The other week I walked into a patient room. I put all my stuff (computer, pen, otoscope and ophthalmoscope) down and washed my hands. In this case, using a hand gel. I then introduced myself and shook hands with my patient. Then the patient then said the craziest thing — “Why don’t you make patients wash their hands?”.  I was at a loss for words. The patient expounded, that if we as patients expect you as Doctors to wash your hands, why don’t you expect us to wash our hands. We are just as “dirty” as you are and we’re the reason that you will get sick and others will get sick. Wow! I didn’t really know what to say except “Good point” and I passed the patient the hand gel. We had a good laugh and then went to work.

This anecdote brings up a very good point and a very difficult point. Physician hands certainly can spread alot of germs and appropriate hand washing will certainly reduce that spread. This is just good ole common sense — grandma was pretty darn smart ID Doc. But we are only addressing half the vectors. Patients don’t wash their hands when they come into the office. How many germs are they bringing in and leaving behind? What kind of pathogens are they leaving behind on my hands after I shake their hand? Are we missing an opportunity to reduce the spread of MRSA, C diff and other pathogens that are floating around in the community.

Asking patients to wash their hands would be very tricky. I remember years ago, in Med School or residency, when a patient complained that another colleague didn’t want to touch them because of the rash they had. The patient was very offended that the staff (and I can’t remember if this was a med student, nurse, resident or who it was) implied that they sick and potentially infectious. They felt like they were not being treated like a human being. These are very good and valid points. Healthcare is about relationships and touch is a very important part of establishing a human relationship. Touch is a powerful healer. But what is that patient was carrying MRSA, Cdiff or other highly infectious agent on their skin? Is it right for patients to assume that physicians must risk their health in order to care for the patient? Is it acceptable for a uninfected physician to now become colonized with a pathogen and then become the vector that infects others ?

Difficult questions and scenarios. But it is interesting to think about. Why is it assumed that Doctors have dirty hands and not patients? Think about that the next time you shake a patients hand.

Why do Doctor’s always have to do something to a patient? What does that mean? Aren’t Doctors suppose to “treat” patients? Aren’t Doctors suppose to do something? Prescribe a pill?, Order a CT scan?, Draw lab work?  There seems to be have developed, an expectation over the past few years, that physicians must do something: order the newest test, use the newest medication, utilize the latest high tech surgical tool. Obviously newer is better. Or is it?  Part of this belief that newer is better is ingrained in physician training and what the expectation of treatment is:  we see a patient, make a diagnosis and then we must order a test, prescribe a medication, do a procedure.  We must do something or we are a bad Doctor. Compounding this issue is that throughout training physicians are taught all the latest innovations. One becomes a “superstar” in training by quoting the latest research paper, utilizing the latest lab test or newest medication to treat a patient. The perception is the doing something is always better and the best physicians are always adopting the latest medication or technology first. But is this the best approach to medical care?

Healthcare organizations are just are culpable for perpetuating this myth. How many times have you seen ads that tout we are the first to offer fill in the blank technology? We are the only organization in the area that has fill in the blank technology? These ads are very effective. The goal is to “get” more patients to come to the sponsor of the advertisement. The problem as highlighted above is that all this new technology may not improve healthcare. The sad fact is that advertising that “Our Doctors and our organization will do less to improve your health and reduce your healthcare costs” does not advertise well.

Patients also have a role to play.  Patients will often say to their physicians something to the effect of “are there any new medications or procedures out there for treatment”.  Or patients will have the expectation, that a physician who offers the “newest cutting edge treatment” or the institution that offer the “latest surgical approach” are the “best” and have the best outcomes.  Using a generic pill that costs pennies to treat hypertension must not be as good as the latest blood pressure pill that the insurance company will not cover. No longer does it seem acceptable to adopt a “watch and wait” approach.  Nor does it seem acceptable not to perform any testing or procedure if they are not warranted. Patients want more testing, more medications more more more. But there is very little thought given to the concept that less is better, older cheap medications may work just as well and the newer and more expensive medicine or technologic breakthrough does not necessarily mean better health or cheaper costs. Given the current state of healthcare in the US, this is a very troubling development.

