My husband and I were seated in our family room when we heard the sirens. Since we live in a canyon, it can be difficult to pinpoint the origin of certain sounds, especially at night. I asked him, “Is that on our street?”

Consumed by the hockey game on TV, he said, “It’s probably the next street over.”

I got up and peered out the window. “I see flashing lights.” I called my friend and neighbor, Sally, who lived a few houses from us. “What’s happening down there? Is it a fire engine?”

Breathless, she said, “No, it’s the paramedics. They’re in front of Dorothy’s house.”

It took me a moment to realize that our 85-year-old neighbor was in trouble. “I’m going down there,” I said.

“Melody’s still sick. I’m stuck here. Let me know what happens.” I hung up the phone, remembering what it was like to have a sick baby with my husband out of town.

As I veered down our driveway, the flashing lights from the ambulance greeted me. The darkness of the October night closed in as I spotted Dorothy’s caregiver in the doorway of the house, her hand covering her mouth, tears streaming from her eyes.

 “Maria, what happened?” I ran to her, my nerves lit up.

Maria choked back sobs. “She not talking right, something is wrong with her. She fell down in the bedroom.”

Male voices clamored from down the hall. “Paramedics?”

Maria nodded.

Sensing her shaking, I put my arm around her. “What do you mean she isn’t talking right?” I wondered if Dorothy had suffered a stroke. She hadn’t been in good health over the last year and now used a walker, Maria always at her side.

Smoky, the gray terrier mix, barked toward the direction of Dorothy’s bedroom. Maria picked him up and held him close to her chest. “She’s not saying the right words. Something is wrong.”

And just then four men dressed in navy blue pants and brown, lace up boots, blew past us, their hands gripping the stretcher with Dorothy lying on her back, her mouth open wide as if gasping for air.

“Get out, move,” one of them yelled at us as they tore down the hallway and out the front door.

I raised my voice, my words directed toward their backs. “Where are you taking her?”

The blond one turned around and said, “Santa Monica UCLA.”

Maria and I watched the paramedics, our eyes glued to Dorothy strapped to the gurney as she was hoisted into the red and white truck.

The dog still under arm, Maria said,  “I called her son.”

“Is he coming down from Sacramento?” I hoped so. I didn’t like the idea of Dorothy being in the hospital without a family member.

“I think so.” Her voice rattled with emotion. “I have to follow the ambulance. I have to know where they’re going.” She released the dog inside, grabbed her purse and keys.

“Maria, you’re leaving Smoky?” I knew she wasn’t going to come back to Dorothy’s house that night, and maybe not the next day either.

She gave me a blank stare, tears combing her eyelashes. “I’m going to stay with Dorothy.”

“I’ll take him, we’ll keep him overnight.” We exchanged cell phone numbers and she thanked me. The expression in her eyes tore through me. “Dorothy’s going to be okay,” I said, although I wasn’t sure she was going to be okay at all. “She’s in good hands. Let’s text each other when you know something.”

I grabbed the dog, watching the taillights of the ambulance disappear into the darkness, Maria following in her Toyota.  I thought to myself, we should all be so lucky to have someone like Maria with us if we’re in our eighties and have no family in town. Dorothy’s husband of forty years had passed away several years before.

Making my way up our driveway, Smoky in my arms, I wondered how many elderly people with medical emergencies end up in the emergency department alone. Dorothy couldn’t speak but she had Maria to talk for her about the onset of symptoms, current medications, medical history, and more. Her son would probably fly down and be there by morning. But what about the older people who don’t have anyone close by and are rushed to over crowded hospitals with multiple medical conditions, on multiple medications, and are unable to communicate what is wrong?

Emergency departments (EDs) are mind numbing for anyone, not to mention for those who might be cognitively impaired. They are scary and overwhelming–the lights, the sounds and smells, the doctors and nurses scrambling to attend to more patients than they can handle.

According to Health Affairs, Transforming Emergency Care for Older Adults, hospitals are already overcrowded, strained to capacity. “Older adults seen in the ED have increasingly complex medical and psychosocial care needs.  Unlike their younger counterparts, they are more likely to have cognitive impairment, falls, depression, and sensory impairment and to be taking multiple medications.” These characteristics complicate the evaluation and management of older adults in the ED.

