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Tuesday, August 31, 2010

Bankruptcy, You Could Be Next.

“Unless you’re Warren Buffett, your family is just one serious illness away from bankruptcy,” said David Himmelstein, an associate professor of medicine at Harvard.

A study published in American Journal of Medicine in 2007 concluded that 62 percent of bankruptcies in United States are partially due to medical illness and bills. Only three quarter of these patients had medical insurance. Hospital bills were the largest factor contributing to bankruptcy.

I had a knee surgery some time back and I researched an average hospital charge nation wide for a knee surgery is $36,644 and Medicare pays around $12,456. Consider what options a patient has when he makes only $24,000 a year.

A friend of mine told me about a lady who was in the hospital, requiring a specialized procedure. This procedure was not available in this specific hospital. She paid around $40,000, all of her life savings to be transferred to another facility.

I will leave the universal insurance debate to politicians and lobbyist. But I think it is a shame that on one hand we are one of the biggest economies in the world but on the flip side some of us have to struggle buying simple but essential medications like insulin. They should not struggle to decide whether they should bring in food or buy medications. Our cardiologist should not have to choose a less effective stent just because the patient is unable to afford the medications which go with it.

By the way the lady whom I mentioned above, died soon after. Share your experiences or of someone you know. 

Blog you later.

About the picture: Empty pockets, my daughter.

Monday, August 30, 2010

Boys Don't Cry.

He was in his mid twenties, I think. His face, as pale as snow, was partially covered by his hand holding a phone. He was lean, tall and stooping forward a little. He was standing rigid at the corner, across the elevator. He was speaking softly on the phone like he was trying to assure someone on the other side, something which was beyond assurance. Tears were rolling down his face but he was not making any attempt to wipe them off. Somewhere at a distance I could hear a woman’s mournful cry.  However, this man was oblivious to everything like his goal was to mend the other person over the phone. His despair was very private and required no solace. I glanced at him while I got in the elevator and the doors closed.

Just another day in the hospital.

About the photo: Gloomy day in Tampa.

Sunday, August 29, 2010

I Stole A Cow. Episode II, COWs Identity Crisis.

So after a year I got acquainted with COWS, I got the news that we can no longer call these creatures COWs (Computer Working Station). From there on we shall name thee “Wows” (Working Station on Wheels). I was perplexed… why, so after digging around I uncovered the alleged story behind re-branding of the COW.

There are strange coincidences in life, where unexpected factors coincide just at the right moment to produce either chaos or miracles. This was not a miracle! Apparently a colleague of mine was looking for his COW around a nursing station. He was asking other staff have they seen his COW. Apparently while this conversation was going on, an obese lady was hovering around the counter.  She thought someone was calling her names, she complained and powers to be decided to create a WOW (Working station on Wheels), formerly know as a COW.

All jokes aside, I find this device very helpful especially when I am busy. I try to encourage my colleagues to start using electronic progress notes rather than just using EMR (Electronic Medical Records) for orders. Once you utilize the whole package you can reduce your total rounding time by at least an hour if not more. Now this is coming from a guy who hated this specific EMR when we switched from paper to electronic records. Now I can’t see my self working without it.

Blog you later.

About the picture: Herd of COWs.

Saturday, August 28, 2010

I Stole A Cow-Episode I

OK maybe I didn’t steal it, I borrowed it. Let me enlighten you how it started… just few years ago.

There was this doctor(Me) who was minding his own business, printing his own list, carrying stacks of labs, writing encrypted doctor notes and filing them in the wrong places. He was approached by a suspicious looking character with thick glasses, smoking a cigar (Stop, OK maybe he was not smoking a cigar!). The only think he was missing was a long overcoat and a brim hat. He whispered “I am an IT tech and I think you should get a cow”. Hmmmm… my mind started to wonder, what will I do with a cow? My house is not big enough to keep a cow. I don’t drink milk. Is he saying that because I am from Pakistan. I am sure that my wife will not approve of it. I can make her steaks! How about if I ask this guy to give me some sheep and lambs to go with it then maybe I can convince my family to open a petting zoo of some sort. I started out by saying “how about”… he cut me in the middle and said “you know a COW, Computer on Wheels”. “Ohh…. oh I know what you mean” I said sheepishly but never blinked.

