Tuesday, November 6, 2018

Massacred

Among the victims of the Tree of Life Synagogue mass shootings was my college friend Jerry Rabinowitz, MD.  Jerry and I shared a lot of classes and remained friendly.  Graduation separated us for the ensuing forty years with an occasional professional snippet from an alumni source.  It came as no surprise that the tributes that followed his murder lauded both his kindness and his dedication as a physician.  It was my honor to have known him in our formative years and to take satisfaction in his personal and professional success.

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Friday, September 21, 2018

Young Adult Trauma as a Marker of Later Health

In my final working weeks, my medical center had cemented an agreement with the Veterans Administration to offer care at our center to veterans who could not be accommodated at the VA for a variety of reasons .  We could use paying patients, they could use doctors of our caliber so our representatives established mutual benefit.  We have always had patients who have served in the military.  For much of my professional life, that has included most men of my father's generation whose young adult years encompassed World War II with its widespread draft.  World War I and Korea conscription was less universal but patients having served in these settings were frequent.  Vietnam service seemed more selective.  For the most part, even when employed as a VA physician 1980-88, the patients' service while appreciated was largely parenthetical to their congestive failure, COPD, or diabetes.  Some had permanent sequelae of their service, missing limbs, shell-shock or post-traumatic stress disorder depending on which military conflict, a chemically related setback often still in adjudication where medical care intermingles with compensation.  Some were more indirect, the many alcoholics or other substance abusers, maybe some of those with hypertension, but these were also highly prevalent in people who never wore a uniform.  But by age 60 when people started getting admitted to the hospital more frequently, the diseases I treated at the VA did not seem very different from those encountered elsewhere, at least on the Internal Medicine service.  They got admitted, I took the best care of them that circumstances would allow for whatever I thought they needed.  In the community hospitals and in the office, I shared patients with the VA though separate payment systems, and people came by who just happened to have been in the army as young adults but were pretty mainstream thereafter, going to college, joining a union, maybe for some latching onto a business, or seeking jobs as they became available without ever acquiring an identifiable occupation.  As prescriptions became more expensive, the VA would often supply medicines to veterans like my father and others who saw the doctor or nurse practitioner as a precondition for having the prescription supplied but regarded physicians external to the VA as the doctors they made most of their appointments to see.

With systems, particularly governmental ones, process often becomes excessive.  This being an important medical center initiative, the first Grand Rounds of the academic year went to the VA's physician representative to this project.  He outlined process.  Every patient admitted to the hospital would have a complete military history, where they served, which unit, injuries, illnesses, anything that might connect to their military service.  This seems to me like a good invitation for some errors of the first kind, those Type I errors that attribute significance to what is non-contributory to the hospitalization.  Even at the VA itself, by the time somebody is 60 years old and has an MI, it was not the military mess hall that made the cholesterol high.  And the need to fill out what may be too comprehensive a questionnaire runs the risk of distraction from more vital information gathering and examination that has a more immediate effect on the encounter of hospitalization.  What we may be doing is propagating an event of young adulthood, labeling it as an imprint which portends an invisible forty year interval until they come to our ER.  I think the process needs to be more selective than what the speaker described in his presentation to be meaningful.  In this era of Electronic Health Records, we already gather reams of historical information that never gets refined or prioritized by its importance, since we often don't know its importance.  Or as the New York Times advertising once told its consumers, "you don't have to read it all but it's nice to know it's all there."  However which portions you read matters a lot.  If the military history acquires an inflated importance by the very time allotted to it, the more immediate medical imperatives risk distortion as well.

The other consideration would be why select military service as the shaping event that forms the underpinning of once's health at some time in the remote future, then trying to reconstruct this in reverse?  In attendance at this Grand Rounds were our residents.  At age 20 they had a fair amount of academic terror, fretting over the Organic Chemistry final that might weed them out professionally.  At age 25 they had The Match culminating the rigors of medical school, some overseas.  As residents many departed their families from Asia or Latin America.  And by the time they get their certificate, many will experience burnout.  Will the experience of medical training in their 20's be more favorable or less to their health at age 60?  And our city campus where I saw inpatients and outpatients has an immigrant population.  West Africa dominates as the region of origin but Bangladesh, Ethiopia, Indochina and the Caribbean are all represented.  Having had the privilege of breaking the ice with some small talk before starting the medical history, a lot of the men were war refugees who came to America as young adults.  Many of the women, particularly those of Indochina, were also displaced by either extreme poverty or a few by adverse political situations.  We have a large African American population with patients who spent their 20's in our penal institutions instead of college or the army.  No question these are all major traumatic events that have enduring impact on the psyche and maybe on health.  And lets not forget those adult patients of another era, though well within my own professional lifetime, the Holocaust survivors, some known to me as patients others as neighbors.  Military service while rigorous and formative, probably falls short of the terror to a young adult of having their families perish and fleeing to an unfamiliar place alone.  While it is expedient for the hospital to select out military service as a base of exploration, I wonder if from a health perspective it may be too short sighted.  If emotional and recoverable physical trauma at age 20 portend health outcome at age 60, maybe the source of trauma needs to be more comprehensively explored to include professional training burnout, civilian victims of civil conflict, crime victims, imprisonment, divorce or family abandonment among others.  We have ample numbers of patients in each category.  If focusing on the rigors of youthful military service make us more sensitive to the many other disruptions that young adults experience so that we consider this in a more general way than we do now, we probably will do much of our population a lot of good over time.  But we have to be careful not to engage in excessive information gathering for its own sake and stay focused on our mission of optimal health long past the traumas of young adulthood.

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.

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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.