The office is closed. The door is locked. If you need supplies, you make a request by email 24 hours in advance. Text when you get there and the supplies will be placed outside the door. Maybe by elves.
I’m in my car. The air conditioner is blowing. I’ve been waiting for 20 minutes for my bag of hand sanitizer, chucks, gloves, masks, gowns, booties, and various dressings and accouterments of wound care. My next case is across town and I’m not getting paid to sit around.
Across the parking lot is Regional Medical Center’s Emergency Room. They’ve closed the waiting room and put up tents in the parking lot with chairs placed well away from each other. I watch as people drive up to be tested for COVID-19 or to unload someone needing emergency care. A tech in full PPE walks out and waives a thermometer across the forehead…OK, next station. Such is medicine in the age of COVID-19.
My first “official” case of COVID-19 is a man in his early 60s. He shuffles to the door with a walker. His skin is hanging off of him in folds. He looks like one of those dogs with droopy flaps around his face. He got sick in February, a construction worker with a cold before we really got the news of a brewing pandemic. Three months he lived on a ventilator. He points proudly to his tracheostomy scar. “It couldn’t kill me,” he says.
I say “official” because you never really know who may be contagious since so many people show no symptoms. I’m standing outside the door of his house at 2 pm on a hot California day wearing a yellow gown, a mask, face shield, blue gloves, and blue knee high paper boots that are making my feet itch like crazy. Sweat is dripping down my forehead onto my glasses and I can barely see a thing. Sweat is also dripping down my back and arms. I think my gloves are full of sweat. I should have drank more water.
He lets me into the house. There is no air conditioning. The windows are all open. The living room and dining room have been stripped bare for remodeling. There are boards piled up, things in boxes, a new floor. It’s going to be nice. He’s staying with his daughter while he recovers and he’s anxious to get back home but still too debilitated to take more than a few steps.
The home health start of care evaluation is 29 pages long—29 sweaty, hot pages. We are sitting on those cheap folding camp chairs. The only other furniture is a small fish tank on the mantle that needs water. The pump is sucking air and making a sound like a jet engine. I rock the fish tank gently back and forth and get enough water to the pump that it starts working quietly again. He looks at me. The fish look at me. I sweat. I hope he’s not noticing the growing splatter marks on his new hardwood floors.
What should take 40 minutes takes 90 minutes. Each step of the way I’m double checking what the patient has touched. Did I give him this pen or that pen? I clean the BP cuff twice. Next time I’ll just leave it there. He’s not even shedding virus any more. He’s recovered. Not exactly spry, but he definitely has the air of a man who escaped the tiger’s den. He doesn’t even need oxygen. He’s a lucky dude. I tell him to buy a lottery ticket. One for me too. He laughs.
I ask him who is in the house and I document each person I come in contact with and what PPE I was wearing. It’s a new policy at our company. We document every person and what we were wearing. Let’s face it, sooner or later, one of us is going to come up positive and it will be the unpleasant job of someone in the office to call all of our recent contacts. I can hardly imagine how that conversation goes.
“You know the nurse that came to visit you? We are calling all of the people that she visited because she has COVID-19 and we want to ask you to get tested yourself and self isolate for 14 days. Also everyone in the household and everyone they’ve come in contact with. Have a nice day.” I pray to God I’m not that one.
So I check everything twice, three times. My next patient is even sicker…and older. I can’t be the dark angel of death. I sanitize my hands again. I stagger out the front door and take off all the gear. Sweat is literally pouring off of me and off the inside of the slick yellow gown. My shoes are soaked. I take a moment to red-bag my PPE and wipe down the outside of my ditty-bag. I have an hour of paperwork to do on this guy. I have to call his doctor and get a verbal order for start of care. I have to drink a lot of water…I mean right now because my vision is getting grey around the edges. The blessed blessed AC is blowing cold in the car. Thank God for small favors.
