Dismantling the Healthcare Hero (Carmen 8/25/2021)

Many thanks to Dr. Desiree Carmen for an evocative Grand Rounds presentation this week entitled Dismantling the Healthcare Hero. A recording of her presentation-- definitely worth your time and attention-- is available HERE. 

Dr. Carmen took the hour to explore the notion of heroism as it applies to medicine. She asked us to question why we liked being called heroes at the start of the pandemic and why that may not feel so good right now-- a year and a half later. And she challenged us to propose alternative narratives to support the systemic change that so many of us wish to see.

Dr. Carmen showed us now-familiar images of healthcare workers as masked altruistic protagonists. As the world shut down in March 2020, she began, we felt the love from companies-- free vacations, discounted goods. . . stories of NYC meeting at 7am to clap for healthcare workers. It felt pretty good to be healthcare hero. 

Our egos, after all, were not averse to the notion that we could be heroes. We signed up for this! For physicians, we took the Hippocratic oath; for nurses, the Nightingale pledge. We adhere solidly to notions of altruism, beneficence, justice, non-abandonment and solidarity. And we want to serve.

But, she explained, I wanted to know why society wanted us to be heroes.

Dr. Carmen showed us 3 hero archetypes that Americans particularly admire:

• The Everyman Hero: this is the person with no special skills, one for whom life has thrown an adventure at them, asked to do heroic deeds 
• The Classical Hero: someone with special abilities and/or skills that puts them above others in the society and grants them their positionality as hero due to those skills
• The Epic Hero: the person with a noble birth story, larger than life

Which do you identify with? Why?

Dr. Carmen segued from these hero archetypes into the work of James Opie Ursom, a mid-century philosopher who wrote about the supererogatory: that is, morally excellent actions that go beyond the duty of the agent-- more than is asked for. All heroic actions are supererogatory, but not all supererogatory actions are heroic. Heroism involves known involvement with risk. i.e. we must CHOOSE the risk. Well, did we?

Risk has not been in short supply during this pandemic. 

But PPE has. 

PPE Shortages: We all are well aware of the experience of working without a feeling that we had adequate PPE (e.g. reusing N95s, gowns, etc). This is not unique to this pandemic; it has, unsurprisingly, been  experienced in epidemics prior to this (including ebola, SARS, H1N1)

And this predictable lack of PPE is due to a well known multitude of forces that are not aligned to ensure health care workers are guaranteed protection. 

Recreated Figure 1 from Cohen J, Rodgers YVM. Contributing factors to personal protective equipment shortages during the COVID-19 pandemic. Prev Med. 2020;141:106263. doi:10.1016/j.ypmed.2020.106263

Of note, 

• Hospitals: work off a budget (profit) model; administrators make short term decisions, rather than long-term vision and goals. PPE is not charged/billed to patients or insurance companies. It is simply a cost to hospitals. Therefore they have no motivation to have updated stockpile.
• Demand shock: common during pandemics, leading to hoarding affected PPE, increased cost
• Government: Trump admin in trade war with China, slow to enact defense production act, federal stockpile inadequate (3 million masks, if 30% of population sick we would have needed 3.5 billion masks). Noted, expired federal stockpile, not restocked by prior administrations
• Supply Chain: US is an exporter of health goods, importer of goods from China. Cost 6x Nn5, gowns doubled cost

Duty to care

Healthcare workers have a great social contract with the public: we have a duty to care. 

But it's not that simple. The Joint Centre for Bioethics Pandemic Work group states, "The Healthcare worker enters into a broad social contract that not only creates their duty to care, but places obligations on society to keep them as safe as possible" 

In this instance society did not keep us safe. And as this social contract disintegrated, our duty to care was undermined.

Race in medicine, racism in medicine. 

Of note, Dr. Carmen points out, there were so many people not cared for during the pandemic. 

We all remember the widespread demonstrations around the world after the murders of George Floyd and Breonna Taylor-- due to ongoing police violence toward people of color. 

