The Handiest Girlie Of All

For Soldier Disfigured in Afghanistan, a Way to Return to the World

Specalist Joe Paulks NY Times Video

 Joey Paulk, center, was badly burned when his Humvee struck a buried mine that ignited the fuel tank.

Specialist Joey Paulk awoke from a coma in a Texas hospital three weeks after he was burned nearly to death in Afghanistan Wrapped in bandages from head almost to toe, he immediately saw his girlfriend and mother, and felt comforted. Then he glanced at his hands, two balls of white gauze, and realized that he had no fingers.

So it began: the shock of recognition. Next came what burn doctors call “the mirror test.” As he was shuffling through a hallway at Brooke Army Medical Center in San Antonio, he passed a large mirror that he had turned away from before. This time he steeled himself and looked.

His swollen lower lip hung below his gums. His left lower eyelid drooped hound dog-like, revealing a scarlet crescent of raw tissue. His nostrils were squeezed shut, his chin had virtually disappeared and the top half of one ear was gone. Skin grafts crisscrossed his face like lines on a map, and silver medicine coated his scars, making him look like something out of a Terminator film.

“This is who I am now,” he told himself.

Every severe injury is disfiguring in its own way, but there is something uniquely devastating about having one’s face burned beyond recognition. Many burn victims do not just gain lifelong scars, they also lose noses and ears, fingers and hands. The very shape of their faces is sometimes altered, forged anew in heat and flame.

More than 900 American service members have been severely burned in Iraq or Afghanistan since 2001, typically from roadside bombs, the military says. Almost all receive extraordinary emergency care and rehabilitation at Brooke. But many will never have their faces restored.

After nearly 30 operations, Joey Paulk began to resign himself to his appearance, but surgery through a program at U.C.L.A. Medical Center helped restore a measure of self-confidence. Here, he is being examined after a chin implant.

Mr. Paulk, though, has come close. After leaving Texas, and the Army, in 2009, his mouth and eye still deformed, he returned home to California and became something of a recluse, hiding beneath hooded sweatshirts, baseball caps and dark glasses when he went out, if he went out at all.

But he found his way to a program at U.C.L.A. Medical Center called Operation Mend that provides cosmetic surgery for severely burned veterans at no cost — and the operations fundamentally realigned his face, restoring not just the semblance of his former visage, but also a healthy chunk of his self-confidence.

He is venturing out again, to bars, beaches and ball games. On Veterans Day last year, Mr. Paulk, 26, rode in the lead car of the New York City parade, his head bared for tens of thousands to see.

“The burns on a soldier’s face are huge: It’s your military uniform and you can’t take it off,” he said. “The surgery changed so much on my face that it completely changed my whole outlook on life.”

The story of Mr. Paulk’s cosmetic and emotional revival says much about the ways private philanthropy can complement the overtaxed military and veterans health care systems. Now in its fifth year, Operation Mend has provided free cosmetic surgery to more than 50 badly burned veterans of the current wars. The program estimates it spends $500,000 on each of its patients.

 
Getting help from his roommate, Devon Hodgen, before a wedding.
 

But the story also underscores the difficulties of bringing private care into the military world. Though Operation Mend’s founder envisioned the program as a model for public-private cooperation in treating wounded soldiers, it remains one of only a few such ventures, which include Center for the Intrepid rehabilitation centers and Fisher Houses for military families.
 

Part of the problem, said Gen. Peter W. Chiarelli, the outgoing Army vice chief of staff who has embraced Operation Mend, is that many military doctors remain uncomfortable referring patients out of their system, which they view as a protective cocoon for troops and their families. But that attitude is changing, said General Chiarelli, who is pushing for a private program similar to Operation Mend for treating traumatic brain injuries and post-traumatic stress disorder. “Our problems are so big,

we have to reach out beyond ourselves,” he said.
 

Mr. Paulk, who grew up and still lives in the town of Vista in northern San Diego County, joined the Army a year out of high school in 2004, thinking it might help him get a job in law enforcement.
 

On his first deployment, with a military police unit in eastern Afghanistan in 2007, he was in a Humvee when it struck a buried mine that ignited the fuel tank and instantly killed his team leader. Mr. Paulk regained consciousness 20 feet from the truck, engulfed in flames.
 

In searing pain yet shivering with cold in the 90-degree heat, an odd question popped into Mr. Paulk’s head as he waited to be evacuated: Do I still have hair? Yes, another soldier said; his Kevlar helmet had saved it. “Maybe,” Mr. Paulk told himself, “the burns aren’t so bad, and I’ll still look like me.”
But it was not to be. By the time he awoke in San Antonio from a medically induced coma, he had already undergone numerous operations and skin grafts to patch his charred face, arms and legs. With his mother’s permission, a surgeon had removed all his fingers, which had been burned black and to the bone and were all but certain to become infected. He had lost 50 pounds in barely four weeks.
Over many months, his body accepted the vast majority of his skin grafts and he regained strength. But the one attempt by a surgeon to replace scar tissue on his face had failed, Mr. Paulk felt. After nearly 30 operations in 18 months, he began to resign himself to his appearance, and prepared to return to Vista, suffering from what his doctors called “surgery fatigue.”
 

“Everyone has a limit,” said Dr. Ivan Renz, the director of the burn unit at Brooke who Mr. Paulk says saved his life. “You get to a point where you go: ‘hold it, I’ve got to go through anesthesia again?’ ”
 

But before he left Brooke in December 2008, Mr. Paulk met a representative from Operation Mend who urged him to visit U.C.L.A. He took her card, skeptical that anyone could make him look good again.
The program had its origins in late 2006 when a wealthy philanthropist, Ronald A. Katz, was watching a Lou Dobbs interview with a badly burned Marine named Aaron Mankin. Charmed by the Marine but appalled at the extent of his wounds, Mr. Katz’s late wife, Maddie, poked him in the ribs and practically issued an order: “You have to do something!”