This is the new normal. Everyone has to make changes. I don’t understand the resistance to wearing a mask that some people have. For some reason, someone in the highest office has decided that wearing a mask makes you liberal. The virus makes no such distinction. I don’t understand how wearing a mask to protect the people around you has any political significance at all. But there you have it—the new normal. Stay safe out there.
Geriatrics is the medical specialty serving patients 65 and older. Usually multidisciplinary, the geriatric team may consist of primary care providers specializing in geriatrics, diabetes educators, psychologists, medical social workers, pharmacists, and support staff. The goal is to keep patients functional at their highest level throughout their elder years. This might mean the difference between a patient living independently, semi-independently, or in a skilled nursing facility.
Let’s say your next patient is a 75-year-old female admitted to the ER for confusion. Vitals are HR 98, BP 102/60, RR 20, SpO2 96, T 98 oral. The patient arrives by ambulance from home. Her clothing is wet with foul smelling urine. She is not oriented to person or place. Her affect is flat. Tenting is elicited on her hands. Skin is warm. You note she has lately been to the ER several times for falls and failure to thrive.
What to do for your patient? After the work up, the patient is diagnosed with a UTI and dehydration. Confusion is often seen in the elderly as the first sign of a UTI. Of course the foul smelling urine and new incontinence were the giveaway. This patient is going to need more than a course of antibiotics and fluid. Although she lives with family, the recent visits to the ER make it clear that the family is overwhelmed. A quick conversation with the daughter confirms this fact. You suggest a geriatric consult to the ER provider and she agrees.
Some inclusionary factors for a geriatric referral are age 65 and older, increased utilization of services, changing/increasing needs, decreased functioning, confusion or dementia, failure to thrive/weight loss, falls, and age related health problems. Our ER patient meets several of these criteria. If the patient has a PCP, coordination with that provider would be necessary. Geriatrics will often do a consult to see if the patient is the right fit. It looks like our patient and her family could use the services of a multidisciplinary team.
Active addiction/alcoholism, recent suicide attempt, acute psychosis, or untreated mental health issues would require different referrals. Substance abuse problems, active mental health issues, or suicide attempts would need to be addressed by addiction services and/or mental health services and the patient stabilized before geriatrics could assess age related changes to memory or dementia. These issues would cloud the clinical picture and make diagnosis of cognitive impairment impossible.
The geriatric primary care provider is part of an interdisciplinary team. Because of this, our patient will have access to a range of services that are can be outside of the ability of the primary care provider to manage. Having everyone under the same roof, steps away, using the same electronic record system, allows for an integration of care that would be impossible using outside specialists. Our patient will get a referral from the ER after the ER provider consults with the patient’s primary doctor if she has one.
The patient will be scheduled for a geriatric consult as soon as her condition has stabilized.
Meet the Geriatric Team
Dr. Nirmala Gopalan, MD, is the site manager for the Santa Clara Valley Medical Center Downtown Geriatric Clinic in San Jose, CA.
“On the patient’s initial visit, I’m looking for inclusionary factors. Does this patient need us? There are a lot of elderly patients whose health care needs are well met by their PCP. The ideal patient to come aboard our service meets the inclusionary factors, has a desire to onboard to our services, and is looking for quality of life, not just disease care.”
Ginny Estupian, PhD, is the geriatric clinic psychologist at Santa Clara Valley Medical Center and works closely with Dr. Gopalan. “My role on the team can be divided into two parts; providing individual therapy and neuropsychological evaluations.”
“When I conduct individual therapy, I focus on reducing troublesome mood symptoms such as depression and anxiety. I may focus on helping the patient cope with chronic health conditions that exacerbate their mood such as COPD, chronic pain, diabetes, and cognitive changes. I help the client understand the relationship between the sleep, pain, mood triad, and we focus on improving one or more of those areas. Mood symptoms can improve by learning coping skills, engaging in age-appropriate exercise, or simply processing how they feel about their overall health.”
