Dementia has been slowly stealing Ruth Perez’s memory and thinking ability for 20 years. Her daughter, Angela Bobo, recalled when it was clear that her mother was never going to be the same.

“She would put food together that didn’t belong together — hamburger and fish in a pot. Mom never cooked like that,” she said.

The mother and daughter live together in Yeadon, Pa., just outside of Philadelphia.

Perez is literally in the center of the family. She spends much of her day tucked under a fleece blanket on a recliner in the middle of the living room. The 87-year-old doesn’t seem to notice as her daughter and grown grandchildren come and go, but they keep up a steady one-sided conversation with her anyway.

“If I kiss her, she might lean towards me, and sometimes she’ll nod,” said Bobo. “What she can do, at times, is smile at you and say a word like, ‘uh huh.'”

Perez can’t lift her arms or move her legs.

A rotating crew of family members takes turns caring for her. They are experienced and they have routines and schedules, but a few months ago, the pressure of lying in one place created a small blister on Perez’s hip. The blister burst and that became a bedsore and wouldn’t heal.

“I couldn’t get it to go away,” Bobo said. “When I say we were at our wits’ end to fix this, we were beyond there.”

About 44 million Americans are unpaid family caregivers like Bobo — sometimes for a child with special needs, more often for a frail older adult, according to a 2015 from the National Alliance for Caregiving. They are often women with a full-time job and children, though now 40 percent of caregivers are men, and millennials are becoming more involved in caring for someone at home, says , CEO of the Caregiver Action Network.

“In too many cases, people just learn this stuff by themselves and that’s really kind of dangerous,” Schall said.

That’s because many people don’t have the necessary skills. Thirty-three states have adopted legislation requiring medical centers to give caregivers basic training or instructions when a patient heads home from the hospital, though how this is carried out is largely up to the hospital.

Ken Everhart, a retired tech guy from North Carolina, became a caregiver for his wife, Genie, for just a few months 10 years ago, when the two were in their mid-50s.

“What we needed was for someone to sit me down in a class and say, ‘Here’s how you change the sheets while she’s still in the bed. Here’s how you take her blood pressure. Here’s how you monitor her breathing,'” Everhart said.

He worried he’d drop her as they struggled to get to the bathroom. He wasn’t sure when to call 911. That uncertainty weighed on Ken — especially when Genie was rushed back to the hospital three times.

“I had given her a straw to drink out of, and a sippy cup, and I went to make a phone call. I wasn’t gone five minutes and I came back in and she was choking,” he said. “I should have sat her up, and I should not have allowed her to have anything to drink while I wasn’t in there to watch. But I didn’t know that.”

Many families can’t afford to use trained caregivers. Hiring help at home for just a few hours a week can cost $10,000 to $15,000 a year.

“When patients leave the hospital, they generally leave quick and sick,” said Susan McAllister, medical director of quality in the Division of Hospital Medicine at Cooper University Health Care in Camden, N.J. Her team includes the social workers, home health nurses and others who help plan a patient’s discharge from the hospital.

McAllister said these days it’s common to come in with a heart attack, get medicine to open a blocked artery, and leave just 48 hours later. The short hospital stay isn’t a problem, she said, but the transition home has to be done right.

In October, Minnesota became the latest state to pass laws to prepare potential caregivers to know what the sick person may need. California, New Jersey, Oklahoma and New York also have versions of a Caregiver Advise, Record, Enable (CARE) Act. Across the country, has lobbied strongly for the proposals.

These laws generally require hospitals and rehabilitation facilities to record the name of the caregiver in the patient’s medical chart. Medical centers and rehab centers must offer caregivers basic training or instructions, and the caregiver is supposed to be notified if a patient is discharged to another family member or back home.

McAllister said years ago, Cooper realized it needed to do a lot more to make sure people were healing safely at home. From day one, caregivers are part of discharge planning, she said. On day two, a social worker might help the family shop for help at home.

“On day three, we may start teaching inside the hospital,” McAllister said.

