Hypothermia

By: Dr. Mary Gipson _ family practice with Medical West
 
We’ve had a few really severe cold spells already this year. And while it can bring some nice things -  snow, maybe some snow days for the kids, and perhaps a comfy movie night with those you care about - it can also bring along some much scarier items, especially to those who may not be able to care for themselves. 

Any time there is an extended period with extreme cold, always check in on the elderly. Whether it’s a relative a few towns over, or just the older couple down the street - make sure to stop by and inspect that they are doing things they need to combat the cold in a safe way. Older folks have a harder time picking up on temperature changes, but their bodies and their health are still at risk. 

But we all are at risk when it comes to prolonged exposure to cold temperatures - which can lead to hypothermia. 

Sometimes it helps to think of the body as if it were an engine. And with all the activities our body is engaged in, it can put off some serious heat. What happens with hypothermia is that your body is exposed to such extreme cold for such a long period of time, that it can no longer produce heat faster than it loses it. 

When this happens, your body’s core temperature drops. Normally, we have a body temperature range of 97.5º to 99.6º F (98.6º is right in the middle).

When your body core gets down to 95º, you have made it to hypothermia. You’ll experience extreme shivering, cold & pale skin, speech will slur, numbness in your extremities, and you’ll experience a deficiency in brain activity (poor judgment, poor balance, etc.). 

 

Should these symptoms present themselves in yourself or someone around you - it’s important to warm them up immediately. Get indoors with some heat (a fireplace, blankets) and if available, a hot beverage or soup would be a good idea. Unless there has been an extreme temperature drop, this will usually get the body back to where it needs to be and no further treatment is necessary. -

 

For cases where there is moderate to severe hypothermia (where the core temp can get down as low as 85º F), seek medical attention quickly. When the core of the body is cold to the touch, the pulse has slowed severely, weak breathing, or a loss of consciousness has occurred - call 911 and get to a hospital. 

 

Once at the hospital, if it is severe hypothermia, physicians can use special techniques to warm the core body temperature safely.

 

I mentioned older folks earlier - but we are all at risk of hypothermia. Anyone can get it, and it can happen to you indoors if you are not properly insulated from the elements. The most susceptible are infants and older adults who do not dress warmly enough.

 

Your body is an engine which can heat itself, but if you don’t protect yourself from extreme cold, even that engine can break down. Be careful and dress warmly this winter. 

 

Dr. Mary Gipson

 

for more information contact:

http://www.medicalwesthospital.org/doctor.php?cn=452

 

 

 

USING RADIAL VERSUS FEMORAL ACCESS DURING CARDIAC CATHETERIZATION MAY HAVE BENEFITS IN WOMEN

By Timothy C. Lee, MD, MPH, FACP, FACC, FSCAI, FASNC, FAHA
Alabama Heart and Vascular, PC

 

Catheterizations through the radial artery have several advantages:

1.  Patient comfort is significantly improved. Because the entry site is at the wrist, patients are able to sit up and walk immediately after their procedure whereas patients having their procedures via the femoral artery approach will often require up to six hours of bed rest. As result, there are fewer issues with back discomfort and patients are able to eat comfortably after their procedure. 

2.  Patients who are scheduled for same day discharge can be discharged at an earlier time period than if their procedure was performed through the femoral approach since the post-procedure recovery is typically shorter than with the femoral approach.

3.  The radial approach is safer than the femoral approach for the majority of patients undergoing cardiac catheterization. Because the artery is smaller and very close to the skin, important bleeding is significantly reduced compared to the femoral approach. 

 

 

Women are at particular risk for bleeding and vascular complications after percutaneous coronary intervention (PCI).   Women also have smaller radial arteries than men making radial PCI potentially more challenging. 

While a transradial approach can potentially reduce these complications, this technique has never been prospectively studied in women.  However, arecent clinical trial conducted exclusively in women suggests that an initial strategy of using the radial artery in the arm as the entry point for cardiac catheterization or percutaneous coronary intervention (PCI) in women has potential for reducing bleeding complications.

“The SAFE [Study of Access Site for Enhancement]-PCI for Women Trial suggests an initial strategy of radial access is reasonable and may be preferred in women,” said lead author Sunil Rao, MD, Duke University School of Medicine, Durham, North Carolina.