This problem is not something new. It has been around for years. But given the limited resources that are available for healthcare and the economic realities of today it has become more pointed. The question that needs to be asked, is what is going to improve a patients health, societies health and reduce healthcare costs. Physicians need to understand and adopt not what is the latest and greatest but what is the most effective and most cost effective treatment for their patients. Healthcare organizations need to ask what is going to improve the healthcare of their community not what is the slickest ad, about the latest technology, that can be run to improve the bottom line. Patients need to understand that doing nothing is sometimes better than doing something, newer is not always better and more expensive does not mean better outcomes or better care.

(As a footnote, this article was published just as I finished this blog http://www.ama-assn.org/amednews/2012/07/30/prse0801.htm )

“Excuse me”.

She repeated ” An orange.”

“Yeah, that’s pretty funny.  Seriously how did she get more comfortable with her epi”, I replied.

After a few minutes of staring and smiling at me — I think she enjoyed having stumped me — she relayed her story. Her daughter, a teenager, never felt comfortable if she had to ever use her epi. She had been taught the right things by her Doctor. She had an epinephrine trainer. She knew how to remove the cap, inject herself in her outer thigh, count to ten and then call 911. She knew when to use her epinephrine as well. But she was still afraid if it ever came time to use her injectable epinephrine she would not be able to inject herself.

Then one day, my colleagues daughter decided to use her injectable epinephrine — despite not have any symptoms of food allergy and anaphylaxis.

“Tell me she didn’t just inject herself for kicks”, I chimed in.

Well, I must have had an interesting look on my face as, my colleague, just starred at me. Now I have known her for a long time and I thought she was just messing with me and having some fun — at my expense. But I also knew she, from past experience, she usually has some good ideas and comments.

“She used an orange” my colleague casually throws out there.

“Really”.

“Yup, she used her expired injectable epinephrine on an orange”. She explained, her daughter was always afraid that the real epinephrine would be more difficult to use than the trainer. Once she used her expired injectable epinephrine on a orange she realized that the it really was not that difficult and now she has no fear or worries about using her injectable epinephrine.

Well this idea, use your expired injectable epinephrine on an orange,  just became apart of my injectable epinephrine education program.

Don’t you hate it when teenagers teach us lessons!

Let’s review some basics about food allergy management. Now this all assumes that one has been properly evaluated and diagnosed as having a food allergy.

1.Know what you are allergic to.

2.Read labels and understand what you are eating.

3.Make sure others know what you are allergic to. Don’t accept or eat any food if you are not 100% sure of the                                                           ingredients. 99.999% is not good enough — if you are not sure don’t eat it. Remember food allergy can kill!

4. If you are going to a party or some other function and you are not sure of the foods that will be there, bring your own food.

5.Have an Anaphylaxis Treatment Plan. Know what do in the event of an exposure to your food allergen or if you develop allergy symptoms even if you don’t think there was an exposure to your food allergen. Treat yourself first then figure out what the exposure was later.

6.Always have your injectable epinephrine with you. Remember, if you have an exposure to your food allergen and develop allergy symptoms the treatment of anaphylaxis is use your epinephrine. Benadryl, albuterol and  other medicines can be helpful to treat your symptoms after you use epinephrine.

7.If you use your epinephrine, call 911. Food allergy reactions and anaphylaxis are life threatening reactions and require emergent care, evaluation and treatment. Epinephrine can be life saving but even with the prompt administration of epinephrine and calling 911 there can still be bad outcomes.

If you have questions about your medical condition or the medication(s) you are taking speak with your physician.  Always remember, your physicians ethical and professional responsibility is to take care of you!

Below is a summary of a presentation on Pork – Cat Syndrome by Jonathon Posthumus, MD, an allergy fellow at the University of Virginia, presented at the 51st Annual Swineford Meeting held at the University of Virginia April 2012.

Pork – cat syndrome was first reported in France, by Drouet et al,  in pt with FDEIA after eating pork. RAST inhibition confirmed shared allergen identified as albumin (67kD) with further characterization revealing that the cross reactivity between cat dander and pork meat are due to shared epitopes on albumin. In European literature, Pork – Cat syndrome symptoms are typically immediate in onset ( OAS, FDEIA and fatal anaphylaxis) with specific IgE to cat epithelium, cat serum albumin and pork meat. Symptoms may be inconsistent and related to co factors such as exercise, alcohol ingestion and dose.

Patients are exposed to animal serum albumins in potentially three way: inhalation, ingestion and dermal exposure. For inhalation, house dust contains high levels of cat albumin, even more than Fel d 1. For ingestion, pork, beef and lamb contain large amounts of albumin. As dermal exposure, children with AD have higher incidence of beef allergy.