There is the reality that medical education and training and medical practice are ripe with racism. Examples Dr. Carmen provided:

• Medical schools continue teach racial inferiority theories-- leading to inequitable management of HF, kidney disease, VBAC. For more information, see this NEJM paper. 
• There is the widely-known Tuskegee Syphilis study and its repercussions, where respected clinicians and scientists intentionally harmed black bodies. 
• Pediatric ED study from 2019, in which providers less likely to order tests/admissions for Latinx and Black children
• And widely held beliefs amongst medical students and resident trainees measured in 2016 that black people  literally have thicker skin than white people and therefore feel less pain. 

Race and COVID

Physicians of color are more likely to care for patients of color. They are also more likely to experience discrimination during patient care, have limited financial safety nets for themselves. And, of course, be more impacted by COVID-- both personally and professionally-- during this pandemic. 

There is the plain fact that COVID disproportionately affected Latinx and Black people all over the US. This applied to our local cases as well.  Physicians of color-- our own trainees here at SRFMR struggled in the winter with their own sense of transference and countertransference as patients of color died before their eyes (see quote below).

Global Inequity

And inequities abound, including in distribution of these highly effective vaccines against COVID-19. Much of the world is anxiously still awaiting access to a vaccine that many Americans are outright rejecting.

What about reciprocity?

In return for accepting personal risk in fulfilling our duty to treat, healthcare workers expected reciprocal social obligations. We wanted people to be careful: to social distance, to wear masks, to limit travel and parties. These obligations would demonstrate support and acknowledge our work in difficult conditions. Unfortunately, however, many in our society-- many of our own beloved patients, in some cases our beloved family members-- have not done a great job of reciprocity. 

In fact, basic public health orders: social distancing, masks, and vaccine recommendation have been flaunted. And, yet again, as people have chosen to not be compliant with public health orders, we healthcare workers watch these numbers rise again. And we continue to go to work and care for our patients. 

This lack of reciprocity leads us to compassion fatigue. Many of us care for patients all the time who make poor decisions-- watching those intentionally make the decision to NOT get vaccinated adds insult to injury. At this point in the pandemic, it makes us tired. Tired of caring for those who are choosing not to care for themselves.

And, then there is the notion of  moral injury, defined as psychological harm caused by transgressing one's deeply held values (altruism, do no harm). We are literally living an allostatic load (getting hit over and over), moments of harm that cause neurologic changes to our brain and, for some, will cause PTSD. Physicians already have higher rates of suicide than general population. We already stink at searching out help. Covid adds to these risks-- making us more socially isolated, reducing our access to support (families and friends) in a profession that does little to seek mental health services

Those of us in Sonoma County who lived through the Tubbs Fire of 2017 and the fires that have since ensued, recognize deeply this graphic on the phases of collective trauma: a sudden impact--> heroic phase--> disillusionment (where we see limitations)--> restoring/rebuilding phase--> wiser living phase.

But, Dr. Carmen points us, COVID feels more like this. Like we might never get to the wiser living phase and are maybe stuck in the disillusionment phase forever. . .

So, says Dr. Carmen, the hero narrative isn't enough. It leaves us feeling let down because it

• fails to address limitations of budget centered hospital model
• is a poor reflection of government inaction
• removes a sense of reciprocity and their responsibility during a global crisis
• centers discussions of racial inequality on individual patients and not institutional change
• did not protect our public health initiatives
• only superficially addresses the mental health efforts of providers 

And so, Dr. Carmen proposes, we need to reject the narrative of the healthcare hero and consider one of  the rhetorical triangle-- a NEW narrative in which we use our physician experience, our facts and our credibility to share our stories about COVID-19 about healthcare about social inequities and push toward institutional and systems change. here's how:

• Logos: dissect our fact to convince our audience
• public health over profit: with regards to PPE, remove profit motive. Strengthen local and state government to have stockpiles, Change industry policy to less foreign alliance, innovative/reusable PPE. Increase physician training pipelines. Change the way we deliver healthcare (e.g. concierge for safety net, wraparound services), explore models of innovative healthcare
• Ethos: build on ethics, sense of credibility. 
• Address racism in medicine. Redesign curriculum to eliminate race-based science, support physicians of color, all healthcare workers of color. Support public health initiatives that use community-based participatory tools to target racial inequality (e.g. Promotora models)
• Pathos: being vulnerable with our emotions. 
• Work collectively to build resilience. Support unionized healthcare workers who are most vulnerable (RNs, EVS, resident physicians), build a stronger telemedicine curriculum, normalize time to access mental health resources (encourage healthcare workers to go to those mental health visits), pay appropriately for work/hazard we have experienced. CA AB650 Retention Bonus (hazard pay), and more.

