April 20, 2013

CDE's Ignore Patients with Depression

I had wondered when I would receive the next email from someone dealing with depression and being ignored by a CDE. This time it was two emails about four hours apart. Both had been referred to a CDE and did need assistance for diabetes. One is a type 1 and the other a type 2. Both had been diagnosed since the beginning of the new year and both were not receiving family or for one even spousal support.

The person with type 1 (19 years of age) was rejected by his family and they did not want him around because there was no history of diabetes and therefore he could not have diabetes. In essence, his family had turned their back on him. He was not welcome in their home and they did not want contact from him until he grew up and admitted he did not have diabetes. Is it any wonder he had depression?

He said in his email that they were almost done with his CDE appointment, but he wanted some information and help with his depression. He stated next that it seemed to him that the CDE could not gather up her materials fast enough and say on her way out the door, that she was late for another appointment. He wanted to know what it was about diabetes that drove people away from him. He knew he had depression because of the parent's rejection and how he was feeling around people. I was fortunate this time as one phone call was necessary and he had an appointment with someone that knew what to do for him. Three weeks later, he sent another email saying that he was happy with the appointment and felt that I had found him the right person. He said he would have several more appointments, but wanted to thank me.

The second person is in his late 40's and is wondering what to do. He had an appointment with a CDE and when she walked in, she asked how he was. He said he answered, depressed, and he said she turned around and left the room. He said he waited for 10 minutes and then walked to the reception area. He was told that this CDE would not see patients with depression. Now he has lost his family and has not been able to find help.

I asked him in a return email what had happened. He said that his wife had been present when he received the diagnosis and over the next month, the situation went from bad to worse. His teenagers rejected him and were asking him when he would have his legs cut off and they refused to change their eating habits. His wife would not change her cooking habits and the highly processed foods and would not prepare separate meals. He said he started cooking again and this helped for a while until the teenagers kept bringing home more horror stories about what happened to people with diabetes. Then his wife said she would not take care of him when things like this happened. He said he came home from work in March and they had moved out and two weeks later, he received divorce papers at work.

He stated that he had tried three different places to get counseling, but could not get an appointment at any of them. I asked if he had talked to his doctor or even to anyone in his church. He admitted that he had not and would talk to his doctor the next day. The next day I received an email saying his doctor had gotten him an appointment with someone and he would let me know if he was being helped. I am still waiting, but the appointment won't happen until near the end of April.

What surprises me is the lack of support the two received and the total rejection by both families. There may have been unknown facts with the second individual, but I have known other divorces where diabetes was the cause and one or the other spouse was not going to help with future health issues. Sad things can happen.

April 19, 2013

Hyperglycemia – No Pain, No Harm Done – Right?

My email inbox had a very interesting question recently. The person said, “If I don't feel sick, how will high blood sugars hurt me?” I have answered the question in several emails, but felt the topic was important for a blog of the experiences this person went through. Too many doctors do not explain high blood glucose and the damage it will cause over time. They most generally just tell people to watch what they eat and leave it at that. This may have been what happened to this person as she was recently diagnosed with type 2 diabetes. Metformin was a good start, but she gave no other information.

A query about blood glucose readings yielded a question mark and her dosage was only 500 mg at the evening meal. I was afraid I had been too blunt about having another visit with her doctor and asking for a blood glucose meter, test strips, and the rest of the equipment, as I did not hear from her for another two weeks. She said the doctor had told her not to be using that and she did not need to know what anything was and that he would tell her everything from her quarterly tests (I assumed A1c from that statement, but I will disclose the actual test later) and would increase her medications if needed. By this time, she was complaining about the problems metformin was causing. She was being sick almost every day.

My immediate email back to her was which type of metformin was she taking and when was she taking it? It was the metformin tablet and not the extended release. The doctor has told her to take it one hour before the evening meal and the pharmacist had said with her evening meal. She had mentioned this to the doctor and he had really chewed her out for not following his instructions. I suggested that she have a talk with the pharmacist and explain what was happening and what the doctor had said.

She had gone to the pharmacy, but passed out on arrival and was rushed to a hospital where she was given tests and a recheck for diabetes. Yes, her reading was over 600 mg/dl and she met with the hospital diabetes educator. The CDE had given her a blood glucose meter and showed her how to use it. She was on insulin while in the hospital and then given a prescription for metformin XR (extended release) and told to find another doctor after discussing what had happened. She also had prescriptions for the test strips and lancets, alcohol pads, and a few other non-diabetes medications.