Hospitals don’t get paid more for those extra steps. But now Medicare hits medical centers with a financial penalty if too many patients bounce back to the hospital and have to be readmitted. The federal government’s was created under the Affordable Care Act.

Many at-home caregivers say the responsibility weighs heavily.

“It scares you,” said Angela Bobo. “When I’m in pain, I can tell you. She can’t tell me that’s she’s in pain.” So when her mother’s bedsore wouldn’t heal after so many days, Bobo said, “That’s when I said: ‘I’m going to take her to the doctor’s, because I don’t know what’s going on with this.’ “

Bobo took her mother to the doctor, and he basically wrote a prescription saying her mom needed more help. That way, Medicare paid for skilled nursing care at home, and Angela Bobo got lessons in cleaning and dressing her mother’s wound. Now she knows what to expect.

“I told her it’s going to get worse before it gets better,” said David Wilson, a registered nurse from who went to Bobo’s house. He’s a wound-care specialist whose job is house calls.

“To get a wound better, you have to remove the dead tissue and start from the ground up,” Wilson said.

Some nurses come to the house, do their job and leave, but Wilson said teaching is part of his work. Lots of times he’s the one nudging reluctant family caregivers who worry they’re going to do the wrong thing.

“I will tell you in home care, the biggest thing is fear,” Wilson said.

Wilson made several visits. He recommended a new wound-care regimen for Ruth Perez’ bedsore, and Perez got an airflow mattress that relieved the pressure on her skin. Medicare paid for that, too. The nurse returned several times to check on the family, and Bobo said that gave her more confidence that she was doing the right things to care for her mother.

This story is part of a partnership that includes WHYY’s health show , and Kaiser Health News.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Yana Shapiro is a partner at a Philadelphia law firm with an exhausting travel schedule and two boys, ages 9 and 4. When she feels run-down from juggling everything and feels a cold coming on, she books an appointment for an intravenous infusion of water, vitamins and minerals.

“Anything to avoid antibiotics or being out of commission,” the 37-year-old said.

After getting a 100-milliliter drip of a liquid the clinic calls  pumped directly into her bloodstream via a needle in her arm, Shapiro said she feels like “a new person.” The infusion, which costs $179, takes less than a half-hour. While she waits, she can recline in one of the cushy seats, watch the 64-inch, flat-screen TV or dim the lights in the room.

“I take this time as ‘me time’ — to relax and kick back and close my eyes for a couple of minutes,” she said.

But if you mostly eat your kale and quinoa, why would you need a boost of vitamins delivered straight to the vein? Skeptical physicians say you probably don’t need it. A healthy gut absorbs all the nutrients we need from food. And anyone well enough to drink fluid, they say, can get all the rehydration they need by mouth.

Still, clinics that market treatments of intravenous fluid to the stressed out and worried well can now be found nationwide.

Shapiro gets her infusions at in Philadelphia, but there are similar clinics in New York, Las Vegas, New Orleans, Santa Monica and Dallas, with names like or . The first wave of such companies billed their treatments as a remedy for excess alcohol and partying or too little sleep. You could get the treatment in a mobile van parked at a music festival, say, or in your hotel room.

Newer firms offer a menu of drips that claim to help , balance hormones, improve chronic medical conditions or simply give the skin a healthier glow.

Osteopathic medicine physician Jason Hartman, who launched RestoreIV with a partner out of his Philadelphia , said people want the experience he offers. Hartman’s specialty is using touch to diagnose and treat patients.

He sometimes helps people remedy a hangover, he said, but his business also includes people with more serious illnesses, including chronic fatigue and migraines. For those patients, he says, IV treatment supports healing. Other clients are generally healthy and want to stay that way.

The basic IV therapy cocktail includes vitamin C, zinc and B vitamins. If you have a headache, the doctor might add a little magnesium.

“These are your natural pharmacy,” Hartman said, “and in chronic diseases these things can be depleted [by] just a stressful lifestyle. And if they become deficient enough, it alters your internal pharmacology enough to possibly manifest as a symptom or disease.”

