Treating Opioid Use Disorder in the Hospital: A Trauma Informed Approach (Strickland, 11/17/2021)

Many thanks to Dr. Tiffani Strickland, who gave an action packed Grand Rounds this week on Treating Opioid Use Disorder in the Hospital. She covered a ton of ground on this important topic-- from opioid use trends to adverse child experiences to trauma informed care to  micro-dosing of buprenorphine in the hospital.

To see a full recording of Dr. Strickland's excellent presentation click HERE.

My notes:

  • Overdose deaths from opioids are off the charts and continue to increase in the US and in our own Sonoma County (see graphs below, including local data)
  • If you only have 5 minutes, watch this video about our current understanding of addiction and social isolation: "Everything you know about addiction is wrong". It challenges our traditional framework for addiction and substance use disorder.
  • Also consider reading this book: Chasing the Scream (by Johann Hari)
SoCo DPH opioid overdose rates (Death and ED visits)

Racism and the opioid epidemic
  • Despite similar rates of drug use, Black Americans (who make up 13% of the population) make up 27% of drug arrests (2018)
  • Disparities in incarceration have affected generations of communities of color
  • African American and Hispanic Americans are 7.5 and 2.3 times more likely to have an incarcerated parent (than white children)
    • having an incarcerated parent puts children at increased risk for future substance use
Adverse Childhood Events (ACES)
We know that ACES (childhood abuse, neglect and household dysfunction)are associated with risk for substance use disorder. I.e. the more ACES you have, the higher risk you have to have issues with substances, including IVDU.

Trauma Informed Care
  • It is our job to care for patients with a hx of trauma by influencing healthy coping mechanisms and helping patients build resiliency
  • The Substance Abuse and Mental Health Service Administration (SAMSHA) decribes 6 principles of a trauma-informed approach. These are SO important to consider in how to engage with all patients, but particularly those with high ACE scores
    1. Safety
    2. Trustworthiness and transparency
    3. Peer support
    4. Collaboration and mutuality
    5. Empowerment, voice and control
    6. Cultural, historical and gender issues
  • Again, providers should consider how to help patients focus on RESILIENCE and COPING
  • Examples of how to do this include
    • Openly discussing harm reduction methods (prevent dying and suffering)
    • Person first language, welcoming, non-discriminatory, non stigmatizing language
      • i.e. person with substance use disorder, person in recovery
      • i.e. avoid "clean" and "dirty" when talking about drug screen results
    • Put up signage offering treatment for opioid use disorder in hospitals and clinics
Words Matter! Check out these tables to make sure that you are using language that is non-stigmatizing.

https://www.drugabuse.gov/sites/default/files/nidamed_wordsmatter3_508.pdf 


Treatment of acute pain and management of withdrawal 
  • If a patient is on BUP, don't STOP it when treating acute pain
    • patients can safely get acute pain meds on top of their BUP
    • you will only precipitate withdrawal at initiation of BUP
    • split dosing to BID for pain management in the acute setting
    • provide sense of calm and comfort (help patient feel safe and connected)
  • Also, schedule tylenol and/or ibuprofen (or toradol) in setting of acute pain
  • consider gabapentinoids, SSRI, TCA, regional block
  • can increase up to 32 mg/day for acute pain
    • add opioids with higher Mu affinity: morphine, hydromorphone, fentanyl
Buprenorphine (BUP) inductions in the hospital (simplified from CA Bridge: https://cabridge.org/tools/resources).
  • Very simple! For uncomplicated withdrawal (COWS>8), start with 8mg BUP SL, recheck in 1 hour, give second dose of 8mg
  • Subsequent days, titrate from 16mg with additional 4-8mg prn cravings
  • Labs to consider (but don't need results to start): UDOA, CBC, HIV, HCV, RPR, HCG, HAV and HBV immunity
  • Adjunctive medications: acetaminophen (pain, headache), clonidine (w/d symptoms), diphenhydramine (anxiety), loperamide (diarrhea), ondansetron (n/v), trazodone, melatonin (sleep)


Microdose inductions of BUP
  • Very slow start of BUP to decrease or even eliminate withdrawal symptoms 
  • Consider: if patient taking methadone, history difficulty BUP start, transitioning from prescription opioids, intentionally taking fentanyl daily
  • Avoid: if already significant withdrawal (it's too slow), don't want to continue full opiate agonist, risk for respiratory depression/sedation, prefer rapid start
Harm reduction refers to a set of policies, programs and practices that aim to reduce health, social and economic consequences of drug and alcohol use. 
  • Reduce stigma by being a safe place, regardless of ongoing substance use
  • Offer clean needles (available at Face to Face, DAAC, but also on PHP formulary (see image below)
  • Always give Narcan Rx
  • Give Fentanyl test strips (available at Face to Face)
  • Resource support
  • If patient leaving AMA, give direct phone # to outpatient MAT care:
    • Marla Pfohl MAT program manager SRCH 707-890-0375
    • Erick Hill, Matt Clinic supervisor SRCH 707-867-8690
    • Never Use Alone phone # 800-484-3731
  • Connect to outpatient MAT, give bridge Rx to outpatient MAT (x-license no longer required)


Gender Affirming Healthcare: Beyond Pronouns and Hormones (Kohli, 11/10/2021)

 Many thanks to local expert, Dr. Arunima Kohli, for her excellent Grand Rounds this week on Gender Affirming Care: Beyond Pronouns and Hormones. 

A recording of her presentation can be found HERE.

