Regional dental clinic meets a need

During its first year, the Rice Regional Dental Clinic at Rice Memorial Hospital had 6,207 patient visits and completed 13,311 procedures, ranging from fillings to extractions.

Even before the clinic opened, health officials knew there was a need for dental services for low-income and uninsured people who had nowhere else to go. But the demand has been even higher than anticipated.

The Rice Regional Dental Clinic is a partnership between Rice Hospital and the University of Minnesota. Dentistry and dental hygiene students from the university come here to complete a rural rotation, during which their skills are sharpened and they have a chance to experience firsthand what it’s like in a rural dental practice.

Over the past 12 months, students were on site for 219 days. On an average day, they saw between 25 and 30 patients. The largest patient category is children and teenagers. Most of these patients have dental insurance through either MinnesotaCare or Medical Assistance, both of which are publicly funded.

Although the majority of patients are from Willmar, they also come from as far away as Detroit Lakes, Moorhead, Mankato and St. Peter.

State and federal grants, plus an allocation from the Minnesota Legislature through the state bonding bill, helped launch the clinic and training program and fund it for the first three years. Hospital officials reported recently that the revenue from patients has been higher than projected, which will help the program somewhat decrease its reliance on grant money.

Invasion of the bedbugs

Bedbug infestations are on the rise across the United States – even in rural Minnesota, where four cases have been reported recently in Worthington, the Worthington Daily Globe reports.

Three of the infestations occurred in rental property; the fourth was in a local motel, which had to be fumigated.

Jason Kloss, sanitarian for Nobles-Rock Community Health Services, said bedbugs often spread on mattresses, furniture, clothing and luggage.

"Never pick up furniture or mattresses from the side of the street – that is the first lesson to be learned here," said Kloss, who investigated all four of the reported bedbug infestations. "Simply picking one up because you need a mattress is not a good plan at all. The infestation may be very evident on the mattress (or box spring) or it may not be."

To see what bedbugs look like, here’s a video. (Warning: don’t click on the link if you’re easily creeped out by bugs.)

Bedbugs usually hide during the day and emerge at night to feast on their human hosts. They rarely transmit disease, but their bites can cause itching and redness and, rarely, a more widespread skin reaction or allergic reaction. You can find out more about these pests and how to deal with them at the Mayo Clinic’s Web site.

Should we stop eating peanut butter?

The pint-sized carton of Ben and Jerry’s Peanut Butter Cup ice cream in the freezer section at the grocery store last night looked tempting (it’s my favorite flavor) but I passed it up and bought the Coffee Heath Bar Crunch instead.

As the salmonella investigation widens, so do the questions: What’s safe? What should be avoided?

To recap, nearly 500 hundred people across the United States (35 in Minnesota alone) have been sickened by salmonella, the source of which has been traced to peanut butter and peanut paste manufactured by Peanut Corporation of America at its processing plant in Blakely, Ga.

Neither product is directly sold to consumers. But as investigators have delved into the case, they’ve learned that peanut butter and peanut paste from the Blakely plant have been distributed to more than 70 companies for use in products ranging from cookies, crackers and cereal to candy and yes, ice cream. Even some brands of dog biscuits have been affected.

The FDA’s latest update offers some reassurance about the major national brands of peanut butter sold by the jar. At this time, these products have not been recalled and are believed to be safe for consumption.

Companies that sell or distribute the recalled peanut products have been asked to pull them from their shelves.

But according to the FDA, officials are still working to identify all the potentially contaminated products that might still be on the market. This means there’s a chance that the recall list could be expanded.

To help answer consumers’ questions, the FDA has put together a searchable database of products and lot numbers that have been recalled. The agency says it will update and revise the list as new information comes in. This database should be consumers’ first stop in their quest to find out whether any peanut-butter products in their cupboards or on their grocery list are included in the recall.

From the U.S. Centers for Disease Control and Prevention comes this advice:

- Do not eat products on the recall list. Throw them away in a manner that prevents others from eating them.

- Postpone eating other products containing peanut butter, such as cookies, crackers, candy and ice cream, until  more information is available on which brands are affected.

- If you’re concerned about a product, check the FDA’s online database. Or you can check with the manufacturer directly, either through a phone call or the company’s Web site.

- If you think you have become ill from eating a product containing peanut butter, contact your health care provider.

- People with pets can learn more at this Q and A posted on the CDC’s Web site.

Health care challenges lie ahead for the White House

America’s new president talked about health care during his inaugural address on Tuesday, but as MedPage Today reports, few specific details were provided:

Similar to his election night victory speech in Chicago, Obama’s inaugural address sought to inspire Americans rather than lay out specific policy proposals.

The president reiterated, however, that one of his goals is using technology to improve health care.

Bob Doherty, a lobbyist for the American College of Physicians, has some sober reflections on the ability of the new administration to deliver on its promises:

The demand is overwhelming. The recession will cause millions of Americans to join the already bloated ranks of the uninsured. State governments are pleading for help from Washington for funds to keep their Medicaid programs afloat. Employers want help paying their employees’ premiums. Will the Obama administration have the capacity to organize a federal response sufficient to meet the demand? And with a trillion dollar deficit, will it have the wallet needed to deliver on its will to reform health care?

Doherty observes that controlling health care costs is likely to be a key focus of the Obama administration. It’ll be a huge challenge, however, and "will test the capacity of our new President to bring about the change we need," Doherty says.

Commenters on Doherty’s blog, the ACP Advocate, agree.

Although health care reformers talk about reducing waste and inefficiency, how do you define what’s wasteful, a physician commenter wants to know. "President Obama will have stiff opposition to reduce health care costs," he predicts.

Consumers need to get on the bandwagon as well, urges another commenter: "We as patients need to not be lulled into a false sense of security that repeated office visits and testing will lead to good health, but rely on changing life styles and asking those difficult questions, such as: Is this necessary?"

On the Mall, medical tents were busy

Workers at the 56 medical tents and warming stations set up along Washington, D.C.’s landmark Mall for the inauguration on Tuesday probably didn’t see much of the ceremony or the parades. They were too busy attending to the hundreds of patients who sought care - most of whom were either suffering from the cold weather or from chronic conditions and other problems exacerbated by the cold.

Hundreds of people had to seek medical attention, the Washington Post reports.

Marshall Anderson, park ranger and paramedic, arrived at his first aid tent northeast of the Washington Monument at 5:30 a.m. yesterday. His first patient arrived at 5:31.

"She walked in right behind me," he said at midmorning, by which time he and his colleagues had seen 17 people.

The first patient, a Maryland woman in her 30s on dialysis, "was on a shoebox full of medications," Anderson recalled. "She was cold, and she just wasn’t feeling well."

His advice after a quick assessment: Go home and watch the inauguration on television.

Not dressing warmly enough was one of the most common problems. Some people got dehydrated and hungry; others had chronic health problems, such as asthma, flare up because of the cold. And personnel at one of the medical tents had to treat a young woman who had a grand mal seizure.

National Park Service rangers and federal employees from the U.S. Public Health Service and other health agencies were brought in to staff the first aid stations.

Off the Mall, the Washington, D.C., Department of Health operated 13 tents, 13 warming buses and four warming rooms, the Post reported. The Health Department also staffed first aid stations at 10 inaugural balls and evening events.

The hardest words

Last in a series

When a Twin Cities hospital made the headlines a year ago after the wrong kidney was removed from a patient, one of the most newsworthy aspects of the story was that the error was even publicly disclosed, let alone explained and discussed.

As recently as five years ago, this might not have happened. Increasingly, however, health care providers are recognizing the value of disclosure – being honest with patients and families when something goes wrong. More than that, they’re starting to learn the value of saying, "I’m sorry."

Disclosure. Honesty. Apology. These are some of the hardest words in medicine.

After a medical injury or error, most patients and families want to know what happened, how and why, writes Dr. Lucian Leape, one of the American gurus of the patient safety movement. Patients and families want someone to take responsibility, and if an error was involved, they want someone to admit it and apologize. They also want the hospital to undertake an investigation and corrective action to make sure it doesn’t happen again.

Historically, however, there’s often been "a big difference between the care patients expect and what they receive after a medical error occurs," Leape says.

For too many patients, a clear acknowledgment that a mishap has occurred is not forthcoming; no one seems to be responsible for what happened or for explaining it, and no one apologizes. There is a sort of charade of pretending either that nothing very important happened, or that the causes are mysterious and unknowable. Patients meet a wall of silence.

Why is this so? The reasons are "many and complex," Leape said. For one thing, most health care providers have not been trained to have these kinds of conversations. For another, there’s an ever-present fear of lawsuits and damage to one’s professional reputation; in fact lawyers and hospital risk managers have usually advised physicians not to admit responsibility or apologize after a patient is harmed.

There’s now a general consensus that being truthful with patients and families is the right, ethical thing to do. Indeed, one of the earliest studies on the issue maintains that "extreme honesty may be the best policy." And the Joint Commission, the main accrediting body for hospitals in the U.S., now requires hospitals to have written policies on disclosing unexpected outcomes to patients and families.

One of the leading advocacy groups for disclosure and apology is the Sorry Works! Coalition whose founder, Doug Wojcieszak, lost a brother to medical error. In a white paper for the Joint Commission, the coalition describes its mission this way:

Sorry Works! entails changing the culture of medicine, medical risk management, and the associated insurance and legal support structure, which requires leaders and decision makers to implement a multi-pronged educational effort in their respective fields. Practicing health care professionals and students must be taught that Sorry Works!-type disclosure is the new way and that covering up errors and bad outcomes is no longer acceptable. This culture shift will not happen overnight, but the anticipated economic and ethical benefits make the long journey worthwhile.

The coalition believes that when patients and families receive a truthful and compassionate explanation of what went wrong, they are less likely to sue, and the relationship between doctor and patient is less likely to be shattered.

Apology is "the first step" in healing for everyone involved, Leape says.

It helps us deal with the normal shame and guilt we feel and provides an expression of the normal empathic concern we have for those we have harmed. By restoring the balance – we’re both hurting – it begins to restore the relationship, which is important to both parties.

Conversely, failure to apologize, or even accept responsibility, is incredibly damaging for the patient and for the relationship. Failing to acknowledge that something went wrong is incredibly disrespectful. It is also dishonest. That dishonesty is corrosive not only to the patient’s trust, but to the physician’s integrity.

Apologizing, in fact, "may be the most important thing we do after a serious event, both to help the patient heal and to heal ourselves," Leape said.

And how do patients feel when someone says, "I’m sorry"?

Trisha Torrey became a patient advocate after being mistakenly diagnosed with a rare and deadly form of lymphoma when in fact she didn’t have cancer at all.

To have a pathologist apologize for the mistake was intensely moving, she writes.

I wept, all the way home.

It’s like this huge elephant has exited the room, a weight has been lifted from my shoulders. You choose the cliche. The emotion is overwhelming.

For anyone who’s ever been harmed by a health care provider or wronged by the system, said Torrey, "know how important it will be to hear that apology from him/her."

Air-to-fakie, or air-to-injury?

Those snowboarding bonks and grabs and air-to-fakies may look inspiring on ESPN, but they can result in serious injuries to snowboarders.

A recent study looked at skiing and snowboarding injuries sustained in terrain parks at two western U.S. ski areas. Among the findings: Male teenagers have the highest injury rate, and head and spine injuries are becoming alarmingly more common.

These are some of the most severe injuries, typically requiring treatment at a hospital, said Dr. Alison Brooks, a sports medicine physician with University of Wisconsin Hospital and Clinics and the lead investigator of the study.

Deaths related to skiing and snowboarding are rare, accounting for 20 to 40 fatalities in the U.S. each year. But they’re still devastating, especially since this is a relatively young and healthy demographic. As snowboarding increases in popularity, the number of injuries also is rising – and snowboarders are more likely to sustain a serious injury than are skiers.

Brooks said some researchers believe the rise in head and back injuries among adolescent snowboarders can be at least partly attributed to terrain parks, which came on the scene in the mid-1990s. Designed with man-made features such as rails, boxes and half-pipes, they allow snowboarders to jump and do aerial maneuvers – but at the same time raise the risk of jumping and landing in a way that causes injury.

One of the study’s more surprising findings was that kids who were injured while snowboarding weren’t necessarily novices. Often they reported themselves as intermediate or advanced boarders.

Brooks said it raises the question of whether these kids are overestimating their skills, or whether they have the skills to try their tricks in a terrain park.

Some ski areas are trying to address this issue by developing different levels of terrain parks based on the difficulty of the features. Many have started injury surveillance and safety programs and are working to identify and solve problem spots where injuries occur.

Tips for reducing the risk of snowboarding injury:

- Wear a helmet. Although helmets won’t prevent a fall, they can significantly reduce the likelihood of a bad head injury while skiing or snowboarding. Safety gear such as knee, elbow and wrist pads also can help reduce the risk of fractures and other injuries.

- Know your skill level. Snowboarding newbies should consider starting in the easier parts of the terrain park. Lessons also can help beginners learn techniques to reduce their risk of injury.

The second victims

Second in a series

More than two decades later, Dr. Gary Brandeland still remembers the day his patient died after an anesthesia catastrophe during a delivery that was supposed to go normally. He remembers looking out the window and seeing nurses "literally running to their cars to escape the horror of what had just happened."

In a gut-wrenching essay in Medical Economics, Dr. Brandeland describes the days, weeks and months that followed: how his colleagues avoided him, how patients walked out on him, how he felt "like I was being beaten with a baseball bat, physically and emotionally."

They’re sometimes called the second victims – the doctors, nurses and other health care providers involved in an event that harms or kills a patient.

In a paper originally published in 2000 in the British Medical Journal and now considered a classic, Dr. Albert Wu of the Johns Hopkins School of Public Health writes about how health care professionals feel when something goes wrong:

Virtually every practitioner knows the sickening realization of making a bad mistake. You feel singled out and exposed – seized by the instinct to see if anyone has noticed. You agonize about what to do, whether to tell anyone, what to say. Later, the event replays itself over and over in your mind. You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient’s anger.

A study that looked at the impact on doctors of medical mistakes found that physicians often remembered mistakes in detail, even after several years. Even the perception of having made an error left physicians with "significant emotional distress," the researchers found.

When Massachusetts General Hospital hosted a roundtable session to allow staff to share their own experiences about making an error, the topic struck a painful nerve.

The participants talked about feeling guilty, vulnerable, anxious. They often felt a strong sense of responsibility, and they agonized over what they might have done differently.

It was apparent that people could actively recall exactly how they felt at the time the error was realized and that these emotions can imprint a permanent emotional scar.

Some of them coped with it by rationalizing their actions, minimizing the harm or blaming the patient or the disease process. Others had a crisis of self-confidence in their skills and abilities.

One of the findings from the roundtable was that health care teams often pulled together when the patient was harmed in spite of high-quality care:

In situations when the right thing had been done but an unpredictable adverse outcome or a foreseen detrimental outcome occurred, staff often found solace in the fact that they had done or attempted to do the right thing to the best of their ability at that time. In such situations, teams often shared responsibility in a protective liaison.

Historically, however, health care professionals – especially physicians – who’ve been involved in an injury to a patient have often looked in vain for support from their colleagues. Here’s Dr. Wu again:

Sadly, the kind of unconditional sympathy and support that is really needed is rarely forthcoming. While there is a norm of not criticizing, reassurance from colleagues is often grudging or qualified… It has been suggested that the only way to face the guilt after a serious error is through confession, restitution and absolution. But confession is discouraged, passively by the lack of appropriate forums for discussion, and sometimes actively by risk managers and hospital lawyers. Further, there are no institutional mechanisms to aid the grieving process.

Nurses, pharmacists and other members of the team also are vulnerable to the fallout from medical error, Wu said.

Given the hospital hierarchy, they have less latitude to deal with their mistakes; they often bear silent witness to mistakes and agonize over conflicting loyalties to patient, institution and team. They too are victims.

What can be done to make the experience of error less harrowing for the health care professionals involved? Experts suggest the same approach as for the patients and families who are victims: bringing it out into the open so they can understand and learn from it.

The hosts and authors of the roundtable survey at Massachusetts General Hospital say this is "the first step in minimizing the emotional damage to both the patient and the doctor."

Expressing regret to the patient and trusted colleagues starts the process of learning from the error, taking measures to prevent recurrence and facilitating emotional adjustment. Hiding a "heart of darkness", soiled by guilt and fear, often causes a physician to harbor significant emotional distress.

Support also is important, according to Medically Induced Trauma Support Services, a nonprofit Massachusetts group that offers information and emotional support to clinicians as well as patients and families who’ve been involved in an error.

We come to work every day to provide the very best care for our patients, and when things go wrong we are not well trained to deal with the aftermath of these events, nor is the healthcare system designed to provide us with support. We are often left feeling isolated and with a sense of shame, guilt and incompetence. The fear of litigation discourages communication with patients, families and colleagues, and the involved care providers are expected to return to their routine patient care as though the event was absent of emotional impact.

Dr. Matt Anderson, a young Minnesota physician, learned lessons in humility and tolerance after being sued early in his career. In a prize-winning essay for Minnesota Medicine, he pleads with his peers to give each other the benefit of the doubt. "I tell them that all the best practices and all the risk-management protocols in the world may not protect them if they get a bad result," he wrote. "It happened to me."

Next: The hardest words

Flu tracker, week 1

What’s happening with influenza during week 1, the week of Jan. 4-10 (How did we get back to week 1? The CDC’s numbering system uses the calendar year, which makes the first week in January week 1):

According to the U.S. Centers for Disease Control and Prevention, influenza activity is still relatively low nationally but has been on the increase. One state had widespread flu activity, 10 states had local activity and one state reported no flu activity. The District of Columbia, Puerto Rico and 33 states had sporadic activity.

In Minnesota, influenza activity remains sporadic but has increased slightly from previous weeks. The Minnesota Department of Health reported that the most common flu strain being seen at the state’s Public Health Laboratory is the type A strain. Flu strains that are resistant to antiviral medication also have been circulating in the state.

No outbreaks of flu in Minnesota schools or long-term care facilities were reported during the week of Jan. 4-10. At the state’s 30 sentinel sites for influenza surveillance, 0.49 percent of patients presented with influenza-like illnesses.