As soon as she was released from the hospital, she went back to the pharmacy and they were happy to see her. The pharmacist suggested two other doctors and said this was a wise move on her part. The pharmacist was happy to see the prescriptions and said that the metformin XR could be taken most anytime, but the hospital had wisely recommended at meal time. Her dose now was 1500 mg at breakfast, and 1000 mg with dinner.

What her email said then really makes me happy that she has this pharmacist. This pharmacist discussed and explained each medication in terms she could understand and then took a highlighter pen and highlighted the important parts of the instructions. Then when it came to the diabetes supplies, the pharmacist asked if she would afford xxx dollars for the strips. She was told yes and the pharmacist said then she would put five containers in her bag and explained that if the insurance did not cover them, she would be billed. The pharmacist then took time to tell her about testing, approximately when to test pre-meal, post-meal, and before bed time. Then she said it was not a bad idea to have one box of alcohol pads around, but not to use them on the fingers for testing, but instead to wash her hands with warm water and soap and dry thoroughly. Not to handle the test strips with wet hands was her next instruction and then she explained what the alcohol would do to her fingers in the winter time. Bravo pharmacist!!!

She had called the first doctor, but he was not taking new patients at this time, but the second doctor was and she had a next day appointment. She took all her prescriptions and meter with her and the telephone number for the pharmacist. The nurse asked for her meter so that it could be downloaded even if it was only a few results. She was surprised when she was called for a blood draw, but did not say anything. After the nurse had gathered all her information and given her meter back, she said she got a big shock when a woman doctor entered and then she realized that her doctor was a niece that she did not even know was in the area. The last communication was when she was in Denver, Co.

The email said that the doctor spent about an hour with her discussing testing and nutrition, and what foods she should avoid and lots of good information. Her A1c was still high as the doctor had expected. Turns out the previous doctor only used the oral glucose tolerance test for everything. I think he is behind the times. She is to bring her meter in for downloading every fourth Monday of the month so the doctor could review it. She is to have another appointment on the next time she brings in her meter. Future appointments will depend on what the meter readings show for diabetes management. She even said the new doctor had discussed hypoglycemia and hyperglycemia and given her a few sheets of facts so she did not need my answer any longer. She said she was happy that I asked so many questions as this had given her the confidence when she was talking to the CDE and to understand how important the information was that she was receiving.

After this, she said the communication from the previous doctor was very unpleasant and between the new doctor and her, they asked the local sheriff if he would pick up her records. For a small fee, he would, but even the deputy reported he was happy that both had provided letters of authorization for the transfer. Her new doctor even had to take time to unseal the box and confirm to the deputy that they were her records and that the box had been received unopened. She would not say that the records were complete, just that she had received what was in the package. She then stated the doctor had sent her a bill for the time and packaging, which she talked over with her new doctor. Both felt it was unethical, but agreed that it should be paid since charges were being filed by other patients for malpractice and this could be added to the charges. She concluded by saying that her new doctor had found several areas of problems and she is to go in tomorrow to review whether these would be added to the complaints since queries had been sent to all doctors receiving patients of his.  She is very happy with her niece as her doctor. 

April 18, 2013

When Patients Can Obtain Their Own EKG

I can appreciate good doctor blogs from time to time. As I said in this blog, these devices are coming. I was somewhat surprised by this one, but we will see more of them in the year ahead. This doctor does what is expected by saying he does not have time to read every EKG presented. That is as it should be under the current medical system, but when the Affordable Care Act becomes the system, and pay is based on cost reductions and penalties for failure to reduce costs, then doctors will have no choice but to consider patient used devices.

Remote patient monitoring (RPM) devices will apparently be coming on the market in a variety of ways (prescribed and over the counter). For those devices that are prescribed, doctors and hospitals would be wise to have one of these in stock and test the reliability for themselves. Then rather than downplaying the FDA approval, they need to discern whether they are as bad as envisioned, or if they are indeed reliable as the Food and Drug Administration has determined. This will mean that the specifications for the patient device may not be a tight as the instrument used by trained personnel in their labs, but it will give some indications of problems needing further medical attention or not.

Doctors and hospitals may also want to have over the counter devices on hand to test them as well. Doctors and hospitals that do not, will be opening themselves to much criticism when they dismiss these as just another device that makes their jobs more difficult. Yes, we know the hypochondriacs will insist on having these devices, but people with the disease or illness will also use them often to their advantage. This will be much like the blood glucose meters people with diabetes use now. Some learn how to use them properly and to interpret the readings, while others just think they are doing this for the benefit of their doctor, which is wrong.

