Fall 2019
PMH STORY
A caregiver at the elderly patient’s home was concerned that there had been a change in mental status. The patient was no longer responding verbally. Her eyes stayed closed and seemed even to roll back when the lids were opened. The member’s son was out of town, and no family were available.
Because of my proximity, I was able to visit the PMH member’s house. I knew well the years of frailty, chronic illness, and dependence that had preceded this visit. At her bedside, I saw occasional spontaneous, purposeful movement in legs and hands. I then spoke with her. There was a minimal verbal response, but good vital signs. There was no distress, but a rash around the left eye. The rest of the exam was unchanged from prior visits. The rash had blisters. It was a subtle, early eruption of shingles.
She wanted to be repositioned but asked that she be allowed to return to sleep. This was her usual manner.
The close knowledge of the patient, the ability to visit at the her home, the easy call by staff directly to the doctor: because of this a call to 911, ambulance, hours in the emergency room, and overnight admission to the hospital were avoided. The problem was shingles, which can cause a change in a person’s energy and capacity when they become weakened. Shingles was the cause of change in this case, and a trip to the hospital would have been no additional benefit to the patient.
There are house call services available. They may or may not respond to this kind of call. There are other doctors that make house calls. Such care, when practicable, is one of the benefits of Premium Medical Home. A conscientious doctor cannot leave an office with a full schedule – this imposes too much inconvenience on other people. But at other times it is practicable and appropriate and is often useful. Even with the doctor’s visit or call, the recommendation may still be an emergency room evaluation because of technology, facilities, and nursing care in the emergency room, which is not available in a person’s home. But it is good to know that a preexisting knowledge of the person, a firsthand examination, a thoughtful weighing of pros and cons, and not just a generic guideline, have gone into the recommendation to undertake a trip to the emergency room.
Robert H. Kelly, MD FACP
Fans, Heat, Physiology
We have many ways of adapting to both cold and hot temperatures. Common sense is probably the best way to decide what to do. But researchers can also add to our knowledge.
Allan R. Kelly, MD, FACP
E-CIGARETTES AND CARDIOVASCULAR RISK
The dangers of cigarette smoke are clear. It appears that treatment with e-cigarettes is safer than nicotine satisfaction with combustible cigarettes. We want patients to satisfy their nicotine addiction with a safer product. This can be patches, gum, or even an e-cigarette (vaping). But sometimes patients will use the e-cigarette and NOT stop combustible cigarettes. Research now identifies that this is dangerous.
Allan R. Kelly, MD, FACP
STATINS AGAIN
Statins are proven to reduce the risk of heart attack and stroke. Guidelines have suggested that as we get into our 80’s and 90’s, the value of statins decreases and it would be prudent to discontinue these medications when given for primary prevention (the use of medications to reduce the risk of a first stroke or first heart attack).
Allan R. Kelly, MD, FACP
PENICILLIN ALLERGY
How important is a history of penicillin allergy? If there are breathing problems, low blood pressure, or trips to the ER, for example, then the diagnosis should not be doubted. But for many, the history of penicillin allergy is a memory from childhood or advice from a parent. Penicillin and its related medication are such a useful group of treatments that one would not want to foreclose their safe use.
Robert H. Kelly, MD FACP
SCAMS TARGETING THE ELDERLY
Many of us have heard stories of an older person with mild cognitive impairment becoming the victim of scam or fraud. Research at the Rush Alzheimer’s Disease Center in Chicago has shed some light on a possible relationship between scam awareness/resistance and an associated reduction in the risk of Alzheimer’s disease. Three basic measures were used, that would predict susceptibility to scam.
Robert H. Kelly, MD FACP
PMH QUOTATIONS
“The scientific literature is replete with good intentions gone awry…Clinicians should continue to provide…care based on existing evidence. Intensive interventions beyond these basic measures warrant additional research and must consider potential harms.”
Seppo Rinne, M.D., Peter Lindenauer, M.D., and David Au, M.D., 2019
“So when [my patient] thanked her family, her friends and her doctors “for literally” giving her life, I wanted to thank her– for giving me purpose, a place in the world, the chance to be part of her life.”
Lisa Rosenbaum, M.D., 2019
“Keep a looking glass in your own heart, and the more carefully you scan your own frailties, the more tender you are for those of your fellow creatures.”
Sir William Osler, M.D., published in JAMA, 1969