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Tramadol-induced hypoglycemia: another reason not to use it

Note: This post was originally published on PalliMed as part of the World Series of Blogs Payback-Ed.

In 2013, there were 43.8 million prescriptions for tramadol filled in the U.S. It has a slightly different method of action from many other pain medications, as tramadol is both a mu-opioid receptors agonist and a reuptake inhibitor of serotonin and norepinephrine. It is also thought that the opioid activity is due to both the parent compound and the more active O-desmethylated metabolite (which, like codeine is metabolized by CYP 2D6 and therefore gives the same big inter-individual differences in pharmacokinetics).

The overall efficacy as a pain medicine is comparable to that of other weak opioids. Most people know it is associated with serotonin syndrome as well as seizures especially when used with other medications that lower seizure threshold. A new study that came out in JAMA IM reveals a pretty robust association between tramadol use and hospitalizations for hypoglycemia, even…

What you can do today to pull the plug on Sarah Palin's "death panel" myth

Perhaps enough time has passed that when you think about Sarah Palin, her antics seem almost cute in their absurdity.  You know, "I can see Russia from my house!" or nicknaming herself a "Mama Grizzly."  With any luck, you might think, the biggest dent she'll leave on American history is her quirky run for the vice presidency that will make for great Trivial Pursuit fodder one day.

Unfortunately, one seriously un-cute gift that Sarah Palin gave the American people during her five minutes of fame just keeps on giving.  In August 2009, she coined the term "death panel" in a Facebook post intended to smear Obama and malign the Affordable Care Act.  She said,

"The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their "level of productivity in society," whether they are worthy of health…

Bumper Sticker Gaming for Geri-Pal Thinkers

Since there seems to be some serious competitions and analysis happening on this blog, I thought I'd put in my two cents so as to gain some broader and serious Geri-Pal thinking about how bumper stickers apply to client care.

Really? Yeah, really.

So, I will not lie to you. I read and analyze bumper stickers as a clinical hobby, of sorts.

 I live in a place that values and cherishes their viewpoints through a bumper sticker phenomenon. Some vehicles are plastered with them. I kind of like that people are into it! I travel a lot so this bumper sticker viewing amuses and inspires me on what could be a solemn day.

Bumper stickers remind me to think carefully. I believe it's truly valuable to watch, listen and think carefully about big and small matters alike. It promotes that life-long-learner concept as well as helps me remember to have a good sense of humor. Bumper stickers are put on cars and other items to share and discuss so it makes sense this gaming experience has…

Gifts for Seniors: Holidays 2014

As stores and the internet light up with gift ideas in time for Christmas, you may have a senior or two on your list. Last year we put together a long list of potential gifts for older adults, which can he found here.


Please enjoy this updated list that I hope can help you give thoughtfully and generously.

For the senior who enjoys walking:

Fitbits, Jawbone and other devices to help seniors live a quantified life, share it, and remain motivated. Says a GeriPal: “Family members can set things up on the computer so friends and family can stay connected and challenge each other to walk do many steps.” (Rebecca Sudore)

For the senior who loves to read, but maybe can’t as much these days because of low vision or other impairments:
A subscription to audible books.A connection to programs at the library, where many have programs for people with vision impairment and audible books. Download old radio programs they may enjoy and put them on CD for them to play.      Boxed sets of TV comedy s…

Make Advance Care Planning Routine

The following is part of a three-post progressive blog about the Center for Medicare Medicaid Services (CMS) choosing not to pay for the new advance care planning codes in this year's Medicare Physician Fee Schedule.  However, now is the time tell CMS why you support reimbursement for advance care planning services in their call for comments.  Please see also Phil Rodgers post on CMS considering reimbursement for Advance Care planningat Pallimed, and Gregg VandeKieft’s update on the state of ACP advocacy at the AAHPM blog.

What will it take for advance care planning to become routine for patients with serious illness?

It is time for US policy makers to put away the negative connotations of the "Death Panel" days and have a mature discussion about serious illness.  No matter what your political persuasion, it is time for us to act to improve the quality of care given to all patients by promoting health advance care planning.  With excellent communication and advance care …

Wanting to survive more than just 30 days

by: Gretchen Schwarze, @GretchenSchwa10

My husband, also a surgeon, was recently discussing donor-nephrectomy with a healthy 65 year-old woman in his transplant clinic.He told her the 30-day survival for this operation was excellent.She was shocked he would quote such metrics, “I don’t want to live for just 30 days!”Yet for years, we in surgery have judged our successes by the number of patients who don’t die within 30 days of surgery.
I know it is easy to find examples of surgeons behaving badly over a postoperative patient whose death seems to threaten his “numbers,” but as a surgeon who has been there I can tell you that it is viscerally painful to watch a patient you operated on succumb to postoperative complications. Deep notions of error and responsibility are ingrained in our culture and are reinforced in many ways including M&M conferences and NSQIP (National Safety Quality Improvement Program) reports. While I’m all for improving safety and quality, I shudder to think about…

Finding dental care for people confined to home

Have you ever had a patient at home who was in need of dental care? Perhaps they were receiving hospice services or maybe they were just discharged from the hospital not on hospice, but still too frail to get to the dentist. Of course the focus is often on the medical issues, yet the most significant issue was broken rotted teeth, which made oral intake nearly impossible without pain. Clearly, the answer here is not opioids for pain control, but rather to take care of the root problem: access to dental care.