IgE cross reactivity against albumins in pt allergic to animals. 200 subjects allergic to animal dander. 30% had specific IgE for various species albumin. Most had high level of cross reactivity between cat, dog and horse. A few albumin sensitized patients demonstrated IgE highly specific for one species.

UVa study to determine specificity of IgE to serum albumin studies. IgE adsorption studies done with porcine, canine, feline and human serum albumin. Sera of 3 patient with cat – pork syndrome used. Studies revealed that IgE to pork meat and porcine serum albumin was completely bound by cat serum albumin. In addition, IgE to cat serum albumin was not completely adsorbed by porcine nor dog serum albumin. All suggesting that sensitization to cat serum albumin is primary event.

Further UVa studies looked at epidemiology of sensitization to cat cat serum albumin in birth cohort of 200 US children and 963 subject from Sweden. Of the 200 US subjects: 31% sensitized to mite, 8% to egg and 3% to cat serum albumin. Of the 963 in Swedish cohort: 242 had IgE to cat epithelium and of those 215 screened for cat serum albumin with 25 being positive for a prevalence of 3%.

Conclusions:

Pt with immediate reactivity to mammalian meats may have IgE to cat and dog albumins.

The structure of albumin is highly conserved through mammalian species which likely accounts for cross reactivity between pork and other meats.

UVa adsorption data suggests that primary sensitization in these cases is feline and/or canine serum albumin rather than pork serum albumin.

Some other clinical pearls:

Cat serum albumin: Fel d 2

Dog serum albumin: Can f 3

In the presentation of three patients clinical history, one patient they used a milk challenge as a surrogate for albumin as milk is very high in albumin. Pt had OAs and urticaria from the milk challenge.

References:

Drouet et al Allerg Immunolog 1994;Oct 26(6) 305-6

Drouet et al Allerg Immunolog 1994; 166-68

Spitzeuer et al JACI 1995;96:951-9

Drouet et al Allerg Immunolog 2001; Apr 33(4):163-5

The focus of healthcare has now changed, in a very dramatic way, from caring for patients to measuring healthcare metrics that may or may not benefit patients. This is a very dangerous change. Doctors are no longer giving aspirin to heart attack patients because it is good care,  we are giving aspirin to heart attack patients because some administrator some where has decided that this metric must be measured and if not followed there will be a financial penalty. So much for caring for patients, we now care about heath care metrics.

This mindset, that quality metrics will improve healthcare,  has insiduously infiltrated medical care and is irreparably harming the physician – patient relationship. Top notch medical care traditionally has required physicians to do what is best for their patient.  Top notched medical care now requires the physician to understand what metrics are being measured – did you give the right medicine? did you give it at the right time? did the patient give you a good evaluation? did you document that you gave the right medicine at the right time? are you communicating appropriately with the patient? do they understand all the complex decision you are making in order to help them? Do the patients like the bed they are sleeping  in? Is the hospital food good? and oh by the way how is your patient doing. I am not sure I can care for my patient and at the same time care about my metrics.

The continued erosion of the patient – physician relationship with the insertion of insurers, administrators, quality metrics analysts and the myriad of others is having a direct negative impact on healthcare. Medicine has become a business focused venture that measures outcomes and metrics. As highlighted by Ryan et al in a recent Health Affairs article ( Health Affairs 31, NO. 3 (2012): 585–592) Medicare’s public reporting on quality measures has had a minimal impact on patient mortality. In fact, there was no improvement in mortality rate for heart attack and pneumonia and only a slight improvement for heart failure this, despite the institution of public reporting of quality metrics. So much for quality metrics improving health care and saving lives.

Physicians must change this paradigm. To continue to go down this road and adopt policies that clearly do not improve healthcare is idiotic. Physicians must stop being sheep and start being the leaders, the true leaders,  in health care for our patients. Physicians must challenge the current, in vogue, healthcare reform paradigm. The health care reform experiments of the past 40 years have clearly been ineffective – and there is no indication that the latest iteration of health care reform will do any better.  Will challenging this paradigm du jour be difficult and challenging? You bet it will. But I  for one would prefer to work to develop healthcare reform measures that actually improve improve patient care and save lives. What do you want to do?

