Thursday, September 13, 2018

My Own Advice

As a kid, I was really skinny.  A coxswain on the freshman crew team at under 120 lb.  I reached a nadir of 108 lb as a young parent with the help of giardia lamblia acquired from my infant daughter and her day care center.  Suit size 36S.  Some quinacrine resolved the infection and my weight returned and remained fairly static until my mid-30's.  During my endocrinology fellowship, I ate lunch more and gained about 10 lb,, feeling observably better in the process.  Weight gradually settled at 140 or , so, stayed there a long time, suit size 38S.  Then about 10 years ago, it rose gradually and as it approached about 160, suit size now 40S, I could tell that it needed some attention, which it got, with roughly the same result that my patients got.  I set a goal of 155, where I still felt well, got as close as 157 but intake is probably an ingrained regulated process so the new plateau settled at 165.  I still feel good, but since I am going on cruise shortly, I decided to have some clothing altered.  That venerable 40S sportscoat could no longer be buttoned.  I did not want to pay $50 for the alteration.  I bought new pants, my usual size, which ordinarily need the length adjusted.  Now it needs the waist adjusted.  Weight is not much different, distribution may be around the midsection.

Since retiring about six weeks back, I have been better than ever with diet and exercise consistency.  I have breakfast every day, I go on the treadmill two days of three with almost no lapses.  For a while supper was less and mid-day snacking less but a new feeding pattern may be setting in.  It's time to do what I tell the patients.  Pick a diet, any diet.  Minimize bread, potatoes, pasta, and rice which happen to be my staples.  Some things I can do easily.  On my kitchen table right now I have a box of Tastycake left over from my son's recent visit, a container of Trader Joe's Cat Cookies which really do not have a lot of calories and Trader Joe's Strawberry bars.  In the refrigerator I have fresh figs and baby carrots.  To my surprise a Shop-Rite crummy bagel has 250 calories.  I do not really need to make Hasidic Noodle Kugel except for a special occasion.  Keep it easy and measure. 

Keep the jacket unbuttoned on the cruise formal nights.

Image result for measure waist size

Friday, August 17, 2018

Attending Grand Rounds

Image result for grand rounds medicineJust under three weeks ago I concluded my mission as clinician, following through on retirement plans set in place five years earlier, delayed by eight months to help my hospital with a transition and at the age I had anticipated ten years earlier.  I do not miss the patients or the clinical challenges they impose.  I thought I would miss the pageantry of the hospital more than I have, but I don't.  This unstructured time sorts out in stages, first being to take better care of myself.  I have an exercise schedule fully maintained and I eat breakfast every day, something that would often take a back seat to the pressures of the clock and the morning commute.  On the advice of a weight control expert who lectured at the Endocrine Society meeting a few years ago, food is verboten from 8PM to 6AM, mostly adhered to.

Part 2 is to get my personal space fully functional.  While a Man Cave seems an excessive extravagance, my hospital always provided me a functional work space which I intend to recapture at home, though it means clearing oodles of paper and obsolete electronics and kids stuff from where I intend my study to be.  Progress there has been satisfactory, limited a little by the amount of recycling that can fit in the bins that get carted off every two weeks, but so far so good.

My mind comes next.  Every six months I read a novel, a non-fiction work and a Jewish work distributed over standard book, e-book, and audiobook.  On schedule.  My journals still arrive, though I have not read beyond the titles yet.  I asked my previous two hospitals to put me on the announcement list for Grand Rounds and other conference schedules, which they did, and I attended my first yesterday.  It took place as a simulcast from the main medical center auditorium twelve miles away at the much expanded hospital in town where I once saw patients almost daily.  The speaker gave a presentation of Medical Homes, a concept that I understand better from the talk, though with some skepticism of whether the mission of better care at less expense will accrue.  Some old friends attended, some retired, some probably asking if I can do it why can't they as some were my contemporaries.  And a lot of residents attended as well.  They had coffee but to my surprise and slight disappointment nothing else.

So which will bring me back, the chance to learn and think about where medicine is headed without me or the handshakes with old friends?  A mixture to be sure.

Tuesday, July 17, 2018

Funky Lab

Asked to see a young man who had been admitted 5 days earlier with what appeared to be extreme alcohol induced hepatitis.  In addition to an extreme liver panel, but not so bad ultrasound, his proteins were very low for a young previously healthy man and his sodium was only 123.  The residents had the presence of mind to address the hyponatremia in the usual way.  Osmolality 335 in serum, 691 in urine, sodium 150 in urine.  This is pseudohyponatremia of extreme degree, though not recognized for that.  After some testing, his cortisol was low at 3.1 so they called me.  The original lab looked like there was some other substance restricting plasma volume so I had the residents repeat the serum osmolality which had come down to 290, still inappropriate to the sodium of 129.  Since his glucose, bun and proteins were not high, this is usually from a lipid problem.  Sure enough, the cholesterol was 1208 and ldlc 1098, by far the highest numbers I have ever seen.  I assume the liver dysfunction impairs some of the serum cholesterol disposal enzymes.

Not sure why it took 5 days to figure this out.

Tuesday, July 10, 2018

Unrestrained PRN

Sometimes we get complacent.  A very nice diabetic came to the hospital about 10 days back having been at our other campus not long ago.  He had a foot wound requiring two toe amputations here.  Glucose management at the other hospital seemed more difficult than it was here, with the continuation of insulin dosing proving too much, particularly the nightly basal dose which brought the dawn glucoses too low.  With some minor revisions the glucose control coasted along, his BP remained decent on medicine and his underlying cardiovascular disease mandated high dose atorvastatin which he continued uneventfully.  He always seemed pleasant, never seemed in any distress, a placid and pleasant fellow who never complained, at least not to me.

Ordinarily I take a look at my medicines on daily rounds.  The computer makes this easy by putting an asterisk next to the medicines I ordered.  There were antibiotics and there were analgesics ordered by other people to which I did not pay a lot of attention, his being in the hands of medical and surgical colleagues who do this professionally.

As he prepared for discharge I went over the list and noted a prn q 4h oxycontin order.  When I called up how much he actually took, it turns out that he has been requesting 4 doses a day on roughly a q4h while awake pattern every day for 5 consecutive days.  It seemed like a much larger amount of medicine than I would have anticipated for somebody who never looked uncomfortable at any of my visits.  Needless to say there are questions relating to his medical care and there are better ways to manage ongoing anticipated pain.  Was his pain control adequate or was there incomplete treatment of its source?  Does he really desire euphoria more than analgesia?  Does the prn nature of the order create a conflict between a patient in pain now and a surgical nurse who is otherwise occupied at the time with other patients whose needs are more immediate?

And who should be the one noticing this aberration?  I asked some of the nurses on the ward at the time if they note excessive prn use of opiates as the patients start demanding it of them repetitively.  Generally no, as no single nurse dispenses more than two in any shift and doesn't really come passively on the overall utilization.  I asked the pharmacist.  There really is no automatic mechanism to detect this.  Every day  there is a group meeting to discuss the progress and discharge planning for each patient.  Needless to say, this would not continue past discharge, but it whizzes by the daily sessions.  And then there is the surgical resident.  They look at wounds at the bedside.  Looking at medicines is a distraction from their surgical tasks.

So as we deal professionally with excess opiate utilization as a public health crisis, how much of that was our own creation, initial legitimate prescribing with a blind eye to use that seems excessive.  We have no mechanism to intercept that other than individual diligence in paying attention to medicine orders and administration.  Alas, good systems work better than astute people, and our system here seems absent.

Friday, July 6, 2018

Old Records

Got a semi-urgent consult, a man with a calcium of 11.9.  He was asymptomatic but what made it urgent was the desire to send him to a rehab facility the next day.  Not being otherwise engaged, I went up to see him, having read the current chart from my desk.  As I got to the charting room, some brand new interns, first week, were milling around, already discussing discharges with each other to the neglect of incomplete medical care.  One of them owned up to having been assigned this fellow who just had his hyperparathyroidism confirmed by the lab.  So the questions were obvious to me:  what was his previous calcium?  Did he have urolithiasis?  Did he ever fracture anything?  Why was he on Casoex?  They looked at the lab work, called me, took no relevant history, did not seek out records, and plotted his exit at the earliest possible time.  Not a good way to imprint the expectations of medical care on medical newbies.

I called the young'un over.  We opened the chart from the other campus of our medical center, about a five minute effort.  He had been hospitalized the previous year.  His calcium was consistently 10.6-11.0.  No testing was done, though he did have an abdominal CT which showed no renal stones at the time.  There was a lab result from six months ago, calcium 11.0 so it is clearly rising.  He had a medicine list.  hctz on it, though stopped here.  Also leupron on it so now it is clear why he also took Casodex.  Renal function normal, then and now. 

Haven't even entered this fellow's room and it was clear he had hyperparathyroidism with a rising calcium and he also had prostate carcinoma that was being treated medically.

Interviewing him did not add a whole lot.  He could tell me who was prescribing the prostate treatment.  He did not have stones, moans, groans, or psychic overtones.  He had also not been told of the calcium elevation before.  And his bp was pretty high, presumably some of it from stopping the hctz.

So he would benefit from a parathyroidectomy and from some revisions in his antihypertensives.

And the new trainees need to redirect their focus away from discharge to more thorough care while the patient is their responsibility.

Wednesday, June 20, 2018

The Non-Consult

Sometimes it is the silliest of things that expose some of the systemic deficiencies of what we do.  One of the psychiatrists asked me to see a patient with a glucose of 295 taken by finger stick in the ER  The patient had no known diabetes.  He had been in the hospital the year before with a random lab glucose of 117 and otherwise normal lab work, so the progression from pre-diabetes to diabetes was plausible.  During his few days in the hospital, several bedside glucoses were obtained and were all normal.  A HbA1c measured 4.9%.  By all evidence he does not have diabetes but had a spurious ER fingerstick, which made for a very brief consult and the lowest billing code available.

What caught my attention, though, was that the entire evaluation was done by the psychiatrist.  Every psychiatric inpatient gets seen by a medical physician, typically the nurse practitioner or on weekends the resident, with review of the hospitalist.  Even though that 295 was the most recent glucose obtained in the ER the day before, there was no recognition of it by the Internal Medicine people, not to repeat it, not to do a HbA1c, not even a concern that he might be a newly identified diabetic.  But the psychiatrist either was attentive, or was the recipient of this lab value by verbal report from the ER and took it upon himself to check it out when it whizzed past the medical people who often function more as scribes to put a paper in the chart than as consultants to take advantage of a patient on the psych unit who frequently slips through the ordinary venues of scheduled outpatient care.

And we have erroneous lab data.  Did that fingerstick belong to somebody else who should have been treated?  Was it contaminated?  Should it prompt a lab draw from the ER?  No, it was just added to the chart, assumed to be true and passed along to somebody, though not necessarily the person best able to act on it.

And yes it is ok to give him Risperdal if it helps the psychosis.  No risk of severe hyperglycemia this time.

Wednesday, May 2, 2018

Copy & Paste

Patients in the hospital get seen by a lot of people.  There's the admitting resident, the hospitalist, any number of consultants each with their own niche. And on transfer out of the ICU a new crew takes over.  As the consultant I do not ordinarily encounter the person on the first day.  By then they can give me a history, which I take, but I also read the History of Present Illness.  Too often, the HPI's done on Day 1 by different providers look a little too identical, though each signed independently.  If journalists did that it would be plagiarism though when doctors do it the term is copy & paste or even more benevolently, gathering needed information from available records.  That's an OK thing to do, even an expected thing to do.  Calling it your own is not, particularly if you never really gathered any information directly from the capable patient but misrepresented what you have done personally.

But while it enhances payment and reduces work, does it harm patient care?  To some extent I think it might, particularly when I look at my histories taken from the patient, usually in happier circumstances, have details and insights not elicited by others but could have been.  Histories are often tapestries, contributions from different interviewers who stumble across something unexpected by relevant that differs from information the previous person obtained.  And sometimes it makes all the difference