Dr. Rao presented the findings on October 29 at the 2013 Transcatheter Cardiovascular Therapeutics meeting (TCT).

“While women are at higher bleeding risk, they have smaller radial arteries that are more prone to spasm, which has been implicated as a major cause of transradial procedure failure,” he said. “The role of radial access in women is unclear.”

The first-ever randomized trial to compare interventional access strategies in women found distinct advantages with radial access over the more traditional femoral route, with a trend toward a reduction of bleeding and vascular complications by about 60 percent through radial access, according to results from the SAFE-PCI trial presented Oct. 29 as part of Transcatheter Cardiovascular Therapeutics (TCT) 2013 in San Francisco.

 

The Study of Access site For Enhancement of PCI for Women (SAFE-PCI for Women) trial prospectively compared radial access and femoral access in 1,787 women undergoing elective percutaneous coronary intervention (PCI), urgent PCI or diagnostic catheterization with possible PCI. Results showed no difference between the radial and femoral groups in 30-day death, vascular complications or unplanned revascularizations.

In the PCI group, patients who underwent radial PCI experienced reduced bleeding and complication rates compared to the femoral cohort (1.2% vs. 2.9%), though this difference proved statistically insignificant. In the broader group—which included patients receiving diagnostic cath—radial access did indeed show a significant reduction in bleeding and complication rates compared to the femoral approach (0.6% vs. 1.7%, p=0.03).

Further, about six percent of women had to convert to femoral access, primarily because of radial artery spasm. Women generally preferred radial access, with 71.9 percent saying they preferred radial access for the next procedure versus 23.5 percent who preferred femoral access.

The trial did not reach its planned enrollment due to early termination. After 1,120 patients were randomized, review by the Data and Safety Monitoring Board (DSMB) showed that the primary efficacy event rate was markedly lower than expected. The DSMB recommended termination of the trial; however, no harm was noted in either arm and the steering committee voted to continue the study until enrollment in a quality-of-life substudy was complete.

Based on the SAFE-PCI trial findings, experts indicate that radial PCI is a viable initial approach in women undergoing cardiac catheterization though operators should be prepared for cross-over to femoral access.

Although some experts agree, "The study provides evidence, albeit not conclusive, for greater efficacy with radial access in women.”

The biggest factor driving the decision to use the radial artery is the physician performing the procedure. The procedure can be more challenging technically, and the physician must have enough experience to feel comfortable with radial procedures. Many physicians are more comfortable with the femoral approach, and will therefore recommend it alone.

There are a growing number of physicians in the United States, however, who prefer to use the radial artery as their default approach. There are also many physicians who use the radial approach in selective situations where the femoral approach may be more complicated, such as in obese patients or patients with obstructions in the blood vessels supplying the lower extremity. The femoral approach may be selected for patients in whom preservation of the radial artery is essential, such as patients requiring dialysis fistulas.

HIPAA/HITECH: The Saga Continues

 

By: Susan Pretnar, President KeySys Health, LLC.

 

HIPAA is that long and complicated story that began in 1996, narrowly focusing on Privacy and Administrative Simplification for most of the early years.  Along came the HITECH Act and suddenly, HIPAA Security, that long languishing detail of the HIPAA narrative, became the focus of the saga.  Make no mistake; it is an ongoing saga, and one the Omnibus Final Rule sought to clarify.  Slow adoption of electronic medical records by the provider community, lulled the healthcare industry into simply ignoring fundamental business practices that would have reduced risk and provided compliance with both Privacy and Security requirements.

 

In a series of 4 blog posts we will examine the basic tenants around required business practices, clarify misunderstandings and half-truths about the Rules, and provide practical solutions for moving forward.     

 

No Kidding – What’s Beyond the Assessment?

 

All providers are bound by HIPAA and the HITECH Act.  For providers who are hoping to attest to Stage 1 ‘’Meaningful Use’ and for those who have already attested, it is easy to see why so many believe they can satisfy the Core Set 15 measure by simply completing a checklist of HIPAA Security requirements, because HIPAA does not require that a specific method be used to accomplish a risk assessment.  Indeed, HHS continues to narrowly reinforce the need for this first step simply because so few healthcare providers have accomplished it.  Some providers have been lead to believe that a self-assessment using a checklist is sufficient to satisfy the requirement under HIPAA and HITECH.     

