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.

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

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.