Monthly Archives: November 2014

Ferguson

The following post was written by Ken Haller, MD a pediatrician in St. Louis MO.  It is  used here with permission.

Follow Ken’s blog at http://drkenhaller.blogspot.com/ 

#ferguson

In the coming days no one knows what exactly is going to happen when the Grand Jury in the Darren Wilson case hands down its recommendation regarding whether he should be indicted for the killing of Mike Brown. I daresay we all hope for peace and justice, and we all hope that everyone will remain safe.

I have been a pediatrician for just over thirty years now. I moved to Missouri in 1986 and practiced in East St. Louis for ten years. For the past eighteen years I have practiced in St. Louis at SSM Cardinal Glennon Children’s Medical Center. I have always worked in what are euphemistically called “underserved communities.” This usually means people who are poor. This usually means people who are black. This usually means people who are both. I have seen parents endure terrible hardships to keep their families together. I have seen grandparents heroically taking on the care of children years after they thought they were done with childrearing. I have been humbled by seeing kids who have done remarkable things under circumstances that, as a kid, would have sunk me.

Sadly, I have also seen families who have not been able to withstand the pressure of being poor, overworked, and marginalized. I have seen families fall apart. I have seen kids who have developed behavior problems because their brains have to be on high alert because of various ongoing threats in their environments. I have seen parents unable to continue to be parents because of the constant strain of wondering how they can feed their kids and keep a roof over their heads while working two or three minimum wage jobs that do not make ends meet.
I have also read posts on Timelines all over Facebook saying that these people just need to “get a job,” “calm down and go home,” “pull their pants up.” These commentators have all been white. They do not understand, and do not wish to understand, what it is like to live another reality, one where you are always, automatically suspect, one where you will not be shown houses in certain neighborhoods, one where your family had no alternative but to send you to a crappy public school. They know that they are doing better than the African-Americans who live a few miles away, and they actually believe they deserve it. They believe that their relative success is all due simply to their work ethic and their good choices. They do not believe in White Privilege, i.e., that being white in America confers certain advantages over non-white persons, because, when you have it, it is nearly invisible, and if you know you have it, your first reaction is to feel really guilty about it. So they deny it because it’s initially too painful to accept it.
But it’s true, and I know how I benefitted from it. I grew up in a safe, white, middle class suburb on Long Island, with excellent schools (our high school had a full time Russian language teacher), lovely parks and beaches, dependable pubic services, where my dad had a good-paying job as an aerospace engineer that he got as a result of a college education on the GI Bill. All that prepared me to go to an excellent college where I got scholarships and to medical school to do the work I am privileged to do today.

I could tick off, one by one, how many of those advantages are withheld from the kids who come to my office, as well as from their parents and families. The strange thing is not that Ferguson is happening; it’s that it’s taken this long to happen.

As I said above, I am a pediatrician. And in that role, I just want to make one plea to anyone who reads this about what may happen in the coming days: I would ask everyone who may be involved in public displays over the next few days to be aware of how this will affect the children in your lives.

Children are not just small adults. As we learn more about child development, we know this to be true on every level: physical, psychological, cognitive, emotional. What children need – and the younger they are the more they need this – is stability, predictability, and a feeling of safety. As a species, humans are altricial, that is, we are born more immature than just about any other mammalian species our size. That means that babies need nurturing, caring, feeding, swaddling longer than do infants of other species. The payoff, of course, is enormous in terms of intelligence, creativity, and the ability to love. Part of that process, though, requires that children know who will be tucking them in, who will feed them, who will bathe and dress them, when that will all happen, and who will love them. They need this to be the same from day to day, as much as possible. They need all this because they are trying to figure out how the world works. As infants mature from beings who, at about two months, smile at everybody, to babies who, at around six to eight months, begin to know who loves them and to choose them over strangers, to toddlers who will run off and jump and climb and fall at the slightest provocation, children have unique needs are various stages of life. What does not change is that they always need to be supervised, and they always, always need to feel safe.

