Uninsured, undocumented immigrants often go to the emergency room for treatment. Since 1986 the federal government has required that patients in the emergency room receive care, regardless of their immigration status or ability to pay.

But caring for chronic conditions such as kidney disease or cancer in the emergency room is expensive. So some states are quietly expanding access for undocumented immigrants to obtain medical treatment beyond the ER.

One of those states is Washington, where an undocumented immigrant named Gonzalo lives with his wife, Ricarda.

Gonzalo is really sick.

“I can’t enjoy the day — go out — because I’m always unwell,” he said in an interview in Spanish.

Gonzalo moved to the U.S. from Mexico about 30 years ago. He’s 60 years old. We’re not using his last name because of his immigration status.

Ten years ago, Gonzalo’s kidneys failed. Since then, he’s gotten sicker and sicker. Five years ago, he had to quit his job as a painter.

“I used to pay the rent. I paid for everything, and we didn’t lack anything,” he said. “But I got sick and everything changed.”

Now, Gonzalo and his wife live with one of their daughters in her apartment south of Seattle.

Across the country, there are about 6,500 undocumented immigrants with kidney failure, according to the National Institutes of Health. What kind of care they get depends on where they live.

In most states, they can only get dialysis in hospital emergency rooms.

That means, every couple of weeks, they go to the hospital when so many toxins have built up in their body it’s life-threatening. Usually, they have to stay overnight so they can be dialyzed twice. That costs nearly $300,000 per person every year.

So seven states, including Washington, have a different system.

“The state of Washington has something called AEM,” said Leah Haseley, a nephrologist — a kidney doctor — in Seattle. She’s talking about Alien Emergency Medical, part of Washington’s Medicaid.

“AEM pays for two things,” she explained. “They pay for dialysis for undocumented people, and they pay for chemotherapy for cancer treatment for undocumented people as well.”

Regular dialysis costs about a quarter of what emergency dialysis does — but it’s controversial.

“The first time that you show up at a hospital with kidney failure, that’s an emergency,” said Matthew O’Brien, with the Federation for American Immigration Reform, a group that advocates for stricter immigration laws. “After that, it’s a chronic condition, and we don’t believe that it’s appropriate to reward lawbreakers with benefits at the expense of U.S. taxpayers.”

But there are others who say even regularly scheduled dialysis isn’t enough: undocumented immigrants who qualify should be given kidney transplants, because the cost of a transplant is less than the ongoing costs of regular or emergency dialysis. But, without health insurance, few undocumented immigrants can afford a transplant.

In 2015, Illinois became the first state with a system for paying for organ transplants for undocumented immigrants.

Dr. David Ansell was a prominent advocate for the change.

“In about a year and a half the cost for a transplant pays itself back,” he said, “but also people can go back to work and contribute to the state.”

So far, more than 200 undocumented immigrants in Illinois have been given access to organ transplants, with their insurance premiums paid for by a non-profit. Now, Dr. Ansell and other public health advocates hope to see a similar program at the national level.

Many who oppose this say, with limited organs available, they should be reserved for citizens and legal immigrants.

But Dr. Ansell says, in Illinois, 75 percent of kidney transplants for undocumented immigrants come from donations from their own family — a much higher rate than the rest of the population.

“If you’re undocumented in Illinois, you can get a driver’s license, and disproportionately the Latino community is signing up to donate their organs,” Dr. Ansell added. “It’s a simple matter of ethics and fairness.”

He said, since Illinois started paying for the transplants, the total number of organs available has increased, because so many more Latinos have signed up for organ donation.

Overall in the US, studies have found that undocumented immigrants donate 2 to 3% of all organs.

Back in the Seattle area, Gonzalo says all three of his daughters are willing to give him a kidney, but he has no way to pay for the transplant.

That’s why his wife, Ricarda, says she’s taken to buying lottery tickets.

She said in Spanish, “I’ve told my husband, ‘If I win the lottery, I won’t think twice. I’m going to get you a kidney.'”

Let’s block ads! (Why?)

Imagine yourself stuck in the hospital.

Would you rather your doctors be well-rested, with a limit on how many hours they can work? Or would you rather they work longer shifts, seeing you through the critical hours of your illness and with fewer handoffs of your care?

That’s the choice being reexamined after a study published in March in the The New England Journal of Medicine found that longer shifts for medical residents were just as safe as shorter shifts.

The results, which support an earlier study that also found no association between shift length and patient safety, have led some physicians to suggest that the issue of how long residents should work has now been “laid to rest.”

University of Pennsylvania’s Dr. David Asch, one of the study’s lead investigators, said in a statement that despite concern about lengthy shifts for residents, “they really don’t seem to have an effect on any important domains.”

Sixty-three internal medicine residency programs participated in the latest study. Half of the programs adhered to limits on how long residents could work. First-year residents were restricted to 16-hour shifts, while more senior residents could work up to 28 hours. For the other half, there was no limit on how long residents could work.

The researchers focused on patients’ mortality rates. They found that the number of patients who died within 30 days of admission to the hospital was similar between the two groups. Though the study didn’t examine medical errors directly, the implication is that the rate of medical error was also similar.

The findings are reassuring, given what we know about the effects of sleep deprivation on cognitive performance. Some studies have found that sleep deprivation can lead to a similar level of impairment as heavy drinking.

Concerns about exhausted physicians in training have been around since at least 1984, when a college freshman named Libby Zion died in a New York hospital from an error made by a sleep-deprived resident. After a high-profile investigation, New York state instituted the first limits on how long physicians in training could work — no more than 24 hours in a shift, and no more than 80 hours in a week. These limits were extended to all residency programs in 2003 and strengthened in 2011.

It seemed like a prudent change. As many have argued, we don’t let our pilots fly without adequate rest.

But some physicians challenged the limits, pointing out that we had no direct evidence to support the change. It had simply never been studied.

Shift limits could have unintended consequences. For example, shorter shifts mean more handoffs between physicians, during which important information can sometimes be lost.

Does the latest study mean that strict limits on shift length should be rolled back, since they’ve not been proven to help patients? Or is there more to the story than medical errors and patient safety?

Just as sleep deprivation has been shown to impair cognition, so too has it been found to dampen empathy for others.

Studies show that a single night of sleep deprivation interferes with our ability to perceive emotions in others and compromises our ability to empathize. Longer periods of sleep deprivation reduce measures of emotional intelligence and interpersonal functioning.

One of the darkest moments of my medical training came at the end of a 28-hour call in the ICU. Firefighters had rescued a woman from a house fire, badly burned and barely alive. She was at the threshold of death when she arrived. Her suffering must have been unbearable, but I’m ashamed to say that all I could think about was how long her death paperwork would keep me awake.

I don’t think I’m alone in finding that sleep deprivation warps my ability to provide compassionate care. In 2002, researchers at the University of Pennsylvania surveyed residents before and after their first year of training. The prevalence of chronic sleep deprivation soared from 9% to 43%. Emotional exhaustion rose from 8.5% to 68%, and measures of empathy dropped 10%-15%.

We can’t say how these changes affected patients, but it’s no stretch to imagine that they were probably harmful to the patient-physician relationship. They were certainly harmful to the residents — the prevalence of depression increased from 4.3% to nearly 30% by year’s end, and burnout leaped from 4% to 55%.

Skeptics about shift limits may point out that both groups in The New England Journal of Medicine study got a similar amount of sleep, when averaged over time. But participants in the group without shift limits were nearly 2.5 times more likely to be dissatisfied with their amount of time for rest and with their overall well-being. They were also more likely to report that patient safety and the quality of their education had suffered as a result of the longer hours.

In 2017, after the publication of an earlier study showing no association between shift length and patient safety, the governing body of graduate medical education backtracked on shift limits. Maximum shift length for first-year residents was increased from 16 to 24 hours, and more shift-to-shift variation was permitted for senior residents, as long as the 80-hour weekly cap was maintained when averaged over four weeks.

It was an important development, according to Asch and his colleagues, because it seemed that educational policy would finally be based on evidence rather than opinion.

Moving toward evidence-based policy in medical education makes sense. After all, as Asch pointed out, we would never approve a new drug without strong evidence supporting its use.

But it’s my view that using these studies to justify further loosening work-hour restrictions doesn’t make sense. This new study provides strong evidence that shorter shifts are just as safe for patients as longer shifts.

Given what we know about the effects of sleep deprivation on emotional capacity and residents’ well-being, why would we relax work limits again without proof that doing so would cause no harm?

Clayton Dalton is a resident physician at Massachusetts General Hospital in Boston.

Let’s block ads! (Why?)

Scientists are gearing up a major study to find out whether a drug can silence the gene that causes a devastating illness called Huntington’s disease.

This development follows the discovery that the experimental drug reduced levels of the damaged protein that causes this mind-robbing ailment. The new study will determine whether that drug can also stop progression of the disease.

It is also another sign that drugs built with DNA, or its cellular collaborator RNA, can be powerful tools for tempering diseases that until now have seemed out of reach.

Huntington’s disease is an apt target because it’s caused by a single mutated gene. It also a frightening and devastating disease.

The symptoms “are like having Alzheimer’s, Parkinson’s and ALS [Lou Gehrig’s disease] simultaneously, when it’s in full swing,” says Jeanette Garcia, a 57-year-old advocate in San Jose, Calif.

If one of your parents has Huntington’s disease, there’s a 50-50 chance you will get it, too. About 30,000 people in the United States carry the deadly gene.

Garcia and her nine siblings lost their mother to the disease. They know the terrible odds. When they get together for family reunions and talk turns to Huntington’s, “it is all of a sudden this terrifying prospect we’re all faced with,” she says.

Garcia decided to take the genetic test for this condition in 2008 and found out she had inherited the damaged gene. She’s recently been seeing the first signs of the illness, including involuntary movements, which she noticed when watching a video of herself, “and I went, ‘Holy crap, OK here we go.’ “

But her disease is emerging at what could be a fortunate moment. She’s heading off to a neurologist to see if she would qualify for a study that is generating a lot of excitement.

Last year, drugmaker Roche’s Genentech unit said that an experimental drug sharply reduced the amount of illness-inducing protein measured in people’s spinal fluid. The results of that study, involving 46 patients, were published Monday by the New England Journal of Medicine.

The protein isn’t eliminated entirely with the experimental drug, but animal experiments suggest that reducing it significantly could be enough to stave off symptoms.

The researchers are now about to launch a trial involving 660 volunteers with early symptoms of the disease, to see if the drug, called RG6042, can slow or stop Huntington’s progression.

“It’s so exciting,” Garcia says. “I want to be a part of it.”

This study marks a milestone for Huntington’s disease. More than 25 years ago, a scientist named Nancy Wexler was able to identify the errant gene that causes the disease by painstakingly studying families in a region of Venezuela where the disease is nearly epidemic.

Her finding was one of the early, great successes in tracking down disease genes. But it has taken all the intervening years to develop this promising angle of attack.

One huge advance has been the development of methods to silence a damaged gene, so cells don’t convert those errant instructions into dangerous proteins, such as the one that causes the symptoms of Huntington’s.

Scientists have developed several methods to jam this signal. The Roche drug uses a custom-built piece of genetic material called an antisense oligonucleotide to block the process. Other advanced research projects aimed at Huntington’s and other diseases use a technique called RNA interference to accomplish a similar result.

Another major challenge has been to figure out how to get the drug into the brain. Scientists at Ionis Pharmaceuticals in San Diego figured out how to make that happen with the antisense oligonucleotide targeting Huntington’s.

The answer turned out to be injecting it into spinal fluid, which circulates up and down the spine and into the brain. “The drug could actually transfer quite readily to the brain and then sink into the target brain tissue,” says Dr. Scott Schobel, who heads the research effort on this drug at Roche, which is co-developing the experimental drug with Ionis.

Roche started recruiting patients for this study in January, but halted the trial to redesign it, after discovering the drug didn’t need to be injected as often as they had planned.

“We’re going to get back up and running over the next several weeks to months,” Schobel says.

The study is supposed to follow patients for 25 months, which should be enough time to determine whether people’s symptoms are held in check by the treatment.

George Yohrling, a scientist at the Huntington’s Disease Society of America, says his main concern is whether the experimental drug will penetrate deeply enough into the brain to stop the disease.

If not, he says other treatments under development could succeed in that regard. One strategy is to use viruses to deliver one of these gene-silencing drugs.

“A lot of different approaches are being worked on in different stages of drug discovery across the world,” Yohrling says. “It’s really quite exciting.”

This development follows more than 20 years of boom-and-bust excitement about gene-silencing strategies.

“Initially there was wild enthusiasm,” says Dr. Judy Lieberman, a professor of pediatrics at Harvard Medical School. “There were literally hundreds of biotech companies formed to do that.”

But they quickly hit technical and scientific roadblocks, she says, “and eventually almost all of them about abandoned these efforts.”

As scientists gradually worked their way through these challenges, Huntington’s disease emerged as an appealing target, despite being a rare disease with a far smaller potential market than, for example, a drug for Alzheimer’s disease.

The first antisense oligonucleotide to be approved as a drug by the Food and Drug Administration treats an even rarer condition, called spinal muscular atrophy. And there are now competitive products targeting that disease, thanks in part to the financial incentives drug companies get to develop drugs for “orphan” diseases. (The drugs are also extraordinarily expensive).

Drug developers are also aware that this strategy could be useful for common disorders, such as high cholesterol. That’s an active area for drug development.

Drug companies would jump on an opportunity to develop a drug for Alzheimer’s or autism, Yohrling says, if only they could identify a straightforward target gene to disrupt. That strategy “now makes the ‘undruggable’ druggable,” he says.

But that’s getting ahead of the story. Before the FDA even considers approving a treatment for Huntington’s, Roche will have to demonstrate that its experimental drug is safe and effective.

Garcia is eager to help them make that case, by joining the study if she can, and encouraging others to do the same. She says she can’t even let herself hope that the treatment will work for her. She’s thinking of her four children and six grandchildren.

She has a grandson who was born blind and is also at risk for Huntington’s, she says. “I’m just not going to stop because I don’t want him to have to deal with this.”

You can contact NPR Science Correspondent Richard Harris at rharris@npr.org.

Let’s block ads! (Why?)

The Trump administration moved forward on Wednesday with its plan to lower prescription drug prices by requiring drugmakers to display the list price “in a legible textual statement at the end of the advertisement.”

Secretary of Health and Human Services Alex Azar said today that when it comes to changing prescription drug prices, “putting prices in TV ads may be the most significant single step any administration has ever taken.” But patient advocates are not convinced it will have an immediate impact on drug pricing.

The rule would apply to prescriptions that cost more than $35 per month or courses of treatment, which are covered by Medicare. The rule is very specific, requiring that the price be displayed, “for sufficient duration and in a size and style of font that allows the information to be read easily.”

Industry groups have fought this move since it was announced in October. They adopted voluntary rules, that would have directed ad viewers to a website with more detailed cost information. Today, in a statement, the Pharmaceutical Research and Manufacturers of America (PhRMA) wrote that the list price is confusing since that’s not what most people pay.

The rule addresses that by requiring an additional statement that reads, “If you have health insurance that covers drugs, your cost may be different.”

PhRMA also said that the rule raises “First Amendment and statutory concerns.”

Court challenges may be coming. The legal authority given by the White House is based on the laws that require Medicare and Medicaid to be run in a cost-effective manner, according to the rule.

Rachel Sachs, an associate professor of law at Washington University in St. Louis and an expert in drug-pricing regulation, told NPR and Kaiser Health News in October that could be a weak legal argument since most drugs are marketed to the broader public, not just Medicare and Medicaid beneficiaries.

Consumer and patient advocates generally hailed the move as a step towards greater price transparency, but questioned whether it would do much to lower high prices.

“We don’t believe that disclosing list prices will shame drug corporations into lowering list prices,” says Ben Wakana, executive director of Patients for Affordable Drug Prices. “Drug companies have been shamed about their price increases for years. They appear to be completely comfortable with the shame as long as it is bringing them in the billions of dollars a year that they make from their outrageous prices.”

He gives the government credit for trying to do something on health prices, noting “taking action on this issue is hard.” But he thinks some of the administration’s other ideas to lower prices — announced in a plan released last May — might have a bigger impact.

Critics have pointed out the government’s plan for enforcing the rule is weak, as NPR reported last fall. The plan for enforcement involves competitors policing each other by bringing legal action against competitors who aren’t compliant, Azar said in Wednesday’s press briefing. He calls it “a quite effective mechanism of enforcement.”

Azar defended the government’s authority to issue the new rule. “This is not without precedent,” he told reporters. “We have for over 50 years required that car manufacturers and car dealers post the sticker price of cars on the windows of their cars and be transparent about — even though there are negotiations and everything else — because it’s a starting point that’s an important part of consumer fairness.”

The car-buying analogy doesn’t work very well for drugs, notes Adrienne Faerber, a lecturer at the Dartmouth Institute for Health Policy and Clinical Practice.

“When you go to the car dealer and you see that sticker price and you can negotiate a better price that can fit your budget directly with the car dealership,” she explains. But, she says, drug prices are negotiated through layers of middlemen: “So you don’t get to negotiate based on these prices like you would with a car.”

In other words, car shoppers have a lot more choices that sick patients do, and a lot more bargaining power.

Faerber says certainly displaying the list price won’t “magically flip a switch and cut a percentage or two off of the total drug costs.” But she says it will be interesting to see how patients react to high list prices on their TV screens.

“Consumers are going to start wondering what are people getting for that money,” she says.

Let’s block ads! (Why?)

The 50-something man with a shaved head and brown eyes was unresponsive when the paramedics wheeled him into the emergency room. His pockets were empty: He had no wallet, no cellphone and not a single scrap of paper that might reveal his identity to the nurses and doctors working to save his life. His body lacked any distinguishing scars or tattoos.

Almost two years after he was hit by a car on busy Santa Monica Boulevard in January 2017 and was transported to Los Angeles County+USC Medical Center with a devastating brain injury, no one had come looking for him or reported him missing. The man died in the hospital, still a John Doe.

Hospital staffs sometimes must play detective when an unidentified patient arrives for care. Establishing identity helps avoid the treatment risks that come with not knowing a patient’s medical history. The workers also strive to find next of kin to help make medical decisions.

“We’re looking for a surrogate decision-maker, a person who can help us,” says Jan Crary, supervising clinical social worker at LA County+USC, whose team is frequently called on to identify unidentified patients.

The hospital also needs a name to collect payment from private insurance or government health programs such as Medicaid or Medicare.

But federal privacy laws can make uncovering a patient’s identity challenging for staff members at hospitals nationwide.

At LA County+USC, social workers pick through personal bags and clothing, search the contacts of an unlocked cellphone for names of family members or friends and scour receipts or crumpled pieces of paper for any trace of a patient’s identity. They quiz the paramedics who brought in the patient or the dispatchers who took the call.

They also make note of any tattoos and piercings and even try to track down dental records. It’s more difficult to check fingerprints because that’s done through law enforcement, which will get involved only if the case has a criminal aspect, Crary says.

Unidentified patients are often pedestrians or cyclists who left their IDs at home and were struck by vehicles, says Crary. They might also be people with severe cognitive impairment, such as Alzheimer’s disease, patients in a psychotic state or drug users who have overdosed. The hardest patients to identify are ones who are socially isolated, including homeless people — whose admissions to hospitals have grown sharply in recent years.

In the last three years, the number of patients who arrived unidentified at LA County+USC ticked up from 1,131 in 2016 to 1,176 in 2018, according to data provided by the hospital.

If a patient remains unidentified for too long, staff at the hospital will make up an ID, usually beginning with the letter “M” or “F” for gender, followed by a number and a random name, Crary says.

Other hospitals resort to similar tactics to ease billing and treatment. In Nevada, hospitals have an electronic system that assigns unidentified patients a “trauma alias,” says Christopher Lake, executive director of community resilience at the Nevada Hospital Association.

The deadly mass shooting at a Las Vegas concert in October 2017 presented a challenge for local hospitals that sought to identify the victims. Most concertgoers were wearing wristbands with scannable chips that contained their names and credit card numbers so they could buy beer and souvenirs.

On the night of the shooting, the final day of a three-day event, many patrons were so comfortable with the wristbands that they carried no wallets or purses.

More than 800 people were injured that night and rushed to numerous hospitals, none of which were equipped with the devices to scan the wristbands.

Staff at the hospitals worked to identify patients by their tattoos, scars or other distinguishing features, as well as photographs on social media, says Lake. But it was a struggle, especially for smaller hospitals, he says.

The Health Insurance Portability and Accountability Act, a federal law intended to ensure the privacy of personal medical data, can sometimes make an identification more arduous because a hospital may not want to release information on unidentified patients to people inquiring about missing persons.

In 2016, a man with Alzheimer’s disease was admitted to a New York hospital through the emergency department as an unidentified patient and assigned the name “Trauma XXX.”

The police and family members inquired about him at the hospital several times but were told he was not there. After a week — as hundreds of friends, family members and law enforcement officials searched for the man — a doctor who worked at the hospital saw a news story about him on television and realized he was the hospital’s unidentified patient.

Hospital officials later told the man’s son that because he had not explicitly asked for “Trauma XXX,” they could not give him information that might have helped him identify his father.

Prompted by that mix-up, the New York State Missing Persons Clearinghouse drafted a set of guidelines for hospital administrators who receive information requests about missing people from the police or family members. The new guidelines include about two dozen steps for hospitals to follow, including notifying the front desk, entering detailed physical descriptions into a database, taking DNA samples and monitoring emails and faxes about missing people.

California guidelines stipulate that if a patient is unidentified and cognitively incapacitated, “the hospital may disclose only the minimum necessary information that is directly relevant to locating a patient’s next-of-kin, if doing so is in the best interest of the patient.”

At LA County+USC, most John Does are quickly identified: They either regain consciousness or, as in a majority of cases, friends or relatives call asking about them, Crary says.

Still, the hospital does not always succeed. From 2016 to 2018, 10 John and Jane Does remained unidentified during their stays (of varying lengths of time) at LA County+USC. Some died at the hospital; others went to nursing homes with made-up names.

But Crary says she and her team pursue every avenue in search of an identity.

Once, an unidentified and distinguished-looking older man with a neatly trimmed beard was rushed into the emergency room, unable to speak and delirious with what was later diagnosed as encephalitis.

Suspecting the well-groomed man likely had a loved one who had reported him missing, Crary checked with police stations in the area. She learned, instead, that this John Doe was wanted in several states for sexual assault.

“It is a case that I will never forget,” Crary says. “The truth is that I am more elated when we are able to identify a patient and locate family for a beautiful reunification, rather than finding a felon.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.

Let’s block ads! (Why?)

It’s early morning in an operating theater at Providence Hospital in Portland, Ore. A middle-aged woman lies on the operating table, wrapped in blankets. Surgeons are about to cut out a cancerous growth in her stomach.

But first, anesthesiologist Brian Chesebro puts her under by placing a mask over her face.

“Now I’m breathing for her with this mask,” he says. “And I’m delivering sevoflurane to her through this breathing circuit.”

Sevoflurane is one of the most commonly used anesthesiology gases. The other big one is desflurane. There are others, too, like nitrous oxide, commonly known as laughing gas.

Whichever gas patients get, they breathe it in — but only about 5% is actually metabolized. The rest is exhaled. And to make sure the gas doesn’t knock out anyone else in the operating room, it’s sucked into a ventilation system.

And then? It’s vented up and out through the roof, to mingle with other greenhouse gases.

These two gases are actually fairly similar medically; sevoflurane needs to be more carefully monitored and titrated in some patients, but that’s not difficult, Chesebro says.

Generally, unless there’s a reason in a particular case to use one over the other, anesthesiologists simply tend to pick one of the two gases and stick with it. Few understand that one — desflurane — is much worse for the environment.

And that bothered Chesebro. He grew up on a ranch in Montana that focused on sustainability. “Part of growing up on a ranch is taking care of the land and being a good steward,” he says.

Now he lives in the city with his three kids and has gradually started to worry about their environmental future. “When I look around and I see stewardship on display today, it’s discouraging,” he says. “I got depressed for a while, and so I hit the pause button on myself and said, ‘Well, what’s the very best that I can do?’ “

He spent hours of his own time researching anesthesiology gases. And he learned desflurane is 20 times as powerful in trapping heat in Earth’s atmosphere as sevoflurane. It also lasts for 14 years in the atmosphere, whereas sevoflurane breaks down in just one year.

Opening a big black notebook, filled with diagrams and tiny writing, he shows how he computed the amount of each gas the doctors in his group practice used. Then he shared their carbon footprint with them.

“All I’m doing is showing them their data,” Chesebro says. “It’s not really combative. It’s demonstrative. Ha, ha ha.”

One of the doctors he shared his analysis with was Michael Hartmeyer, who works at the Oregon Anesthesiology Group with Chesebro. “I wish I had known earlier,” Hartmeyer says. “I would have changed my practice a long time ago.”

Hartmeyer says he was stunned when Chesebro explained that his use of desflurane was the greenhouse gas equivalent of driving a fleet of 12 humvees for the duration of each surgical procedure. It’s “only” half a hummer if he uses sevoflurane. Hartmeyer notes that outside the operating room he drives a Prius.

“You try to be good,” he says. “You take shorter showers or [don’t] leave lights on, or whatever else. But you know there’s always more that we could probably do. But this was, far and away, a relatively easy thing that I could do that made a huge impact.”

The anesthesiology carts that get brought into operating theaters tend to have a row of gases to choose from. So Hartmeyer was able to switch pretty much overnight.

Other anesthesiologists made the switch, too. And it didn’t hurt that sevoflurane is considerably cheaper.

Hartmeyer’s change saved his hospital $13,000 a year.

When Chesebro shared his findings with the anesthesia departments at all eight Providence Health hospitals in Oregon, they prioritized the use of sevoflurane. They now save about $500,000 per year.

Providence’s chief executive, Lisa Vance, says the hospital system didn’t change its use of the gas because of the money. It changed because the World Health Organization now says climate change is the No. 1 public health issue of the 21st century — and because of Chesebro.

Vance said Chesebro teared up in front of 2,000 people when talking about the gas, his children and the Lorax from Dr. Seuss. “Unless someone like you cares a whole awful lot, nothing’s going to get better — it’s not,” says Vance, quoting the book.

Jodi Sherman, an associate professor of anesthesiology at Yale School of Medicine, calls Chesebro’s efforts remarkable and important.

She says several hospitals around the country have tried to make this shift, but with mixed results. Some just gave anesthesiologists the information, and not much changed. Other hospitals took desflurane away, but that left many anesthesiologists feeling disrespected and angry.

She thinks Chesebro succeeded because he chose to persuade his colleagues — using data. He showed doctors their choice of gas, plotted against their greenhouse impact. And it helped that he showed them over and over, so doctors could compare their progress with that of their peers.

“Providing ongoing reports to providers is the best way for this movement to catch on and grow,” she says. It can reinforce over time, she adds, not just what their carbon footprint is, but also what progress they’re making.

Sherman says efforts such as Chesebro’s are sorely needed because the U.S. health sector is responsible for about 10% of the nation’s greenhouse gases. “We clinicians are very much focused on taking care of the patient in front of us,” she says. “We tend to not think about what’s happening to the community health, public health — because we’re so focused on the patient in front of us.”

In an emailed statement, Baxter International, the manufacturer of the anesthesia gas, says it is important to provide a range of options for patients. The firm also says inhaled anesthetics have a climate impact of 0.01% of fossil fuels.

“The overall impact of anesthetic agents on global warming is low, relative to other societal contributors, especially when you consider the critical role these products have in performing safe surgical procedures,” the statement reads.

It’s a fair point, Chesebro says, but he has a counterargument.

“Well, if it’s there, it’s bad. And if I can reduce my life’s footprint by a factor of six … why wouldn’t you do it?”

The surgery Chesebro was involved in that morning at Providence was a success. Chesebro estimates that by using sevoflurane on his patient, the same greenhouse gases were produced as in a 40-mile drive across the Portland region.

If he had used desflurane instead, he says, it would have been like driving the more than 1,200 miles from Seattle to San Diego.

Now Chesebro’s hospital bosses are hoping other doctors will follow his lead, research their own pet peeve, and maybe solve a problem no one’s thinking about.

This story is part of NPR’s reporting partnership with Oregon Public Broadcasting and Kaiser Health News, which is an independent journalism program of the Kaiser Family Foundation and not affiliated with Kaiser Permanente.

Let’s block ads! (Why?)

Workers with a steady paycheck already know that wages have been stubbornly slow to rise. Meanwhile, those who get health insurance through a job have seen their deductibles shoot up. In fact, says Noam Levey, a health care reporter for the Los Angeles Times, deductibles have, on average, quadrupled over the last dozen years. As a result, even some people who have health insurance are having trouble affording medical care. We talked with Levey about his latest reporting into how the issue is affecting workers and their families.

Interview Highlights

On why he decided to embark on this project:

We’ve spent so much time fighting about Obamacare over the last 10 years and talking about the uninsured that I think we lost sight of this quiet revolution that’s happened with health coverage for the tens of millions of Americans who have coverage through an employer. These are the people who’ve seen deductibles rise astronomically — rising four times in the last dozen years from about $350 on average to $1,350 on average. In some cases, people are seeing $4,000, $5,000, even $6,000 deductibles that they have to pay out of their own pocket before their health insurance kicks in. Needless to say, many, many Americans can’t afford those kinds of bills.

On what he heard in talking to people:

We heard some really heartbreaking stories. So we did a nationwide poll with the Kaiser Family Foundation as part of this project. One of the things that we found was that half of Americans who get job-based coverage say they or an immediate family member in the last year have put off going to the doctor, not filled the prescription or delayed some other kind of medical care because of concern about cost. We found one in five had depleted their savings to pay a medical bill in the last year and one in six reported that they have had to make some kind of difficult sacrifice in order to pay a medical bill.

Some of them were really gut wrenching. We talked to a 27-year-old chef in western Virginia trying to start a family with his young wife. His wife had a miscarriage. They got such huge medical bills he had to take two extra jobs and was working from 5 a.m. until 11 p.m. some days.

These are people with health insurance. This used to be something we heard about all the time for people who didn’t have health insurance, but in many cases these are middle-class people making $75,000 or $100,000 a year. But if they get a $5,000 or $6,000 medical bill — a family of four, kids in school — it’s hard for a lot of people to come up with that kind of money.

On what’s coming next in his reporting

We’re going to be looking particularly at how these high deductibles are problematic for people who have serious medical conditions — diabetes, heart disease, even cancer. One of the things we found particularly troubling is that these people who should be going to the doctor, even they are cutting back on their treatment.

We’re going to be looking at how these high-deductible plans are exacerbating inequality at a time when this is a major issue for Americans about who’s getting the gains in our economy. If you’re living paycheck to paycheck and you get sick, it’s really tough for that group of people.

One of the other things that’s amazing, and I know NPR has looked a little bit at this, is that the growth of online charities and crowdfunding sources like GoFundMe is being driven in large part by people seeking to pay medical bills. And one of the amazing things about those people is that many of them have health insurance.

Noam Levey reports for the Los Angeles Times and can be found on Twitter: @NoamLevey.

Let’s block ads! (Why?)

In what would likely become the most restrictive abortion ban in the country, the Alabama House Tuesday passed a bill that would make it a crime for doctors to perform abortions at any stage of a pregnancy, unless a woman’s life is threatened. The legislation is part of a broader anti-abortion strategy to prompt the U.S. Supreme Court to reconsider the right to abortion.

Republican state Rep. Terri Collins of Decatur, Ala. defended her “Human Life Protection Act” during, at times, contentious debate on the House floor.

“This bill is focused on that baby that’s in the womb that is a person,” Collins said. “That baby, I believe, would choose life.”

Democratic lawmakers walked out in protest before the final 74 to 3 vote. During debate, they questioned the motive for an abortion ban in a state that’s refused to expand Medicaid. “I do support life, but there are some people that just support birth they don’t support life,” said Democratic Rep. Merika Coleman of Birmingham, Ala. “Because after a child is born there are some things that need to happen. We need to make sure that child has adequate health care,” Coleman said.

Other states, including neighboring Georgia and Mississippi, have passed laws that prohibit abortion once a fetal heartbeat can be detected. But Alabama’s ban would apply even earlier.

“When a woman is pregnant, an abortion is no longer legal,” says Collins, explaining the bill.

The bill criminalizes abortion, meaning doctors would face felony jail time up to 99 years if convicted. The only exceptions are for a serious health risk to the pregnant woman, or a lethal anomaly of the fetus. There are no exceptions for cases of rape or incest. A woman would not be held criminally liable for having an abortion.

Collins says the bill follows a constitutional amendment approved by Alabama voters last year that recognizes the “rights of unborn children.” It defies the U.S. Supreme Court’s landmark decision that protects a woman’s right to abortion.

“This bill is simply about Roe v. Wade,” says Collins. “The decision that was made back in 1973 would not be the same decision that was decided upon today if you relooked at the issue.”

Her bill cites abolition, the civil rights movement and women’s suffrage as justification for establishing the human rights of a fetus. Alabama is one of more than two dozen states seeking to restrict abortion rights this year, testing federal legal precedent that prevents states from banning abortion before the point at which a fetus could survive outside the womb.

Alabama Pro-Life Coalition President Eric Johnston says there’s a reason there’s so much activity now.”The dynamic has changed,” Johnston says. “The judges have changed, a lot of changes over that time, and so I think we’re at the point where we need to take a bigger and a bolder step.” The bold move to outlaw nearly all abortions is drawing protests from abortion rights advocates.

A coalition called Unite for Reproductive and Gender Equity demonstrated outside the Alabama statehouse last month.

“This bill is an awful piece of grandstanding,” said Amanda Reyes of Tuscaloosa, Ala. She’s president of the Yellowhammer Fund, a group that helps women pay for abortions. “If you make abortion illegal somewhere that doesn’t mean that abortion goes away,” says Reyes. “It just becomes more difficult and more dangerous to access.”

The bill is expected to win final passage in the Republican majority Alabama Senate. The ACLU of Alabama says it will sue if the abortion ban becomes law.

Executive Director Randall Marshall says the bill is unconstitutional. “There is simply nothing that Alabama can do to interfere with the right of access to abortion,” Marshall says. “That is a federal right and the Federal Constitution clearly trumps all state law.” With two Trump appointees now on the U.S. Supreme Court, anti-abortion forces are optimistic that judicial interpretation could be reversed.

Let’s block ads! (Why?)