My notes:

Transgender Awareness Week, observed November 13th to November 19th, is a one-week celebration leading up to the Transgender Day of Remembrance (TDoR), which memorializes victims of transphobic violence. In Santa Rosa, TDoR will be honored during an event at Brew Coffee House Saturday 11/20/21 5pm. More information click HERE.  All are welcome.

Of note, in talking about gender affirming care it is important to acknowledge who we are and what our biases are.

No lecture on gender affirming care is complete without going over terminology and definitely not a presentation without the Gender Unicorn. Take a look at the unicorn and try to identify where you would place yourself. 

  • gender is a construct AND a spectrum
  • gender identity is different than gender expression, physical and emotional attraction are also separate (sexual orientation)

In addition to the gender unicorn, Dr. Kohli likes to think of gender as a multi-dimensional ball-- everybody is kind of fluid-- we are all constantly figuring out our identity, especially when we are younger. This is not isolated to people who identify as trans.  

Language keeps evolving in this field. Very quickly.
  • gender diversity and gender expansiveness: umbrella terms that capture the full spectrum (including gender binary people)
  • transgender: person whose gender does not correspond to sex assigned at birth based on traditional expectations
  • cisgender: person whose gender does correspond to sex assigned at birth
  • non-binary (enby): person whose gender does not fit into typical binary norms, based on traditional expectations
  • intersex: people with unique variations in reproductive/sexual anatomy, may or may not need to talk about hormones, pronouns, etc
Terms to avoid: transgendered, transgenderism, trans-sexual, biologically/genetically/born as, gender reconstruction surgery. Instead use assignationdesignation, and socialization

What is gender affirming care? "Health care that holistically attends to transgenders people physical, mental and social needs and well being while respectfully affirming their gender identity."
  • social: pronouns, clothing, gender expression, community support
  • legal: name change, sex designation, gender marker or legal documents
  • medical: gender affirming HRT, surgery, laser tx, voice therapy, pelvic floor therapy
  • mental: medication management, mental health service
Professional Guidelines for gender affirming care

Health disparities in the gender expansive population are marked
  • 1/2 of trans people had to teach their healthcare provider about trans care
  • 20% of people don't access health care for fear of mistreatment
  • 62% (or more) of gender expansive people suffer depression
  • High rates smoking and alcohol
  • Higher rates of HIV infection, particularly in black trans women population
Data specific to teens (CDC data)
  • Nearly 2% of high schoolers identify as transgender (number increasing)
  • 27% of trans-identified high schoolers feel unsafe at school
  • 35% of trans-identified high schoolers report being bullied at school
  • 35% of trans teenagers attempt suicide
  • Higher rates of early sex, multiple partners, having sex without contraception or STD prevention
cdc mmwr 2017


It is INCREDIBLY effective to have supportive parents for trans kids. Check out this graphic to understand why! Markedly improved rates of depression, suicide attempts. . .
https://transstudent.org/graphics/youthsupport/


Gender affirming care is life saving care
  • Well documented improved mental health in adults and children with gender affirming care (including psychotherapy, gender affirming surgery, hormones, even proper use of pronouns)
    • decreased depression, anxiety, SI
  • Decreased rates of suicide attempts by 40% if there is ANY gender affirming person in a trans person's life
  • increased engagement with health care system
  • improved school performance, improved social skills
. . .But affirmation isn't everything. 

Discrimination
  • 65% of trans-people experience discrimination (DMV, nursing homes, gym/health club)
  • 59% of trans people avoid using public restroom because of fear of discrimination, 1/3 limit food and drink so they can avoid bathrooms
  • 3x higher unemployment rate, worse in BIPOC
  • 2/3 of states coverage cover gender affirming hormone therapy
  • Few states have Medicaid protections for transgender people
  • Being undocumented is additional risk factor; high rates of anti-trans violence in Latin America, have 
  • Higher rates of incarceration, higher rates of assaults in prisons, many denied medically necessary gender affirming healthcare while incarcerated
Safety is a real issue
  • Sexual assault, sexual violence
  • 2021 
https://transrespect.org/en/tmm-update-tdor-2021/

What do we do as health care providers?
  • Advocate for change in health systems
    • EMR
    • Ask EVERY one who comes into your system SOGI (sexual orientation, gender identity), not just those who you assume are different
    • organ inventories (so you don't assume gender tells you screening needs)
    • formulary
    • education and trainings for staff
    • hiring people who are transgender
  • Do the work before you signal you are safe!
  • Learn the language and vocabulary
  • Learn insurance rules: sometimes insurance will initially decline but they are not allowed
  • Think beyond your own panel
    • specialists, other providers--> improve access 
  • In CA, all medically necessary care MUST be covered for transition (this includes everything in WPATH of what is medical necessity and what procedures, e.g. laser, body contouring)
  • Know your State and National Laws, Legal rights about restroom, Sports participation, etc
  • Know local referral providers (e.g. surgeons for gender affirming surgeries)
  • Advocacy with schools and workplaces
Additional resources





What Every Health Provider Needs to Know about Drowning (Hoffman, 11/3/2021)

 Thank you to Dr. Ben Hoffman who gave a profoundly moving talk on Drowning Prevention in Children. What an honor to host the national expert on accident prevention!

A recording of the excellent presentation is HERE

I consider this presentation a MUST for all of us that care for children. This is PRACTICE CHANGING.

Here are our notes:


Drowning is the leading cause of unintentional injuries in children 1-18 from data collected between 2009-2018-- that’s over 9,000 children. 

  • Imagine 9 school buses of children-- 72 kiddos in each bus-- that die every year from drowning.
  • Drowning is the single leading cause of death in children ages 1-4, and the 2nd leading cause in children 15-19.
  • We must remember the BIPOC community who suffer disproportionately from incidents of drowning.
    • we can trace this reality back to systemic racism and lack of access to pools, swimming lessons, etc.

