Month: January 2015

Google Fiber Is Getting Closer!

~ Frank ~ Leave a comment

This is an out of character post for the ‘mission’ and overall focus on this blog, so the author begs your indulgence. I had always intended this blog/outlet to be for me a sort of Hyde Park debating mini-platform to comment on social, cultural, and political trends in the US from a “veteran psychiatrist’s point of view.

But this story is too ‘big’ for that.

When I and my family moved to this part of western North Carolina after nearly five years as the consultant helper psychiatrist for the Eastern Band of the Cherokee Indians’ reservation health care system, the “Qualla Boundary” as is more properly known, this area was listed as the eighth most hard hit economic sinkhole in the country. Jobs were almost nonexistent except in the large start institutions that have been in this area for literally over a hundred years. They include the western North Carolina catchment area for the residential treatment center for the severely intellectually disabled, the state psychiatric hospital, a former adolescent-young adult prison unit which was quite forward thinking, progressive and rehabilitative with its clients, a local hospital and of course the area’s consolidated school system.

Over the previous two decades, this area had seen literally 90% of its traditional jobs in tobacco, furniture manufacturing and textiles go overseas largely to China and Mexico after the passage of NAFTA during the Clinton Presidency which was supposed to help through globalization of trade. The exact opposite happened.

Hickory NC, one of the cities of this MSA’s (metropolitan statistical area) economic scope lost over half its jobs and over 25% of its population which were reflected in the same devastating proportions in the school systems’ populations in the three counties and cities. Families and their children moved out of the droves. Schools began to show enrollments rates of nearly 50%. Counties were faced with closing many commonly accepted institutions, agencies and services from schools to police forces. Economic austerity suddenly became a way of life. Businesses cancelled plans to build new restaurant outlets in the three county area by the droves. Even law and chiropractic offices began to decrease in number.

Hickory used to host a gargantuan furniture convention twice a year at a specially built exhibition building, the “Furniture Mart” that rivalled such such facilities as the Muscone Center in San Francisco and Hickory barely had a population of 35,000 or so. Not an MSA with over 1-2 milion in the drawing economic area by any stretch of the imagination. The area was THE WORLD’S center for furniture fashion akin to the impact and importance of women’s fashion shows and revealing of famous designers’ lines seasonally in such centers of fashion as New York, Paris and Milan. Except Hickory was it for furniture virtually for the world. Tens of thousands of furniture buyers from around the world, even the ultral chic Scandinavian furniture brands came to Hickory to see the new lines and designs at the Mart. They filled motels ranging from Asheville to literally the GreensboroRTP areas communting long distances to attend the daily shows which lasted a week. Central NC is not Las Vegas and does not have hotels like the Mandalay Bay with 47,000 rooms. The lodgings in this entire state until the advent of the Cherokee Casino in the last 12 years, were your average 50 room chain unit. Now the Mart still exhibits twice a year but it is a shadow of its former self.
This area was one of the earliest area in the country to suffer the economic downturn including mortgage foreclosures and families abandoned their homes they could no longer pay for in droves. Banks went bust and were bought up by BIg National Banks at fire sale prices. Real estate went in the deepest tank in the country. In some areas half of businesses everyone everywhere takes for granted, such as McDonalds, CLOSED. Gas stations, department stores, shoe stores, and especially specialty stores closed by the bunches. Strip malls emptied. One had to drive to larger cities to buy anything if it was not carried at the sole surviving WalMart.

