Autonomic Neuropathy And Heart Disease

My name is Marc Laderriere. Born and raised in France. I lived in Paso Robles, for the last 10 years. I work a lot. You know, less exercise, you know, you paying less attention, and then, the one day you realize, hey, I’m a little tired, what’s going on, you know Also, we noticed, that I was sweating very, very little, and I was very susceptible to heat, and I would basically get very, very tired and like hit a wall. After multiple series of blood test through the local doctors, we decided to go to Stanford.

To see what we could do. Mr. Laderriere was referred to us really because of the fatigue, but also because his primary care physician noticed that his blood pressure was changing quite a bit. When we examined him in the clinic, a few things were striking. First, his pupillary reaction was not as we expected and his skin was unusually dry and we happened to evaluate him here during a very hot day. So, he clearly had issues with perspiration. And then, we measured his blood pressure again and we had him lay down for about 10 minutes, stood him up and there was.

A persistent drop in his blood pressure. Dr. Jaradeh pretty much right away felt, it probably was something that had to do with the autonomic nervous system. The autonomic nervous system is the part of the nervous system that controls all the vital functions and the organs that are independent of our own will. For instance, the reason why your heart beats is independent of your will. The range of the autonomic disorders can be fairly wide, as you might expect. The most common problems we find are first problems in patients who cannot stay upright very long.

Sometimes, patients present with unexplained arrhythmias where the heart, you know, palpitates like crazy, the other presentation usually, is patients who have major digestive issues. Then, heat tolerance can be a problem, because if somebody cannot sweat, it’s really difficult for them to be out in the heat, they can develop heat stroke fairly quickly. Testing these patients requires an integrated approach, which is not available in many areas. During the first meeting, he asked, Have you ever been treated for Lyme Disease and I said, Absolutely not. So, we went through that right away, and of course, we discovered.

Right then that, I had Lyme Disease for probably 5 to 10 years. So, he, wanted me to be on antibiotics, to eradicate the different markers of Lyme Disease. Now, I do not have any more Lyme Disease. But it was clear, however, that I did have a autonomic nervous disorder of sorts. We believe that we found the cause and we’re trying to address it. And then, we basically worked with him a regimen where we give him medication that could help him with the sweating function, and in fact, he has noticed some benefit from that. We also started giving.

Sean Stephenson Super Shake

Think about all the words that you’re using to talk to yourself. Are you saying things like I’m important I want to change this planet. Well what if no one likes my idea What if it doesn’t work You have to own that right now you are where you are, so you can go where you want to be. I believe my life purpose is to rid the world of insecurity. I know that when I meet you that you have something to teach me. What’s up my man What’s going on What are we making today We’re making the Sean’s Supershake.

Alright, should we tell them what’s in this shake The Sean Stephenson Supershake. That’s right. What do we got in it, my man We got cucumber, spinach, kale, avocado. We’ve got. This is a hardy shake. Yeah it’s thick, it’s thick. And then we got a milk substitute, like coconut milk, coconut water. We can get almond milk, if you want. That’s how we like to make juice. Alright we making Sean’s magical juice recipe. Sean Supershake. By the time they’re going to watch this tutorial they’re definitely going to walk away with great alkalizing, tasty, vibrant, nutrientdense smoothie.

Can I tell them what we else we’re going to do at the end of this thing. Do it. Coz the smoothie is badass. Here we go, what do we got We got spinach. Boom. Kale. Boom. We’ve got pineapples loaded with bromelain, and then berries as well. Good antioxidants. Organic as well. Good for the brain. Yup, good for the brain. This is great for the brain. What do I call this God’s butter. God’s butter. We’ve got cucumber here. Right. We’ve got a little ice, we’ve got coconut milk. What kind of coconut do you like.

You know this is a debate between Mindy and I. She likes the unsweetened nonvanilla. I like the sweetened vanilla And I just want you to know that this guy really does believe that you’re important, and that what you have to offer to the world needs to be shared. So he’s going to keep making sure get stretched out of your comfort zone by doing things like having vegetables and blended up goodness in your life so you can be the best version of yourself. Drew, thanks for doing what you.

To this planet. Thanks my man. Alright guys thank you for watching this tutorial. It it the big old thumbs up. Check out Sean, really really good stuff. Thanks for coming on today, dude. Thank you. This recipe is awesome. If you love this recipe, if you want more information about your health, more tutorials like this, check out JuiceWithDrew Get the detox program, he’s too humble to say this but you need to be spending some money here coz his program is amazing I would reach into your pocket right now, and make it worth your time.

So thank you. I love you buddy. Good to see you man. Alright guys, later. Sean and Drew take two. Don’t block the veggies now. Is this required This is Sean Stephenson, and this is Drew Canole. This is your show so you should start it with. Alright, we’ll make the Supersahke. Alright, it’s time for the Supershake. Not that shake, you silly man. Alright, what kind of shake are we making today Sean Stephenson.Sean Stephenson. Sean Stephenson. Sean Stephenson. Sean Stephenson. Sean Stephenson. Sean Stephenson. Sean Stephenson. Oh that was close. That was wild.

Autonomic Dysreflexia Training Session tutorial for Clackamas Community College

Hello my name is Doctor Jerry Ryan PhD I’m here today to give a presentation on autonomic dysrelexia 00024.920,00025.779 as a training session for emergency room staff and EMTs and autonomic dysrelexia is basically a lifethreatening condition for people spinal cord injuries the way I’ll cover this today will be we will talk about what causes autonomic dysrelexia what it is what the signs and symptoms are and what the treatment and then we’ll have a review at the end this presentation is supported by grant number five forty five from the.

Paralyzed Veterans of America Education Foundation and it’s produced by myself Doctor Jerry Ryan from the Oregon chapter of the Paralyzed Veterans of America This presentation is designed to be an introductory overview and it’s derived from the following publications that are produced by the consortium for spinal cord injury and medicine and that is funded through the Paralyzed Veterans of America the two documents that this presentation is taken from the first one is a clinical practice guidelines for professional medical staff it’s called the acute management of autonomic dysreflexia.

Individuals a spinal cord injury presenting to health care facilities the second document is a consumer guide and it’s called autonomic dysrelexia what you should know the presentation is intended merely to raise awareness about the symptoms and the treatment of on autonomic dysrelexia in persons with spinal cord injury has to be used in conjunction with the above cited publications viewing this presentation does not substitute for reading the guidelines in their entirety I have a special note for the EMTs the information that I’m going to give in this presentation.

Because it is not an authorization to disregard your state laws regarding the limitations of EMT medical care we will cover some treatment procedures that probably won’t be legal in some states for them to use so what you should do as an EMT is to make sure that you check your state laws on what’s going on and basically for the EMTs this is to let the ER staff know about the autonomic dysreflexia in a patient all right so what is autonomic dysreflexia 00243.889,00245.119 or AD throughout this I’ll say autonomic dysreflexia I may just say dysreflexia.

May just say AD they’re all interchangeable it’s also called hyperreflexia autonomic dysreflexia is basically an abnormal responsive person with the spinal cord injury to some stimulus in a part of the body that’s below the injury and it’s an emergency condition and it’s life threatening for the individual so it does require immediate attention so for the basis of what on autonomic dysreflexia is the body controls blood pressure and the body temperature through a series of capillaries and it comes through the autonomic nervous system the autonomic nervous system.

Is both within and outside of your spinal cord and it runs parallel with the regular central nervous system and all these nerves interconnect and there are controlled by the brain and spinal cord so what happens in an episode of autonomic dysreflexia is the spinal cord injury basically jeopardizes the person’s ability to control their body temperature as well as a blood pressure and blood pressure is the key issue here what happens are the nerve impulses are blocked at the site of the injury and so the result basically is the.

Nervous system getting a mixed response or a confused response and it doesn’t have a clear picture of what the stimulus is so what happens is the autonomic nervous system kicks in and it basically sends the person’s blood pressure through the roof and some others things like that will cover in a moment now who is at risk primarily it’s quadriplegic and tetraplegic which is another interchangeable term patients so injuries above thoracic level six t six or above are the most common people for autonomic dysreflexia although there have been cases.

As far as t10 as far down the spine as t10 where people can have signs and symptoms of autonomic dysreflexia so this information is still be helpful for folks with injuries below t6 alright the common warning signs these are some graphics slides to give you a kind of a depiction of what the signs are now the worst and most uh. important sign to take care of is the fast rapid increase in blood pressure the biggest problem here is the increase in the blood pressure pounding headaches those type of things.

And when I say a major increase in blood pressure what we mean is twenty five to forty points systolic above normal normal for quadriplegic will not be the typical one twenty over eighty for example I’m a quadriplegic and my baseline blood pressure is ninety over sixty so if i come in presenting at one twenty over eighty you should be suspecting a problem pounding headache is another sign of autonomic dysreflexia goes along with the increase of blood pressure sweating heavy sweating particularly in the area of the face neck shoulders.

Once again it’s usually but not always above the point of the spinal cord injury the same type of thing happens with the skin it can change color you can have a little blotches thumbnail sized blotches of red or the entire skin can have a flush complexion and again this is usually above the site of the injury goosebumps another sign on the skin again usually above the site the site of the injury feeling of tightness in the chest a constriction like you’ve got a belt around your chest those types of things trouble breathing.

Blurred vision or seeing spots uh. primarily related once again to the blood pressure increase anxiety or jitters this can also turn into confusion agitation and a stuffy nose it’s another one of the signs so symptoms in review the elevated blood pressure again this is the most critical aspect of an autonomic dysreflexia episode and if you’ll note there it’s with a normal or low pulse and speaking with many physicians about this this is the only time you’re ever going to see an elevated blood pressure with a normal or low pulse and again it’s twenty to forty.

Points above the baseline for that individual you will probably need to question the individual about what is their baseline severe and pounding headaches once again accompanied by the blood pressure the sweating above the level of the injury nasal congestion the skin changes again that includes a goose bumps and the flushing of the skin or the little blotches agitation confusion anxiety jitters those types of things now one of the causes of autonomic dysreflexia as I’ve stated before dysreflexia is usually caused by some form of irritation below the level of.

The injury the most common cause is a bladder problem either bladder distension or other urinary complications the studies show that this is about eighty five to ninety percent of the time the problem so this should always be the first place you look to alleviate the situation for the patient check the urinary system and note in red at the bottom of the slide IV fluids are not advise prior to ruling this out this person is going through an episode of dysreflexia for bladder distension last thing you want to do is plug an IV into them and give more fluids.

The issue is to drain the fluids that they have at that point right so let’s continue with the urinary system i’ll go through a couple of different systems to to check out for causes of autonomic dysreflexia as i stated bladder distension is the A number one cause of this problem and that includes blocked catheters and that type of thing bladder or kidney stones can also do this as can be doing cystoscopies or any type of urologic procedures in the gi system this is the second area if.

The person’s bladders draining fine the second problem to look for is impacted bowel constitutes probably the remaining ten ten or so percent if it’s not bladder move to the bowels so the other problems within the GI system that can cause autonomic dysreflexia besides bowel distention and impaction would include gallstones gastric ulcers appendicitis any type of the GI exam can do it and hemorrhoids can also cause an episode integumentary system the skin constricted clothing belts if their shoes are too tight the sock can be bunched up inside of the shoe.

The leg bag urinary leg bag straps could be too tight anything like that over time can cause an episode of dyreflexia contact with a hard or sharp object in an area where the person doesn’t feel it burns people have gotten this from having their feet too close to a heater in the winter time those type things sunburn infected toenails and ingrown toenails insect bites all of these things and pressure sores if a person has a pressure sore and they’re trying to get up and sit on it their bodies will let him know.

That that’s not what they need to do and it’ll cause an episode of dysreflexia reproductive system the natural act of intercourse and ejaculation can set off an episode of dysreflexia as can STDs epididymitis for men scrotal compression or sitting on the scrotum or even having the pants bunched up by the scrotum can set that off and for women the menstrual cycle and vaginitis can cause episodes of dysreflexia all right those are the three main areas you start with the urinary bladder and then you move onto the bowel and the.

Skin and here are some either systemic causes that are maybe one to five percent of the time these would be a problem if you have ruled out the other three you start looking for DVTs deep vein thrombosis excessive alcohol or caffeine or any other diuretic consumption of that fractures bone fractures will definitely set off an episode of dysreflexia pulmonary emboli heterotopic bone heterotopic bone is basically a calcium deposit in a joint area on somebody hasn’t moved that area for quite some time some other systemic causes would include boosting.

This is something that is done by a SCI athletes I’m not terribly familiar with it but it is documented in the literature functional electrical stimulation that’s where they would put the electrical pads on and individual’s legs and stimulate them to facilitate them pedaling a bicycle for example this type of stimulation can cause an episode dysreflexia substance abuse of any type beyond alcohol overthecounter drugs prescribed stimulants and any type of substance abuse can set this off and of course invasive procedures or surgical procedures would definitely set it off.

And for women childbirth is another area that is of concern for autonomic dysreflexia obviously it’s going to happen during the labor and delivery portion of the pregnancy it may happen at other times but labor and delivery is the most common and everybody involved the entire obgyn team needs to be aware of that and taken precautions prior to the labor and delivery now if you think your patient has autonomic dysreflexia and again I need to make your reminder for the EMTs that you need to check your state laws.

To make sure that you can do some of these procedures and I’m about to cover with your state law some of the following procedures can only be performed by authorized medical personnel and will not be legal in some states for EMTs so you need to check your state laws alright the very first thing to do if you suspect the individual has autonomic dysreflexia is begin checking their blood pressure you’re going to want to do that every three to five minutes until you resolve the problem if the person has signs and symptoms but doesn’t have a high blood.