How is a rushed health care staff in an emergency department supposed to work quickly with an older adult who might not be able to communicate what is necessary for an accurate diagnosis and treatment plan? According to the Annals of Emergency Medicine, older patients account for up to a quarter of all ED visits and experience higher risk of adverse outcomes. 

To address those adverse outcomes and the special needs of older patients is the emergence of geriatric emergency departments. According to The John A. Hartford Foundation, there is a growing number of compassionate emergency physicians with experience in geriatrics who are trying to improve emergency care for older people. The American College of Emergency Physicians, The American Geriatrics Society and others, have created Geriatric Emergency Department Guidelines  for the growing number of geriatric EDs.

But most hospitals still don’t have them.

Geriatric emergency departments are a good step in the right direction. We need more of them. According to the American College of Emergency Physicians, the geriatric ED should be different from other health care settings, complete with non-skid flooring, guardrails and handrails, non-glare lighting, and staffed with medical professionals who are trained in geriatrics. Included in the recommendations are hearing amplification devices, magnifying glasses, clocks, signage with large lettering, and more.

Don’t our grandparents, parents and other seniors deserve emergency care tailored more specifically for their needs? If you’ve ever been with an older loved one in a hospital, you’ll agree that they do.

That night, Dorothy was admitted to a hospital that did not have a geriatric ED. But she received decent care. She was diagnosed with kidney failure and stayed there for three days. Maria was there with her every step of the way, even after the son arrived. Dorothy is back home and doing fairly well. But what happens the next time, and there will be a next time, when she has a medical emergency and she happens to be home alone? I just hope her neighbors, my husband and I included, will be around. 

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The Crown Princess (owned by Princess Cruises) docked at San Diego with 94 passengers and 23 crew members who are  sick with Norovirus. 117 were confined to their cabins with acute gastrointestinal symptoms, including severe vomiting and diarrhea.

Imagine being stuck on a cruise ship, unable to escape, and you and over 100 fellow passengers are vomiting and suffering with diarrhea. You’re cowering in your room, hovering near the bathroom, and you know people in neighboring cabins are doing the same thing. It’s enough to make you avoid cruise ships for good.

The Crown Princess isn’t the only cruise ship plagued by Norovirus. A Royal Caribbean cruise ship returned home early on January 20, 2014, because 700 of their crew and passengers fell ill with severe flu-like symptoms. It’s likely Norovirus was the culprit on this ship too, as the passengers were vomiting and suffering with diarrhea.

Now if that isn’t enough to keep you off of cruise ships, I don’t know what is.

CNN reported that cruise ships are floating petri dishes and are ripe for spreading illness. Outbreaks of Norovirus are the leading cause of acute gastroenteritis and occur most frequently in close quarters. And that means cruise ships, nursing homes, and dormitories.

According to the CDC, Norovirus is the most common cruise ship illness that spreads easily from person to person, through contaminated food and water and from contaminated surfaces. That covers just about everything on a cruise ship from the people preparing the meals, transmitting it to food, passengers eating with contaminated utensils, to touching any public surface on the ship and being in contact with people who are ill.

Egads!

If you think these are isolated incidences, think again. So far in 2014, the CDC reports eight cruise ships infected with viruses, causing passengers to get sick, most because of Norovirus and E.coli. In 2013, eight ships were infected with Norovirus and E.coli . In 2012, sixteen ships were infected with the same.

If you’re going on a cruise (buyer beware) there are some things you can do to protect yourself:

1. Check the CDC’s Vessel Sanitation Program website and search for the cruise line  on which you’ll be traveling. See link here

2. Wash your hands frequently, which means with warm and soapy water for 20 seconds.

3. Avoid touching your mouth unless you’ve thoroughly washed your hands. This includes: eating and drinking, smoking, and brushing your teeth.

4. Avoid using the public restrooms on the ship. To keep these clean, they have to be bathed in bleach. 

5. Gel sanitizers. If you can’t wash your hands, use a gel hand sanitizer with 60% ethanol.

6. Get plenty of rest and drink a lot of water. Rest helps restore your immune system, and drinking water helps to prevent dehydration.