So to those who will choose to be part of a demonstration, I respectfully hope that you will choose not to bring your children. While I completely understand the desire that your children should be witnesses to history – and I have no doubt that Ferguson will be part of the litany that now includes Selma and Montgomery – young children will not remember this. Their brains are not wired to retain clear memories during the first few years of life. Everyone in St. Louis and around the world knows that the only thing we can predict about the upcoming days is that they will be unpredictable. And that is not an atmosphere that is healthy for kids. If they see their parents yelling, being yelled at, being assaulted, they will experience only fear and threat, and that is never healthy for a child. I know you love your kids, and you are doing this to make a better world for them. Please leave them with a responsible adult. Please make sure you get home to tuck them in. Please tell them the stories of these days when they are old enough to understand the sacrifices you made for them.

And to those in law enforcement, if you encounter demonstrators with kids, please be aware of how your interactions will affect these children. One thing that has amazed me, both before August 9 and since, is that when I ask African-American kids who come to visit me in my office what they want to be when they grow up, a significant plurality of the boys say, “Police.” So many of these kids already see you as people of power. Please do all you can to make sure that your interactions with them and with their parents leave them with a sense of respect for you and what you do, rather than fear.

I truly believe that both demonstrators and law enforcement want to assure that everyone remains safe in the coming days. I truly believe that both demonstrators and law enforcement are doing what they do to make the world a better place for our children. And I truly hope that everyone will keep their kids at home where they can be safe and be best prepared for this better world to come.

– Ken Haller, MD 11/19/2014

Follow Ken’s blog at http://drkenhaller.blogspot.com/ 

 

Be Very, Very Scared! What You Don’t Know CAN Kill You…

Hospital Associated Infections Part 2: Catheter Associated Urinary Tract Infections (CAUTI)

Posted by Deborah Caputo Rosen

54,500. That is the number of reported urinary tract infections linked to the use of a catheter in acute care hospitals in 2012. (cdc.gov/hai/progressreport/index.html) That is the GOOD news. The number of reported urinary tract infections linked to the use of a catheter was 93,000 in 2011! (cdc.gov/Other/disclaimer.html) Focused efforts to reduce healthcare associated infections such as these helped to reduce the incidence.

In 2008 the Federal Center for Medicare and Medicaid Services announced new rules for payment for the cost of treating “conditions that could reasonably have been prevented” (CMS 2012). Hospitals could no longer bill those e patients for any charges associated with hospital-acquired complications. Catheter associated urinary tract infections (CAUTIs) were identified as among those complications.

Why? Let’s understand urinary catheters.

A urinary catheter is a thin, flexible, sterile tube that is inserted into the urinary bladder through the urethra. Catheters can be used to drain the bladder only once and then removed or they may be “indwelling” and remain in place once inserted.. Indwelling catheters have a balloon that is inflated inside the bladder. This prevents the tube from slipping out of the body. Such catheters (often called Foley catheters) are connected to sterile tubing and a bag to collect and measure urine.

Catheters are inserted when a patient cannot urinate normally. Catheters can prevent damage to the urinary tract (bladder, ureters and kidneys) caused by retained urine. They may be used when a patient is anesthetized for lengthy surgery, for reconstructive surgery to the urinary tract, and when normal urination is not physically possible due to spinal cord injury.

Catheter associated urinary tract infections result from microorganisms entering the body via the catheter during insertion or handling of the tube. The system may also become contaminated by opening the collecting tubing and/or drainage bag. The drainage system works by gravity and must be kept below the level of the patient’s bladder to avoid backward flow of urine. Many of the common organisms that cause infection form “biofilms” on the catheter and are difficult to eliminate with antibiotics.

Catheters should be inserted only for appropriate medical indications and left in place for the shortest period of time necessary. Skin and mucous membranes that remain intact are good barriers to microorganisms. It is critical that the professional who inserts a catheter utilizes proper sterile technique and minimizes irritation to the lining of the urethra and bladder. All healthcare staff caring for patients with a catheter system always must practice correct hand hygiene, assure that the drainage system is not opened and maintain it below the patient’s bladder.