Pressure yet then you need to get that individual to the consultant that is appropriate for the symptoms now if the blood pressure is already elevated most important thing to do is sit that individual up once again this is somewhat counterintuitive people want to lay everybody down on the stretcher and put an IV in them in the case of autonomic dysreflexia these are the two worse things you could do you want to keep that person sitting up until their blood pressure is normal so he’d be sitting up.

With their legs dangling is preferred and just sitting upright the next thing to do is loosening tight or constrictive clothing obvious things like shoes socks and again checking the urinary collection system to see if the leg straps are too tight anything like that then again while you do this you continue to monitor the person’s blood pressure and pulse every three to five minutes now you may begin to look over the patient to see what’s causing the problem and you’ve already loosened the clothing so once again we’re going to go to the urinary system because again eightyfive.

To ninetyfive percent of time this is where the problem lies if the person does not have an indwelling catheter catheterize the patient at that point you’ll see the note there that says for the EMTs to check the laws in their state regarding characterization now prior to putting in a catheter in this individual use some two percent lidocaine jelly and give it a couple minutes to numb the area you have to realize this person is already going to an episode of AD and it’s caused by some type of noxious stimuli and you’re about to catheterize a.

Person which is a fairly traumatic experience so you want to have the area and as numb as possible if the person already has an indwelling catheter check the entire system from top to bottom for any type of kinks any type of blockage or anything that could be obstructing the flow if you can find the problem there correct it immediately now if the catheter appears to be blocked you can flush the catheter now you want to use body temperature normal saline for this because once again the person is going through stimulation.

That’s noxious and if you start instilling cold water or cold saline rather and or the saline’s too warm you’re going to add another traumatic event to the process so use about ten to fifteen ccs that’s plenty of saline to irrigate the catheter and get flow and again dont be tapping on the bladder or any type of those techniques to try to get the bladder to function because you will cause stimulus and spike the person’s blood pressure now if the catheter’s draining and the blood pressure remains elevated.

Then proceed to recommendation sixteen which will cover in a moment if the cathethers not draining and the blood pressure remains elevated then you need to remove the catheter and replace it there must be some type of the internal clog to the system that could be blood clots there could be any number of things that are occluding the catheter at that point once again prior to replacing this catheter be sure use that lidocaine jelly because this is going to be fairly noxious stimulus to the person and you want to.

Alleviate that as much as you can so use the lidocaine jelly and give it about two minutes on that if you have any difficulty in replacing the catheter and this oftentimes happens because that person will be the body will just be goin through so many things that the bladder sphincters are going to cooperate like they don’t normally do so you may have to consult an urologist he may have to try to pass a coude catheter this is something to bear in mind and all the while you’re doing this be sure you also maintaining.

Monitoring a person’s blood pressure and pulse okay now if you’ve done all this and the person still is exhibiting the signs and symptoms and has a high blood pressure you should suspect fecal impaction that’s the number two reason for an episode of AD at this point also if the blood pressure is over one fifty systolic you might want to consider doing some pharmacologically management which via short duration type thing antihypertensive agents primarily that would be nitro paste something that has a rapid onset but a short duration.

Once again note for these type of procedures I’m about to explain EMTs need to check their local state laws because some of this won’t be allowed for EMTs depending on state to state now also if the person’s blood pressure is not about one fifty systolic then you can move right on to number twenty we’ll get to that a second now if you’re going to use an antihypertensive agent with this individual once again nitro paste would be the selection of choice it has a rapid onset short duration it quits delivery as soon as the nitropaste.

Tape is removed once you if you were determined to give a person some type of pharmacological management for their blood pressure continue to monitor the person’s blood pressure to look for signs of hypotension because once you relieve the problem that’s causing the dysreflexia then you’re going to have a problem with the person’s blood pressure bottoming bottoming out if you put him on some type of antihypertensive prior to that so keep constant monitoring on the blood pressure now if a fecal impaction is suspected and if the blood pressure is less than one fifty systolic.

Then you’ll check the rectum for stool and do it in the following manner very much like catheterization you’ll use a topical anesthetic once again to avoid anymore noxious stimulation to the individual so get some two percent lidocaine jelly and instill it into the rectum and wait a couple of minutes before you start checking once you. once a couple minutes have passed using a gloved hand obviously and a lubricated finger again with the lidocaine jelly check the rectum for stool and if there is any remove it now oftentimes the.

The stimulus regardless of the anesthetic jelly will cause a person’s dysreflexia to increase if that does happen what you want to do is stop and instill more of the topical anesthetic and give them about twenty minutes for it to take really good effect alright now if these if this has not taking care of the problem we need to start looking for the less frequent causes at this point you’ve taken care of loosening the clothing you’ve checked the urinary bladder and all connective tubing and you’ve checked the bowels.

At this point you may want to consider hospitalizing the patient until you find out what the cause is now this is the followup care any time a person has an episode of dysreflexia they need to be instructed to continue to monitor their symptoms for at least a couple of hours to make sure that it doesn’t reoccur and part of that training will also be educate the individual to seek some medical attention should it recur and if the person is an inpatient then according to who his primary health care team is they should be.

Monitoring him for all the signs and symptoms for two hours as well once again you would consider admitting an individual to the hospital primarily at the signs and symptoms of dysreflexia do not resolve if you have not been able to find the problem or if they just had a poor response to what you have done anyway you may have to hospitalize them and also if you suspect there’s any kind of obstetrical complications in a female with a spinal cord injury presenting with dysreflexia further items in the followup include documenting the episode of dysreflexia.

In the patient’s medical record that includes all the presenting signs and symptoms and what their course was throughout the episode what the treatment was that you instituted with the individual all the recordings of blood pressure readings and pulse and i’d like to point out that the reason for taking them every three to five minutes is once you find the cause it will take the body three to five to even ten minutes before the blood pressure goes back to its normal baseline and another thing that you would want to include in your patient’s records is.

Of course his response to treatment you’ll need to evaluate the effectiveness of the treatment according to the outcome the outcomes are the obvious that the cause of dysreflexia has been identified and resolved that the blood pressure has gone back to its baseline and here i point out that’s ninety two hundred ten systolic it’s not the one twenty over eighty that traditionally would be a baseline Another criteria is that the press rate has gone back to normal and the individual is comfortable exhibiting no further signs of dysreflexia.

Including the high blood pressure cranial pressure or a risk of heart failure once the person has been stabilized you’ll want to review the entire cause of the dysreflexia episode with the individual his friends his family his significant others and anyone who brought him there or came with him so that they can be educated on it and understand why it happened and take care of it in the future in a preventative fashion which is number twenty seven give the individual an educational plan basically to prevent and to treat it in an emergency.

On their own and so basically you would adjust their treatment plan so that they recognize those further episodes and that they can take care of them at home and ideally they would avoid them altogether in addition to that you want the person to be able to minimize the risks of getting that and to solve the problem when it comes up so they’re not constantly calling nine one one if their catheter’s blocked or something like that that they can understand exactly what’s going on take the steps to resolve it before it occurs so that there.

They’ve reduced the incidence and then if it does occur for whatever reason they can troubleshoot and find out what’s going on to resolve it themselves as quickly as possible and at the time of the patient’s discharge you’ll want to get them as much information about autonomic dysreflexia as possible that includes a consumer wallet card that’s available through PVA it has all the signs and symptoms listed on it and they come in both english and spanish the card looks like this and that has all the signs and symptoms in and it even has the treatment program.

Written on it if you ever have a patient with spinal cord injury and you suspect autonomic dysreflexia and they hand you this card please look at it i’ve had the unfortunate occurrence myself of having a dysreflexic episode and i gave this to the EMTs they set it aside and gave it to the ER physician and they set it aside spinal cord injury patients pretty much know their body and know what the problems are so it’s very important to listen to the patient but you do want to give the patient one of these cards they’re available through.

The PVA website and then if you have a patient has continuously reoccurring autonomic dysreflexia you need to schedule some detailed medical exams to find out exactly what the underlying cause is and this is important for the emergency room staff and for the EMTs you can get the entire clinical guidelines and the consumer guide they’re available to download on the paralyzed veterans of america website that website is www dot pva dot org the particular documents that you’ll want to download are the ones that this presentation is taken from.

As a professional clinical practice guidelines which is the acute management of autonomic dysreflexia in individuals with spinal cord injury presenting to health care facilities the other document is autonomic dysreflexia what you should know that’s the consumer guide that’s available both in english and spanish print copies of these documents are available through the PVA distribution center it has a tollfree number one eight eight eight six zero seven two four four and if you have further questions about this there’s a PVA healthcare hotline that you can also call toll free.

House Brave Heart

Sirens blaring ltigt man LEFT! LEFT! HE’S GOING LEFT!ltigt I’M GONNA HAVE A HEART ATTACK. Monotonix’sltigt Set Me Freeltigt I DON’T BELIEVE IN MIRACLES TRIED TO SAVE MYSELF PRETENDING TO TRY grunting NOWHERE TO GO, BUTTON. WHAT THE HELL WAS THAT WHAT ARE WE CHASING GO THAT WAY. THERE ARE SHADOWS IN THE CITY, OH, SO FAIR SET ME FREE SET ME FREE SET ME FREE YOU BETTER SET ME FREE.

AW, YEAH panting OH, WHOA ltigtUP, DONNY, UP. HE’S GOING FOR THE ROOF.ltigt SET ME FREE SET ME FREE OW. DAMN IT. JUST GO, GO! SET ME FREE SET ME FREE SET ME FREE WELL, ALL RIGHT WHOO IF YOU EVER SEEM TO FACE OFF DONNY, NO! IT’S TOO FAR! OH! OH! OH! sirens blaring Massive Attack’sltigt Teardropltigt.

I CAN REST AT HOME. WE CAN’T RELEASE YOU FOR AT LEAST TWO DAYS. YOU HAVE TWO BROKEN BONES, A SEVERE CONCUSSION, COLLAPSED LUNG. BUT YOU DIDN’T FIND ANYTHING LIFETHREATENING, RIGHT YOU FELL 30 FEET. YOU SHOULD HAVE DIED. I THINK THAT WAS THE POINT. COULD YOU SHUT UP YOU HAVE SUICIDAL THOUGHTS NOT ONCE. NEVER. HE JUST THINKS HE’S GONNA DIE SOON, SO IT DOESN’T REALLY MATTER NOW YOU SHUT UP. I’M THE ONE YOU’RE NOT COVERING WHEN YOU PULL YOUR CRAZY STUNTS. WHY DO YOU THINK YOU’RE GONNA DIE SOON.

WELL, MY DAD, GRANDFATHER, AND GREATGRANDFATHER ALL DROPPED DEAD OF HEART PROBLEMS RIGHT AFTER THEY TURNED 40. LOOK WHO TURNS 40 NEXT WEEK. I CAN REFER YOU TO A CARDIOLOGIST, IF YOU NAH, I’VE BEEN THERE, I SPENT MY EARLY 30s GOING FROM ONE DOCTOR TO ANOTHER. AND YOU THINK THEY’RE WRONG I KNOW THEY’RE WRONG. AT A CERTAIN POINT, YOU JUST GOT TO LIVE YOUR LIFE. BY LIVE YOUR LIFE, IF THERE IS SOMETHING WRONG, I KNOW A DOCTOR WHO WILL FIND IT. door opens sighs OH, GOD! I’LL BE BACK IN TEN.

I’M PICKING LINT OUT OF MY BELLY BUTTON. I’M CONVERTING THE STUDY INTO A BEDROOM. HUH. SIX WEEKS. FOR YOU TO NOTICE THAT I’M SLEEPING IN YOUR LIVING ROOM, AND OFFER OTHER OPTIONS. I DIDN’T EXPECT YOU TO BE HERE THIS LONG. TRUE, BUT THAT’S NOT WHY YOU DIDN’T EXTEND THE INVITATION. DO YOU REALLY NEED TO DECONSTRUCT THIS YOU DIDN’T WANT ME TO SLEEP WHERE YOU AND AMBER SLEPT. OKAY, YES, YOU DO. AFTER SHE DIED, YOU CONVERTED THE STUDY TO A BEDROOM AND THE BEDROOM TO A STUDY. EXCEPT IT’S NOT A STUDY, IT’S A SHRINE.

CAN I TELL YOU SOMETHING I WASN’T PICKING LINT OUT OF MY BELLY BUTTON. OKAY. I AM NOT READY TO TRANSITION FROM MY DEAD GIRLFRIEND’S SHRINE TO YOUR. MORNING GLORY. I JUST NEED IT TUESDAYS FOR ANIMAL SACRIFICES. OH, MAN! PATIENT’S A GENETIC TIME BOMB. THERE’S NO FUSE. RIGHT NOW HE’S NOT A PATIENT EITHER. YOU SAYING WE IGNORE THREE GENERATIONS OF CARDIAC PROBLEMS I’M NOT IGNORING IT. I’M LABELING IT A COINCIDENCE. YOU HATE COINCIDENCE. WE RECONCILED. IT WAS A WHOLE THING. HAS THREE GENERATIONS THAT DIED AROUND AGE 40.