8. If you see someone sick (vomiting or diarrhea) leave the area.

9. If you are sick, report it to the crew and stay in your room until you are well.

You might look into portable plastic bubbles (joke) if you’re intent on taking a cruise. For germaphobes like me, I’ll take a plane or car. Hand washing can be very effective but if there is an outbreak and your fellow passengers are throwing up and heading for the bathrooms, you’ll have to confine yourself to your cabin for at least a few days. 

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I’ve been suspect of certain generic medications for quite some time, much to the frustration of certain pharmacists and physicians who staunchly defend their quality and efficacy. Apparently, the FDA is now concerned as they have recently begun a 20 million dollar testing program on generic drugs that involves at least a dozen academic medical centers in the U.S. 

In light of the problems with a number of generic drugs and that 80 percent of prescriptions in the U.S. are for generic medications, it’s about time the FDA started a testing program on a grander scale.

Check out these facts:

2014: The U.S. imposed restrictions on India’s generic drug manufacturer, Ranbaxy, and banned imports of products made at their newest factory due to quality and safety concerns such as falsified drug test results and selling fake medicines. This is the third time Ranbaxy imports have been blocked in the U.S. since 2008. See New York Times article here  

2013: The U.S. banned imported drugs from specific Ranbaxy plants. In May of the same year the company pleaded guilty to federal drug safety violations and paid 500 million in fines and penalties. See New York Times article here 

2012: Ranbaxy exported generic Lipitor to the U.S. but the company stopped production of this drug after tiny pieces of glass were found in the tablets. See  CNN article here 

2012: The FDA recalled the generic form of Wellbutrin 300mg XL exported from Impax Laboratories and marketed by Israel-based Teva Pharmaceuticals, because it was ineffective. See the Forbes article here

At first the FDA ignored patients’ complaints about certain generics. In 2012, The People’s Pharmacy notified the FDA about hundreds of patients who registered complaints about side effects of the generic Wellbutrin 300mg XL. According to the Forbes article, A Drug Recall That Should Frighten Us All About The FDA, “The FDA brushed off The People’s Pharmacy and others that raised the issue,” and suggested that people who had a mental disease were more prone to perceived problems with a change in medication than others.

In a 2009 report, the FDA revealed that the generic Wellbutrin 300mg XL had never undergone bioequivalence testing but based on the 150mg tests, it had approved the 300mg version. The FDA recalled the generic Wellbutrin 300mg XL medication in October of 2012.

At least 40 percent of generics are made overseas and 80 percent of the active ingredients in those drugs come from foreign plants. In 2009 the FDA inspected only 11 percent of the more than 3,700 foreign facilities where drugs and active ingredients are made for the U.S. market, according to a 2010 report to Congress from the Government Accountability Office. See link here

It would appear that the U.S., at present, has little control over the generics it imports. Even as of today, the FDA’s website still states, “A generic drug is identical-or bioequivalent-to a brand name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use.”

But we don’t really know that, do we?

Thank goodness for The People’s Pharmacy and others like it that take patients’ complaints seriously. Not all pharmacies do.

Case in point—a pharmacist recently told me that the breathing problems I experienced while taking a generic drug, were psychosomatic. Yes, he actually said that. This was after I’d tested the drug several times (several days on it, several days off, then repeat and repeat.) I suspect that my side effects were a result of the inactive ingredients in the generic drug. The inactive ingredients in generic drugs are not required to be the same as brand medications.

To compound the problem, The Supreme Court ruled in 2013 that makers of generic drugs could not be sued under state law for adverse reactions to their products. Makers of brand medications can be liable for inadequacies in safety warnings. This is a major loophole for pharmaceutical companies since generics are not consistently tested for efficacy and impurities. See Washington Post article here 

The FDA’s new generic drug testing program will run through 2017 and will focus on heart drugs, ADHD treatments, immunosuppressants, anti-seizure medicines, and antidepressants.

That’s a long time to wait. What are patients to do until then?

Tips for patients who experience problems with certain generic medications:

 1. If you have undesired side effects from a generic drug or suspect that it isn’t working, report it to your doctor, pharmacist and to the FDA’s MedWatch website. 

2. Ask your pharmacist or provider to switch you to a different generic.

3. Ask your doctor to do a pre-authorization for the brand form of the prescribed medication. No guarantees that your health insurance will approve it, but it’s worth a try.