This story raises some concerns and questions. First off, as described this was not a delayed reaction to peanut allergy. This child has a known exposure to a known allergen and “Max said he knew there was trouble when after just a penny-sized bite, his tongue started itching.” Then over the course of the next thirty plus minutes his symptoms progressed to severe anaphylaxis. Anaphylaxis is an immediate reactions to an allergen that can progress over time. This is exactly what was described in this article – the child had a known exposure to a known allergen developed symptoms immediately that progressed to more severe symptoms over the course of at least 30 minutes. This was not a delayed reaction to peanut exposure this was classic anaphylaxis.

Second, it does not appear from the article that this child ever received epinephrine for his symptoms. After he had the peanut exposure the school called his parents and he was taken to the emergency department. No where was it noted that he received epinephrine. Furthermore, according to the author of the article, “The boy complained of a stomachache but was talking and breathing comfortably. After 30 minutes in the emergency room, the child broke out in hives and his throat was tightening.” Subsequently more symptoms developed and he become very ill and came close to death. The statements as reported above, suggest that this child with a known peanut allergy and asthma may have gone as long as 30 minutes without receiving epinephrine despite progressive symptoms.

There are several lessons to be learned from this article as reported:

1) peanut allergy can be quite severe and life threatening; 2) an asthmatic with peanut allergy and known exposure to peanut and develops symptoms should be treated with epinephrine immediately; 3) delay in treatment of peanut allergic individual will result in progressive symptoms that will be more challenging to treat;  4) asthmatics with peanut allergy are at risk for more severe reactions when exposed to peanuts and 5) schools need to have good guidelines for treating asthmatic peanut allergic children who are exposed to peanuts – not just calling the parents.

Peanut allergy is a serious disease. Peanut allergy patients with asthma are at particularly increased risk for serious reactions to peanut exposure. Prompt recognition of symptoms and aggressive use of epinephrine is required to treat these patients. Are you prepared?

Now there are alot of unknowns in this case — I freely admit this. But what is very concerning is that the consultant seemed to completely discredit the role of the outside physician. The outside physician could have very easily and quickly answered the question that was posed. ( It was a very easy question for an allergist to answer just an FYI). Instead, the patient will now probably have to see another physician at the healthcare system at significant cost. Does not seem to me that this was the most judicious use of dollars.

As physicians, we can all relate to this scenario. Undoubtedly, we all have anecdotes that we can share that are similar. What is more concerning is the anecdotes that we don’t know about – i.e. those patients who are referred to another physician by a colleague and are left with the impression that you did not know what you were doing. All of us can relate to the patients we send to the large medical – industry referral center to never see the patient again.

It makes me wonder with the advent of local or regional medical – industry complexes how much savings will be done? If a patient has the “nerve” to see physicians who are in different medical systems, how much care will be repeated? How much information will be shared? We have reached our benchmarks for this patient and this disease so we are not sharing the information? How much do the physician corporate medicine executives really care about patient care? Or do they really care more about the system and the bottom line?

Time will tell with all these changes, but one thing is certain, patients will be the guinea pigs and they won’t even know it!

Let’s take a step back and review health care insurance. Every month an employer and the employee pay certain amount of money for an individuals healthcare – this is the premium that is paid for the insurance.  Those monthly fees can be several hundred to several thousands dollars a month depending upon the policy ( single, family, deductibles, formulary etc). In general, one’s employer pays the bulk of the monthly premium as a benefit of employment and the employee parts the rest as a pre tax deduction on their paycheck. Based upon the plan chosen, the insured may have a deductible and /or copays for various covered services ( Doctors visits, labs, xrays, hospital stays etc). These deductibles / copays are generally some fraction of the total cost of the visit.

What is readily apparent is that health care premiums are increasing associated with increased copays for the service for which the health insurance is purchased. The result is the insurer is making your cost for your healthcare, which you and your employer already paid for, more expensive for you. All with the justification that the higher copays keep premiums keeper — yet every year the cost of premiums continue to increase. The result of which is, because these copays are so high, you choose not to seek the care you need, the insurer does not have to pay for services you did not seek and keeps more of the money that you and your employer already paid for insurance. In essence the insurers collected thousands if not tens of thousands dollars for premiums and because you can’t afford the copays your can’t seek medical care — which is exactly why you have purchased health care insurance. Think of it this way, you  paid money to go to a gym but the gym charges you more money at the door to get in. What happens, you don’t go to the gym, the gym keeps your money and does not deliver the benefit of using the gym. Who wins… the gym they get all your money and don’t have to provide you a service. This is absolutely crazy but exactly what is happening in healthcare today. You purchase health insurance to help cover your health care cost but because the insurers demand higher copays you don’t seek medical so the insurers keep all your premiums dollars and you get no health care.

