Every Friday, Christine Crawford has a counseling session at a clinic at New York City’s Mount Sinai Health System as she moves ahead with plans for gender transition surgery later this year. In addition to the many medical and psychosocial issues, there are practical ones as well. So, Crawford was thrilled when a Mount Sinai representative told her they would assign a lawyer to help her legally change her name to Christine.

The lawyer filed her name-change petition with the court and helped Crawford with other steps, such as notifying her former spouse and publishing the name change in the newspaper. She gave Crawford information about what she needed to do to make the change official with organizations such as the Social Security Administration and the Department of Motor Vehicles.

Perhaps best of all, when Crawford graduated with a master’s degree in social work last month, her diploma had her new name on it.

“[The lawyer] was able to expedite the petition and the court date,” Crawford says. “She was a godsend.”

As health care systems continue to shift toward becoming comprehensive medical homes for patients, health care providers are increasingly incorporating lawyers into the team of professionals who are on hand to help with legal issues at no additional charge to patients.

Roughly 300 health care systems, children’s hospitals and federally qualified health centers have set up these programs, says Ellen Lawton, co-director of the National Center for Medical-Legal Partnership at George Washington University in Washington, D.C.

The pairing makes sense in many ways. Legal issues all too often can cascade into problems with bad medical outcomes. Lawyers might file for an order of protection from a violent spouse, help appeal an insurance claim denial or get involved in child custody, guardianship or power of attorney issues.

For Care Connections at Lancaster General Health/Penn Medicine in Lancaster, Pa., housing problems are a key area that requires legal expertise. The four-year-old program provides comprehensive primary care services for people with complex health and social needs, especially patients who are frequently hospitalized, says Dr. Jeffrey Martin, managing physician for the program.

For someone with severe asthma and other chronic medical conditions, “it’s hard to use inhalers and take 16 other medications if you’re living in the back of a car or on someone’s couch,” Martin says.

When someone is fighting eviction, has problems with federal housing subsidies, suffers a utility shut-off or has poor housing conditions, the staff members of Care Connections call on Catherine Schultz. She is a legal aid attorney with MidPenn Legal Services, which has a contract to work on such cases for Lancaster General Hospital.

Martin describes the case of one patient, a licensed practical nurse in her mid-30s who was diagnosed with multiple sclerosis. The woman lost her job because she could no longer work, and then her car was repossessed. She stopped taking her medications and couldn’t make it to her medical appointments.

Schultz worked to get this patient a federal housing subsidy and helped her apply for Social Security disability benefits, and then appeal the administration’s denial of benefits. They’re awaiting the results of the appeal.

In fee-for-service medicine, the hospital’s work traditionally was considered finished once patients were discharged, Lawton notes.

But health care has shifted toward value-based care that focuses on outcomes and avoiding preventable hospital readmissions. Now, “you are accountable for patients beyond the four walls of the hospital, and you have to think creatively about how to create stability for them,” Lawton says.

With that in mind, many health care systems are focusing on medical-legal partnerships that target patients who are high users of services.

“Once upon a time, the attitude of the provider was, ‘It’s not my problem that you have mold in your apartment,’ ” says Emma Kagel, manager of medical-legal partnerships at Denver-based Centura Health System. ” ‘I’m just going to keep pumping you full of steroids and give you an inhaler.’ ” That attitude, she says, doesn’t work with value-based care.

Funding is always a problem for these programs where demand far outstrips supply. They are frequently staffed by legal aid attorneys under contract to the health care providers. Some programs use private sector lawyers working on a pro bono basis.

Mount Sinai, whose program is just getting off the ground, is taking a hybrid approach. In addition to a grant from the Manhattan District Attorney’s Office to provide child and family law services, the hospital partnered with law firms and other organizations to provide transgender and end-of-life legal services on a pro bono basis.

Sena Kim-Reuter, president of the Mount Sinai Medical Legal Partnership, says she’s focused on identifying gaps in patients’ needs where she can offer assistance. “There’s no way to handle all of it,” she says.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Follow Michelle Andrews on Twitter @mandrews110.

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Nancy and Dan Gapinski of Glendale, Wis., remember a time when they couldn’t really communicate with their own son.

“He used to not really have any kinds of conversations with us. He did a lot of echoing things that we said, and scripting from movies,” Nancy Gapinski says as she and her husband wait for their son Ben’s school bus to arrive. “A lot of times kids didn’t know how to respond to him then, and didn’t know what he was trying to say and conversations wouldn’t really go anywhere.”

