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Sunday, October 31, 2010

Lemon Tarts.

She is in her late twenties very energetic and compassionate. She is always bouncing around from one patient room to another, along the way “trying” to boss around all the physicians.

The amount of energy she has is infectious, but looking at her you can never tell she had an open heart surgery just a few years ago. When you think about open heart patients, twenty year olds do not come to mind. It is one of those medical mysteries where we have no answer why she had coronary artery disease at such a young age.

Now she has a new lease on life. She is now married and has a young son. She says that she meets her son everyday like this may be the last day of her life. She has a very positive approach towards life. She thinks she had this ailment for a reason. She believe that through her people find strength and hope, when they see a person living a normal life despite going through this major surgery, they feel they can go through it too. It is true people can associate more when they have some thing in common.

There is no rhyme or reason as to why life has dealt these cards. You can sulk and make your life miserable. It is your choice to be a passenger or be a driver of your life

As they say if life hands you lemons, make lemonade or be smart make lemon tarts. 

About the picture: I am keenly aware that this picture is neither a lemon nor a lemon tart. But I should get credit for it being yellow.

Thursday, October 28, 2010

1928 Cell Phone?

We are close to the weekend now, so I will try to keep it light.

I saw this clip on Youtube. CNN also ran a story about this. This clip is from "Circus"
a Charlie Chaplin's movie from 1928. 
You will notice a lady walking in the background while she appears to be talking on a cell phone.
The only problem is that there were no cell phones in 1928. So what is she doing? 
Hearing aid or time travel?

What do you think?

Wednesday, October 27, 2010

Tele Neurologist. Specialist On Call.

In a time not so far away, you just brought a friend to the emergency room with symptoms of stroke. Patient has developed right sided weakness and also complaints of slurred speech. ER physician enters the room and evaluate your friend. He recommends that your friend can benefit from thrombolytic therapy. Then he goes on to say that he would need a neurologist to make that call, however, there is no local neurologist on call. You start to get upset and…………….drum rolls…..

………and enters neurologist on wheels, this robot like device is being dragged in to the room by a nurse. On the monitor you see a doctor’s face. “Robot” asks you different questions, examines your friend with certain devices and eventually review your CAT scan of the brain while sitting miles apart. Finally he recommends that he concurs with thrombolytics. He orders it and the nurse administers the lytics. Soon your friend who was unable to speak a minute ago now is talking with you and moving his extremities. Finally you take a deep breath. You know what’s so peculiar about this scenario? THE TIME IS PRESENT, IT’S HERE.

I was invited today to meet with Specialist On Call (S.O.C). They provide expert consultation and evaluation for stroke patients. Their model is telemedicine, where a board certified physician is sitting at a remote facility and evaluates your patient. He makes recommendations appropriately, utilizing most advanced tools available through a computer portal.

This company provides specialty care to those hospitals which lack certain specialties. Like in our program we do not have a neurologist on call for stroke.  So patient who live close to our hospitals are taken to a remote facilities to be treated with thrombolytics.

 Initially I was apprehended by the presentation but after listing to the speaker he was able to answer most of our concerns. SOC was founded in 2005, they are currently working in 105 hospitals around the country and they are (Joint Commission) JACHO accredited. They guarantee a patient–teleneurologist encounter within 15 minutes and are available 24/7. They had 6734 consults in 2009 and recommended 380 thrombolytics. National average for cerebral bleed after thrombolytics is 6 %, they are at 4.5 %.  They recommend collaboration with local neurologist for post thrombolytic care.

Though it seems like a good alternative but it would require a comprehensive protocol before this could be implemented. There is a company in Georgia who is also using the similar device to fill in for nocturnist/hospitalist and so far they have seen good results.

I would appreciate feedback if anyone has been involved with similar projects. 

How Many Times Have I been Sued. Malpractice Lawsuits.

