more in favour of surgical intervention for weight-loss and we are seeing coverage by provincial and extended health carriers. One of the reasons for people to consider surgery is persistent lack of success with diet and exercise. My question is – if we were to divert the $15,000 (the low-end of the cost for gastric bypass – high is $50,000) to offering nutritional counselling and paying for personal trainers (which have no to very low coverage) would the success rate be better for the non-surgical intervention? You can buy a couple of years of 3 day a week personal training sessions for $15,000.

I think this preference for surgery is a part and parcel of our health care system’s preference for fixing with intervention rather than offering outpatient support.  For my situation I would love to access enough money to support my having a personal trainer for a few months to get me back to a reasonable weight and to support some life changes now, when I have no weight-related health problems. Instead I have to do it on my own, or wait until I am worse off in terms of weight and attendant health problems before I can get help – and even then the support will only be for a doctor altering my body – not for me trying to alter my body.

 

More about weight-reducing surgery:

  • In BC the only type of weight-reduction (bariatric) surgery covered by MSP is what is commonly called gastric bypass – which results in the largest weigh losses
  • The most common weight-reducing surgery is gastric banding – which has the quickest recovery but there are more complications and a lower level of weight loss
  • the newest weight-reduction surgery being offered is the insertion of a balloon into the stomach which is then inflated in the stomach. This is fast, reversible and seems to be working. It is the only option that requires no incision and no general anaesthetic.
  • In a study of 243 gastric bypass patients those in the obese and morbidly obese categories had excellent levels of loss and maintenance The “super obese” class (BMI > 50 at time of surgery) had the least success both in terms of amount of weight loss and the maintenance over time.
  • Gastric bypass surgery can cost anywhere from $15,000 to $50,000 NOT including personal training, the bulk of counselling suggested, the wardrobe changes or the cost of any plastic surgery to deal with the changes in body shape that result.

    gastric bypass

    Gastric balloon

     

    the lapband apparatus


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Intuition and the Proactive Patient

| July 4th, 2011 | No Comments »

I have a friend, named Magdalen, whose periodic blogs always make me think about the insubstantial aspects of being human that somehow form the grounding and weight of our lives. Today, I received one of her links and it lived up to that expectation in full.  In addition to reminding me to trust in myself, it provided me with an insight into my work as a wellness consultant.  This blog is about the intuitions I gained from that article.

I encourage my clients to make themselves participants in their health and wellness care.  I provide them with information, support, time and resources.  While reading Magdalen’s blog I realized that I also try, in my own way, to hold the “calm crucible” that I know she so strongly projects.  I want to ensure that any “knowing” that my clients have is given the opportunity to surface through the worry and stress that seems to always accompany medical decisions so that they can make their best choices from the start.

Given my emphasis on complete, quality information, how does what I do fit with the definition from, the Psychology of Intuition that intuition is “the process of reaching accurate conclusions based on inadequate information” that Magdalen references?  Though your doctor is unlikely to say this, the very nature of medical care requires that we use intuition.  Medicine is not about miracle cures, it is about options for hope.  Despite the wonders of modern medicine -antibiotics,  CT scanners and robotic neuro-surgery, etc. – there are still many times when you have two patients with the same diagnosis, who get the same treatment, but have different outcomes.

You must take the knowledge of what you have and what you know could be done about it; couple those with your deep knowing of yourself to decide on the best option.  This path leads to satisfaction with and belief in your chosen path, which is often the most powerful tool in determining the destination.

I can help with the information, I can hold the “calm crucible”, but only the person experiencing the process can decide what is best suited to their wellness.  Once you have the facts, it is your intuition, your innate knowing, that will lead you onto the best path for you.  So thanks to Magi and her words for helping me find my words.

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E-patients

| June 29th, 2011 | No Comments »

I love TED Talks.  A few months ago now my husband introduced me to TED and I have become a huge fan.  I follow TED on facebook so that every day I can see what is up in that world.  Their talks range in subject matter from recycled fashion to architecture to engineered silk to transplants and pleuri-potent cells.  I never know what I might find on TED or how it may thrill me.

Today, I got an extra big thrill from “e-patient Dave” (aka Dave deBronkart).  You wouldn’t think Dave is a cancer patient, would you?  He is a man of about 60 who was diagnosed 4 years ago with a cancer that gave him 6 months to live.  Through networking with other patients online he managed to find a treatment that has allowed him to live on in good health for four years so far.  A treatment his doctor did not know about.

The reason I found Dave so thrilling is that he is advocating for the type of proactive patient behaviour that I want to support and encourage.  Dave emboldens patients to go out and find for themselves the information they need.  To be “e-patients” that is: equipped, engaged, empowered and enabled (as coined by Dr. Tom Ferguson).  To make themselves heard as the vaulable resources they are in their own care.

The services I offer as a wellness consultant are aimed at supporting people in becoming e-patients.  I can give you the tools and support to jump start you in this role.  I can also offer ongoing support, advocacy and time to your quest to become the star in your health care.

We need doctors and health care professionals to provide us with services and exercises the skills they work very hard to master and maintain…and they need us.  Doctors need us not as mute recipients of their skills but as vital contributors to our care.  We need to offer our expertise about ourselves.  We need to gather resources and information that best serve us and our needs so that our health professionals can better serve those needs.

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