Can I fix this here and now? No. I have too many common sense ideas that the politicians and insurers would never consider. But I do have some ideas that you need to consider to keep your allergic disease under control and for you to be healthy.

1. Keep your regular scheduled appointments – I can do a better job keeping your allergic symptoms under control when the are under control. I can devise plan that you can implement at home to deal with flares of your disease.
2. Ask for samples. I can’t believe I just wrote that! I am generally not a big fan of the intense marketing that PHARMA utilizes. I am however a big fan of free. Think of samples as free money. If we can provide some samples of medication, you won’t have to buy the medicine, consequently you won’t have a copays for that medication.

1. Use Coupons – Our website has a link for coupons that exist for various allergy medications. USE THEM!!!!!!!  There is a show on tv called “Extreme Couponing” where individuals will go food shopping and almost pay nothing because of all the coupons they have. Do the same for your medications. If you are taking three medications a month and you can find coupons for $10-$20 off thats $120 – $240 or potentially more a year in savings. Once again, free money

1. Tell us there is problem. If you are having problems paying your Doctors bills most physicians are more than will to help you out. But you have to talk to us so we know what is going on. Understand that federal laws and contractual obligations with your insurers may will limit what we can do.

The practice of Medicine is rapidly changing. It is not the same as it was 20, 15, 10, or 1 year ago. There are a myriad of forces that are working to forever alter the practice of medicine. The physician – patient relationship is in critical condition. In my mind, the physician – patient relationship is the most important part of your healthcare, without this there is no practice of medicine and no one to really care for you – the patient.  Several weeks ago I was at a medical society meeting and a politician was speaking. This person had a family member who was very ill and close to death. It was only through the excellent physician care that the patient survived and is doing better. This politician, who has not been a friend of physicians in the political arena had an epiphany. They realized that at three o’clock in the morning the patient needed their Doctor. Not their lawyer. Not their insurance company. Not their pharmaceutical company. Their Doctor!

I am not going to solve this complex problem in a few paragraphs, but I hope the above offers you the insight that we care about you and your health and preserving the physician – patient relationship. If WE don’t do this, no one will!

I want to be very clear on this first point — anaphylaxis kills! Let me repeat that, anaphylaxis can kill a person. Anaphylaxis is a true medical emergency that requires an immediate and swift response – i.e. the use of one’s auto injectable epinephrine. The literature has become very clear over the past few years on this topic: those that don’t use or wait to use their epinephrine potentially do not have good clinical outcomes; conversely, those who use their injectable epinephrine at the first signs of anaphylaxis generally do much better.

Epinephrine is THE LIFE SAVING DRUG to be used to treat patients with anaphylaxis. It is the drug that treats the underling pathophysiology of anaphylaxis. It is the drug that can potentially save your life. No other medication, oral antihistamines, bronchodilator medications or steroids, has been shown to save lives in anaphylaxis. These (antihistamines, bronchodilators or steroids) medications are important secondary medications that can potentially be used in patients experiencing anaphylaxis. My clinical experience and review of case reports in the literature invariably has revealed that the vast majority of those who have complicated courses or die from anaphylaxis either never were treated with epinephrine or did not receive epinephrine promptly. Sadly, there are those who do treat themselves promptly with auto injectable epinephrine and seek immediate care who will still die.

Anaphylaxis is a very serious medical condition. I do not want patients paralyzed by fear because they have anaphylaxis. Nor do I want them paralyzed with anxiety about using epinephrine during an episode of anaphylaxis. The potential risk of a bad outcome in anaphylaxis when epinephrine is not used or used too long after the reaction started far exceeds the risk of a bad outcome from using epinephrine promptly during an episode of anaphylaxis. So please, if you or your child is experiencing anaphylaxis, do not hesitate use auto injectable epinephrine and call 911.

If your or a loved one are concerned about anaphylaxis, the symptoms of anaphylaxis, how to treat anaphylaxis or worried about using auto injectable epinephrine, talk with your physician. Don’t wait until it is too late.