 PREVENTION: the AAP has created both a toolkit https://www.aap.org/drowning and a policy (attached) to help providers educate family’s on drowning prevention. The toolkit has both general information and patient handouts and posters for your office.

https://www.aap.org/drowning

The bottom line: LAYERS OF PROTECTION to prevent drownings, and we should focus particularly on new parents of children <4, teens, BIPOC families, and children with disabilities and epilepsy.

                *infants: never leave unsupervised – even a second- in water.

                *toddlers: their curiosity is dangerous. Never leave a toddler unsupervised around any water. They can get into tubs, toilets, wading pools. Lock or empty these when not in use.

                *swimming lessons: no evidence that they protect infants, but there IS evidence that they work for children 1-4 yrs old and shows a significant reduction in drownings.

                *water competence: we should teach our families that learning to swim is a life skill. Many BIPOC parents were never taught to swim so consider the water dangerous.

                *erect barriers: particularly pools – 70% of pool drownings are when it’s not “swim time”. Pool fences that have 4 sides with a locking gate reduce drownings by 50%.

                *supervision: constant, close and capable supervision-at arm’s length if a child can’t swim competently. Don’t rely on lifeguards – children still drown in their presence.

*life jackets: only coast guard approved life jackets are appropriate (and a must when our families visit the Russian River or the Sonoma Coast). Never rely on anything inflatable. The coast guard approved life jackets are more expensive than the inflatables.

*advocacy: some cities have life jacket loaner programs. Dr Hoffman will be glad to speak to anyone who is interested in starting a program locally (for example Spring Lake loans them with boat rentals).









 A great big thank you for years of ethics support in the hospital AND for a great Grand Rounds on How to Mitigate Moral Distress among Providers by our very own Sutter Senior Bioethicist, Dr.Shilpa Shashidhara. 

A recording of her presentation is available HERE. Please watch it if you can!

And here are my notes:

What is moral distress? 

Moral Distress was first defined by Dr. Andrew Jameton (1984) as a natural response to violation of one's core values. In healthcare, it is a feeling of uncomfortableness that arise when providers are unable to do the thing they believe is the "right" thing to do. It is an inability to act within our individual and/or professional values. 

These are ethically challenging situations, where providers feel powerless. 

Moral Distress can lead to disengagement and burnout, can have negative impact on patient care. Prevalent in high stress environments (e.g. ICU: critically ill patients, family members in distress, etc). Has been magnified by the pandemic: challenging clinical situations, managing really ill patients, not having PPE, concerns about allocating resources in stressed healthcare system

  • "I don't know if this is the right thing to do"
  • "I feel stuck"
  • "Both options are equally bad"
  • "I feel like I am causing harm to someone"

If not addressed, moral distress takes toll on personal and professional well-being

3 areas that cause moral distress

  • clinical situations (e.g. non-beneficial treatments that family is requesting, sense false hope with discordant prognosis by different providers, unrepresented patients that cannot make decisions for self and we don't know their values and acceptable quality of life)
  • internal constraints (e.g. fear of speaking up, self doubt, anxiety, wish to not cause conflict, lack of confidence, feeling "stuck" in the middle)
  • external constraints (e.g. power imbalance: RN vs. MD, resident vs. attending; fear of legal action,  poor communication)


Moral distress is a root cause of burnout. 

  • 42% physicians experience burnout (long hours, overwhelming workload, lack of support)
  • 54% of nurses experience moderate burnout with emotional exhaustion,28% high burnout
  • significant role of burnout in organizational turnover
How do we mitigate moral distress to best support providers to reduce burnout?
Identify the problem--> Express a concern

Use debriefing sessions, specifically interdisciplinary debriefing sessions
  • mitigate negative effects
  • normalize and validate experience of negative emotions
  • supports providers
  • uncovers gaps
  • promotes team cohesion
  • opportunity to explore systemic problems
Debriefing sessions: goal is NOT just venting session, but also action planning. Both together are more effective
Part 1: Preparatory: identify needs of healthcare provider, gather relevant information, set goals, plan logistics
Part 2: Implemental: 8 step method

4 As to Rise Above Moral Distress (Developed by the American Academy of Critical Care Nurses)
Can be done as individual or ina group

What else can we do?
Targeted education training for providers, promoting provider ethical decision-making. What is appropriate in a complex situation?
Communication skills and practice
Don't forget to take concerns to hospital/clinic administration to be sure they understand what is happening and look at systems-based solutions



                

Beyond Intimate Partner Violence Screening (Agudelo, 10/20/21)

Many thanks to Dr. Lucia Agudelo for her Grand Rounds presentation this week titled Beyond Intimate Partner Violence (IPV) Screening. Dr. Agudelo, who did professional work in this field before entering medical school, shared the high prevalence of IPV in the US, presented us with new framework of how to approach IPV conversations with our patients, and encouraged us to rethink our goal when we screen for IPV--from one of disclosure to one of support.

I do encourage you to watch a recording of Dr. Agudelo's presentation, available HERE.

For those of you who prefer a written summary. . 

IPV is a pattern of assaultive and coercive behaviors that can include physical injury, psychological abuse, sexual assault, progressive isolation, intimidation and threats. It is aimed at establishing power and control of one partner over the other.

https://www.theduluthmodel.org/wheels/

In the US, an average of 20 people experience IPV every minute, which equates to more than 20 million abuse victims annually.

