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Showing posts from January, 2019

Rehabbed to Death NEJM Perspective: Podcast with Lynn Flint

Three reasons you should listen to or watch this podcast: The issue of patients cycling back and forth between the hospital and skilled nursing facilities near the end of life is common, will ring true to those of you who are clinicians, and has largely been ignored in the literature.  This is core bread and butter geriatrics and palliative care.  Unfortunately, it's not something we have focused on to the same extent as "code status" or "advance care planning."  But you can make the argument that it's as or more important as those issues. It's about a hot off the press article published today in the NEJM .  I think the NEJM was interested because this issue is driven by a number of health policies that create perverse incentives to cycle patients back and forth between hospital and skilled nursing facilities, rather than care for them at home.  We wrote it up primarily because we were interested in the communication failures issues that perpet

Fever, malaise, AMS -- Is it an infection? Podcast with Jeff Caterino

Geriatrics teaches us that older adults with infections often present with non-specific symptoms rather than typical localizing symptoms of infection present in younger adults.  Sometimes they present with fever, delirium, malaise, or fatigue.  In today's GeriPal/JAGS joint podcast, Jeff Caterino challenges this common teaching by examining the extent to which non-specific symptoms are predictive of infection for older adults presenting to the emergency department.   Turns out - they're not so predictive as you might think! This is a hugely important issue - antibiotic use and misuse among older adults is rampant, and not only endangers these patients, it endangers others by creating antibiotic resistant organisms.   Enjoy! -@AlexSmithMD Links: - JAGS Study by Jeff Caterino - JAGS editorial by Tom Finucane - AGS Choosing Wisely recommendations Listen to GeriPal Podcasts on: iTunes  Google Play Music Soundcloud Stitcher   Transcript: Eric: Welcome t

The View From Here

Imagine walking into a mythological epic and giving advice. Center stage, Achilles is about to take out Hector. From stage right, a guy in a white coat, Orthopedicus, confidently strides up to Achilles and offers reconstruction of the big tendon that joins his calf to his heel, noting that if he cuts it and reattaches it, Achilles will do better as he has seen with so many other patients. Achilles is distracted by the battle, only half listening to Orthopedicus, and nods his assent. Tragically, he dies on the table the moment the tendon is cut. I propose this is exactly how most medical care is offered. We see a problem, we fix it. The back story (whom the problem is attached to, for instance) is too hard to gather in the midst of a busy clinic, a busy emergency room, a busy day of hospital rounds. We have created a specialty that takes time to consider the whole person. Palliative care often improves outcomes, alleviates suffering and saves money. It is a wonderful thing. I

Effect of Palliative Care in ICUs: Podcast with May Hua

In this week's GeriPal podcast we talk with May Hua, an anesthesiologist, critical care physician, and researcher from Columbia (in NY, not the country).   We've had a number of podcasts and blog posts about palliative care in the ICU: Bill Ehlenback on primary palliative care in the ICU Jessica Zitter on palliative care in the ICU Doug White on a nurse-led communication intervention in the ICU May Hua's study addresses the still unanswered question - do specialized palliative care consults in the ICU do anything?  She looked a number of outcomes comparing ICU patients in hospitals with and without palliative care consults.  While most outcomes were similar, rates of hospice use were higher in hospitals with palliative care teams.    One issue Eric raises toward the end deserves highlighting.  We know of no trial demonstrating the effect of cardiology, endocrinology, or gastroenterology consults in the ICU.  Why do we feel compelled to study and prove the effe