“The second part of my role is conducting neuropsychological evaluations. I assess for changes in cognition that may occur due to Alzheimer’s disease, vascular disease, or other age-related conditions. Findings from neuropsychological testing are discussed with the multidisciplinary team, then discussed with the patient and family in order to coordinate ongoing care that meets the specific needs of each client.”
Carol Lee, PharmD, is a pharmacist for Santa Clara Valley Geriatrics Clinic. “The first thing I do with the new patient is go over the medication. I’m looking for appropriateness, contraindications, drug interactions, compliance…”
“I look at the patient in terms of the 5 Ms of geriatrics: Mind, Mobility, Medications, Multi-complexity, and Matters Most. Does the patient have dementia, cognitive decline, delirium, or depression? Can the patient tell me why he or she is on this medication? Is the patient an active participant in care or is someone else managing it? Age is just a number. Patients have a wide variability in ability. We don’t prejudge, we assess.”
“Can the patient navigate the pharmacy system? Are they having difficulty with refills or medication timing? Our pharmacy can set up automatic refills, home delivery, blister packs, and other services to assist our patients.”
“Another thing I asses for our patient population is herbal supplements. I educate them on the pros and cons of taking supplements and over the counter medications. The patient needs to weigh if they are getting benefit or detriment from them. I go over each one with them, looking for interactions.”
“Finally, polypharmacy has to be addressed. Some patients have been to many doctors over the years or have seen multiple specialties and they can have a lot of medication burden. Having the patient’s care totally within our system, on the same electronic charting system, and doing a medication reconciliation with each visit helps me to drill down to exactly what the patient is taking, what we can toss, and what we can keep. The patient has health goals, that’s what ‘matters most.’ The proper medicine, and nothing extra, is my job with the geriatric patient.”
Danette Flippin, MSW, MSG, also at Santa Clara Valley Medical Center Geriatric Clinic, looks at not just the whole patient, but at the patient’s support system.
“When assessing the new patient I always think in terms of biopsychosocial and spiritual assessment. Starting with the patient, I ask what is this patient’s level of functioning in the world? What are the physical, cognitive, emotional, and psychological abilities that allow this patient to address needs or to cope with challenges? What deficits are preventing healthy coping or access to health care, or engagement with community support?
“Simultaneously, as a medical social worker, I am looking at the patient’s environment and support systems such as family, friends, social/senior networks, church communities, etc. What is important to this person as they navigate the later stages of their life cycle, place meaning and address the existential questions and factors in their lives?
“When we look at an older adult, we are assessing the well-being of the caregiver as well. The patient and family centered approach is key to assessing, identifying problems, and integrating helpful, successful interventions. When all the information is in place I form a plan on how best to serve this person, not this person’s diseases.”
As we each progress through the stages of life, it’s good to know there are resources available. Not every elder patient needs the services of a geriatric specialty clinic, but the ones that do definitely get value. Don’t forget to evaluate your geriatric patients for specialized care.
I sprained my knee. That’s how I found out my 14-year-old daughter was struggling with her gender identity. I was combing the house for an ace wrap and found it in the dirty clothes basket in Karen’s room. It looked like it had been through a war. No elastic left. Karen had always been a tomboy. She wanted to mow the lawn, play with bugs, play sports…she was always moving and had zero interest in “girl stuff.” I took her to Claire’s in the mall a few times and she looked totally lost as I picked out headbands, earrings, and miscellaneous froufrou. I guess she was sending signals for years, but I wasn’t picking up the phone.
I don’t know how it dawned on me that she was binding her breasts. It just came to me and so I asked her, “Are you binding your breasts?” She started crying.
“I was born in the wrong body!” She said between racking sobs.
I’m ashamed to say it, but my first thought was, “Why me?” I took her to the pediatrician. She told me that this is just a phase. Karen is hanging out with the wrong people. Monitor her closely. Watch her friends. Ignore it and it will go away.
I was already pretty obsessive about who she hung out with. On play dates I would make sure I went in the house and met everyone involved. When I took her and her friends to the mall, I quizzed the friends about their home life and their grades. I thought I was doing everything right. Over the next year, our relationship deteriorated. I found marijuana, vape pens, bongs…she became a stranger to me. It was all yelling and grounding and taking the phone away. She didn’t do homework. She hated me. So much for the pediatrician’s advice.
I reached out to one of the pediatricians I had worked with and respected and asked him to recommend a doctor who worked with transgender teens. I made an appointment. Dr. Mitch spent an hour with Karen…without me in the room. When Karen came out of the appointment, a weight seemed to have lifted from her shoulders. Later, Karen told me the nurse had given her a shot to “make my period go away.” I was beside myself. I called the office and demanded to speak with the doctor. My rights as a parent had been violated. How dare he give my child something without discussing it with me first. I wasn’t against the shot so much as being cut out of the decision.
Dr. Mitch called me back that afternoon and spent an hour on the phone with me. Can you imagine? An hour. He patiently discussed what Karen was going through and informed me that children over 12 can get birth control without parental consent. I had no idea. He explained that Karen had gender dysphoria: The constant feeling that her body was the wrong sex. Karen had anxiety, anger, feelings of hopelessness, and diminished self-worth. My child was in pain. Thus, started my education in transgender children. I knew by now that it wasn’t a phase but, I have to admit, I was still hoping that it would go away. My own feelings of self-worth had taken a hit, honestly. What kind of a parent was I? How could I let this happen?
WPATH (www.wpath.org) is the World Professional Association for Transgender Health and they write the standards of care for transgender health care. Dr. Mitch suggested I look over the information on the website and I did. It answered a lot of questions. Dr. Mitch assured me that there was nothing wrong with me and that Karen was always going to be my child. He suggested that if Karen wants to dress like a boy, it’s not permanent. He suggested I just back off and let her do what makes her comfortable. Of course, I was terrified that she would start taking hormones and have permanent changes that she would regret later. Dr. Mitch told me that Karen needs to live as a boy for a year and see a therapist every week to discuss her journey to make sure it’s the right thing. He wouldn’t prescribe hormones until Karen has been living as a boy for a year and his therapist signed off on the treatment.
Karen started seeing therapists who specialized in transgender teens. Insurance was a constant battle. The quality of the therapists was spotty. Karen, now Tony, was angry and impatient. He wanted testosterone now, now, now. He went to group meetings with other transgender teens and I think he saw how many of them struggled with no parental support. I remember seeing a young boy with long lanky hair and a defeated demeanor at a couple of his pizza party groups. I saw him, or her I should say, walking there and walking home. I really felt sad for this kid who wanted to be a girl so much. Tony told me the girl was grinding up DVDs and eating them because she heard the plastic works like estrogen. I really felt terrible for her. I determined that I was not going to be like her parents. However, I was not going to let Tony make any irrevocable decisions until we both were sure this was the way forward.
That year was a bit of a blur. Lots of appointments, Tony being angry. Kids and teachers at his school wouldn’t get with his name change and preferred pronoun. I blew it myself many times. I was so used to Karen, my daughter…not Tony my son. Problems at school came to a head and Tony pulled out of high school in favor of going to an alternative school. Things got better and worse, better and worse. I was at my wits’ end. All Tony wanted was to be seen by others as he saw himself, as a boy, not a girl. He bought some binders online and that worked, but they were uncomfortable and over time, left him bruised and misshapen. His girlish hips and curvy legs were problematic.
When he finally got the go ahead to start testosterone, he was so excited. Looking back, I think he thought that once he started hormone therapy, he would magically change into another person. It wasn’t like that. He still had problems with his old friends misgendering him. He still was behind in school. He still had all his old problems. That first year was the angry year. From my perspective, things got worse once he started testosterone. The doctor assured me that it wasn’t the hormones, it was just teenage angst. Tony went from twice a month dosing to once a week, halving the dose. I don’t know if that made things better or worse or didn’t do anything. I was scared, Tony was miserable.
Over that first year of testosterone, Tony gradually got more stable. I guess it was probably two years all in all before Tony got the body he wanted…or close enough that he can live with it. He’s 18 now and looks very boyish. He doesn’t bind his breasts anymore, but he does hunch his shoulders and tape his nipples flat when he goes out. We’ve discussed top surgery and I think the conclusion is that he can live with a small chest for now. There’s no talk of bottom surgery. I think Tony is finding a new middle ground between being a boy and being a girl. I tell him he doesn’t have to be binary, either/or. He can just be himself and I’m cool with whatever that self is. He is OK with being a boy with breasts. I know that given a choice he would choose not to have them. However, for now, the discomfort and risks of surgery are not worth the benefit.
Being a teenager is difficult in the best of circumstances. Tony is an adopted immigrant from Vietnam with a white single gay parent and born in the wrong body. Is it a surprise that his teen years were stormy? Not really. Tony worked all summer long at Chipotle and saved up his money. He bought his own car. He works two jobs. He’s smart and responsible. He’s good with money. He’s still afraid of school. He was tormented in high school and I think he has a lot of anxiety about going to college. I gently nudge him, but there is no hurry. He’s just about as perfect a person as I’ve ever seen. The trauma of those years of his transitioning is with us both, but gradually fading. I’d say he is a success story. He’s my son.
The 57-year-old woman is standing in the hall outside of the exam room. She is agitated. “I’m waiting for the doctor. I’m freezing! My back is killing me!” I note she is pale, unable to stand still, and has a sheen of perspiration on her forehead. She is in withdrawal. I get her a blanket and ask her to wait in her room. The pain clinic nurse is downstairs at the pharmacy getting the patient’s prescription for Suboxone for induction. Induction is the process of starting the patient on medication and finetuning the dose.
An hour later the patient is back in the hall calling me, “Thanks for the blanket!” She is smiling. Her color is back. She is clear eyed, calm, and collected. What happened? Suboxone. Suboxone is a combination of buprenorphine and naloxone that is used to treat opioid addiction. Buprenorphine is a partial agonist of the μ-opioid receptor with a high affinity and low rate of dissociation from the receptor. In English, the buprenorphine molecule sticks to the opioid receptor in the brain, but only partially activates it. Then it stays there for a long time, blocking it from opioids, before dissociating. What this means for the addict is that they get enough opioid receptor activation that they don’t get sick from withdrawal. They can function normally with less of the problematic effects of a full agonist like morphine or heroine.
The addition of naloxone, a full opioid antagonist (blocker), keeps the Suboxone pills from being crushed and injected. Though naloxone has a strong effect when given parenterally (by injection), its effect when given by mouth is negligible because it is poorly absorbed sublingually. Suboxone disintegrating tablets are given under the tongue.
So, what is this wonder drug all about? In 2000, federal legislation (Drug Addiction Treatment Act of 2000) made office-based treatment of narcotic addiction with schedule III-V drugs legal. Until then, the only option for addicts was abstinence-based treatment or methadone clinics. The ever-increasing rates of drug overdose deaths in the United States showed this was not working. At first, only MDs specially approved by the Department of Health and Human Services could prescribe medications to treat addiction. In 2016, President Obama signed the Comprehensive Addiction and Recovery Act allowing nurse practitioners and physicians assistants to prescribe schedule III-V drugs for the treatment of addiction. Previously, they could prescribe these medications to treat pain but not to treat addiction.
What does this mean for the addict? For starters, Suboxone and similar drugs are now more widely available. Until recently, the only way for a heroin addict to keep from getting withdrawal sickness was to use more heroine. These patients were considered toxic to regular doctors because their disease lead to ever-increasing doses, seeking medications from multiple providers, decreasing levels of health, and ultimately death. Now that there is an option other than going cold turkey, the addict without some kind of pain diagnosis can get access to health care whereas before they would avoid it because of the stigma of being an addict. Because Suboxone is a partial agonist with high affinity to the μ-opioid receptor, it decreases the ‘high’ if the patient continues to use narcotics causing the patient to lose interest. It offers the benefit of allowing the addict to function in life, decreases the likelihood of death from respiratory depression, and increases the quality of life because there is no need for the addict to ride the wheel of withdrawal—drug seeking, using, running out, and then seeking again to the exclusion of every joy of life.
What happens when a person starts buprenorphine? After a largish battery of tests, the prospective recovering addict will be asked to abstain from narcotics before induction to Suboxone. How long before the first dose the addict has to abstain depends on the person’s addiction. Longer acting drugs like methadone could be 24 hours. Shorter acting drugs like morphine could be as little as six hours. The person should be in the early stages of withdrawal. The reason for this is the “partial” part of partial agonist. The buprenorphine molecule will muscle other narcotics off the receptor site where it was fully activating the receptor. Now, the higher affinity buprenorphine is sitting there doing half the work that the heroine was doing and this leads to symptoms of withdrawal. Giving a person a drug that puts them immediately into withdrawal will turn them off to it completely. You won’t see that person again. Higher success rates are tied with higher levels of symptoms of withdrawal before induction. Now instead of precipitated withdrawal, the person has relief from symptoms of withdrawal even if they are not getting high.
A person who has been successfully inducted to Suboxone therapy will find almost immediate relief. The terrible body aches, muscle pain, abdominal pain, depression, diarrhea, and cravings evaporate. Our patient might just have found a new way to live, free from the constant need to find more narcotics. She can focus on her life instead of her disease. Most of the clinic patients have jobs. They want desperately to be productive members of society for themselves and for their families. Buprenorphine therapy coupled with lifestyle interventions provided by mental health professionals, self-help groups like Narcotics Anonymous, and patient-initiated interventions (like taking a class or going back to school) are part of the success story of a growing number of recovering addicts.
What’s it like to come off Suboxone? Eh, probably a lot like getting off heroine. Same withdrawal profile or pretty close. Patients wanting to get off all narcotics, including Suboxone, can be weaned off gradually depending on their desired treatment goals. Someone facing a jail sentence or travel overseas that needs to detox from opioids quickly may be on a tapered dose of Suboxone for just a few days or weeks. Other people may decide that the burden of staying on Suboxone is worth not having to go through withdrawal and choose to stay on a maintenance dose for the rest of their life. The addiction specialist will help guide the patient through the decision process. Many patients decide to stay on the medication as a hedge against relapse since buprenorphine has a higher affinity for opioid receptors than street drugs. This coupled with the very slow rate of dissociation means that a person would have to stop the buprenorphine well in advance of restarting heroine or other opioid in order to get high.
What does this mean for health care? For one, at least some addicts who eschewed health care in the past can now get treatment for this disease. At some point, most addicts will desire to get off narcotics. Having a real treatment option available instead of a far-away methadone clinic or withdrawal will work to drive these patients into recovery. Another thing is that it’s possible that some of the stigma of addiction will be lifted, at least slowly, as treatment becomes available and success stories become commonplace. As the DEA and FDA work to get a handle on the 70,000 overdose deaths per year by educating doctors and enforcing distribution laws, these drugs will become harder to get. During the 12 months prior to July 2017, overdose deaths fell in 14 states for the first time during the opioid epidemic, according to the Centers for Disease Control and Prevention. In the rest of the nation, at least the numbers have leveled off. Greater access to Narcan (brand name of naloxone, one of the drugs in Suboxone), and more treatment options for addicts will hopefully drive these numbers lower over time. It’s not time to celebrate, but at least there is a glimmer of hope. The priority is to keep addicts alive until they can (or they are ready to) get treatment for their disease.