~1 in 5 women and 1in 7 men report having experienced severe physical violence from an intimate partner in their lifetime

~1 in 5 women and 1 in 12 men have experienced contact sexual violence by an intimate partner

IPV has wide ranging effects on physical and mental health and can exacerbate a huge range of medical problems-- everything from asthma and diabetes to depression/anxiety to unplanned pregnancy to menopause symptoms, to GI disorders and fibromyalgia. 

Dr. Agudelo reminded us to consider IPV on our ddx when we are seeing patients with uncontrolled chronic conditions that don't seem to be able to get under control with standard therapies. This may include someone with high blood pressures or difficult to control blood sugars or even chronic pain. For more information on this, check out the 2019 NEJM article on IPV

https://www.nejm.org/doi/full/10.1056/NEJMra1807166

IPV has unsurprising wide ranging impacts on children, including physical injuries and child abuse, fear, depression and anxiety, sleep disturbances, eating disorders, and even impact on early brain development.

Dr. Agudelo introduced us to an evidence-based intervention to address domestic and sexual abuse in health settings called CUES. This methodology has been designed and created to offer support to men and women who are experiencing violence and connect them with help and support if they need/want it.

https://www.futureswithoutviolence.org/wp-content/uploads/CUES-graphic-Final.pdf

C: CONFIDENTIALITY

  • know your state's reporting requirements
  • always see patients alone for a part of every visit so you can bring up safety
  • use professional interpretation (not family/friends) if you cannot speak the patient's language

UE: UNIVERSAL EDUCATION AND EMPOWERMENT

  • give patient TWO Safety cards (see graphic)
    • "I am giving these cards to all my patients to be sure they know how relationships can impact health"
  • Make sure you let the patient know you are a SAFE person to talk to
  • Giving cards to EVERYONE (and not just those you suspect are at risk) makes it more likely that people who need the information will get the information

S: SUPPORT

  • though disclosure is not the primary goal, you need to be ready to support someone if/when they do disclose
  • be ready to make warm handoff to local support agencies with experience with IPV
  • offer care plans that take IPV into account
Here is another assessment once IPV has been identified to determine if a person is at high risk of homicide or severe injury from an intimate partner: Danger assessment, available at https://www.dangerassessment.org/


https://www.dangerassessment.org/

Reporting requirements
In California, healthcare providers must file a mandatory report to law enforcement (OES-920) if they see a patient with a current physical injury that is known to be due to assaultive or abusive contact
There is no guidance on mandatory reporting from telephone visits.
If you suspect child abuse and/or neglect, you should report to CPS. If you suspect elder abuse/neglect, you should report to APS. 

Local resources:
YWCA 24/7 Support line (shelter, counseling, etc) 707-546-1234
Family Justice Center (counseling, legal aid) 707-565-8255
SR Courthouse (restraining orders) 707-521-6630
Verity (survivors of sexual assault) 707-545-7270
WOMAN Inc (Bay Area shelter census) 415-864-4722
CLAW (LGBTQ) 415-777-5500

Additional resources:
National Domestic Violence Hotline 800-799-7233
https://www.futureswithoutviolence.org/

Dr. Agudelo finished the presentation by encouraging us to hold our institutions of employment accountable to visible and concrete IPV safety-- including posters on the walls and signs in clinic rooms and bathrooms that denote safety and offer resources, the availability of safety cards and/or safety plans, easy access to resources (numbers, internet sites) for those who may be experiencing IPV and need help.  How doe the clinic or hospital where you work ensure that patients know their rights and that this is a safe place?

Interventional Radiology for the Hospitalist/Primary Care (Page, 10/13/2021)

Many thanks to Dr. Alex Page (Redwood Radiology Group) for a great presentation this week titled Interventional Radiology for the PCP/Hospitalist. It seems IR docs can do just about anything these days-- certainly with all kinds of tricks up their sleeves. But what should I know as a primary care doc? Who can I refer? What can patients expect? And how should I manage common post-IR procedural issues?

A recording of his presentation is available here: https://youtu.be/9wmAL7s9KAQ

For clarification, interventional radiology is defined as minimally invasive image-guided treatment of medical conditions that once required surgery, like surgery only MAGIC. ☺


IR physicians work with practically every body system (minus brain, skin and heart. Their work can be broken into two broad categories:

  • Endovascular procedures: including vascular access (vein, artery, lymphatics) and catheterization (stenting, embolization, angioplasty, venoplasty)
and 
  • Percutaneous interventions: using CT/ultrasound to advance a needle to put in drain, biopsy lesions, ablate tumors/growths, etc
"We can almost get anywhere" (danger zones where your local IR doc may take a moment: mediastinum, around heart, deep abdomen)

For detailed ideas of possible IR procedures, see the image below from Society of Interventional Radiology for the wide scope of IR docs
www.sirweb.org



Vascular Access
IR can place a range of central lines, HD catheters, and ports

Central lines (for abx/meds, not the same as PICC; locally our PICC nurses place these)

**Central line Pearl: If you are concerned that patient is heading toward ESRD and possible HD, PICC lines can ruin peripheral veins and make it hard for vascular surgeons to make AV fistula, so consider opting for a central line in that circumstance

HD catheters (large bore, two lumens)

**Pearl: Right after being placed, bleeding from tunneled catheters can only be in two places: along the tract where catheter is tunneled, the vein around the catheter at the IJ site. If it has been placed for some time, pressure should be held at the neck only because bleeding only coming from the IJ site

**Pearl: Noe that the Cuff (made of dacron) is supposed to be inside tract, body scars down on it to prevent CLABSI. If the cuff is EVER visible, catheter needs to be exchanged