The military already had a state-of-the-art burn center at Brooke. But while the center offered reconstructive surgery, its focus was on saving lives and getting the wounded back on their feet. The Department of Veterans Affairs did not provide reconstructive surgery unless it was deemed medically necessary to restore, promote or preserve health — criteria that did not seem to include making someone look better.
 

During the coming year, Mr. Katz enlisted the support of U.C.L.A. and a respected reconstructive surgeon on its faculty, Dr. Timothy Miller, a Vietnam veteran. One of Mr. Katz’s daughters-in-law began assembling volunteer “buddy families” to meet patients at the airport, entertain them and accompany their families to the hospital. He met with General Chiarelli and began to slowly win over the doctors at Brooke.
Mr. Paulk remained a tough sell. But the smaller indignities of his injuries made him relent when an Operation Mend representative called again. He could not open his mouth wide enough to eat a hamburger. Could Dr. Miller fix that? And what about his misshapen lips, which made it impossible for him to pronounce his own name? Dr. Miller pledged to have Mr. Paulk whistling and eating double cheeseburgers again.
With the first surgery, Dr. Miller removed scar tissue, raising the eye lid and lower lip. With second and third operations, he improved the alignment of Mr. Paulk’s eyes and lips by replacing scars with healthy tissue. A fourth surgery implanted silicone to add definition to his chin.
At a recent checkup in Dr. Miller’s office, Mr. Paulk admired his new profile in the mirror. “From a distance, you can’t tell I was injured,” he said.
There are still uncomfortable moments. Some drunks taunted him about his looks at a baseball game, nearly starting a brawl. And Mr. Paulk admits to moments of self-consciousness about his hands. When, for instance, a little girl gawked at him at U.C.L.A. recently, he reflexively tucked his palms under his armpits.
But he has also learned how to function: to put on socks, pull up zippers and tie shoes. He can send texts and drive. He can’t play his beloved baseball, and video games remain a challenge, but he manages to catch a football and spike a volleyball with his palms.
 

And he looks remarkably comfortable holding a drink at a party.
“Sometimes I’ll hold my cup against my body so I can talk with my hands, and I’ll maneuver and pick it up and everyone thinks it’s so intriguing,” he said. “But I’m just doing what I’m doing to survive.”

NY Times

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Suits could force L.A. to spend huge sums on sidewalk repair

The civil rights actions claim that broken sidewalks and missing curb ramps violate the Americans With Disabilities Act. The city could be on the hook for hundreds of millions of dollars.

 

Brent Pilgreen, 53, is a quadriplegic. He is a plaintiff in one of the cases against the city of L.A.

 

Los Angeles may be the land of the freeway, but it is notorious for its bad sidewalks — buckled, cracked and sometimes impassable. By the city's own estimate, 42% of its 10,750 miles of pedestrian paths are in disrepair.

Now a series of civil-rights lawsuits against Los Angeles and other California cities is for the first time focusing attention — and money — on a problem that decades of complaining, heated public hearings and letter-writing campaigns could not.

The lawsuits were filed by disabled people who say broken sidewalks make it impossible for them to get around and seek repairs or improvements. The plaintiffs contend that the conditions violate the federal Americans With Disabilities Act, a tool that has been used across the country to force better access at restaurants, department stores, movie theaters and the like.

The tactics are already paying off. In the biggest sidewalk-related settlement in California, the California Department of Transportation in 2009 agreed to spend $1.1 billion over 30 years to fix state-controlled sidewalks, crosswalks and park-and-ride facilities.

Sacramento settled a similar case by agreeing to allocate 20% of its annual transportation fund over the next 30 years to make repairs and install ramps.

In Los Angeles, the city has settled two cases for about $85 million. That money will be used over the next two decades to build thousands of sidewalk access ramps at curbs.

But there are four other cases pending that could leave the city on the hook for hundreds of millions of dollars.

Fixing all of Los Angeles' sidewalks would be a daunting task: Officials estimate the cost of improving them all would top $1.5 billion. But advocates for the disabled hope they can make a measurable dent in the problem.

"The city has never developed a comprehensive plan to address this issue, even when economic times were good," said Surisa Rivers, an attorney with the L.A.-based Disability Rights Legal Center. "Such failure hasn't been a story about the city's inability to finance disability access, but the lack of political will to do so."

The campaign is being led by the disabled but is also winning support from advocates of alternative transportation. They argue the city spends far too much fixing roads and not enough making L.A. a more walkable place.

"We need to think of our streets as a place that we move people not just in their car, but on their feet, on a bike and on a bus," said Deborah Murphy, founder of L.A. Walks. "That's our public space…our streets are where we get together."

There is little dispute that the sidewalks are an embarrassment. But some officials question what the city can do when it already faces a $72-million budget shortfall.

"We got at this point because the city is not invested in its infrastructure," said Councilman Bernard C. Parks, who added that the problem is difficult to solve because "there is no money."

Disabled residents like 53-year-old Brent Pilgreen say bad sidewalks mean they are effectively unable to safely leave the block they live on. Pilgreen, who is quadriplegic and uses a motorized wheelchair,is a plaintiff in one of the cases.

"I can't make it north, south, east or west to any commercial business without having to go through some sort of gantlet or ride in the street and compete with cars," he said.

As a test, Pilgreen recently embarked on an arduous journey to the Denny's a few blocks from his home in Sherman Oaks. Even with a few recent improvements to the sidewalks, he couldn't make it because of a metal sign pole stuck in the middle of the path.

"If I want to go out of my house ... If I want to go up to the corner and buy an ice cream or anything, a soda pop, I can't go there," he said. "I have to have a secondary person with me to spot me and prevent me from falling."

City lawyers believe they can successfully defend against the lawsuits.

While repairing and maintaining roads has long been the duty of City Hall, the responsibility for sidewalks has a more murky history. Decades ago L.A. homeowners had to directly pay for their sidewalks through an assessment process.