Recently I came across an article by Paul Levy, it mentioned a support system among doctors at Brigham and Women Hospital. This support system is in place to meet the physician who is being sued. They provide counseling and assist in anyway they can. I also received a report from a very good friend of mine, an interventional cardiologist Dr Raxwell about percentage of lawsuits among different sub-specialties.

When I initially moved to Florida, I was asked to meet a hospital chief of staff. During the interview process he asked me how many times have I been sued,  I replied none. He smiled and said “you want to say that you have not been sued, yet”.  

I have seen a large number of doctors struggling with insurance and lawyer issues that they can hardly live a normal life.  A colleague of mine was sued over a lipid-lowering drug by a 75 year old lady,  who had been her patient for over a decade. She asked the lady why? The patient said that she still likes her, insurance was going to award her the money that she thinks would not affect the doctor and …….. She is almost 80 year old and  likes to go to casinos.

Here is the report from AMA physician practice survey.

You should specially look at cardiovascular surgeons, 75% of them have been sued, 56% for the second time, almost 15% in the last 12 months and finally their number of claims per 100 doctors were 297%. WOW….

Knock on the wood, I still have not been sued… as of yet!  So what do you think. 

Tuesday, October 26, 2010

What If Walls Could Talk?

What if walls could really talk? Would you be scared? Would you really want to listen? What stories would they have. If walls talked would you be appalled, overjoyed or disgusted with their sordid tales. You could hear the resonance of  soft whispers among lovers and their promises to each other.

These fortifications may divulge your stories and secrets, stories about you, things you do not want anyone to know. On the flip side you may hear a hearty laughter from your childhood days.  full of fun as a child, sound of your innocent and pure laugh, not yet corrupted by social obligations.

Maybe you will cover your ears, as you can no longer bear to listen to these atrocious stories. Or maybe you will listen just a tad bit more to satisfy you innate curiosity.  You may not like yourself when it will remind you of the unkept promises and blatant lies. It may show your lack of integrity, gold standard test for integrity is not measured on the basis of our social interactions but by what you do when you are alone.

Or maybe it may remind you how much you are needed and what you have done for others.

 PS: I have been lazy about writing blog lately as I have not been feeling well.

About the picture: Field Museum, Chicago

My Friend With Cancer, Words of Wisdom.

Sun is cherished and romanticized the most at sunrise and sunset, so is birth and death. These are two focal points, which we rejoice and grieve the most, more than anything in between. A friend of mine is suffering from terminal cancer, I previously wrote about this few moths ago.

The last few days have been very turbulent and conflicting for me.  On one hand I have to face the eventuality of this situation and on the other hand I feel guilty because I can not control myself from thinking that what if this was me. I feel a certain bond with him as I have two daughters too of the same age. What would I have done? Would I have shown the same dignity?  I try to distract my self in other things so that I do not have to think about this.

I was sitting next to his bed just a couple of days ago. How do you answer when your friend ask you is there any hope when there is none. It is different when you tell a patient that they are dying, it is quite different when you have to say to a loved one. I held his hand and firmly informed him that this is the end of the road and controlled myself from showing my emotions.

But I am not writing today to tell you about how I feel, as someone said it once, regardless of how bad one feel for the other, you can never feel close to the despair the other person is going through.

This is what he said to me with shallow breaths and teary eyes for almost thirty minutes after I told him what I think. I got his permission to write this and I will try to quote him the best I can.

“One thing cancer has taught me is that the world is not about you. When you turn the world about you, your life becomes very difficult. You have stressful days and you have days of agony. When you decide that your life is about others, about friends, about relationships, your world becomes a lot easier. When you stop focusing on “me”, and start to focus on people and relationships around you, you world starts to get easier. That is tough lesson I have learned from my cancer.

He paused briefly, then continued "I am really into my 2 little girls, just like any father. I had a very touchildhood…. My life long goal was to have a perfect family. And to have kids, and to shower them with parental love more than which I ever got. With this mentality I started my family. If I would have known my life would take a sharp turn like this I would have never done it. I did not know I was going to die this young. Because I can not bear to think that my kids will miss and not look at me in their later lives. I do not want them to wonder where is daddy, when is daddy coming home?

