Ecology and the Physician: Therapeutic Considerations for your Patients AND the Environment (Bacon, Fetke 3/24/2021)

Many thanks to Drs. Bacon and Fetke for their presentation. 

A recording of their presentation can be found here: https://youtu.be/gtypRTzS2e8 

A written summary will be added later this week.

Radiology Potpourri (Kujala, 3/17/2021)

Many thanks to Dr. Nick Kujala, Sutter Radiologist and mid-West Scrubs and hockey fan, who gave an entertaining and informative presentation this week, covering a range of topics in radiology: from the history of the first radiograph to the risk of radiation exposure to the invention of the CT scanner. The video recording is available HERE.

Here are a few summary points from his presentation:

1) Radiation Exposure: Many patients (and clinicians) have concerns about the risks of radiation exposure with imaging studies. It may be helpful to note that living on earth gives us daily background radiation exposure, and certain jobs/situations (e.g. working as flight attendant or pilot) increase the amount of that exposure over time. Of note,  exposure from one chest x-ray is the equivalent of  ~10 days of background radiation, whereas at CT of the chest is equivalent to ~2 years. 

Information on radiation exposure for patients is available at this website:  https://www.radiologyinfo.org/en/info.cfm?pg=safety-xray

Also, remember that MRI and ultrasound are alternative imaging modalities that offer ZERO radiation exposure.

2) Breastfeeding and contrast: Women who are breastfeeding can safely receive contrast (iodinated and gadolinium-based) for imaging studies without concern. The dose absorbed by an infant is exceedingly low. There is no need to pump and dump, but ultimately the decision should be left to the lactating mother.

3) ACR Appropriateness Criteria: The American College of Radiology (ACR) has an excellent, information-packed website to help clinicians make the correct choice about imaging studies. Everything you want to know about radiology imaging (indications, risks/benefits, radiation exposure, alternatives) can be found here: https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria

An excerpted example of these ACR criteria for abnormal uterine bleeding is pictured below.

4) MRI and Gadolinium: Gadolinium has been used as contrast in MRI for over 30 years. There is a known phenomenon of gadolinium deposition in some tissues (bone, kidney, brain); however, there has been no consistent evidence to suggest that these deposits are associated with neurotoxicity. However, as recent as 2016, some scientists have suggested a condition called Gadolinium Deposition Disease, linking these deposits with a constellation of neurological symptoms and signs.  While Dr. Kujala and the ACR  support the safety profile of gadolinium, it is not recommended during pregnancy

5) More IS Better! Give your radiologist as MUCH clinical information as possible when ordering an imaging study-- you will get more clear results back. And if you have a question, call your local radiologist sitting in his dark reading room (or at home) at x-44551.

Extras:

Roentgen's first ever radiograph of his wife's hand (1895) 

Hounsfield's invention: the CT Scanner (he shared the 1979 Nobel Prize in Medicine)

And finally, what is an Aunt Minnie? The origins of the term "Aunt Minnie" are a bit hazy, but it's believed to have been coined in the 1940s by Dr. Ben Felson, a radiologist at the University of Cincinnati. He used it to describe "a case with radiologic findings so specific and compelling that no realistic differential diagnosis exists."

Can you name the Aunt Minnie below?

Answer: Tension Pneumothorax

End of Life Care: Cultural Values in the Latinx Community (Panameño, 3/3/2021)

Dr. Karla Panemeño gave thought-provoking and important Grand Rounds this week on End of Life Care: Cultural Values in the Latinx Community. You can watch a recording of her presentation here: video to be uploaded.

Dr. Panemeño began her presentation with a brief history of hospice, and she pointed out that hospice is very much a "western phenomenon" with much of Latin America is still lacking the concepts of hospice and palliative care principles embedded in their own healthcare systems. She also reminded us that the Latinx community is the fastest growing ethnic minority group in the US, and that the COVID-19 Pandemic has disproportionately affected Latinx in our country (3x the hospitalization rate) and our own local community (while Latinos make up 27% of our SoCo population, they comprise 67% of our cases).

There is mixed evidence on Latinx use of end of life services, but generally the Latinx community tends to be less likely to have an advanced care plan and less likely to take advantage of hospice service. There are many reasons why this may be true, including: language barriers, financial barriers (many immigrants are not eligible for Medicare), knowledge about the resources, and cultural values.

Dr. Panameno then spent a good percentage of her remaining time describing key Latinx cultural values that may influence the interactions of Latinx patients with end of life care. She encouraged us that recognizing these cultural values may help us give better care. She reminded us, however, to be careful not to generalize, as the Latinx population in the US is itself a diverse group of people. Also, being aware of an immigrant patient's level of acculturation is important in understanding how these values shape their decisions

• Familismo (family unit)
• Personalismo (personal interactions)
• Respeto (respect)
• Confianza (trust)
• Fatalismo (fatalism)
• Dignidad (dignity)

For me, exploring these cultural values and how to integrate them into the care of acutely and chronically ill and dying patients is such an important take home message.

Here are a few pearls:

Familismo is a family centered model of decision-making highly valued in the Latinx community, may be valued more than autonomy (whereas medical system often values autonomy over all else), involves broad networks of support that extend beyond the nuclear family 

• this may be seen in medical decisions being made as a family unit, rather than by an individual
• also family members very much see themselves as caretakers and often have a strong sense of duty to care for their dying family member
• How do we navigate familismo in the care of patients?
• identify the family spokesperson
• actively engage family members in decisions
• educate and support the whole family

Respeto is a notion that relationships are based in common humanity, and one must establish respect as part of that relationship

• this may be seen in hierarchy within families as to who is designated spokesperson
• patient and family may not be assertive in expressing their concerns, disagreements with clinicians

Personalismo is a value that places an emphasis on your personal interactions, rapport is built on warmth and regard

• pleasant and agreeable conversations with healthcare provider (even when they disagree)
• may not want to disclose poor prognosis to the patient
• How do we navigate personalismo and respecto in the care of patients?
• Be respectful (in the language you use, who you address, etc)
• Respect the familial hierarchy
• Give families time to process
• Take time to know each member of the family -- don't underestimate the value of family 

Confianza is trust in a person with the belief that the other person in the relationship has your best interests in mind.

• many Latinx patients have experienced discrimination based on race, language, etc in the healthcare setting
• How do we navigate confianza?
• follow up on promises, spend additional time with patient/family, make small talk, have open dialogue about prejudice, discrimination, language barriers
• use important key community members (e.g. pastor)

Dignidad: feeling worthy and valued

• may manifest as anxiety at time of death, fear/anger around dying, 
• How to navigate? Open conversation with family members, be curious about the feelings in the room

Fatalismo: a belief ones future is not in your own hands, not in your own control

• patients may seek care late in their illness
• may express hope for a miracle
• How to navigate? Explore thoughts/feelings/values, validate the role of others' control

I encourage all of us who take care of Latinx patients to consider how these cultural values may influence our patients' interactions with us and with the healthcare system, and not to overgeneralize but rather apply this lens humbly in how we care for patients.