WITH NONGENETIC HEART ISSUES. ltigt DICE HAVE NO MEMORY. ltigt GENES DO. IF WE RAN A BATTERY OF TESTS ON EVERY NONSYMPTOMATIC THE GUY GOES EVERY DAY ASSUMING HIS LIFE WILL END AT AGE 40. BECAUSE HE DIDN’T WANT TO DIE ON THEM THE SAME WAY HIS DAD DIED ON HIM. YOU WANT TO TAKE THIS CASE ‘CAUSE HE’S YET ANOTHER ltigtLONELY, SAD PUPPY.ltigt YOU SHOULD HAVE BEEN A VET. IT’S A LEGITIMATE CASE. ltigtForeman DIFFERENTIAL DIAGNOSISltigt FOR GENETIC HEART CONDITIONS. THAT SOLD YOU MARFAN SYNDROME, BRUGADA. AND YOU EMILIO HYPERCHOLESTEROLEMIA.

HE’S ONLY AGREEING WITH YOU ltigt’CAUSE HE WANTS TO HAVE SEX WITH YOU.ltigt AND BY THE WAY, I AGREE WITH YOU TOO, ESPECIALLY IN THOSE PANTS. WE’RE NOT WASTING OUR TIME. AND LAST WEEK, CHASE SAID THAT I WAS THE DE FACTO BOSS. DE FACTO MEDICAL LICENSES. LET’S START WITH GENETIC TESTS. AND AN ECHO TO CHECK THE INTEGRITY OF HIS HEART. I’LL START ON BLOOD SAMPLES. UGH. I FORGOT MY WATCH. ltigt COULD HAVE SWORNltigt I SAW YOU PUT IT ON THIS MORNING. ltigtMUST BE IN THE LOCKER ROOM.ltigt I’LL BE RIGHT BACK.

I NEED TO KNOW WHAT YOUR PLANS ARE. FIRST WE TAKE BERLIN. AND THEN WE CIRCLE AROUND BEHIND POLAND AND YELL, SURPRISE! WITH REGARDS TO YOUR EMPLOYMENT. I LIKE THINGS THE WAY THEY ARE. I GET JUST ENOUGH PUZZLE TO SOLVE WITHOUT THE SCORNFUL VISITS FROM YOU. UNTIL NOW. PRETEND TIME’S BEEN GOING ON LONG ENOUGH. I DON’T HAVE A MEDICAL LICENSE. ALL I CAN DO IS PRETEND. AND I’M GONNA HAVE PAYROLL SEND YOU OVER SOME PRETEND CHECKS STARTING TOMORROW. YOU NEED TO COMPLETE 120 HOURS OF ROUNDS TO REQUALIFY.

NO, I DON’T. I’M NOT SAYING YOU DON’T WIN. I’M JUST SAYING DO YOU REALLY NEED TO PUNISH ME BY MAKING ME CARRY A CLIPBOARD FOR YOUR LACKEY OF THE WEEK IT’S A STATE REQUIREMENT. I HAVE TO CERTIFY THAT YOU’VE COMPLETED ALL YOUR REQUIRE EXACTLY. THE REQUIREMENT SETS OUT WHAT YOU HAVE TO DO CERTIFY, WHICH YOU CAN DO WITH ONE HAND TIED BEHIND YOUR BACK. NOW, IF YOU WANT TO TIE MY HANDS. DR. SINGH SUPERVISES ROUNDS ON THURSDAYS, STARTS AT 700. NOTHING. SO WHAT NOW SEND HIM HOME.

TO CONTINUE BELIEVING HE’S GONNA DROP DEAD WHEN HE TURNS 70, HE’LL BELIEVE US. THERE ARE OTHER THINGS WE CAN CHECK. YOU DO THE DAD. I TAKE IT HE HAD A SEALED CASKET. THE WATCH STORY WAS CRAP, RIGHT I FORGOT IT. IT’S NO BIG DEAL. WHERE DIBALA DIED. I’LL SEQUENCE THE GENE FOR THE CARDIAC SODIUM CHANNEL. sighs I FELT LIKE I WAS GONNA HAVE A PANIC ATTACK. I’VE CROSSED SOME LINE. AND I’M HAVING TROUBLE GETTING BACK TO THE OTHER SIDE. I CAN MOVE THE PATIENT TO ANOTHER ROOM.

CAMERON WILL ASK QUESTIONS. YOU SHOULD TELL HER. ltigtSHE’S YOUR WIFE.ltigt door opens HOW’D YOU GET A COURT ORDER TO DIG THEM UP SO FAST WE JUST NEEDED THE GUY’S CONSENT. chuckles YOU FIND ANYTHING ltigt NOT YET.ltigt BUT YOU’RE JUST IN TIME TO DO THE DAD. HE’LL BE BACK IN THE MORNING. YOU’RE TREATING A POLICE OFFICER. DONNY COMPSON SECOND FLOOR. A NURSE WILL HELP YOU FIND HIM. I DON’T WANT TO SEE HIM. DONNY AND I USED TO GO OUT A LONG TIME AGO. HE DOESN’T WANT TO SEE ME. I DON’T WANT TO SEE HIM.

SO DID YOU COME TO SEE ME FOR PERSONAL ADVICE YOU’RE LOOKING FOR GENETIC CONDITIONS, WHICH MAKES SENSE, WITH WHAT HAPPENED TO HIS DAD AND GRANDPA. UNLESS YOU WERE HIS GIRLFRIEND AND HIS SISTER, YOU GOT NOTHING TO WORRY ABOUT. I’M NOT WORRIED ABOUT ME. BUT HE HAS A SON. DIAL EXTENSION 742. TELL DR. FOREMAN YOU GOT SOME COOL INFORMATION. GOOD NIGHT. indistinct whispering ltigt TREAD SOFTLY LEST WE TREAD ON OUR DREAMS.ltigt whispering continues indistinctly YOU OKAY YEAH, FINE. whispering resumes COULDN’T FIND ANY CONSISTENT GENETIC MUTATIONS ACROSS 15 AREAS BETWEEN DONNY’S ANCESTORS,.

POSSIBLY INDICATING THERE ISN’T ONE. AND UNDEGRADED DNA. I THOUGHT HE DIDN’T WANT KIDS. ltigtHE DIDN’T. ltigt WHERE’S HOUSE DEAR BLEEDING HEARTS, SINCE YOUR PATIENT’S MED HISTORY IS A COINCIDENCE, AND HE ISN’T. SICK, ltigt I’VE GONE BACK TO SCHOOL.ltigt ltigtBACK IN 120 HOURS. ltigt CHARMING. I’LL GET A BLOOD SAMPLE. IF WE’RE LOOKING FOR SOMETHING AS SUBTLE AS A MUTATION, IT MAKES SENSE TO GET THE DNA WHERE IT’S MOST PURE. YOU’RE GONNA ASK THE MOM TO CONSENT TO A BONE MARROW BIOPSY ltigtSHE WANTS TO KNOW IF THERE’S SOMETHING WRONG WITH DONNYltigt.

RIGHT. SPIKE A TENYEAROLD’S HIP BECAUSE GRANDPA WAS SICK. WE SAVE TWO PEOPLE. I DON’T WANT TO. CAN WE SPEAK OUTSIDE FOR A MOMENT YEAH. YOU NEED TO TELL HIM. I CAN’T. HIS FATHER IS DOWN THAT HALLWAY THROUGH THOSE DOUBLE DOORS. I’VE BEEN LYING TO HIM HIS WHOLE LIFE. WHAT’S HE GONNA THINK OF ME YOU’RE TRYING TO PROTECT HIM. DONNY NEVER WANTED KIDS. HE CERTAINLY DOESN’T WANT TO MEET HIM. IF DONNY DOES DIE, THIS COULD BE MICHAEL’S ONLY CHANCE TO MEET HIS FATHER. AFTER ADMINISTRATION OF IMMUNOGLOBULIN, PATIENT HAD NO FURTHER PAIN, AND OVERNIGHT LIVER FUNCTION TESTS.

PATIENT’S READY TO BE RELEASED. monitor beeping rapidly ltigt STATS ARE DROPPING.ltigt DOCTOR SINGH SHE’S CHOKING. ON YOUR FINGERS. ltigtSHE CAN’T BREATHE.ltigt ltigtHOUSE.ltigt PLEASE TAKE YOUR FINGER OFF THE TEST BUTTON. OH! beeping stops I SEE. WOW, SORRY ABOUT THAT. I COULD’VE SLIT HER THROAT. WELL, WE’RE ALL HERE TO LEARN. YOU KNOW, DR. CUDDY WARNED ME ABOUT YOU. SHE TELL YOU HOW TO STOP ME LOOK, I’M ASKING YOU AS AN ADULT TO PLEASE STOP. scoffs WELL, THAT OBVIOUSLY DIDN’T COME FROM HER. BUT FAIR ENOUGH. EXCELLENT PRESENTATION, NONA. ltigt AH!ltigt.

NOW I’VE DONE IT. THERE’S URINE EVERYWHERE! GOSH. THE GREAT THING ABOUT THE TEACHERSTUDENT RELATIONSHIP IS THE TEACHER CAN OFTEN LEARN MORE FROM THE STUDENT. HAVE YOU LEARNED ANYTHING YET YOU HAVE A SON. I WAS PREGNANT WHEN WE BROKE UP. I’M SORRY I NEVER TOLD YOU, BUT I KNEW HOW YOU FELT ABOUT HAVING KIDS. YOU HAD NO RIGHT. MAYBE. IT’S A LITTLE LATE FOR THAT. HE’S HERE. HE WANTS TO MEET YOU. I DON’T WANT TO MEET HIM. I’VE NEVER ASKED YOU FOR A DIME. HE’S HERE TO HELP FIND.

WHATEVER’S WRONG WITH YOUR HEART. I DIDN’T ASK HIM. I DIDN’T WANT HIM. JUST SAY HI TO HIM. door sliding open HI. HI. I’M YOUR UH. YEAH, YOUR MOTHER TOLD ME. WHEN YOU GET BETTER, MAYBE WE COULD DO SOMETHING. SEE A MOVIE NO. ltigtMY DAD DIED WHEN I WAS YOUR AGE.ltigt IT WAS THE MOST PAINFUL THING I EVER WENT THROUGH. ltigtTRUST ME, AS MUCH AS I’M SURE THIS HURTS RIGHT NOW,ltigt ltigtIT’S BETTER.ltigt PLEASE TAKE HIM OUT OF HERE. CHROMOSOMES FOR 28 CARDIOVASCULAR CONDITIONS ltigtNO TRANSLOCATIONS, DELETIONS, OR INVERSIONS.ltigt.

I DIDN’T NOTICE THAT THE KID’S DADDY CHROMOSOME HAS BEEN SEVERELY DAMAGED BY SOMEONE ELSE’S BLEEDING HEART CHROMOSOME. IT WAS THE ONLY WAY TO GET MICHAEL TO DO THE MARROW BIOPSY. I’M SURE THERE ARE PLENTY OF LIES WOULD’VE WORKED JUST AS WELL, EXCEPT WITHOUT THE YEARS OF THERAPY. DON’T YOU HAVE SCHOOL RECESS. SO WHERE DOES THAT LEAVE US CHASE SORRY. WHAT I WAS SAYING, DO YOU THINK THESE SHOES WORK IN THIS COLOR SEND HIM HOME. HE’S NOT GONNA BELIEVE HE’S HEALTHY. YOU’RE NOT VERY GOOD AT YOUR JOB.

YOU DON’T DESERVE CANDY. HE’S BEEN PREPARING HE’S HAD DOZENS OF DOCTORS YEAH, I DO. CHASE, WALK WITH ME. GREAT CONTRIBUTIONS BACK THERE. THERE’S NO CASE. I HAD NOTHING TO ADD. YOU HAD NOTHING TO ADD. BECAUSE YOU WERE DISTRACTED. ltigtA LITTLE DEVIL ON YOUR SHOULDERltigt TOLD YOU TO KILL A GUY, AND NOW THE LITTLE ANGEL WON’T SHUT UP, ltigtTELLING YOU YOU’RE GONNA BURN IN A LAKE OF FIRE.ltigt I’M FINE. elevator bell dings YOU SHOULDN’T BE. TALK TO SOMEONE. DOCS FIXED ME UP IN SEVEN WEEKS. YOU’RE. TEN MINUTES, TOPS.

THANKS. GLAD WE HAD THIS LITTLE MOMENT. COME ON. YOU COULDN’T FIND ANYTHING, COULD YOU YOU HAVE ORTOLI SYNDROME. ltigtDR. CHASEltigt ltigtYOU SURE ltigt TESTS DON’T LIE. RIGHT. UH. clears throat WELL, IT’SIT’S A. IT’S A VERY RARE DISORDER THAT SHORTCIRCUITS THE ADRENALS, WHICH SHORTCIRCUITS THE HEART. ABOUT MEDICAL MUMBO JUMBO TELL HIM THE TREATMENT. IT’S. WELL, IT’SIT’S COMPLICATED. DOCTORS ALWAYS WANT TO MAKE EVERYTHING SOUND SO COMPLICATED. IT’S NABASYNTH. WHAT NABASYNTH. YES. SO ALL WE HAVE TO DO NOW IS WRITE A PRESCRIPTION AND, UH, HAVE HIM PICK UP THE PILLS.