That lasted until 1973, when residents complained and the City Council assumed responsibility for needed repairs because of damage from tree roots. Money for that work quickly ran out and officials have tried to reinstate the previous practices with little success, often maintaining that property owners already own the sidewalks and are responsible for repairs.

Nazario Sauceda, head of the Bureau of Street Services, said that for several years his department has received no funding for permanent sidewalk repair, which can cost $250,000 to $300,000 per mile.

Instead, city workers mostly rely on temporary measures: pothole-repair trucks dumping hot asphalt on cracks and breaks in the concrete pavement. But that can be an obstacle in itself because the asphalt creates protruding black bumps that are difficult to navigate in a wheelchair.

The sidewalks in Judy Griffin's West L.A. neighborhood are in such bad shape that she often rides her wheelchair in the street because she refuses to be sequestered in her home.

But it isn't easy. She has tipped over on Westwood Boulevard while trying to get to a physical therapy appointment, was struck by a motorist who didn't see her crossing an intersection, has powered through low-hanging branches and has fought seemingly endless battles with City Hall to improve the sidewalk on her own street.

Griffin said she often feels like a second-class citizen and is frustrated that city officials are not more empathetic to those with disabilities and have bigger projects in mind than fixing sidewalks and curbs.

"They're not sensitive to it and they have other priorities," said Griffin, who is a plaintiff along with Pilgreen in a class-action suit. "It's very easy to go for the big gold, to go for the stadium, rather than patch up the sidewalks for people you don't value."

LA TIMES

One Soldier’s Progress Against Traumatic Brain Injury

Sgt. Victor Medina, who suffered a brain injury from a roadside blast in Iraq, walks down the hall while tossing a tennis ball from hand to hand working on dynamic hand-eye coordination at Mentis Neuro Rehabilitation Center in El Paso, Texas

When Army Sgt. Victor Medina returned home from Iraq in the summer of 2009, his life was a shambles. His tour had been cut short after he suffered a concussion during a roadside blast. Though his injury wasn't visible, he struggled with balance and noticed that his ability to read, think and even talk had changed for the worse.

But in the spring of 2011, Medina became one of the first patients at the National Intrepid Center of Excellence, the military's $65 million, state-of-the-art treatment center for brain-injured soldiers.

During his three weeks at the Bethesda, Md., center, the staff developed a rehabilitation program designed specifically for Medina. His recovery has progressed rapidly ever since, he and his wife, Roxana Delgado, told ProPublica and NPR.

Medina has continued to work from El Paso, Texas, by videoconference with a speech therapist based at the center, and he said his stutter is improving. After his injury, he had struggled to read more than a paragraph; now he says he can read and absorb two pages in one sitting. Medina also was ordered to stop driving after his injury, but he told ProPublica and NPR that he has regained his ability to do that, too.

"It's like night and day," Delgado said of his improvement.

The couple believes that Medina benefited dramatically from media attention. In June 2010, ProPublica and NPR published stories about the couple's struggle to get medical treatment for Medina at Fort Bliss, Texas, where he was stationed at the time. The Army's vice chief of staff, Gen. Peter Chiarelli, denounced the reports at a hearing before the Senate Armed Services Committee as a "disservice ... to everyone." But a year later, Chiarelli flew the couple to Washington so they could talk privately to top commanders about their battles at Fort Bliss, and how to improve treatment for troops with TBI.

Last year, Medina became one of NICOE's first patients. He received more than 100 hours of personalized treatment from neurologists, psychologists, physical therapists and others at the center, a NICOE spokesman said. Medina also had access to some of the center's virtual-reality equipment, which is used to simulate ordinary civilian activities like crossing the street and driving a car. Delgado and Medina have become advocates for victims of traumatic brain injury, or TBI, the signature injury of the Iraq and Afghanistan conflicts. Last week, Delgado was invited to attend President Barack Obama's Stateof the Union speech as a guest of Rep. Silvestre Reyes, D-Texas, whose district includes part of Fort Bliss.

 

In an interview with ProPublica and NPR before the speech, Delgado said the invitation was "very empowering because it tells me that leadership and people in Congress are paying attention to traumatic brain injuries," she said.

But not every soldier with a brain injury has been as fortunate as Medina.

Delgado told ProPublica and NPR that she frequently receives calls from military wives who've had a hard time getting their husbands enrolled at NICOE, which has treated only about 200 soldiers since it opened in October 2011, center spokesman Joshua Stueve told ProPublica and NPR.

By comparison, recent estimates show that nearly 230,000 soldiers have been diagnosed with traumatic brain injuries, Stueve said. "We aren't going to make a huge dent in that population," said Stueve. Most of the center's $35 million budget is spent on research, not clinical care, he noted.

To get into the program, a service member must be referred by a physician at his or her local military hospital, agree to live with other soldiers in a group house near the facility, and plan to continue military service after treatment.

Brain-injured troops who don't plan on staying in the military have to rely on U.S. Veterans Affairs Department hospitals for treatment once they get out. But VA hospitals don't have the same resources or equipment as NICOE.

Stueve said troops at NICOE benefit from being treated by an "inverted system" in which a soldier has the opportunity to work with perhaps 10 doctors at once, instead of being at a hospital where there might be just one doctor for every 10 patients. The advantage, he said, is that a patient isn't shuffled to separate referrals from multiple specialists over the course of treatment.

Stueve said the center "doesn't keep data" on how many soldiers are rejected, and handles only 20 patients at a time for about four weeks of concentrated treatment.

"The real story here is patient experience," Stueve said. "The service members, when they come here, they feel like they are in control, and they play a huge part in their own treatment."

Delgado agrees but said she knows "that's not the case for all service members, because some are denied a chance to go to NICOE. This should be the standard of care for everybody."