4. Pay attention to your body and any symptoms if you have started a new medication. You might try creating a journal/diary of symptoms and log in the side effects, day and time, so you have a complete grasp of the problem.

5. Speak up.

More information on this topic:

Dirty Medicine, CNN Money 

Medicines Made in India Set Off Safety Worries, The New York Times 

Generic-Drug Testing Goes Widespread in U.S. FDA Effort, Bloomberg News

FDA Chief to Focus on Generics’ Safety on Visit to India, Bloomberg News

 

I welcome your comments!

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The first time our health insurance plan was cancelled was in 2012. Anthem Blue Cross stated in a letter that our 15-year-old plan was “being phased out.” We were offered another plan, which dropped our premiums a bit but increased our out-of-pocket costs.

A year later, I was shocked when we received a letter from Anthem informing us that our newer plan was cancelled because it was not in accordance with the ACA. I dove into the Covered California website and searched for new plans. Anthem no longer offered health insurance plans that included any of our doctors or the hospital in our area. Neither did the other insurers.

What was going on? I thought Health Care Reform was supposed to increase patients’ access to care, not deny it.

I did some research. I found out that my family and I were in the Doughnut Hole of subscribers. My husband and I are self-employed and purchase individual coverage for ourselves and our daughter. I discovered that for the self-employed, health insurers are limiting doctors and hospitals on their plans to control costs. 

But then I uncovered something else. We might have had the option of keeping our 15-year-old policy that we’d had with Anthem if it were a Grandfathered Plan and if we’d had it since 2010. Wait a minute–our 15-year-old plan had been cancelled in 2012 and we’d only had our new plan for a year. Was our original plan cancelled intentionally?

Covered California didn’t offer much to us as individual purchasers of health insurance. Every single one of the plans increased our premiums and denied access to our doctors, including our primary care physician (PCP.) Blue Shield offered one plan with coverage of a hospital near our home but none of our doctors were affiliated with it. Why buy a health insurance plan that covers a hospital if your doctor doesn’t have privileges there? I wouldn’t. And neither should you. If your doctor is not affiliated with a hospital, he/she cannot take care of you there.

Eventually, I found a plan through another health insurance company that covered our PCP and our local hospital. But our new policy premiums increased over $350 a month. Ouch. Not only that but all brand medications are denied by this plan. Not covered at all, not even a portion? I’ve been taking brand Synthroid for a thyroid condition for over 25 years. My doctor wants me to stay on brand Synthroid for a reason as many doctors do with that medication. In addition, our daughter has been taking a medication for two years that does not come in generic. In the past I’d been able to reduce the cost of her medication by obtaining a discount coupon off of the drug company’s website coupled with the portion our old health insurance plan contributed.

The process of obtaining pre-authorizations for the brand of both my Synthroid and our daughter’s medication was maddening. I spent hours going back and forth between the pharmacy, doctors’ offices, and the new health insurance company because everyone had a different belief about how pre-authorizations for medications were handled. I was then informed by the pharmacy that our cost for both medications had increased. This is what we get for increased monthly premiums? I can just imagine what’s going to happen if one us is in need of emergency medical treatment and our health insurance company steps in.

Many physicians I’d interviewed for my latest book, The Take-Charge Patient, expressed a lot of frustration with health insurance companies denying treatments they’d prescribed for their patients. Most were incensed by non-medical providers interfering with treatments doctors were trained to prescribe. Some even said that health insurance companies were now dictating medical care.

Now I was dealing with this mess first hand.

My family and I are lucky—we don’t have serious illnesses or medical conditions. But consider the cancer patient in California who had been treated for stage 4 cancer and her health insurance plan was cancelled. She couldn’t find a new plan to cover the doctors who were keeping her alive.

The financial ding of health insurance doesn’t just hit individuals. According to Kaiser Health News, employers are now shifting health costs to employees, forcing them to pay more, which in essence, boils down to a pay cut. 

But wait, there’s more. According to the article in Forbes, It’s Fact, Not Anecdote, That ObamaCare is Turning Us Into a Part-Time Nation, companies all over the country are firing full time employees in favor of part time workers because they cannot afford to provide their employees with health insurance. One restaurant’s solution to this problem is to pass on the costs of providing health insurance for employees to its customers as in a percentage of the bill. At least with restaurants, we have a choice about whether to frequent them or not. 

