Thursday, April 19, 2018

Reviewing Medicines

Obsessive-compulsive, probably not.  Attention to detail, probably.  Inquisitive, for sure.  Two interesting encounters this week, both very typical consults on uncontrolled diabetics.

First fellow came in with ketoacidosis following a lapse in insulin from a previous prescribing snafu that left him without basal insulin for two days.  He had been a type 1 diabetic for more than 50 years.  His history was an interesting one, being started on NPH and regular insulin in the 1960's as a preschooler, then having a number of revisions in his protocol as the fashions for using these types of insulins changed from decade to decade.  He had been on the same treatment since the 1990's, maintained by his primary doctor from visit to visit, never converted to the current analogs.  he had been seeing a nephrologist as his creatinine rose.  At his last encounter, the switch was made but he had marginal prescription coverage and never received it, resulting in the current hospitalization.  After treatment of the ketoacidosis, Levemir and Humalog were initiated and an endocrinology consult was requested.  He had an interesting glucose pattern for the previous three days:  normal or low in the morning but 400+ at lunchtime every day.  On looking at the medicine record, it seems he had not received the Humalog at breakfast for each of the last three days, since the nurse opted not to give it based on the morning glucose, which was never extremely low.  That's easy enough to figure out and correct for that patient, a lot harder to correct as a system-wide policy where the aggregate nurses think this is the right thing to do for that situation each time it arises, despite the predictably adverse outcome.

What struck me more was the conversation with the referring resident who asked why I thought those spikes were occurring.  Having received the patient from the ICU, he never expanded the history beyond that needed to address the presenting crisis.  He also never sought an explanation of why the glucose would spike the way it did, even though it would be obvious from a review of what insulin the patient actually received.

The other consult was also very typical, a man with uncontrolled diabetes that came under reasonable control after resumption of insulin following an unintended interruption.  He had injured an amputation site which was revised.  However, five days later he was still requesting his prn iv opiates at just under the minimum allowed interval.  The residents were next to me in the computer room.  I asked them how his pain was doing, told OK, and then showed them the narcotic administration record.  Either he is having a lot of pain, or the sensation that he desires from the hydromorphone is more euphoria than analgesia.   Needless to say, he needs his pain revisited as he should not be needing that much IV narcotic.  Or if the pain were not going to resolve, there are many better ways to give this than q 4-6 IV dosing.  In either case, nobody read what is actually being given and therefore did not appreciate the need to reassess the pain management before they sent him home with that iv prn order still in place and no better long term alternative.

The essence of work rounds in my era, and in my office encounters today, has been to focus primarily on the medications.  What are people taking and how are they doing on what they are taking?  What is prescribed often differs considerably from what is actually being swallowed or injected.  At least the hospital medication records are accurate, the office ones border on fiction.

And there is also the question of being inquisitive.  If something looks extreme, as a glucose going from 70 to 400 on consecutive days would be, this cries out for an explanation.  Even if it had no bearing on what I am there to do, it's presence would attract my attention, as did the opiate schedule which was really not integral to the endocrinology consult.

One of the attending physicians of my residency, an outstanding rheumatologist, once pulled me aside and told me how he was taught to do consults and passed the advice to me.  Be thorough.  If you see something that needs to be fixed that seems to be neglected, mention it in the note even if not rheumatology.  It is that ingrained attention to detail that has kept the patient encounters professionally challenging, even as other elements of being a physician in the modern age have taken their toll.

Monday, April 16, 2018

Keeping People Independent

Diabetic blindness used to be much more common than it is now but fortunately with laser photocoagulation and vitrectomy, sight preservation has advanced greatly as more diabetics live longer and become more subject to this.  Still, visual loss is an unfortunate reality while their diabetes and need for testing and insulin continues.