The Pentagon plans to expand the NICOE system to other bases, Stueve said, but that effort could be stymied by pending defense budget cuts. The defense department is drafting a plan to cut $259 billion from its budget over the next five years.

The military is already having problems with its budgets for TBI and post-traumatic stress disorder. In a recent report to Congress, the Government Accountability Office said the defense department can't provide reliable data on how it spent $2.7 billion allocated to treat soldiers with brain injuries and psychological health problems.

 

PRIMARY BLAST INJURY

Traumatic brain injuries have been called the "signature wound" of the wars in Iraq and Afghanistan. While improvements in armor and battlefield medicine mean more soldiers are surviving bomb blasts that would have killed them in previous wars, the explosions are leaving some of them with permanent wounds. Mild traumatic brain injuries are difficult to detect as they leave behind no obvious signs of trauma. While many soldiers recover fully from the injury, others are left with persistent mental and physical problems 

An explosion generates a blast wave traveling faster than sound and creating a surge of high pressure followed by a vacuum. Studies show that the blast wave shoots through armor and soldiers' skulls and brains, even if it doesn't draw blood. While the exact mechanisms by which it damages the brain's cells and circuits are still being studied, the blast wave's pressure has been shown to compress the torso, impacting blood vessels, which send damaging energy pulses into the brain. The pressure can also be transferred partially through the skull, interacting with the bra

in.

SECONDARY BLAST INJURY

Shrapnel and debris propelled by the blast can strike a soldier's head, causing either a closed-head injury through blunt force or a penetrating head injury that damages brain tissue.

TERTIARY BLAST INJURY

The kinetic energy generated and released by an explosion can accelerate a soldier's body through the air and into the ground or nearby solid object. Once the body stops, the brain continues to move in the direction of the force, hitting the interior of the skull and then bouncing back into the opposite side, causing a coup-contrecoup injury.

 

ProPublica

 

Lucas and Juno: Special bond of a rescue dog and dying boy

Tennessee dad had a gut feeling that he could train the shepherd to help his son, 4

Lucas Hembree and his dog Juno. When his dad Chester saw a posting about her on a rescue group’s website “I had the feeling in my gut that I had to go see this dog,” he said.

As nearly anyone who has adopted a dog or cat from a shelter can attest, there’s something special about a rescued pet; it’s as if the animal senses he’s been given a second chance at life. That’s certainly the case with Juno, a Belgian Malinois who was rescued from a shelter just days before she was to be euthanized. But since coming to live with her family in Alcoa, Tenn., Juno has taken on the role of rescuer to four-year-old Lucas Hembree.

Lucas suffers from Sanfilippo syndrome, an inherited, metabolic disease caused by the absence or malfunctioning of an enzyme needed to break down long sugar molecules. As the disease progresses, children lose the ability to speak, walk and eat. The disease also causes severe neurological damage that leads to aggressive behavior, hyperactivity and seizures.

“The most catastrophic thing parents hear when they learn their child has this disease is that there’s no cure or treatment available,” says Lucas’ father, Chester.

Unless that changes, Lucas isn’t expected to live past the age of 15 and may be in a vegetative state by the time he is eight. Realizing that every moment is extra precious, Chester and his wife, Jennifer, want their son to experience as much as he can while he still has the capacity to enjoy it.

 

Juno calming Lucas in the hospital during a recent stay.

Prayer and persistence

So when the disease started to take a toll on Lucas’ joints, Chester looked into getting a service dog to keep Lucas steady when he walked. “I was told that a service dog would cost at least $15,000, and that Lucas wasn’t a good candidate because of his deteriorating abilities and his behavior,” Chester says. “I refused to accept this answer.”

A combination of prayer and persistence led Chester to Juno. “I came across a posting about her on a rescue group’s website,” he says. “I had the feeling in my gut that I had to go see this dog.”

The whole family made the two-hour trip to meet Juno, who was being held at an east Tennessee shelter. “She was emaciated, and was days away from being euthanized,” Chester says. “She had been surrendered to the shelter because her previous owners didn’t understand the Belgian Malinois.”

Fortunately, Chester did. He’d gotten to know and love the breed while working as a law enforcement officer years earlier.

“I used to help with the training of police K-9s, and our dogs were Belgian Malinoises,” he says. “I loved their desire to work and their ‘never quit’ attitude.”  In addition to being a popular choice for police dogs, the breed is often used in combat. In fact, it’s believed that the dog that helped Navy SEALs take down Osama bin Laden was a Belgian Malinois.

Showered with love and affection

 
But while the breed has proven its prowess on patroland in combat, Chester needed to be sure Juno would be a suitable service dog for his little boy. “I put her on a loose leash and she walked with me and never pulled,” Chester says. “Next came the Lucas test. They took to each other immediately, like kindred spirits.”

The Hembrees brought Juno home and showered her with love and affection.

“I wanted to make sure she had plenty of time to adjust to the family before I started the formal training,” Chester says. Yet, from the beginning there seemed to be something instinctive about their relationship. One day, Chester noticed Juno circling Lucas while he was in his wheelchair. “She was whining and nudging him with her nose,” Chester says. “I checked his oxygen levels and they were very low.” After giving him oxygen, Lucas returned to normal and Juno greeted him with licks and affection.

Lucas and Juno received more than 6,000 Christmas cards from well-wishers. This was the first batch.

 

“That’s when I knew she had the ability to pick up on his neurological changes,” Chester says. “Now she alerts us when Lucas is about to have a seizure or if his oxygen levels drop really low. She has saved him several times."

 

Juno has become a literal shoulder for Lucas to lean on when walking, and a calming influence when he’s agitated. And while Chester makes sure that Juno gets time off, he says that it’s hard to get Juno to leave Lucas’ side. “You don’t see one without the other close by,” he says. “It really feels like it was meant to be.”

NBC TODAY

Lucas's FaceBook Page

 

 

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Wheelchair users block Oxford Circus to protest at disability cuts

'We're not scroungers and fakers' say wheelchair protesters

Wheelchair users complain that they are seen as an easy target.