Apparently with time I got acquainted with a spanking new COW of mine….. my precious.  I found COW and all it’s cousins as an invaluable tool. Whether you carry a laptop, a tablet PC or a notebook, all of these devices improve your efficiency and may in turn improve patient care and satisfaction. Data is essential to patient care. For example if you are in the room and you have a data device on you, you can show patient’s what their chest X-ray looks like and what their labs are as compared to the day before. Rather than doodling on a napkin, you can show them an illustration from various web resources.

This process transformed in few years and made way to CPOE (Computerized Physician Order Entry). CPOE is tough love, it is like breaking a wild horse. It takes time and relentless effort in the beginning but once you break it, it becomes your best companion.

Unfortunately people steal my COW all the time, not literally. They “borrow” it and than I have to send a search and scout party to find it. Sometimes I am forced to steal someone else’s COW.  

Hence I am a COW thief. You may wonder why is there an Episode I? In the next episode I will discuss “COWS go through Identity crisis”. So bear with me.

About the picture: I am on a prowl, stalking a potential unsecured COW.

Thursday, August 26, 2010

The Plural Of Anecdote Is Data.

“The plural of anecdote is data” said Raymond Wolfinger. Sometimes it is misquoted as “The plural of anecdote is not data” by Frank Kotsonis. I like the first one better. This quote echoed in my mind after I met with our new ER directors recently, Dr Nunez and Dr Brambhatt. It is good to see young passionate and well trained physicians, who strongly believe in evidence based medicine. In this era of unlimited flow of information, data and studies, it is imperative to be current on emerging studies and literature. To see doctors coming in with that frame of mind is very refreshing.

Embracing new concepts should not be left for academic institutes only. We should continue to entertain new ideas. I find UpToDate as a good resource to answer an assortment of questions I have each week. I remember reading a book by Jackson Brown Jr. “Life’s Little Instruction Book” (Everyone should have this book). He writes “Don't waste time learning the "tricks of the trade", instead learn the trade”.  Knowing all is impossible; at least we should have the ability to identify what and where the tools are to know more.

It will be depressing to see our current team of ER physicians leave in few months. Most of them have provided excellent service for years. I wish them all the best. It was pleasure working with them.

About the Picture: I took this shot outside Museum of Fine Arts, St. Pete, Florida

I met Harriet Tubman.

She was not Mother Theresa  or J.F. K nor was she Martin Luther King. But I think she was no less. She could be the person you pass on the street every day but fail to see behind their faces.

I saw her in my clinic years ago when I use to have clinics. She was a frail 64 year old African American lady. I saw every month or so for arthritis related problems. She worked as a janitor at a local Wal-Mart. There was nothing extraordinary about her. She was a quiet person, kept to  herself and never complained much about anything. Then I didn’t see her for almost a year.  One day she just walked in to our office with her daughter. She appeared to be much weaker and in poor health. Her symptoms of arthritis were worst and she was having difficulty with walking. 

I recommended a rheumatology evaluation. As she was about to leave her daughter asked me to tell her mom not to work so much. I concurred and I advised her to take it slow. Her daughter said that she is not talking about her regular job but what she does after that. Apparently she has been working 5 days a week for the past thirty four years at different shelters. She volunteered her time, worked with homeless people and talked to them and gave them hope. Volunteering your time few hours a week or a month is different but volunteering your life is something else.

It has been years since I last saw her. She told me later the reason why she does what she does is when she was a child she spent some time with her parents in shelters. Her father died in a shelter during her teen years, after that she was taken by her Aunt. She decided at that time to help homeless people…… and she did.

When I think back she reminds me of Harriet Tubman (1820-1913), an African American who spent all her life working to abolish slavery. She was a slave by birth, after she got her freedom she performed menial jobs half the year to earn enough money so that she could free her fellow humans from slavery. She used safe houses to smuggle slaves to freedom. She made 19 visits and freed around 300 slaves. They used to call her “Mosses”.

I think the lady in my office was Mosses of our times, invisible Mosses.

About the picture: This is in front of Tampa Museum.

Wednesday, August 25, 2010

White board R’ us.

There is a white board in every patient's room. This is used to keep patient oriented and provide them with basic information. You would see some data on it, most of the time there is a date scrolled on it, name of the nurse and maybe physician’s name.