 

The Office of Civil Rights (OCR) is charged with enforcing the HIPAA Rules.  Their published audit protocol requires them to analyze the methodology used to accomplish a risk assessment, but also looks at the steps taken to implement policies and procedures that assure the privacy and security of electronic protected health information (ePHI) and evaluate the rigor of the ongoing risk management activities.  When CMS investigates beach complaints, they are also going well past the assessment to determine the reasonableness of the steps taken to secure PHI.    

 

There seems to be widespread misunderstanding of the terms regarding risk:  risk analysis, risk assessment and risk management.  A FAQ on the HHS web site provides an excellent definition of these terms:

 

 “Risk analysis is the assessment of the risks and vulnerabilities that could negatively impact the confidentiality, integrity, and availability of the electronic protected health information (e-PHI) held by a covered entity, and the likelihood of occurrence. The risk analysis may include taking inventory of all systems and applications that are used to access and house data, and classifying them by level of risk. A thorough and accurate risk analysis would consider all relevant losses that would be expected if the security measures were not in place, including loss or damage of data, corrupted data systems, and anticipated ramifications of such losses or damage. Risk management is the actual implementation of security measures to sufficiently reduce an organization’s risk of losing or compromising its e-PHI and to meet the general security standards.”

 

And, from the HITECH Act, the requirement is expressed this way (emphasis added):

 

“Conduct or review a security risk analysis and implement security updates as necessary and correct identified security deficiencies as part of its risk management process”.

 

Much to their chagrin, business associates of covered entities are also required to comply with these requirements.   There is now shared accountability and shared liability for breaches of PHI.   

 

So, the inadequacy of a simple checklist is apparent, especially if that checklist does not provide a way for the entity to prioritize needed remediation work based on their vulnerability to gaps in compliance.   The clear expectation is that a true risk management program be implemented by both covered entities and their business associates, based on findings revealed through risk analysis.           

 

The value obtained from a well-designed risk management program will almost always struggle to demonstrate a hard return on investment.   However, you likely invest in risk avoidance by insuring against general business and clinical risk, which only yields a return if it is needed to save your business.  Privacy and security risk management is the 3^rd leg of the stool.  Implementing reasonable and appropriate business practices yields a similar return on that investment.  Simply put, you maintain patient trust, secure your reputation, avoid financial ruin, and can demonstrate compliance with HIPAA.

 

Prior to the frequent announcements of major breach incidents, patients assumed their medical provider properly secured their protected health information.  The new reality is that patients will now demand that providers protect their healthcare information with the same level of diligence that their banks learned long ago was required to secure financial information.   Indeed, there is much beyond the risk assessment. 

KeySys Health, LLC. provides the people, processes, and technology needed for all phases of the risk management program development lifecycle.  Our mission is to provide a blueprint for a covered entity to implement and efficiently manage a HIPAA Security Risk Management Program.

 

Music Therapy

 

 

by Ann P. Gervin, MT-BC  with

HealthSouth Lakeshore Rehabilitation Hospital

Music Therapy

 

 

             Being a music therapist at HealthSouth Lakeshore Rehabilitation Hospital in Homewood, AL is rewarding and challenging experience.  I am a member of an interdisciplinary team of highly trained professionals (Physical Therapy, Occupational Therapy, Speech Therapy and Music Therapy) who strive daily to help our patients regain their independence.  The individuals served, suffer from traumatic brain injuries (TBI), cerebrovascular accidents (CVA), or from degenerative diseases such as Multiple Sclerosis or Parkinson’s.  In each case, independence has been compromised .

 

             When meeting someone for the first time, I find it helpful to explain music therapy is not entertainment.  However, it is the use of instruments and elements of music (rhythm, dynamics, melody, etc.), that will be used to help them reach non-music goals.  Examples of those goals range from improving physical abilities (use of arms, hands, and fingers), cognitive abilities (memory, impulse control, focused attention), and the ability to communicate.

 

                Recently, I had the opportunity to work with Mr. C., who had a stroke (CVA) which left him with a weak right side, poor coordination, and unsteady gait.  In our individual sessions, the ukulele was used to increase awareness of his right side as he strummed.  The sound and tactile sensation of his thumb on the strings increased his awareness and use of his hand and that side of his body.