Ports: if you look closely can see the image of a C/T on the port. If it is right side up, you should see it on the x-ray. In addition, the tip should be right at the top of the  R atrium (approximately two vertebral bodies below the carina, one vertebral body below bronchus intermedius)

Of note, the tip of Catheter/port does move based on patient position (when breathing out, tip will be at lowest position). If too deep, can cause arrhythmia. If too shallow (way up in SVC), can cause stenosis and create access issue. Fine balance to have in right spot

Ports can be implanted for 1-2 years, should be able to remove without difficulty

Do not use HD tunneled catheter for vascular access unless emergent

Ports can be easily accessed (usually by RN protocol); has to be accessed with a Huber needle (slight curve with hole on the side to prevent coring the membrane from the port), use sterile technique, pin down with fingers (has 3 little bumps),

Veins used for port/cath: IJ (nicest easiest, safest)>> EJ>> subclavian (can be done with landmarks)>> femoral (higher infection incidence, less clean)>>IVC>> hepatic veins

Fistulas and Grafts

Fistula is an abnormal connection between artery and vein, created by surgeons, can use either a native vein (i.e. fistula), e.g. brachial artery connected to cephalic vein
Takes time for vein to mature (months), more durable, last longer

If fistula not an option, they use a graft: firm loop use PTFE to create a circuit, can be used much sooner, don't last as long (because foreign material), anastomosis


Can have venous outlet stenosis, can do angioplasty to save fistula
Should feel a "thrill" instead of a pulse


Possible complications:
  • Patients with MAJOR  upper extremity swelling= central stenosis of the fistula, indication for IR referral to help open
  • Prolonged bleeding can also be caused by central stenosis, indication for IR referral
  • Infection; native fistula doesn't commonly get infected (except thrombophlebitis), graft infection is major issue (needs to be removed): erythema pain, fever
  • Steal syndrome: claudication, painful hand, especially during HD

Abscess Drains

Diverticular abscess most common. Additional abscess include: appendiceal abscess, hepatic abscess, pancreatic pseudocyst, cholecystitis, percutaneous nephrostomy tubes, tubo-ovarian abscess

Normal sequence for drains
IR places drain--> Bulb suction (flush until minimal clear output)--> Abscessogram vs. CT vs. "just pull"

Major problem: fistula
Repeat abscessogram q2 weeks until fistula closes
Can work with GI if place a wire in fistula to clip diverticula
Fistula= surgery (colectomy in setting of diverticulitis)

How much to flush:  many IR docs use 10ml flush (can do less if small cavity)

Abscessogram: fluoroscopic (moving x-ray, live x-ray used to do procedure), inject with contrast--> look for pocket where abscess was (when contrast injected, if big and distended, means pocket is still there). Can also visualized presence of fistula. Repeat until  pocket/fistula disappears

Biopsies
lung, liver, bone, lymph notes

CT and/or ultrasound (if a hollow viscous containing air, cannot see through it on ultrasound)

Lung biopsy is the most dangerous (20% of small pneumothorax, 5% chance for chest tube due to air leak, hemoptysis, air embolism=death)

Solid organ biopsies are risky because of bleeding (kidney, liver): if sending a patient for liver/kidney, SBP must be <150

INR and platelets: varies by procedure (HIGH vs. Low risk bleeding procedure)
platelets >50, INR <1.5

High risk bleeding procedures
Low risk bleeding procedure (e.g. port, tunnelle lines paracentesis, bone marrow bx): platelets can be quite low, BM <20
There is a document from SIR which dictates INR/platelet counts based on procedure

Kyphoplasty
can lead to immediate pain relief
Indications: osteoporosis, acute/subacute vertebral body fracture (<30 days) with midline pain/tenderness, cannot do too high (high thoracic, cervical spine)

Advance needle into vertebral body (through pedicle, stay lateral of medial aspect of the pedicle to avoid the spinal canal), inflate a meeting, put in cement, fill the anterior aspect of the vertebral body and stops fracture fragments from moving and can signficiantly improve pain

Risks: fracture adjacent vertebral body (because cemented body is so much stronger than natural bodies), cement migration

And finally, information to have ready for IR consultation
1) Desired procedure
2)  Indication for procedure
2) urgency of procedure
3) anticoagulation/platelets
4) NPO status

Who to call?
SSSRH scheduler: 707-576-4278
SRMH scheduler: 707-525-5269
IR on call: 707-571-7007



Is it Vaccine Hesitancy? (Thompson 9/22/2021)

Many thanks to Dr. Cherriese Thompson for a thought-provoking Grand Rounds this week titled "Is it Vaccine Hesitancy?" in which she explored the historical and present day impediments that make it challenging for BIPOC to accept and receive the COVID-19 vaccine and discussed ways to mitigate barriers to vaccine admin and acceptance. 

Dr. Thompson defined vaccine hesitancy as: "a delay in acceptance of refusal of vaccines despite availability of vaccine services". This definition, Dr. Thompson, told us, assumes a level of complacency, convenience and confidence. We may want to question these assumptions. 

A recording of her presentation is available HERE.

