*UPDATE* I am happy to report that I have passed the internal medicine recertification! Next step in my life long learning plan: nephrology recert in 2011...

Click here to view my CNE Certificate

Dr. Michael L. Aaronson (Kidney Doctor / Nephrologist): Today I have the pleasure of interviewing Dr. Pierre Lavedan, M.D. Medical Director for palliative care and also a hospice physician for Alegent Health Hospice. Thank you Doctor for joining us today.

Dr. Lavedan: My pleasure.

Dr. Aaronson: What did you do prior to becoming medical director of the palliative care service?

Dr. Lavedan: I was a family medicine doctor for 12 years. I delivered babies for 10 years. I started with hospice care about five years ago.

Dr. Aaronson: Can you define palliative care for us in layman's terms?

Dr. Lavedan: Palliative care is attention to the patient and attention to symptoms a patient might have as the patient approaches the end of their life: We coordinate with social workers. We address the patient's spiritual needs and work with the chaplain. We focus on treating a patient's pain. We also take care of symptoms that take away from a patient's comfort such as shortness of breath, nausea, vomiting, diarrhea, constipation and other issues related to pain.

But also, palliative care is meant to be given in some circumstances alongside aggressive medical therapy. So if the goal is curative, that does not exclude the use of palliative care medicine.

Dr. Aaronson: I think that's a key take home message. To reiterate: I, as a kidney doctor, can perform dialysis, treat a patient with an intent to cure, and still use your services. The reason why I like to have palliative care involved, is that in the setting of a sick patient, sometimes curative therapy is futile, and the palliative care service can facilitate the transition from cure-focused, which may be uncomfortable, to comfort-focused which enables the patient to have dignity when they pass. You are there to help them with that transition.

Dr. Lavedan: We can also help the transition to hospice care, so a patient can be transferred out of the intensive care unit to their home or another facility.

Appropriate consultation to palliative care is the following: the diagnosis of chronic obstructive pulmonary disease or emphysema when the patient is requiring oxygen; the diagnosis of congestive heart failure; the diagnosis of kidney failure including the possible need for kidney dialysis...

Dr. Aaronson: I like to use you in this setting very often. Sometimes the decision of whether or not to perform kidney dialysis is quite complicated. I like to think of your service as a third-party independent team of people that helps the patient decide what to do. Just because dialysis is available doesn't mean a patient has to go on it.

Dr. Lavedan: My pleasure. We can also help patients who have diabetes and are approaching end-stage. End-stage means when the diabetes is starting to affect multiple organs: heart problems, eye problems, and kidney problems. In other words, everything taken together. Sometimes, despite what we do the patient is gets worse and not better.

Dr. Aaronson: Why did you decide that palliative care was your calling?

Dr. Lavedan: I was a part of the ethics committee prior to making the change. I felt that there was a lot of misunderstanding in terms of what can or what cannot be done.

Dr. Aaronson: That's a good point. The ethics committee is a group of people who may not be directly involved with the patient. Palliative care enables you the opportunity to discuss the situation with the patient or their proxy/durable power of health care directly.

Dr. Aaronson: I just wanted to let the public know that palliative care at Alegent health is growing at a rapid pace. Palliative care medicine is widely available.

Next question: For those who do not believe, here's a tough one for you. Why can't I do what you do? Why can't the primary care provider, who has known the patient for possibly 20 or 30 years, do what you do? What makes it worthwhile to have you on board?

Dr. Lavedan: Let me give you my perspective. As a family medicine physician, I look at life from beginning to end. As a palliative care physician, I look at life from the end to where we are currently at. I do this full-time, and I look at life backwards. I have totally reoriented the way that I view life. I think about how the patient is going to progress naturally, and I do everything I can to help anticipate and control symptoms so that the patient has comfort. In order to do this, it does takes special expertise. Just like you have special skills and expertise taking care of patients with kidney problems, hypertension, and critical care issues, my expertise is palliative care and hospice care. In fact there is a board certification in palliative care that is available and that I have passed.

Our team focuses on how much time is left, how can we help the patient and the patient's family. We also want to make sure that the patient and family address issues early so that a smooth transition can be had. This approach is much preferable to a series of emergencies.

For example, if the patient is living at home alone, is the patient doing that successfully? If you are driving, should you stop driving? If you are not living alone, if you are now living with your family because you need extra support and care, how are they doing and are they adequately planning for the time when more care is needed? If the patient's family is not able to perform a higher level of care, then what's the plan? Should the patient go to assisted living at this point? What about nursing home care?