The several years ago the Cherokee Tribe and a tech firm called Drake, ‘strung’ the highest speed Internet backbone line in the country running from Raleigh and North Carolina State Unversity State University, to Durham and Duke University and UNC-Chapel Hill. Then it went to Greensboro, to Winston=Salem and Wake Forest University-Bowman Gray School of Medicine, and then all the way to the community college in Murphy NC, at the extreme western tip of the state. Murphy unfortunately is only famous for the several year hide out for Eric Rudolph the 1996 Atlanta Olympic Bomber who eluded the FBI for years. That Drake-Cherokee Internet backbone also went down to Greenvillle SC to Furman University and Greenvillle Technical Collegel one of the most innovative community colleges in the entire country because of its close affiliation with BMW which had set up its humungous manufacturing plant comparable to Boeing almost in Seattle in size in the late 1980’s saving the Upstate of South Carolina from the generalized economic failure that was enveoloping almost all of North Carolina after NAFTA.
Google I expect and speculate started watching alll this, especially the start of high tech small start up companies migrating from Atlanta to Ashevillle because of the Drake Cherokee backbone. Google sometime in the late 1990’s made the decicision that truly high speed Internet lines had to become commonplace in this country. It also made the decision that the phone companies WERE not going to make the investment necessary to do so as they were focusing on their short term plans for profits from piddly cellular phone upgrades and service. Stupid short sighted companies falling behind the curve and not even realizing it…
Google looke at the NC Internet backbone as it announced plans to shake up the the industries and starts its own ONE GIGABIT speed Internet service in Kansas City the first city it selected as its try-out and the Internet Gold Rush was On! Did the phone companies notice or figure out what was happening, no they were to preoccupied with competing with another dying outdated technology, the reviled cable companies. After all Eric Schmitt of Google just said this week that the Internet as we know it now, “is dying.” He means the companies who are doing it under the current technology are dinosaurs and do not even know it yet. He’s right.

So Google a few years ago suddenly announced it was building a lab and huge server farm in lowly Lenoir NC which had virtually emptied since the the 1980’s. It found the NC backbone, a readiness of a desperate business community to welcome anything even a drastic “high falutin'” enterprise like fiber optics from Google to rejuvenate their area. The three area community colleges received monies from the Golden Leaf Tobacco multi-BiLLION dollar national settlement to retrain displaced workers from the big three industries that had been destroyed by globalization. They were savvy enough to foresee programs to train workers in the technologies in the New Age of the Internet based businesses and its hundreds of support mini-industries and future companies would be needed and establlished such companies at Buncombe Tech (Asheville), Western Piedmont Community College (Morganton), Catawba Community College (Hickory) and Caldwell Community College (Lenoir NC). It worked!

Google sank an initial $600M into its first installation in Lenoir out in the “boonies,” and then another $600M was announced and building started for an addition over a year ago in the same area.

And now, just yesterday, January 27, 2015 Google announced Charlotte AND the Raleigh Durham area will be two of the next several cities in the eitre USA selected for Google Fiber Internet! Our Gold Rush will now really take off. Kids are taking coding camps by the dozens for free the three community colleges every summer even before the Raspberry Pi hit the world scene. A new STEM academy has started for the school system in Morganton housed in a renovated beautiful educational building not used in years, Jeter Hall (not named after Derek Jeter unfortunately as that would have helped PR…) at the North Carolina School for the Deaf in existence since the 1890’s.

So things are really shakin’ down here in Hicksville Central North Carolina, and as they say on the longest running tv show in in American, ” COME ON DOWN!”

Nursing Homes Seizing Patients’ Custody/Guardianship to Collect Debts

~ Frank ~ Leave a comment

This very past week I discovered through my array of Net crawling Google “searchbots,” ar article from Jan. 25th in the NY Times by Nina Bernstein. You may read the article in its entirety here.

I had not been at aware of this phenomenon but apparently with the confluence of many factors, the ever rising  numbers of the elderly needing long term nursing home care and inadequate funds to pay for the also ever growing medical bills as we all age and accumulate new chronic medical problems, bills to patients now increasingly outpace the resources that even those who have planned, and saved and have long term care insurance. This article features an elderly former couple of professional education and occupations. The wife needed nursing home placement for the ‘gateway,’ reasons, difficulty performing daily functions and hygiene ad gait impairment and then went on the develop probable Alzheimer’s dementia. [As an aside women develop Alzheimer’s dementia more than do men, partly because they survive and live much longer and the odds of developing Alzheimer’s greatly increase as you hit the magic threshold of 80 years of age].

In any case as the account detailed, the bills mounted and well meaning husband who was diligently paying the nursing home suffered the indignity of finding an envelope one day on his wife’s bed which was a guardianship petition by the nursing home in order to have total control not only over her medical care decisions, but also control over her finances, so they could be assured of being paid [sic more].

Now if that is not a conflict of interest I do not know what is.

The article further shocked me by going on to detail that a study by the well respected Hunter College of NYC into this issue found that this had been going on for some years. and that at least TWELVE per cent of nursing of guardianship petitions in the area (NYC or NY state?, I am not sure).

Another case in which this happened to a 94 year old nursing home resident was quoted and the judge’s decision in a lawsuit was brought by the family to contest this action. A Justice Hunter (I guess no relation to Hunter College…) wrote: “It would would be an understatement to declare that this court is outraged by the behavior exhibited by the interested parties–parties who were supposed to protect the person, but who have all unabashedly demonstrated through their actions in connection with the person that they are only interested in getting paid.”

As they say, “Nuff said.”

 

The Narcotic Prescription Epidemic–Part IV

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To buttress my assertion that for the most part until recently physicians have been ‘babes in the woods’ as far as addictions are concerned and this has lamentably reflected in their lax prescription practices, I would offer two developments. In 2000-2002 when buprenorphine started to move into the prescription market as the newest and best narcotic antagonist, that could be used to detox someone in literally less than two weeks, and/or be used for intermediate daily maintenance through private physician office prescription instead of having to attend a five day a week ‘public’ methadone federally regulated dispensing clinic. I was I think the 4th MD in North Carolina trained now 14 years ago to do this work as one had to be trained and certified (and still do). I welcomed this tool and a real improvement and evolutionary step in our treatment armamentarium of battling opiate addiction. But within several years studies began emerging from multiple monitoring groups that four out of every five physicians who were certified to do this kind of work, found out they intensely disliked working with addicts and gave up their special DEA licenses to be able to utilize buprenorphine and simply stopped working with addicts. Addicts as a group and most of them individuals are a real hassle to deal with. They do not play by the rules of the treatment relationship that almost all MDs expect and are comfortable within. Addicts can be some of the most difficult, ornery, demanding, dishonest, patience exhausting individuals any practitioner deals with. And buprenorphine in its earlier forms began to be massively diverted as well…

The second observation I would put forward in supporting the assertion that MDs by and large have been inept at best in managing the difficult shoals of prescribing narcotics, is the fact that for the better part of this past decade or so, scads of continuing medical education courses have emerged from many many medical educational organizations, state medical boards, board certification organizations and most medical schools and “area medical health educations centers” organizations almost no civilian has heard of. The latter are everywhere in the country and legally mandated to offer medical, nursing, pharmacy, almost any kind of healthcare advanced or refresher training one can imagine. One nearby to where I practice and live in western North Carolina is “MAHEC,” Mountain Area Health Education Center. The point is all these bodies have been offering free and for fee courses on the many aspects of opioid prescribing, management and monitoring, in a national effort to help curb this prescription drug epidemic. {By the way, it might be wise to inqiure of your health care provider what her/his intentions are in this area]. It is coming for us all…I myself am taking my umpteenth course in this area, a four part online excellent course since I see and treat addicts routinely in my present setting of a state psychiatric hospital.

The third argument I offer that MDs must have re-training or better training in the use of narcotics, is that for the last several years the DEA (Drug Enforcement Administration) has been working on implementing and moving toward mandatory training courses and certification in the use of narcotics by all MDs for controlled drugs. That is likely to include such controlled drugs beyond opiates such as the potentially dependency producing anxiety medications such as Xanax, Valium, Librium, Klonopin and Ativan; sedatives such as Ambien, Halcion, Restoril; and the stimulant drugs used in the treatment of ADHD (attention deficit hyperactivity disorder) which affect perhaps 5-9% of all school children. I cannot tell how many MD colleagues and MDs I do not know but have talked this over with at medical education meetings, who have declared with palpable relief that when this measure becomes as it were, “medical law,” they will decline to take the training and be shed of dealing with these drugs and with addicts. They realize that they will be leaving their ADHD patients and cancer pain patients with no options within their own practices, but it cannot be overestimated how many physicians, as the ‘tv newstory’ move of some 20 years ago stated in its famous line: “I’s sick and tired of it and I’m not going to take it anymore!” From my perspective this is going to be a real mini-medical crisis of delivery of care.

The Narcotic Prescription Epidemic–Part III

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One additional monumental regulatory national policy mistake made in this country in the early 1990’s accelerated the easier access to prescribed narcotics. This came from the organization, the JCAHO, that certifies hospitals to stay open and operate through every three year or so on site reviews, “inspections,” made the ‘adequate treatment of pain,’ a national priority and requirement. This is when the “smiley face” pain quantification chart came out. Suddenly if you are old enough to recall those days, your medical practice’s nurse or physician began asking you at EVERY contact if you had any physical pain and if so to rate. The “Joint Commission” as the above mentioned hospital accreditation body, made it clear the so-called “undertreatment” of pain had to be corrected. Physicians reacted defensively and began to drastically change their opioid prescribing practices and the veritable floodgates opened. Again many many physicians who lived through that time felt that opioid prescribed was at least somewhat more rational but after the machinations of the Joint Commission (JCAHO or “Jayco”) in the have felt this was one of the most misguided bureaucratic maneuvers in modern American medical history. The informal consensus is that this helped wrongly educate patients to expect narcotics as more regular interventions and helped to form the ‘perfect storm’ along with all the other opioid facilitating developments discussed in this series.

The emerging subspecialty of pain management specialists arose to try to fill the need along with physical medicine specialists, both of which specialists there are woefully too few. Consider that just a few years ago the pain management fellowship programs graduated less than 300 such physicians a year in this country. Their rise to recognition coincided and in essence was a result of new technology of invasive spinal column endoscopy in which we could fairly safely insert these wondrous flexible minicathter tubes with little tiny camera lenses on their ends, much as had been done in gastroenterology used to visualize the insides of stomachs to see ulcers, colonic polyps and cancers, etc. This was a giant boost to the diagnostic and treatment potentials and approaches of GI medicine. It started to be applied a few decades ago in investigative learning efforts all over the country in big medical centers to spinal cord pathology. At first of course it was applied to the simpler, VISIBLE conditions such as fractures of the pedicles (like Cam Newton recently had in his truck accident), to bulging disks that were physically accessible to the threading of these “photographic catheters.” Thee had had decades of safer and safer experience in “invasive” or “interventional cardiology” in which these miniature cameras on a catheter had displayed for medical science the insides and blockages in coronary (heart) arteries, permitting “clot busters” therapy in strokes, placement of coronary artery stents or aid in determining that coronary artery bypass graft surgery was the proper next therapeutic step.

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The Narcotic Prescription Epidemic–Part II

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2) the other major development in medicine was the correct general realization that we were truly not treating pain sufficiently in certain groups of patients. I can remember that prejudice toward chronic pain patients especially the back pain patients whom everyone but dreaded treating, as they very often bore out the vein that led to addiction as sure as shootin’ as we would say in the Southwest. A back injury, or back then a whiplash neck injury occurred that often unfortunately was minor. In a sizeable number of patients it was major, required surgery and was demonstrably real. But the majority of back injuries did not respond consistently or very successfully to surgical interventions. Subsequently the overwhelming majority of long term review studies retroactively done at many reputable neurosurgical and orthopedic meccas have shown again and again that back surgery often does little or nothing to ameliorate or relieve chronic back pain. In fact the more conservative measures, though not curative by any measure, even, “shudder,” chiropracty had more salutary effects in “managing” reasonably this chronic condition. Acupuncture, heat treatments, TENS unit local stimulation, nerve blocks and intra-dura or nerve root exit injections of depot local anesthetics and anti-inflammatories did more. The term “failed back syndrome’ came into vogue and helped to group together and target this suffering group of patients.

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