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Healthcare for immigrant parents

When your parents come to the United States, what should you think about regarding their healthcare?

If they come here for a short-term visit, like a six-month stay, a short-term healthcare insurance for visitors could be your choice, but those usually don’t cover for existing conditions. If your parents have chronic conditions like diabetes, hypertension, heart diseases, etc, they may need medications and maybe some visit to the clinic or emergency room.

US healthcare insurance is largely based on employment and due to parents’ immigrant status (B1/2 visitor visa), there are very limited choices for healthcare insurance. A few options are as belows, but I suspect better knowledge is with local healthcare brokers.

-some employment-based healthcare insurances allow you to add parents as dependents, such as VA or Tricare

-some supplemental healthcare insurance offers some cost deduction by providing low out-of-pocket costs

-some visitor healthcare insurances offer choices for acute onset of pre-existing conditions

So what if an emergency happens and parents are not insured or under-insured?

-emergency rooms, according to law, all the ERs in the US have to accept patients no matter what, so they will be seen in the ER but you are going to expect to receive some bills with large numbers. Well, you can negotiate with their billing department later but it is always not pleasant to receive a bill that may make you broke. But if there is really any life emergencies, don’t hesitate to bring your parents to ER.

-free clinics or fee-scaled community health centers, usually different states and cities have some free clinics run by government or charity groups but they usually open on 9-to-5 regular hours. If they need hospitalization, the social workers at a hospital will help you apply for emergent Medicaid (depends on states), which will cover the costs of in-patient stay.

-private cash-only clinics, you can find some private clinics in lower Manhattan/Chinatown or Flushing, NY that accept cash for visits.

-call your own primary care physician and see if he/she can fit your parents into a schedule and charge a reasonable fee based on cash or fee-scale.

-some cash-based telemedicine services

How about medications?

They can bring enough medications to the United States for the duration of stay.

Or

-some pharmacies provide low-cost common medications like CVS, Target, Walmart’s low-cost Rx program

-use GoodRx for wholesale prices for medications

-ship medications from home from mail but sometimes the Customs may be scrutinous about that since there are regulations to prevent smuggling cheaper medications to the US

If you have any experience exploring the US healthcare system with immigrant parents, share it in the comments section!

 

Is that possible that you missed a STEMI?

When I was in medical school or even in my residency, my thought was like – oh, you can’t miss a STEMI, it is just too obvious to be missed. But the truth is that it is very possible to miss a STEMI and actually in real life, many STEMIs have been missed. The reasons why STEMIs are missed:

STEMI EKG changes can be transient. Once I thought after STEMI the EKG should go down the route of showing q waves etc, but sometimes STEMI EKG can go back to normal looking. So if somehow the STEMI EKG is not cited or not seen or misplaced (oh those paper EKGs flying everywhere…), the diagnosis is missed. I remember where I was trained, ER attending always have to sign the EKG with date/time and their name, a really good practice indeed to make sure every EKG is read by an attending. While on the floor, we don’t have this kind of practice or habit, so I did encounter a case that the EKG done during a rapid response was later found to have clear patterns of STEMI.

Secondly, as you all know there are STEMI equivalents and posterior MI. Sometimes V2-V3 elevation could mimic early repolarization pattern. Single avR elevation. With some residency program hosted by a hospital without a cardiac cath lab, most of these patients are screened and shipped to somewhere else, and residents are not exposed to as much high-risk EKGs as they should.

When to call consults for your patient

This is a big headache for hospitalists – when to call consults. I have seen crazy practices such as calling consults for every single issue the patient has, oh you have COPD and p/w SOB, let’s call pulmonary. But what is more common in the daily clinical practice is that the consults will tear you apart if they think you are calling unnecessary consults and if you somehow miss something and the consult will also come to tear you apart – why you didn’t call me earlier? Leave some safety margin and smell the smoke before it becomes a fire.

Now people think you should call consult only when it is necessary. Is it true? The judgment of when it is necessary solely depends on your understanding of the case and you are only a generalist and you may not even have the knowledge to tell when it is necessary. This fundamental paradox seemingly cannot be overcome and is the root cause of the conflicts between generalists and specialists – the best solution I have seen is to trigger a consult automatically when the case meets certain criteria and these criteria can be discussed beforehand with the specialists. Or you can curbside.

Curbside vs. Formal consult: do not trust a curbside consult fully – things can go wrong in many ways. The information you give to the consult might not be sufficient for him/her to make the best clinical judgment – the way you describe the case might not be right due to your own blindspot BECAUSE you are not as educated as the consult with the issue at hand.

Sometimes, the person you curbside might be only a fellow/PA/NP instead of the attending on the service, would you trust that clinical opinion? I would not. (I had a case with low baseline cortisol level and normal cosyntropin response and the endocrine fellow let the patient go).  Last but not least, if their name if not on the chart, they care less than when their name is on the chart. Some good ones may tell you hey this is s tricky case do you mind putting in a formal consult and I will see the patient later; but sometimes it just happens that everyone is busy.

Last caveat: if you feel like once you call a consult and they come to see your patient, your job is done, then you are totally wrong. Consults miss things all the time. There was one time I had a patient with bacteremia and asked ID consult where is the source (twice!) – he documented in the note that the patient had some IV a few weeks ago and likely has phlebitis. On the day of discharge, patient said he had neck pain and steroid injection to his neck a few days before he was admitted! Of course, I rushed him to the MRI for a scan.

Interesting case this week

– heart murmur is only heard when patient has ECHO done

– STEMI is only diagnosed when troponin is going up – a young male presented with typical unstable angina symptoms and ED noticed Inferior leads 1mm ST elevation and reciprocal ST changes on precordial leads but cardiac cath lab refused to take him stating those were early repolarization. Later troponin keeps going up from 0 to 0.05 to 0.13, then rushed to cardiac cath…

– how to dose warfarin if liver failure and INR already 2?

Breastfeeding tips

During first few days when milk doesn’t come in yet

-skin-to-skin as much as possible, more time with baby means more time to try latching and more chance of success

-avoid using nipple shield unless really necessary (nipple shield may create nipple confusion and hinders milk transfer)

-hand express breast milk (study shows hand express in first few weeks to empty breasts increase production down the line)

-track weight daily to avoid drastic weight loss (if weight drop more than 10%, suggest starting formula supplementation of 15-30cc per feeding)

-no bottle feeding (may create nipple confusion), please use Medela Supplemental Nursing System to keep baby at breasts

-mum only nurses and rests, no other housework

-get hospital grade pump with battery/car charger

After breast milk comes in

-use both hand express and breast pump after feeding to increase production

-set clock to empty breasts regularly (even one time of delayed emptying may cause clogged ducts and mastitis)

-to prevent mastitis, wash nipples with warm water  and clean pump tubing every day

-if any breast pain/redness/fever, start taking antibiotics and once feels fluctuation/pus formed, get needle aspiration as soon as possible to avoid I&D

-if clogged duct, warm compression every 2-3 hrs right before pumping/electronic tooth brush and cold compression in between; lethicin?; if not relieved in 24-48hrs, be more aggressive and be careful of mastitis

 

 

 

How I ended up with a 4cm hole in my breast one month after delivery…

The title says it all.

I am in a dark mood now but I plan to write about my experiences of how mastitis turned my life upside down for the past week.

Among all the outcomes of lactational mastitis, having a 4cm by 1.5cm hole in the breast is not the worst outcome but does stand on the ‘bad’ end of the spectrum of all possible outcomes. From a very quick recovery and resuming breastfeeding, to a series of needle aspiration and eventual recovery without scars, to an emergent incision and drainage with a gaping wound on the breast. But anyway, I didn’t develop bacteremia/septic shock/death and still alive so thank goddess for that.

But this is the true reality of healthcare. A mixture of bad luck, rapidly progressing disease and subsequent clinical decision making behind the disease progression curve, you will find yourself end up in some place you never imagine would be.

Even now, I am still waiting to see where it goes since the wound is not healed.

I think it started on last Saturday when I found some area near my right nipple painful and bulging – thought it was some milk pouch since it was clogged duct there with hardened clots and it was difficult to see the redness as it was near areola. But I kept pumping – the next day pumping was so painful I even went to the hospital to borrow another hospital grade pump and the lactation consultant pointed out to me – isn’t that more red than usual?

Actually no, I think it all started when I was still staying in the hospital and son didn’t learn how to properly latch. Because he did not learn how to properly latch so I had to pump and nurse at the same time to increase my milk production (which never exceeded 3-5oz per day), and I had developed lots of clogged ducts which never went away and eventually developed into mastitis?

Chain of events.

How to choose your own physician?

Everyone has their own philosophy when it comes to choosing a physician.

For primary care, you need a responsive staff from the office, no matter how brilliant your primary care physician is. The utmost important thing about a primary care office is how responsive they are to the calls because you are going to call them a lot for basic stuff – physical exam form, lab test results, prescription refill, triage your symptoms at night. This usually relates to how the practice is managed, but less pertains to the capabilities of physicians who work there.

Secondly, you need some continuity in your care – do you want to see a different provider every time you go there and repeat again and again your own story? No one writes such a detailed note for the visit so all the information retains. Considering finding some physician who is not close to their retirement age so you can build a long-term relationship instead of being handed over to someone else in a short period. In addition, make copies of your medical records every a few years – some clinic purge records according to the statue limitations, which means once it is out of the legalized time period of keeping the medical records, “poof”, they are out of the window.

Thirdly, bedside manner vs. technical excellence vs. conscientiousness vs. experiences. This is really the field that everyone has a different taste for.

 

My journey of breastfeeding (1)

Young parents usually underestimate the work needed for feeding their newborn.

First night

Our son was born around evening time, and on that specific night, I was so tired from the 12-hour long laboring and really wanted to sleep through the night, but when the nurse asked if I would like to have some room-in time with my son to try breastfeeding, I said yes. As you know, we’d better take advantage of newborn’s suction instincts, the earlier we try to let them latch on, the better. If you put them on your breasts for the first hour of their life, they actually start seeking out your nipple just by instinct. But trust me, when you are so tired, you forget all things learned from breastfeeding class took weeks ago (early room-in, early hand expression of colostrum, etc).

So, when I tried and failed my attempt for breastfeeding for that night (there was no lactation consultant  to help you at night) and overwhelmed by the desire to sleep, I tried to send him back to nursery (during the tour of the labor & delivery ward, they told us we can leave the newborn in the nursery overnight). It turned out I am too naive about this.

After I sent him back and started to fall asleep, my door was knocked and a nurse assistant wheeled him in. Instantly I knew what was wrong, the nursery staff didn’t want to deal with a crying baby! With the very last strength in me, I picked him up and held him on my breast and he calmed down a bit.

He slept on my breasts for a few hours and started to cry again. I noticed he has a poopy diaper so I tried to send him back to nursery again to change his diaper. This time I even walked him to the nursery myself with the hope that he won’t be sent back to my room again. I was totally wrong – in 15 minutes, the nanny wheeled him back to my room again saying he was hungry and he needed to eat. I was so tired thinking – “I tried, there was no milk yet…” and almost argued with her about this practice of bringing him to my room every one hour just because he was smacking his lips…

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Looking backward, there were a few things we could have done better to kick-start our breastfeeding journey.

  1. Put the baby to your breast right away after delivery – I felt very weak after the labor and initially didn’t even want to have a screaming baby on my chest but once he was there I felt a flush of love and joy for this little guy.
  2. It is not a crime to give some formula to a baby if you felt too tired to feed him the first night, but you need to discuss this with your nurse.
  3. You can hand express some milk and feed to him if the baby still hasn’t got the hang of latching yet. Check out “hand expression Stanford hospital” for the video.

Continue reading “My journey of breastfeeding (1)”