From The President

Much has changed over the past decade, since the advent of PPS. Many nursing homes have gone from long term care facilities to a focus on short term rehabilitation. The patients are more complicated, and the expectations have never been higher. Fortunately, our facilities, providers, and medical directors have been spending the same period improving upon processes and their expertise in the providing of care. While we have made great strides in improving the care and patient experience, we still have great challenges ahead of us.

From the standpoint of patient care, we will never be able to rest on our laurels. We must continue to increase our knowledge base and put what we learn to use for the benefit of our patients/residents. This is what is not only expected of us, but it is in the best interest of all involved.  Through the ongoing process of quality assurance, we must also continually examine our performance and implement whatever we can devise to provide the best possible care.

Who is going to provide the care in our facilities over the next decade? While the number of geriatricians declines, the demand for our services marches on. While the government and others try to figure out what they can do to change this worrisome trend, we must do our part to make the continuum of care a place that providers of all levels will wish to practice. Examination of satisfaction surveys tells us that if we wish our patients and their families to be satisfied with the care, we need to take care of the workers and their environment. Physicians, nurse practitioners, and physician assistants must be willing to do their part in education of staff, residents, families, and other providers. We must lead by example, and do our part to make our profession self sustaining.

Not only must we do what we can to learn and teach ourselves how to perform the best possible care, but we must also encourage others to join us in this endeavor. We must educate students of all levels as to the need and rewards of caring for those who come to our buildings and organizations.  We all need to do our part to dispel myth, and demonstrate that what we do does matter. We need to teach that there is great benefit to treating those that we cannot cure and that maximizing function and/or minimizing symptoms is not only greatly needed, but greatly appreciated.

I wish all providers to put as much of their minds and hearts into their work as possible. I ask that we park arrogance at the door when we enter one of our buildings. Please consider that while we know a great deal, ourselves and others will benefit from our knowing more. We care for frail individuals who will all meet the same fate at some point, as we will ourselves. I ask that you keep this in mind, and put yourselves in your patient’s place at the time of each interaction, and ask yourself, “what can I do for this person today?” and “what would I want if I was in their place?” Please give them a smile, and do what you can do help them smile. Please show your respect and appreciation to the staff, as that goes a long way to help them come to work again tomorrow. Know that you are appreciated, and that what you do really does make a difference. 

My final wish is that you join us in Charlotte for both the fall meeting of the Carolina Medical Directors Association, as well as for the annual AMDA symposium in March of 2009. Please encourage other providers, administrators, pharmacists, and nurses, to take advantage of the tremendous amount of information and experience that will be shared. Please also come for the camaraderie, as our profession can only function optimally as an interdisciplinary team made up of some pretty special people. I hope to see you there.

Respectfully,

Christopher Patterson MD CMD

Featured Article

Inhaled Lasix

by Chris Patterson, MD, CMD

                After years of reading about and using nebulized furosemide, I have developed the theory that furosemide via the inhaled route may decrease dyspnea by selectively vasodilating the capillaries in the best ventilated areas of the lungs, thereby reducing V/Q mismatch. I also believe that this may also be the mechanism by which nebulized morphine sometimes helps, as they are both vasodilators at a micro vascular level. The benefits of using furosemide over morphine include lack of sedation, lack of diversion risk, and the lack of need for a hard script.

                While not every patient with dyspnea benefits, my anecdotal experience has been a response rate of about 75% in the 50 or so cases where I have prescribed or recommended it. Since it is both inexpensive and well tolerated, I often find that it is worth a trial for a week or even a few days.  I plan to write up a case where a patient improved so much that he became ineligible for hospice and had to be discharged. That patient cut down his need for albuterol to one third while greatly improving his exercise tolerance.  Since dyspnea is a subjective symptom, I let patients tell me if they feel it has helped, but it is not unusual to be able to measure an improvement in their functional capacity as well.

                Since dyspnea is a complex symptom, I find that it may hard at this point to predict who will respond and who won't. Given this lack of predictability, I have found it most useful to consider a trial of 20mg in 2 –3 cc saline q 6 hours for a week in patients who are unable to get sufficient palliation with the use of more conventional treatments.

REFERENCES

The following excellent references regarding inhaled Furosemide for dyspnea are available on our web site:

www.CarolinasMDA.com

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