My older one knows that what is going on. My relationship with her has changed. She is more quite. She gives me hugs everyday, the kind of hugs she did not give me before. Before she used to give me hugs which a typical 9 year old gives to her  daddy depicting “I love you so much”, in the past few months she gives me a hug which is more like “daddy I do not want you to go”, for a nine year old to go through this, is heart breaking.

I fight this disease because of my daughters. Your life should revolve around your family. Your should not sacrifice your family”.

Well I just want you to know buddy, the love and affection your girls have already received, very few children get it in their whole lifetime. 

Wednesday, October 20, 2010

A New blood thinner in 50 years. Dabigatran.

In the history of blood thinners, FDA has approved Dabigatran, a new blood thinner for the first time in fifty years. Dabigatran (Pradaxa) has been approved for strokes associated with Atrial fibrillation. It inhibits thrombin.

Warfarin is one the the best and most dangerous medication we have been using for decades for clot related problems. It requires constant monitoring. Unlike Warfarin, Pradaxa does not require periodic monitoring.  It carries decrease risk of bleeding as its counterpart. It will be available in 75 mg and 150 mg capsules. The cost is going to be an issue. It can be 10 times higher than Warfarin. I think it should be available in the next 6 months.

Well this is as exciting as it gets for us.

About the picture: On top of the ferris wheel at Navy Pier, Chicago. 

Monday, October 18, 2010

Doctors Are In For The Money!

I was recently reading an article at KevinMD, about doctors, that they are in for the money. Well I thought, to give you some perspective, I should list the jobs that I have done in my life, during my transition years.

In Pakistan I already finished my training after post graduation and I was running my own practice. However, once in the US I needed to do this all over again, so I was waiting to restart this process. The problem was that this cycle takes a year before you can get a position. So, I had about 18 months to kill. When I came to America, I did research with Dr. Harvey Priesler and Dr. Azra Raza, two of the smartest people I know in the field of Leukemia and Myelodysplastic disorders. I thoroughly enjoyed the experience but on the flip side the stipend that I earned only covered my studio rent in Chicago.

So I started to look for other jobs. I started my quest, beginning with trying to get off of a forced-vegetarian diet i.e., one of the cheapest meal prepared with garbanzo beans and diced tomato which takes only few minutes to cook. A friend of mine (who is now a high-risk Obstetrician in Detroit) tagged along and we stared to look for jobs. Our first stop was a pizza place. We filled out an application. There was a slot in there about education; we were naive enough to mention our qualification. They turned us down due to lack of relevant experience. My friend tried to argue that if he can deliver a baby, he can deliver a pizza without any problem. We lost the argument when the owner said that this oven works in a different way.

Finally I found a spot at a pizza joint. I delivered pizza for 3 weeks. It was the most stressful job I ever held. I used to park my antique car (my father bought me that car) in downtown Chicago and run up to deliver pizzas. The problem was that I got so many parking tickets that the net revenues were in the negative. After getting mugged and punched in the belly I was forced by my wife to quit that job.

Next stop, Chinese take out restaurant. I think the owner did not appreciate my talent. He kept on asking me to cut the vegetables faster and faster. I tried telling him that you can not be hasty, cooking is an art. He did not agree and I was given a pink slip along with garlic chicken on my way out.

Finally I found a job which I kept for over a year, carpet cleaning. I use to do high tech leukemia research with different clinical protocols in the morning and in the evening I use to clean carpets in the dead winter of Chicago. In fact the job was so “lucrative” that some of my other friends joined in too. One of them is now an Interventional Radiologist in Wisconsin and another one a Critical care Intensivist in Phoenix.  I will let you in a secret; I can still clean the carpets with floor stripping better than many, just do not tell my wife.

As I was diligently doing these two jobs I received a call from a program at Beth Israel Hospital/Harvard about an off cycle radiology position. They asked me to be there in 2 days. The problem was that I only had $280 in my account which would not have paid for the whole plane trip and stay. I told them I am busy for the next 2 days I can be there in 3 days. 

