I’ve often thought of myself as sort of a rodeo clown in the whole Maintenance of Certification (MOC) and MOL debate. The real heroes are leaders like Dr. Paul Kempen, MD, who will be delivering a presentation entitled “Challenging MOC & MOL: Evidence-Based Medicine, or Monopolized Income Stream for the Medical Boards?” at a Michigan event you can learn more about at link, OtherCare: Liberation & Innovation in American Healthcare – Eventbrite##. While I don’t necessarily agree with everything espoused in the announcement, I respect them,  and my views generally coincide with that of Dr. Kempen’s when it comes to the MOC and MOL.

I guess they don’t call them rodeo clowns anymore. They call them bullfighters.

I wonder who will offer their signatures in order to get beyond the unlucky thirteen?

It looks great and there’s a nice quiz feature; see link POGOe QBank | POGOe – Portal of Geriatric Online Education. You can even make your own quiz. It’s designed for health care professionals and the resource is free. It requires registration.

When you get your free username and password, try the dementia quiz at QBank Quiz – Dementia test | POGOe – Portal of Geriatric Online Education.

I double dog dare ya. Great job POGOe!

I think this resource is a much better way for senior physicians to improve their knowledge and skills than trying to introduce them to Maintenance of Certification (MOC) or Maintenance of Licensure (MOL). The American Psychiatric Association (APA) makes a valiant attempt to support the principle of lifelong learning, PsychiatryOnline | Psychiatric News | News Article Senior Physicians. I just think we can do better than the MOC.

Incidentally, according to psychiatrist Paul Wick, MD, chair-elect of the American Medical Association Senior Physician Section, there are more doctors in the 65 and older age category than in the 40 and younger bracket. Maintaining competency and quality care is a top priority, says Dr. Wick. And he emphasized “Aging physicians will leave the future supply of physicians in a critical condition.”

Wick’s comments were taken from a recent Psychiatric News Alert from the APA in a short article entitled “Needs of Senior Physicians Focus of New AMA Group.” The story was about an educational session at a recent AMA House of Delegates meeting in Chicago entitled “The Aging Physician: Opportunities and Challenges.” One of the items focused on was MOC for seniors and strategies for retaining older physicians in the workforce while ensuring safe practice.

I would point out that the fear some senior physicians might have that they might be expected to participate in the MOC will serve to drive them into retirement earlier than they otherwise would.

That is the critical condition.

“…And we must build a culture of humanistic clinical excellence.”—Jamos the Elder

The short answer: not much at all. This is despite the willingness of the MICU staff to host the psychiatric consultant to round with them once a week for 9 months, offering impromptu 3-5 minute talks about delirium, including how to distinguish it from primary psychiatric disorders. The method included preintervention and postintervention surveys, and remember, this was to assess attitudes and beliefs of nurses, internal medicine residents–not actual knowledge so much.

The telling conclusive remark by lead author, Dr. Scott Beach, MD:

Though this intervention was reported subjectively as being “very helpful” in terms of enhancing the overall care of patients and appeared to improve relations between medicine and psychiatry, thus fulfilling the goals of the liaison intervention, the presence of a psychiatry consultant rounding with the intensive care unit team once weekly for 9 months appeared to be insufficient to meaningfully affect the attitudes and beliefs of trainees and nurses regarding delirium.

While the project may have fulfilled one of the “…goals of the liaison intervention…” by opening the door to building a constructive working relationship between psychiatric consultants and internal medicine physicians, it missed on the most important one–changing the culture of medicine regarding the recognition, management, and prevention of delirium, a major safety problem in all hospitals. He acknowledges that in the last sentence of the discussion:

Finally, given the frequent rotation of trainees through the intensive care unit, successful interventions may benefit from a “train-the-trainer” mindset and involve targeting of critical care attending physicians and nursing leadership to further embed educational objectives and effect a culture change from within (boldface mine).

I have marveled at the difference between implementation and education in delirium prevention for years.  Education is simply not sufficient by itself. I have remarked to critical care teams that “a psychiatrist is an anomaly in the ICU.” I truly believe, because of scope of practice limitations, most psychiatrists are in the worst position to guide internists on how to prevent and treat delirium. I realize one thing. We may be better at recognizing what delirium is not–a primary mental disorder. The point of that remark is to highlight the main reason why I think psychiatrists are continually called about delirium in the critical care unit or anywhere else in the general hospital for that matter. Delirium, because it affects all areas of the brain, mimics a host of psychiatric disorders because of the dramatic changes it produces in affect, behavior, and cognition. It quacks like a duck; therefore it must be a duck.

The problem with that attitude is that treating delirium as if it were the primary psychiatric disorder it mimics does nothing to reverse the underlying emergency medical cause of all the quacking. And it looks like the strategists who make psychiatrists the lead ducks in teaching health care professionals about delirium have laid a colossal egg as far as creating substantial change in the medical culture. I have quacked myself blue in the bill about delirium for my entire career as have, I’m sure, many of my colleagues in consultation psychiatry, including Dr. Beach, whose tenacity I admire. He and his co-authors created a psychiatric liaison.

Attempting to create a psychiatric liaison service, even temporarily, is a monumental undertaking nowadays in this rapidly changing health care system. “A liaison service requires manpower, money, and motivation…the psychiatric consultant…must be able to attend rounds, discuss patients individually with house officers, and hold teaching sessions for nurses”…”In epidemiologic terms liaison psychiatry attempts to deal with the denominator of the prevalence of psychiatric morbidity in the medical setting, whereas consultation psychiatry, by the very nature of the referral process, is involved only with the numerator.”–James J. Strain, MD.

The liaison idea has great merit, and so does helping internists find champions within their own ranks who will own and drive the mission to prevent delirium.

1. Beach, S. R., MD,, D. T. Chen, MD,, et al. (2013) Educational Impact of a Psychiatric Liaison in the Medical Intensive Care Unit: Effects on Attitudes and Beliefs of Trainees and Nurses Regarding Delirium. The Primary Care Companion for CNS Disorders 15,  DOI: 10.4088/PCC.12m01499

Objective: Despite high rates and increased risk of mortality, delirium remains underdiagnosed and a minimal focus of formal medical education. This is the first study to examine the educational impact of a psychiatric liaison on beliefs and knowledge about delirium among both nurses and residents.

Method: One psychiatrist spent 9 months rounding weekly in the medical intensive care unit, interacting with critical care nurses and internal medicine residents. Preintervention and postintervention surveys were distributed in July 2009 and June 2010, respectively, to staff (critical care nurses: n = 23 and n = 25, respectively; internal medicine residents: n = 31 and n = 23, respectively) and a comparison group (psychiatry residents: n = 29 and n = 23, respectively). Participants responded to 12 statements regarding delirium on a 5-point Likert scale.

Results: There were no statistically significant differences between the presurveys and postsurveys for any item when examining all respondents together, as well as psychiatry and internal medicine residents as individual groups. Critical care nurses showed a significant change between surveys for the statements, “Patients with new-onset anxiety or depression in the intensive care unit most commonly have delirium” (17.4% agree presurvey vs 56.0% agree postsurvey, χ2 = 7.62, P = .006) and “Delirium is diagnosed less often than it actually occurs” (100% agree presurvey vs 80% agree postsurvey, χ2 = 5.13, P = .023).