The promised benefits of this sort of intravenous treatment vary from company to company.

At the bottom of the website for , you’ll find this warning:

“These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease. This service is intended only for healthy adults.”

Hartman said any intravenous infusion comes with a small risk of infection — or pain, bruising or bleeding if the needle misses the vein. Moreof an IV treatment can include a blood clot, or inflammation of the vein.

And people with certain medical conditions — some metabolic diseases, for example, or congestive heart failure — shouldn’t get these treatments, Hartman cautions. That’s why, he said, his clinic questions every client about their medical history before a treatment begins.

At RestoreIV, the treatments cost from $150 to $200, and there’s an initial $35 fee to consult with the doctor. The business doesn’t accept health insurance; patients pay Hartman’s office directly.

So, with the out-of-pocket expense, and only anecdotal evidence of benefit, why do people sign up for these sessions?

, a doctor of naturopathic medicine and health researcher at the Yale School of Medicine, said that if an IV infusion of this type makes people feel better, it’s probably because of the placebo effect. And the placebo effect can be powerful.

Several years ago, Ali and his colleagues tested a popular IV treatment called the  on a small group of people with fibromyalgia, a syndrome of muscle pain and fatigue that can be hard to ease. Half the 34 participants in his got Myers’ intravenous cocktail of vitamins and minerals in weekly treatments for eight weeks, and the other half got without vitamins.

“The interesting finding,” Ali said, “was that everyone got better.” People in both groups reported less pain, and said they were better able to do the things they need to do every day.

The placebo phenomenon is more complicated than many people understand, Ali explains. Research has shown, for example, that injections, or other invasive procedures, can generate a than dummy pills do.

If, as in the case of his study, people feel a fairly innocuous treatment is helping them, and they haven’t been able to get relief in other ways, that may be a reason to use it, Ali said — even if the “fix” is 100 percent placebo effect.

“When your child falls down and scrapes their knee, you give them a kiss,” he said. “There’s value in that, whether or not there’s clinical trial data showing that giving a kiss is better than doing nothing.”

Still, Ali said he can’t ethically recommend the intravenous vitamin treatments for healthy patients.

“If people are just using it to feel good or for an energy boost,” he said, “I would just say go exercise for 30 minutes and you’ll get more out of that.”

This story is part of a partnership that includes , and Kaiser Health News.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

When a young African-American man dies in the city of Philadelphia, more than half the time there’s one main reason why, says Scott Charles.

“It’s because somebody pointed a gun at him and pulled that trigger. It’s not because of cancer; it’s not because of car accidents; it’s not because of house fires. It’s because somebody pointed a trigger,” he says.

Charles is at Temple University Hospital. The medical center now offers bystander first-aid training, called Fighting Chance, to give friends and family something to do in the minutes before help arrives.

At 6 o’clock one evening, kids run around while their parents and neighbors gather in an elementary school cafeteria. There are training stations set up, and at the back a nurse is showing people how stop blood flow from a gunshot wound.

“The pressure point is located on the inside of the arm,” he explains. “And basically, you’re going to take your hand and get up underneath the inside of the arm and clamp it down.”

Each person takes a turn, taking an old towel or T-shirt and wrapping it around the fake bloody arm tight until help arrives.

Everyone’s talking, but emergency medicine doctor Tim Bryan’s voice is the loudest. He’s a Navy veteran, a former combat medic, and he’s used to giving commands. A shooting scene is chaotic and frightening, but Bryan says in just two hours of training, people get enough of the basics so they will know how to respond.

“You have that ‘aha’ moment and people are like, ‘Wow, I can do this. I can control the scene. I can remember to call 911 and tell the person to put direct pressure on even if I don’t do anything else.’ And it does make a difference,” he says.