Is the doctor right to be concerned about the legal aspects of prescribing a remote-monitoring device? He is probably right to be concerned, but eventually, our medical system is going to need to realize that devices approved by the FDA for patient use must be excluded from frivolous lawsuits against doctors. This will be especially true when remote patient monitoring becomes required under the Affordable Care Act. Yes, even then there will be people that purchase the wrong device and sue because it malfunctioned for them. The get rich quick schemes people think up will continue until they are no longer alive and then another person will take up the scheme.
Image courtesy of maximintegrated.com

Do I expect to see many more devices for patient monitoring being blogged about? Yes, some will be balanced and concerned like this doctor, but many will be ranted about and have little value for the consuming public.

April 17, 2013

Does Your Doctor Care If You CAM?

Maybe your doctor will not care if you are using complementary and alternative medicine (CAM), but you should. Not informing your doctor can cause health threatening and even life threatening situations if you keep this a secret. There are too many cases of patients saying that these medications are natural and therefore my doctor has no need to know, and they end up in the hospital or dead. Family members then are left to wonder what happened. Of course, they will blame the doctor, but this is when an autopsy can uncover the real cause.

If patients and doctors both used communication, most of these problems could be avoided and everyone could be in a better state of health. Many times doctors will just sarcastically dismiss CAM or tell the patient not to be taking vitamins, herbal medications, or homeopathic products. It is the wise doctor that will take the name of the medication and look them up and maybe learn something, but most doctors are against CAM because they were not taught about it in medical school and therefore it holds no value.

I am surprised by this doctor actually blogging about her experience, but this must be an above average (and I mean way above the norm) doctor. Claire McCarthy, MD is a primary care physician and the medical director of Boston Children’s Hospital’s Martha Eliot Health Center.

She states that in a study, researchers in Canada found that 64.5 percent of children were using some form of CAM, but more than a third did not tell their doctor. She also says that in the general population about 75 percent of patients using CAM don't make this known to their doctors. She cites three reasons for this secrecy – patients are afraid their doctors won't be happy; patients don't think their doctor needs to know, and the doctor did not ask.

I agree with her assessment that safety should always be first and foremost. Doctors will not know whether they are being safe in prescribing a medication without knowing everything the patient is taking. Medications can have interactions and not always good interactions. Therefore, it is imperative that patients communicate all medications and CAM being taken. Not all CAM physicians are cautious when giving out herbal and homeopathic medicines and can cause adverse drug interactions unintentionally.

Dr. McCarthy states, “We doctors have a strong (and understandable) tendency to think within our own traditional medicine worlds. But, there is a much bigger world than traditional medicine when it comes to making patients feel and get better. And sometimes it’s patients who need to teach doctors.” This is a doctor that has her patient’s safety where it should be – first.

In her blog, she even lists the National Center for Complementary and Alternative Medicine (NCCAM) so that people can explore the site. She blogs here and here and is interesting to read for parents with small children.

April 16, 2013

More Americans Are Managing Diabetes, Oh Really?

The introduction to this article is not a good indicator of what is happening and it should not garner the readership it is receiving. It should not make people with diabetes feel confident either. The title is very misleading as it only mentions diabetes when it should also mention the three measures or health issues they were discussing. They are talking about blood glucose, blood pressure, and cholesterol levels.

All three of the sources I found actually mislabeled the article. Two said diabetes and the third source – Medscape – listed it as diabetes risk factor. I fail to see how diabetes risk factor is involved when a person already has diabetes. Granted using the term diabetes probably brings more readers like it did me, but this is promoting the wrong assumption about the article and they don't mention the three issues until the second paragraph.

Yes, we all need to be concerned about the three issues as they are interrelated and one can affect the other two to a point. However, what bothers me is that they don't give this interrelation, but they say that two decades, yes, two decades ago, the rate of people with any type to diabetes meeting or exceeding the three measures of good diabetes management was only two percent. Now 20 years later the number has risen to only 19 percent. Shame on the ADA and the rest of the medical establishment for this lack of progress.

They then claim this is a huge improvement and don't even give the numbers of people with diabetes in 1988 and the number of people in 2010. The begs the question of how are they relating the numbers to claim this is a huge improvement. Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City, not participating in the study expresses my feelings. He says that with the increased awareness of diabetes and many newer medications, it is disappointing that only 19 percent meet all three measures.