Conclusions: Though introduction of a psychiatric liaison was very well received by clinical staff, we did not meaningfully affect the attitudes and beliefs of trainees and nurses regarding delirium. Robust and lasting changes in attitudes regarding delirium may require more intensive efforts involving longer intervention periods, greater rounding frequency, or additional didactic teaching.

So is this about lies or art? I just caught up to the whole mermaid thing last night, Charlie Foley Created Animal Planet’s Mermaids – Business Insider. The only thing was, I was napping on the couch before I could see the disclaimer about the show being fiction, mermaids new evidence disclaimer – Bing Images. After I found out it was a mockumentary, I was reminded of Orson Welles’ radio show, The War of the Worlds, The War of the Worlds (radio drama) – Wikipedia, the free encyclopedia. I pride myself on being a skeptic, but I have to admit, I got caught up in the drama, as many did from Welles’ radio show, which was clearly identified as fiction at the outset.

People were angry about being fooled by The War of the Worlds; these were the ones who didn’t hear the disclaimer. They felt lied to and were probably embarrassed. I really liked the mermaid show and finding out it was fiction didn’t bother me. I’m not sure why everyone calls it a hoax. Nobody lied to the viewing public about it.

This also reminded me of some of my colleagues who seem to think that psychiatrists are better at detecting liars than other health professionals are. Hmmm…

I received an e-mail announcement about an event called the Nearly Naked Mile. It was about a clothing drive for which the University of Iowa Alumni Association’s S.T.A.T. (Students Today, Alumni Tomorrow) Ambassadors sponsor an annual walk or run race (1). Donations benefit United Action for Youth (UAY), an organization whose mission is “Nurturing the potential of all youth to create, grow and lead”. Their vision “is one in which young people and adults work together in partnership to create a safe and healthy community.” Their values include:

Respect: Treating each person with Unconditional Positive Regard

Excellence: Providing quality programming

Collaboration: Building constructive partnerships to achieve our goals

Integrity: Maintaining trust with those we serve

Stewardship: Using resources respectfully

The UAY has been active in Johnson County in Iowa since 1970. They serve over 2,600 young people and parents annually. It’s a safe place where kids can go and be “…silly, thoughtful, outrageous, or sad” (2).

Anyway, running nearly naked in the Nearly Naked Mile is thankfully optional. I’m too shy to run even close to nearly naked, and I’ll be on duty anyway on the day of the event, but the announcement jogged a couple of memories loose for me.

First, when I was a resident in psychiatry early in my training at The University of Iowa Hospitals and Clinics, I remember occasionally interviewing and trying to help a few of the UAY-mentored kids in the emergency room, some of them listed as “runaway” on the intake sheet. Looking back, they weren’t so much running away as running headlong into a bewildering world seemingly bent on wounding them. They needed so much more than psychiatric treatment. They needed acceptance, understanding, and guidance, which UAY tirelessly provided. I like to think I helped.

Second, I was reminded of my own undergraduate school mentor at Huston-Tillotson College in Austin, Texas, a historically black enrollment college now called Huston-Tillotson University.  As an African-American growing up in mostly white enrollment schools in Iowa, I enjoyed an extraordinary learning experience for several semesters in the mid-1970s because I was given the opportunity through an outreach drive to enroll students of color led by Dr. Hector Grant, whom I’ll mention later.

One of the first lessons at Huston-Tillotson was adjusting to the sweltering Texas heat. The glue on the binding of nearly all of my paperback books melted in the un-air conditioned Beard-Burrowes male residence hall.

Dr. Jenny Lind Porter, PhD was my professor of English as well as Classical and English Literature during freshman and sophomore years I spent there. Dr. Porter was a distant cousin or niece (depending on which source you read) of O. Henry, a writer famous for hundreds of stories, many about the turn-of-the-century West. Dr. Porter was also an accomplished writer, and a few years ago, I finally obtained an early copy of one of her poetry collections, The Lantern of Diogenes and Other Poems (3). It arrived with a handwritten note from the Austin bookseller:

It’s rare to find a book of this age that when you open the pages it creaks like it is unread. I guess someone liked the way it looked on their bookshelf!

It mystifies me why the book would sit on anyone’s shelf unread. One of my favorites is “I Go to Church Within My Heart”.

I Go to Church Within My Heart

I go to church within my heart,

The only one I know,

There is no door to push aside,

God hears my footsteps, slow,

Come stealing down the shadowed aisle

Until I reach His light,

And then we sit and talk of things

Till separated quite

From bone of earth and flesh of life,

I cannot find my way

Back from the chalice, wine, and bread

Into the dusk of day.

Why would the Nearly Naked Mile remind me of her? Well, it isn’t just free association, and it involves a church. Huston-Tillotson professors held an annual talent show—given by the professors. I remember Dr. Porter’s act, vividly. Wearing a lovely gown, she gracefully stepped on to the stage of the King-Seabrook Chapel to read from a volume of classical poetry. She had a beautiful voice. And even then, she was lovely in—other ways. As she read, articles of clothing seemed to drift away. It’s funny how your mind can block recognition of reality, which tends to be very well draped; that is, until it is nearly naked.

The longer Dr. Porter read her poetry, the less gown seemed to be evident, and the more creamy white flesh became visible. The unveiling of a white woman in front of an audience filled with black males even in the 1970s produced nearly naked amazement.

A verse would end. A shawl would drop. A brilliant metaphor would fall gently on my ears—followed by a brightly sequined skirt dropping noiselessly to the floor. Meter by meter, the miraculously iambic conjugated with the spectacularly revelatory, promising the celestial by successive approximations while delivering the earthly through sartorial regressions until she was—nearly naked. The strip tease poetry reading brought the house down. Sorry, I don’t recall which poem she read.

Dr. Porter was much more than courageously clever. She was inducted in 1985 to the Texas Women’s Hall of Fame and was appointed Poet Laureate of Texas in 1964 by Texas Governor John Connally. She received international recognition for her work, including The Lantern of Diogenes. In 1979, she received the Distinguished Diploma of Honor from Pepperdine University, the only woman to do so. She was named one of the Outstanding Educators of America and was selected for the International Who’s Who of Poetry (4).

She was a devotee of Rosicrucianism back then, and made a valiant though futile attempt to teach me about it. She persuaded me to submit a poem to the college’s annual poetry contest. I can’t remember if it was published in 1975 in the creative writing collection students entitled Habari Gani, Swahili for “What’s the News?” or more loosely translated, “What’s Going On?” This was during a time in the United States that African-Americans were building a new identity, and Habari Gani is linked to Kwanzaa, an African-American cultural holiday created in 1966 (5).

Dr. Porter was, in fact, very supportive of racial, ethnic, and cultural diversity long before it was cool. The values she espoused and cultivated in the 1970s were very similar to what UAY promotes:

Respect: She commanded respect in her classroom and from her colleagues, even when doing a strip tease down to nearly naked while reciting classical poetry.

Excellence: She inspired excellence in every student, without which Habari Gani would not have been created or published.

Collaboration: She was the exemplar of collaboration across the disciplines of humanities and science and across cultures because she could listen deeply and made sure she understood what others meant before she spoke.

Integrity: She had enough integrity as a scholar and a leader among women to stand nearly naked before a black audience in a church in the 1970s, which won both our hearts and our minds.

Stewardship: She held in stewardship classical ideas and philosophy that will forever stand the test of time about honor, diligence, acceptance, and wisdom, the last of which, after all, means skill in living.

It was easy to trust her. It remained easy to trust her even after the school aired the TV landmark miniseries Roots in 1977, based on the book by Alex Haley. It was impossible not to cry when Levar Burton, as Kunta Kinte, writhed and leapt in the transformation from warrior to slave when captured and bound in chains. And when Chuck Connors, as a slave owner, convincingly conveyed the evil of that role, one young man in the audience cried, “I’m not watching the rifleman no more!”

But we didn’t transfer any resentment to Dr. Porter subsequent to that searing revision of American history. When a visiting professor gave a speech about what Black men were allowed to do in America in that era, that we could be clowns, athletes, or noble savages—but not men, we didn’t gaze on Dr. Porter with suspicion. I thought of her while I was reading what I believe is the most important work since Roots, The Warmth of Other Suns: The Epic Story of America’s Great Migration by Isabel Wilkerson, an African-American author who won the Pulitzer prize for this New York Times best seller. I wondered what kind of lively conversation these two women from different races, reared in different cultures, and born with different temperaments might have had about freedom, acceptance, and leadership.  I suspect they would have had a nearly naked admiration for one another.

Whether Dr. Jenny Lind Porter is alive or dead is a mystery to me. The customer review of her book The Lantern of Diogenes that I wrote on Amazon.com in the fall of 2011 was answered by one of her former students who basically said, “Amen” to my sentimental praises and promised to get in touch with me if she discovered anything of her whereabouts.  She called her “…a very bright star in the vast sky of life (6).” Amen to that, but I’ve heard nothing yet.

She accepted much that is troubling in the world, all the emotional, spiritual and physical ambiguities at large and within. She moved serenely in academia, which can be a jungle populated by brooding geniuses and impetuous dreamers.

She was tenacious and practical in her pursuit of all we know and all we need to know about truth and beauty. She taught me to be tenacious and practical in my own way, from the emergency room with runaway teens, “…the bone of earth and flesh of life…” to the church within my heart.

I admired other teachers at Huston-Tillotson, of course. Major Lamar Kirven taught Black history and sociology, and the poor devil tried in vain to teach me about patience. When I lost my patience, he reminded me, “Brother Amos, patience is a virtue.”  He was the blackest man I ever saw. His voice was soft, his laughter loud and joyful—and his handwriting on the chalkboard was always comically illegible. And Reverend Hector Grant, who taught Philosophy and Religion, wrote books about his native Jamaica, and tried to counsel me after my humiliating defeat as captain of the debating team at the hands of someone who won merely by being bombastic. He told me, “Never be afraid to concede a point.” But the teacher I remember most vividly is Dr. Porter, the object of my nearly naked admiration.

What little I know of Dr. Porter nowadays are meager crumbs I’ve collected from the labyrinthine internet, though no trail back to her has appeared. These little clues melt even as I bear them tenderly “…Into the dusk of day.” I have not yet seen an obituary (although I’ve seen that of her late husband, Lawrence Evans Scott, identified in the first line as “…spouse of Texas Poet Laureate Jenny Lind Porter.”). But I’ve seen a notice about her burial plot in the Texas State Cemetery. Her birth date is entered—but the spaces after the sections “Died” and “Buried”—are blank. The mystery suits me. Even now, I sing this song softly, trying not to peek too boldly behind me to see if she is following me out of Pluto’s cavern while I try to “…charm the Lord of the Dead…” and “…bear her away from Hades,”—a fragment from the story of Orpheus and Eurydice in Mythology by Edith Hamilton,  one of her favorite books she assigned our literature class as required reading (7). What might she say of my search, and what I’ve written here? “News of my near-nakedness and my death are greatly exaggerated?” That would not surprise me.

She should have the last word, after all. My favorite poem from The Lantern of Diogenes is the one of that title, which fits her best.

The Lantern of Diogenes

All maturation has a root in quest.

How long thy wick has burned, Diogenes!

I see thy lantern bobbing in unrest

When others sit with babes upon their knees

Unconscious of the twilight or the storm,

Along the streets of Athens, glimmering strange,

Thine eyes upon the one thing keeps thee warm

In all this world of tempest and of change.

Along the pavestones of Florentian town

I see the shadows cower at thy flare,

In Rome and Paris; in an Oxford gown,

Men’s laughter could not shake the anxious care

Which had preserved thy lantern. May it be

That something of thy spirit burns in me!

Image: Diogenes, jpg downloaded from http://www.jeanleongerome.org/Diogenes.html
Artist: Jean-Leon Gerome; born May 11, 1824, died January 10, 1904; the date of the painting is 1860; medium is oil on canvas; Dimensions: Height: 74.5 cm (29.3 in). Width: 101 cm (39.8 in). ; with frame: Height: 105.2 cm (41.4 in). Width: 132.6 cm (52.2 in). Depth: 15.2 cm (6 in). his country of origin was France

1.         The University of Iowa Alumni Association. Nearly Naked Mile 2013. Accessed February 8, 2013; Available from:
http://www.iowalum.com/STAT/events/nnm/
.

2.         United Action for Youth. Accessed February 8, 2013; Available from:
http://www.unitedactionforyouth.org/content/
.

3.         Porter, J.L., The Lantern of Diogenes and Other Poems. 1954, San Antonio: The Naylor Company Book Publishers.

4.         Texas Woman’s University. Texas Women’s Hall of Fame: Jenny Lind Porter. Accessed February 7, 2013; Available from:
http://www.twu.edu/twhf/tw-porter.asp
.

5.         Karenga, M. Kwanzaa: A Celebration of Family, Community and Culture. Accessed February 7, 2013; Available from:
http://www.officialkwanzaawebsite.org/origins1.shtml
.

6.         Amos, J.J., M.D. Customer Review: The Lantern of Diogenes and Other Poems by Jenny Lind Porter. 2011. Accessed February 7, 2013; Available from:
http://www.amazon.com/review/RDT4JK82XV0RN/ref=cm_cr_pr_cmt?ie=UTF8&ASIN=1258049716&linkCode=&nodeID=&tag=#wasThisHelpful
.

7. Hamilton, E. and S. Savage (1969). Mythology. New York, New American Library.

This is another lyrical guest post by Dr. Luisella Magnani on the subject of pediatric delirium, specifically as it occurs in the preverbal child. She publishes her work on her website, Luisella Magnani » The PreverbalOncologicChild’s Delicate-and-Private World. She has gotten the attention of researchers with the Vanderbilt Delirium Group, ICU Delirium and Cognitive Impairment Study Group. She always dedicates her work to her nephew, Giampaolo, who died as an infant of cancer and who suffered from delirium. She is Professor at the College of science of Linguistic Mediation of Varese, disciplines General Linguistics; Researcher at Università Cattolica del Sacro Cuore of Milan, and Professor of Aesthetics at the Università Cattolica del Sacro Cuore in Brescia. She also teaches seminars monthly on delirium in preverbal children with cancer at the Pediatric Hospital. You can see her other posts on this blog under the Delirium title in the menu below the header. The websites for the artist Donald Zolan, the American painter of children, will likely not work properly. His website was under construction at the time this post was published. Many videos on Zolan’s art are available on YouTube. Of course, I could not duplicate her prose in the original calligraphy, but she has published it on her website at link Luisella Magnani » The Best Practice Of The PreverbalPediatricEmergenceDelirium Scale, PPED Scale. Many thanks, Luisella!–J. Amos

 The Best Practice

Of

The PreverbalPediatricEmergenceDelirium Scale, PPED Scale

First Part

Luisella Magnani » Preverbal Pediatric Emergence Delirium Scale pPED

Luisella Magnani

In order to display the Best Practice of the PPED Scale, in the Non-Pharmacological-Care dimension, I begin with a sentence I live, because it is the soul, mind and body of this Scale, Being-in-the-Language You Say, in the Sign and Gesture You Shape, this is the In-Presence for the PreverbalOncologicChild. EveryPreverbalOncologicChild asks for in his private and deep silence, as well as in his private and deep cry. And, his asking for is always a urgent asking for.

The importance of time and space is so  great. Because if on one hand,  t i m e  is a tissue which permits to analyse and classify deeply and clearly the inner nature, the inscape and the insight of the PreverbalChild, on the other hand, s p a c e  is the context within which this tissue permits to be analysed and classified.

Seven are the steps of the PPED Scale,  Cognitive Behaviour, Gestural Behaviour, Behavioural answer to the environment stimuli, Behaviour which threats the Child-Safety, Motor Behaviour, Dis-affective Behaviour, Vocal Behaviour.  Being before the PreverbalChild approaching him sweetly and softly constantly. This way of being sweet and soft in words, signs and gestures   m u s t   b e   constantly and substantially. That’s well appreciated by the PreverbalChild in pain, despite everything, everywhere, everywhen and everyhow, against everything, everywhere, everywhen and everyhow, Dysphoria, Fixed glance, Helpless glance, Frightful glance, Helpless-and-frightful glance, Hypomobility.  In such a way, the Caregiver is creating his own personal and private atmosphere. The PreverbalChild perceives the Caregiver’s voice as air caressing his own face, air that his eyes are breathing and That is perceived by the Caregiver, when the Child looks at him and  his eyes  are saying to him: “ I thank You for having reached my private-and-intimate world. I was waiting for You. Now, I am no more alone, because I feel that I am understood.” Constancy and Substance in words, signs and gestures devoted to him. Constanceness-and-Substanceness in the Caregiver’s behaviour create what is new for the PreverbalChild. Constanceness-and-Substanceness create new time and new space for him. Being before a PreverbalChild in pain means to listen to the willingness to be within the inner scape of that Child, and  his  I n s c a p e   asks to be considered, valued, cared, cradled and loved. His Inscape. Imagine, Imagine, Imagine the terrible distress,  great pain,  silent suffering of a PreverbalChild in Delirium. Imagine, Imagine, Imagine. Only when the Child feels understood, he feels shared in all his dimensions, despite everything. F e e l i n g   u n d e r s t o o d  (Claire Vallotton, 2008)  is a great event, because the Child knows that he is not alone within his private pain. Atmosphere is very important, the environment is very important. But, the atmosphere and environment that the Caregiver succeeds in creating owing to

his  behaviour is                               

the most important, because the magic of thinking, of speaking and acting creates in his inner scape the atmosphere of all the atmospheres and the environment of all the environments.  All That He Perceives Fully.

The PreverbalChild’s behaviour asks for being analyzed deeply and deeply, second-by-second (Claire Vallotton, 2012), and that permits fully to analyze the communication owing to eyes, because he knows that eyes are the channel owing to which communicate, owing to which find the other from him. And, his eyes can portray disgust, dissmell, stress and distress, sadness, pain, solitude, anxiety, anguish, shame, fear, anger and rage (Paul C. Holinger, 2011). His eyes can contain these feelings  s i m u l t a n e o u s l y. And, all together, they create a  unit-of-wholeness.  They dictate the behaviour of crying. And, imagine What-Is-Happening-Within-Himself. His perceptions, sensations, emotions, actions of thinking. Imagine, imagine, imagine. And when we realize that all these feelings are lived by the PreverbalChild in Pain we are entering his very private-and-intimate world. A very private world waiting to be discovered, cared, cradled and loved, second-by-second, because the real incidence of delirium in PreverbalChildren may be much higher than  n o w  observed in daily practice (Erwin Ista, 2012).

The individuality, the unicity, the subjectivity of EveryPreverbalChild in Pain |Mark, 7 months old – Nicholas, 13 months old – Thomas, 17 months old|  I s the concrete tissue of his very private world, a world where his individual Cognitive Behaviour, Gestural Behaviour, Behavioural answer to the environment stimuli, Behaviour which threats the Child-Safety, Motor Behaviour, Dis-affective Behaviour, Vocal Behaviour are his mind-and-body’s answer to a context of high pharmacological care.  ‘A minute of pain is an eternity for most children’ […] ‘Keeping pace with the Child’ (Leora Kuttner, 2010) means entering his mind-and-body space, living his emotions and perceptions totally and completely, observing him second-by-second, being before him in order to be within him and the PreverbalChild feels All That.  This is his very private feeling. All That permits him to cope with what is happening in his mind-and-body. Firstly, the voice-atmosphere, the Caregiver’s voice,

my little-little-little heart, my little-little heart of my heart

invites the PreverbalChild to listen to a voice concentrated just on him. The same words are repeated, repeated more times, changing the rhythm of voice, changing the position of words,

my little-little-little heart,

my little-little heart

of my heart

you, my little-little-little heart, are my little heart of my heart

of my heart, my little-little-little heart, you are

And keep this sentence. Don’t forget it, because, this sentence asks for being repeated again and again, during the day long, during the night long. Repetition is the intensification of meaning. Sign-atmosphere and gesture-atmosphere fill the Child’s space and time. The rhythm you give to your voice is the same rhythm of your hands in movement. If he is crying you collect his crying with one of your hands as if you were collecting a bubble floating on air. Every sign and gesture must be cared in its sweetness and softness. A new atmosphere must be created for the PreverbalChild. New words, new signs, new gestures fascinate him and his indifference  begins to be transformed into listening to different sounds, and he looks at different signs and gestures. Building  atmospheres  means to build that floating in-between (Gernot Böhme, 2001), where sounds of words, signs and gestures are between what is happening in his mind-and-body and his perceptions of all that.

Among ‘the preventive and interventional approaches used for delirium attempt to keep the healthy brain “awake” and decrease the further dysregulation of neurotransmission in the critical care setting’ (Heidi Smith et al., 2013), there is the painting-atmosphere,
http://www.donaldzolan.com
,
http://www.donaldzolanvideo
. Donald Zolan (1937-2009) was the American painter who painted the Innocence of Children. His paintings portray Children in very, very different contexts. And these paintings, above all videos of these paintings, fascinate a lot the PreverbalChildren, because they meet themselves in every painting, they meet other Children like them. And the painting-atmosphere ‘takes Children’ into the PreverbalChildren’s care setting room. They see new environments, new shapes and shades. And when the PreverbalChild’s attention is focused on a particular video, the same video is suggested again, intepreted to the Child, studied with the Child. Sounds, words, signs and gestures, images in moving create delicate

sound-atmospheres

word-atmospheres

sign-and-gesture atmospheres

image-atmospheres

All that softly and sweetly, collecting every kind of behaviour coming from the PreverbalChild in Pain. His clapping the hand on his breast to say I am afraid invites the Caregiver to caress his clapping-hand, caress it again and again, blowing in it, on it, kissing it more times sweetly. The Caregiver’s behaviour shows to the PreverbalChild his willingness to understand him fully and deeply, as well as when he claps his clenched fist on his breast to say I am in pain. These are two very important gestures which state the PreverbalChild’s urgent calling for. Only observing his hand, and touching it, speaking to it, considering it with a very great interest, the PreverbalChild feels understood. These gestures tell us what is happening inside him. And when he feels that these gestures are considered and valued softly, sweetly and silently, a tuning-in process (Leora Kuttner, 2010) is created.

What is happening inside him when He throws on the floor his small dish full of food, He tears his hair out, He pulls out lines, He pulls out tubes, He beats himself, He scratches himself, millisecondly? This adverb of time is so important, it is introduced by Professor Paul C. Holinger in his recent writing, June 2013 Newsletter,

But note the rapid back-and-forth of the infant’s facial and bodily expressions of interest and enjoyment with moments of distress and fear. Recall that the expressions of these affectcs are very brief, i.e. milliseconds.

What a precious expression, milliseconds. An expression which is precious as well as conscious, concrete and delicate, because the content of consciousness (Heidi Smith et al., 2010) is disclosed, and that leads more and more to the inner and private space of the PreverbalChild’s bodily presence. The space of time, milliseconds, closes within it all the variables displayed in the PreverbalPediatricEmergenceDelirium Scale,

Communicate owing to eyes, turn-taking, joint-attention, indifference, the preverbalChild does not recognize his parents, solitude, dysphoria, euphoria, inattention, disorganization, dismiling, decreased consciousness, impaired memory, worsened concentration, thoughtful, context of gesture, context of sign, sequence of sign, frequence of sign, high frequence of sign, semantics of sign, variability of sign, new sign, unusual sign, rare sign, emotion-sign: clapping one hand on his breast to say I am afraid, action-gesture, sensitive-gesture, time-gesture, space-gesture, disorientation, hallucinations, tactile hallucination, sensitive hallucination, tasting hallucination, auditory hallucination, visual hallucination, olfactive hallucination, no-participation, no-observation, suspension, fixed glance, helpless glance, frightful glance, helpless and frightful glance, isolation, reduced mobility, reduced movement, changes in appetite, lethargy, he throws on the floor his small dish full of food, he tears his hair out, he pulls out lines, he pulls out tubes, he beats himself, he scratches himself, he beats his breast with his clenched fist, as a sign of pain, he beats with energy his hand on his breast, as a sign of fear, he turns- and-turns on himself and falls down, irritability in his movements, inconsolability of his cry: he screams, he yells, he cries out, disorganization in his movements, very quick movements, repeated movements intensively, hypermobility, hypomobility, slower-and-slower movements, he scratches his mother’s face, he bites his mother, he beats his clenched fist on his mother, glacial silence, inexpressive silence, inner silence, severity on his face, rage on his face, his lips draw a line, as perception of pain, his lips draw an O, as perception of pain, continuous moaning, inconsolability of cry, acute screams, continuous screams, he always repeats the same vowel as if he wants to throw it away, he always repeats the same babbling, as if he wants to throw it away. All these variables are behaviours and these behaviours are the results of feelings … We now can “see” feelings and understand how they work. (Paul C. Holinger, June 2013 Newsletter). And within the space of  … “see” feelings, within the verb to see, we can find also the verb to taste feelings, to touch feelings, to smell feelings, to feel feelings, to hear feelings, and that happens when the Caregiver is the    In-Presence  before the PreverbalChild in pain.

Gernot Böhme studies atmospheres as totalities: atmospheres imbue everything, they tinge the whole of the world or a view | Donald Zolan’s Paintings|, they bathe everything in a certain light |the Power of Language, Signs and Gestures|, unify a diversity of impressions in a single emotive state|seeing Feelings, tasting them, feeling them, touching them, hearing them, smelling them|. … Can one really make atmospheres? The term making refers to the managing of material conditions, of things, apparatus, sound and light. But atmosphere itself is not a thing; it is rather a floating in-between, something between things and the perceiving subjects. The making of atmospheres is therefore confined to setting the conditions in which the atmosphere appears.

In conclusion, let’s read together what Gernot Böhme |born 1937, Dessau, Germany, German Philosopher| writes referring to The Space of Bodily Presence. It’s just within the words of this wonderful page that second-by-second I study that being-and-doing the best for EveryPreverbalChild in Pain,

The space of bodily presence is something deeply subjective … The space of bodily presence is the space within which we each experience our bodily existence: it is “being-here”, a place articulated absolutely within the indeterminate expanse of space – absolutely in the sense that it is without relation to anything else, especially to things: the “here” is implicit in the intuition of oneself …  Bodily space is the manner in which I myself am here and am aware of what is other than me – that is it is the space of actions, moods and perceptions. As a space of actions, the space of my bodily presence comprises my scope for actions and movements. It might be called my sphaera activitatis. As such it is certainly also centred, and is articulated by characteristic physical  directions such as above/below and right/left; but for the rest it is larger or smaller depending on the situation – for example, the presence of light or darkness. Bodily space as the space of actions is experienced essentially as possibility, as scope.

The space of moods is physical expanse, in so far as it involves me affectively. The space of moods is atmospheric space, that is, a certain mental or emotive tone permeating a particular environment, and it is also the atmosphere spreading spatially around me, in which I participate through my mood.

The space of perceptions is my being among things, that is, the way in which, through perceiving, I am outside myself; or it is expanse, insofar as my own presence is articulated through the presence of things.

… Although bodily space is always the space in which I am bodily present, it is at the same time the extension, or, better, the expanse of my presence itself. The space of moods is the space which, in a sense, attunes my mood, but at the same time it is the extendedness of my mood itself. The space of actions is the space in which I can act, but also the scope of my possibilities. The space of perceptions is the space in which I perceive something, but also the expansion of my involvement with things.

Imagine, if EveryPreverbalChild in Pain knew about all these studies and researches created Just for Him, That would be Already a therapy for Him, because in respecting boundaries, roles and responsibilities for specific disciplines, it is acknowledged that there are some aspects of competence in practice that transcend disciplines and would be expected of any practitioner working in the field of palliative care, irrespective of their professional field and role (Sheila Payne et al., 2013).

This study is in Memory of my Little Nephew, Giampaolo (5^th March 2009  - 17^th October 2010), whose Delirium was underrecognized, underestimated, understudied. To His Memory, in His Love, for all the PreverbalOncologicChildren in Italy, in Europe, in the World.

Sunday, 9^th June 2013

References

Heidi Smith, Emily Brink, Catherine Fuchs, Wesley Ely, Pratik Pandharipande PEDIATRIC DELIRIUM  MONITORING AND MANAGEMENT IN THE PEDIATRIC INTENSIVE CARE UNIT    Pediatric Clinic North America Elsevier – Volume 60 Issue 3, June 2013 – Pages 741 -760

Heidi Smith, Catherine Fuchs, Pratik Pandharipande, Frederick Barr, Wesley Ely  DELIRIUM: AN EMERGING FRONTIER IN MANAGEMENT OF CRITICALLY ILL CHILDREN, 2010 National Institutes of Heath

Paul C. Holinger   DR. PAUL’S PLACE FOR PARENTS AND CHILDREN – JUNE 2013 NEWSLETTER

Paul C. Holinger   TODDLERS, LANGUAGE, AND THE POWER OF TRANSLATION – GREAT KIDS, GREAT PARENTS – 2011 Psychology Today

Monique van Dijk, Hennie Knoester, Babette S. van Beusekom, Erwin Ista  SCREENING PEDIATRIC DELIRIUM WITH AN ADAPTED VERSION OF SOPHIA OBSERVATION WITHDRAWAL SYMPTOMS SCALE (SOS), 2012 Springer Intensive Care Medicine

Claudia Gamondi, Philip Larkin and Sheila Payne   CORE COMPETENCIES IN PALLIATIVE CARE: AN EAPC WHITE PAPER ON PALLIATIVE CARE EDUCATION – PART 1, PART 2, 2013 European Journal of Palliative Care

Leora Kuttner   A CHILD IN PAIN, 2010 Crown House Publishing Limited

Claire Vallotton   INFANT SIGNS AS INTERVENTION? PROMOTING SYMBOLIC GESTURES FOR PREVERBAL CHILDREN IN LOW-INCOME FAMILIES SUPPORTS RESPONSIVE PARENT-CHILD RELATIONSHIPS  2012 Elsevier

Claire Vallotton   SIGNS OF EMOTION: WHAT CAN PREVERBAL CHILDREN “SAY” ABOUT INTERNAL STATES?  2008 Michigan Association for Infant Mental Health

Gernot Böhme   AISTHETIC. VORLESUNGEN UBER ASTHETIK ALS ALLGEMEINE WAHRNEHMUNGSLEHRE, 2001 Wilhelm Fink Verlag, München

Hey, does anyone know when the Diagnostic and Statistical Manual (DSM)-5 is going to come out on the iPad or android? That’s the question on everybody’s mind, DSM-5 Goes Mobile! App allows users to… – American Psychiatric Association |
Facebook. It was supposed to be available starting June 1, 2013 but so far–no DSM-5 mobile app.

Did somebody forget to tell iTunes?

Many patients have medical conditions that militate against using antipsychotics, including but not limited to prolonged cardiac conduction, often approximated by the QTc interval. Occasionally I’ll suggest considering Dexmedetomidine as an alternative anesthetic agent, which is not a psychotropic drug but one with which intensivists are likely to be familiar [3].

It’s not unusual to find hospitalists who are unfamiliar with standard screening tools for delirium, like the Confusion Assessment Method (CAM). Others include the Delirium Observation Screening Scale (DOSS), which nurses adopted for use at our hospital [4].

Ideally, we’d like to prevent delirium, preferably using nonpharmacologic multicomponent methods, some of which can be replicated in smaller community hospitals. One limitation might be coming up with the twenty or so volunteers needed to implement many of the interventions [5-7].

We also need a comprehensive change in culture and policy with respect to our approach to training medical professionals and prioritizing the prevention of delirium in hospitals [8]. O’Hanlon and colleagues had a nice list of a dozen points for improving care. It might even be a nice idea for a Dirty Dozen.

12 point plan for improved delirium care from O’Hanlon, S., et al., Improving delirium care through early intervention: from bench to bedside to boardroom. Journal of Neurology, Neurosurgery & Psychiatry, 2013.

REFERENCES:

1. Teslyar, P., V. M. Stock, et al. (2013). “Prophylaxis with Antipsychotic Medication Reduces the Risk of Post-Operative Delirium in Elderly Patients: A Meta-Analysis.” Psychosomatics 54(2): 124-131.

Background Delirium commonly occurs in hospitalized elderly patients, resulting in increased morbidity and mortality. Although evidence for treatment of delirium exists, evidence supporting pharmacologic prevention of delirium in high risk patients is limited. Objective This review examined whether delirium in at-risk patients can be prevented with antipsychotic prophylaxis in the inpatient setting. Data sources A systematic literature review of articles from January 1950 to April 2012 was conducted in PubMed, PsychInfo, and Cochrane Controlled Trials and databases. Study selection Five studies (1491 participants) met our inclusion criteria for analysis. Medication administered included haloperidol (three studies), risperidone (one study), and olanzapine (1 study). All five studies examined older post-surgical patients, spanning five different countries. Data extraction Only RCTs of antipsychotic medication used to prevent delirium were included. Key words used in the search were: “delirium,” “encephalopathy,” “ICU psychosis,” “prevention,” and “prophylaxis.” Studies had to include a validated method of diagnosing delirium. Data analysis was performed using the Metan command in Stata (Stata Corp LP, College Station, TX). Results The pooled relative risk of the five studies resulted in a 50% reduction in the relative risk of delirium among those receiving antipsychotic medication compared with placebo (RR(95% CI): 0.51 (0.33–0.79; heterogeneity, p < 0.01, random effects model). Examination of the funnel plot did not indicate publication bias. Conclusions Although few studies have examined prophylactic use of antipsychotics, this analysis suggests that perioperative use of prophylactic antipsychotics may effectively reduce the overall risk of postoperative delirium in elderly patients.

2. Meagher, D. J., L. McLoughlin, et al. “What Do We Really Know About the Treatment of Delirium With Antipsychotics? Ten Key Issues for Delirium Pharmacotherapy.” The American Journal of Geriatric Psychiatry(0).

Despite the significant burden of delirium among hospitalized adults, no pharmacologic intervention is approved for delirium treatment. Antipsychotic agents are the best studied but there are uncertainties as to how these agents can be optimally applied in everyday practice. We searched Medline and PubMed databases for publications from 1980 to April 2012 to identify studies of delirium treatment with antipsychotic agents. Studies of primary prevention using pharmacotherapy were not included. We identified 28 prospective studies that met our inclusion criteria, of which 15 were comparison studies (11 randomized), 2 of which were placebo-controlled. The quality of comparison studies was assessed using the Jadad scale. The DRS (N = 12) and DRS-R98 (N = 9) were the most commonly used instruments for measuring responsiveness. These studies suggest that around 75% of delirious patients who receive short-term treatment with low-dose antipsychotics experience clinical response. Response rates appear quite consistent across different patient groups and treatment settings. Studies do not suggest significant differences in efficacy for haloperidol versus atypical agents, but report higher rates of extrapyramidal side effects with haloperidol. Comorbid dementia may be associated with reduced response rates but this requires further study. The available evidence does not indicate major differences in response rates between clinical subtypes of delirium. The extent to which therapeutic effects can be explained by alleviation of specific symptoms (e.g. sleep or behavioral disturbances) versus a syndromal effect that encompasses both cognitive and noncognitive symptoms of delirium is not known. Future research needs to explore the relationship between therapeutic effects and changes in pathophysiological markers of delirium. Less than half of reports were rated as reasonable quality evidence on the Jadad scale, highlighting the need for future studies of better quality design, and in particular incorporating placebo-controlled work.

3. Mo, Y. and A. E. Zimmermann (2013). “Role of Dexmedetomidine for the Prevention and Treatment of Delirium in Intensive Care Unit Patients (June).” The Annals of Pharmacotherapy.

OBJECTIVE: To review recent clinical studies regarding the role of dexmedetomidine for prevention and treatment of delirium in intensive care unit (ICU) patients.DATA SOURCES: MEDLINE and PubMed searches (1988-Feburary 2013) were conducted, using the key words delirium, dexmedetomidine, Precedex, agitation, α-2 agonists, critical care, and intensive care. References from relevant articles were reviewed for additional information.STUDY SELECTION AND DATA EXTRACTION: Clinical trials comparing dexmedetomidine with other sedatives/analgesics or with antipsychotics for delirium were selected. Studies that evaluated the use of dexmedetomidine for sedation for more than 6 hours were included in this review.DATA SYNTHESIS: Dexmedetomidine is a highly selective α-2 receptor agonist that provides sedation, anxiolysis, and modest analgesia with minimal respiratory depression. Its mechanism of action is unique compared with that of traditional sedatives because it does not act on γ-aminobutyric acid receptors. In addition, dexmedetomidine lacks anticholinergic activity and promotes a natural sleep pattern. These pharmacologic characteristics may explain the possible anti delirium effects of dexmedetomidine. Eight clinical trials, including 5 double-blind randomized trials, were reviewed to evaluate the impact of dexmede to midine on ICU delirium.CONCLUSIONS: Currently available evidence suggests that dexmedetomidine is a promising agent, not only for prevention but also for treatment of ICU-associated delirium. However, larger, well-designed trials are warranted to define the role of dexmedetomidine in preventing and treating delirium in the ICU.

4. Young, R. S., K. Hinami, et al. (2012). “Hospitalists’ lack of knowledge of the Confusion Assessment Method: a barrier to systematic validated delirium surveillance.” Hosp Pract (1995) 40(4): 56-63.

INTRODUCTION: Delirium is frequently missed by inpatient health care providers despite the existence of a highly sensitive and specific assessment for delirium, the Confusion Assessment Method (CAM). The CAM, due to its test characteristics and ease of use, is an ideal physician instrument for systematic inpatient delirium screening; however, little is known about hospitalists’ knowledge of the CAM. METHODS: A short survey with items assessing respondents’ perceptions of delirium detection, familiarity and proficiency with the CAM, and knowledge of the CAM algorithm was administered at a regional hospital medicine conference. Participants included a group of hospital medicine providers comprised of physicians (79.9%), nurse practitioners (7.2%), and physician assistants (12.9%). Results in the form of counts, percentages, and distributions of Likert scale responses and multiple-choice questions were reported. RESULTS: Of 157 surveys distributed, 94% (n = 147) were returned. Approximately 3 of 4 of providers (77%) reported encountering delirium at least once per week, with 45% reporting encountering delirium more than once per week. Yet, 82% had never used or heard of the CAM; only 3 respondents felt proficient with its use. Of the knowledge items, 4 respondents were able to correctly indicate the 4 clinical features of the CAM. Only 1 respondent was able to answer all knowledge items correctly. The respondents also agreed that nurses have an important role in delirium detection (65%), delirium diagnosis is often delayed (68%), and reported that not knowing patients’ baseline cognitive status (53%) and having difficulty separating delirium from dementia or psychiatric illnesses (25%) were important challenges to delirium diagnosis. CONCLUSION: Hospital medicine providers who responded to the survey reported encountering delirium often in their clinical practice; however, they also reported poor familiarity with and demonstrated poor knowledge of the CAM. These results suggest a potential barrier to systematic inpatient delirium screening and support increased delirium education and the use of validated delirium assessments among hospitalists.

5. Reston, J. T. and K. M. Schoelles (2013). “In-facility delirium prevention programs as a patient safety strategy: a systematic review.” Ann Intern Med 158(5 Pt 2): 375-380.

Delirium, an acute decline in attention and cognition, occurs among hospitalized patients at rates estimated to range from 14% to 56% and increases the risk for morbidity and mortality. The purpose of this systematic review was to evaluate the effectiveness and safety of in-facility multicomponent delirium prevention programs. A search of 6 databases (including MEDLINE, EMBASE, and CINAHL) was conducted through September 2012. Randomized, controlled trials; controlled clinical trials; interrupted time series; and controlled before-after studies with a prospective postintervention portion were eligible for inclusion. The evidence from 19 studies that met the inclusion criteria suggests that most multicomponent interventions are effective in preventing onset of delirium in at-risk patients in a hospital setting. Evidence was insufficient to determine the benefit of such programs in other care settings. Future comparative effectiveness studies with standardized protocols are needed to identify which components in multicomponent interventions are most effective for delirium prevention.

6. Zhang, H., Y. Lu, et al. (2013). “Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized trials.” Crit Care 17(2): R47.

INTRODUCTION: The ideal measures to prevent postoperative delirium remain unestablished. We conducted this systematic review and meta-analysis to clarify the significance of potential interventions. METHODS: The PRISMA statement guidelines were followed. Two researchers searched MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles published in English before August 2012. Additional sources included reference lists from reviews and related articles from ‘Google Scholar’. Randomized clinical trials (RCTs) on interventions seeking to prevent postoperative delirium in adult patients were included. Data extraction and methodological quality assessment were performed using predefined data fields and scoring system. Meta-analysis was accomplished for studies that used similar strategies. The primary outcome measure was the incidence of postoperative delirium. We further tested whether interventions effective in preventing postoperative delirium shortened the length of hospital stay. RESULTS: We identified 38 RCTs with interventions ranging from perioperative managements to pharmacological, psychological or multicomponent interventions. Meta-analysis showed dexmedetomidine sedation was associated with less delirium compared to sedation produced by other drugs (two RCTs with 415 patients, pooled risk ratio (RR) = 0.39; 95% confidence interval (CI) = 0.16 to 0.95). Both typical (three RCTs with 965 patients, RR = 0.71; 95% CI = 0.54 to 0.93) and atypical antipsychotics (three RCTs with 627 patients, RR = 0.36; 95% CI = 0.26 to 0.50) decreased delirium occurrence when compared to placebos. Multicomponent interventions (two RCTs with 325 patients, RR = 0.71; 95% CI = 0.58 to 0.86) were effective in preventing delirium. No difference in the incidences of delirium was found between: neuraxial and general anesthesia (four RCTs with 511 patients, RR = 0.99; 95% CI = 0.65 to 1.50); epidural and intravenous analgesia (three RCTs with 167 patients, RR = 0.93; 95% CI = 0.61 to 1.43) or acetylcholinesterase inhibitors and placebo (four RCTs with 242 patients, RR = 0.95; 95% CI = 0.63 to 1.44). Effective prevention of postoperative delirium did not shorten the length of hospital stay (10 RCTs with 1,636 patients, pooled SMD (standard mean difference) = -0.06; 95% CI = -0.16 to 0.04). CONCLUSIONS: The included studies showed great inconsistencies in definition, incidence, severity and duration of postoperative delirium. Meta-analysis supported dexmedetomidine sedation, multicomponent interventions and antipsychotics were useful in preventing postoperative delirium.

7. Zaubler, T. S., et al. (2013). “Quality Improvement and Cost Savings with Multicomponent Delirium Interventions: Replication of the Hospital Elder Life Program in a Community Hospital.” Psychosomatics 54(3): 219-226.
Delirium is a common problem associated with increased morbidity, mortality, and healthcare costs in the hospitalized elderly, yet there is little research outside of academic medical centers exploring methods to prevent its onset. The authors adapted the Hospital Elder Life Program (HELP) for use in a community hospital and assessed its impact on delirium rate, length of stay (LOS) and healthcare costs in elderly patients. Delirium episodes and duration, total patient-days with delirium and LOS were assessed in 595 patients 70 years of age or older admitted to a general medical floor at a community hospital. Pre-intervention outcomes were assessed on the medical floor for 4 months. Interventions adapted from HELP occurred over 9 months and included daily visits, therapeutic activities, and assistance with feeding, hydration, sleep, and vision/hearing impairment. Delirium was assessed on a daily basis with the Confusion Assessment Method (CAM). The rate of episodes of delirium decreased from 20% in the pre-intervention group to 12% in the intervention group, a relative 40% reduction (P = 0.019). Total patients days with delirium decreased from 8% in the usual care group to 6% in the intervention group (P = 0.005). LOS among all patients enrolled in the intervention group decreased by 2 days (P < 0.001). Interventions resulted in $841,000 cost savings over 9 months. HELP can be successfully adapted for implementation in a community hospital setting to decrease delirium episodes, total patient-days with delirium and LOS, and generate substantial cost savings.

8. O’Hanlon, S., N. O’Regan, et al. (2013). “Improving delirium care through early intervention: from bench to bedside to boardroom.” Journal of Neurology, Neurosurgery & Psychiatry.

Delirium is a complex neuropsychiatric syndrome that impacts adversely upon patient outcomes and healthcare outcomes. Delirium occurs in approximately one in five hospitalised patients and is especially common in the elderly and patients who are highly morbid and/or have pre-existing cognitive impairment. However, efforts to improve management of delirium are hindered by gaps in our knowledge and issues that reflect a disparity between existing knowledge and real-world practice. This review focuses on evidence that can assist in prevention, earlier detection and more timely and effective pharmacological and non-pharmacological management of emergent cases and their aftermath. It points towards a new approach to delirium care, encompassing laboratory and clinical aspects and health services realignment supported by health managers prioritising delirium on the healthcare change agenda. Key areas for future research and service organisation are outlined in a plan for improved delirium care across the range of healthcare settings and patient populations in which it occurs.

Sena gets a big kick out of the pet dogs people bring to the event. She  was captivated by a miniature version of a pug, a breed that will forever remind me of one of my favorite movies, Men In Black. This year there was a large tent devoted to displaying the talents of younger artists, all the way from kids barely out of toddlerhood to University of Iowa undergraduates.

It’s a tradition for us to visit the downtown Ped Mall, which was really the only place to go when we first arrived back in the late 1980s when I entered medical school. Iowa City has done a marvelous job preserving the area and it continues to thrive. We always have lunch at The Brown Bottle, a downtown icon since 1972. And the music is phenomenal during the festival.

Sena saw a picture of an owl that she said spoke to her. The artist who sold it to us said it was a good thing she listened.

What is happening to the profession I love? I found out recently that the Medical Society of New Jersey adopted a resolution to oppose Maintenance of Certification (MOC), American Board of Medical Specialties under Fire for Maintenance of Certification™ Program | Welcome to the Medical Society of New Jersey’s official blog.

I know some will cheer it. I’m not sure how much difference it will make. Though it brings to a considerable handful the number of state medical societies formally adopting resolutions to oppose a system of lifelong learning that some call “lifelong larceny” (referring to the obscene amount of money it brings to so-called ‘non-profit” boards)–those of us who love our profession and want to convey that we do indeed love the principle of lifelong learning will probably remain in the minority of physicians recognized as long as we formally and informally oppose MOC and its duplicative, redundant second cousin, Maintenance of Licensure (MOL).

I’m getting older and long for retirement sometimes as I watch the conflict over this issue and others threatening the integrity of the practice of medicine. I would never recertify again if I knew that I could make a living as a psychiatrist without this empty, regulatory shackle.

But I can’t. And boards know it. How did this happen? Physicians let it happen. I’m doing what I can to show I love what I do and love the principle of ensuring that I’m the best doctor I can possibly be. But the irony is I don’t have time to do what I think I should as long as I’m compelled to do time-wasting, foolish documentation of activities like ”feedback” which will be meaningless cherry-picking nonsense.

And this nasty infection is spreading into residency training programs in the form of “Milestones”, another mind-numbingly complicated and time-consuming snare promoted by the same regulatory organizations that make the MOC, Save Time for Patients – The Practical Psychosomaticist.

And it had to be a reader to bring to my attention that the Federation of State Medical Boards (FSMB), who is promoting the MOL, (which practically no state wants, Roll Call for MOL? – The Practical Psychosomaticist) may have been a subject of a U.S. Senate Finance Committee investigation for conflicts of interest surrounding drug company funding of Dr. Scott Fishman’s book “Responsible Opioid Prescribing: A Clinician’s Guide.” A quote from the reader is “It should be noted that Fishman as well as the FSMB are currently under U.S. Senate investigation for their alleged involvement in pushing opioids for profit fueled by the pharmaceutical industry. The Senate wants answers as to whether the FSMB, Fishman and others promoted misleading information about the risks and benefits of opioids while receiving financial support from opioid manufacturers.”

The story originally broke last year in a Wisconsin newspaper, Follow the Money: Pain, Policy, and Profit. Many organized groups who have a beef with the FSMB picked up the story, one them referring to the FSMB as a “rogue organization”:

Senate Finance Committee Reacts to Reports of Opioid Abuse and Conflict of Interests: Letters to Manufactures and Organizations – Policy and Medicine

ANH-USA: Is Your State Medical Board in Bed with the FSMB?

Pain Medicine News – Senate Finance Committee Investigates Rise in Prescription Opioid Use

Makers of pain pills, advocacy groups at center of Senate probe – Medical Marketing and Media

I cringe as I read this again, because I actually praised Fishman’s book and had no idea that it might have been under any shadow. I sent a message to one of the Iowa legislators who wrote the letter to the FSMB about their role in this thorny issue. I asked if there really is an ongoing investigation, because the letter looks like it’s a year old now, 05092012 Baucus Grassley Opioid Investigation Letter to Federation of State Medical Boards. I have not yet received a reply. It looks like I may have another bone to pick with the FSMB.

But let’s be clear; I still believe that Fishman’s book does not convey any bias toward big Pharma. I have actually read the book, unlike many of the critics. And to be fair, I could not find a record of any sort of investigation against FSMB on the U.S. Senate Finance Committee website, though I found it very confusing and difficult to navigate.

The point is that this kind of ”news” further shakes my faith in the major organizations which purport to have the best interests of patients and physicians at heart.

I’m saddened by the American Association of Physicians and Surgeons (AAPS) decision to file a lawsuit in federal court against the American Board of Medical Specialties (ABMS). But it had to be done, painful as it is to reveal to our patients and the rest of the world at large that the house of medicine is rocked by such divisive controversy.

How do we heal this wound?

Hey, the European Delirium Association (EDA) website is finally back! I’ve replaced the links in the top menu and you should be able to access all the cool educational content on this great sister site to the American Delirium Society (American Delirium Society, ADS), which had a stunning annual meeting early this month in Indianapolis I’m told.

Would the U.S. Postal Service send a parcel addressed to me at WordPress if I did not work there? There is a legal precedent for my claim. It has already been proven beyond the shadow of a doubt in court that Santa Claus is real because the post office delivered mail to him, as shown in the well-known documentary, Miracle on 34th Street (1947):

This concrete evidence with legal support entitle me to all the perks of employment at WordPress:

1.  Annual salary of $40 million

2. Keys to the executive washroom at WordPress Corporate Office & Headquarters, 60 29th Street #343 San Francisco CA 94110-4929; phone 1-877-273-3049

3. A sumptuously appointed top floor office suite overlooking the majestic view of whatever is on 29th Street

4. A silver jaguar

5. A monogrammed pen that works, please

6. A generous donation to Dr. Igor Galynker, MD, PhD, Update on the Suicide Trigger Scale (STS-3) – The Practical Psychosomaticist

I’ll write you a letter after my wife and I have finished the move to our palatial estate.