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.

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.