Clearly dentists and their staff are not part of a hospice or palliative care IDT, but when you need them, boy do you need them. If the short case I outlined is not clear enough for you, I would really encourage you to read “Love” by Jean-Noel Vergnes, DDS, PhD recently published in the Annals of Internal Medicine (paywall). Written by a dentist in France caring for his wife who had a stroke and was desperately in need of dental care he himself could not provide, it illustr…

6 tech innovations that will make you say "nifty!"

Generally at GeriPal we focus on low tech, high touch interventions.  Like talking to people.

But this week we had an inspiring visit this week from  David Atashroo, MD, from Stanford.  The title of his talk was "Innovation in Aging."  And some of the stuff he shared is really exciting, and worth sharing.  These are innovative technologies that can be used to help aging seniors.  Many of these are in the early stages of development or are at the startup level.

1.  Check out this wheelchair.  Who says wheelchairs have to be, well, ugly?  This thing looks cool!  Made by Whill.



2.  Now check out this car.  You can roll your cool wheelchair right into it.  And it's electric.  Brilliant!  Made by Kenguru.


3. Check out this spoon.  You know how noise canceling headphones block out background noise?  Well, this spoon, made for patients with essential tremor, cancels out the tremor, so the spoon stays steady.  Made by LiftLabs.


4. This is a dog avatar that for people with demen…

Lessons from the Stage: A Lesson About Patient Communication Learned in an Improv Class

My husband and I took a beginner’s improv class not long ago. Two of the most fundamental rules they taught about performing improv with a partner were: (1) never say “no”—it kills the storyline that you should be working with your partner to build. And (2) never say “yes, but...”…. because you might as well have just said “no.”

It plays out something like this: You and your partner get a prompt, such as pretending to be cops. Your partner has an idea for where the scene could go next. Little does your partner know that you have a brilliant idea for where you want to take the scene next. Your partner boldly proclaims, “Alright, partner, I just heard from the sheriff and there’s a murder to investigate.” Still holding to your own idea, you reply, “Yes, but before we get there, we first need to fulfill our assignment as undercover go-go dancers.” Yes, but… you just killed your partner’s storyline instead of building on it.

It sounds so simple. An easy two words to avoid. …

Time to act! Urge your senators to confirm Dr. Vivek Murthy for Surgeon General

by: Alex Smith @AlexSmithMD

Vivek Murthy was nominated for Surgeon General of the United States by President Obama in November of 2013.  A bipartisan group of Senators approved his nomination in February 2014 and pushed it forward for a full vote.

A (not so) funny thing happened on the way to the vote.

In his confirmation hearing, Dr. Murthy was asked by Senator Lamar Alexander about his tweet that gun control is a public health issue.

Tired of politicians playing politics w/ guns, putting lives at risk b/c they're scared of NRA. Guns are a health care issue. #debatehealth
— Vivek Murthy (@vivek_murthy) October 17, 2012 Senator Alexander noted that "Americans have a first amendment right to advocate the second amendment."

Daily Show commentator Jon Stewart responded on his show "Yes, Americans have a first amendment right to advocate the second amendment.  And apparently, you don't have a first amendment right to have a different opinion from that.  Everyone …

Some say Geriatrics is not glamorous, but I say it is.

Tonight I was having a discussion with some close friends.I’ve got to brag here, I have some very smart, passionate physician friends from residency.One of the hospitalists asked for our collective advice about a recent difficult clinical encounter:
“How would you handle a 90 year-old patient in the hospital who refuses to let the nurses change her until we let her go home?She’s been sitting there in her own urine for 24 hours, and I just don’t know how to help.”
Five months into my geriatrics fellowship, I thought maybe I could handle this one.I suggested that likely she’s likely very frustrated about her declining health and her ability to care for herself.She recognizes that her independence and freedoms are slowly being taken away from her.She’s probably trying to exert control the only way she can.
The other comments from the group were very different.“More colace,” one said jokingly (from the friend who thinks that’s all I prescribe).“Oh that’s ‘failure to thrive,’ she should b…

Geriatrics and Palliative Medicine: Partners in a Common Mission

Over the past decade, the disciplines of Geriatrics and Palliative Medicine have become intellectual cousins.
Within Palliative Medicine, the recognition that Palliative Medicine is not just about end of life care has been a paradigm shift.There is now recognition that core skills of Palliative Medicine, including symptom management, communication, and caregiver support are needed throughout the course of serious illness.While these needs of seriously ill patients transcend age, it is a demographic fact that older persons will be the bulk of persons with these chronic palliative care needs.So, the population that has long been of interest to Geriatrics is now of great interest to Palliative Medicine.
Within Geriatrics, we have become consumed with the recognition that most frail older persons have multiple illnesses.We realize that treating each illness separately, rather than treating the whole patient leads to considerable harm.Geriatricians strongly advocate for a focus on whole p…

Family caregivers give up $522 billion in income per year to care for seniors

by: Alex Smith @AlexSmithMD

You don't get something for nothing.

We've blogged previously about the silent long term care system of informal caregivers in the US.  These are the families and friends who provide the bulk of care for older adults in the US.  The National Caregiving Alliance estimates that nearly 1/3 of US aldults are caregivers.  This caregiving is seemingly "free" - it appears to cost the US Healthcare System nothing.  Often, however, this work comes at great cost to the caregivers, including higher rates of depression and other health effects.  It also means the caregiver is providing care, and not earning an income for themselves or their family.

Today we have more information about the economic costs of informal caregiving in the US.
Amalavoyal V. Chari and colleagues published a national study of the costs of caregiving for elders in the US in the journal Health Services Research (link to an interview with Dr. Chari here).  They focused on how …