Such a person came to my attention recently, nice fellow on oral agents whose family member had been testing his glucoses twice a day.  He developed a foot wound, came to the hospital rather hyperglycemic.  Hyperglycemia persisted after below knee amputation while the residents tinkered with his pills and eventually added basal insulin.  Cavalry called in, basal insulin increased, pills discontinued, and prandial insulin introduced.  Quick, easy, straightforward,  Glucoses corrected in a day and remained controlled the remainder of his stay, with a slight insulin dose reduction toward the end.

In New Age Hospital Medicine, once corrected people just kind of go on auto pilot with no refinements to medical care but all sorts of efforts to move people to their post hospital destination. And so it was here. Ready to go, all fixed.  And then came the phone call from the intern, what do we do about his insulin if he cannot see?

Forgive me, but the medical center pays through the nose for a very expensive discharge planning process that includes a meeting on every floor every day from the day of admission attending by a who's who of hospital functionaries experienced at sending people home.  This isn't really very hard, and why was it not addressed by these people of professional title earlier?  So I asked the intern, who lives at home with the patient?  He didn't know.  How was he getting his finger sticks done all these years?  He could not tell me if the patient had an auditory machine or if somebody at home did it for him.  I knew, because I asked him as  part of the initial consult.  Basically there is somebody else home most of the time.  And he had one leg less than when he arrived, not that the infected leg was of much use for walking prehospitalization.  So keeping him independent would require more than providing him insulin.

Basically, they had two choices, either pre-fill syringes one week at a time and keep the two types of insulin separately in the refrigerator in different shape containers that he could identify by feel and inject himself, or send him home with pens that either somebody else could give him or since the doses are low, he could probably just count clicks on the dial with each injection.  Amid the grandiosity of a hasty exit from the hospital, sometimes the simplest of things cause the impediments.

Wednesday, March 21, 2018

Nine Mg Riders

Too often what the residents want you to address is so they don't have to except for infectious problems where they putz around with antibiotics until lunchtime on Friday, then call ID.  For me this seemed rather routine, a diabetic with another medical illness,  not terribly well defined in the hospital records but including atrial fibrillation and congestive failure at presentation.  At day 9, with pressure from the DRG Lady to discharge pronto, they figured that might be a good idea to have some predictable insulin dosing and reliable office follow-up so they called me.  Nine days of hospitalization gives a lot of electronic record clutter, and most of the progress notes were the usual copy and paste of limited intellectual input on their part.  Of note, the magnesium level never quite corrected.  When I examined her, there was a Mg rider hanging, with the last measured level 1.7 mg/dl, a little low, but not dangerously.  I finished the exam, decided what to do for the insulin and went back to the hypomagnesemia.  On presentation, she was in atrial fibrillation with a serum Mg 1.0 so nobody would look askance at the two IV infusions she received in the ICU.  However, on day 9, she was receiving infusion #9 for a very borderline result.  I went back through the lab testing and notes, absolutely devoid of any search for cause or any discussion short of the orders for repetitive IV replacement.  As I typed the consult in the computer room, I asked who was responsible for her care on the floor.  The resident two screens down owned up, so I asked him about this.  Well, the Mg was low so he replaced it.  Well, does everyone need to be euboxic, a term that had pretty much disappeared from medical slang at about the time he was born.  Of course not.  And more importantly, if you do nothing to fix it and send her home with neither daily monitor or replacement, what did he think would happen to her?  If the answer was nothing, she got at least six infusions too many.  Excessive care is a variant of WRONG.  Thoughtless care sometimes goes beyond WRONG to NEGLIGENT.

Lest this be an electrolyte problem, I've seen people get ten amps of D50 for low finger glucoses and normal sensorium in the absence of hypoglycemic agents, only to find that the venous glucose done simultaneously was normal.   If they really have a hypoglycemic disorder they deserve diagnostic testing which starts with a bedside assessment.  Even with a prolonged fast for insulinoma, the blood doesn't get drawn in the absence of symptoms even if the glucose reads low.   If they do not generate enough capillary blood to give a proper measurement, their fingers and the pharmacy's D50 supply should be spared.

I see two issues that are very common, neither addressed well.  We seem to teach by algorithm, if this do that.  The first event will probably get you by.  The next one should arouse some suspicion, either to read the chart, see the patient, get a consult, or at least put on the thinking cap.  The second failure may be lack of accountability.  The resident sitting two screens over was one of four that had responsibility for her care over those nine days.  There was an attending hospitalist too, a bystander for the days in the ICU and pre-occupied with CHF and two resident teams to get the detail.  Nor do we have the pharmacy as a safety net to intercept questionable care, outside of antibiotic use where certain automatic reviews take place.  I would think in this day of computerization, 5 Mg or K-riders or 10 amps of D50 might be more easily identified by the pharmacy than by rotating residents and hospitalists.  Those are patients who need a little more than just being processed through in the shortest length of stay for their assigned DRG. 

One of the elements of internal medicine that attracted me as a student and remains forty years later has been the analytical challenge.   That may be the final deterrent of burnout.  The inquisitive mind can probably still overcome the irritations of the medical computer and the functionaries you talk to at the pre-authorization desks, as neither of them think as well as a methodical clinician.

Friday, March 2, 2018

Keeping Engaged

As I experience some lumbar discomfort in what seems to be the left quadratus lumborum distribution, it is good to have very little running around and some desk time to study some medicine.  There is some pretty good work floating around.  NEJM has some articles on ICU experimentation with glucocorticoid + mineralocorticoid supplementation and different IV fluid options.  I've been through the last six months of the Leonard Davis Institute Blog which has some items on how we practice.  While the NEJM helps determine low value or high value interventions, we still do the things of low value.  An LDI article looked at how docs would look at being penalized for doing things of limited value.  They targeted use of urinary catheters to measure urine output in people not critically ill, use of cardiac monitoring without a preset end point, and use of ulcer prevention medicine in people who were not likely to get ulcers.  I do not see too many catheters at my place.  There are a lot of people on telemetry, mostly play it by ear.  And proton pump inhibitors are now cheap and don't cause a lot of harm so people tend to get them irrespective of risk, though I've yet to see an ulcer develop during hospitalization, maybe because these were used or maybe in spite of them being used.  So they asked if the docs who do these things should incur a financial penalty.  Well, unneeded catheters can cause harm to people.  Monitors cost somebody money.  PPI's short term probably don't cause harm and don't cost much money though there seems to be some correlation of acid inhibition with opportunistic infections so maybe they do.  Like the majority of the respondents, I have relatively little sympathy for the hospital or insurer making less money than they could have, which would be the outcome of less monitoring.  Having insurance premiums go up because of these expensive days is a little more problematic so the societal cost does merit some consideration, as it did to those polled.  And the catheters are a no-no as they harm patients.

However, we all do non-productive things.  The residents order Mg and Phos on everybody and then give IV replacement for trivial variances.  These people will have the same variances at home, undetected by the lab, and do just fine ignorant of those results and absent any intervention.  We do ac and hs glucose monitoring and supplemental insulin on all diabetics.  Probably nobody's microvasculature will be improved from this practice though for some people it does help recommending chronic insulin dosing.  We are just not selective about this.  We have acts of omission too.  I've yet to see a resident include a rectal exam in the initial H&P, irrespective of its value.  Reviews of old records leave a lot to be desired.  These cost nothing, can add a lot of value, sometimes save money on not repeating things that will not have changed and infuse a habit of thoroughness that reaps its rewards later.  We are just not selective enough or thoughtful enough in what we do.

But penalties for excessive care?  Being punitive rarely improves care and probably wouldn't here either.

Wednesday, February 28, 2018

No Consults Thus Far Today

No consults today thus far.  While these requests for advice seem to be the last clinical work that keeps me energized from one day to the next, the slack time is appreciated when it arises.  Some time to read, some time to think, some time to organize.  Doctors never really run out of things to do, though we often run out of things we want to do.  Spent yesterday on the phone and on the screen with an afternoon in the office.  One consult that was straightforward, a person with newly acquired tsh suppression, borderline free t4, no symptoms and a fairly normal exam.  The hospitalist watched me do the consult, concerned most about whether the person could be sent home.  This being a common office referral, there was no problem with discharge and a decision made later on antithyroid drugs if the T3 was elevated or watchful waiting if it was not.  But none so far today.  I can look at more lab work or I can renew prescriptions and test strips though none of that is nearly as satisfying to me as taking a medical record apart from the first available entry and matching it with what becomes apparent at the bedside.  Maybe later or maybe tomorrow I'll get my next chance.

Sunday, February 18, 2018

First Responder

Image result for first responderMy first real post.  By way of introduction, I am an endocrinologist, class of  '77, on medicine's exit ramp, or at least planning to retire from office care.  We can debate whether my hospital's EMR killed the golden goose or Father Time just caught up with me, but I have a genuine Medicare card in my wallet that has started to fray.  The final vestiges of my engagement are a real fondness for hospital consults, the more extreme the lab work, the more enthused I become, and expressing my opinion, which accounts for my not being on any important committees ever in forty years.

This weekend the beeper went off Saturday morning with at least one consult that should not wait until Monday.  It could have waited until Sunday, but having declared Sunday a Me Day, right after Shabbos Services, I schlepped to the hospital.  While there, I may as well round on everyone or at least look at all the glucoses.  I started from the top floor, planning to work downward. Player #1, just an insulin adjustment.  Player #2 I greeted as the physical therapist put him through his paces with a walker.  His sugars had gotten high and the therapist informed me of chills and a swollen arm.  Sure enough, he had been febrile for two days, seen by the ID consultant, judged not real sick, and wait and see advice seemed reasonable at the time.  But with chills and a temperature just under 39C, he got a real exam.  Ordinarily I would call the resident but he was assigned a non-resident service so I'm on my own.  Having been a hospitalist before there were hospitalists everywhere, I knew how to address a fever.  Some abdominal tenderness, probably a hot right wrist or cellulitis of the forearm.  However, I do not know much about antibiotics.  I called the attending physician to convey the findings, the ID consultant in a mournful plea for help, and ordered blood cultures x 2, urine culture, an xray of the wrist and forearm, and a single dose of vancomycin at the recommendation of the attending physician.  And he needed more insulin.  That I know how to do.   A resident stopped by and showed me how to enter an IV order on the computer.  And before I left, the cavalry in the form of the ID consultant made a trip in to save the day.

Then downstairs to newly identified rip-roaring primary hyperthyroidism, something I know how to address without help.

While I have become something of a mullet at sorting out fevers, diarrhea, headaches and insomnia, the things nurses call residents about, I am still from an era where we were taught to read charts and examine people.  A fever could come from anywhere.  That hot wrist could only be found if you went and looked at the patient without any preconceptions of where the fever might be originating.  It was a challenge, totally unexpected, but pretty gratifying to still be able to do this.

Tuesday, January 23, 2018

The Singing Pen of Doctor Jen: In defense of SOAP notes

The Singing Pen of Doctor Jen: In defense of SOAP notes: Our hospital system's IT department has recently encouraged us all to change our default encounter note template from the traditional &q...

Hi Jen:

Never been a fan of SOAP notes but our templates both in and out patient follow that format, however the A/P are lumped together.  The S is also problematic, as patients are often here for nothing that really has an S like an incedentaloma on an imaging study, though they do have pertinent negaitives. 

Interestingly, now that we have PDOCS for consults and Dragon Dictation, I find myself doing consults with Stephen Covey's sage advice "Begin with the end in mind."  I will list the problems, dictate the analysis and solutions, the go back to page 1 and dictate the HPI, copy and paste the pertinent lab in the lab section, then click what's needed for past history, ROS and exam, with a few phrase dictations where needed.  What's different between my note and our residents' output is that mine has no fake news.  If I didn't ask about dyspareunia, which I don't, it is left blank.  My patients with prostheses never have pulses in them, and if a thyroid is palpable there is a description of that.  Where we lose out in the EMR seems to be in the copy/paste which saves time but propagates falsehood.