Surprised chuckles THAT’S IT I TAKE SOME PILLS, AND I’M GONNA BE OKAY THE REAL TRAGEDY HERE IS THAT THE TIBURON SWAB TECHNOLOGY DIDN’T EXIST TO DETECT ORTOLI BACK IN YOUR DAD’S DAY. HE COULD’VE LIVED. sighs THANK YOU. IF YOU’LL SIGN THESE DISCHARGE PAPERS, I’LL GET YOU A BOTTLE OF MEDS. TAKE ONE TWICE A DAY FOR A WEEK, YOU’LL LIVE A LONG, HEALTHY LIFE. indistinct whispering pounding constant pounding ltigt ANSWER THE DOOR, HOUSE.ltigt ltigt IT’S GOT TO BE FOR YOU.ltigt ARE YOU WATCHING TV ltigt IT’S THE DOOR! ltigt.

Pounding continues WERE YOU ON THE PHONE NO. JUST NOW, WERE YOU TALKING NO. I’M ALONE. YOU OKAY, HOUSE sighs WHY ARE YOU HERE DONNY COLLAPSED FOUR HOURS AFTER WE DISCHARGED HIM. HE’S DEAD. HIS APARTMENT MANAGER FOUND HIM ON THE FLOOR IN THE LAUNDRY ROOM. SAID HE WASN’T BREATHING. HE CALLED THE EMTs, BUT IT WAS TOO LATE. I SENT THE GUY HOME WITH MINTS. WHATEVER IT IS, WE ALL MISSED IT. I MISSED THE FACT THAT THERE WAS SOMETHING TO MISS. WHAT IS WRONG WITH ME YOU HAD GOOD REASON.

PATIENT PRESENTED WITH NO SYMPTOMS, AND ALL HIS TESTS CAME BACK NEGATIVE. WHAT’S THE OFFICIAL CAUSE OF DEATH AUTOPSY HASN’T BEEN PERFORMED YET. EMTs BROUGHT HIM TO GENERAL, BUT I REQUESTED THEY SHIP HIM BACK TO OUR MORGUE FOR THE POSTMORTEM. GOOD. HON. WAKE UP. WHY ARE YOU DRESSED YOU GO TO SLEEP I WANT TO GO TELL CHERYL THAT DONNY DIED. IT’S 400 IN THE MORNING. THEY’RE NEARLY TWO HOURS AWAY. I FIGURE BY THE TIME I GET THERE, SHE’LL BE AWAKE. BABE, COME BACK TO BED. CALL HER IN A FEW HOURS.

IT’S THE SORT OF THING SHE NEEDS TO HEAR FACETOFACE. IS EVERYTHING OKAY EVERYTHING’S FINE. LAST WEEK, I UNDERSTOOD THAT YOU WERE STRESSED OUT ABOUT THE DIBALA M AND M, AND I GAVE YOU YOUR SPACE. BUT THAT’S OVER NOW, AND YOU’RE STILL ACTING. I’M WORRIED ABOUT YOU. DON’T BE. I’M FINE. REALLY. AND YOU’D TELL ME IF YOU WEREN’T PROMISE YEAH. OKAY. HEY. I LOVE YOU. I LOVE YOU TOO. door closes DONNY COMPSON, AGE ‘. saw whirring whirring stops IT’S HIS HEART, SO LET’S LOOK AT HIS HEART. NICE YINCISION.

Saw whirs, stops YOU CAN’T PERFORM AN AUTOPSY WITHOUT A MEDICAL LICENSE. REALLY ‘CAUSE I DON’T THINK THERE’S ANYTHING I COULD SCREW UP THAT WE HAVEN’T ALREADY SCREWED UP. OPENING POSTMORTEM INCISION. BEGINNING AT THE MIDLINE OF THE STERNUM. saw whirring THAT’S ODD. ltigtIT ALMOST LOOKS LIKE HE’S.ltigt BLEEDING. screaming all screaming I THINK THE AUTOPSY’S GONNA HAVE TO WAIT A LITTLE BIT. ltigt Foreman HE WAS BRIEFLY CONSCIOUS,ltigt ltigt THEN HIS SYSTOLIC DIPPED BELOW 60,ltigt ltigt AND HE WAS OUT AGAIN.ltigt DIFFERENTIAL DIAGNOSIS FOR RESURRECTION. ltigt GO. ltigt OBVIOUSLY HE WASN’T DEAD.

LtigtHIS HEART SLOWED ENOUGH THAT THE EMTsltigt YES, THE FACT THAT HE’S NOT DEAD MEANS WE DID ABSOLUTELY ltigtTHERE’S SEVERAL DOCUMENTED CASESltigt WHERE TETRODOTOXIN INGESTION CAUSED APPARENT DEATH. IT WASN’T SOMETHING HE ATE. IT’S SOMETHING HE ALREADY HAD. AND HIS DAD, ltigtAND HIS GRANDPA, ANDltigt ltigt EXTREME BRADYCARDIAltigt COULD BE CAUSED BY SICK SINUS SYNDROME. ltigtSINOATRIAL BLOCK. ltigt WHAT IF IT’S NOT HIS HEART LET’S WORK FROM THE TENUOUS ASSUMPTION THAT WE’RE NOT IDIOTS UP, DOWN, SIDEWAYS SO WE NEED TO THINK ABOUT CAUSES IN PLACES YOU DIDN’T LOOK. indistinct whispering.

LtigtCOULD BE METABOLIC.ltigt YOU OKAY whispering continues YEAH. WHAT ABOUT A GENETIC PREDISPOSITION TO AN AUTOIMMUNE DISEASE ISOLATED ANTIRO ANTIBODY COULD ALSO BE PASSED THROUGH FOUR GENERATIONS. AUTOIMMUNE IT IS. HEY. HOW YOU FEELING MY WHOLE HEAD IS KILLING ME. YOU JUST CAME THROUGH A SEVERE TRAUMA. WHAT DO YOU REMEMBER grunts I WAS CHANGING MY LAUNDRY OVER TO THE DRYER. ltigtTHAT’S ITltigt YOU WERE DECLARED DEAD. YOU MADE IT ALL THE WAY TO AUTOPSY. sighs MY JAW ACHES. AND OBVIOUSLY I DON’T HAVE ORTOLI SYNDROME. IT ALL ENDS THE SAME WAY.

Soft tone soft tone OUTER AND MIDDLE EAR RESPOND WELL. HEARING THRESHOLDS ARE NORMAL AT ALL FREQUENCIES. EARDRUM IS PERFECTLY HEALTHY. WHAT IF I, UH. IF I SOMETIMES HEAR WHISPERING THEN YOU’RE PROBABLY HEARING SOMEONE WHISPERING. I HAD SOME DENTAL WORK DONE IN THE PHILIPPINES WHEN I WAS A KID. ADJOINING METAL FILLINGS COULD CORRODE AND PICK UP A.M. RADIO SIGNALS. OPEN YOUR MOUTH. YOUR FILLINGS DON’T TOUCH. SO THERE’S NO REASON FOR ME TO BE HEARING THINGS. I CAN ONLY TELL YOU THAT YOU’RE HEARING SOUNDS AS YOU SHOULD. YOU’D HAVE TO TALK TO SOMEONE WHO DOES BRAIN.

I ONLY DO EARS. door opens, closes BRAVO! IT’S AMAZING HOW YOU DID 120 HOURS IN ONE DAY. I WASN’T ON MY BEST BEHAVIOR. I ADMIT. ALLOW ME. FROM NOW ON, I’M GONNA SUPERVISE YOUR PRACTICUM REQUIREMENTS. THAT WON’T BE NECESSARY. YOU WANT TO ANNOY ANOTHER DOCTOR FIRST EVENTUALLY IT’S NOT NECESSARY, BECAUSE I’M NOT READY TO BE A DOCTOR AGAIN. I’M SORRY. sighs door opens sighs ARE YOU SLEEPING OUT HERE JUST.DOZED OFF IN FRONT OF THE TV. WITH BEDDING MAYBE! ltigtI CAN’T SLEEP IN THERE.ltigt THE HEATER’S SCREWED UP.

IF YOU NEED TO TALK. I’M JUST TIRED. I’M RIGHT HERE. GREAT. CAN YOU BE RIGHT HERE SOMEWHERE ELSE MY JAW STILL HURTS. MY TOOTH ACTUALLY, A LOT. I’M SORRY, YOU’RE MAXED OUT ON YOUR PAIN MEDS. TRY TO SLEEP. grunting in pain groans groans loudly, panting DENTIST LOOKED AT THE TOOTH THE GUY PULLED OUT. THERE WAS NOTHING WRONG WITH IT. SO ASIDE FROM HIM BEING AN IDIOT, WHAT ELSE HAVE WE LEARNED THE PAIN IS REAL. IT’S COMING FROM SOMEWHERE. WHAT ABOUT BONE CANCER YOU CAN’T CONNECT BONE CANCER TO THE HEART.

HOUSE FIGURE THIS CAN WAIT TILL THE MORNING ACTUALLY, HE TOLD CUDDY HE’S NOT READY TO WORK. HE QUIT APPARENTLY. IT’S A POWER PLAY. BONE CANCER COULD TRIGGER A PARANEOPLASTIC SYNDROME, WHICH SHUTS DOWN THE HEART. PRIMARY BONE CANCER ISN’T HEREDITARY. LIFRAUMENI SYNDROME. ltigtIT’S HEREDITARY, AND IT INCREASESltigt A PERSON’S RISK OF HAVING BONE CANCER. YOU HAVE ANOTHER THEORY MY THEORY IS IT’S NOT BONE CANCER. GAMMA SURVEY WOULD LOCATE THE TUMORS. ambient noises bird chirping, traffic indistinct whispering sighs I HAD PEA SOUP TODAY. YOU’D LOVE MY BREATH RIGHT NOW.

ALL I WANT TO DO IS. sighs NO CANCERS ON THE LATERAL CUNEIFORM BONE. NAVICULAR’S ALSO CLEAN. CHASE IS LYING TO ME. AND I KNOW YOU KNOW. TELL ME WHAT’S GOING ON, PLEASE. I’M GONNA TELL YOU THE SAME THING I TOLD HIM. TALK TO YOUR SPOUSE. NO BREAKFAST NOT TODAY. I’M HALLUCINATING. WHAT HAPPENED IT’S NOTHING VISUAL THIS TIME. IS THAT WHY YOU’VE BEEN ACTING SO WEIRD ltigtIS THAT WHY YOU QUIT ltigt I’M LOSING IT. I’M SURE THERE’S A RATIONAL EXPLANATION. THE WIND A NEIGHBOR’S TV ltigt I CHECKED EVERYTHING.ltigt.

WHAT’S REALLY SCARY IS THAT I HEAR WHISPERING WHILE NOT ON VICODIN. I’M GONNA CHECK MYSELF BACK INTO MAYFIELD. OKAY. OKAY YOU DON’T THINK THERE MIGHT BE A LOGICAL EXPLANATION SOMETHING I MISSED YOU’RE THE SMARTEST GUY I KNOW. IF YOU HAVEN’T THOUGHT OF IT, IT DOESN’T EXIST. ltigtI’LL DRIVE YOU OVER.ltigt I JUST NEED TO MAKE SOME TEA FIRST. YOU KNOW. THAT YOU’RE AN ASS YEAH. ltigtYOU OVERHEARD ME TALKING TO MY DEAD GIRLFRIENDltigt AND THOUGHT TO YOURSELF, HMM. WHAT KIND OF FUN CAN I HAVE WITH THIS WHY ARE YOU TALKING TO HER.

YOU RUN OUT OF LIVING PEOPLE YOU CAN TALK TO ME. I’M RIGHT HERE. I MISS HER. TALKING TO HER MAKES ME FEEL BETTER. YOU DON’T. PATIENT LAUREN MAYBAUM, 27, PRESENTED TWO DAYS AGO WITH SEVERE ABDOMINAL PAIN. SORRY I’M LATE. YESTERDAY YOU SAID YOU WEREN’T READY. YESTERDAY I WASN’T. TODAY I AM. AND TOMORROW IS IT POSSIBLE FOR ME TO GET A FIVEDAY FORECAST I’M FEELING MUCH BETTER. THANK YOU FOR NOT ASKING. EITHER YOU DID HAVE A PROBLEM WHICH I CAN’T IGNORE. OR YOU WERE JERKING ME AROUND WHICH I CAN’T IGNORE.

YOU ARE A WOMAN. YOU CAN DO ANYTHING. FOR EXAMPLE, I CAN TALK TO YOU OUTSIDE. ARE YOU SURE YOU’RE ONLY ONE WOMAN THIS IS THE PART WHERE YOU PLAY THE EMPLOYEE, AND I PLAY THE BOSS. I CAN SEE YOUR NIPPLES. YOUR TURN. THESE KIDS ARE NO WONDER SHE HATES HIM. MM, THAT’S NOT HATE. ltigt IT’S FOREPLAY. ltigt IT’S INAPPROPRIATE. whistling GAMMA SURVEY REVEALED NO TUMORS. SO IT’S NOT BONE CANCER. sighs WHERE’S CHASE DON’T KNOW. HM. TWO MYSTERIES, COOL. THEORIES DID I COME IN TOO SOON OKAY, I’M GONNA TAKE ANOTHER LAP.

AND I WANT THREE NEW IDEAS BY THE TIME I COME BACK. ONE OF THEM’S GOT TO BE NOT STUPID. WHERE THERE’S PAIN. THERE’S NERVES. HEREDITARY SENSORY AUTONOMIC NEUROPATHY, TYPE ONE. MISCOMMUNICATION IN THE BRAIN STEM MISTAKES NERVE PAIN FOR TOOTH PAIN. IT WOULD EXPLAIN THE BRADYCARDIA TOO. AND I LIKE THE WORD HEREDITARY IN THE TITLE. CARBAMAZEPINE FIXES HIM. I’LL GET HIM STARTED ON THE MEDICATION. NOPE, CHASE SPECIFICALLY ASKED IF HE COULD DO IT. thud gasp SLEEP AT HOME. SO I DIDN’T DO THE GAMMA SURVEY. IS IT BONE CANCER.

NO. YOU SHOULD CONGRATULATE ME FOR NOT WASTING YOUR TIME. ARE YOU GETTING SOME HELP OR IS THIS THE WAY THINGS ARE GONNA BE FROM NOW ON WHAT’S PATHETIC IS YOU HAVEN’T GOTTEN HELP BECAUSE YOU WANT TO FEEL BAD. YOU WANT TO SUFFER, ‘CAUSE IF YOU FEEL GUILTY, THEN YOU’RE NOT A PSYCHOPATH. PATIENT NEEDS SOME CARBAMAZEPINE. NOW, I DON’T CARE HOW MUCH THAT ROOM SCARES YOU, YOU’RE DOING YOUR JOB. ltigtHOW LONG BEFORE YOU CROSSltigt THIS ONE OFF THE LIST A COUPLE OF HOURS. YOU EVER SHOOT ANYONE TWICE.

YOU EVER KILL ANYONE NO. ltigtI KNOW A FEW GUYS WHO DID, THOUGH.ltigt DID THEY EVER GET OVER IT ltigtA CAPTAIN I KNOW COMPARES IT TO TAKING OUT THE TRASH,ltigt ltigtLIKE IT’S NOTHING.ltigt OTHER HAND, I GOT AN EXPARTNER WHO NEARLY DRANK HIMSELF INTO OBLIVION. DID HE GET HELP YEAH. HELP DIDN’T HELP. OH, GOD! WHAT IS IT I WENT TO THE BATHROOM. monitor beeps PATIENT’S LOST BOWEL CONTROL. MEANS WE WERE WRONG ABOUT HSAN, AND IT MEANS HE’S GETTING WORSE FAST. WOULDN’T WANT TO BE THE DUTY NURSE DOODY NURSE.

FINE. DO THE DOCTOR THING. WE PUT HIM ON STEROIDS. HE DIDN’T RESPOND. IT’S NOT AUTOIMMUNE. COULD BE WILSON’S DISEASE. A DISEASE THAT ADVANCED WOULD’VE HIT THE LIVER. IT IS POSSIBLE THE LIVER’S SO FAR GONE, THE LABS LOOK NORMAL. ltigtIT’S WORTH A SHOT.ltigt GO TREAT WITH PENICILLAMINE. ltigtAND WHEN HE DOESN’T GET BETTER, COME BACK QUICKLY,ltigt SO WE CAN GET ONE MORE SHOT AT IT. BLESS ME, FATHER, FOR I HAVE SINNED. ltigtpriest TAKE YOUR TIME.ltigt breathing rapidly ltigtHOW LONG HAS IT BEEN SINCE YOUR LAST CONFESSIONltigt I KILLED A MAN.

LtigtOHltigt BUT IT WAS THE RIGHT THING TO DO. WHO LIVES OR DIES IS NOT YOUR DECISION TO MAKE. SOMETIMES IN THE OPERATING ROOM IT FEELS LIKE IT. I’M A DOCTOR. ltigtWELL, THEN YOU SHOULD KNOW MORE THAN ANYBODYltigt ltigtTHAT EVERY HUMAN LIFE IS SACRED.ltigt WHY TELL ME WHAT’S SACRED ABOUT A DICTATOR THAT KILLS HUNDREDS OF THOUSANDS OF HIS OWN PEOPLE. ltigtWHAT IS SACRED ABOUT A DOCTOR WHO KILLS A PATIENTltigt IS IT JUST THE SLIPPERY SLOPE YOU’RE WORRIED ABOUT AFRAID THAT FORGIVING ME FOR KILLING THE WORST PERSON ON EARTH SETS A BAD PRECEDENT.

I PROMISE. I WON’T TELL ANYONE. sighs JUST FORGIVE ME. ltigtSAYING TEN HAIL MARYS ISN’T GOING TO DO YOU ANY GOOD.ltigt THEN WHAT DO I HAVE TO DO WHAT DOES GOD NEED ME TO DO ltigtYOU CAN’T HAVE ABSOLUTIONltigt ltigtWITHOUT FIRST TAKING RESPONSIBILITY.ltigt YOU HAVE TO TURN YOURSELF INTO THE POLICE. WHAT. AND GO TO JAIL FOR THE REST OF MY LIFE WHAT’S JUST ABOUT THAT breathing heavily I DID THE RIGHT THING. THERE HAS TO BE ANOTHER WAY. ltigtYOU WANT ABSOLUTION, I’VE TOLD YOU HOW TO GET IT.ltigt door opens.

SEND THIS IN TO THE STATE LICENSING BOARD. I’VE SIGNED OFF ON ALL YOUR HOURS. WHY BECAUSE IT’S EASIER THIS WAY. YOU’RE UNCOMFORTABLE WITH ME. NO. GOING BY THE BOOK WAS POINTLESS. YOU WERE GONNA LEARN NOTHING. GOOD, I THOUGHT IT WAS BECAUSE OF THE SEXUAL TENSION. THERE WAS NO SEXUAL TENSION. THERE WAS TENSION. AND.IT MADE ME FEEL FUNNY, SO. HERE. ltigtTHAT’S TOO BAD.ltigt ltigtI WAS KIND OF GETTING INTO THE WHOLEltigt HOTFORTEACHER THING. YOU SURE YOU’RE OKAY YEAH. FALSE ALARM. WHAT ABOUT US WE’RE GOOD. YOU PRESS MY BUTTONS, I PRESS YOURS.

BY BUTTONS, YOU MEAN. HUH. YOU DO MAKE ME FEEL FUNNY. YOU’RE NOT GONNA DIE. I’VE ACCEPTED IT. IT’S OKAY. IN ADDITION TO HIGH ARCHES AND SOME CRYSTAL BOWL IN THE SHAPE OF A TUNA, YOU ALSO INHERITED A SELFDESTRUCT BUTTON. IT FORMS IN THE BRAIN STEM. ltigtTECHNICALLY, IT’S AN ANEURYSM.ltigt ltigtPRESSES ON THE NERVES,ltigt ltigtTHAT CONTROL EVERYTHING FROM TOOTH PAIN TO HEART RATE.ltigt ltigtAS YOU GET OLDER, IT GETS BIGGER,ltigt ltigtUNTIL FINALLY.ltigt THE BUTTON WHICH I’LL CALL INTRACRANIAL BERRY ANEURYSM, ‘CAUSE I HAD A FRIEND IN HIGH SCHOOL WITH THAT NAME.

LtigtSTOPS THE SIGNAL FROM YOUR BRAIN TO YOUR HEART.ltigt ltigtAND BAM!ltigt HOW DO I KNOW YOU’RE NOT STILL LYING TO ME SAYING I’M HEALTHY JUST TO MAKE ME FEEL BETTER IT DOES SOUND THAT WAY, DOESN’T IT BUT THIS TIME, NO SUGAR PILLS. I’M GONNA CUT INTO YOUR BRAIN TO MAKE YOU THINK THAT I’M FIXING IT. AND IF OUR FAKE TESTS CONFIRM IT, I’M GONNA BE CUTTING INTO YOUR SON’S BRAIN TOO, ‘CAUSE I’M JUST THAT COMMITTED. MICHAEL’S GONNA BE OKAY UNLESS HE WALKS OUT OF HERE AND GETS RUN OVER BY A BUS,.

IN WHICH CASE, I WILL RECONSIDER YOUR FATE ARGUMENT. YOU WANT TO GIVE HIM A CALL VISITING HOURS DON’T APPLY TO MY PATIENTS. YEAH. IN A BIT. YEAH. THAT’S WHAT I THOUGHT. THE SAVING THE KID FROM PAIN STUFF WAS CRAP. YOU JUST DON’T WANT ANYTHING IN YOUR LIFE THAT WON’T LET YOU DO WHATEVER THE HELL YOU WANT TO DO WHENEVER THE HELL YOU WANT TO DO IT. YOU’VE HAD IT EASY. SORRY TO SCREW YOU UP. Ben Harper’sltigt Faithfully Remainltigt I’VE LEARNED TO SAY GOODBYE.

MOM TO SAY GOODBYE TOO YOUNG I’VE LEARNED TO DUCK FROM WORDS LIKE BULLETS MAYBE WHEN WE GET OUT OF HERE. WHAT KIND OF MOVIES YOU LIKE HOW LONG CAN YOU PRAY HOW LONG CAN YOU PRAY HE’S BEEN MISSING FOR EIGHT HOURS. ltigtROBERT CHASE.ltigt ltigtCHASE. ltigt HEY! NEVER MIND, HE JUST WALKED IN, SORRY. ltigtYOU COULD’VE CALLED ME.ltigt sighs OH, II FORGOT. TO CALL ME IT’S 200 IN THE MORNING.

Testing Your Health With the Max Pulse Bountiful Chiropractor Family Wellness Center

Hello, my name is Dr. Giles. I’m a Doctor of Chiropractic and a Natural Internist, and today I wanted to tell you about something that literally could save your life. This is so, so important. It’s a way that we can actually determine what’s going on with your cardiovascular system and your autonomic nervous system. Cardiovascular, you understand that. That’s heart and lungs and vessels. The autonomic system is what happens to you automatically from your subconscious, from emotions and from that system that runs everything from your heart rate to your thyroid function to your eyes dilating, all that is autonomic.

So I want to show you this wonderful report that we get from what we call the max pulse. It’s a neat scanner that will scan your cardiovascular system and the autonomic system. So I’m going to go over this report with you and show you what other things that we can look for and how objective they are. It’s amazing. As you look at the report, this upper part right here, this is the average heart rate, the pulse. This is the high pulse and the low pulse, giving you the average. So that’s just at a resting heart rate, what does this patient.

Look like. Next we look at this report here, which is what type you are. The type represents your thickening of the arteries, how much plaque you have within your arteries. So a TypeI, which is the, I don’t know if you can see that right here, that shadow line is what a TypeI pulse, or this is off of an EKG off of your finger. So it’s checking the contraction of your heart and so many other different things are shown here. But you can see where this is a shadow. That would be a Type1. This patient comes in at a Type4.

So at Type4, usually when were at a Type1, we’re measuring from here to here. So as this angle drops flatter, and then ultimately heads down this way, down to a Type7. A Type7 would almost completely full of plaque. So this is a demonstration of plaque. So a Type4 is not very good. We want to be up at a Type1. So the Type1 is here, a great way to determine if the patient has a lot of plaque within their system. Next, the DPI represents the overall strength of the heart itself, the heart muscle in general. We want to see that.

These numbers end up being in the optimal range of 70 or greater. That’s optimal. Normal would be 3070, but that’s kind of normal for the United States, which the number one reason for death, in the United States, is cardiovascular disease, plaquing of the arteries and heart problems. So we want to see that this DPI and all of these four measurements would end up over here in the 70’s. Eccentric contraction is the contraction of the left ventricle. The left ventricle is the side of the heart that contracts and pumps blood.

Throughout the whole system. So we want to see that that number, again, is 70 or above. Arterial elasticity is how much elasticness there is within the artery. How pliable is it Is it full of calcium Is it all plaqued off within, you know, within the actual tissue of the artery So we want to be able to see that have elasticity. As our heart contracts we want to see it open and shut, if you will, stretch. That’s arterial elasticity. The next is residual blood volume, that’s how much blood is left in the heart after it’s contracted.

We want to see that there is not as much blood. It’s configured so that this will also give us 70 or above. So the overall wave type is a Type4. That’s the flat here. So we want to see that move toward a Type1. There’s a wonderful supplement called KARDIAR, which I’ll explain now is a combination of Larginine and Lcitrulline and other supplements that help build the heart muscle. So KARDIAR, in fact, let me just stop. Let me run in the room next door really quick. I’ve got to get a slick of what KARDIAR is. This is a great.

Picture of what KARDIAR does. If you look at this cross section of the artery, inside the center these are epithelial cells that produce nitric oxide. NO is Nitric Oxide. Withing these cells now as they produce the nitric oxide, it’s actually lining the arteries, making them to become smoother, almost like Teflon, smoother so that the plaque and things can’t build up. It also helps to create more elasticity of the artery. It drops the overall plaque. It helps to remove plaque. It also helps to drop the overall cholesterol in the.

System. So KARDIAR is the 1998 Nobel Peace Price winner for health. The concept of Larginine and Lcitrulline, Larginine at 5000 mg, Lcitrulline at 1000 mg. So five to one ratio is what the research showed helped to drop the plaquing out of the arteries. This is what we’re seeing. We’ve seen this over time that as the patient takes this amount of arginine to citrulline, that it will drop that, drop that plaquing out of the arteries. It’s just, it’s an amazing process. So as we take the KARDIAR, we’re going to expect to see this start to come.

Back up to a three, four, or three, two, one. As we saw today with one of our other patients that has been working, her numbers are starting to resolve and that’s what we expect to see. So that’s a Type4. We want to move it to Type1. So this section here is cardiovascular. This section here is autonomic. Now there are three basic ideas here. It will show us, the scanner will show us how much physical stress the patient has, how much mental, and ultimately the stress resistance. So stress resistance would be their ability to handle.

Stress, their adrenal glands, their thyroid, their ability to handle all the things coming at them. We want this number, the stress score to be 50 or below. So as the stress resistance comes up, and we’re able to work with some of the mental stress and help them to adjusting of vertebrae and so forth, help drop their physical stress, you’re going to see this kind of reverse itself to come like this. So there’s going to be more stress resistance built up. So this is a tremendous way to see what their overall stress score is.

Next, we’re going to look at their Power Spectral Density. This information comes as specifically associated with parasympathetic nervous system and sympathetic nervous system. These two bars here are associated with the autonomic nervous system. Sympathetic is the break pedal, or excuse me is the gas pedal. Parasympathetic is the break. So when we’re, if my eyes need to be dilated because I’m running from a bear, I’m going to be in sympathetic. My eyes are going to be dilated. I’m running, looking for the next tree to run up. Once I get up.

To the tree and I start to have my lunch, I want to shift into parasympathetic. So we want to see that these two numbers are able to move back and forth. Further, from the Power Spectral Density we’re able to see high frequency, low frequency, very low frequency, and overall total power of the autonomic system. We can, each one of these represents an issue. For example, very low frequency represents temperature regulation and hormone regulation. So if they’re down, these numbers should fit within these brackets. So if they’re down,.

We can give them the supplement, a maca supplement that helps to balance that system out as well. So each one of these represents a certain part of the autonomic system. Lastly, we look at the heart rate variability. This patient is quite low. There’s not much change within the heart. As we’re having the scan run, we’re talking to the patient explaining what’s happening. So we should see an increase and a decrease in their heart rate. It should kind of elongate and slow down and so forth. When there’s not appropriate balance in the autonomic system,.

It just flat lines. So you can see how this is just basically flat. Now this is the first, not the first of the same patient. These are two different patients. But I wanted to show you what it would look like if it were healthy. This patient is a significant racer. She rides cycles. So she street races and does long cycling. For example, that’s a perfect Type1, a 100 percent Type1, where this patient had actually zero, 88.5 percent were Type4. Others were Type5. This patient is 100 percent Type1. That means that during that three minute scan.

Period 100 percent of her contractions show this wave form, but as they start to become sick, you’ll get some moving in, like she might have had 90 percent or maybe 80 percent were Type1 and 20 percent Type2. So as it gets sicker, there’s going to be more waves starting to go towards the Type7, if you will. Those are the ones that have plaque within them. But look here. Compared to DPI, this one is at 19 and she’s clear out here at 76 percent. Eccentric contraction of the left ventricle up here at 76. Arterial elasticity.

Is 74, but interesting she has 60 on the residual blood volume. I would think that she would have had a lot more because of how much, how strong she was. But look at this. Physical stress, mental stress, almost nothing, stress resistance off the chart. It can happen very easily. So stress resistance increases with exercise as well, not just supplementation. Her spectral density analysis shows up, she’s clear past here. Just a little bit of trouble here with hormone. I’m sure she’s pushing when she rides her bike so much. Her hormones.

Are probably decreased a bit. So we would give her some maca. It would help raise that up. But compare this heart rate variability to this heart rate variability. This one literally is just a flat line. This ones moving quite well. Her average heart rate is 47 with a high of 61, low of 41. So that’s what we would expect to see with someone that’s as exercised as she is. This is tremendous guys. I don’t know if you can see, but we can actually find out where your problems are in your cardiovascular system and give you specifics to help you.

And then recheck it in a couple of months and see progress. We’d expect to see some major significant progress cardiovascularly with the KARDIAR. Again, 5000 arginine, 1000 citrulline and other things, other herbs to support heart overall. We can stop this. We can stop and reverse cardiovascular aging and plaquing. That’s what the research shows. That’s what we see. So that’s a wonderful process for you. If you have questions, please feel free to call the office at the number below. We can answer questions for you. We can do the scan. I charge 50 dollars for the scan, which is.

Working Together to Manage Diabetes A Toolkit for Pharmacy, Podiatry, Optometry, and Dentistry

I am Dr. Pam Allweiss, an endocrinologist with the CDC Division of Diabetes Translation. I would like to welcome you to this webinar. Today PPOD is not a vegetable it’s a wonderful team of passionate providers who have come together to develop materials and a webinar to illustrate how team care for people with diabetes can become a reality. They energize all of us, and we are trying to walk the walk when it comes to team care. You can see all of their bios on the screen. PPOD providers may be the first person who.

Sees somebody with diabetes. Our goal is to have team care on your radar screen. We are not trying to make optometrists into podiatrists. Some general points The materials are in the public domain no copyright. Please copy as you wish download them in your office. There are materials for providers and for patients, which have been pilot tested in many of our provider’s offices. For instance, we have a patient checklist that has been developed and evaluated by our PPOD providers, as well as by primary care providers such as.

Family practice docs, nurse practitioners, etc. Everything will be available on the Web site, including the slides and the recording of this webinar. At the end, we will answer general questions and, eventually, all questions that you submit to us will be answered. I have two requests Please stay connected at the end and fill out the quick survey about today’s webinar, and then please, please fill out the survey that will arrive in your box in a few weeks to evaluate if there has been any change in how you practice team care.

We really need the information to help us evaluate what we are doing and to improve. Now, I would like to turn it over to Dr. Dennis Frisch. Thank you, Dennis. Dr. Frisch Thank you, and thank you, everybody, for taking some time out of your day to learn about team care. In this section, we are going to learn about the NDEP, which is the National Diabetes Education Program, the scope of diabetes in the U.S., and the PPOD team care approach what it is and why it’s important. So, what is the NDEP.

The NDEP was established in 1997 as an initiative of the U.S. Department of Health and Human Services. It was established to promote early diagnosis of diabetes, improve the management of the disease and its outcomes, and prevent and delay the onset of type 2 diabetes. The NDEP is jointly sponsored by the CDC and NIH. NDEP brings together more than 200 federal, state, and private sector agency partners. We at the NDEP believe in the importance of team care approach to diabetes. A team approach among PPOD providers, as well as many other.

Health care professionals, is of crucial importance in helping patients to maintain their diabetes and to take the needed steps to lower the risk for complications, including, in our particular case today, those related to feet, eyes, teeth, and medication management. Working Together to Manage Diabetes, a toolkit for pharmacy, podiatry, optometry, and dentistry, offers resources to support providers in this important work. So, what is PPOD PPOD is a team approach among pharmacy, podiatry, optometry, and dental providers, as well as other health care professionals, and is of critical importance in.

Helping patients to manage their diabetes and take the needed steps to lower the risk for complications, including those related to our particular fields of feet, eyes, teeth, and medication management. PPOD providers are well positioned to deliver key diabetes management and prevention messages, to communicate the need for metabolic control, and encourage patients with diabetes to see their optometrist, podiatrist, and dentist at least once a year and to review their medication therapy with a pharmacist at least annually. Our PPOD message emphasizes the importance of all health care providers treating patients with diabetes.

PPOD providers have the opportunity to educate patients with diabetes about their disease, to encourage them to practice selfmanagement, and to provide appropriate treatment. As we’ve discussed, diabetes is a serious problem that affects many people each day in the U.S. and its territories. Why is PPOD important PPOD makes a difference for patients with diabetes. Not only can it provide treatment outcomes, but it can also greatly enhance a patient’s treatment experience. A team approach to diabetes care reduces risk factors, it improves management of the disease, and it lowers.

The risk for complications that can result from the disease. PPOD providers are in a unique position to make a difference in their patients’ lives, as they may often be the first health care provider to see a patient experiencing a new problem. For example, a patient may complain of blurred vision at a visit with his or her optometrist. The patient may not realize that this can be a sign of diabetes, allowing the optometrist an opportunity to ask other questions about the patient’s condition. As a part of a PPOD team, the optometrist will be aware of.

The signs and symptoms of diabetes and can refer the patient to his or her primary care provider to seek further tests andor treatment. PPOD providers are in a unique position to identify signs and symptoms that could otherwise be missed, and they may continue to monitor a patient’s condition at routine checkups, such as dental cleanings, dilated eye exams, and annual podiatric exams. Many patients turn to these professionals before consulting primary care providers with common diabetes questions about selfcare or medications. NDEP encourages all health care professionals to understand.

Their unique contribution to diabetes team care so their advice to patients is consistent. There are tremendous opportunities for getting messages about diabetes control and prevention. The team care approach has a number of benefits for patients. A team approach among PPOD providers, as well as other health care professionals, allows access to integrated diabetes care across specialty and primary care areas. A team care approach encourages regular communication among a patient’s team of health care providers and emphasizes the importance of prevention. At this point, I’m going to turn it over to Sandra Leal, who is.

Going to speak to us about the role of pharmacists in PPOD. Dr. Leal Thank you very much for the introduction, Dr. Frisch. This is a pleasure to be here representing the pharmacist’s role in diabetes management because of the importance that pharmacists can have in really assisting patients to be advocates for their own condition. And so, a couple of really key points about the role of the pharmacists. They are a unique member of the healthcare team and oftentimes, because patients are taking multiple medications for diabetes and comorbidity, such as blood pressure issues or.

Cholesterol issues, they might be seeing their provider up to seven times more often than other providers, so this offers a unique opportunity for the pharmacists to be able to intervene several times during the year, several times during the month, even, if the patient is coming in to the pharmacy on those occasions. So, the pharmacist is often the most accessible health care provider since there is no appointment required to see the pharmacist, and pharmacists are also available at all hours of the day. There’s 24hours pharmacies they’re also available in the.

Weekends, and again, because there is no appointment needed, the pharmacists can play a unique role in being able to help the patient navigate through this condition. Some of the roles that the pharmacists have really takenand the American Diabetes Association has promotedis the role of the pharmacist in monitoring the drug medication regimen. This is really, really key, because of all the opportunities to help the patient work through their plan and be able to better and more effectively use their medications. The pharmacist may work with the patient to develop a plan that.

Reduces the side effects and drug interactions and really advise a patient on how to take the medication properly. The pharmacist may also help the patient with other things that are very important to control, and one of the things that’s very key are things around medication affordability. With all the medications that a patient takes, sometimes this is a key intervention that the pharmacist really takes a lead on, and trying to help assist the patient in being able to afford not only medications, but things like testing supplies that they might need to better control.

Their medication regimen. Another big key role that the pharmacist can play is communicating with the health care team. Sometimes the pharmacist is the one that contacts the provider on behalf of the patient or encourages a patient to schedule other appointments that might be necessary, like followup for an eye exam or a foot exam, if the patient is communicating some of these issues with the pharmacist. Some of the key questions to ask your patients about medication therapy management, as you are seeing a patient, and really an opportunity to refer to the pharmacist, are related to.

These questions that are listed below. So, the patient should be referred to a pharmacist if the answer to any of these questions are no or unsure. Do you have a list of all your medications, vitamins, and supplements If you are seeing a patient and they don’t have a good knowledge of what the medications are or the indications for the medications, the pharmacist can really work to help develop a medication list with the patient that makes sense for them and is current and is updated on a regular basis.

Do you know the reasons why you take each medication Again, the indication is very key. Sometimes you’ll see a patient bringing bottles to your appointments, and you’ll find that, you know, you ask them, Why are you taking this medication for And they say, Well, I’m not sure, the doctor prescribed that for me, and I don’t really know what that’s for. So, that would be another key trigger to say, You know, this might be an opportunity for you to work with your pharmacist to get more information about.

Why you’re taking medication. Have you reported any side effects from your medication to your pharmacist Sometimes patients will report that they stopped taking a medication or that it makes them have bad side effects from it. It’s another key to find alternatives for the patient that’s necessary, or to work through some of the concerns that they’re having. Do you have any difficulty affording your medications and testing supplies Again, very key with the population that we are serving, especially because there are so many medications that the patient might be taking, and the testing supplies might be.

Something that is actually preventing them from really obtaining good control. And another key question is, Do you understand the importance of timing your medication in relation to your meals And I think this is even more important when a person is on insulin. Sometimes, they may be taking the insulin after they eat or several minutes to hours before they eat, which might be actually causing adverse events for them. And a pharmacist can really be key in helping them understand the timing of the meals, the importance of adherence to.

The medication, and really understanding how the medication regimen is working for them. This is an example of PPOD in action, so if a patient comes inthis is a 40yearold woman who notices blurry vision and asks her pharmacist about reading glasses. The pharmacist discovers that the patient was diagnosed with diabetes last year, but did not return for followup visit. The pharmacist advises that changes in vision may be a sign of diabetes and not a need for reading glasses. And we see this quite a bit in practice, where patients are.

Looking for some readers. They might be complaining of needing to go to the ophthalmologist, when in reality the cause is high blood sugar and, with better control, they could actually avoid that tremendous cost of obtaining glasses that might not work for them once their blood sugar is in better control. But this is an opportunity for the pharmacist to step in, arrange a primary care visit or a visit with the ophthalmologist, or both, and really help the patient be an advocate for themselves and have better control. So, pharmacists can also refer her to the NDEP Web site,.

Which is listed as cdc.govdiabetesndep for more materials. But again, a lot of ways to intervene on multiple occasions because of the multiple opportunities to see the patient, and that would really serve the patient a continuous and a consistent message as they have to continue to navigate this chronic condition. Thank you. I will pass it down to Dr. Javier La Fontaine, who is a podiatrist. Thank you. Dr. La Fontaine Good afternoon to everybody. One of the other key members of the team is obviously the podiatrist. Diabetes leads to 60 percent of the nontraumatic lower limb.

Amputations, and diabetes per se increases the chance of amputation, as I just mentioned. But fortunately, those patients with diabetes who are involved in routine foot care will have treatable foot care problems, and therefore we could essentially increase prevention this way. Ulcerations are very common they lead to amputation. Unfortunately, once we get these ulcers healed, they often reulcerate. Up to 80 percent of them will reulcerate in 12 months. So this is an ongoing problem that we need to treat. And we need to do aggressive prevention, and the patient needs to be aware of this.

Successfully, if a patient is involved in a routine foot care program, over 80 percent of these ulcers can be preventable, and therefore we can decrease ulceration and amputations. This is how an ulcer is going to look, and usually these ulcers do come up in the bottom of the foot because the main problem that people with diabetes get is what we call the critical triad, which is neuropathy, deformity, and trauma. So, trying to identify these patients at risk will decrease ulceration. Neuropathy is the most important component that leads to.

Ulceration, so therefore that is the number one target that we are actually trying to accomplish on prevention. And obviously, blood flow is also an important component, because once you get a wound, you essentially need good blood flow to get it healed up. So, we are going to identify those patients with neuropathy. That is what we can, as a PPOD member, podiatrists, we can help you identify these patients with neuropathy, vascular disease, and deformity. You know neuropathy, like you probably all know, is essentially the nerve damage that occurs in diabetes, but.

Often this patient is going to come in to your office and they are just simply going to tell you, My feet are numb. They are going to have other symptoms that may lead you that they do have neuropathy like tingling in the feet, pins and needles in their feet, either burning, shooting pains. Sometimes, their feet get really sensitive to anythingto touch, heat, coldsometimes they do come up and tell you I do have numbness. You obviously don’t need to learn this, but once you refer the patient to us and we are going to identify.

This patient with neuropathy, this is what we are going to do for the patient. Just simply do tests. We are going to feel for vibration, which is the fastest sensation that disappears on patients with diabetes. We do that with a tuning fork and we do touch with a filament, which will help us identify those patients that are lacking the touch sensation. We are also going to screen for vascular disease. So essentially, just like in this picture, it is going to essentially show you how we palpate for the pulses, you know.

The dorsal inaudible and the posterior pulse, and if we notice that these are absent, then we do the appropriate referral to a vascular surgeon. And last but not least, these are some of the deformities we are going to be able to identify for the patient, so bunion, thickened toenails, ingrown toenails, history of amputation, toe deformities, etc. Essentially, we can identify this and educate the patient as well, and provide them appropriate shoes. You can see on the picture on the top, identifies that somebody with a bunion on the right foot like this, and is.

Unable to perceive a tight shoe, it is going to lead to an ulcer. But, you know, obviously, it is not that simple for the patients. So, some of the questions that you can ask the patients. If they tell you no or they are unsure, they are very simple. Did you get a full exam by a podiatrist at least once a year Do you know how diabetes can affect your feet, and do you know how to check your feet every day If you ask these three questions and they answer to you.

No or unsure, we can just make a simple referral to the podiatrist, and we can take it from there and educate the patient and categorize it and put it on their risk level, and therefore continue the appropriate referral for these patients. Now, this is a laundry list. You obviously don’t need to memorize this. But if you want to ask these patients a little bit more about their degree of neuropathy or vascular disease, then we can ask them these questions, like Are your feet numb Do you have burning pain sensation.

Are you sensitive to touch A lot of the patients think that is normal for them, since it has been happening for two, three years, so just triggering them to think about some of these questions. Then you will be able to further identify these patients at risk and then do the proper referral. Again this is a laundry list, this is going to be in the materials that you can download from the NDEP Web site and the PPOD link, so this should be easy for you to keep in your office.

Now, some of the questions you are going to get from patients are Why are my feet numb And I just essentially gave you the answer, and they are essentially having some symptoms of neuropathy. My legs hurt when I wake. What could cause that Or My legs get tired very easily. Those are usually signs of neuropathy, or it can be a sign of vascular disease, so again, these questions are key for making the proper referral for the patient. I have a callus on my foot, what should I do.

Obviously, we don’t want the patient messing with it, so maybe making the proper referral to the podiatrist, that would be also an important referral to do. And last but not least, I have an ingrown toenail, should I see a podiatrist The answer is yes. Why are my legs swollen Obviously, leg swelling can be due to neuropathy, can be due to vascular disease, but it could be many other problems like kidney disease, liver disease, heart disease. So, you know again, these are some of the questions that you are going to get from the patient.

These are probably the most common ones I see in my practice, so any of these questions should trigger a proper referral to a PPOD or podiatrist. Thank you, and I think I am going to leave you with Paul Chous, which is the optometry part of the PPOD team. Dr. Chous Well thank you very much that was really a fantastic presentation. I’m going to talk a bit about eye health and optometry’s role in that. It remains a fact that diabetes is still the leading cause of new blindness amongst working age Americans.

Less than 74 years old. The estimates are somewhere between 15,000 and 25,000 Americans become blind, principally from diabetic retinopathy, each year. In addition, about 11 percent of adults with diabetes have some form of vision impairment, which ranges from mild to severe. Now, it can be something as simple as an improper glasses prescription, and in fact, the majority of patients with vision that is subnormal in the diabetes population can be corrected by having an updated refraction done. Many of the eye complications of diabetes, especially diabetic retinopathy and glaucoma as well.

These are painless conditions and may cause few or no symptoms until the eye disease has progressed to a stage where treatment may be far less effective. And this is really a key message for all of us PPOD providers good vision on an eye chart does not mean that patients don’t have serious eye disease. Patient surveys suggest that fear of losing vision concerns people more than any other diabetes complication. Health care providers need to be aware that the increased risk of depression amongst those with vision loss is readily apparent.

To those of us who provide their eye care. Adults with loss of vision function are about 90 percent more likely to have clinical depression than those without vision loss. In addition, these patients are at increased risk for falls that result in fracture as well as, at some point, requiring nursing home care. Health care providers need to be aware that patients with loss of vision from diabetes can often be helped by seeing eye care providers who specialize in the prescription and dispensing of low vision aids specifically designed and customized for.

Various degrees of visual impairment. This is a whole separate subspecialty within my profession, called low vision, helping people with significant vision loss. Let’s talk about annual eye exams for a moment. People with diabetes can maintain optimal vision and healthy eyes by having an annual comprehensive vision examination that includes a dilated retinal examination. With early intervention of retinopathy or other serious ocular complications of diabetes, such as glaucoma, are found. Doctors of optometry routinely perform these tests and many others, including sophisticated imaging of the retina on our patients with diabetes and other health conditions.

We have a couple of images here, just depicting diabetic retinopathy on the left, with dot and blot hemorrhages throughout the retina, and to the right is an optical coherent tomography scan, kind of an optical crosssection of the retina, showing fluid edemas. So this is a patient with diabetic macular edema. Often these patients have good visual acuity. More than 90 percent of vision loss caused by diabetes can be avoided with good diabetes management, including the ABCs of good diabetes care good A1C, good blood pressure, control of blood lipids, and avoidance of.

Smoking, and early detection and timely treatment. It is really important to realize that eye disease caused by diabetes is often associated with other complications, including cardiovascular, podiatric, and periodontal disease. This fact really underscores the importance of a collaborative team care approach. The other things that are much more common in our patients with diabetes are things like dry eye. So if the other providers see patients that are complaining that their vision is fluctuating constantly and they have red eyesa lot of patients with diabetes have dry eye. About twice as common in people with diabetes than.

The rest of the population. This is something that eye care providers can really help them with, and it’s also a sign, oftentimes, of autonomic neuropathy. A lot of patients won’t have symptoms of dry eye, their eyes will be red, but they’re not as symptomatic as their nondiabetic counterparts would be. Let’s look at some of the key questions we should all be asking our patients about eye health. By asking some of these simple questions, larger issues can be uncovered that could be potential red flags for good management of diabetes.

If patients are answering no or are unsure about the answers to any of these questions, it is recommended that they be referred to their optometrist to seek further care, counseling, and, if necessary, treatment or referral for treatment. In my experience, one of the key concepts that we all need to be aware of, is that good vision, as I said, does not mean there are no serious eye complications from diabetes. I got diabetes when I was 5 years old. I had perfect vision until I was 21. I went in to see my optometrist, who saw bleeding in my eyes.

I got treatment. I had perfect vision on the eye charts, but visionthreatening eye disease. I see patients all the time with severe, sightthreatening diabetic retinopathy, as well as glaucoma that can rob them of vision, who are able to read 2020 or better on the eye chart at the time they are diagnosed with their eye disease. This is a reality that underscores the importance of regular eye examinations, even in patients with no visual problems. Here’s a good example of PPOD in action. In this example, there’s a situation in which.

A PPOD provider uses a routine visit as a way to engage in a broader dialogue with the patient, and in this particular case, the patient’s daughter. Having knowledge about diabetes and its risk factors, the eye care professional knows the patient’s daughter is also at increased risk for developing diabetes and is able to provide the family with an NDEP brochure, and is able to advise the patient’s daughter to make a followup appointment with her own primary care physician to be screened for diabetes. Additionally, the optometrist knows that.

Diabetic retinopathy is present in one of five newly diagnosed patients with type 2 diabetes. That’s a profound statistic. So, patients with type 1 diabetes don’t have retinopathy at diagnosis they have had the disease for a relatively short period of time. But we all know by the time a patient is diagnosed with type 2 diabetes, they have had the disease oftentimes for between 5 and 8 years, and that’s why retinopathy, even severe retinopathy, can be present at diagnosis. It’s so important to refer patients for eye examinations, even if their vision is fluctuating.

You want to wait on prescribing glasses for patients because their hemoglobin A1C is high these patients still need to be evaluated for the presence of sightthreatening eye disease. The other factor that is examined in this case is the optometrist recommends that the daughter of the patient also get an eye exam, because African Americans past the age of 40, in particular, are at dramatically increased risk for glaucoma, which is another leading cause of blindness, especially among Black Americans. Oral health and diabetes. Even though oral health complications are very commonly.

Associated with diabetes, we can find that 85 percent of patients with type 2 diabetes report they have not received any information on the association between diabetes and oral health. In turn, this extends all the way into the health care professional community. Many health care providers have little to no training about the oral, systemic health association. Diabetes and periodontal disease is a twoway relationship. Periodontal disease is a bacterial infection with inflammatory complications. That systemic inflammation signals increases in blood sugar levels. Also, like any other infection, it can impair the body’s ability.

To process or to utilize insulin. On the other hand, diabetes does not cause periodontal disease, but it is a leading complication of diabetes. Diabetes lowers the resistance to infection and greatly increases a person’s susceptibility of developing periodontitis. In turn, that periodontal disease makes it more difficult to control blood sugar levels, so it is a twoway relationship. It’s certainly associated with the poor glycemic control. In addition, tobacco use and poor nutrition are also risk factors for compromised oral health. PPOD providers can help change this. As they collaborate with other members of this health care.

Team, we can reduce the rates of periodontal disease and other oral health conditions. Oral health exams. Diabetes patients really should be encouraged to adhere to annual oral examinations. The recall interval for oral patients is really determined specifically for each patient according to his or her needs and risk assessment. The management of periodontal disease in people with diabetes can result in significant reduction in A1C numbers, so people with diabetes really should be encouraged to have perio disease treated to eliminate infection and for the aid in metabolic control.

Dental visits can also be used as an opportunity to educate patients and to begin a dialog with the lowrisk patients in order to prevent them from becoming high risk. Dental professionals are also comfortable discussing the relationship between oral health and nutrition. These opportunities can also be used to affect the stem of obesity and its relationship to diabetes. Key questions to ask your patients about oral health. People with diabetes are often not aware of the significance of diabetes and poor health. As I have stated, the health care provider whole entire.

Network does not seem to be very familiar with the oralsystemic link. By asking patients a few simple questions about their oral health, larger issues may be uncovered that could be potential red flags for the management of their diabetes. If patients answer no or unsure about the answers to any of these questions, it is recommended to please refer them to their dental provider to seek further direction in care. Ask them if they had visited their dental provider within the last year. Ask them if they know how important the relationship is.

And how the effects can be in their mouth and if they really do know the early signs of tooth, mouth, and gum problems. Healthy teeth do matter. So an example about PPOD in action. Managing diabetes medications certainly can be complicated, and it is also confusing for diabetes patients to understand how to adjust their medication around certain events, such as a dental procedure. For a patient who has to have a dental procedure scheduled, the dental professional might recognize that the patient is really unsure how to manage their insulin injection, and.

Because she is told that before the dental procedure she should not eat. So to provide direction for the patient, the dental professional arranges a pharmacy consultation for her to resolve any unanswered questions and ensure that the procedure does not interfere with her needed medications. She can call the pharmacist. The pharmacist can help her work around not eating and when her insulin injection should be taken. I have treated many patients with diabetes and have spoken to other dental professionals who can attest to the fact that many, many people out there need the intervention of.

Dentistry, along with the collaborative effect with other health care providers. Once again, healthy teeth do matter. And I thank you and I take you back to Dr. Frisch. Thank you everybody, and thank you for the presentations. What we are going to do now, you have emailed some questions in on the chat box, and also, we got a bunch of questions on the presurvey questionnaire. What we are going to do is try to parse them out to the different presenters and remind everybody that if we don’t get to your question, we will answer them.

Over the next month or so, we are going to break these out into the different providers, and they will get an email and they are all busy practitioners, so please give them a little bit of leeway, but your questions will all be answered. And some of the questions, again to remind everybody, these slides and mountains of other material in many languages are available at our Web site. So I did get a whole bunch of questions regarding billing, and I would like to say that that is unfortunately not.

The focus of our presentation. Unfortunately, the billing works are the individual work of your professional association, so I encourage you all to become members, if you are not already, of your association because that involves a different level of government, CMS. And what our goal here today is to really to teach us all to be better practitioners and more caring practitioners within our community. So, am I going to get paid to tell somebody that the right thing for them to do is to call the pharmacist No, I am not.

Could I perhaps document a higher level of visit if I am counseling the patient That may be a possibility, but I am not going to break down ways to get paid, because frankly for a large part, there are not ways to get paid. It is the satisfaction of knowing that what we are doing is the right thing, of becoming well known and well identified as caring practitioners within our community. The way we will all benefit from this is that we will be identified as those people, and we will work with other.

Groups within our community. You will have your own referral network within your community and build your own individual level of experience and care and reputation doing this. Dr. Leal, we did have somebody ask about pharmacieswhen patients use mailaway pharmacieshow would they speak with a pharmacist Would you like to address that, please Dr. Leal Yes, thank you very much for the question. So, there are a couple of ways. You can definitely call the mail order, but I think even just walking into a pharmacy locally, the pharmacists that.

I have worked with, and I historically worked in a retail pharmacy myself, we are very willing to help patients who walk in, even if they are not obtaining their medications at the pharmacy that we work at. So, that is one of the nice things about having an accessible provider that is available to you nights, weekends, is that you can walk in and ask your questions and they would be willing to help, despite the fact that you don’t go to their particular pharmacy to have your medications dispensed.

I do want to say though, if the patient were to bring their medications or their medication list, they would probably have a better interaction with the pharmacist, because they would know exactly what they are receiving, so that would be something that I would recommend. But I think any pharmacist in any community setting would probably be willing to speak to the patient. Dr. Frisch Thank you. Dr. La Fontaine, we had a question regarding diabetic shoes. Would you like to do a general comment regarding diabetic shoes And somebody asked here specifically how their.

Foot related conditions are being or not being documented Dr. La Fontaine Yes. So yes, the shoe bills from CMS. You know, the requirement has been changing over the years. Obviously it is a cumbersome process, because the podiatrist is a prescribing physicianif you are prescribing to a Medicare patient, the prescription needs to go together with a certification of primary care physician that is handling the diabetes for the patient. So for the patient to essentially get the shoes approved by Medicare, one, has to have certain risk factors. Two, has to have a certifying physician stating that.

The patient does have diabetes and does have those risk factors. And three, may need a prescription to make the shoes. Now, one of the things that we have encountered in our hospital is that often whenever we said the patient has vascular disease, hammer toe, neuropathy, whatever the risk factor is, it needs to be documented on the patient’s chart, so that note can accompany the prescription to get the shoes. And yes, that is probably the most difficult one to get because most of us practice in different locations, so.

You don’t have access to the record of another doctor to include Yes, this patient has vascular disease, or he has a bunion. So yes, you may be able to get a patient, to get from the primary care physician, the certification that they have diabetes. And may also get it either from the certified physician or the podiatrist to say, Yes, this patient has a bunion and all this too, and then take that to the orthopedist or whoever is going to be making the shoe. So yes, the process is cumbersome.

Dr. Frisch So, a recap of that for everybody on the call, we all know that we have patients come in and they are going to say, My neighbor got free shoes from Medicare, how do I get my free shoes I have diabetes. It is not as simple as that, and they do need to discuss this with their podiatrist or primary care provider or endocrinologist. There was a question for oral health here that says, Could you please explain in additional detail how the control of periodontal disease can.

Lead to improved A1C and glycemic control Ms. Furnari That seems to be a very, very scientific question, and I would be happy to refer the person who has asked the question to a study, which I apologize I do not have at hand right now, but when we do answer all the questions, I’d be happy to refer the person to the study, with the results of that. Dr. Frisch Thank you, and I will also just add, and I am podiatrist, so not a dental health care professional, but I can tell you that simple dentition changes the diet.

So if people are not eating healthy foods because they can’t chew them appropriately and they are eating high carb foods, softer foods, more prepared foods, it can be as simple as their dentition, and so we prevent periodontal disease and help them keep their own teeth, it can be that simple. So, some questions, other general questions that people asked. Is the toolkit available in Spanish Yes, there are tons of language products available. Another question was low health care literacy materials. The answer is, yes, they are available and I will repeat.

What the opening comments were. None of these are copyright protected you can reproduce these, you can put your own logo on them. This, honestly for everybody on the call, is easier than you think. Just be familiar with the materials and take a moment to care, and you can call a pharmacist and introduce them. We did have a comment here that was very profound from somebody. I am trying to scroll to it so forgive me, but the gist of it was, it is better to have a list of providers in.

Your community, rather than simply saying See a podiatrist or See an optometrist. So, if you are an optometrist and you work with a few pharmacies, it is simply a matter of saying, If you need to have some of your patients who come in who have questions regarding their diabetes, I will be happy to see them. It’s like starting your practice over, when you knocked on doors and said, I am new in town. Here are some cards, please come see me. Well, now we are starting a new program.

We are starting a program to improve diabetes care in our community. And that’s the pebble in the pond, ripples that will grow. You may reach outas a podiatrist I’ve called several of the local optometrists within a geographic range of my officeand ask if they have desire to see diabetic patients. One of the other things that are available on the Web site is a simple checklist for patients that they can actually fill in. It is a piece of paper, and you hand it to them and it says,.

What was the last date I saw provider X Or When is my next appointment So they can keep this and put it in their little folder of health care information and move forward. A question somebody has asked us about the prevalence of depression and anxiety is common, and does the team access the need for behavioral health services These materials were all vetted through the behavioral health services, and it is mentioned throughout that it is an important factor in it. But the PPOD team was developed simply as we began.

The program, is very often, we as providers are the first line of people to see somebody with diabetes, and you all see it every day even more. If you’re asking somebody to sign the keypad that they received their prescription, and they are pulling out glasses or saying, I can’t see the box, you simply say Have you had a recent exam You just gave them their medication that you know they are diabetic. If somebody comes in to have their teeth cleaned and they are wearing slippers, we know that is an inappropriate behavior,.

So all we have to say is, Gee, Ms. Smith, I see you are in slippers today. Is something wrong There are hundreds of simple little moments, care moments, that we can all give and become more excellent providers. Sandra, we have a question here. What recommendations do you have to improve coordination of referrals to pharmacists We have diabetes programs in place, but it can be difficult to get physicians to see the value and refer their patients. Dr. Leal Thank you for the question. Yes, it can be difficult depending on the practice.

That you are at, but definitely marketing. I think you mentioned, Dr. Frisch, some of the things. Just go out and introduce yourselves. As a pharmacist, I work in a health system, and we’ve built in some automatic referral type of mechanisms within our electronic health record, where one of the dropdowns for the referrals that can trigger a visit to the pharmacist. So there are ways you can create that referral system. I think the other way is definitely marketing to the patients and having the patients ask for referrals.

To see the pharmacist. There are other opportunities with Medicare Part D to do medication review, and you can also even have referrals from other pharmacists to be able to refer to your program, especially if you are finding that patients are having difficulty controlling their diabetes. So really, looking at your system and figuring out trigger points where you could be able to remind people about the services you offer, making yourself available, and then just going out and like you said, knocking on doors and introducing your services and then talking to patients about.

Self referrals are key ways to get those appointments filled. Dr. Frisch Thank you. If there are more questions, please feel free to type them in your chat box, and we will continue to address them. So, here is one that somebody asked. What have been the biggest challenges in the transformations And honestly, the biggest challenge is inertia. It’s us taking a moment in a busy day to do one extra step. It’s nice to have the plug and play and have our own electronic records do some of the work, and.

It’s nice to hand out materials, but it does take a little extra step. It doesn’t always have to be you as a provider. Sometimes it can be your staff, sometimes it can be, Please see the receptionist on check out, and she will print something out. On our office Web site, my own personal office Web site, I simply have a referral page, and the referral page in the back tells patients how to access NDEP. It also tells them how to go to smoking cessation classes and what have you.

And I can simply tell them, Please access the Web site, the information you need to go and get things is right there. This toolkit right now that we are all talking about addresses us as providers. There are other patientdirected materials there as well. So that Web site is a very vastand you can get lost sometimes within it. If you have an hour some day, spend some time because there are incredible things in there, even recipes and cookbook referrals. So please review it. Somebody asked the question about a DSME program, and if.

You would clarify what you are specifically wanting from that, I will be happy to refer you to our appropriate answer. So let’s see, what else do I have on my question list How does a solo practitioner in practice over 25 years implement this I think I addressed some of that. It is just simply talking to the sources that you already use. At 25 years, you are the person we want, because you already have your network, you already know who your key pharmacists are in your area and your.

Key optometrists and your key dentists. If any of you are so inclined, your local county dental society or optometry society, go and attend as an outside practitioner and say, Hey, I would like to do this with some people in my area, who is game These slides are available for you to download and take and present. Remember, if you do that, as a podiatrist today, Dr. La Fontaine’s job was not to educate podiatrists about podiatry careit was to teach the other providers a little bit about what we do, and that is what each of our.

Jobs were here with working with you today. So let me see if I have any other questions. Seeing none popping right up, I will turn it back to Dr. Allweiss for a wrap up. Dr. Allweiss Thank you Dennis and everybody for participating and the good questions. On the slide it says PPOD, how to get started, and that has the link to the materials. You will find PowerPoint presentations that you can send to providers. Eventually, this will be there as well. We have also have things for consumers.

As Dennis mentioned, we have the one pager checklist on one side, and on the other side, we have what kind of questions for all of the PPOD providers, so it’s like a one stop. It’s a onepager that you can just download for your patients. We have that in English and in Spanish. We also have onepagers on each of the PPOD specialties for consumers. These have been screened for health literacy, simple language, and they are called Healthy Eyes Matter Healthy Feet Matter Know Your Medications. Basically, they are onepage educational tools that you can.

Download and give to your patient, and it will tell them about why it is important to take care of your eyes, your feet, your teeth, and also how to talk to the pharmacist. So all of the tools are there, just go to that link, and you can find many of them as well as other NDEP products. We want people to share consistent messages, and we want people to know that folks should control their A1C, their blood pressure, their cholesterol, and they should not use tobacco products. These are all consistent messages that we feel.

The primary care folks, as well as PPOD providers, can give to their patients. Team care involves a lot of folks. PPOD just happens to be one more organized group. Somebody had sent us in a chat box, Are there any other examples And indeed, in Massachusetts there was a Massachusetts PPOD group, and we even have some slides from presentations from them in the past. Be sure you pay attention to the problems in your other PPOD areas. As Dennis said, if somebody comes in to your office and you are a dentist, and they are wearing slippers,.

That is a sign. Just notice it and be sure that you ask the patient and the patient’s family, Has this person had any other problems with their feet or whatever. So, it is a team approach, and it is important to call. If you have a question, call the primary care provider, because they want to hear from you. And so we want you to collaborate with everybody with the podiatrist, the pharmacist, the optometrist, the dentist, but also don’t forget about the primary care folks and nurse practitioners, the nutritionist as well,.

Also community health workers. These folks can really help you bring your message to your patients. And talk to your local associations as Dr. Frisch said, and the local chapter of the national associations, so the optometry association, the podiatrist specialty organization. They are all in the community. Tailor and use your PPOD materials. So certainly, if you are in your office, put your logo on it. These materials are evidence based. They have been pilot tested. They are credible. We are trying to make your job easier. So if you need any more information,.

Please go to the NDEP Web site. I would like to thank our presenters, Dr. Frisch, for being the moderator all of the participants. You can see the general NDEP Web site, and if you do have any questions, please email me and I will be forwarding the email to the specific specialist who will be able to help you, and then we will email you back an answer. So thank you so much for participating. Everything will be posted on the Web site I think it was slide 44. It might take a couple of weeks while we process everything, but.

24.5 Complications of Diabetes for Older Adults Diabetes 5 of 6

Hi, I’m Mary Alexander from Home Instead Senior Care, and today, I’m talking about the health complications associated with diabetes. Having diabetes increases your risk for developing many serious health problems. Let’s talk about a few. People with diabetes are at an increased risk for eye complications, particularly disorders of the retina, and have a higher risk of blindness. The National Institute of Health has found that hearing loss is twice as common in people with diabetes. The most common type is called sensory neural hearing loss. It usually can’t be cured, but most cases can be treated with hearing aids. Foot problems are very.

Common in people with diabetes. Nerve damage, called neuropathy, causes pain, but can also lesson your ability to feel pain, heat, and cold, resulting in foot injuries. Poor circulation, very dry skin, callouses, and ulcers on your feet are complications of diabetes. If neglected, ulcers can result in infections, which can result in the loss of the limb. Another complication is high blood pressure. This raises your risk for heart attack, stroke, eye problems, and kidney disease. High blood sugar can also overwork the kidneys, causing them to stop working properly. Once kidneys fail, replacement therapy via dialysis or.

Digestive disorders and the nervous system

Hello this is Doctor Daniel Farkas and I’m here to talk to you today about digestive problems and natural remedies. The digestion system itself begins in the mouth and it ends upon excretion of liquid and solid waste as everybody knows. Everything that happens in between is a very intricate process that is completely regulated by the nervous system which consists of the brain the spinal cord at the nerves that leave the spine to go into the entire digestive system from the mouth, to the esophagus, to the stomach, systemic to the small intestine, to the large intestine,.

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