Greyhound used to take 28 hours from Chicago to Boston.  I got in a bus within 12 hours and made my way to Longwood Avenue in 28 hours, changed into a suit at a restaurant at Fenway park. It was a very humbling experience to be cleaning floors one day and standing at Harvard Medical School the next. Finally I got this position, during my stay there I learned so much from Dr. Sughra Raza, Dr. Janet Baum and Dr. Brook Longwood. They all made a significant impact on my professional life. My career started to shape up from there one..... and here I am.

Well so there it is, you be the judge.

About the picture:  Not mine!

Sunday, October 17, 2010

Charity Waters.

Charity Water is an NGO; which supplies clean and safe water to developing countries.
Ideas mean nothing, unless you act on them and this young guy decided to act on it. It was originally founded by Scot Harrison, a young socialite, a nightclub promoter and fashion events organizer out of New York City.  After living a life of self indulgence, he decided to do the opposite of everything he had done in the past, and do something for others. He traveled to Africa with a charity organization and never really left.

The idea started three years ago, it was to provide clean water which you and I drink every day; which is not available to 1 billion people around the world. Within three years this charity organization has collected 13 million dollars through 75,000 donors. In Africa millions of kids travel miles barefoot just to get water, these kids should be spending their time in school rather than looking for water.

Scot started with nothing and on his 31st birthday he asked all his friends to give him $20 dollars each, 700 hundred people showed up which enabled him to make 6 water wells in Uganda. At his 32nd birthday he asked people to donate $32, his team was able to collect $150,000 which went towards obtaining clean water for hospitals in Kenya. On his last birthday, Charity Water was able to collect 1 million dollars. The best thing about this organization is that 100% of your donations go towards the cause. Administrative cost is funded by major corporations.

Maybe for his next birthday you can give him a gift. Maybe you would decide to choose a different organization, but do choose one.

I remember this analogy about a man at the beach; he was throwing back starfish which were doomed to die on the beach. Someone shouted sarcastically at him “you can not save all of them, there are millions of them”. He looked back at him, tossed another one at the sea and said “made a difference to that one”

So just make a difference in someone's life, if it only means one life only.

About the picture: Sunset at one place, sunrise somewhere else. 

Thursday, October 14, 2010

Hatred. Tyler Clementi.

Pablo Picasso said once about abstract art “Many people say they don't like my art because they don't understand it. Well, I don't understand Chinese, but that doesn't mean I don't like [it]”. 

We all fit somewhere in the spectrum of life, dull, bright, dark or translucent. Just because we do not understand something, it does not mean that we should disregard it or show contempt, unfortunately we do. We tend to dislike things which are different, some more than others. Our degree of contempt accelerates, depending how different the polarity is.

Things which are not comprehensible to us, start to plague us. Not so surprisingly our level of disapproval starts to grow depending how different something is. Our fear from darkness seeds from the sole reason, our inability to see in the dark. In darkness we are still the same, objects around us stay still but our fear of unknown and loss of control make us anxious. Our demons go away as soon as we turn the lights on. As usual when we can not perceive, we succumb to fear. 

Alien ideas, actions and concepts induce different reactions from everyone, some are not affected at all and some shows extreme agitation and some become phobic. It is so easy to detest something, much easier than trying to understand or rather accept the differences.  It requires no effort to go with the flow, however, accepting contrast need a conscious effort.  So, we decide to follow the same old route lets hate, let’s hate other faiths, beat the gay guy, make fun of how you look, and in fact hate anything which is different. 

Recently I read about Tyler Clementi, a promising musician at Rutgers University. Tyler jumped off a bridge after he was targeted for being gay. Clementi was one of many who are bullied everyday for being different. I took care of a victim of hate crime once and it was not pretty. Please spend sometime and view this link, this was sent to me again by my friend from Italy who earlier sent me this post too. Gays and lesbians are one of the many groups who are targeted for being different. History has taught us we do not discriminate in our hatred like we do for our affection.

I am not trying to make a political point nor is this an attempt to undermine any religious belief. My point is the human aspects of this tragedy. Someone lost a loved one just because he was different. You can not harm someone just because you like red and he likes blue. Millions of people are suffering because they either not look like you, worship a different God, have different facial profile or a different skin color.  Next time if you decide to go with the flow, take a hard look at yourself and see how different you are from the person next door. It is not about being tolerant; I think this is about acceptance…….you do not have to be like me, I like the way you are.

About the picture: Colors of life.

Tuesday, October 12, 2010

Stuck Between A Chicken and A Grape. Human Genome Project.

Since we discovered the genetic code, scientists have been trying to figure out the number of genes in a human genome.

Initially Vogel in 1964 estimated that there are 6.7 million genes, which were supposed to be pretty high but it was assumed to be right. Even Vogel found this number to be “disturbingly high”. National Institute of Health report in 1990 estimated that the total number is around 100,000.

Later that was dismissed too. I came across a very informative review published by Mihaela Pertea and Steven Salzberg at Genome Biology. Due to our better understanding of the genome and automated DNA sequencing we can have a better estimate of the number of human genes. Also as now we have an improved definition of genome itself, this has drastically decreased the total number of genes in human genome.

Here is an estimate of genes.

Grape  30,343
Human 22,333
Chicken 16,736
Fruit Fly 14,889after
Influenza 11

So with all our might, wisdom and resources, we are slightly better than a chicken but worse than a grape.

About The Picture: I don't know why, but there were just too many chicken in Kauai.

Turn off E-Babysitter. Children And Television

Next time you are going to turn Dora the Explorer on; you may want to think again. Unfortunately TV has become a second babysitter in our lives. It is very convenient to turn it on and put the child on auto, just so we can take a breather. 

At University of Bristol, researchers studied 1,000 children aged 10 and 11. Children who were in front of a TV, video games or computer screens for over 2 hours were noticed to have 60% higher rate of developing psychological problems, peer related issues and emotional disturbances, regardless of physical activity. They also noticed that these problems were worse in children who have less than an hour time of vigorous exercise.  

These children rated their emotional state from always, sometimes and never and answered questions like ‘I am often unhappy, down-hearted or tearful’, or ‘I am usually on my own’, ‘I generally play alone or keep to myself’. It is sad that a young child feels "unhappy" or tearful" all the time. 

There was another study from the same institute which evaluated parental TV viewing. Higher parental TV viewing was associated with higher child TV viewing among both boys and girls. This would in turn cause problems which I mentioned earlier. As we already know obesity has also been linked to prolonged TV viewing.

For some time in our household we have instituted a policy of no TV during the week. However, during their toddler years they did watch a fare share of the silver screen, which I am not proud of.

So next time, think again before we welcome SpongBob into our homes.

About the picture:

Monday, October 11, 2010

Hospital Medicine Program (HMP), Code Blue And Expectations.

This blog is a continuation of hospitalist issues which I wrote here and emerging expectations from a Hospital Medicine Program (HMP). As I have mentioned earlier, we are in the process of making a transition from a traditional call-from-home service to a 24/7 in-house hospitalist service. At this moment in time around the nation 39% of HMPs have adopted a 24/7 model, which is growing every year. There are several factors which play a part in this transition and this brings certain expectations.

  • 24/7 model presents a real time admitting service. Meaning in a conventional hospitalist group, a patient admitted with pneumonia at 7 pm by a hospitalist, may not be seen by a physician until 7 AM. 24/7 model assures that patient is seen within a specific time. This not only helps with the ER patient flow but also shortens the length of stay along with assistance in pre-operative clearance and decreased crowding of observation patients. Not to mention improved patient satisfaction.
  • Staffing: You need to have adequate number of physicians to cover a 24 hour rotation. Considering our program is relatively new, we need to make sure that we have enough referral source to support all physicians.

  • With 24/7 service, it is natural that hospitalist should be able to provide Code Blue coverage. This is easier said than done, but very much doable. This would require a) Change in hospital privileges for some physicians b) ReTraining courses to brush up their skills c) preceptors for the initial 5-10 procedure d) Back up assistance preferably from ER if needed e) All hospitalists should have FCCS (Fundamental Critical Care Support)  certification. f) All physicians involved need to make a firm commitment to be part of the process. It is imperative to have clear guidelines for implementation, as at the end of the day safety of the patients comes first than changing paper protocols.
  • 24/7 model is expensive and difficult to adopt by private groups. Historically nocturnists are expensive and less desirable by private groups as they generate comparatively less revenues.
  • It is imperative to have a reliable staff and an ability to retain physicians. For instance, if a physician decides to leave the group, it can destabilize the whole shift model. On the other hand there needs to be a process where a back up system is in place either by locums or an incentive plan within the group if such a situation arises.
  • The program needs to be marketed to the rest of the physician staff where private physicians should be comfortable admitting patients to the hospitalist group at night if they wish to and these patients can be signed off to them in the morning. This would benefit all the parties involved; the patient, the HMP and the private physician.  
Well these are some of the issues involved; I would keep you apprised as things develop.

About the picture: The angel represents hope and Prometheus, the Gold Statue at Rockefeller Plaza

Hospitals Cannot Cure Some Pain. Hospice.

It was a dimly lit room, up on the sixth floor.  I am not sure why they would not fix the light in that corridor. Even during the day, I would find this area poorly lit. Maybe it was not the light but the grim atmosphere of Oncology floor. Some of the patients there were with terminal illnesses and they would still act like they had decades to live for. You will be surprised how you find bravery at unexpected places. Maybe they were not really brave but pretending to be, I could never find the difference.

How do you find such strength? Maybe they are hopeful that they would get better, maybe they will get few more years to wonder this road. Hope keeps us going… I guess. Their optimism was like a breeze in the garden, which surrounds you in a subtle way. Those were one of the times you want to forget the statistics and all that prognostic data and just reassure them. You want to tell them that survival numbers are just numbers which mean nothing.

He was a resident of the sixth floor. He had mesothelioma, suffering with pain, not the kind of pain which can be cured by medications. He was leaving his family, for good. For some it is a passage from one phase to another, for some it is the end of the line. Some believe that they will come back as better or worst. No matter what they believe… we all go cross over. He worked in an asbestos factory for the most part of his life which eventually caused his cancer. Once I asked him sitting down next to his bed, has he ever thought about suing the company he worked for, he said no, he was supposed to die one day anyway…. so be it.

I offered to increase his medications to improve pain, he said “the kind of pain I have, you do not have the medications for it yet”. I think he was right. His son requested us to keep him comfortable. He wanted him not to suffer. In the end he requested to be released home, he said “I would rather die with my loved once; I have had enough of these hospitals.

And I think this is where hospice plays a very significant role. As much as we are trained to prevent death, we are not trained to deal with it. One of my professors actually said “death is just a phase, one to another”. He actually lost his wife to ovarian cancer. I learnt a lot from him about end of life issues. He said “sometimes we love our loved ones so much that we are not willing to let go of them for our own selfish reasons”. I try to tell my patient families to think from the patient’s perspective rather than their own. Who would like to be lying in bed with all kind of tubes sticking out? Versus dying in peace

These days there are fellowship available in Hospice medicine and palliative care. They teach and train principles which embraces compassion, integrity and ethical views to take care dying patients. There is a misunderstanding that patients with cancer can only be a part of hospice. Actually patients with terminal diseases of any kind, advances dementia and gravely ill patients can be enrolled in these programs.  We just need to realize their need and the great service they provide.

About the picture: Dwindling lights.

Friday, October 8, 2010

Healthcare Reform Bill.

 So actually there are some good things about this health reform bill despite all the uproar against president Obama. Here is a brief summary.

  • Your cost for preventive measure would be ZERO dollars. So next time you are having a colonoscopy, mammography etc, you do not have to worry about your co pay, your insurance would pay it all.
  • You can get insurance even if you have any pre existing condition.
  • You can get a rebate check for the “donut” hole.
  • Children up to 26 can be covered under your insurance.
  • There will be no annual or lifetime limit on benefits through Medicare.
  • 35% tax credit for small business against premium payments. These measures would also help in the long run where mega companies like McDonald provide mock insurances plans, where there is a cap at $2000, this amount would likely cover only your foot at the door in a hospital.
  • This would extend coverage to 32 million Americans who are currently uninsured. This would help these individuals to get insurance.
  • The law will cost the government about $938 billion over 10 years, according to the nonpartisan Congressional Budget Office.
  • Insurance companies could no longer deny children coverage based on a preexisting condition. 
  • In 2014, everyone must purchase health insurance or face a $695 annual fine. There are some exceptions for low-income people.

So now get ready to pay more taxes.

About the picture: Somewhere in Smokies.

Thursday, October 7, 2010

Camel Jockey

What do you do when you are infuriated? Most of the times I just smile and sometimes not. Maybe it is my way of dealing with stress. Everyone acts in a different way; I try to hide my annoyance behind a screen of a smile. At times I fail and sometimes I succeed. Practice makes you perfect. You can pretend to be in a good mood and after a while no one can sense the difference.

I remember seeing a patient long time ago who was in the hospital for myocardial infarction. I got a call in the evening that he wishes to sign AMA (against medical advice). I was in the hospital, so I went down to see him, where his nurse was standing at bedside. I asked him why he wants to leave against medical advice. He replied that he wants go out and smoke. I said, this can cause serious consequences especially when you are having a heart attack. Initially he argued than he asked me “where are you from”. At that moment I realized nothing good is going to come out of this conversation. I said I moved from Boston but originally I am from Pakistan. He said “were you a camel jockey over there?”............

I looked at him and smiled. I said “well I guess not a good one, so I switched professions and became a physician”.  He was not very appreciative of my response and started to enlighten me about things I did not even know about my self and my ancestry. Nurse came to my defense and eventually we were able to talk him down.

Now I am not trying to sound holier than thou. I exhibit ample moments of weakness where I want to just isolate myself self from a situation like this. On the other hand let’s say this patient goes home and die. Then I have to live with my conscience. Would you have done something else?

Isolating your personal ego is a very difficult thing to do. We can only try. 

About the Picture: Going to work.

Wednesday, October 6, 2010

Is Compassion A Mutant Gene?

When we are young we are full of countless ideas, not yet corrupted by the world. I had a childhood friend, very smart guy, now a remarkable mathematician. We use to debate about things, some of those we were not able to comprehend and some we did, but lost it with time to the sirens of reality.


He would make a case that people are bad by nature and if some one is good than it is against our intrinsic nature. He was a total cynic. “So you think goodness is a mutant gene” I would counter him. We would debate to and fro and go around in circles. He would try to support his hypothesis by theorizing evolution.


He would say “Darwin’s theory is it about survival of the altruistic or is it about survival of the strongest? We are what we were. Since we started to walk upright we have been fighting over food to land and everything in between. What do you think natural selection or survival of the fittest is? It is exactly what it sounds like; YOU TAKE WHAT YOU GET”. He would add “compassion is a trait we have just started to learn, merely for few thousand of years, do not bet on this newbie”.


I would argue “if you truly believe in evolution than compassion and empathy is a gene in evolution. Maybe after struggling for so many thousand of years some of us are now fortunate enough to get the better end of evolution. We may be evolving into a higher beings”.


But when I see character like the one I mentioned in my earlier post Predator I start to doubt myself. On the other hand the people like the lady I met who volunteered all her life to care for homeless people, affirms my faith.  Amongst us live people who have ascended to a higher level of living; but there still those primitives; who prowl in the murky nights for prey.


We may not have control over what genes to pass but we can at least learn to modify our behaviors.


About the picture: Phoenicopterus/Flamingos are not genetically pink, they turn pink after taking high carotene diet. Shot at Busch gardens.

Tuesday, October 5, 2010

Female Is A Woman Not An Electric Connector.

Somehow we are seeing more females and males in the hospital rather than women and men…. I hope you catch my drift. There is a subtle difference between the two. These days I come across a lot of History and Physical (H &P) which refers to the patients as 54 year old female or 43 year old male. I find it a little peculiar. It strips vibrance off their personality. There is no denying the fact that they are male and female but so are electric connectors and dogs.

I was rounding once with an intern and he was presenting a case, he said “This is a 54 year old male who presents  ...” I stopped him in the middle and added “well he looks like a man to me”.

My point is; it is important to put things in context. If you keep on referring to your patients as male and female; you may loose the point that we are not treating a thing but we have some one’s father, brother or sister. It makes it personal.

Maybe it is a frivolous thought, but sometimes it is the small prints which matter the most.

About the picture: I took this picture in a small village in Pakistan, this lady shied away as soon as she realized I was taking her picture which embarrassed me a little.

Monday, October 4, 2010

Empowered Patient, Myself.

I was watching a news report on CNN the day before, titled The Empowered Patient. There was a story about a lady who was misdiagnosed by a doctor which almost cost her life.  I occasionally come across these situations in my professional life. But the story I have for you is more personal and involves my then 3 year daughter.

We just moved to Tampa around that time. We were sitting on a new sofa which we recently bought, watching a late night TV show. My 3 year old daughter was doodling something on a paper at the same time chewing on a pencil. After a while she tried to climb the couch, as soon as she came up she fell down, face first with the pencil in her mouth. She started to cry and I saw a speckle of blood at the corner of her mouth. I immediately examined her mouth and I noticed a small amount of blood at the palate. My wife who is a physician too washed her face, gave her some cold water to drink and everything seems to be alright.

Around 11 pm my daughter started to fuss a little more and complained of mouth pain. I decided to take her to the ER after my wife insistence. In the ER she was examined by a familiar physician. He examined her ear, nose and throat along with a chest X-ray. He diagnosed her with middle ear infection and prescribed her codeine and antibiotics. I was perplexed; I could not fathom how she would develop an ear infection after this kind of injury. He assured me she must have an underlying problem which is manifesting now. He added “Irfan, you are analyzing things like a father rather than a physician”. I was confused, but there was nothing else to do. After his repeated reassurance I brought her home around 4 AM with instructions to restart feeding with milk and food.

Her condition at home started to deteriorate, around 5:30 AM she started to develop shortness of breath and became lethargic. My wife looked at me and said “We need to take her back to a different hospital; my motherly instincts are telling me that there is something terribly wrong here”.

As we were putting her back in the car I got a call from director of the ER. He said “ the other doctor missed a finding on the chest x-ray, you daughter has pneumomediastinum”. I felt like being kicked in the chest. Knowing pneumomediastinum is an air collection (mostly after a trauma) in the space between the lungs, this space is in the middle of the chest (the mediastinum). Basically the pencil penetrated her throat, made its way into the space in the middle of her chest. This created an opening between the throat and the chest. We had been feeding her milk, a perfect medium for bacteria. Infection with pneumomediastinum has a very high mortality rate.

We literally ran to a different hospital where she was seen by an excellent ENT and ER physician. She had few procedures, couple of tubes and she was admitted to the ICU for a week. She recovered without any residual problems and we brought her home. A happy ending.

There are certain concerns though. To err is human. But how do you deal with your mistakes. Full disclosure would help in most cases. I never got a call from the physician who was involved, he never explained what happened even after we met; considering this could have resulted in a disaster if we were even an hour late. A sincere explanation would have sufficed. That is where transparency comes in.

On the flip side systems puts in place for patient safety helped us save her life. Any X Rays read by ER physicians are read again by the radiologist, which decreases the chances of error. I am glad that this system of checks and balances exist, as this improves the safety of our patients.

About the Picture: At a lake nearby.