Zonszein also states something that is upsetting for many - 100 percent of people with diabetes should be on statins - because only 50 percent were on statins. He also said that the 50 percent of the people not having the recommended levels of blood pressure should be on drugs for that. That is right – he wants to shove pills at people rather than see if other means might help first – typical medical response.

Then as if rubbing salt into the wound the article states that is it important to keep these measures as close to the “recommended” goals as possible. The article says this will avoid serious complications like heart disease, kidney failure, and vision problems. They quote of the ADA recommendation for A1c as being 7.0 percent as if this will prevent complications. I'm sorry to say that this may only slow the rate complications and allow diabetes to progress, but this is not a goal. We want to stop complications and prevent progression. Even though the recommendation by the American Association of Clinical Endocrinologists (AACE) of 6.5 percent is not ideal, but much better even for the elderly.

Even though Zonszein is abrupt and seems to lack compassion in his statements, he does raise a few good points. He states that young people developing type 2 diabetes seem to have a particularly aggressive form of the disease. They seem to respond less to insulin and are more insulin resistant. He does state that education is the key for all people with diabetes. Where he gets this is a puzzle. He says that presently people often don't get education until late in the disease. This may have been partially true two decades ago, but today with the internet; more people are getting education earlier. Whether they apply the education is the question.

Fortunately, with the internet, his next point is where many people draw the line. He says that people need the education to know what is going on so that you will take the medications. He claims that when you are not feeling sick, it is difficult to take the pills. He may be partially correct, but young people of today use the internet to look up the different “pills” and find the side effects and purpose of medications.

I agree with Zonszein that this paper is an alarm, but only because our medical community is doing so little to educate people and bring diabetes under better management.

April 15, 2013

Personalized Risk Assessment Aids Decisions

This is a generalized study about risk assessment. Diabetes is not among those discussed and this is a disappointment. With the fact that the American Association of Diabetes Educators (AADE) does not emphasize risk assessment for diabetes, and even the American Diabetes Association (ADA) does not have firm guidelines, this is a shame on these groups. There are many writers, bloggers, and other medical sources that write about risk assessment, but our professional organizations seem not to care. Stopping the diabetes epidemic should be a higher priority.

The ADA does have a program in place that people may use, but this is different from having a public policy or doctor recommended assessment procedure. In addition, the link here will take you to the diabetes risk test. This is not an assessment test, but a one-size-fits-all risk test. I admit I have seen poorly constructed risk tests, but this one does not properly evaluate your diabetes risk. The first panel only allows four age groups and stops at 69. Apparently, people over 69 are not at risk for developing diabetes. They may also figure that people over the age of 69 are not worth the effort of assessment. I have to call this age discrimination and add to this care discrimination. It is no wonder that the AADE does not have practice policies in place for the elderly.

Yes, the ADA does have several “stop diabetes” programs, but this is merely lip service. The ADA is not aggressively promoting diabetes risk assessment for doctors and does little to educate doctors. You say that they issue new guidelines every year. Yes, but how many doctors even read them, much less practice following them. If they really understood the ADA guidelines, then why do we encounter so much of what the next paragraph says?

Many of the sites having diabetes risk assessment tools available do a much more thorough task of assessment, but then bail on giving specific instructions about conferring with your doctor that is knowledgeable about diabetes. They do say to talk to your doctor. If your doctor is not current with the knowledge about diabetes, you may end up with a warning that “your blood sugar is above normal, watch what you eat” or something similar with no diagnosis of diabetes.

Always ask for your lab results so that you may see what the results of the tests state. If your fasting blood glucose or plasma blood glucose levels are above 125 mg/dl, then you may need to ask for the oral glucose tolerance test (OGTT). If your A1c level is above 6.4 this also applies. If the doctor balks, then I urge you to consider a change of doctors. The higher the results are above 125 mg/dl, the more urgent the need for a change of doctors. If your fasting or plasma blood glucose results are above 180 mg/dl, and your A1c is above 7.9%, then it is urgent that you find a doctor that will do the necessary testing for analysis. You need to know to be able to take actions to stop or prevent the development of any complications.

If the results are between 100 and 125 mg/dl, then you are at risk to develop diabetes. This is the range considered “prediabetes” and you should then learn what preventative measures you may take to prevent the onset of full diabetes. The A1c range is 5.7% to 6.4%. Most doctors seem to ignore this range, but there are preventive measures that are possible to take to prevent the onset of full diabetes.