 

               Prior to his CVA he played African drums as a leisure pursuit.  This instrument was incorporated into other sessions.  Initially, his lack of coordination caused safety issues as he hit the drum with too much force.  By discharge, his coordination had improved, and he was thrilled to be able to safely play this instrument again.

 

               A  co-treatment opportunity arose when external auditory cues (Rhythmic Auditory Stimulation) were provided by my singing and playing an autoharp when he and his physical therapist worked on walking.  A steady strum was provided with the instruction for him to take a step with each strum.  In six sessions, he progressed from a walker to a large based quad cane, his walking was safer and more coordinated and the external cues were no longer need.

 

             Mr. C’s examples show how music therapy techniques were applied in three different ways.  In the end he went home with increased independence and the ability to resume his life.

               HealthSouth Lakeshore Rehabilitation Hospital has a long tradition of superior care in physical and neurological rehabilitation.  Through our interdisciplinary treatment approach we meet the needs of individuals entrusted to our care.  Music therapy is an important component in the patient’s day.  This and much more is happening here at HealthSouth Lakeshore Rehabilitation Hospital.

 

Medical specialists at Children’s of Alabama use teamwork and technology for cardiovascular care

By: Dr. Yung Lau, a pediatric cardiovascular electrophysiologist, is director of the Division of Pediatric Cardiology at Children’s of Alabama.

Children’s of Alabama recently marked one year since pediatric cardiovascular services moved into the new Joseph S. Bruno Pediatric Heart Center from University of Alabama Hospitals. This move has markedly improved the scope and delivery of care. The program has been the primary referral point for patients with pediatric and congenital heart disease from throughout the state but the move has allowed us to progress quickly to advance the care of our patients further and more completely.

 

Two elements have contributed to this progress: Our technology and our team.

 

Our new facility provides one of the best platforms for care in the world. We have the latest equipment in the right configuration. First, the Bruno Heart Center is really a heart hospital within a hospital — located on the entire fourth floor of the Benjamin Russell Hospital for Children.

 

The center includes a 20-bed intensive care unit, a 16-bed telemetry ward, two dedicated cardiovascular surgical suites, two catheterization labs; one of which is a “hybrid” room where a patient can undergo surgery and catheterization simultaneously. The intensive care unit has four rooms dedicated to extracorporeal membrane oxygenation (ECMO), which is similar to the heart bypass process often used during cardiac surgery.

 

Having all these facilities and equipment located on one floor is critical for the care and comfort of our cardiovascular patients. Operating rooms are near catheterization labs. And they are on the same floor as the hybrid room and the ICU. So children who are on many intravenous medications and even on ECMO can be moved among any of these rooms without ever having to switch floors. That is really, really huge. Our intensive care unit used to be housed in a large, single room. Now, there are private rooms with space for parents to stay while their child is hospitalized.

 

While the facilities are world-class, we are just as proud of the multispecialty, multidisciplinary team that has been assembled to deliver comprehensive care. Cardiologists, surgeons, intensivists and anesthesiologists all work together. It’s not just in name only. Every one of those specialties is dedicated solely to the care of children with heart disease. I don’t know if there is any other field where there is such a close alliance and such teamwork among so many different specialties.

 

We’ve always taken care of the children well, but the big advantage of coming to Children’s of Alabama has been creating this team, and gaining greater depth in our support staff. We have dedicated cardiovascular nurses, dedicated nurse practitioners, a dedicated registered dietician, dedicated speech therapists, dedicated occupational and physical therapists, dedicated social workers, a dedicated child life expert and a dedicated pharmacist.

 

A counselor who only treats CV patients is available to our patients through Children’s Harbor. When children undergo serious illnesses, there is a psychological burden that comes with that. Counseling can be helpful in the child’s and family’s adjustment to their new reality.

 

In all, a team of about 250 medical professionals and support personnel are working to conduct 400 heart surgeries a year, along with 700 catheterizations and electrophysiology studies.

 

We are also committed to delivering the best possible outpatient cardiology care to children in a timely and efficient manner. Our next available appointment for any patient is within two weeks, which is almost unheard of among pediatric subspecialties. Being able to see patients in a timely manner has really strengthened our bond with cardiologists, pediatricians and primary care doctors throughout the state. They are now sending their patients to us instead of out of state.

 

For us physicians, this move to Children’s of Alabama has been an once-in-a-lifetime opportunity to help design the facilities, choose the best equipment and develop this team approach to pediatric cardiovascular care in a true collaborative fashion.

 Dr. Yung Lau, a pediatric cardiovascular electrophysiologist, is director of the Division of Pediatric Cardiology at Children’s of Alabama. He has 20 years of experience as a pediatric cardiologist. He earned his MD at Loma Linda University, and received addition training at the University of Alabama at Birmingham and Medical University of South Carolina.

Shining a Light on the Pancreas

By Dr. Kenneth M. Sigman

Mention the pancreas to most non medical people and you will get a questioning stare.  Most do not know where it is, its functions or the diseases that can affect it.  Mention the pancreas to most medical professionals and the reactions will most likely be dread and fear of its disease processes.  The two best known problems that affect the pancreas are pancreatitis and pancreatic cancer.

Pancreatitis

Pancreatitis is a condition of inflammation of the pancreas.  There are many different causes such as gallstones, excessive alcohol use, various medications, hypertriglyceridemia, and auto immune diseases being the most common.

Inflammation may affect only the pancreas in mild cases or cause widespread multiorgan system failure and death in severe cases.

The hallmarks of treatment are intravenous fluids and careful monitoring and treatment of any complications such as respiratory or renal failure, or infections.  The pain is usually treated with narcotic analgesia.

The diagnosis and criteria for judging the severity of the inflammatory process is made with several blood tests and imaging studies such as CT scanning.

If there is evidence of one or more gallstones or other processes causing blockage and pancreatitis then a special endoscopic technique - ERCP - can be used to relieve the blockage.

ERCP or Endoscopic Retrograde Cholangiopancreatography is a combined endoscopic and radiographic technique to visualize the bile duct and pancreatic duct.  Additional instruments are available to remove stones, take tissue samples and place stents to improve drainage as well. Many of the causes and complications of pancreatitis can be treated with ERCP.  This can save patients from having further episodes and long term complications from pancreatitis.  We are fortunate to have all of the most modern, cutting edge equipment at Trinity Medical Center for the diagnosis and treatment of pancreatic diseases.

Pancreatic Cancer

Cancer of the pancreas is one of the most deadly and feared diseases in the world.  There are approximately 45,000 new cases of pancreatic cancer in the United States each year with the overall 5 year survival less than 5%.  The most common presenting signs and symptoms are decreased appetite, weight loss, fatigue and painless jaundice.  Although it can begin anywhere in the pancreas, the most common site is in the head of the gland where it blocks the bile duct and causes jaundice.  We don’t know the true causes of pancreatic cancer but we do know there is a heredity factor in some cases and that there is an association with tobacco and alcohol use.

The diagnosis is based on a combination of blood tests, imaging studies and endoscopic techniques with tissue sampling.  Elevated liver test and the tumor antigen CA19-9 may signal bile duct obstruction.

 

CT scanning is the best non-invasive radiographic imaging study for evaluating pancreatic cancer and bile duct obstruction as well as local and distant metastatic involvement.  Endoscopic Ultrasound is a highly specialized procedure where an ultrasound probe built into the tip of the endoscope allows the operator to “see through the wall” of the stomach and duodenum to better identify the tumor, surrounding blood vessels, and lymph nodes.  Also with this technique direct targeted biopsies can be taken with minimal invasion and high diagnostic yield. 

Trinity Medical Center was the first hospital in Alabama to have endoscopic ultrasound and continues to provide the most advanced diagnostic equipment anywhere in the Southeast. 

ERCP, described above for pancreatitis, also plays a major role in diagnosis and treatment of pancreatic cancer.  Tissue samples can be obtained from the bile duct and pancreatic duct and stents can be placed to relieve obstructions.  We take a multispecialty team approach to the diagnosis and treatment of pancreatic cancer. Combining the expertise of gastroenterologist, radiologist, surgeons, and oncologist brings the best care for all patients with pancreatic cancer.

 

 

 

 

Birmingham Gastroenterology Associates and Chief of Gastroenterology at Trinity Medical Center
Dr. Sigman specializes in ERCP