Can we?

Can you?

Type 2 Diabetes Management: What is new in 2021? (Magnotti, 8/18/2021)

SMGR Endocrinologist, Dr. Michael Magnotti, gave an information-packed review of the latest and greatest in DM2 management at Grand Rounds this week. It was fast and furious and full of really great info on updated management of DM2. A video recording of Dr. Magnotti's presentation is available HERE .

Here are my take home points up front:

1) Goals for DM management should include: achieving a specific a1c goal (based on age, risk factors, etc), avoiding hypoglycemia, avoiding weight gain (promoting weight loss if possible), minimizing side effects, and decreasing CV events. Insulin, unfortunately, doesn't accomplish many of these goals.

2) SO. . .first line, old school for DM management, is still metformin AND comprehensive lifestyle changes (including weight loss and physical activity)

3) Second line meds should be GLP-1 receptor agonist OR an SGLT-2 inhibitor for ALL diabetics. This is because these meds reduce a1c, do not cause hypoglycemia (unlike sulfonylureas), promote weight loss, and decrease CV events. This is even true if a1c is at goal (see ADA guidelines below)

4) SGLT-2 and GLP-1 have additional indications for which we might consider them regardless of DM; with established ASCVD, and heart failure (HFrEF and HFpEF), and chronic kidney disease with GFR>30 and/or proteinuria. There is rapidly evolving evidence that even in the absence of DM2 (or DM with good control), these medications can improve outcomes. More and more, the are be covered by insurance for these indications alone

5) GLP-1 agonists have the most potent a1c lowering and weight loss effects. They also clearly reduce CVD risk.

6) In addition to CVD risk reduction, SGLT-2 have evidence for improved outcomes in heart failure and CKD. This is a class effect. Don't get caught up on individual indications for which med. All SGLT-2 except ertugliflozin, the oldest and cheapest) impact all three conditions.

***

Dr. Magnotti showed us this image of the Ominous Octet-- the eight pathways through which hyperglycemia occurs with DM2. You can see which mechanisms are in effect with the GLP-1 and SGLT2 medications. 

This, too, for your reference is the most updated graphic version of the 2020 ADA guidelines. Note the two LEFT columns, we are to consider the addition of meds for ASCVD, HF and CKD independently of a1c. The RIGHT two thirds of the page direct us to consider medications based on a1c not being at goal.

https://care.diabetesjournals.org/content/diacare/43/Supplement_1/S98/F1.large.jpg

For the life of me, I cannot EVER remember their names of these newish classes of meds and which is which. I think I am getting old. So for your reference and mine:

GLP-1 Analogs: semaglutide (Ozempic injectable, *newer oral form Rybelsus), liraglutide (Victoza), dulaglutide (Trulicity), and exenatide (Byetta)

SGLT-2 Inhibitors: canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance), ertugliflozin (Steglaro)

Okay, so let's recap the key points on both these categories of meds. 

First GLP-1:

• GLP-1 agonists begin working as soon as food hits the mouth--> hormonal disruption leading to decreased glucagon production and increased insulin, early satiety, and slowed gastric emptying (which is why they help with weight loss)
• if patients complain of nausea with GLP-1 it's probably because they are eating too much, need to cut back on food intake and nausea may improve
• GLP-1 agonists have been shown:
• 1-1.8% reduction in a1c
• 4-13 pounds weight loss
• NO hypoglycemia
• CV risk reduction
• Side effects: nausea/vomiting/constipation/Headache/injection site reaction/hypoglycemia (only if combined with insulin or sulfonylurea), and unclear link with pancreatitis
• Absolute contraindication: black box for animal studies showing association with medullary thyroid cancer and MEN2
• Relative contraindications: CrCl<30 (except exenatide, which has no SCr cutoff and okay in HD). There is a warning of AKI, which is a result of volume depletion
• GLP-1 Agonists that are HUMAN GLP-1 based: semaglutide, liraglutide, and dulaglutide (all of them EXCEPT exenatide) have CV risk reduction
• Oral semaglutide has no CVD reduction data (trials ongoing)

What's new about GLP-1 medications in 2021?