I recently read an article “getting the most out the humble white board” by Deborrah Gesenway. This is an excellent read and I would strongly recommend that you should try reading it. Dr. Niraj Sehgal, a hospitalist at the University of California conducted a survey regarding the use of white board. He inferred at the end of survey that “white board should be a patient centered tool”. This can be used to convey to the patient what the goals are for the day and what kind of test or procedures they should be expecting.

So after reading the article I decided to give it a try. I borrowed a color marker from our unit secretary and started my new quest. When I am finished talking to the patient I take out my marker and write down the plans in a bullet format. For example,

  • My Name
  • CT Abdomen today.
  • GI consult requested.
  • Transfuse 2 units of blood.

This hardly takes few seconds but provides point of reference for the patient and they feel much better when they know what their goals are for that day.

I have been doing this for the past 2 weeks, since then I feel my patients are better informed and more appreciative. What do you think?

About the picture: Umass reminds me of the old times although this is quite a big white board for some one in Tampa Bay.

Monday, August 23, 2010

Fly me to the moon.

Poor Mr. Sick Guy was in the hospital for almost 2 weeks. He was visiting from Michigan when he got sick. He developed fever and abdominal pain. He was diagnosed with perforated ulcer. Unfortunately he had multiple complications during hospital stay. But with the help of medical care and great support from family he started to improve.

So after 2 weeks when he was feeling better he asked me “Doc when do you think I can fly?” I said “You can never fly sir; I can understand that you think we are good but we are not that good. You would still need a plane to fly”. He smiled and said “I like that one”.  I often hear patients say "Can you get me a new body" Usually I reply "sorry not today, how about first thing in the morning".

Humor adds joy to someone’s life immediately. Humor in medicine plays a significant role in improving patient-doctor communication. Humors ease patient’s defenses and make them more receptive what you have to stay.

There have been studies which demonstrated that laughter enhances immune system, reduces blood pressure and decreases stress.

So next time, just laugh a little.

Appreciate the response and comments I have received from all of you here on this blog, facebook and via email. I specially appreciate Mr. Paul Levy input and advice.

About the picture: I took this picture from my home in Tampa.

Sunday, August 22, 2010

Who is the captain? Are we there yet?

Being a hospitalist I often see patients sitting in the hospital for days at length for no reason other than poor planning. Sometimes I feel that physicians who are involved in patient care are oblivious of each other. Everyone is in their own domain rather than working as a team. Increase length of stay in the hospital not only increases the cost of health care but also adds to the risk of medical complications including hospital acquired infections and medical errors.

There are several factors which contribute to poor outcomes, errors, poor plan of care and increase in patient length of stay. Some of the leading causes which I have observed are;

  • For the most part lack of leadership role by physicians involved in patient care.
  • Delay in patient-admitting physician contact from the time ER admits a patient to a 1:1 contact by the admitting physician.
  • Lack of proper follow up. For example patient is ready to be discharged but there is no confirmed follow up for labs like sub-therapeutic INR, low potassium levels, pending culture results etc. Some of these patients are doing nothing but waiting for labs which will not change management. These patients can very well be discharged with responsible follow ups.
  • Some patients need transfer to rehabilitation centers. However, if they have Medicare as their primary insurance then they can not be transferred as per Medicare rules.  They need to stay 3 days in the hospital before they are eligible for discharge.
  • Unfortunately few physicians may be pressed for keeping their patients in the hospital for monetary gains.
  • Lack of nocturnist hospitalist.
  • Lack of support staff for procedures and test over the weekends.

For example, Mr. Delay In’Discharge presents with chest pain and admitted at 5 pm. He is not seen until the next morning by the admitting physician. He was ruled out for myocardial infarction but has an abnormal nuclear stress test and this requires a cardiac catheterization. In the mean time a CT of the chest with contrast is performed to rule out pulmonary embolus. This comes out negative; however, the patient develops contrast nephropathy and acute renal failure. He also develops Foley catheter related urinary tract infection.

This is a typical patient encountered on a regular basis. This patient may end up with an army of consultants. So in this particular patient you would have an admitting doctor either a Hospitalist or an Internist, a Cardiologist for chest pain, a Nephrologist for renal failure and an Infectious disease consultant for urinary tract infection.

From here on a cardiologist would write in progress notes that he will perform cardiac catheterization when Mr. Delay In’Discharge kidney function improves, infectious disease consultant would like to wait until urinary tract infection resolves. On the other hand nephrologists could have already cleared the patient for cardiac catheterization but this has not been conveyed to the rest of the team. Hospitalist writes his daily notes but never takes the time to call and inquire about the plan. Now comes the weekend, no procedure could be done over the weekend. By now 6 to 7 days have already passed, where patient is stable and ready to move on to the next phase but as no one has reviewed each others notes, all is at a stand still. Regrettably, no single physician is ready to take a leadership role and everybody is just going with the flow.

Leadership role in patient care plays a significant part in appropriate patient management. Majority of the times we rely on the other person to take the initiative. I remember once I called a specialist who saw the patient at 9 AM to ask his opinion about starting plasmapheresis on a patient of thrombotic thrombocytopenia, the answer was “I was thinking about it but I will ask the surgeon to put the line in the morning, as it is already too late in the day (It was 7 pm)”. The problem with this statement is 1) This is a medical emergency which require immediate care. 2) If he was really thinking about it why was it not conveyed on time. 3) This is delay in care which increases the risk of developing various fatal complications.

I witness this many times that a physician comes up with a plan however, it is not communicated properly to the rest of the team. A lead physician needs to formulate a plan, communicate with other physicians in the team and decide what needs to be done in the hospital and what could be done outside the hospital. I think considering the position a hospitalist is in, they should take that leadership role as they are eventually responsible to review not just one area but all aspects of patient care.

Hospitalists are known to rely on too many consultants. Every time a patient comes there could be 3 or more consultants asked to see the patient. I respect the need for specialists and their expert opinion. I do rely on their recommendations, especially in this day and age of medico-legal medicine. But on the other hand all kidney failures do not require a nephrologist, all anemia do not require a hematologist and requesting an oncology referral without a tissue biopsy results in waste of their time.

So what are the solutions for these problems?

  1. As we are moving more and more toward the era of electronic medical records (EMR). A physician should be able to task other physicians, just as they can do it in the office utilizing EMRs, We can debate if these task should be part of medical records or not. This could substitute physician’s hesitation to call other physicians and allow all members of the team to review the proposed tasks for the day.  Whenever a physician opens the chart of a patient they should not be able to close the chart or sign out their orders or progress note unless those tasks have been reviewed or answered.
  2. There should be training workshops for physicians regarding the significance of leadership role in patient care.
  3. We should hire full time “discharge planners” who can assist in scheduling (confirmed) follow up visits with out-patient doctors and arrange for desired labs. These planners should be given access to add notes in EMR so concerned parties can review their work flow. (We could argue that case managers should do this job, but most of the times they are consumed with utilization review or with nursing home discharges; they do not have time to keep a track of these things). These discharge planners needs to be certified in a curriculum which provide them complete comprehension of these task and needs of patient and physicians.
  4. We should have more services available over the weekends for patients.
  5. Reformation of Medicare 3 day rule regarding transfer to rehabilitation centers.
  6. Review time between ER encounter to patient-physician contact.
  7. Utilization of Nocturnist as a routine in all hospitals programs. (It will be very difficult for private groups considering the cost involved and decreased revenues generated by them)

In all honesty we have not been successful in implementing all of these measures in our hospital. However, we are making an effort to reach these goals. I will provide an update monthly once we achieve goals.

We will keep on trying them like I told my daughter a little while back that failure is an integral part of success.

About the picture:  I took this picture from our sailboat in Hudson River, New York
Back to work tomorrow.

Saturday, August 21, 2010

I Am Not Fat Enough, 12 Step Program.

I was walking in Chinatown, New York yesterday behind an obese almost 350 lbs lady, we will call her Lady A.  She was huffing and puffing while walking. There comes another obese girl (Lady B) who was coming straight ahead. She was a little lighter maybe around 300 lbs. Obese lady A was with few friends. She crossed obese lady A, turns around and looks at her condescendingly and said “If I am ever this fat I am going to start exercising”. 

That was an interesting comment. How big is big. I think we all suffer from a syndrome which is an opposite of body dysmorphic syndrome.  I do not think that we realize how big we are. If we do we all would take a little better care of our selves.

Two third of Americans are obese. We have developed an addiction to food. We live a sedentary lifestyle and continue to be in denial. We need to have a paradigm shift and treat obesity more in terms of addiction rather than just another medical problem. If you are an alcoholic you will always be, so you abstain from alcohol all your life.

So if you are obese, diabetic, hypertensive, you are for all your life , we need to place the same standards of therapy for obesity etc. I think implementing 12 step programs in these cases would help.

On TV you see more TV shows about weight loss, the Biggest loser and Huge have been quite popular lately. I am not sure if the point is really to promote weight loss or we just like to see some obese people running around. I hope it is not later.

Let us try to increase awareness as much as we can. 

Blog you later.

About the picture: Billboard I saw in Manhattan of the TV show Huge.

No Problem My Mother Can Take Antibiotics for Dogs.

Life is a cocktail of joy and sorrow. Sometime I think life is bipolar, it has peaks of elation followed by depression. I guess you need both, so that they can compliment each other. Sometimes you try to forget but you can not. Memories remain stuck in your head.  I am visiting New York today and last night before going to bed I was watching news about the flood in Pakistan.

It all came back to me last night watching the news, reminiscing about the time I spent in Pakistan. Whenever poverty sets in a nation, it brings an all inclusive deal. You get many days and nights of corruption, daily rounds of crime, daily entertainment with nightly news of more problems and general frustration. At the same time I also saw extraordinary stories of compassion, altruistic acts and love. It is much difficult to be nice and generous when you have nothing. We all share the same genetic code, live on the same planet and dream while looking at the same moon. We are all alike; the only difference is conditional learning.  I am hopeful, given time things would turn around.

I went to medical school in Pakistan. In early nineties corruption was at its peak. Patient would be admitted to the hospital but not treated appropriately due to lack of resources. I remember an instance where a patient was admitted for a possible stroke. We could not get a CT of the brain as patient was unable to afford a forty dollar CAT scan. We were not able to place a central line on someone as our hospital had none at times. There were hundreds of these events every month. There was and there is still a very dangerous trend in Pakistan that at professional institutes there are political parties for students. These student groups represent national political counter parts. Almost all of them have ethnic or religious agendas. Their goal is to recruit new “talent” and desensitize them.

When I entered medical school I decided never to be a part of these organizations. Though it was a hip thing to do, their membership used to come with a lot of perks which I would rather not explain here. Our number one problem in the hospital was shortage of common medications, no screening of blood for HIV and hepatitis C and lack of organization. Drug addicts would make a line at the blood bank and sell their blood everyday.  We made a decision to do what we could. I got together with some of my close friends and started collaboration with two NGOs. We eventually formed a single organization, our goal was to provide free of cost medications  to patients, arrange blood transfusion drives all over the city and screen it for HIV, Hepatitis B and C. We were able to get major contributions from like minded people.  It took us two years but we succeeded in our goals. We were able to provide medications at no cost to patients and all blood was screened before transfusions.

What we didn’t realize was we were attracting attention from members of these political parties. First they came and harassed us. They asked us to give them portion of our revenues. When we declined they kidnapped some of my junior members including yours truly and beat us up. They even banned us from coming to the medical school if we did not comply.  Eventually, we were allowed to come back again after some negotiations but we never gave them a cent.

I still remember that day when we came back like it was yesterday. I came to school in the morning and I saw our office with all our supplies burnt to the ground. Our years of effort gone just like that. When I saw the office I was literally paralyzed. I couldn’t say or do anything. I sat down with our other team members and basically lied that this was not a big problem, we would start again. A 12 or 13 year old boy walked into our former office as we were talking. He came to me and said that his mother has bad lung pneumonia and the physician has asked him to get this particular antibiotic. He could not afford it so this doctor asked him to come to us. We had the antibiotic the only problem was that it was baked. In Karachi during summer it is so hot that you can really fry an egg on the pavement and this little kid walked at least 5 miles to come to us. He was an orphan or maybe his father left them, his mother was the only one who provided for him and his younger sister. I went back to see his mother and she appeared to be in sepsis due to pneumonia. Blood culture showed Staph. Aureus infection which was resistant to almost all antibiotics except for a few. We started calling different pharmacies but unfortunately there was a shortage of this antibiotic.

This kid came to us in the morning and in late afternoon I got a lead that this particular antibiotic is available at a remote location. I drove my very cheap and unreliable car to this place. When I reached the pharmacy the guy who was working there told me that this particular preparation of antibiotic is for the dogs, however they have given it to humans in the past. I was horrified, first of all I was just a student I did not know any better. I called the physician back and told him the story. He said it should work as there were no other options any way. The kid agreed and the physician gave me a green light.

I reached the hospital around 7 pm. I was excited that I got the job done. I entered “Ward V” through the old wooden doors and started to walk towards the patient. Everything which happened next is in slow motion as I recall. I turned to my left and saw this little kid sitting at the end of the bed in a poorly lit room. He was holding his mother’s feet, she was covered by a white sheet from head to toe.  He looked at me and than ignored as I was not there. I saw a tear roll down his eyes when I turned around to head out. Apparently she died ten minutes before I came.

I never faced the kid, I just could not. They say that no parent should have to bury their child; I think no kid should have to bury their mother either.

I left the country after a year. In fact I just realized that all those who were with me left in the next few years. One of them is a critical care physician in Phoenix, another an ophthalmologist in London, one a psychiatrist in British Colombia and an anesthesiologist in Arkansas

You may wonder what happened to the guy who burnt the office. Only in movies you have a marvelous ending where evil is punished… not in real life. He is doing very well. He received a political asylum in England. He is an advisor to a politician there. I saw his profile the other day on facebook, of course he is not on my list of friends. I often think of letting him know but I have not done it so far. Not so sure if I should.

The good news is history repeats it self. After we left some of our fellow students carried the baton and created a far better organization than we did. They established Pakistan's first burn unit, it has been doing great, serving patient with no cost to them for the past decade or so.

I was at time square maybe an hour ago. I saw people of every color, race and religion having the time of their lives. Now that is an American dream. I hope we all follow this.
This flood in Pakistan has already caused more destruction than the Tsunami, Haiti and Kashmir earthquake together. Do what you think is right.
About the picture: I took this picture of a billboard in Manhattan few hours ago. 

Thursday, August 19, 2010

My Heart sings…. What?

The year was 2000, place was University of Massachusetts Medical center and yours truly was learning again to be a medical doctor which was a change from radiology training which I received earlier, now that is a whole new story I have to blog some other time. When you are an intern, you are really at the bottom of the barrel.

It seems during that time the moment you walk in the hospital someone slaps a bull’s eye on your face. Hierarchy plays a major role in academic institutions, unfortunately as an intern you rank at the bottom. Patients worry because even they have heard of July syndrome.  Nurses are on your case; after all they eagerly wait for one year to implement their new devices of torture. Residents, who just get promoted from being interns, suffer from an early God syndrome. They want to create you “in their own image”. Attendings don’t suffer from God syndrome… they are Gods. They are eager to teach you with reminders at the top of every hour that this generation of interns is basically lazy. Gone are the days when they used to work days at length before they could get a day off. Well maybe those of us who are not physicians can understand why you are really scrapping the barrel to survive. This festival of Spanish torture is celebrated annually.  

So getting back to where I started.  After working as an intern for few weeks I entered a patient room. I saw an 80 something year old man who suffered from cardiomyopathy, lying on the bed with his eyes closed. Using my intern instincts I inferred that he must belong to that subclass of nursing home patients which is non verbal, demented and  usually sent from nursing homes when their staff is low with made up mundane reasons, or on the other hand there could be a simple reason that he could be sleeping. I proceeded to examine the patient as he would not open his eyes after I yelled his name a couple of times. As I was about to place my stethoscope on his chest he suddenly opened his eyes and blurted out” Hi Doc, sorry didn’t know you were here, I am partially deaf”. Frustrating….. my intern sense was failing me on many levels. But I carried on as I had already figured all that out.

After talking for a little bit I said “very well Mr. G lets have a look”. I again tried to steer my listening device towards his heart. He whispered “I must warn you that I have a singing heart”. I thought ah haa so I was not wrong he is delirious a little bit. But at the same time I began to second guess myself. The new intern syndrome started to dawn on me. I thought maybe he has a combination of different kind of murmurs that I don’t remember; maybe he has a rare murmur… I mean very very rare. I also entertained the notion if there could be a machinery murmur then why could there not be a singing murmur. Puzzled and mystified I advanced and placed my stethoscope on his chest. All of a sudden this 80 year old with already wrong diagnosis of dementia with a very bad heart started to hum “Singin’ in the rain….I am singin’ in the rain … ”  He stopped briefly and spoke very softly “didn’t I tell you that I have a singing heart”.  Both of us burst out laughing.  It was truly a glorious feeling.

That particular day was a good day, July didn’t look so bad, nurses were ready to share their expertise, residents appeared prudent and friendly and attendings showed wisdom which I lacked. By the way they did work much longer hours during their training as compared to us.

I learned some thing very valuable that day.

  • You are what you make of your self.
  • You can choose to be effected by negative feedback or learn to be proactive.
  • You have the power to brighten someone’s day.
  • No one should be put in a situation where they hate coming to work. 
  • And in the end if you don’t have any good thing to say just don’t say anything at all.

Blog you later.

About the picture:  Disclaimers. If my wife develops heart burn then she may not find her Zantacs tablets, if I develop knee pain I can still take my Motrins as the one above are hers! Special apology to my children if they develop cough I ran out of cherry cough syrup and there is no mention of chocolate syrup which represents cardiomyopathy. J

Wednesday, August 18, 2010

Cut, Burnt and Poisoned.

“I have been cut, burnt and poisoned” said a friend of mine who has been recently diagnosed with esophageal cancer. He has gone through surgery, radiation and chemotherapy.  He is merely 40 years old. He has lived a very good life, successful in his career and married with two little daughters who are my daughter’s age.  I can relate to him on so many levels because of   many similar traits in our personalities and among our families.


We used to go out a lot before he was taken by this ailment. We have shared some good laughs and enjoyed some great times. I remember going out once for a snorkeling trip. There were at least fifty or so people floating around us.  So here we were snorkeling up and down the river, we would come back up to our canoe and move to different spot.  It started to rain and we continued to do what we were doing. After a while I come up and notice there is no one in the river any more. My friend realized it too. I asked him where did everybody go. He said possibly because it is raining and, after a pause he said ……lightening too. We suddenly realized that we are sitting in an aluminum canoe. Moment of panic struck us at the same time. It was an open invitation for a lightening bolt to strike us. We both paddled for our lives and reached the shore on record Olympic time. Once we were safe we laughed at our stupidity for a very long time….. We still do.


We would also meet on the weekends where my 6 year old daughter would go for karate class. His daughter was just too good despite being the same age as my daughter. I was afraid she may break someone’s arm or leg. One day he told me how he taught her daughter to throw a perfect punch, I envied him because even I don’t know how to throw one. I thought well maybe I can teach my daughter not to throw a perfect tantrum.


Sometimes I wish we can have that time back. I wish he can get better like this has never happened before. I asked him how come he is so brave, I would tap out so fast. He replied I am as brave as any father would be. I am doing this for my daughters.


After he received his first cycle of surgery, radiation and chemo he waited for a month before the CT chest and abdomen were repeated. He was very optimistic, doing everything right and embracing any therapy available for this disease. He was even getting imported Japanese herbal tea which can help with cancers. Then came the results of the CT scan which showed that there was no remission, in fact there was progression of disease with lymph node involvement.


I remember the day when I found out. I had a tough time sleeping that night.  But he did not flinch and started the process again with chemo. I asked him how it feels. He said “It is like you prepare for your tests and work really hard, you sit at the day of test and do really well. But when the result come out you find out that you got a F. That’s how it feels like”. I was speechless.


His courage, dedication and strength is inspirational. We met few days ago and during our conversation he told me casually that he sold one of his cars just in case if he is not around things would be simpler for his wife. To come in terms of one’s mortality is not an easy thing to do. His wife who is a physician too puts up an act so convincing that it is hard to figure out what is going on behind this veil of bravado.


I read a book The Last Lecture by Randy Pausch, a computer professor who stood in front of 400 people at Carnegie Mellon University in Pittsburgh and frankly talked about his fight with pancreatic cancer with few months to live. Later in the lecture he did some push ups followed by a lecture about how to achieve childhood dreams. He writes in his book “We cannot change the cards we are dealt, just how we play the hand”.


I think my friends have played it well. Sometimes I feel guilty that in the game of life the dice coughed out the wrong numbers. Sometimes I have trouble looking straight in his eyes thinking he may discover that I fear for him. But there is never a time when I don’t envy his strength. I wish I could have been a better friend.


Anyway my friend I just want you to know we are here for you always and I hope we are stupid again to snorkel during thunder and lightening soon.


Blog you later.


About the picture: I took this picture at our house but my daughter provided me with the ketchup.

PS: This is a follow up.

Monday, August 16, 2010

Shadow People.

Considering the rat race we are in, there is very little time to pause and reflect on your life.  Niccolo Machiavelli founder of political science once wrote "the end justify the means". Or is it the other way around. This is a difficult question. I found my self at a crossroad few months ago when I heard a story from a patient of mine.

It started like any other patient encounter. I met him for the first time in the hospital lying on somewhat dirty bed and wearing not so modest hospital gown. He was tall but frail. Despite being in his late seventies he appeared to be untouched by time. He was trying to listen to an overhead page calling for some doctor who was again not on time. When I entered his room he tried to fix his thinning hair and straighten his already crisp mustaches. He greeted me with a frail smile.

He greeted me with respect and gratitude which you do not see very often these days. He was in pain, I could sense it, though he was trying to conceal it.  Despite everything he was going through, he still appeared composed and had an aura of tranquility. As we began to talk he opened up to me.  He informed me that he is a veteran and served in second world war. Actually was a crew member on one of the first navy ships to arrive in Hiroshima in late August of 1945.

I am not sure how many of us have ever met someone who was in Hiroshima right after the nukes, I never had an opportunity so I was naturally intrigued. I asked him what he saw and what he remembered. His voice started to break and he began to cry. I shared his grief and started thinking of the burden he is carrying on his shoulders that even after 65 years he still is overwhelmed by these tragic memories. When I asked him what he remembered the most. He said "doc I cannot forget the shadows, they still follow me". I asked him to elaborate. He said when he was in Hiroshima and later in Nagasaki he saw these people-shadows on the street. Later on he was told that these shadows were from the people who were standing when the bomb went off, the body absorbed the radiation and intense heat  left a shadow behind. He felt like there are still corpses on the street where ever he went. He would ask other people not to step on these shadows. When I left the room later he was still crying.

This all came back to me as we are again in the month of August when this all happened in 1945. “Little boy” a barely ten foot bomb was dropped on Hiroshima by Enola Gay at 8:15am on August 6, 1945. This resulted in an immediate death of 80,000 people followed by another 130,000 people due to radiation exposure.  Three days later on August 9, 1945, Bockscar dropped “Fat man”. Interestingly the primary target was Kokura but due to low visibility the secondary target was chosen and the bomb was dropped at Nagasaki. Estimate immediate deaths were from 40,000 to 75,000. Does end justifies the means or not it is for us to decide.

I guess in my life I have seen some shadows and they still haunt me.

Talk to you later.

About the picture: I took this self portrait at children museum in Chicago.

I am not a carpenter.

Working as a physician gives you deep perspective of our society. I decided to be a physician because I  care about the human factor in medicine. Now you may wonder what does that mean. Well sometimes we are so immersed in evaluating data, recent studies and X-rays etc. that we forget the emotional and human aspects of a person. I feel in order to heal a person you need more than a computing mind., no wonder we have no robots doing this job. Sometimes sitting down with the patient and inquiring them about their emotional needs does more than just asking them if they have chest pain of SOB (shortness of breath not to be confused by a common street phrase).

Healing is a holistic process. If our job only requires fixing a broken bone with screws and plates or opening a blocked vessel than we are nothing but glorified carpenters or for some plumbers. I sometime feel that this is what we are some times.

Today I had a meeting where I was discussing how we are suppose to meet Medicare requirements. But than I thought we need to go a little more than that. Isn't meeting bare requirements mean that you are admitting for being a mediocre doctor. Our goal should be to achieve excellence. On the other hand in this day and age where we have to worry more about volume of patients in order to keep afloat, there is not enough time to go above and beyond. You feel guilty because you have to meet your RVUs (revenue value units). But if you won't we have to deal with powers to be.

Unfortunately medicare does not have a code for physicians to sit at the bedside and hold a dying patient's hand. Though do pay very well for putting a pace maker (40 grand just for the pacemaker) on a 93 year old woman who I had today with advanced dementia, she is constantly asking for her dolls. Maybe I am naive and ignorant and do not understand why at this stage of her life a pacemaker would probably comfort more than a gentle hand.
But what do I know I also work in the mill though not a true carpenter!

Anyway catch you later.

PS: I took this picture on my visit to Chicago.