Disability activists blocked one of central London's busiest road junctions on Saturday with a line of wheelchair users chained together in the first of a series of promised direct action protests against government welfare cuts.

The demonstration, which brought much of Oxford Circus to a standstill for more than two hours, was the product of an alliance between disabled groups and UK Uncut, which came to prominence by staging similar direct actions against corporations accused of avoiding tax.

Planned cuts to the disability living allowance could see 500,000 disabled people losing money, the charity Mencap has said.

Many of those taking part said they had never before joined a demonstration, let alone taken such direct action, but felt angry at the proposed cuts and the associated rhetoric from ministers and the media.

"The tabloids have created this idea that we're scroungers, or fakers," said Steven Sumpter, 33, who left his home in Evesham, Worcestershire, at 6.30am. "This has allowed the government to do this [propose the cuts]. Disabled people are seen as a good scapegoat."

Merry Cross from Reading in Berkshire said disabled people needed to join together. "We're seen as quite an easy target," she said. "We don't necessarily live in the same places and we can find it hard to get together. That makes it easy for the government to think they can target us"

 

Guardian

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Pharmacists Failed to Flag Dangerous Drugs in Nursing Homes

A woman with a medical history of seizures was prescribed the antipsychotic drug Seroquel, despite research showing that elderly people who take antipsychotic drugs are more likely to experience seizures. She was also given the antidepressant Trazodone, which has been linked to an increase in seizures among older patients. And then, according to a recent investigation by the California Department of Public Health, the woman was given a second antipsychotic drug, Risperdal. The combination of the two antipsychotic medications, the investigators said, could cause “life-threatening arrhythmias (irregular heartbeats).”

 

Despite these potentially dangerous side effects, the pharmacist responsible for reviewing the prescriptions of the woman, a resident of the Greenhills Manor nursing home in Campbell, told state investigators that he had not noted these irregularities or addressed them in the patient’s chart.

 

 

Pharmacists responsible for reviewing the medication of patients in California nursing homes routinely allowed inappropriate and potentially lethal prescriptions of antipsychotic medications, and failed to correct other potentially dangerous drug irregularities, according to recent state investigations.

In reports obtained by The Bay Citizen, the department found that in 18 of the 32 investigations conducted in California nursing homes between May 2010 and June 2011 — 17 of the 32 were in the Bay Area — pharmacists failed to red-flag cases in which residents were inappropriately prescribed powerful antipsychotic medications like Seroquel, a drug used to treat schizophrenia. Pharmacists also overlooked or approved cases in which medications were prescribed at questionable levels or in unsafe combinations that could put patients at risk of seizures, accidents or even death, according to the public health department.

“The consultant pharmacists’ review, which is intended to identify unnecessary or potentially inappropriate drugs among nursing home residents, is defective in the state of California,” said Dr. Jonathan Evans, a geriatrician and the vice president of the American Medical Directors Association. He called the problem “widespread.”

The state investigations also suggested a “probable correlation” between the inadequate review of nursing home patients’ medications by pharmacists and the failure of those nursing homes to pay a fair market rate for the pharmacists’ services. A 1982 anti-kickback law requires nursing homes to pay a fair rate for pharmacy services to discourage consulting pharmacists from endorsing or extending the prescriptions of expensive, and potentially dangerous, drugs. A majority of the nursing homes where the state found patients who were inappropriately prescribed antipsychotic medications were paying below-average fees for pharmacy services.

 

The California investigations come in the wake of a report last year by the United States Department of Health and Human Services. The report revealed that, in nursing homes nationwide, at least 40 percent of all Medicare claims for so-called atypical antipsychotics, like Risperdal, are inappropriate, given in excessive doses, given for too long, given without the need for use, without adequate monitoring or “in the presence of adverse consequences” and should be reduced or discontinued.

By California state law, consulting pharmacists who work for nursing homes are required to review residents’ charts monthly, and recommend to prescribing doctors that medications be stopped, reduced or changed if they pose potential dangers or are causing harmful side effects. The state health department found in its investigations that pharmacists failed to identify the misuse of antipsychotic medications in 90 percent of cases. In 59 percent of those cases, violations occurred in nursing facilities that were cited for accepting pharmacy services below cost.

The average pay rate for California pharmacists is $56.29 an hour, according to the Bureau of Labor Statistics. But a review of nursing home records indicated that some were billed much less, in some cases as low as $11 an hour. The state anti-kickback law bans nursing homes from accepting below-market rates “from any pharmacist or pharmacy as compensation or inducement for referral of business to any pharmacy.”

“When pharmacy services are provided below cost, the pharmacist may be recouping the losses by making drug recommendations according to financial incentives instead of the best interests of the residents,” said Anthony Chicotel, a lawyer with the California Advocates for Nursing Home Reform, which plans to release a report on the state investigations. “When their independence is compromised, the integrity of their protective function is eviscerated.”

The state investigations yielded a number of examples where the pharmacists’ protective function appeared to be compromised.

At Hillside Senior Care nursing home in Fremont, for example, a consulting pharmacist was billed at a rate as low as $16.24 an hour, and no more than $19.16 an hour, between January and May 2011. In the same period, according to state investigators, a pharmacist at Hillside contradicted a doctor’s request to cut back antipsychotic medication.

“We have corrected this already with the department,” said Vilmar Agustin, Hillside’s director of nursing.

At the Herman Health Care Center in San Jose, investigators found that between August 2010 and January 2011, pharmacist services were billed for as little as $23.75 an hour and not more than $29.75. The state also found prescription irregularities.

Mandy Sollis, Herman Health’s business office director, wrote in an e-mail: “We did increase our rate of pay to the pharmacy per regulations.” She would not specify the amount, saying it was private.