Here are my notes:

We all know that COVID-19 disproportionately affected BIPOC in the US with increased rates of hospitalizations and death over population levels (see image below)


Racial breakdown of vaccine trials: while these vaccine trials have been praised for inclusion and diversity, there is still much work to be done to be sure they are reflective of the population


Rates of vaccination by race/ethnicity (updated 9/21/2021):


Concerns about COVID-19 vaccination in communities of color include medical and structural racism, as well as historical and present day trauma

For Black/African American people
  • Centuries-long history of experience of discrimination in health care, being ignored or dismissed: "if you haven't cared about me in the past, why should I believe you care about me now?
    • slave ships in Middle passage: sick slaves thrown overboard or forced treatment
    • medical experimentation on black women's bodies
    • withholding medical treatment for slaves
    • 1973: yellow fever outbreak, one physician believed black people were immune and didn't give treatment
    • 1932-1972 Tuskegee study, knowingly withheld treatment to 400 black men for syphilis to watch the progression (100+ died) 
  • Concerns about vaccine incentives: lack of trust in governmental organizations 
  • "Medical racism: The New Apartheid" antivax organization, film specifically targets black communities, weaponized history of experience of black people, "should you really get this vaccine?", false claims regarding potential vaccine harm
  • Social media: misinformation on Twitter and FB, e.g. Nicki Minaj (famous rapper) on Twitter:

For Hispanic/Latinx people
  • concerns about female fertility
  • concerns that the vaccine contains stem cells, ethical to take vaccine if prolife?
  • worries that the vaccine itself may give you COVID
  • Spanish language information (on Whatsapp and Telegram channels) discuss ineffectiveness of masks, vaccine ineffective
  • Vaccine being used to track down immigrants and deport them
For Native American/Indigenous
  • historical trauma leading to skepticism
    • 1970: Family Planning Act: sterilization of more than 25% Native American women without consent
    • 1989 Havasupai Tribe asked for assistance from John Martin, anthropologist to understand diabetes in their community; blood samples provided were used without their consent to study schizophrenia, alcoholism, inbreeding and origins and migrations of their people
  • concern people might be injected with COVID from the vaccines
  • huge concern about speed of manufacture
  • historical distrust: "Am I willing to gamble that they care this time?"
  • lack of involvement of their own populations in clinical trials
And, unfortunately, this is not just about historical trauma, but ongoing/current lived experiences for BIPOC
Reframe. This is NOT hesitancy. There are real impediments, many impediments. 
  • Among the impediments: skepticism, lack of accurate information, actual vaccination access, including online only signups, issues with appointment scheduling transportation
  • Having the time to be vaccinated: working multiple jobs
  • Valid concerns about being unable to get vaccinated due to vaccine side effects and not be able to take time off work, or because you are caring for others
  • Pharmacy Deserts (residents living >1/2 mile from a pharmacy), many exist in communities of color. A lot of these communities lack reliable transportation to get/to from pharmacies to get vaccines. CVS, Rite Aid, Walgreens, local pharmacies may not have capacity to carry and administer these vaccines 
Okay, what can we do?

1) Get more BIPOC included in clinical trials
  • recruitment of diverse populations, particularly Native American communities-- working with sovereign government and respecting data sovereignty
  • FDA: Enhancing the Diversity of Clinical Trials, ideas include reducing visit frequency, provide flexibility, using electronic communication if possible
  • PhRMA's Equity Initiative
    • building trust and acknowledging mistrust
    • reducing barriers to clinical trials access
    • utilizing real world data
    • boost info of diversity and inclusion in clinical trial participation

2) Increase access to trusted information
  • There is so much misinformation/disinformation out there, more accessible
  • meet people where they are: go into the community, being present to answer questions
  • being a resource to isolated populations
  • Empower individuals to question info they see on social media, question the source, question the validity
  • Provide trusted information: Voto Latino partnered with another organization to provider accurate info to Latinx (they also partnered with Uber/Lyft to transport Latinx to vaccination)
  • CDC: information on vaccine equity, increasing uptake in racial/ethnic communities, communication toolkits, printed resources and posters in multiple languages

3) Improve access to vaccination sites
  •     mobile vaccination units
  •     reach places where access to healthcare is already a problem (rural and urban)
  •     targeting opening vaccination sites within vulnerable communities (i.e. Roseland Library)
  •     pop up vaccination sites
  •     home vaccination (to the most vulnerable)
  •     clinics and pharmacies providing access

4) Foster trust and utilize empathy
  • creating a space for patients in the room
  • take the power away, ask the patient "Can I talk to you about the COVID vaccine? What are your concerns? What have you heard about it? How has it affected you?"
  • Create open dialogue to explore skepticism
  • foster continued discussion
  • provide accurate information
  • show empathy: patients often will trust their doctor over time, if they felt heard/held

5) Shift the blame
  • there will be skepticism; don't blame the individual patient for their skepticism
  • relieve the blame to foster an environment of trust and open dialogue

6) Increase BIPOC pipelines in healthcare
  • more funding and access for BIPOC in healthcare
  • "Because I am black, and I have been vaccinated. . .and I hear your concerns. . .Here is what I experienced." That means so much to a lot of my black patients
7) Dismantle structures of racism inherent in medicine

Many thanks to Dr. Susan Milam Miller, who gave an excellent Grand Rounds this week titled "Caring for our Children, our Family, and Ourselves during COVID-19". Dr. Milam Miller covered a range of topics about our mental health in this pandemic-- from March 2020 as Alexander and the Terrible, Horrible, No Good Very Bad Day, to community and complex trauma, ambiguous loss, and unresolved grief, to trauma-informed care, and even a bit about the magic of a window into children's lives via video visits.



HERE is the recording of Dr. Milam Miller's presentation. 

Here are my notes:

Dr. Milam Miller reminded us that no child exists as as single entity-- children exist within their natural environment, including their families and their community. Listening between the lines to children and their attached adults is important. Knowing what their natural environment looks like is also key.

Clearly, here in Sonoma County, many children (and adults) have lived the trauma of several fire seasons and evacuations, compounded for the last year and a half by the COVID-19 Pandemic. These traumas have caused a tremendous amount of stress for many of us-- children are no exception. As such, we can expect to see signs of traumatic stress in our children.

Traumatic Stress manifests in a range of responses in adults and children:

  • Emotional: emotional dysregulation (sadness, fear), numbness, detachment
  • Physical: somatization (headaches, stomach aches insomnia), changes in brain function, hyperarousal
  • Cognitive: how we think about ourselves and others, triggers, re-experiencing, nightmares/daymares, dissociation, dampening of connection via thoughts and emotions
  • Behavioral: the way the mind directs the body: self harm, substances, avoidance (behaviors that are NOT adaptive over time, even if they help at first)
  • Interpersonal: pulling away from loved ones, difficulty trusting and forming trusting relationships
Identifying these "adaptive" behaviors that may not serve us over time is key to helping our patients and ourselves survive the trauma. 

Community Trauma  is a strong and powerful shaper of relationships and health
How does a community emerge from trauma? How do we recover and repair? How do healthcare providers care for their community in times of trauma but also for themselves? How do we model for our children and families what healthy coping with community trauma entails?

Complex Trauma describes both children's exposure to multiple traumatic events—often of an invasive, interpersonal nature—and the wide-ranging, long-term effects of this exposure. ... They usually occur early in life and can disrupt many aspects of the child's development and the formation of a sense of self. In COVID times, the list of multiple traumatic events may be long
  • what about medical trauma of repeated COVID testing?
  • what about shutting down schools?
  • what about losing church and extracurricular activities?
Ambiguous loss is a loss that occurs without closure or clear understanding. This kind of loss leaves a person searching for answers, and thus complicates and delays the process of grieving, and often results in unresolved grief. I personally found myself intrigued for the rest of the day by this notion of ambiguous loss-- classically a dear one who disappears on a hiking trip, never to be found again. What about these years of pandemic create ambiguous loss?
  • what does it mean to have never finished fourth grade because schools shut down in March 2020?
  • what does it mean not to have a graduation ceremony from high school?
  • what does it mean to go through puberty during pandemic times without community support?
Trauma Treatment classically has 3 stages:
  • Stage 1: Stabilization and establishment of safety (this may include psychotropic medications, DBT to help managing distress, relationship building)
  • Stage 2: Addressing and processing of trauma memories or related beliefs and/or grieving the losses inherent in trauma (this is somewhat controversial but has been standard of trauma treatment)
  • Stage 3: Restoring or creating connection between survivors and their communities by increased engagement in meaningful and positive activities and relationships
Unsurprisingly, in trauma healing, relationship building is key.
Trauma informed care
“Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. 
  • Safety
  • Trustworthiness and transparency
  • Peer support
  • Collaboration and mutuality
  • Empowerment, voice and choice
  • Culturally, historic and gender appropriate
Relationship and relational care is everything. Dr. Milam Miller says at some point, we expend WAY too much energy on individual treatments and interventions, really we need to consider community interventions, group treatments, and shared treatments. I love 

Closing questions to ponder from Dr. Milam Miller
1) Who is your buddy? (i.e. the person you call, lean on, ask for help)
2) What does healthy coping look like in these times?
3) Can you recognize the ambiguous loss of this COVID pandemic for the families you care for? Once recognized, how do we process our grief?

Birth Equity (Jimenez, Lund, Bacon 9/8/2021)

Many thanks to Drs. Jimenez, Lund and Bacon for an important presentation on Addressing maternal health disparities and birth equity this week. A full recording of their excellent presentation is available HERE.

https://youtu.be/Y2uJEZyT1ZE

My notes:

What is birth equityBirth equity is the assurance of the conditions of optimal births for all people with a willingness to address racial and social inequities in a sustained effort  

https://www.cmqcc.org

Dr. Jimenez led off with a review the concept of race

  • The notion of race is a social construct designed to divide people into groups ranked as superior and inferior. Societies use race to establish and justify systems of power, privilege, disenfranchisement and oppression
  • Scientific consensus: race has no biological basis (we are all one race)
  • In a racialized society like the US, we are all assigned a racial identity, whether we are aware of it or not
  • Geographic ancestry (which does have genetic importance) is not the same thing as race (which does not)
  • 1700s, Carl Linnaeus, father of modern taxonomy, classified our own species into races based on reports from explorers and conquerors 
    • Americanus, Africanus, Europaeus, Asiaticus, Monstrosus
    • Western concept of race is based on a classification system that emerged from, and in support of, European colonialism
He followed with a review of racism and bias
  • Racism is an organized system premised on the categorization and ranking of social groups into races, and devalues, disempowers, and differentially allocates desireable societal opportunities to racial groups regarded as inferior (Bonilla-Silva 1996)
  • Racism often leads to the development of negative attitudes (prejudice) and beliefs (stereotypes) toward non-dominant stigmatized racial groups and differential treatment (discrimination) of these groups by both individuals and social institutions 
  • Bias is a decision we make so quickly that it simply occurs to us as data; we don't even rela
Dr. Jimenez finished his section with real life examples of racism in maternity care (past and present) and an encouragement that we must begin to come to terms with our own past
  • The 2018 story of tennis star Serena William's emergency c-section, complicated by PEs and failure of her physicians to listen to her and diagnose her quickly
  • Slave-holding surgeon (Francois Marie Prevost) pioneered c-section surgeries on American enslaved women's bodies through repeated experimentation
  • In the 1840s, J Marion Sims, father of modern gynecology, was a plantation physician and then gynecological surgeon in Alabama--> experimental surgeries on enslaved women for vesico-vaginal fistulas. Did not use anesthesia, despite it being readily available. Got rich and famous from his work.
  • Consider reviewing the image below to understand how racism impacts obstetric care
Dr. Lund took part 2 of the presentation to review disparities in maternity care in the US
  • Black women experience far worse outcomes than any other racial or ethnic group. Black women:
    • are 3-4x more likely to die than their white counterparts
    • comprise 13.5% of live births, but 35.5% of pregnancy-related deaths
    • have higher preterm delivery (13.4% vs. 9%)
    • have higher c-section rate (RR 1.23)
    • have higher PPH rates (3% vs. 1.6%)
    • have higher peripartum infection (4.9% vs. 4.1%)
  • Pre-E, diabetes, and and unintended pregnancy are also higher for black women
  • American Indian/Alaskan Natives (AI/AN) are also at risk for adverse outcomes
  • Black and AI/AN infants are more likely to die in their first year of life
    • black infants diet at greater than 2x rate of white infants (11.4 vs. 5.2 per 1000 live births)
California has been working hard since 2006 to reduce our maternal mortality rates, and it's working!
(this graph below shows a decline by 55% 2006 to 2013)
However, despite tons of successful work to reduce maternal mortality, the disparity ratio (black women vs. white women) remains unchanged (see image below):
Dr. Lund also shared some of our local stats at SSRRH
  • ~50% of our deliveries are to Hispanic patients (~ 20% US-born and 30% foreign born)

  • Another 37.5% of our deliveries are to non-Hispanic White identified Patients
  • 4.5% of births to Asian or Pacific Islander patients
  • <2% of our deliveries to non-Hispanic Black identified Patients
  • About 2% “other” which primarily represent American Indian/Alaskan Native patients
  • A full 6% were race/ethnicity “unknown”
Dr. Lund shared important outcomes for our maternity patients, including NTSV c-section rates, maternal morbidity, preterm birth rates, unexpected newborn complications, and exclusive breastfeeding at discharge:
  • Hispanic born US rates of pLTCS are the lowers of all, much lower than state average
  • Non-Hispanic black patient cesarean rates are about 4% higher than almost all others but lower than state average. 
  • Our “other” category (largely AI/AN) exceptionally high NTSV c-section rate. Total # of patients in the “other” category higher than for non-hispanic black but still only about 145 patients over 5 years. 


And for preterm birth:

  • Non-Hispanic Black preterm birth rate is similar to others at our facility and lower than state average, however note that #’s are quite small so should continue to trend over time 11 patients out of 124 patients total in 5 years. 
  • Rate of PTB among white patients higher than the rest of CA
  • “Other” preterm birth rate is quite high, mostly represented by AI/AN individuals, numbers still low 28 patients out of 144 over 5 years. 


What can be done?

Dr. Bacon capped off this week's Grand Rounds presentation with a series of recommendations of how you might engage in local advocacy and beyond to work on birth equity:

  • Individual work: if you are unsure where to begin and/or unsure about what you think about this information, individual work is the place for you
    • consider reading and/or listening to podcasts, listening to the experiences of others (particularly BIPOC), assessing your own personal unconscious bias, and work on retraining your brain on these biases
    • Listen to Dr. Camara Jones
    • Visit Project Implicit
    • I personally recommend Seeing White on Scene On Radio as a good place to start (we have been listening to this as a faculty for our anti-racism work)
  • Institutional work
    • there are lots of robust toolkits and trainings to help guide institutions
    • these might help you help guide YOUR institution
    • try: CMQQ, ACOG/SMFM, https://blackmamasmatter.org/, CDC's Hear Her campaign
    • Locally, attend CEDAWG grand rounds, September 22 Foundations for Health Equity Workshop, UCSF Differences Matter, Trauma informed care trainings
    • Check out the SSRRH Labor Culture Committee (LCC) at SSRRH (inquire with Julie Barajas or 
  • Community Work
    • Workforce development, pipelines
    • Community health workers
    • Doulas
    • Black midwifery
    • Centering pregnancy
  • Statewide and National work
    • Pay attention to what is happening in politics and policy:
      • SB65: a bill that creates a committee to investigate maternal deaths, examines adding a doula benefit to medi-cal funding, and helps low income communities have access to midwifery care
      • California AB4: removing documentation status for Medi-cal benefits
      • Governor Newsom's 2022 budget, which includes California extension of OB Medi-cal to 1 year postpartum
    • Also take a look at commonwealthfund.org Maternal mortality and maternity care project

And more resources:

Jenee Desmond-Harris: Implicit bias means we're all probably at least a little bit racist. https://www.vox.com/2014/12/26/7443979/racism-implicit-racial-bias

Eric Deggans: 'Not Racist' Is Not Enough: Putting In The Work To Be Anti-Racist. https://www.npr.org/2020/08/24/905515398/not-racist-is-not-enough-putting-in-the-work-to-be-anti-racist

Camara Phyllis Jones, MD, MPH, PhD: 


https://www.projectimplicit.net/

CDC Hear Her campaign: https://www.cdc.gov/hearher/resources/download-share/warning-signs-poster.html

ACOG Health Equity Curriculum: https://www.acog.org/education-and-events/creog/curriculum-resources/additional-curricular-resources/health-equity

ACOG CO 649 (2015): Racial and Ethnic Disparities in Obstetrics and Gynecology https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2015/12/racial-and-ethnic-disparities-in-obstetrics-and-gynecology.pdf

Black Mamas Matter Alliance Toolkit: https://blackmamasmatter.org/resources/toolkits/




Treating Opioid Use Disorder in the Hospital: A Trauma Informed Approach (Strickland, 11/17/2021)

Many thanks to Dr. Tiffani Strickland, who gave an action packed Grand Rounds this week on Treating Opioid Use Disorder in the Hospital. She...