One challenge faced by patients is that the doctor or clinician who prescribed the catheter may not remember or notice that a patient remains catheterized; resulting in longer than necessary catheterization. As a precaution, patients and family members should be prepared to remind the healthcare team. The nurse caring for you should assume responsibility to obtain orders to remove the catheter.

Know, Ask, Speak

Wilson-Stronks advises all patients and their care companions to keep in mind the Wilson-Stronks patient safety mantra of “Know-Ask-Speak” to decrease risk of healthcare acquired infections, including catheter associated urinary tract infections (CAUTIs). When you or a patient you love enters the hospital….

Know:

  • What a catheter associated urinary tract infection or CAUTI is.
  • Why a catheter is being recommended/was used.
  • The name and credentials (MD, RN, PA, NP, medical or nursing student)) of the professional who will/did insert the catheter.
  • The difference between a single catheterization and an indwelling catheter.
  • This fact: The risk of CAUTI increases after 24 hours with an indwelling catheter.
  • This fact: If you/the patient is older than 60 years or has had a compromised immune system the risk of CAUTI is increased.
  • Fever is one sign of infection.
  • Collection of urine specimens (if indicated) should be done without opening the drainage system.
  • Urine should drain freely. Debris from the body can sometimes collect and obstruct a catheter. If the catheter is still necessary it must be replaced, not irrigated.

Ask:

  • Are there any alternatives to catheterization?
  • Can an ultrasound of the bladder can be done before catheterizing to measure the volume of urine and allow safe waiting for natural urination?
  • If a catheter must be inserted, can a single (“straight”) catheterization be performed instead of an indwelling type? When will the catheter be removed? And who will remove it?
  • Every day: Why the catheter is still in place and when it will be removed.
  • Whether you/the patient has a fever.
  • How the any required urine specimen will be collected. (It should be done without opening the collecting system and should follow sterile procedures).

Speak:

  • Request that providers wash their hands in front of you.
  • If a collection system is above your/the patient’s bladder insist that it is relocated correctly below the bladder to prevent back flow of urine.
  • If a specimen of urine is needed, insist that it is collected with sterile procedures without opening the collecting system.
  • Refuse to allow anyone to disconnect the drainage system.
  • Refuse to have the catheter irrigated because it is “clogged”. If it is still medically necessary, it must be replaced.
  • Tell your nurse and doctor if you have pain or feel feverish or achy.
  • Tell your nurse if you/ the patient seem(s) confused or unusually restless.
  • Notify your nurse if the urine in the collection bag appears cloudy or unusual in color.
  • If you/the patient may have fluids, drink as much as possible.

Be Very, Very Scared! What You Don’t Know CAN Kill You…

Hospital Associated Infections: “C. Diff”

Posted by: Deborah Caputo Rosen

What do Harvard Magazine and AARP: The Magazine have in common? In the past five months both have published articles about “Superbugs”. “Superbugs” are those microorganisms that have developed resistance to commonly- used antimicrobial medications. “Superbugs” are dangerous and difficult to treat.

The Centers for Disease Control and Prevention (CDC) has been in the news providing guidance on the prevention and science of Ebola infection. But Ebola, although terrifying to many, has sickened only a handful of Americans, and only one person has died in this country of Ebola.

Scarier than Ebola is that on any given day about 1 in 25 hospitalized patients has at least one healthcare-associated infection (HAI). In 2011 there were 722,000 HAIs in hospitals. About 75,000 people died from these infections¹.

What does this mean? It means that people are admitted into hospitals without infections but develop an infection during their hospital stay.

Some of the types of infections patients and healthcare workers need to be vigilant about include: catheter-associated urinary tract infections, central-line associated bloodstream infections, ventilator-associated pneumonia, surgical site infections and hospital-onset Clostridium difficile infections (CDI or “C. diff” infection).

Why do patients acquire infections in the hospital? Let’s use C. diff as our example. In 2012, 107,700 cases of C. diff were reported in acute care hospitals². Often, these cases are preventable.

C. diff is the most common cause for infectious diarrhea in hospitals. Long-term care (LTC) facilities may be at even greater risk. In 2003, 2% of patients discharged to long-term care carried a diagnosis of C. diff infection.

There are people who carry C. diff without symptoms. These bacteria produce spores that are shed in feces. The spores can persist for 5 months on hard surfaces that have not been adequately cleaned. They are transferred on the hands of healthcare workers and are not adequately removed with alcohol-based hand rubs. Alcohol-based rubs do not kill the spores. Using them alone, without soap and water washing, merely spreads spores around on the hands but does not completely remove them.

C. diff spores are dormant in the colon until the normal bacterial environment is disrupted. The usual culprit is an antibiotic. Antibiotics can kill harmless C. diff spores. When that happens, C. diff transforms into a form that inflames and damages the colon, causing colitis of varying severity.
C. diff requires both exposure to antimicrobial agents and new acquisition of the organism. This occurs by transferring fecal spores to the mouth, usually by touching contaminated surfaces. Symptoms begin soon after infection; with watery diarrhea 3 or more times per day, cramping pain and tenderness, and fever. If unrecognized and untreated, the symptoms worsen.

The mortality rate for CDI varies. Some patients may recover without therapy other than discontinuation of antibiotics. That is the appropriate first step. Although it may seem counter- intuitive, additional antimicrobial agents are usually prescribed. Elderly patients who are frail and who do not respond to the first or second medications frequently used to treat the infection and supportive therapy for dehydration may become seriously ill, with a mortality rate as high as 25%.³

CDI recurs at least once in 50% of people, either because the first infection was incompletely treated or because of a new exposure. Highest risk groups include the elderly, those taking antibiotics and those with long and/or frequent hospitalizations. Virtually every antibiotic can increase the risk. The risk of acquiring the infection increases with time and can be as high as 40% with prolonged hospitalization. This is due to exposure to healthcare workers’ hands as they care for infected patients, touch contaminated surfaces and experience failures of correct hand washing technique.

Breaking the cycle requires proper hand hygiene, environmental decontamination and a hospital program of antibiotic use monitoring (“antibiotic stewardship”).

Know, Ask, Speak

Wilson-Stronks advises all patients and their care companions to keep in mind the Wilson-Stronks patient safety mantra of “Know-Ask-Speak” to decrease risk of healthcare acquired infections, including C. difficile. When you or a patient you love enters the hospital….

Know:

  • What C. diff is.
  • What the symptoms are.
  • How it is transmitted.
  • How to properly wash your own hands and when to do so.
  • Whether you/the patient has been taking or is now being given antibiotics.
  • Whether you/the patient has had a long or recurrent hospital or LTC stay.
  • If you/the patient is older than 60 years, has had a compromised immune symptom, or recent gastrointestinal surgery.

Ask:

  • Why antibiotics are being prescribed?
  • Whether and what tests will guide antibiotic selection?
  • Whether the symptoms could be C. diff?
  • How the C. diff will be treated?
  • If your room has a patient with C. diff in it?
  • Whether disposable equipment can be used?

Speak:

  • Request that providers wash their hands with soap and water in front of you, reminding them that alcohol rubs do not kill C. diff spores.
  • Learn how equipment, including BP cuffs, portable commodes and rectal thermometers are disinfected.
  • Learn how surfaces, including floors, bedrails, bedside tables, call buttons and bathrooms are cleaned.
  • Tell your nurse and doctor if you have cramping pain or watery diarrhea, especially if you are taking an antibiotic.
  • If you become infected with C. diff: learn if you will be in a private room or with another patient with C. diff, if contact isolation precautions will be observed, if visitors should follow such precautions.
  • Learn what the likelihood of recurrence is and how to reach help if you have symptoms after discharge.

¹/hai/eip/antibilotic-use_techinfo.html

²/hai/progress-report/index/html

³Cohen S, Gerding N, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-455.