In the case of the elderly woman in Campbell who was prescribed drugs that the state investigators said were potentially life-threatening, “With regard to the investigation, I know there was a deficiency and a plan of correction,” said Ed Basa, who had been the administrator at Greenhills Manor at the time of the investigation last June.

At the Empress Care Center in San Jose, investigators found that a resident was kept on Risperdal and that the dosage was increased “without evidence of effectiveness over an eight-month period.” Another patient was on the antipsychotics Seroquel and Haldol, despite side effects that included “continuous lip smacking and shaking of the arms and legs.”

The resident told investigators “he had been like that for a very long time.” But the state found nothing in the resident’s chart to indicate that he suffered from side effects.

In another case at Empress, the state found that a resident with dementia who “refused to shower, dress and be groomed” was prescribed Zyprexa, one of a group of medications called “atypical” antipsychotics, which the Food and Drug Administration warned in 2005 were not approved for use in elderly people with dementia because they increase their risk of dying. That warning was extended in 2008 to include older antipsychotic drugs like Haldol.

Administrators at the Empress Care Center did not return calls asking for comment.

Anita Gore, a spokeswoman for the California Department of Public Health, said the recent investigations prompted her agency to pass a regulation limiting the prescription of antipsychotics for Medi-Cal recipients in nursing homes to uses approved by the federal Food and Drug Administration.

As a matter of routine, Ms. Gore said, nursing homes found by the state to be deficient have 10 days to submit plans of correction, but they can request an extension. “There is no set deadline for submitting a plan of correction,” she said.

Mr. Chicotel of California Advocates for Nursing Home Reform said he was disappointed with the state’s response to its own findings. Mr. Chicotel said he was concerned that “not a single facility was issued a citation or fined.”

 

New York Times

A woman with a medical history of seizures was prescribed the antipsychotic drug Seroquel, despite research showing that elderly people who take antipsychotic drugs are more likely to experience seizures. She was also given the antidepressant Trazodone, which has been linked to an increase in seizures among older patients. And then, according to a recent investigation by the California Department of Public Health, the woman was given a second antipsychotic drug, Risperdal. The combination of the two antipsychotic medications, the investigators said, could cause “life-threatening arrhythmias (irregular heartbeats).”

Despite these potentially dangerous side effects, the pharmacist responsible for reviewing the prescriptions of the woman, a resident of the Greenhills Manor nursing home in Campbell, told state investigators that he had not noted these irregularities or addressed them in the patient’s chart.

Source: The Bay Citizen (http://s.tt/15pHo)

Disability Advocates To Join D.C. Council Chairman Kwame Brown To Voice Support For Wheelchair-Accessible and Green Taxis in D.C.

Cabs with New Benefits for All to be on Display as
D.C. City Council Transportation Committee Begins to Consider Legislation

 

 

WASHINGTON, D.C. –

National disability advocates and district residents who use wheelchairs will join
D.C. City Council Chairman Kwame Brown at a press conference to voice support for legislation thatwould pave the way for more wheelchair-accessibletaxicabs using clean-burning, less expensive,domestic natural gas as an alternative fuel.
 

Washington D.C. is one of a growing number of major cities -- including New York City, Chicago andPhiladelphia -- considering plans to dramatically improve their taxi fleets, making them cleaner andaccessible.

The D.C. City Council’s Committee on Environment,Public Works and Transportation is holding a hearing on the issue on Monday.Attendees and members of the news media will have the opportunity to view and tour the new vehiclesthat are equipped to serve the 14 million Americans for whom existing fleets are inaccessible.

The vehicles will be parked outside of the John A. Wilson Building where the event is occurring.
 

WHAT:
Rally to show support for legislation on new and better taxis for D.C.
 

WHO:

Kwame Brown, Chairman of the D.C. City Council
Mark Perriello, President and CEO, American Association of People with Disabilities
Kelly Buckland, Executive Director, National Council on Independent Living
James Weisman, General Counsel, United Spinal Association
Madonna Long, Consumer Advocate, Pride Mobility Products, Inc.
Fred Drasner, Chairman, Vehicle Production Group
Mark Riley, Vice President, Clean Energy
 

 

WHEN:

Monday, January 30, 2012, 10:00am ET
 

 

^WHERE:

Corner of Pennsylvania Avenue and 13 ½ Street NW
(Outside the John A. Wilson Building)
Washington, D.C.

AAPD

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For a Veteran, Disability Payment Is Long in Coming

The year Leroy MacKlem lost his veterans disability compensation for a bad hip, gasoline cost 27 cents a gallon, a Yankee shortstop named Rizzuto was the American League’s most valuable player and President Harry S. Truman ordered production of the hydrogen bomb. It was 1950.

He is about to get it back. All of it.

In a case as much about government bungling as one man’s perseverance, the Department of Veterans Affairs said last week that it would end years of litigation and repay Mr. MacKlem, 88, for six decades’ worth of disputed disability compensation, about $400,000.

“This case has been resolved, and Mr. MacKlem will receive V.A. disability compensation retroactive to April 1, 1950,” the department said in a statement.

To which Mr. MacKlem, a World War II veteran from Portland, Mich., replied, “I’ll believe it when I get the settlement.”

Mr. MacKlem’s case shines new light on a process, later disallowed by federal courts, that the department used in 2007 and 2008 to review large awards. The number of cases reversed under that process is not known, but Mr. MacKlem’s victory is sure to give hope to scores of veterans looking to appeal decisions from that period.

The case is also a reminder of how disputes over veterans’ benefits can drag on for decades after wars end.

Of the 850,000 disability claims currently pending before the department, more than 35,000, or 4 percent, are from World War II veterans.

“MacKlem is now the poster boy for all these cases,” said Mike Viterna, Mr. MacKlem’s lawyer and president of the National Organization of Veterans Advocates, a nonprofit organization. He called the retroactive award one of the largest he had ever seen.

Mr. MacKlem did not fight for his compensation after it was first rescinded, perhaps because he did not have the strongest of cases.

He enlisted in the Army in 1943 at the age of 19 and participated in the invasion of Sicily that year, legal papers show. But he developed hip pain so severe that the Army evacuated him that November.

Army doctors attributed his problems to a car accident that dislocated his hip in 1941, before he enlisted. Mr. MacKlem reported no pain during his initial Army physicals, but said he developed problems in basic training that worsened in North Africa.

In 1944, he received a medical discharge and was assigned a 20 percent disability rating for service-connected arthritis in his hip, entitling him to disability compensation. Mr. MacKlem later went to work in a plastics factory in Detroit.

But in 1950, the Veterans Administration, as it was then known, severed his compensation, saying that his pain resulted from the “natural progress” of his pre-service injury. His monthly payments of $105 ended.

And there the case sat for 56 years.

In 2006, Mr. MacKlem — for reasons his lawyer could not explain — decided to appeal, saying the department made a “clear and unmistakable error” in its 1950 decision. A regional office in Detroit rejected his argument, and he submitted a notice of disagreement.

Then a curious thing happened. Mr. MacKlem received a letter in June 2007 saying that a review officer had concluded that the 1950 ruling was indeed wrong and that he should be granted retroactive benefits.

Mr. MacKlem was not supposed to get that letter. But as it turned out, it was a lucky break for him that he did.

A few weeks later, the department sent him another letter saying that the June notice was only a draft and that his benefits would not be restored. He appealed. And while his appeal was pending, a federal court ruled in 2009 that the department’s “extraordinary award procedure” for reviewing compensation awards larger than $250,000 or for retroactive payments dating back more than eight years was illegal.

In 2010, the Court of Appeals for Veterans Claims ruled that the department had to reinstate Mr. MacKlem’s award because it had been reversed under that now illegal “extraordinary award procedure.” Even though the department might have had good reason to rescind his compensation in 1950, it would have to repay him all of it.

This month, a federal appeals court upheld that decision.

Mr. Viterna said that if the department had not sent Mr. MacKlem the June 2007 letter, he probably would never have known that he had been reviewed under the illegal procedure, and his case might have died.

Mr. MacKlem has now asked the department to hurry up its payment because of his age.

“I’ve always had the feeling that the government was hoping that I would die so they wouldn’t have to pay,” said Mr. MacKlem, a widower with no children. Disability payments to veterans with no immediate survivors are returned to the department, Mr. Viterna said.

Asked if the Department of Veterans Affairs had dragged out the case to avoid paying Mr. MacKlem, a spokesman replied, “That is simply not true.”

NY TIMES

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Depression’s Criteria May Be Changed to Include Grieving

A proposed change to the definition of depression could pathologize normal grieving and greatly expand the number of people treated for the mood disorder, researchers contend in a new report, the latest salvo in a bitter skirmish over the diagnosis that has gone on largely under the public radar.

The criteria for depression are being reviewed by the American Psychiatry Association, which is finishing work on the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., the first since 1994. The manual is the standard reference for the field, shaping treatment and insurance decisions, and its revisions will affect the lives of millions of people for years to come.

In coming months, as the manual is finalized, outside experts will intensify scrutiny of its finer points, many of which are deeply contentious in the field. A controversy erupted last week over the proposed tightening in the definition of autism, possibly sharply reducing the number of people who receive the diagnosis. Psychiatrists say current efforts to revise the manual are shaping up as the most contentious ever.

The new report, by psychiatric researchers from Columbia and New York universities, argues that the current definition of depression — which excludes bereavement, the usual grieving after the loss of a loved one — is far more accurate. If the “bereavement exclusion” is eliminated, they say, “there is the potential for considerable false-positive diagnosis and unnecessary treatment of grief-stricken persons.” Drugs for depression can have side effects, including low sex drive and sleeping problems.

But experts who support the new definition say sometimes grieving people need help. “Depression can and does occur in the wake of bereavement, it can be severe and debilitating, and calling it by any other name is doing a disservice to people who may require more careful attention,” said Dr. Sidney Zisook, a psychiatrist at the University of California, San Diego.

In blogs, letters, and editorials, experts and advocates have been busy dissecting the implications of this and scores of other proposed revisions, now available online, including new diagnoses that include “binge eating disorder,” “premenstrual dysphoric disorder” and “attenuated psychosis syndrome.” The clashes typically revolve around subtle distinctions that are often not readily apparent to those unfamiliar with the revision process. If a person does not meet precise criteria, then the diagnosis does not apply, and treatment is not covered, so the stakes are high.

“The world has changed” since the last revision, in 1993, said Dr. James H. Scully Jr., chief executive of the psychiatric association. “We’ve got electronic media around the clock, and we’ve made drafts of the proposed changes public online, for one thing. So anybody and everybody can comment on them, at any time, without any editors.”

Many doctors and therapists approve of efforts to eliminate vague, catch-all diagnostic labels like “eating disorder-not otherwise specified” and “pervasive development disorder-not otherwise specified,” which is related to autism. But a swarm of critics, including two psychiatrists who oversaw revisions of earlier editions, has descended on many other proposals.

“What I worry about most is that the revisions will medicalize normality and that millions of people will get psychiatric labels unnecessarily,” said Dr. Allen Frances, who was chairman of the task force that revised the last edition.

Dr. Frances, now an emeritus professor at Duke University, has been criticizing the current process relentlessly in blog posts and e-mails. Dr. Robert L. Spitzer, who oversaw revision of the third manual in 1980, has also voiced concerns, as have the American Counseling Association, the British Psychological Society and a division of the American Psychological Association. Some of the concerns have to do with important technical matters, like the statistical reliability of diagnostic questionnaires. Others are focused on proposed changes to the most familiar diagnoses.

Under the current criteria, a depression diagnosis requires that a person have five of nine symptoms — which include sleeping problems, a feeling of worthlessness and a loss of concentration — for two weeks or more. The criteria make an explicit exception for normal grieving, which can look like depression.