• Higher doses of dulaglutide (Trulicity (3.0 and 4.5mg)) have new data showing even more improvements in Hba1c, increased weight loss, but also more nausea (makes sense). 
• Titration can happen weekly, starting with 0.75mg--> 1.5mg--> 3--> 4.5 as tolerated
• Newish oral semaglutide MUST be taken on a completely empty stomach (with no other meds and <4 oz of water) to be effective. Otherwise it doesn't work
• Injectable dulaglutide now how has primary prevention data for CVD 
• consider rx'ing for patients with high CV risk
• Injectable semaglutide at high doses (2.4 mg vs. normal 1.0mg dose) has shown promise for even more weight loss 10-16% of body weight, with over 50% of patients losing 15% of their body weight

Okay, onto SLGT-2: 

• SGLT-2 meds block reabsorption of some (not all) of glucose from the tubules, causing glucosuria and urination, essentially a diuretic effect. They also have a Na effect on urine
• You can consider their positive impacts as a class effect, except ertugliflozin. You can use most of these interchangeably for CV risk reduction
• SGLT-2 studies show:
• A1c reduction 0.8-1.2% (little less than GLP-1)
• BP reduction of about 5mm Hg
• Weight loss 2-4% of body weight
• Renal protection (DM or CKD without DM)
• CV mortality risk reduction
• HF reduction (diagnosis and exacerbation, HFrEF and HFpEF)
• 3 point MACE reduction
• Contraindications to SGLT2: renal insufficiency (GFR<30, though data evolving), caution in advanced age (risk of orthostasis, volume depletion)
• Side effects: yeast infection (women>>> men, okay to treat through the first yeast infection, but if recurs, should stop), polyuria, volume depletion and transient decrease in GFR, orthostasis, small bump in LDL, hypoglycemia when combined with insulin/sulfonylureas, DKA with minimally elevated blood sugar, fournier's gangrene

What is new in SGLT-2 in 2021?

• Renal protection data (in BOTH diabetic and non-diabetic CKD)
• Canagliflozin RCT in pts with DM2 w/CKD with proteinuria--> decreased doubling of SCr, ESRD, renal death
• Empagliflozin in pts with DM2 with or without CKD--> reduced rates of doubling creatinine, progression to proteinuria, initiation of RRT, and renal death
• Dapagliflozin in pts with CKD GFR 25-75 and proteinuria (+/- DM)--> decreased doubling SCr, end stage renal disease, renal death (almost 50% risk reduction)
• HF risk reduction data (also presence/absence of DM)
• studies found decreased exacerbation of HF as well as diagnosis of HF in patients on SGLT-2 medications
• 30% reduction in hospitalization 
• Full data on HFpEF coming out this month. Stay tuned
• CV risk reduction data
• empagliflozin study found 38% reduction in CV mortality after 3 years of treatment (this is the most dramatic result)
• canagliflozin showed 0.86 reduction in 3 point MACE, liraglutide 0.87 reduction, semaglutide 0.74 reduction

Diverticular Disease (Sawyer, 8/11/2021)

Diverticulitis is. . . 

• the 3rd most common cause of GI illness requiring hospitalization
• the leading cause of elective colon surgery
• a bit unpredictable but often managed medically
• 15% of cases ultimately require surgery 
• surgical indications: medical therapy failure (or not amenable)

Medical management

Medical/conservative treatment of uncomplicated diverticulitis generally involves antibiotics x 7-10 days

Note: there is NO high quality evidence regarding the ideal duration of antibiotics and which abx are superior

Good abx choices include: bactrim DS/flagyl (favorite of Dr. Sawyer), cipro/flagyl, levo/flagyl augmentin, and more

Diet

There is NO high quality evidence for specific dietary management of diverticulitis

Older surgeons prefer clear liquids x72 hours, advancing as tolerated after that (the rationale for this is really about possibility of surgery-- to be better prepared for a bowel prep if a surgery becomes necessary)

Of note, more recently trained surgeons will often let patients eat as tolerated (i.e. ad lib)

Of note, avoiding nuts, popcorn, seeds, corn, tomatoes, strawberries, etc is NOT evidence based and not necessary (JAMA 2008 paper). Do NOT tell patients to avoid these foods to prevent diverticulitis.