I don’t have great answers to the challenges with the ACA for individuals and employees, but I can offer some basic tips to become better informed. The deadline for open enrollment ends March 31, 2014. If you don’t already have health insurance, better get moving.

5 tips to become better informed about your health insurance options:

1.When choosing a health care plan, ask which medical services and products the plan covers and does not cover. Ask about the deductible, co-pay, any co-insurance and other out-of- pocket expenses. You don’t want to be surprised by an unexpected medical bill. Ask questions. 

2. Find out if your doctors or hospital of choice are covered by the health insurance plan you are considering. 

3. See in-network providers. Ask each doctor, nurse, hospital, or other medical facility, if they take your health insurance plan. This includes anesthesiologists. If you need anesthesia for a procedure or surgery, ask ahead of time if they take your insurance. I’ve heard sad stories from many patients who were admitted into the hospital that was covered by their plan, only to find out later that the anesthesiologist’s fee was not covered. Ask questions.

4. Review your Explanation of Benefits (EOBs). There can be errors that affect your out-of-pocket costs.

5. Call the customer service phone number on your health insurance card or from their website and ask questions.

Become informed. That’s the only way to make better choices for you and your family.

 

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Part of being a take-charge patient is preparing ahead of time, becoming informed so you can make wise choices, and participating in your health care. This includes end-of-life wishes. You may not want to think about this, and not many of us do, but it’s so necessary to take steps to prevent what happens to  many people in our health care system. They end up receiving care they didn’t want, didn’t anticipate, and endure prolonged suffering because of it. Not to mention the family members who are put in a position of making medical decisions in conjunction with the patient’s physician if  advance care planning documents are not in place.

Advance care planning is the most loving gift you could give to yourself and to your loved ones. I’ve completed these documents myself and have discussed my wishes with my family. Why? Because I don’t want decisions made for me if I am not able to be part of the conversation. This is my way of creating an insurance policy to avoid what I witnessed with my 82-year-old uncle, and years ago with my mother, my godmother, and countless others.

The purpose of health directives is to allow you to express your preferences concerning medical treatment in an extreme medical situation, such as when you cannot communicate or at end of life. Terminally ill patients often receive aggressive medical treatment in the hospital that can lead to needless suffering. See article here http://www.cbsnews.com/news/end-of-life-care-for-elderly-often-too-aggressive-study-says/.

It’s very important to discuss the following with your doctor and loved ones. Communication is key—the more your loved ones and doctor know, the easier it is for them to fulfill your wishes. Create the necessary legal documents once you are clear on what you want. Whether you want everything done to sustain your life or very little, spell it out and have a conversation with your doctor and loved ones.

Legal Documents To Create

Health Care Advance Directive: any legal document that gives instructions about your health care or appoints someone to make medical treatment decisions for you if you cannot make them for yourself.

Durable Power of Attorney: (also known as health care proxy) this legal document gives another person the legal authority to make health care decisions on your behalf if you are unable to. This person should make decisions for you as you would. Make sure that she/he is willing to be your agent and  lives close to you. Don’t choose your doctor, employee, or anyone who professionally evaluates your capacity to make decisions. Naming a health care proxy does not take away your authority. You always have the right, if you are competent, to override the decision of your proxy or to revoke your directive.

Living Will: this states your wishes about life sustaining medical treatment if you are terminally ill, permanently unconscious, or in the end stage of a fatal illness. You’ll want to ask yourself if you are comfortable with artificial feeding, mechanical ventilators, resuscitation, defibrillation, dialysis and pain management. If you do not create these documents and have not appointed a surrogate decision maker, your doctors, hospital staff and loved ones will do the best they can for you.

As a take-charge patient, wouldn’t you rather ensure that your wishes are honored at the end of life instead of leaving them up to chance? Be sure that any document you sign is consistent with your beliefs and wishes. Remember, you can change your mind at any time about any end-of-life decisions you make. Be sure a responsible adult knows where you keep your health care directive documents and provide a copy to your regular doctor. Take the documents with you if you are admitted to a hospital.

Review your wishes every year or any time your health or family status changes.

Guides and Resources to Help You

For more information, please visit www.thetakechargepatient.com

 

 

 

 

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