But the proposed diagnosis of depression has no such exclusion, and in the new study, Jerome C . Wakefield of New York University and Dr. Michael First of Columbia concluded that the evidence was not strong enough to support the change. “An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward,” said Dr. Wakefield, author of “The Loss of Sadness.” “This would pathologize them for behavior previously thought to be normal.”

But Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh School of Medicine and the chairman of the task force making revisions, disagreed, saying, “If someone is suffering from severe depression symptoms one or two months after a loss or a death, and I can’t make a diagnosis of depression — well, that is not being clinically proactive. That person may then not get the treatment they need.”

Another point of growing contention is a proposed new diagnosis, “attenuated psychosis syndrome,” which would be given to people who experience delusional thinking and hallucinations and sometimes say things that do not make sense. Psychosis is the signature symptom of schizophrenia, typically a lifelong, disabling mental disorder. Psychiatrists have long hoped for a way to catch it early, before it turns into full-blown schizophrenia.

But critics say these symptoms are poor predictors of the disorder. In studies, 70 percent to 80 percent of young people who report these strange experiences do not ever qualify for a full-blown schizophrenia diagnosis, yet the label increases the risk of being “treated” with powerful anti-psychosis drugs.

“There’s already overuse of these drugs in children and adolescents, and having this vague diagnosis, regardless of its intent, will only increase misuse in this vulnerable population,” said Dr. Peter J. Weiden, director of the psychosis treatment program at the University of Illinois at Chicago.

Some outside experts say the same is true of other proposed additions, like premenstrual dysphoric disorder (lethargy and other depressive symptoms in the week before menses, among other things) and binge-eating disorder (out-of-control bingeing, complete with self-loathing). Getting the diagnosis increases the likelihood of being treated for what is normal behavior, or close enough.

Task force members argue differently: If a person is in distress and seeking help, then treatment ought to be offered — and covered by insurance.

For now, these revisions are still in play; the completed manuscript is due to the printer in December. In the longer term, the politicking is likely to have a corrosive effect on the process, some experts said. Recent findings in genetics show that nature does not respect psychiatric categories — many different disorders seem linked to some of the same genetic glitches.

Already a federal agency, the National Institute of Mental Health, has set up its own independent effort to classify mental disorders, called Research Domain Criteria, based on research findings rather than existing categories.

In time, said Dr. Steven E. Hyman, a resident scholar at the Broad Institute of M.I.T. and Harvard, this kind of approach should ground the field more in nature and less in expert opinion. Until then, there is and will be the diagnostic manual.

 

New York Times

Stop calling disabled people scroungers

Disabled people are being demonised in the press as “work shy” and “scroungers” and as a result are facing hostility from the public and in some cases physical attacks.

 

In response, the NUJ’s Disabled Members Council has issued a statement urging journalists to operate within our recognised code of ethics, which calls on all NUJ members and media colleagues to “support and sustain fair and balanced reporting of matters relating to disabled people”. 

 

The council talks of a drip feed of stories relating to incapacity benefit fraud, when the facts show it is, at 0.3 per cent, the lowest of all welfare benefit frauds. Michelle Stanistreet, NUJ general secretary said:

“The NUJ stands up for fair and accurate reporting of disability issues. The union has a long-standing ethical code of conduct and provides reporting guidance to NUJ members.

 

“In the current climate we are asking all journalists to think long and hard before writing stories that whip up hatred against disabled people and those with long term health conditions. The NUJ is opposed to all prejudice and scapegoating based on a person's disability or perceived disability and this includes anyone who is targeted as a result of their physical disability, sensory impairment, learning disability or mental health.

 

“Our disabled members are reporting increased discrimination and physical attacks – so we have issued the following NUJ statement to raise awareness and express our solidarity.” 

 

NUJ Disabled Members Council Statement relating to media coverage of disabled people:

Over the last few months we have seen a continuous drip-feed of stories which have promoted a range of inaccurate and generalised accusations against disabled people with long term health conditions. As a result disabled people have faced greater hostility from the public, with many claiming that they have experienced hostility, discrimination and even physical attacks from strangers.

 

The majority of disabled people actively support legal action against those few who do falsely claim, but equally, Scope, and other charities agree that there is powerful evidence that a "backdrop of negativity" behind the cuts is leading to a rise in hostility and even violence towards some of the most vulnerable in society who fairly and correctly claim benefits. 

 

The Work and Pensions Select Committee on Incapacity Benefit have themselves criticised the Government for the language it uses when it releases and comments on official statistics on the incapacity benefit reassessment programme resulting in some media using terms such as "scrounger" and "work shy". 

 

Further investigation into the Government's own statistics on the incapacity benefit fraud rate reveal that this particular benefit has a fraud rate of 0.3% which is the lowest of all welfare benefits. Disability Living Allowance also has a low rate of 0.5%, again, much lower than other benefit rates.Rather than offering constructive support to disabled people, certain stories and features have portrayed disabled people as unsustainable, unproductive and even not disabled at all, but profiting from fraudulent benefit claims. However, little attention is paid to the poor performance of ATOS Healthcare in respect of their medical assessments which continue to be criticised by UK Parliamentary inquiries as well as by advocacy groups such as the Citizens Advice Bureau. Indeed the UK Department of work and Pensions is reported in 2011 to have by far the highest number of decisions overturned at appeal by any UK Department of State.The NUJ Disabled

Members Council calls on all journalists to continue to operate within our recognised code of ethics, which upholds the rights of all individuals and groups to fair and just representation. In line with our code the Disabled Members Council call on the NEC, all NUJ members and media colleagues to support and sustain fair and balanced reporting of matters relating to disabled people who are increasingly fearful, not just of the cuts being forced on them, but also of the continual demonising of disability.

 

National Journalism Union of Journalism

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