This source is one of many risk assessments you may do yourself, but if you do not have diabetes now, take this seriously. If you are at risk, do your health a favor and schedule a doctor appointment with the specific instructions that you want to tested for diabetes.

April 14, 2013

Sleep Apnea - Are You a Prepared Patient?

What do you know about your sleep apnea? Do you know your equipment? Do you know what your options are – for equipment, equipment replacement, parts replacement, and other supplies? I am sorry to report that many people do not and some do not care. Others hate the equipment and still others let vanity rule. There are some things about my equipment that I do not like, but I still use the equipment as I feel better using it and know what will happen if I don't.

You will have to excuse me for a little ranting, but I have a friend that only wears his mask for short periods each night and then takes it off. Why does he do this? I don't know as I have helped him adjust the snugness and even had him order the nasal mask liners from this source, but still he would not wear it throughout the night. With the nasal mask liners, he was able to loosen the tension on the mask straps even more. Finally, I started kidding him that it was vanity that caused him to remove the mask. He questioned why I would say this. I said that he was so self-conscious about the lines the straps could cause that he did not want them when he woke in the morning.

He finally admitted that this bothered him and I won't go into some of the things I said to him, but if we were good friends, he would have told me to get lost and never see him again. We did settle on a weekend and I worked with his significant other (SO) to adjust the straps and he did give it an honest try. Even his SO said that he did not have lines an hour after he awoke. Then the following weekend to prove this, I took away his nasal mask liners and had him tighten the straps to prevent air leaks. It took almost three hours for the mask lines to go away. He was finally convinced and now he wears his mask all night.

Yes, there are many choices that are available to people with obstructive sleep apnea. One choice that you do not have is walking into a medical supply store and choosing a piece of equipment, a mask, and other supplies, paying for them, and walking out with them. You must have a prescription, obtain equipment that your insurance will cover, and have counseling by your sleep doctor or a sleep therapist. Even if you can afford to pay for the equipment, the law does not allow them to sell you the equipment without a prescription.

Equipment choice may be more flexible as the doctor can influence the choice and sometimes force the insurance to cover equipment they do not want to, but this still may be a point of contention. So be careful when writers claim that you can make the choice.

This article makes a lot of sense and does cover many of the facts that need to be covered. I do appreciate the fact that she mentions mild, moderate, and severe sleep apnea. I even needed to laugh at her analysis leading up to her question – are you a dead man walking. Yes, sleep apnea of any type can cause you to die if not properly managed.

The sleep study is the first step that needs to be accomplished. This will determine your apnea hypopnea index (AHI). This is then used for the type of machine the doctor may recommend, the pressure setting(s), and the type of sleep apnea you are diagnosed as having. The next piece of vital information is your oxygen level according the author and in checking with my sleep doctor, it is not a measure they do other than as part of the sleep lab at the beginning and end of the lab experience. This is something some sleep labs did not measure until recently. High blood pressure in connection with low oxygen levels puts us at risk for a heart attack or stroke.

In summary, to become a prepared patient, your objectives should be:
  1. Take responsibility and lead your healthcare team.
  2. Know your AHI and oxygen levels.
  3. Understand the anatomical features that cause your OSA .
  4. Know your equipment choices, machine pressure and take responsibility to learn patient controlled comfort and adjustment features.
  5. Report all problems and challenges to your healthcare team as quickly as possible for resolution.
  6. Maintain due diligence by scheduling routine follow up visits with your sleep doctor.

I would add that you need to forget about vanity and do some testing to see how long the lines from the straps actually last before giving up. This is when number 5 above should be used and discussed with your sleep team.

I admit I don't remember the exact number for my AHI, but in both sleep studies, it was over 100 apneas per hour. I have attended several of the maintenance sessions and not had any problems. They have called me in several times to download the data from the disk, but after doing it once or twice, the insurance company quit complaining and asking for more. My sleep doctor knows that I use my machine and asks how I keep it so clean. I say that I use only distilled water and clean the filter monthly or more often if needed. I use a clean cloth to wipe the outside of the machine.

My wife complains that I don't clean the nasal mask often enough, but with the nasal mask liners, they do a pretty good job of keeping it clean, so I don't need to clean it that often. Apparently, I take better care of my equipment than most do. The sleep specialist is always surprised that I don't need replacement parts at the frequency of many people. I am now happy that I do take care of my equipment as Medicare is monitoring how often people need to replace equipment parts and has set some limits.  For most supplies, it used to be quarterly, but now much of it is biannually, except for some parts.