But that’s all changed. On a recent Friday afternoon, 10-year-old Ben hops off the bus, greets both his parents and starts chatting about his day.

“So what I did today was I had an extra recess today, and also I had to do two star math tests,” he reports. He says he did pretty well on those tests.

When Ben was a toddler he was diagnosed with an autism spectrum disorder. He barely communicated with his parents and needed constant monitoring to stay safe.

The Gapinskis needed help. They found a therapist to work with Ben for 24 hours a week, which cost more $50,000 a year. Dan’s workplace insurance paid for some of the costs, but not all.

So they turned to Medicaid.

Ben’s disability was severe enough – he was deemed by the state to require “an institutional level of care” — that he was eligible for Wisconsin’s children’s long-term care program, funded by Medicaid.

“They work with the child on basic language skills, trying to learn words, trying to do some intellectual exercises,” Ben’s father Dan recalls. “It eventually graduates into some back and forth conversation, and doing homework and doing things that are more like what normal kids do.”

While Medicaid is best known as a health care program for poor people, more than 80 percent of its budget goes to care for the elderly, the disabled and children, according to the Kaiser Family Foundation. Only 15 percent goes to health care for able-bodied adults.

The program has been growing in recent years and it now makes up almost 10 percent of federal spending. That’s why it’s the number one target in President Trump’s proposed budget, and figures prominently in the Republican proposal to replace the Affordable Care Act. Some estimates suggest the program could be cut by more than 1 trillion dollars over 10 years.

After three years of intense therapy, Ben now goes to his local public school and works on grade level in math and English. He no longer works with his private therapist or uses Medicaid benefits.

“We just decided not to reapply,” Nancy says. “The need had been met.”

President Trump and Republicans in Congress have proposed massive cuts to Medicaid’s budget over the next decade, and Nancy and Dan Gapinski worry that the services they used for Ben won’t be there if he needs them in the future, or be there for other families.

“I don’t know what Ben will need in his lifetime,” Nancy Gapinski says. “Our goals for him are very much like our goals for our daughter Zoe. We really want for them to be active, engaged citizens.”

Ben’s not the only one in the Gapinski home who has used Medicaid services. His grandmother Evelyn Benjamin is also a beneficiary.

Evelyn is 84. She’s had a few falls and depends on a walker to get around. She also has heart disease and uses three different inhalers.

“They take very good care of me,” Evelyn says, sipping tea in the living room surrounded by her family. “I’m very lucky to be one that can stay in my home, and know that I’m cared for.”

Evelyn has health insurance through Medicare. But after her husband suffered a stroke and needed constant care, she depleted her savings and now qualifies for Medicaid as well. It helps pay for her 12 prescription medications and, through a Medicaid-funded program called IRIS, she gets in-home help.

Wisconsin’s IRIS program is an example of how states tailor Medicaid to their own needs. It gives beneficiaries a budget to use for the services they need, and it allows people to hire whoever they want.

So Evelyn hired her daughter, Nancy, who gave up her full-time career to care for her mother and son. She works part-time from home, and supplements that income with $11.50 an hour for 20 hours a week caring for her mother. She says it’s helped keep them out of bankruptcy. And her hourly rate is a fraction of the going rate for such services from an agency. According to a 2015 study by Genworth, home health aides and homemaker services in Milwaukee cost an average of about $22 an hour.

“It’s just a big, big help for not only me, but for my daughter who worries about me constantly,” Evelyn says.

Nancy Gapinski worries that help may disappear under the proposed budget cuts. That’s because the services her family uses are considered optional under the Medicaid law. The program is required to pay for doctor visits, hospital care and even nursing home care. But in-home support services that Evelyn uses and therapies like those Ben received aren’t.

Dan Gapinski says his children love having their grandmother around. When they have nightmares they climb into her bed and they giggle with her in the living room.

“I don’t think we, as a society, appreciate the value of that,” he says. “There’s a lot of talk about entitlements and how that’s become a bit of dirty word. We don’t take the satisfaction in having made a greater society by making these kinds of situations possible.”

The day I visited the Gapinskis, Ben was excited to go on a sleepover at his aunt’s house. He was packing up pajamas, his Nintendo DS game, some comic books and Minecraft books.

As he heads for the door, his grandmother calls out for a hug.

“Give my love to Aunt Susie OK?” she says, while reaching her arms around Ben.

“Yeah, I’ll give your heart to Aunt Susie,” he replies with a laugh.

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There is a whole range of feelings that happen with the delivery of bad news. In my case, like many others, knees lock, the heart speeds up and the hairs on my arms get a funny little tingle. My circumstances, however, were a little less expected.

When my dad told my husband and me that he and my mom wanted to come into Manhattan for dinner, I was excited to see them and quickly made a plan for an 8 p.m. dinner at Café Orlin — my favorite for Middle Eastern food. As soon as we sat down, I knew something was very wrong.

My mom had been in and out of breast cancer treatment for 15 years and had been managing and treating the disease like it was no big deal, even though she was just in her 50s. Were they about to tell us that the other shoe had dropped and she was dying? No, this time it was about my dad. He had stage 4 pancreatic cancer. My 28-year-old world shook. We all knew what this meant.

As a photojournalist, I did the only thing I knew: I picked up my camera and documented my parents’ dual cancer treatments for the next 24 months and our lives as they unfolded. From the seven-hour chemotherapy infusions to running errands with Mom according to her to-do lists, I was there with my camera slung across my shoulder.

When I look back on the time I spent documenting these complicated months, I don’t immediately remember feeling scared. I remember the pee-your-pants laughter, high-calorie dinners (as per the doctor’s request, of course), the late-night dance parties in my parents’ kitchen and the never-ending conversations over a cup of Chappaqua roast from Susan Lawrence Gourmet Foods and Bea’s Bakery blueberry pie.

Everyone deals with their fears, especially death, in their own way. My family leaned on humor to carry us through this difficult time. I remember one night sitting on my parents’ bathroom floor as my father began to cut off my mother’s hair, which had become flat dreadlocks tightly knotted against her scalp. The chemo had stopped its growth, but she hadn’t been ready to part with her hair for the third time — once with each cancer diagnosis. I remember cursing the universe, asking it to give my mom a break just this once. The next thing I knew, my mother jumped in front of me and my lens, discarded hair held to her face like eyebrows. A fashion show followed suit, as we all wore her hair as costume, including the dog! That she found the lightness and ability to find joy in this moment speaks to the tremendous woman she was.

By confronting what I feared most, using my camera as my shield, I was able to move past the trauma that I anticipated and truly enjoy the time we had left together. Had I hidden away from the reality, I wouldn’t have the beautiful photo of my parents holding hands across the chemo chairs as they received their respective treatments. They were the definition of strength and courage, and seeing these images reinforces to me the importance of not letting fear hold me back. It also reminds me to appreciate each day and not lose perspective. As Mom once told me, “There’s also life going on here. I am having marshmallows, you know!”

Was it scary? Of course. When he died in 2013, my dad, Howie, was 58. My mom, Laurel, was 59 when she died one day shy of the anniversary of my dad’s death. But what was most notable was how those final months were filled with love and life.

Although my parents are gone, my siblings and I continue to feel their love and guidance, as we sift through decades of found letters and notes, including one small stack of Post-it notes from our mother, exemplifying the importance of leaning into fear and taking chances: Courage isn’t the absence of fear — it’s knowing that you are afraid and doing it anyway. Don’t spend your days avoiding risk, being fearful. Act. Live your life on your own terms. Life is precious; spend it without regrets in your own precious voice. For my three angels: If you want to talk or feel my love, look up at the night sky — I am always watching over you.

Nancy Borowick is a photojournalist based on the island of Guam. She has covered humanitarian stories for many organizations including The New York Times, The Washington Post and CNN. Her book documenting her parents’ life with cancer, The Family Imprint: A Daughter’s Portrait of Love and Loss, is now available, and the work will be on exhibit beginning Friday in Brooklyn, N.Y.

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After a lifetime of smoking, Juanita Milton needs help breathing.

She’s tethered to an oxygen tank 24/7 and uses two drug inhalers a day, including Spiriva, which she calls “the really expensive one.”

“If I can’t afford it, I won’t take it,” Milton says.

The 67-year-old’s chest was heaving one recent morning from the effort of walking down the hallway into the kitchen. Her voice was constricted as she loaded medication into a device about the size of her palm.

“Capsule in. You close it and you push this blue button,” Milton says, demonstrating how the device punctures the pill. She then takes two labored breaths to inhale the powder inside the capsule. “And that’s it.”

Milton, like many Medicare enrollees, is on a fixed income. She has $2,000 a month to pay for a mortgage, car payment, Medicare premiums and other expenses.

“I got to stretch out that, plus I have the less costly medicines that I have to pay for and also my oxygen,” Milton says. “You can only stretch it so far.”

An estimated 1 in 9 Medicare beneficiaries are diagnosed with chronic obstructive pulmonary disease, or COPD. And, in 2014, COPD was the third-leading cause of death in the country, according to the U.S. Centers for Disease Control and Prevention. Inhalers like Spiriva and Advair account for billions in Medicare spending each year.

Yet, even if they are only responsible for monthly copays, many enrollees like Milton can’t afford their inhalers. Milton depends on free samples provided by her doctor for her prescription of one inhaler, Breo Ellipta, but the supply is limited, so she regularly skips one of the two daily doses. And, in order to afford her Spiriva, she applied for drugmaker Boehringer Ingelheim’s financial assistance program and received one year’s worth of free samples.

But, on a recent morning, Milton was down to two doses of Spiriva. Holding up a silver sleeve of medication, Milton says “This is all I have left. So, if [the drugmaker doesn’t] approve me for this year, I’m going to have to ask Dr. Stigall if there’s something else I can take.”

Dr. Brian Stigall of Hill Country Medical Associates in New Braunfels, Texas, keeps a closet full of free drug samples for patients like Milton.

“Thank goodness, the drug reps are good. They bring us lots of samples,” Stigall says. “I save those samples back for those Medicare patients.”

Without the inhalers, patients suffer, he says. “They are going to end up back in the hospital and they’re going to end up seeing me much more often.”

Patients who suffer a full-blown attack, due to low oxygen intake, could need three to seven days of emergency treatment, Stigall says.

Retiree Ken Wagar, who lives in Winter Haven, Fla., buys his inhalers overseas. Instead of paying Medicare copays of more than $500 for three-month supplies of Advair and Spiriva, Wagar pays $248 for the same amount of Advair and $73 for Spiriva.

“It’s common and easy,” says Wagar, 68. “You have to order in advance because it takes a while to ship. … You do what you have to do.”

Across the country, doctors who treat COPD say costs are a common problem for patients. Dr. David Mannino at the University of Kentucky College of Public Health says some patients cut pills in half or take a prescription once a day instead of twice, just to save money.

Dr. Momen Wahidi, a pulmonologist at Duke University School of Medicine, says many patients “weren’t able to use [an inhaler because they] couldn’t get it, couldn’t afford it.” And, when Dr. Peter Castaldi of Brigham and Women’s Hospital in Boston surveyed thousands of Medicare patients in 2006, up to a third said they couldn’t take their medication because of cost.

“Even at a relatively, seemingly, low amount of $20 per month out-of-pocket costs, you could see the effects of cost on people being able to take their medications,” Castaldi says.

And prices have only increased since 2006. Spiriva’s list price has jumped 31 percent the past five years to $368 for a 30-day supply, according to drugmaker Boehringer Ingelheim. And Breo Ellipta’s price has risen 20 percent since 2013 to $321.74 a month, according to drugmaker GlaxoSmithKline.

Spokespeople for both drug companies say insured patients would not pay those prices because of discounts, rebates and other price concessions negotiated with insurers and pharmacy benefit managers. For example, GlaxoSmithKline estimated that the average out-of-pocket cost for patients with Medicare’s drug coverage, Medicare Part D, was $33 in 2015 when the drug’s list price was $281 for a month’s supply.

But it’s “not unusual [for patients] to be on more than one inhaler” and those costs add up, says Dr. Chien-Wen Tseng, with the University of Hawaii John A. Burns School of Medicine and the Pacific Health Research and Education Institute.

In a recent letter published in JAMA, Tseng analyzed Medicare’s prescription drug formularies in 2015 and the projected cost of deductibles and copays. She found that Medicare Part D beneficiaries with multiple inhalers could spend more than $2,800 in out-of-pocket costs annually.

The high price of inhalers is expensive for the Medicare program and “drives people into the doughnut hole,” she says. The dreaded doughnut hole is a coverage gap for Medicare Part D patients. Enrollees pay more for drugs out-of-pocket once the coverage gap is reached.

“Medicare Part D was really designed in 2006 with 2006 prices,” Tseng says. In 2017, with much higher drug prices, “does Medicare Part D really still work?”

For Milton, the answer seems obvious: It doesn’t.Most mornings after taking her Spiriva, Milton sits on her back patio. There, she talks with God.

“I don’t pray,” she says. “I talk. I carry on a conversation.”

And that conversation often turns to her struggles with COPD.

“I understand and I have to accept it. I know that it was my doing,” Milton says, adding, “everything is in his hands.”

Sarah Jane Tribbleis a senior correspondent atKaiser Health News, an editorially independent newsroom that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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The state of Ohio has sued five major drug manufacturers for their role in the opioid epidemic. In the lawsuit filed Wednesday, state Attorney General Mike DeWine alleges these five companies “helped unleash a health care crisis that has had far-reaching financial, social, and deadly consequences in the State of Ohio.”

Named in the suit are:

• Purdue Pharma
• Endo Health Solutions
• Teva Pharmaceutical Industries and subsidiary Cephalon
• Johnson & Johnson and subsidiary Janssen Pharmaceuticals
• Allergan

The lawsuit — only the second such suit filed by a state, after Mississippi did so earlier this year — accuses the companies of engaging in a sustained marketing campaign to downplay the addiction risks of the prescription opioid drugs they sell and to exaggerate the benefits of their use for health problems such as chronic pain.

Or, as DeWine’s office put it in a press release Wednesday, the “lawsuit alleges that the drug companies engaged in fraudulent marketing regarding the risks and benefits of prescription opioids which fueled Ohio’s opioid epidemic.”

“We believe that the evidence will show that these pharmaceutical companies purposely misled doctors about the dangers connected with pain meds that they produced, and that they did so for the purpose of increasing sales,” DeWine tells NPR’s All Things Considered. “And boy, did they increase sales.”

By the late 1990s, DeWine’s suit says, each of the five companies had embarked on a persuasion scheme targeting doctors, whom the state positions as victims of systematic misinformation:

“Defendants persuaded doctors and patients that what they had long known — that opioids are addictive drugs, unsafe in most circumstances for long-term use — was untrue, and quite the opposite, that the compassionate treatment of pain required opioids.”

Asked by NPR’s Robert Siegel whether doctors had a role of their own in overprescribing potentially dangerous medication, DeWine says more fault rests with a culture created by these companies.

“This was not something that the pharmaceutical companies just woke up some day and just started to do a little bit of it,” he says.

“I mean, there was a concerted effort for an extended number of years to really pound this into the heads of doctors. And when you’re told something time and time and time again and there’s a lot of advertising that is being spent, yeah, it takes a while to turn that around.”

In a statement provided to the Cleveland Plain Dealer, a spokeswoman for Janssen, one of the defendants, called the lawsuit “legally and factually unfounded”:

“Janssen has acted appropriately, responsibly and in the best interests of patients regarding our opioid pain medications, which are FDA-approved and carry FDA-mandated warnings about the known risks of the medications on every product label.”

Purdue Pharma, another defendant, told The Plain Dealer that it has been involved in seeking to combat widespread opioid addiction:

“OxyContin accounts for less than 2 percent of the opioid analgesic prescription market nationally, but we are an industry leader in the development of abuse-deterrent technology, advocating for the use of prescription drug monitoring programs and supporting access to Naloxone — all important components for combating the opioid crisis.”

And that crisis shows few signs of ebbing soon.

As All Things Considered notes, the state of Ohio estimates some 200,000 people within its borders are addicted to opioids — a number roughly the same as Akron’s entire population.

In his release Wednesday, DeWine says he filed the suit in Ross County for a reason: “Southern Ohio was likely the hardest hit area in the nation by the opioid epidemic.”

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Doctors can save thousands of lives a year if they act promptly to identify sepsis, an often lethal reaction to infection. Sometimes called blood poisoning, sepsis is the leading cause of death in hospitals.

A 4-year-old regulation in New York state compels doctors and hospitals to follow a certain protocol, involving a big dose of antibiotics and intravenous fluids. It’s far from perfect — about a quarter of patients still die from sepsis. But early intervention is helping.

“Intervention has to be quick,” says Dr. Howard Zucker, commissioner of the New York State Health Department.

He knows what happens when it isn’t. In fact, he says, he has a cousin in the hospital right now who has been struggling to recover from a severe bout of sepsis — hospitalized in another state, he adds.

Doctors didn’t immediately realize that he was developing sepsis, and by the time they did, Zucker says it was much more difficult to treat. “That’s what we’re trying to do. We want people to intervene quickly. That’s the regulation, to intervene fast in a situation of this nature.”

Indeed, sepsis death rates in hospitals have declined where these rules are in place.

But Dr. Jeremy Kahn at the University of Pittsburgh has mixed feelings about these regulations.

“If we [doctors] were great at doing the right thing — the thing that most people agree on — then we wouldn’t need regulation,” he says. But in reality, doctors don’t all keep up with the latest best practices and follow them, Kahn says, so regulations save lives.

“The downside is that a regulatory approach lacks flexibility,” he adds. “It essentially is saying we can take a one-size-fits-all approach to treating a complex disease like sepsis.”

That’s problematic, because doctors haven’t found the best way to treat this condition. The scientific evidence is evolving rapidly, Kahn says. “Almost every day another study is released that shows what we thought to be best practice might not be best practice.”

Kahn wrote a commentary about the rapid changes earlier this month for the New England Journal of Medicine.

For a while, medical practice guidelines distributed to doctors called on them to use one particular drug to treat sepsis. It turned out that drug did more harm than good. Another heavily promoted strategy, called goal-directed therapy, also turned out to be ineffective.

And a study presented last week at the American Thoracic Society and published electronically in the New England Journal of Medicine finds that one of the steps required in New York may not be beneficial, either.

The regulations call for a rapid and substantial infusion of intravenous fluids, but that didn’t improve survival in New York state hospitals.

Many doctors consider fluids helpful, but “what we haven’t learned is the specific type of fluid to give patients, how much and how fast of a rate,” says Dr. Christopher Seymour, a critical care researcher at the University of Pittsburgh who co-authored the analysis. “It’s been quite controversial.”

“There are consequences and adverse effects that can come from too much fluid,” Seymour says.

In fact, some doctors believe that most patients are better off without this aggressive fluid treatment. There’s a study getting underway to answer that question. Dr. Nathan Shapiro at Harvard’s Beth Israel Deaconess Medical Center hopes to enlist more than 2,000 patients at about 50 hospitals to answer this life-or-death question.

But that study will take years, and in the meantime doctors have to make a judgment call.

“It is possible that at present they are requiring hospitals to adopt protocols for fluid resuscitation that might not be entirely appropriate,” Kahn says.

There could also be other big changes on the horizon for treating sepsis.

Doctors scattered coast to coast are trying a new protocol that, in addition to limiting fluids, uses high doses of intravenous vitamin C, steroids and vitamin B1. That has generated a great deal of enthusiasm and some startling claims of success, though it remains to be seen whether it is indeed an exciting advance or will become another disappointment in treating sepsis.

Dr. Zucker at the New York Health Department says the current regulations would not stand in the way of advances to treatment.

“If there is a disruptive technology that comes out, or a therapy that comes out, we would adjust accordingly.”

You can reach Richard Harris at rharris@npr.org.

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Receiving a diagnosis in 2017 — at least one made at a medical center outfitted with the latest clinical gadgetry — might include a scan that divides your body into a bread loaf of high-resolution digital slices. Your DNA might be fed through a gene sequencer that spits out your mortal code in a matter of hours. Even your smartphone might soon be used to uncover health problems.

Yet nearly 130 years since its inception — after decades of science has mapped out our neuronal pathways — a simple knob of rubber with a metal handle remains one of medicine’s most essential tools. I’m referring to the cheap, portable, easy-to-use reflex hammer.

This unassuming device can be invaluable in diagnosing nervous and muscular disorders, and in determining whether a patient’s pathology lies in the brain or elsewhere in the body. It can also help curtail healthcare spending by preventing unnecessary, often expensive testing. Yet like so many major medical and scientific discoveries, the reflex hammer has humble origins, in this case: the basement of a Viennese hotel.

The inn was run by the father of Leopold Auenbrugger, an 18th century doctor who is considered to be among the founders of modern medicine. To gauge how much wine was left for customers, hotel employees would thump casks with their hands and listen for a dull thud or hollow tympany. Auenbrugger realized that the same technique — now called “percussing” — could be applied to the human torso to, say, determine how much fluid had built up around a diseased heart. He wrote as much in his 1761 paper New invention to detect diseases hidden deep within the chest.

Relflex hammer warfare

Thought to be more accurate than the human hand, it wasn’t long before percussion hammers were being designed to more precisely diagnose disease. Competition ensued.

Scottish physician Sir David Barry’s model, released in the 1820s, was the first. German doctor Max A. Wintrich’s came shortly after and was more popular, but was not without its critics: “[Wintrich’s hammer] is inconvenient to hold, it is rigid … it required education to use it, and even then it does not fulfill its purposes,” a rival inventor commented.

As neurologist Dr. Douglas J. Lanksa wrote in a 1989 paper on the many types of reflex hammers, “Some were T-shaped or L-shaped, others resembled battle axes, tomahawks, or even magic wands.” He adds that no material was off limits: wood, ebony, whale bone, brass, lead, even “velvet-covered worsted” (a type of yarn).

As percussion hammer warfare waged on, doctors and scientists were also beginning to understand the concept of reflexes, or involuntary, near-immediate responses to stimuli that occur before any sensory information reaches the brain. Muscular jerks. Blinking. Sneezing. Gagging. All of these are automatic feedback loops between sensory and motor neurons that help us navigate our environment and protect us from danger.

In 1875, German neurologists Drs. Heinrich Erb and Carl Friedrich Otto Westphal were among the first to realize that eliciting a reflex by briskly tapping the tendons of major muscles might be useful. They felt the knee jerk — or “patellar-tendon” reflex — in particular could help assess nerve function.

Hammers specifically suited to test reflexes were soon developed, the first of which had the now classic shape we’re accustomed to — a thin metal handle with a triangular rubber head. Designed by American physician John Madison Taylor in Philadelphia in 1888 — and modified ever since by many — the simple device was heavy enough to elicit reflexes, and had round edges to ease impact. An entry level model runs just $2.25 on Amazon.

The Krauss hammer, developed by German-American physician William Christopher Krauss, was designed around the same time. It had two rounded heads: a large one for knees and a smaller one for biceps. Dr. Ernst L.O. Trömner’s did too, but it also tapered to a thin end to assess skin reflexes. There were also the Queen Square hammer, the Babinski hammer, the Buck hammer and the Berliner hammer. The Stookey hammer flaunted a camel hair brush to get a better sense of touch sensation. The list goes on.

Past to present

Daniella C. Sisniega is a third year medical student at the Boston University School of Medicine. Last month at the American Academy of Neurology’s annual meeting, she presented a poster explicating the reflex hammer’s past.

“I’m fascinated by how the reflex hammer started out as a percussion hammer, but was [then] adapted to elicit reflexes and has been in every neurologist’s tool box ever since,” she told NPR. “I also did not know that the little rubber triangle was the first reflex hammer. I feel like I owe it an apology!”

Sisniega jokes about the lackluster quality of the inexpensive Taylors.

“The little tomahawk is included in the kit everyone receives when they enter medical school,” she recalls. “The rubber is cheap and very light, while the other hammers are heavier on the head so that you can use the ‘swing’ of the hammer as opposed to the strength of the strike to test the reflex.”

While attending the AAN conference myself, I asked multiple sclerosis expert Dr. Stephen Krieger about the role of the reflex hammer in modern medical diagnosis.

“We could argue about the nuances of the hammer — the Queens Square, the Tomahawk, plastic handle, metal handle, weighted, flexible or rigid — but the hammer itself is always in the hand. Reflexes tell the story of neurologic diseases of all sorts,” he says.

Krieger explains how disorders of the brain, like a stroke or brain tumor, result in hyperactive reflexes, while conditions affecting muscles and peripheral nerves usually result in reduced or non-existent reflexes. Reduced reflexes are, for example, a common symptom of back pain due to degenerative disk disease.

Dr. Andrew Wilner, an assistant professor of neurology at the Mayo Clinic, recounted the story of one of his patients, who had back pain, weakness and numbness of the legs. Wilner was leaning toward a diagnosis of either Guillain-Barre Syndrome (GBS) — an autoimmune disorder of peripheral nerves — or a myelopathy, an injury of some kind to the spinal cord. Both conditions can lead to medical emergencies, but each requires drastically different treatment.

“The reflex hammer was arguably our most important tool in narrowing down the differential diagnosis,” he says. “Had we found diminished or absent deep tendon reflexes, GBS would have been more likely. As it turned out, the patient had brisk pathological knee jerks, pointing to a lesion in the brain or spinal cord.”

Based on these findings, Wilner ordered an imaging study of the patient’s spinal cord, where a lesion was found — as opposed to pursuing the costly tests involved in a GBS diagnosis.

Wilner feels that the simple art of interviewing and examining a patient can get overshadowed by the myriad new diagnostic technologies. When it comes to clinical tools, he feels, sometimes basic is better.

“Technology is glorious,” admits Krieger, “and [it] will teach us things about patients that we could never have known or imagined. But the simple, elegant, inexpensive almost plebeian swing of the reflex hammer has a cost/benefit ratio that I think no advanced technology will likely ever match.”

Bret Stetka is a writer based in New York and an editorial director at Medscape. His work has appeared in Wired and Scientific American, and on The Atlantic.com. He graduated from the University of Virginia School of Medicine in 2005. He’s also on Twitter: @BretStetka

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There’s a narrative about the methamphetamine epidemic in Montana that says the state tackled it in the 2000s, yet now it’s back with a vengeance because of super labs and drug cartels in Mexico. But here on the Fort Belknap Indian Reservation, it never really went away.

“Getting high in your car in front of the store; that ain’t a big deal,” says Miranda Kirk.

Kirk works on the reservation, which is about 40 miles south of the Canadian border. She says no one even bothers to hide their drug use.

“Leaving your paraphernalia out in the open for someone to walk in, that’s alright. Having and seeing needles everywhere, that’s ok. Even talking about selling your needles — that’s normal too,” Kirk says.

Kirk is a 27-year-old mother of four. Born and raised in Fort Belknap, home to the Aaniiih and Nakoda tribes, she grew up around drugs, alcohol and addiction. She struggled with opioids after a miscarriage landed her in the ER and she was discharged with a handful of prescriptions. But, she says, with the help of her church, she broke that addiction. Now, she wants to help others.

According to the Tribal Epidemiology Centers of the Indian Health Service, dependence on methamphetamine and other psychostimulants more than tripled for tribal members in Montana and Wyoming between 2011 and 2015.

“People are saying they’re seeing it as young as third grade, because, ‘Oh that’s ok, I see that at home — my aunt does this, my mom does this, my dad does this, my grandpa does this.’ So, they can’t see the error in it. Or they don’t see it as a risk,” says Kirk.

Miranda Kirk and her sister, Charmayne Healy, felt like everyone had given up trying to do anything about the rampant drug use. And, they worried about their kids falling into the same trap. So they went to tribal leaders last year and said someone needs to do something — now.

George Horse Capture, Jr., vice president of the Fort Belknap Tribal Council, helped the sisters persuade the council to declare a state of emergency against methamphetamine last January. Tribal leaders then gave Kirk and Healy $150,000 to fund a substance-abuse prevention and treatment program.

The sisters were caught off guard, but right away, Kirk started hunting for a model that might work with the strengths of Fort Belknap. She heard about something called peer recovery, a movement centered on the idea that people who have succeeded in conquering from their own addictions are uniquely equipped to coach others.

“The light bulb came on,” Kirk says. “That works, because what got me clean, in a sense, were peer mentors. They’ve been there. That made it easier for me to be able to express myself and not feel judged, or condemned. Like I’m a horrible person for what I was going through.”

She’s determined to break the stigma attached to reaching out for help.

In early 2016, Kirk and her sister officially launched the Aaniiih Nakoda Anti-Drug Movement, a native-led peer recovery project.

Jessica Healy, 30, came knocking before they were even up and running. Her only son was taken away last year.

“They helped me. And it took a big step … it took all that I had,” Jessica Healy says.

She had been using drugs on and off since the age of 18.

Once a week, one of Kirk’s peer recovery groups, the Life Givers Circle, meets at the Lodge Pole Elementary school.

“We talk about stuff and we make ribbon skirts, [do] activities, and we just help each other out,” Jessica Healy says.

It’s one of about four peer support groups that Kirk and Charmayne Healy have helped start, both on and off the reservation.

“It was a good feeling to be clean and to be close to people that had been going through the same thing. To know that there are others out there,” Jessica Healy says.

In addition to peer meetings, Aaniiih Nakoda members go to schools and talk to kids about prevention. They help organize events like zombie walks, in which people pretend to be the drug-addled walking dead.

There’s only one outpatient drug treatment facility in Fort Belknap, and no emergency housing or sober-living facilities. The only longer-term support available is Kirk’s group.

Dr. Aaron Wernham, of the Montana Healthcare Foundation, says that what Montana needs is a more integrated, team-based approach to treating addiction. That means primary care doctors working next to behavioral health professionals, and coordinating care all along the way.

“Peer recovery fits in very well with it, but if you decided you were just going to build a whole treatment system around peer recovery, you probably wouldn’t end up getting the results you want,” he says.

A new state law enacted in March goes a long way toward recognizing peer support specialists as legitimate members of a treatment team.

The law sets clear professional standards, and paves the way for billing insurance companies and, potentially, Medicaid.

The challenge is how to bring that comprehensive care to Fort Belknap.

Until that happens, the sisters’ grassroots peer program is one of the only options available for people. And she’s intent on doing that work, no matter what.

“You have to keep your phone on during the night because addiction don’t sleep and normally we don’t either,” she says.

This story is part of a reporting partnership with NPR, Montana Public Radio and Kaiser Health News.

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