Known complications of diverticulitis:

• Perforation
• Fistula
• Obstruction

Perforations that are very small are characterized as microperforations: conservative treatment with abx (oral/IV) is appropriate for microperforations; of note,19% of microperforations go on to form abscesses. Random pearl: diverticulitis as seen on CT often looks "worse" than the patient. 

Classification of perforation

• Microperforation (not included in Hinchey classification system)
• Hinchey I pericolic or mesenteric
• Hinchey II walled off pelvic abscess
• Hinchey III purulent ascites
• Hinchey IV feculent ascites

Hinchey I and II can be managed non-operatively, III and IV should be managed with surgery

4cm abscess is used as the cutoff for IR drain placement

<4 cm diameter, abx alone usually sufficient 

>4cm diameter, IR drain + abx

if an abscess is exactly 4cm, it's at the discretion of the interventionalist/location of the abscess that determines best practice for management

What if it doesn't work?

If patients fail to improve after 48-72 hours of abx (usually repeat imaging is done), the next step is  a bowel preparation (if pt can tolerate it) and a surgical anastomosis. Of note, a "contaminated" peritoneum may require a diversion.

Surgical options:

colon resection w/primary anastomosis: one step, requires well-vascularized, non-edematous bowel, good nutritional status, good immune state (not immunocompromised)

colon resection w/proximal diversion

Hartman's procedure

open vs. minimally invasive: MIS preferred if feasible, shorter hospitalization/ileus and less pain. Long term, outcomes are about equal

Goal of surgical management of diverticulitis:

1. Source control: remove the perforated segment
2. Restore intestinal continuity-- depends on hemodynamics of the patient, degree of contamination, and surgeon preference/comfort

Free perforation (in an unstable patient) requires urgent damage control, which involves limited resection (if possible), peritoneal lavage, and usually a temporary abdominal closure. Alternative is a "Hartman's Procedure" with a limited resection, peritoneal lavage, end colostomy, and temporary closure.

• in a study of 58 patients with generalized peritonitis and perforated diverticulitis, 9% mortality (5 patients). OF the 53 survivors, 44 were stoma free at 2 years (pretty good!)

Stable patient with feculent peritonitis (Hinchey IV) generally requires Hartman's procedure.

• these can be difficult to close (only 50-60% have closure)
• need to wait 6 months to 1 year for all the inflammation to resolve before rehooking

Of note, BOTH require a second look (return to the OR) at 24-48 hours

Fistulas can occur:

colo-vesicular 65%

colo-vaginal 25%

colo-enteric 7%

colo-uterine 3%

Obstruction: if diverticulitis is leading to obstruction, you MUST rule out cancer. Stenting-- while can be helpful in cancer-- is not helpful in diverticulitis

And, finally, the SSRRH Diverticulitis PROTOCOL

• admit with IV abx
• re-image at day 2-3
• if improved on imaging--> abx management (7-14 days)
• if imaging stable OR worse--> 
• if drainable abscess, then IR drain, followed by surgery in 6-8 weeks,
• if abscess NOT drainable, then mechanical bowel prep with surgery in 1-3 days

Elimination of TB in the US: 2021 Updates (Toub, 8/4//2021)

Many thanks to Dr. Danny Toub, a family physician, teacher, and public health professional-- who so often bridges the impossible gaps that exist between individual patient care conundrums and public health. While this bridge may seem intuitive, it is often rickety and not always clear how to begin to build it-- look to Dr. Toub, though, he always shows us the way. 

A recording of his presentation is available HERE. 

This week's topic was Tuberculosis (TB), a global behemoth; the original and ever-present airborne illness that still kills 1.4 million people worldwide per year, more than HIV/AIDS While we sit in the middle of a harrowing COVID-19 Pandemic and the words N-95 have become every day jargon, TB is still global problem. And while we have made great progress in the US with TB eradication, TB still unnecessarily killed 542 Americans in 2018, 200 of which were right here in California.

TB, much like COVID, disproportionately affects people who are living in poverty, people of color, and those who have less access to stable housing and health care services.

What is our responsibility as primary care providers?

• Screen ALL patients for TB Risk
• Screen HIGH RISK patients with a Tuberculin Skin test (TST) or interferon gamma release assay (IGRA)
• Treat Latent TB infections (LTBI)
• Report to Public Health any active TB cases and/or any LTBI in children or recent converters (<2 years)
• Oh, and don't forget to have TB on your ddx for other acute/subacute illness presentations!

If we break that down,

1) Screen ALL patients for TB Risk using the California TB Risk Assessment Tool which can be found HERE and is pictured below as well. 

Remember to AVOID testing low risk folks for LTBI (this form alone counts as a screen!) and if you have limited resources, prioritize those who are most likely to convert from LTBI to active TB. Key risk factors include being foreign born/immigrant from certain regions, immunosuppression, and those who have been in close contact with someone with TB. 

Important additional risk factors include, recent conversion, substance use disorder, patients with DM, patients with CKD, those with autoimmune conditions, people who smoke, people with cancer, and more. 

The point of screening is to prevent a future conversion to active TB by treating people before they get sick. Low risk patients have ~10% lifetime risk of converting. Higher risk (e.g. people with diabetes) have ~ 30% lifetime risk, and highest risk folks (e.g. HIV + LTBI) have a 7-10% per year risk of converting. 

2) Screen HIGH risk patients with TST or IGRA. The best TB test depends on your pretest probability. Here is a good cheat sheet.

• Low risk patient--> do not screen
• Asymptomatic child--> use the California Pediatric TB Risk Assessment
• Asymptomatic adult--> use the CA Adult TB Risk assessment
• Volunteer for school without risk factors--> use the CA Schools TB Risk Tool
• College or University student--> use the CA College tool
• Health care worker--> use CDC guidelines#
• Pregnant woman--> pregnancy itself is not a risk factor
• 2 year old foreign-born patient--> TST*
• Foreign born >2 year old, hx BCG--> IGRA**
• Patient experiencing homelessness--> IGRA
• Patient to start TNF alpha blocker--> IGRA
• Patients with >4 weeks cough, 5 pound weight loss--> Chest Xray
• SE Asian smoker with RUL cavity, and a1c>9%--> sputum (x-pert MTB)+

#Note that the CDC no longer recommends annual TB testing for healthcare workers!! Official recommendations released in 2019 are available here and recommend a risk based technique. Maybe that means YOU don't need that annual TST!

*TST: tuberculin skin test, **IGRA: interferon gamma release assay (often referred to as quantiferon gold). There is limited data in IGRA in children <5. IGRA are more specific than TST in pts with a history of a BCG vaccine.

+Remember, a negative IGRA or TST does NOT rule out active TB (you need sputum!)

3) Treat LTBI infection. Treatment for LTBI has been shortened and simplified over the last decade. It does not involve routine lab work (except in high risk folks) or directly observed therapy (DOT). 

Dr. Toub recommends this handy LTBI pocket card to help simplify your decision-making and treatment regimen planning. The image below to too small to actually read, but follow the link for specifics on indications, completion criteria, considerations, etc. 

Briefly, prior to initiating LTBI treatment, you want to be sure to r/o pregnancy, check for pre-existing peripheral neuropathy (which can be a side effect of tx), screen for liver disease risk factors (e.g. alcohol use disorder, NASH, HCV). 

Baseline LFTs are only indicated for patients with HIV, known liver disease, regular alcohol use, pregnancy or < 3 months postpartum, and other risks for liver disease.

And, Dr. Toub reminded us to remind your patients that EVERYthing will be orange (sweat, tears, and urine). Also be sure to check for drug drug interactions on any tool that you use for this purpose, as there are many. 

4) Report to SoCo Public Health any active TB cases and/or any LTBI in children or recent converters (<2 years). 

5) Oh, and don't forget to have TB on your ddx for other acute/subacute illness presentations! Remember TB can show up just about anywhere. 

For local assistance, you can utilize the Sonoma County TB Control Guidelines, which you can find at the bottom of this webpage. And if you ever have any TB questions, reach out to our local TB Control program at 707-565-4567.

And, finally, a list of trusted resources from Dr. Toub: