Central PA Medicine Spring 2024

WE DIDN’T CHOOSE

A HIGH-RISK PREGNANCY, to have but we did choose

UPMC.

- Cassandra and Dalton S. Central, Pa.

Cassandra and Dalton were thrilled to learn they were expecting twin girls, but the pregnancy took a scary turn at 16 weeks. One baby’s amniotic fluid was low, putting both babies in jeopardy. The couple was referred to UPMC Magee-Womens in Central Pa., a member of the state’s largest network of top-rated maternity care, where they received advanced care for the remainder of the pregnancy. Today, both girls are thriving. “The team of experts cared for our girls even before they were born,” Cassandra said. For more information about advanced care, visit UPMC.com/ChooseCPA.

Joseph Answine, MD President

Andrew Lutzkanin, III, MD Vice President

Everett C. Hills, MD

Secretary/Treasurer

Shyam Sabat, MD

Immediate Past President

Michael D. Bosak, MD

Robert A. Ettlinger, MD

John Forney, MD

John D. Goldman, MD

Virginia E. Hall, MD, FACOG, FACP

Saketram Komanduri, MD

John C. Mantione, MD

Mukul Parikh, MD

Gwendolyn Poles, DO

Andrew J. Richards, MD FACS, FASCRS

Jaan Sidorov, MD

Andrew R. Walker, MD

William Wenner, Jr., MD

Paul Williams, DO

Gerard

, DCMS Executive Director

Joseph F. Answine, MD, Editor in Chief

Robert A. Ettlinger, MD

Gloria

Puneet

Mukul

Meghan

FREEDOM OF SPEECH COMES WITH A PRICE PAY IT

By JOSEPH F. ANSWINE, MD, FASA

It is exciting to be writing an editorial for the “reboot” of the Central Pennsylvania Medicine magazine. As president of the Dauphin County Medical Society and editor of the magazine, it is an honor and privilege to be able to place my thoughts and feelings in print as a practicing physician and anesthesiologist.

But free speech is not free. As opposed to many other countries, our First Amendment states that we have freedom of expression without government restraint. Obviously, it is not protected if the speech or other means of expression are obscene, plagiarized, defamatory, or a threat to our country or another individual as the Supreme Court has clarified over the years. But, even without government intervention, your words have consequences, and to assume otherwise is foolhardy.

I wrote an editorial in November 2023 published in a national newsletter (War Games: Private Anesthesia Group Versus Hospital System Versus Private Equity Firm. Anesthesiology News. Online, November 28, 2023, and Hardcopy February 2024) that was telling but controversial.

Of course, I did not expect the government to intervene, however, I knew other significant entities would take notice. After its publication, I was told by one colleague that I just committed career suicide. Since I am in my seventh decade of life and my career is in its fourth, it would be more akin to a slow lingering death. Regardless, I knew what he said could be true.

Pushback and some retribution did come.

Many ask, knowing what I know now, would I still write the editorial? I thought long and hard about it. Answer: Absolutely!

When we exit this world, the memories we leave behind of importance are those of love, integrity, and some life lessons for those that follow us.

If you think it is the right thing to do, and it will help more than it will hurt, use that which is protected by the First Amendment of the United States Constitution and pass it on. Educate and enlighten the world, or your little part of it.

EXECUTIVE DIRECTOR'S Message

A MESSAGE FROM THE DCMS EXECUTIVE DIRECTOR,  GERARD EGAN

Dear DCMS Members,

As we enter a new quarter, I am excited to reconnect with all of you and introduce myself to those of you who may be new to our Society or publication. I’m Gerry Egan, the Executive Director of our esteemed Dauphin County Medical Society.

My professional background includes extensive experience in financial and operational management activities for both hospitals and physician group practices. I have a public accounting background combined with a variety of healthcare financial and managerial roles which, hopefully, will help me to bring practical, technical, supervisory, and relationship building experiences to you, the members of our Society.

More specifically, my past experiences include strategic planning, project management, financial statement analysis and reporting, budget preparation, cash flow forecasting, payer contracting, payment compliance and denial management. I have deep experience with OAG and FTC regulatory proceedings, coordinating physician work session resources based on best practice protocols, managing practice mergers and acquisitions, “on boarding” of physicians and advanced practice providers, facilitating property and equipment project feasibility along with the required due diligence, and interacting and collaborating with hospital leadership, physicians, bankers, accountants, and attorneys.

I understand and appreciate the unique concerns and intricacies of the current and foreseeable challenges facing healthcare systems and physician practices. I am committed to building a stronger bond between our physicians, our healthcare partners, and our Dauphin County community members through professionalism and respect.

Within the pages of this issue, you can expect a mix of content thoughtfully curated by practicing physicians, local leaders, and community members. From the latest medical news or educational articles to local stories, our overarching goal remains the same: to provide you with articles that both inform and resonate with your interests and current events.

One of the highlights of this quarter is the launch of our new website, a user-friendly platform designed to better serve our current members, welcome new members, and engage with the community. This will serve as a hub for accessing resources, staying up to date on events, housing the digital Central PA Medicine magazine, physician directory, and more.

In addition to our website launch, we are expanding our social media presence on Facebook. We aim to broaden our reach by sharing engaging content with members and the community. We invite you to follow us on Facebook and stay connected!

Lastly, as part of our ongoing commitment to keeping our members informed, we will be ramping up our email marketing efforts. Through the distribution of regular newsletters, and timely updates and announcements, we strive to provide you with pertinent, relevant information, and opportunities for involvement.

To digest the full impact of these new communications and marketing initiatives we invite you to read more on page 8.

In conclusion, I want to thank you all for your continued support of the Dauphin County Medical Society. We hope that you find this edition both informative and inspiring, and that our new initiatives for 2024 will further enrich your experience with us. I am grateful for this community’s continued support!

Paving the Way for a Stronger Dauphin County Medical Society

Through the Utilization of Strategic Marketing Initiatives

By GERARD EGAN, DCMS EXECUTIVE DIRECTOR

In the rapidly evolving landscape of healthcare, effective communication and marketing strategies have become essential for medical societies to grow and thrive. The Dauphin County Medical Society (DCMS) is taking a proactive approach by embracing new marketing techniques to enhance our member engagement and community outreach. Through the development of a new website, the use of strategic email campaigns, and a strong social media presence, DCMS is setting the stage for a successful program that caters to the needs of its members.

At the heart of DCMS’s revitalized marketing approach lies its newly created website, a pivotal element in connecting members and the community. Offering a user-friendly interface and seamless navigation, the website features a physician directory for easy colleague identification. Our updated calendar will help you stay informed of medicine-related community events, board meetings, executive committee meetings, and more. Convenient links provide access to valuable member resources, ensuring essential tools are at your fingertips. Additionally, users may immerse themselves in a digital version of the Central PA Medicine magazine, delving into a wealth of healthcare insights and updates. The DCMS website is your gateway to a well-connected medical community.

We have also embraced the power of email marketing to enhance communication with our members. Tailored newsletters and updates keep members informed about the latest industry trends, legislative changes, community news, and upcoming events. By maintaining an open line of communication, we ensure that our members are always on top of society and community news.

The last piece of DCMS’s digital efforts is social media. Facebook provides us with the opportunity to share timely information, promote events, and foster connections within the medical community. Social media has proven to be an effective tool for building brand awareness and establishing us as a reliable source of healthcare information in Dauphin County.

To undertake this new venture, we’ve established a strategic partnership with MADJ Marketing, our affiliate marketing partner. This marks a significant step in our commitment to staying at the forefront of the dynamic healthcare marketing landscape. By leveraging their expertise, we will continue to enhance our online presence, attract new members, and provide additional value to our existing membership and community at large.

MADJ Marketing stands as a distinguished leader and expert in healthcare marketing, operating as a full-service creative agency and marketing firm located in southeast Pennsylvania, near Reading. With an extensive client portfolio, MADJ specializes in, but is not limited to:

• Crafting innovative social media strategies

• Designing and optimizing websites for maximum impact

• Facilitating talent acquisition and recruitment marketing efforts

• Developing engaging print and digital advertising campaigns

• Producing high-quality video and drone content

• Offering certified promotional products

MADJ is committed to making a significant impact across various industries and markets, ensuring clients stand out and see success driven by their creative and strategic services. Kevin Bezler, President and CEO of MADJ Marketing, stated, “Serving as DCMS’s affiliated marketing partner, our goal is to redefine engagement strategies, not only with current society members but also with new members and the community. Together, we embark on a journey to create impactful and dynamic marketing initiatives that will foster the mission of DCMS, driving positive change.”

Our partnership with MADJ further solidifies our commitment to innovation and sets the stage for a successful and exciting future for DCMS, our members, and the broader Dauphin County community. Together, let’s embrace the opportunities that lie ahead and continue forward as a cohesive team for a bright and healthy future!

THE SYNDROME

Malignant Hyperthermia

The Anes thesia Disease

By JOSEPH F. ANSWINE, MD, FASA

Malignant hyperthermia (MH) is a hereditary disorder of skeletal muscle that classically presents as a hypermetabolic response to being exposed to certain anesthetics. Specifically, halogenated anesthetic gases (desflurane/sevoflurane/isoflurane, etc.) and/or the depolarizing muscle relaxant succinylcholine.

It is now known to also occur rarely in humans with stressors such as exercise, heat exposure, and acute infections such as the flu.

MH susceptibility is commonly due to a Ryanodine Receptor 1 (RYR1) gene mutation usually found on the long arm of chromosome 19. The RyR1 gene encodes for the RyR1 in skeletal muscle.

Commonly, MH follows autosomal dominant inheritance in humans which means that 50% of an affected individual’s offspring will have it. It occurs in 1:10,000 to 1:50,000 adults and 1:15,000 children. It occurs in males greater than females. Interestingly, the prevalence of the genetic abnormality may be as high as 1:2000 to 1:3000, therefore, there is incomplete penetrance.

There are other diseases associated with MH such as Central Core Disease, Multiminicore Disease and King-Denborough Syndrome. Their genetic mutations also create abnormalities at the RyR1.

There are only 1.6 MH deaths in the United States per year. As a reference, there are over 30 deaths per year from lightning strikes in the United States. HOWEVER, if MH occurs, the death rate is 5% to 30% depending on time to identification and patient co-morbidities. So,

anesthesiologists always have it in the back of their minds.

THE RYANODINE RECEPTOR

It is a family of receptors that are the largest known ion channels. There are three subtypes. RyR1 is predominantly found in skeletal muscle cells. RyR2 is mostly found in cardiac muscle cells. RyR3 is found in the brain and many other tissues.

RyR1s are embedded in the sarcoplasmic reticulum. To bring back bad memories of physiology class, it is a bag of calcium within a muscle cell.

RyR1s (and all RyRs to differing extents) are modulated by multiple endogenous and exogenous factors that include dihydropyridine calcium channels (voltage changes), calcium, magnesium, adenosine triphosphate, protein kinases, caffeine, and halogenated anesthetics.

RyR1s are essential for excitation-contraction coupling, linking action potentials and contraction of the striated muscle by releasing calcium ions required to activate the contractile proteins.

Ryania Speciosa is a shrub or small tree that is native to Central and South America. It is found in tropical and subtropical regions, often in rainforests, and on the edges of forests. The alkaloid, Ryanodine, is an insecticide isolated from the stem and root of Ryania speciosa (isolated in 1948). Ryanodine has a high affinity for the RyR1. At nanomolar concentrations, ryanodine locks the receptor in a half-open state leading to massive muscle contraction. It fully closes the receptor at micromolar concentrations leading to paralysis. This is true for both mammals and insects.

NORMAL MUSCLE PHYSIOLOGY

There is stimulation at the neuromuscular endplate due to acetylcholine binding leading to muscle cell depolarization. The depolarization (the opening of sequential Na+ channels) travels throughout the myocyte (muscle cell) via the transverse (T) tubule system. This activates dihydropyridine (DHP) receptors within the T tubule membrane. DHP receptors are coupled with those skeletal muscle calcium release channels (RyR1) within the wall of the sarcoplasmic reticulum. Calcium release and voltage changes from the DHP receptor trigger the RyR1 to release calcium from the sarcoplasmic reticulum into the intracellular space. The calcium combines with troponin which leads to the removal of tropomyosin inhibition allowing for the crosslinking of actin and myosin leading to muscle cell contraction. Reuptake of calcium into the sarcoplasmic reticulum by Sarco(endo)plasmic Reticulum Calcium ATPase (SERCA) allows for muscle cell relaxation.

OK, I am on a roll!

MECHANISM OF THE HYPERMETABOLIC STATE

The gene for the ryanodine receptor RYR1 is the primary site for mutations linked with malignant hyperthermia. The gene mutation codes for the skeletal muscle-type ryanodine receptor protein abnormality. The defective RyR1 now located in the sarcoplasmic reticulum (SR) membrane underlies MH susceptibility. There are many proteins involved with the RyR1 so many variants of MH exist. The signs and symptoms of MH are related to an uncontrolled release of intracellular calcium from the skeletal muscle

cell sarcoplasmic reticulum via abnormal RyR1s and/or other channels depending on the variant. The high intracellular calcium levels allow for prolonged formation of the troponin-calcium complex and continued exposure of myosin to actin. The end result is prolonged skeletal muscle contraction or muscle spasm and the hypermetabolic state.

EVALUATION FOR MH

The current gold standard test for diagnosing MH is the (in-vitro) contracture test which involves obtaining a “generous” specimen of the vastus lateralis muscle ( up to 1 cm by 5 cm) and exposing the freshly obtained muscle bundles to triggering agents such as 3% halothane and increasing concentrations of caffeine in a muscle bath. This test is not only expensive but is too invasive to be practical as a widespread screening tool. There is no other test available that is reliable in diagnosing MH. Currently, genetic screening for MH is currently only useful as an adjunct to the contracture test in patients with a known family history of MH mostly because of the many mutations.

MH SIGNS AND SYMPTOMS

SECONDARY TO THE SUSTAINED RELEASE OF INTRACELLULAR CALCIUM

• Sinus Tachycardia

• Increasing end tidal CO2 due to increased CO2 production

• Respiratory acidosis

• Muscle rigidity

• Metabolic acidosis

• Markedly high fever (LATE)

• Rhabdomyolysis: rapid breakdown of damaged muscle tissue (LATE)

• Severe Hyperkalemia potentially into the double digits (LATE)

• Organ failure (TOO LATE)

• Death due to all of the above.

MH TREATMENT

First, since MH can occur anytime during the anesthetic or hours after exposure, a high index of suspicion is needed for early identification since the symptoms are nonspecific. Most cases are diagnosed by tachycardia, elevated ETCO2, and a respiratory acidosis.

• If MH is suspected, call for help. You will need it.

• Have them bring the MH cart which is required anywhere triggering anesthetics are provided.

• Place large bore IVs and start fluid resuscitation with a balanced salt solution such as LR.

• Remove the triggering agents (potent inhaled agents or succinylcholine).

• Change the disposable portions of the anesthesia circuit including the CO2 absorbent.

• Turn on high fresh gas flows with 100% oxygen. There is high oxygen consumption with MH.

• Anesthesia can be maintained with intravenous anesthetics since they are non-triggering.

• Hyperventilate to reduce the carbon dioxide burden.

• Give sodium bicarbonate IV to treat the metabolic acidosis.

• Consider placing an arterial line for frequent arterial blood gases and blood pressure monitoring.

• Apply cooling blankets and infuse refrigerated fluids.

• Give furosemide to induce a diuresis for renal protection.

• Give insulin and glucose, as well as calcium, if hyperkalemia develops.

• DO NOT give calcium channel blockers. AND… DO GIVE Dantrolene!

• Monitor the patient in the hospital for 24-48 hours.

DANTROLENE

Dantrolene is an RyR1 blocking agent. Although there are binding sites for dantrolene on all three receptor subtypes, its inhibitory activity appears to be selective for RyR1. The dose is 2.5 mg/kg IV then repeat every 5 minutes until symptoms resolve (tachycardia/elevated ETCO2/ rigidity). The upper limit is recorded as 10 mg/ kg but you can give more if symptoms persist. Maintenance: 1 mg/kg every 4-6 hours or 0.25 mg/kg/hr IV infusion for 24 hours.

WHY NOT CALCIUM CHANNEL BLOCKERS?

One could theorize that calcium channel blockers would help with MH since high intracellular calcium levels are the problem. However, calcium blockers, especially verapamil, are contraindicated when using dantrolene. The combination of dantrolene and calcium channel

blockers can lead to life-threatening hyperkalemia and myocardial depression due to inhibition of the sodium/potassium pump with the eventual “low” intracellular calcium levels.

Yea, my head hurts too.

IT SEEMS LIKE A PARADOX

Since hyperkalemia is the most likely cause of early death, give insulin, glucose and calcium if extreme hyperkalemia is identified. I would give them earlier.

Yea, it seems weird to give calcium since this is an intracellular calcium problem in the skeletal muscle, however, total body calcium is usually normal. Furthermore, the calcium makes the high potassium induced cellular excitability better by re-instating the resting to threshold potential difference, and then re-activating the needed sodium channels.

THERE IS A LONG DIFFERENTIAL DIAGNOSIS

Commonly, we may be treating something else when suspecting MH, however, the benefits of treatment outweigh the risks.

The differential includes:

• Inadequate anesthesia depth.

• Sepsis.

• Insufficient ventilation.

• Anesthesia machine malfunction.

• An anaphylactic reaction.

• Pheochromocytoma.

• Thyroid storm.

• Underlying neuromuscular disease (especially in kids).

• Carbon dioxide increases due to laparoscopic procedures.

• Drug intoxication.

• Serotonin Syndrome.

• Malignant Neuroleptic Syndrome.

In conclusion, it is fascinating science if nothing else. Of interest, it is possible that those suffering from heat stroke may have underlying RyR1 abnormalities. Truthfully, most reading this do not have to give MH much thought…. until they do!

“Bad Husband”

By J. ERIC GREENSMITH, MD, PHD ASSOCIATE PROFESSOR ANESTHESIA & CRITICAL CARE MEDICINE M.S HERSHEY MEDICAL CENTER, THE PENNSYLVANIA STATE UNIVERSITY

It is a sad reality, but all physicians are trained these days to recognize the telltale signs of abusive relationships. Whether it is the inexplicable cowering of an elderly patient in response to elder abuse or the precocious sexuality of a 10-year-old that suggests child abuse, there are objective clues as well as a “gut” feeling when things don’t seem quite right on the home front. Scars, burn marks, or x-rays with multiple fractures in various states of repair are all clinical findings that cry out for an explanation.

Of course, some specialties are more likely than others to see the initial presentation of a problem – the E.R. triage nurse, the school nurse, and the pediatrician are but a few examples that come to mind. Still, it is incumbent on all clinicians to remain vigilant for signs of abuse and intervene as needed.

One day I scanned my Operating Room list and saw that most of the day would involve shoulder repairs – from rotator cuff surgery all the way up to total shoulder replacement. These surgeries are all quite painful and generally include a block of the nerves to the shoulder as part of the anesthetic.

My first patient was a woman in her forties with multiple tattoos and a husky laugh that told me that she had smoked for many years. I explained my plan to give her both a nerve block and a general anesthetic. As I pointed out the area on her left neck where I planned to do the nerve block injection, I saw what appeared to be either a large birthmark or a substantial bruise.

“How long have you had this mark on your neck?”

“Oh, about a week,” she answered with an air of indifference. Clearly this is not a birthmark.

“What happened?” I pursued.

“Bad husband,” she replied.

I could feel my spine stiffen – this was it – the kind of situation we were supposed to spot and handle gracefully. She did say “husband” – yes, “bad husband.” I felt clunky and awkward. What to say next? Keep your response even, don’t express surprise or condemnation. Control facial features, modulate voice, sound casual.

“Uh, how long has this been going on?” I stammer.

“Three years,” she replies, matter of factly.

“Is he still abusive to you?”

There, I’ve said it; I said the “A” word. Abuse. It is out of the bag. A lot hangs on her next response. I guess I have to report this. I see it all – the OR schedule comes to a grinding halt, I am filling out forms, I am in one of those wooden witness boxes surrounded by the severe majesty of the American Judicial system describing my findings and this very conversation to the jury – it all spins out in front of me and it is not fun to contemplate – all because I saw her bruise...

The patient interrupts my reverie with a snort, a sly wink, and an incredulous chuckle. “He’s not abusive, this is a hickey!”

When Hospice Should be a Treatment Option

By HANNAH GEARHART MSN, RN, CCP

No matter who you are, the topic of hospice can leave anyone feeling uncomfortable. Let’s face it: discussing end of life care can be emotional and stressful; not just for the patient and family, but also for the message deliverer – you. The good news: discussing hospice with patients and families doesn’t have to be uncomfortable, and being equipped with knowledge can help. This article will discuss some common misconceptions of hospice and will give resources to help you to know when and how to start conversations on end-of-life care.

Myth: Hospice Requires Ending all Treatments or is “Giving up”

When the “H” word AKA hospice is mentioned, people often assume all care is taken away and that they are “giving up.” It’s a myth that treatments are stopped when hospice is initiated. While hospice may require discontinuing some lifesaving treatments, such as dialysis and chemotherapy, most patients receive more treatments, more quickly, and with fewer restrictions when under hospice. For example, a patient with hypertension may still receive antihypertensive medications if it means that their blood pressure is kept controlled and uncomfortable high blood pressure symptoms are reduced. Another example: when a frail elderly patient with end stage COPD presents with increased difficulty breathing, mucus production and fever, antibiotics and steroid treatments may

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Features

be prescribed to help improve symptoms. Under hospice, treatments are dispensed within hours of the onset of symptoms. This decreases their chances of requiring an uncomfortable visit to the emergency room, or worse, being hospitalized. This same patient, when not under hospice care, may take up to three to five days to secure an outpatient appointment and medications, which is risky in their frail state. Additionally, when more equipment like hospital beds or wheelchairs are needed, it doesn’t take a face-to-face visit and large amounts of documentation to get this covered.  Bottom line, care is increased and obtained much more quickly and easily under hospice.

Myth: Hospice Care is Only for the Last Days or Weeks of Life

Hospice agencies report that many patients miss out on the extensive benefits of hospice care and wait too long to initiate them. The average length of stay in hospice is ten weeks after services are initiated. Those who received hospice care reported that they wished they started services sooner. Earlier hospice care can prolong and improve quality of life, ease disease burden and honor patients’ goals of care. Some patients can do so well under hospice care that they recover and “graduate” to be discharged back to their usual care. So, how can healthcare providers bridge the gap and reduce the delay in this care treatment option?  It starts by understanding how it works, and what exactly the benefits and health care coverage are in the US and the state of Pennsylvania.

When to Initiate End-Of-Life Discussions

An article written by Innovation of Aging indicates that when hospice services were initiated, many patients and their caregivers were not fully aware of their prognosis or disease trajectory. This was especially the case of a non-cancerous diagnosis. When should a provider initiate discussion of endof-life care? A 2020 study in the Journal of Palliative Care poses a “surprise” question: Would you be surprised if the patient in

front of you died in the next 12 months? If you wouldn’t be surprised, you need to start to have a conversation about hospice. Conversations should be ongoing and over the course of time. It includes providing thorough education and understanding of the disease process, prognosis, and predicted quality of life if aggressive treatment is pursued. Patients should leave the exam room with a clear picture of all treatment choices with hospice care on the “platter” of options.

Benefits of Hospice

• Visits from physicians, registered nurses (RN), licensed practical nurses (LPN) & social workers.

• 24/7 on-call care for urgent or emergent care needs.

• Home durable medical equipment.

• Medical supplies.

• Medications when used for comfort and symptom relief. Medications prescribed for treating conditions other than the terminal/ end-stage illness may be covered under the hospice benefit, or by the primary insurance carrier.

• Home health aides and minor housekeeping.

• Respite care for caregivers.

• Counseling and/or spiritual services, both during and after death for families.

• Volunteer services.

• Physical therapy, occupational therapy, speech therapy, and dieticians.

• Inpatient treatment for symptom management or respite care if needed.

Finding Appropriate Hospice Agencies

It’s important to mention that not all hospice agencies are created equal. Depending on the types of diagnosis and comorbid conditions, certain agencies may accept patients who wish to continue palliative radiation, palliative chemotherapy, or physical or occupational therapy, as long as the focus is for comfort as the primary reason for the continuation. Some agencies have been known

to slowly wean patients from chronic medications until they are psychologically ready. Long and short, it’s good for patients to ask questions to ensure they have care aligned to the patient’s specific goals of care.  Some agencies provide specialized care for specific diseases like dementia/Alzheimer’s or heart failure. There are hospice or home health agencies that offer Palliative care services which can help serve as a bridge to hospice for patients who are not ready.

How to Discuss Hospice with Patients

Does your patient know the prognosis of their advancing condition(s), and or new terminal diagnosis? It starts by sharing your observations – perhaps you noticed their increased need for medication adjustments or failure of medications to treat symptoms, hospital, or emergency room visits, or spread of their disease. A discussion of their wishes should be introduced as a normal discussion and describing scenarios will normalize the conversation. For example, the Pennsylvania Orders for Life Sustaining Treatment form (POLST) is a form that can be used as a tool to begin these conversations. Many other states have a similar form and can easily be located online. The form is recommended for patients that are frail and/or have an advanced chronic illness or terminal condition. Patients are provided with scenarios for each section of the form. In the context of the patient’s chronic illness or prognosis, practitioners should share the likelihood of certain treatments to be effective. For example, how effective will CPR be if performed on a 90-year-old, frail patient diagnosed with Stage 3d heart failure and stage 3b chronic kidney disease? Many patients have a skewed impression of the success rate of CPR based on what they see in movies or on TV. Patients need to hear what is realistic for their survival and quality of life post-CPR. Of course, patients may still choose CPR, but POLST will give you the opportunity to re-introduce the topic later as their condition worsens. The POLST provides the perfect segue to share hospice and its benefits.

Tips For the Busy Provider:

• Initiate POLST discussions earlier: Ask yourself “Would I be surprised if this patient died in the next year?” If you wouldn’t be surprised, then it’s time for the POLST discussion. Ensure the patient’s primary care giver and/or medical power of attorney is part of the conversation.

• Schedule another appointment for advanced care planning and POLST completion. CPT code 99497 can be billed for the first 30 minutes (minimum 16 minutes documented) and 99498 for each additional 30 minutes.

• Refer your patient to a palliative care specialist – inpatient, outpatient or through a hospice or home health agency.

• Get more training. In the state of Pennsylvania, the website polst. org provides information for providers and patients. A YouTube search on “How to have a POLST conversation” will produce many great examples.

How are Hospice Services Covered?

If your patient has Medicare Part A, a special carve-out benefit is available to cover hospice services at no cost. To qualify for hospice a patient must:

• Be certified as terminally ill through a physician order with six months or less to live. This is re-evaluated at six months; services will continue based on symptoms/disease progression.

• Agree to receiving comfort measures rather than aggressive curative treatments.

• Sign an agreement for the Medicare hospice benefit to cover their services and treatments for their terminally ill diagnosis and related conditions.

Some Exclusions:

• Medications may have a 5% cost for drugs used for treating pain and symptoms.

• Respite care or placement to a facility are not typically covered.

• Home health aides do not provide 24/7 care in the home.

• Ambulance, emergency room or hospital visits are not initiated by hospice.

Many patients who choose to forgo comfort measures and receive emergency care may forfeit their hospice benefit. It’s important for them to talk with their hospice agency before they seek emergency medical care.

Introducing hospice to your patient doesn’t have to be scary, or initiated when your patient is on their deathbed. Your patients and their loved ones deserve to understand their prognosis and to have hospice introduced earlier and given as a treatment option.

References:

1. Bhatnagar M, Lagnese KR. Hospice Care. [Updated 2023 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537296/

2. CHP Home Care & Hospice. (2022).“What is a “Hospice Graduate”?” https://comhealthpro.org/what-is-a-hospice-graduate/

3. CMS.gov. Billing and Coding: Advance Care Planning https:// www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=58664#:~:text=Use%20CPT®%20code%2099497,for%20 each%20additional%2030%20minutes.

4. Medicare.gov. Hospice care https://www.medicare.gov/coverage/hospice-care

5. Monteiro, J. F. (2020). End-of-Life Ethical Dilemmas. In Bioethics in Medicine and Society. IntechOpen.

6. Pennsylvania Orders for Life-Sustaining Treatment Guidance for Health Care Professionals https://www.papolst.org/pa-polst-forms/implementation -and-appropriate-use-of-polst/11-guidance-for-health-care-professionals/file

7. Sarah H Cross, Janel R Ramkalawan, Jackie F Ring, Nathan A Boucher, “That Little Bit of Time”: Transition-to-Hospice Perspectives From Hospice Staff and Bereaved Family, Innovation in Aging, Volume 6, Issue 1, 2022, igab057, https://doi.org/10.1093/geroni/igab057

The Maui Fires Beyond the Numbers

By DENISE OCAMPO NORTHERN ARIZONA UNIVERSITY - B.S. BIOMEDICAL SCIENCE 2020 PENN STATE COLLEGE OF MEDICINE - M.D. CLASS OF 2027

On August 8th, 2023, I was in my 3rd week of medical school at the Penn State College of Medicine. I had been adjusting to my new life in Hershey, wondering how I ended up on the other side of the country. I spent most of my young life in Kihei, Hawaii, a town on the south side of the island of Maui. My parents and brother still live on the island, and they had recently made the 4,773 mile trek to move me into my new apartment and attend my white coat ceremony. I left Maui after I graduated from Maui High School in 2017, but returned annually to visit family and cherish the undeniable magic of the island.

The first text I got was from a close friend on the morning of August 9th, 2023:

“Hey I saw that there was a fire on Maui last night. Are your parents good?”

I was surprised to hear news about a fire. I try to keep up with local news, but being so far away and embedded in my school work, I am not always on top of it. This friend is a firefighter, so I chalked it up to something small they heard about through their line of work. Out of an abundance of caution, I texted my parents, who simply mentioned that they were fine and there was a fire in Lahaina, a town on the west side of the island, not near to our home. The extent of the fire was not known to most people yet.

Another text came in that evening, from a former physician mentor:

“Sorry to text you so late. Just got home and saw the news. Hope your folks are safe.

Sending prayers”

I read the text immediately, and the alarm bells in my head started ringing. I took to the internet, and that is when I learned the true extent of the destruction that the fire had inflicted on Maui. A fast moving fire that started on the afternoon of August 8th, 2023, tore through the historic Lahaina town fueled by high winds and dry brush. Lahaina is known to be the dry side of the island, and the hot summer days were not helping the ongoing drought Maui had been facing for years.

I reached out to Luisa Ogawa, a former mentor and a Nurse Practitioner practicing on Maui. She recalled the moment she found out about the fires.

“During the fire, everything was at a standstill, and no one knew what happened unless you were there. No one knew, there were no sirens [or warnings]. That night we were watching the news, and there was drone footage on the local news from the fire, and that’s when people started to find out. I couldn’t sleep that night, all I could think about was that Maui was on fire.”

Updates continued to roll in over the next several days as the news of the disaster spread across the country. I contacted friends and family who were still on the island and learned that family friends had homes and businesses that burned in the fire. Heartbreaking videos were shared by those who survived the fires. I watched as the missing person posters were shared on my social media feeds by the hundreds. Utter devastation enveloped as the world grieved for this historically important town. Lahaina was the first capital of the Kingdom of Hawaii, and holds spiritual and cultural significance for Native Hawaiians. The devastation continued as we learned of the 101 people who lost their lives (Fortin & Hassan). It was a new and devastating reality, the pain of which continues to ache to this day.

Following the fire, Luisa was on the front lines with many other medical professionals to aid those affected by the fires. She told me that local community health agencies joined together, stepped up, and rendered aid needed by the people. She and her coworkers went into Lahaina and shelters housing those affected to give medication refills and treatment to those who needed it. Healthcare workers were sent in from the mainland to aid, and the American Red Cross provided assistance alongside them. Luisa historically has performed patient home visits, and recalled a story of a Lahaina patient who survived the fire, and the struggle with consistent shelter:

“My oldest patient was 102 years old and survived the fire. [His family] had a split second to decide to bring him down from the second floor using a bedsheet before they had to drive away to escape the fire. They have been moved 5 times to different hotels since the fire happened. I still feel emotional every time I see him. I hear that everyone is still emotionally affected by this. People are crying, sadness lingers throughout the entire island.”

I came home in December of 2023, my first time home since the fires. I went to see the aftermath with my own eyes, and the truth of what happened to Lahaina hit me. It didn’t feel fair to the local people for their lives and livelihood to be ripped away from them. It is projected that the clean up of the fire ravaged areas will take at least until January 2025 (“Maui Recovers – Help Center”), and residents will not be able to rebuild or use a temporary shelter on their land until then. The already strained housing market makes it difficult for survivors to have long-term shelter, limits employment options, and impedes their ability to remain on the island. As I observed the charred remains of the magical Lahaina, the silence was deafening as I contemplated the years of financial, emotional, and physical suffering our community would endure.

Months later, the community is beginning to embark on the lengthy healing process. Maui still needs the help of the world, with years of recovery ahead. It is important to Luisa and I that we keep talking about the effect the fires had on our land and people. Luisa says:

“Keep telling our stories. People can help our island indirectly by spreading our story, or help us directly by continuing to donate. Thank you to everyone who hears our stories, please remember that our island is trying to thrive and we still need your help. Donations, even if small, can help – water, supplies, and financial donations are welcomed as people continue to need gas and food.”

Maui will continue to heal and recover, but we need your help to help spread aloha, spread the word, and step up for our neighbors. Recently, Bill 21 was passed to expedite the building permit process, which will relieve some of the burden on landowners when the time comes to rebuild their property (Cook). A bipartisan legislation package has been presented, consisting of 10 bills and 2 resolutions, and is currently working its way through the House of Representatives (Mizuo). House Bill 1836 would allow pharmacists to refill prescriptions for up to 30-day supplies during declared states of emergency if the failing to refill the medication would be detrimental to the patient’s health and if the prescriber cannot be contacted. House Bill 1839 would provide funding for long-term monitoring of communities affected by the fires for air and water quality to better understand the environmental consequences. House Bill 1843 would create the role of a state fire marshal, as Hawaii is the sole state without one. Senate bills have also been presented, including Senate Bill 3068, which would allocate millions of dollars in general obligation bonds to aid in recovery efforts, including shelter for displaced residents for fiscal year 2025 (“Senate WAM Committee Advances Bills Relating to Wildfire Recovery, Economy, Homelessness and Housing: Maui Now”). We must continue to advocate for the people and the land of Maui, and prioritize the well-being of our citizens. I hope that Pennsylvania communities and beyond continue to aid our island and share our stories. We hope that you do not forget how far our island has come and the strength of our people. We hope you can support our island despite being far away and recognize the resilient spirit of our people. Together, we are Maui Strong.

References

Fortin, Jacey, and Hassan, Adeel. “Death Toll of Maui Wildfire Rises to 101.” The New York Times, The New York Times, 17 Aug. 2023, www.nytimes.com/article/maui-wildfire-victims.html

“Maui Recovers - Help Center.” Maui Recovers Help Center, intercom.help/mauirecovers/ en/. Accessed 10 Mar. 2024

Cook, Thomas. “Council Passes Bill to Approve Emergency Permitting for Expedited Housing in Lahaina and Upcountry.” Mauicounty.Us., 9 Mar. 2024, www.mauicounty. us/press-release/council-passes-bill-to-approve-emergency-permitting-for-expedited-housing-in-lahaina-and-upcountry/

Mizuo, Ashley. “Bipartisan Maui Wildfire Legislative Package Focuses on Prevention and Preparedness.” Hawai’i Public Radio, 31 Jan. 2024, www.hawaiipublicradio. org/local-news/2024-01-30/ bipartisan-maui-wildfire-legislative-packagefocuses-on-prevention-and-preparedness#

“Senate WAM Committee Advances Bills Relating to Wildfire Recovery, Economy, Homelessness and Housing: Maui Now.” | Senate WAM Committee Advances Bills Relating to Wildfire Recovery, Economy, Homelessness and Housing, 2 Mar. 2024, mauinow. com/2024/03/02/senate-wam-committee-advances-bills-relating-to-wildfire-recovery-economy-homelessness-and-housing/

Mizuo, Ashley. “Bipartisan Maui Wildfire Legislative Package Focuses on Prevention and Preparedness.” Hawai’i Public Radio, 31 Jan. 2024, www.hawaiipublicradio.org/local-news/2024-01-30/ bipartisan-maui-wildfire-legislative-package-focuses-on-prevention-and-preparedness#

The Pitfalls of Home Medication Management

By HANNAH GEARHART MSN, RN, CCP

Polypharmacy in older adults is common, especially for those with multiple comorbid conditions and frailty. What is polypharmacy?

Polypharmacy is defined as anyone who is prescribed multiple medications, typically five or more medications at once. The term excessive polypharmacy occurs when a patient is prescribed at least ten or more medications according to most definitions. Typically, these medications are taken chronically, are not short term, and may include over the counter (OTC) medications. One study identified that over 96% of hospitalized patients also have polypharmacy. This demonstrates a link between medical complications and taking multiple medications. Are patients being prescribed too many medications, or is it that the more medications patients take the more chances they are taken incorrectly?  Medication management can be confusing for anyone, but especially so when prescriptions multiply from one to many. As medications are added, doses adjusted, prescribed by multiple prescribers and for multiple reasons, it can be hard to keep straight even for medical professionals.  Studies further back-up the fact that as patients age, polypharmacy increases risks of adverse events such as falls, cognitive impairment, unplanned hospitalizations, emergency room visits, and even worse, death. How can providers empower individuals to take medications safely and effectively? How can providers really know what their patients are taking at home after they leave the exam room?

Let’s explore some common barriers to medication compliance:

Common Barriers to Medication Compliance:

• Trouble reading or understanding the label or instructions due to small print or low health literacy.

• Hand dexterity limiting the ability to open pill bottles, prepare injectable medicine, or use inhalers.

• Patients not knowing what their medications are treating.

• Patients not feeling good on their medications and self-discontinuing them.

• Unable to afford medications.

• Overwhelmed and confused after hospitalization.

• Frequent dosage changes.

• Difficulty navigating multiple specialist prescribers.

Common Home Medication Error Examples:

Home health nurses could write books full of stories of what they discover in their patients’ homes during medication reconciliation. For example, Mrs. B skips taking her “water pill” (Furosemide) every Thursday morning so she doesn’t have an accident at her weekly hair appointment. Mr. S combines new medication refills into the old pill bottles, throwing away the bottle that explains the latest prescription, including dose, frequency and how many refills were left. Mr. S also keeps every medication ever prescribed in case a doctor might prescribe it again, even though several have expired years ago. Mrs. J’s daughter fills a weekly pill box each Sunday, but Mrs. J has decided she doesn’t feel good after she takes the pink pill and skips it for an entire week. Mr. K doesn’t know he has to remove the external plastic covering from his insulin pen needle before injecting his insulin. He has wondered why his insulin would leak onto his abdomen with every injection. He hasn’t told anyone about this for months, yet his physician keeps telling him to increase his dosage because his blood sugars haven’t improved.  Mrs. P is prescribed 12.5 mg of Metoprolol but uses her blunt kitchen butter knife to try to split a 25 mg Metoprolol tablet in half, with inconsistent dosages as a result. These are just a few examples of common medication errors patients make at home. It’s important for providers to not only learn what medications patients are taking, but also how they are taking them.

Here are some practical ways to improve your assessment during appointments:

• Ask patients to bring their pill bottles with them to their appointments, especially if they recently were discharged from the hospital or rehab.

• If they decline to bring in the bottles and wish to bring their handwritten list, remind them that errors can still exist even if the patient is correct; sometimes pharmacies mess up too.

• Never ask “Are you taking your medications?”, of course the answer is yes, this is not going to help you identify if they skip or have stopped taking a specific medication.

• Ask “What medications are you taking?”, instead of “Have you had any recent medication changes?”

•  “Recent” can be misinterpreted as last week, last month or last year. Seek to understand what they are taking right now instead.

• Ask “Have you missed taking any medications lately?”  to identify if memory trouble, affordability or side effects exist. The patient may have forgotten to mention that they keep forgetting to take their 7 pm medication because they fall asleep.

Researchers have tried to understand the most effective interventions for improving medication compliance. Interventions require understanding your patient, their health literacy and psycho-social and financial status. According to research, the top four most effective strategies include: dose simplification, patient education, electronic reminders, and financial incentives/reducing out-of-pocket costs. Let’s explore some practical strategies that can be used to improve medication compliance and safety.

Strategies for Safe Home Medication Management:

1. Dose Simplification:

• Have a pharmacist evaluate medications and identify ones that can be eliminated, decreased, or adjusted.

• Look for combination medication alternatives that can be taken less often but provides the same or a similar benefit.

• Adjust twice daily dosages to a time of day where they will more likely remember to take them; like at mealtimes.

2. Patient Education

• Understand the medication(s) purpose; include the names: generic and brand and strength or dosage.

• Know how and when to take medications and side effects to report.

• Check expiration dates and discard outdated medications.

• Know how to properly store medications and organize them i.e. weekly pill boxes, refrigeration.

• Keep an updated medication list regularly and check them against pill bottles for accuracy. Ask for help from a loved one, friend or neighbor or pharmacist.

• Purchase a pill cutter over the county at the pharmacy and ask the pharmacist if the pill can be cut in half.

3. Electronic Reminders:

Most people own a cellular device, but there remains a generation of older adults that do not use smart devices. If no smart device is available, ask for help from a family member, neighbor, or friend. Use a standalone timer or alarm clock.

Use a calendar and daily cross off each day after medications are taken. If blood sugars or daily weights are required, a calendar is a great place to store that information and then can be brought to appointments.

Specialty pharmacies have mail order, pre-packaged medications shipped directly to the home. There are free or low-cost options for patients. Some companies provide locked/timed medication boxes that open at a set time of day. These are typically not covered by insurance but can be a good option for someone struggling with memory difficulties and forgetting to take medications consistently.

4. Financial IncentivesOut-of-Pocket Cost Reduction

• Medication errors can involve a costly emergency room or hospital visit. Many older adults who live on fixed incomes may wish to avoid a trip to the ER. Decreasing the need to pay hospital bills may be an incentive for patients to pay close attention to their medications or be willing to receive help from others.

• Research shows positive results when monetary rewards or vouchers were given for medication compliance at the point of care, specifically for patients receiving prescriptions for mental health, HIV, or anticoagulants.

• Large health corporations that are involved in value-based contracting with health insurers can leverage drugs at a reduced cost if certain patients choose programs associated with them.

Tools/Resources:

AHRQ How to Create a My Medication List- Teaches patients in simple terms and provides printable blank medication cards.

https://www.ahrq.gov/health-literacy/improve/pharmacy/ medicine-list.html

Medication Safety Tips: At Home  https://www.consumermedsafety.org/safety-tips/ medications-at-home

Know your Medicines: Learn How to Read Pill Bottle Labels

https://www.consumermedsafety.org/additional-resources Nurse Next Door: 4 Tips for Organizing Medications https://www.nursenextdoor.com blog/4-tips-for-organizing-medication/

References:

Fatma Aldila, Ramesh L. Walpola, Medicine self-administration errors in the older adult population: A systematic review, Research in Social and Administrative Pharmacy, Volume 17, Issue 11,2021, Pages 1877-1886, ISSN 1551-7411, https:// doi.org/10.1016/j.sapharm.2021.03.008

HealthInAging.org (2023). What Older Adults can do to manage medications. https://www. healthinaging.org/medications-older-adults/ what-older-adults-can-do-manage-medications

Laura J Anderson, Teryl K Nuckols, Courtney Coles, Michael M Le, Jeff L Schnipper, Rita Shane, Cynthia Jackevicius, Joshua Lee, Joshua M Pevnick, Members of the PHARM-DC Group, A systematic overview of systematic reviews evaluating medication adherence interventions, American Journal of Health-System Pharmacy, Volume 77, Issue 2, 15 January 2020, Pages 138–147, https://doi.org/10.1093/ajhp/zxz284

Laurie E. Davies, Gemma Spiers, Andrew Kingston, Adam Todd, Joy Adamson, Barbara Hanratty, Adverse Outcomes of Polypharmacy in Older People: Systematic Review of Reviews, Journal of the American Medical Directors Association, Volume 21, Issue 2, 2020, Pages 181-187, ISSN 1525-8610, https://doi.org/10.1016/j.jamda.2019.10.022.

Natalie S. Hohmann, Tessa J. Hastings, Ruth N. Jeminiwa, Jingjing Qian, Richard A. Hansen, Surachat Ngorsuraches, Kimberly B. Garza, Patient preferences for medication adherence financial incentive structures: A discrete choice experiment, Research in Social and Administrative Pharmacy, Volume 17, Issue 10, 2021, Pages 1800-1809, ISSN 15517411, https://doi.org/10.1016/j.sapharm.2021.01.018.

Pazan, F., Wehling, M. Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences. Eur Geriatr Med 12, 443–452 (2021). https://doi. org/10.1007/s41999-021-00479-3

Previdoli G,  Alldred DP,  Silcock J, et al.  ‘It’s a job to be done’. Managing polypharmacy at home: a qualitative interview study exploring the experiences of older people living with frailty. Health Expect. 2024; 27:e13952. doi:10.1111/ hex.13952