Dr. Aaronson: I think that's a great explanation. I would add that you are also a specialist in pain control. I sometimes feel a patient's pain is under-treated, and I'm glad that you are there to take over that part of the patient's care.

Dr. Lavedan: We also are very helpful in the setting of when a patient wants something done and the patient's family wants something else done. We can help facilitate coming to a conclusion so that everyone is on the same page. We can help the family decide what should be done. The key here is to come at it from the point of view of what the patient wants, not what the family wants, not what the doctor wants. The focus is on what the patient wants or would want. Our goal is to try to help it all make sense.

Dr. Aaronson: What to do for fun?

Dr. Lavedan: Not a lot of time for fun. My main hobby for fun right now is sailing.

Dr. Aaronson: What you do in the winter? Do you ice fish?

Dr. Lavedan: No ice fishing. And no ice sailing -- that is when the ice freezes over and people actually sail on ice. Otherwise I spend my time taking care of my family. I have three children. They keep me busy. I have a lot of school and sports activities. We are active in the school church.

Dr. Aaronson: If someone is interested in using your services, what approach should they take to get you involved?

Dr. Lavedan: Since palliative care medicine is a specialty not a primary care practice, it is proper to go through the primary care doctor. Sometimes a specialist with the blessing of the primary care physician will call us directly to let us know about the patient's situation. Of note, we do have an outpatient clinic located at Lakeside.

Dr. Aaronson: Thank you so much for your time today. I think we've all learned quite a bit.

Dr. Lavedan: Thank you for the opportunity.

Dr. Aaronson: Here is the link to the palliative care website at Alegent health. Thanks for listening!

I received the mist version of the H1N1 flu vaccine. Since I received a live virus, I wondered if I kissed my children more than I usually do whether or not I would be able to transmit inactivated virus to them and therefore protect them from obtaining the real Mccoy. Dr. Dave Quimby with Infectious Disease and Epidemiology Associates was gracious enough to grant me an interview to answer this question as well as some others that I had.

Aaronson: H1N1 influenza virus: what’s the latest? Has anything changed?

Quimby: Not really. One new development: If a person contracts this virus, becomes sick and has to be admitted to an intensive care unit and is unable to take medications orally like tamiflu, there are some new antiviral drugs that we can obtain from the centers of disease control that can be given intravenously.

Aaronson: You and I have been involved in taking care of some patients who have been really sick in the hospital with H1N1. Some have done well, others have not. In your opinion, if someone is sick enough to get admitted to the hospital, what predicts whether a patient will do well or not? If Alegent Nephrology gets called because of kidney failure, what is the patient’s prognosis compared with not having kidney disease?

Quimby: The more organs that shut down, the worse off you are. If the kidneys have failed the person is at high risk.

Aaronson: Is the H1N1 influenza vaccination still effective?

Quimby: It is as effective as any flu vaccine.

Aaronson: Have there been any changes or mutations in the H1N1 bug?

Quimby: There have been a handful of cases where the H1N1 flu was resistant to Tamiflu. But those are very, very few and far between.

Aaronson: Why are some people afraid of the vaccine?

Quimby: Because of a lot of incorrect information out there, you’re going to find people afraid of any type of vaccine. There’s no more reason to be afraid of this vaccine than any other vaccine. The vaccine is safe. I got it. You got it. I gave it to my two and half year old who qualifies under the guidelines.

Aaronson: I would like my kids to get it, but availability of the vaccine is hard to find. Alegent does have a phone number people can call (402-717-H1N1) to check availability and to schedule an appointment. My understanding is there will be more vaccine available soon. I encourage all my patients and everyone I know to call that number and get on the list so they can get their vaccine as soon as possible. If a person has a choice between the mist and the shot, which one should they choose?

Quimby: Because of the shortage, I would go with whichever one a person can get their hands on. If a patient has a bad medical condition such as leukemia or is receiving chemotherapy, I would not recommend a live vaccine in general. I would just do a shot.

Aaronson: Let’s talk about the standard flu shot. There are people who opt out of receiving a regular influenza shot, thinking "if I get the flu, I get the flu. I’ll take the risk." Now that we are at risk for contracting swine flu, should this opinion change?

Quimby: In general, people usually mistake the common cold for the flu. Actual influenza even in a healthy person, will knock you down for a week and a half. People I see who get the real flu learn how horrible it is and usually decide to get a flu shot yearly from that point on. The reason why H1N1 is so virulent [infectious] is that people have never seen this new strain, and they have no partial immunity to it. The reason why H1N1 can kill healthy people so easily is that it is different from anything most of us have seen before.

Aaronson: Why can’t a person get both the standard flu mist and the H1N1 mist at the same time?

Quimby: I don’t know. But there such a shortage of both of them that it usually is not a big issue at this time.

Aaronson: As you know, I got the H1N1 flu mist. I was wondering if I kissed my children more than I usually do if I could give them an inactivated form of the virus and protect them from the real thing. Is that crazy?

Quimby: It’s not crazy, but it’s not likely to work. The mist is a live virus that has been weakened. Therefore the chance of spreading it person to person is exceedingly low. Since the virus is so weak, it’s very unlikely that it will make you sick. So although well intentioned, your display of affection most likely was just that.

Aaronson: There is a concept called to herd immunity that infectious disease folks like to talk about. Wiki defines it as "a type of immunity that occurs when the vaccination of a portion of the population (or herd) provides protection to unprotected individuals. Herd immunity theory proposes that, in diseases passed from person to person, it is more difficult to maintain a chain of infection when large numbers of a population are immune. The higher the proportion of individuals who are immune, the lower the likelihood that a susceptible person will come into contact with an infected individual."

So here is my question, if many people in Omaha and its surrounding areas get vaccinated, are the ones that refuse or can’t get vaccinated protected from infection? Does that concept apply here?

Quimby: Not really in this case because the H1N1 flu is so easily spread to others, unless almost all of the people in Omaha get vaccinated, if there’s any flu virus around, those not vaccinated are still at very high risk. These unvaccinated people are at high risk because of the way H1N1 is transmitted person to person. So people need to get their vaccine. Make sure you bold that. Right now, we don’t have enough vaccine to give to everybody, and that’s why we risk stratify – we give it to those who need it the most.

Aaronson: And the Alegent hotline, 717-H1N1, does just that. I would encourage our readers to pick up the phone and give a call so that they can get vaccinated as soon as possible.

Quimby: That is correct. It should be noted that once more vaccine becomes available, anyone who wants it will be able to get it.

Aaronson: I’ve seen in the news the suggestion that now that the first wave of infectious H1N1 has passed through Nebraska the need to get vaccinated has lessened. Since I am a kidney specialist who spends a lot of time in intensive care units helping to take care of very sick patients, I’ve seen some really bad cases of the swine flu. I disagree with the thinking that the unvaccinated population is safer now than before. Is my thinking based on a referral bias, where I think a certain way because I’ve seen the small percentage of people who’ve gotten so sick that they have needed to be admitted to an intensive care unit for support and therapy? Since infectious disease specialists such as yourself are also consulted on these patients, you know what I’m talking about. Are we safer now?

Quimby: No. It is still very important to get vaccinated when you can. Many people still have not been exposed in any fashion to H1N1. So the risk will still be there until H1N1 goes away, you get actual herd immunity from vaccines, or you get actual H1N1. Since most people have not had the flu vaccine or the flu, the risk of getting it is still very high. There are still many people who can get it and that keeps this terrible infection going.

Aaronson: So let’s pretend that I am a patient, and I have cold symptoms. I’m worried that I have H1N1. I go to my primary care Physician and ask the question should I be tested for H1N1? How would you answer?

Quimby: A nose swab can be done in a primary care setting. The problem is that this rapid test for influenza type A is NOT the H1N1 influenza virus. There is a cross reaction, so a positive test implies that there is a possible H1N1 infection. The problem is that a person can test negative and still have H1N1. So in other words, if a person actually has H1N1 influenza, the immediate test done it in a primary care office setting is positive six out of 10 times, which is basically the same as flipping a coin.

Aaronson: That’s why I don’t recommend it unless I’m worried about standard influenza A or B virus. However, I do think it is important for people who are concerned and get sick very quickly to go to their doctor as soon as possible to see if they are a candidate for Tamiflu.

Quimby: I base this diagnosis for the most part on the patient’s clinical picture. How they present.

Aaronson: Thank you professor for your time. We appreciate hearing your expertise on this issue.

In sum, remember to call 717-H1N1 if you have not gotten your H1N1 vaccine yet and get vaccinated as soon as you can! You can also visit the Alegent Health Flu Center for the latest updates. Thanks for reading.