The topic is serious, but the mood isn’t. Alice Kellam, 63, wears a camouflage tracksuit and rhinestone hoop earrings. She’s chatty and laughs with friends all evening — except when she talks about her husband, who was murdered in 1990. She doesn’t have a lot to say about that, except that it was senseless.

“They took his sneaks and his hat. That was it,” she says.

Many people in this North Philadelphia neighborhood have a story about someone and remember a moment when they felt helpless.

Louise Smith (“Everybody calls me Miss Midge,” she says) is a perpetual volunteer, and at the big summer block party at 12th and Cambria, she’s the lady who hands out the flavored water ice.

“About a year ago, we seen a shooting around here,” she says. “It was a shame the two boys died right on the sidewalk, there wasn’t nobody there to help them.”

A severely injured person can bleed to death in less than 10 minutes. But it can take much longer for police to arrive and calm the situation, so the trainers teach the class how to move a victim away from danger and flying bullets.

Registered nurse Maureen Quigg explains how to do a two-person lift-and-carry.

“The knee closest to the victim is down and the other knee is up, and that’s what you stand up with, the power from your legs and not your back,” she says.

Quigg reassures the smaller women that they indeed can help a 200-pound person.

“If it’s someone you care about or in a situation where there’s a lot of activity, your adrenaline is going — you have all this extra energy, you have all this extra power,” she says. “And if you focus on doing it and doing it the right way, you can lift someone you’d never think you could lift, and you can do it without hurting yourself.”

Advocates say learning first-aid skills to stop bleeding is the essential step in bystander education, not unlike learning CPR or making sure a defibrillator is nearby to jump-start someone’s heart. The federal Department of Homeland Security provides an introduction to these lifesaving techniques online in its program.

At the end of the evening, the trainers stage a minidrama to test the group.

Bryan sets the chaotic scene and calls out directions. One person is the victim. There’s a pretend shooter.

“Remember, you can ask somebody: ‘Help me control the scene.’ That’s good,” he calls out.

Charles helped develop the first-aid education program after a local resident came to him to complain that he was sick and tired of hearing about young men who died before getting to the ER.

“As we wait for laws to be changed, many people are going to find themselves on the wrong end of a gun,” Charles says. “While those things are certainly important, we have to put the power in people’s hands to address this issue.”

The goal is to saturate one neighborhood with people who have basic lifesaving skills. About 250 people have been trained so far.

This story is part of a reporting partnership with NPR, WHYY’s health show and .

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

To hear a patient’s heart, doctors used to just put an ear up to a patient’s chest and listen. Then, in 1816, things changed.

Lore has it that 35-year-old Paris physician was caring for a young woman who was apparently plump, with a bad heart and large breasts. , an obstetrician at East Tennessee State University who collects vintage stethoscopes, said the young Dr. Laennec didn’t feel comfortable pressing his ear to the woman’s bosom.

“So he took 24 sheets of paper and rolled them into a long tube and put that up against her chest, listened to the other end and found that not only could he hear the heart sounds very, very well, but it was actually better than what he could hear with his ear,” Davis said.

Or, maybe it was poor 19th century hygiene — lice and the smell of an unwashed body — that kept Laennec from getting too close to his patient.

Either way, he went home and crafted a wooden cylinder with a hole down the middle and that became the first stethoscope.

It took a while for the art of listening to the body through a tube to catch on. But the new tool fit into an evolving idea that doctors needed a more focused approach to diagnosis, “that you should distinguish tuberculosis from a lung abscess — and not just call it all consumption,” said , a professor at Drexel University College of Medicine.

He said doctors used to get praise if they had the “ear” to hear and interpret the subtle body sounds that travel through a stethoscope’s rubber tubing; the stethoscope is the iconic symbol of a physician.

, a first-year student at the University of Pennsylvania’s Perelman School of Medicine, is still getting used to hers.

“You don’t realize until you are wearing it and trying to use it, how pokey it is in your ears,” she said. “I’m almost embarrassed to wear it because it implies I have knowledge I don’t have yet.”

Medical schools teach the art of listening.

“I am astounded at the things I’ll find with my stethoscope,” said , a third-year student at the Perelman School of Medicine. “I had a patient who had pneumonia, and it was really wonderful to be able to listen to her and say, ‘This is what I think it is.’ And then, later, see on the chest X-ray that, that was exactly what it was.”

But some argue that the stethoscope is becoming less useful in this digital age. , an emergency medicine physician at Mt. Sinai Hospital in New York, said clinicians now get a lot more information from newer technology.

An ultrasound, for example, turns sound waves into moving images of blood pumping and heart valves clicking open and shut; those visual cues are easier to interpret than muffled murmurs and may produce a more accurate diagnosis, Nelson said.

He admits the stethoscope is an icon, but doesn’t buy the argument that if you lose the stethoscope, you lose the tradition of “healing touch.”

“Pulling an ultrasound machine out of my pocket, or wheeling the cart over next to the patient [and] talking through with them exactly what I’m looking for and how I’m looking for it — the fact that they can see the same image on the screen that I’m seeing, strengthens that bond more than anything in the last 50 years,” Nelson said.

Nelson is 42 years old and graduated from medical school 16 years ago. He teaches medical students and said it’s helpful to show new learners what “lies beneath.” At Mt. Sinai, when medical students are taught to examine a heart, they learn how to use the stethoscope and an ultrasound machine on the same day.

“They know how to feel it, they know how to listen to it, and they know how to look at it,” Nelson said.

Still, obstetrician George Davis wants to keep the stethoscope around for a while. High-tech machines and imaging scans are great backup resources, he said, but his stethoscope helps him figure out which patients actually need additional testing.

“How much do those ultrasound machines cost?” Davis asked. “I can get a good stethoscope for less than $20. We are not going to sit there and do an echocardiogram on every patient who walks through the door.”

Davis worries that a whole generation of doctors is learning to rely too much on technology; he wants to hold on to first-line tools that are safe, effective and cheaper.

“Shouldn’t we be using what is low-tech and practical?” he asked.

Nelson counters that point-of-care imaging is becoming less expensive every day. Twenty years ago, he says, an ultrasound machine was as big as a refrigerator and cost $400,000. Today, a handheld, portable device plugs into a computer tablet, and costs less than $10,000.

Many care providers in the community may even have an ultrasound in their pocket one day soon, he says, combined in a single device with, “a slide rule, a calculator, a flashlight, a phone, a computer terminal and 36 video games.” In other words: on their smartphone.

This story is part of a reporting partnership with WHYY’s health show , and Kaiser Health News.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

The gym at Riverside Correctional Facility in Philadelphia is through the metal detector, two heavy doors and down the hall.

There’s a basketball court like one you’d see at any high school, except there’s a corrections officer on guard near the three-point line.

Sixteen stationary bikes are set up in a half circle in the corner. On bike number two, Lakiesha Montgomery, 32, from Philadelphia, is pedaling fast and singing along to the Nicki Minaj’s song “Fly.”

“I didn’t think I’d be able to keep up, I’m not the skinniest thing in the bunch,” she says.

But she is keeping up.

In 2011, biking advocates from the nonprofit group persuaded prison administrators to let them bring in bikes to teach indoor cycling. Founder Kristin Gavin says before that she had mentored ex-offenders in the community.

“Over and over I had conversations with women who were saying, ‘While I was incarcerated, I put on 60 pounds, I put on 70 pounds,’ ” she says. Then she would ask them how long they were in prison and she says they’d typically respond, “six months.”

At Riverside, Montgomery spends time in the prison yard most days but doesn’t get much exercise there.

“The outside is not a real outside, it’s like a mini garage. They have a basketball court there, but I don’t play basketball. It’s a lot of people that come out so you don’t have room to really jog or walk. It’s like you sit out to just get some air,” she says.

She has arm tattoos and a sprinkle of freckles across her nose. Her hair is braided back into cornrows. She also has high cholesterol.

Montgomery was charged with assault this year, among other charges, and has been in county jail for about six months.

“First time, last time,” she says. In the meantime, spin class is something to do.

“Keep away frustration being locked up, it helps you get through,” Montgomery says.

The Department of Justice surveyed the health of state and federal inmates in 2012 and found that women are more likely than men to be obese.

A study of prison health in Kentucky found greater weight gain for women compared to men. Women on average gained nearly 11 pounds, men only gained 2.5 pounds.

Gearing Up is working with researchers at Temple University to track the weight and body image of the women who spin at Riverside Correctional. The study was just eight weeks long and small, but they’ve already found small improvements in resting and recovery heart rate—two preliminary measures of heart health.

Gavin says often the women come to class initially to stop gaining weight then later find other reasons to keep coming back.

“I can speak to myself, if I weren’t given the opportunity to be physically active, I’d probably go a little crazy. I probably wouldn’t be able to manage my emotions, my temper, my anger. I think anger management is a huge issue for a lot of women who are in prison; they are victims of trauma and abuse,” Gavin says.

And, of course some of the women have hurt other people.

Exercise can be a way to release all sorts of emotions.

Erica Tibbetts from Gearing Up often leads the spin class.

Tibbetts is in bike shorts. Everyone else has on prison blues: long navy pants and a white t-shirt.

“The worst seems to be women don’t have good sports bras in here,” she says.

No one has a water bottle and exercise shorts aren’t allowed. Tibbetts says the women come to class anyway and work with what they have.

Climb on a bike and there’s a sense of freedom, even if you’re not going anywhere.

At the beginning of class, one by one, the women call out their intention for the ride. The ritual is called “clearing.”

Christina wants to leave behind shakedowns. Jean wants to forget “cough and squat.”

Sheik is leaving behind “wrongful mistakes.”

Others want to shake off the past, stress and depression.

In a 2010 survey, women at Riverside gained about 36 pounds in a year, on average. But after some changes at the facility, that weight gain dropped to 26 pounds when the medical team checked again in 2015.

Bruce Herdman, the prison’s chief of medical operations, says weight gain is a problem, but it’s not the most urgent health problem his team is managing.

“The chlamydia rate — 6.6 percent on admission. We’ll treat a thousand people for HIV. The hepatitis C rate here, largely because of intravenous drug use, is 13 percent. Then you have hypertension, diabetes, all the regular things,” he says.

The prison pays Gearing Up to hold spin class three times a week. There’s also an occasional yoga class, but the big change affecting women’s weight was the food. The meals are certified heart healthy by a nutritionist. There’s a lot of it, but portion sizes are smaller now. Last year, the prison cut calories from nearly 2,900 a day to 2,500 for men and women.

That helped, but the facility-provided meals aren’t the only food around. Inmates also make do-it-yourself meals with food from the prison commissary. A favorite is called “chi-chis.”

“It’s where you mix Ramen Noodles with cheese puffs. You put it in hot water, you put the meat inside, you can do honey mustard sauce or ranch on top, and you just put in a potato chip bag and you mix it up. It’s actually pretty good,” explains Amanda Cortes.

Cortes has been in jail for five years and eating that way for most of that time. She’s facing several charges including involuntary manslaughter and is waiting for a court date. She says lots of women use food to cope with boredom and depression.

“Some people get two or three trays, so they get fat like that. They take whole loaves of bread to their room,” Cortes says.

So Cortes cycles to keep the weight off, and on visiting day, her 10-year-old son noticed.

“When he first seen me he was like: ‘Mommy you got skinny!’ So I was excited,” she says, smiling.

During a year, going to three spin classes a week, Cortes dropped 90 pounds.

At the end of the Gearing Up class, just before the goodbyes and sweaty hugs, there’s one last ritual.

The women share what they’ve brought back from the ride.

One women says she’s “bringing sexy back.” She and everyone around the circle has a wish: “I’m Jean, and I’m bringing back my bikini. I’m Ruth, and I’m bringing back faith and confidence.”

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

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .