You Think You Got It Bad.

Usually I do not post these videos, but sometimes you see certain thing which make you wonder how. If you think that you got it bad you got to see this video.

Last Chapter.

My friend who inspired me start this blog died last week. I wrote about him here and here.

I was out of town when this happened. My motivation was really low to write anything. Around the same time I had couple of injuries, I tore a muscle and most recently a hand injury while running. So all of these events compounded to this recent hiatus.

I came back last night and I saw his family today. The problem is what can you really say? not much. Even if you say anything it does not change anything. 

He recently received Patriot Award, this award goes to employers who support their employees beyond basic requirements by law.  He was that kind of a guy.

A friend of mine says that the last chapter of life is the most difficult to write. His last days were full of bravado, courage and inspiration. I think his last chapter was too short, however it was most admirable. RIP.

About the Picture: Busch Gardens.

Computerized Progress Notes and CPOE.

Yesterday I gave a talk about computerized progress notes to some of our staff physicians. As we are now doing 100% CPOE orders, our next phase is to be paperless at some time in the near future.

I am very proud to say that our group of hospitalist are now 100% paperless. This includes computerized physician order entries, admission and discharge medication reconciliation and now progress notes.

I started doing electronic progress notes almost a year back. It was a challenge for the first few days but now I don’t think I can go to paper again. So these are some of the advantages I see in doing electronic notes.

• All the data you need can be pulled into your progress notes including labs, microbiology, radiology, vital signs, pathology and is updated automatically everyday.
• You don’t have to look for charts which are never there when you need them
• This makes it a one stop process, rather than first writing your note, place orders somewhere else and review data under 10 different tabs.
• You can see all your patients and than sit at one place and complete your charts.
• When you sign off, your partners can copy your notes and edit them and create a new note without inventing the wheel all over again.
• You can improve your coding as your note has more components.
• It is a much faster process.
• You can create your personalized templates and use them as needed.

Next stop history and physicals, if they become user friendly.

I Have A Question.

I was talking to a friend of mine, Dr Nawaz who has Internal Medicine and dermatology practice in Wesley Chapel, Florida. He raised a very good point the other day. He said a good doctor is skeptical; he raises questions, even for common problems. And that…..defines a good practitioner.  

He gave a very good example, he saw a patient who has been complaining of ear pain for some time. He was seen by various doctors and eventually was diagnosed with an ear infection. He was treated with antibiotics and what not. Patient finally came to him and he saw this patient in the clinic. His examination was not consistent with an ear infection. He ordered CT brain and found out that patient had a brain mass.

His point was that you have to ask questions even for your everyday problems. Every GI bleed is not due to an ulcer, every sore throat is not pharangitis and every chest pain is not because of a heart attack. I am not trying to say that you should order a brain CT for every earache, however, when we see a recurrent problem without any relief, you need to start asking questions fast.

As they say in medicine common things are common. You should not be looking for Zebra all the time, but you should know when you need to take your binoculars out. There is an unsaid rule in the ER, if you have recently discharged a patient from the ER without admission and if he comes back soon with the same problem, you got to admit him. Even if conventional wisdom says otherwise. We as hospitalist usually try not give them any grief when they call us for those admissions.

So the bottom line is that you should be ready to think outside the box, and more importantly you should know when too.

Dentist.

Maybe it is me but I am just not too crazy about dentists per se, do not take me wrong I am not too crazy about other doctors too when I have to see them as a patient. Anytime I go to a dentist (no names), I come back with a new problem.

So this time I saw him for a regular cleaning. I spent a good fifteen minutes with a dental technician and after she was done I saw a glimpse of my new dentist through my peripheral vision as he was always on my side. If I see him on the street I probably would not recognize him..... unless I see him from the periphery.

I found out soon I was in a precarious situation, I may loose all my teeth in the next 30 years, if I won't get my cavities filled out. Now 30 years is a long time. I was injected with five vials of Novocaine, which I think was a lot and still I was having pain. I was informed that the reason I am still having pain is because "certain Indian and Pakistanis have dual nerve supply". I was not sold with that idea because with that amount of Novocaine, the whole population of India and Pakistan could be anesthetized.

Anyway I was finally done with instructions to come back for some more...... I have more sensitive teeth now as compared to what I presented with but still I have to go and get all this mess fixed up or else......

Please tell me I am not the only one with this problem.

Death Valley.

A friend of mine Dr Rippe recently visited Death Valley, California. He shared this picture with me.  It is a strange. So I did some research this is what I found out.

It is favorite place for tourist, somehow this place has evaded me so far. It is a spectacular geological site. Strange and mysterious with melted rocks scattered around.  Pretty hot there with temperatures over 110 at times. Its favorite attraction is Racetrack Playa, known for moving rocks. There are these rocks which moves leaving behind tracks. 

For centuries people have not been able to figure out how these rocks move. Some theorist suggest that it is because of the rain, some say it is because of magnetics. Considering it is so dry no one really knows. It is a strange site and quite a mystery. 

If you know of any better theories do let me know. I found one explanation here. 

About the picture: Credit goes to Dr Rippe, thank you for sharing.

FCCS. Fundamental Critical Care Course.

For the past couple of days I have been busy taking a FCCS (Fundamental Critical Care Support) certificate course at Tampa General Hospital. It was a great experience in many ways. This course is directed towards hospital physicians who are non intensivist. The goal is to emphasize what needs to be done for patients who are in a critical state and what kind immediate critical support they need for survival in the first few hours when a critical care physician is not available. Dr Luis Llerena, a trauma surgeon conducted this course. His way of teaching was excellent and I would strongly advise other colleagues to attend his courses. 

This is specially helpful for our group which is moving towards a 24/7 scheduling and with plans to be available for code blues and rapid response situations. I believe that in the next 5-6 months we should be able to provide this service. As I mentioned before in a previous post, that is is a natural progression of hospital medicine otherwise hospitalist would be glorified internist.

The picture above shows an algorithm based on a study Dr Emanuel River, dealing with goal directed therapy in the treatment of sepsis, published in New England Journal of Medicine. This study gives a very simple protocol for a very complicated problem. There are numerous times we see patient being treated for severe sepsis with vasopressors alone with intravenous fluid boluses. 

All in all it was very educational and informative. 

Droid In The Room. Autonomous Mobile Robot.

When I was growing up I use to tag along with my older brother who was a big time Star War fan, we use to watch all kind of Star Trek episodes together. I realized later, that in the process I have been transformed into a Trekkie and technology enthusiast. 

So as I was starting my rounds today I had a Star War moment. I saw a R2-D2 like character from Star Wars roaming our hospital corridors. I shot this video earlier today of this contraption, AMR (Autonomous Mobile Robot) going on its merry way. This  is along the same lines as my post earlier regarding Tele-Neurologist. This robot is crafted by a company Swisslog, which creates solutions for logistics automation. So make way to your next generation carrier. By the way, I think my amusement overwhelmed its handlers today. 

This robot carries digitally locked boxes containing various materials. You push a button and it will carry the samples to the lab or carry medications to different units from pharmacy. You can call it to your station by pushing a button. It can open doors, get into an elevator and may even has a capacity to carry medications to patient rooms. Our hospital just started using this robot, it is not operational, at least as of yet, but soon it would be. It will assist in all kind of logistics and distribution jobs around the hospital. 

Everything has its pros and cons. This carrier does not require a 401 K plan nor does it require any benefit plans. Nor it would take smoking breaks or stop on its way for a chat. However, all automated devices come with their own problems. Hey I have an idea, why don't we combine AMR with Tele-Neurologist technology to provide automated service. Anyways be aware,  soon you may find my replacement entering patient's room fully charged and on four wheels with an Apple logo....... here enters IAli,M.D.

So if you have any doubts, tomorrow is already here today. 

Baby Crying.

I saw a patient recently, she had a fetal demise. I came out of the room in our OB part of the hospital, I could hear a baby crying at a distance along with other people chattering away. As I started to tell the nurse  what my plan is, she gently interrupted me and asked "did you close the door behind you" I said no. She said "No problem I will, it is just that I do not want her to hear the baby crying". 

It took me a second to realize her sensitivity to this situation., it takes a certain personality to be so kind. 

I wonder what other things we do without thinking everyday?

Snowbirds.

Yes they are almost here, they are coming in cars, trucks, planes and …… ambulances. They come from Maine, Canada, Massachusetts, Michigan … pretty much everywhere where the temperature is sub zero. I often kid around with my doctor friends from up north that whatever they do with their patients all year, we have to fix it in a very small amount of time. (I am sure they probably say the opposite).

Population of our city triples during winter. You can not beat the sunny weather of Florida neither can a hundred thousand people who swarm from every where.

On my way to the hospital you see tens of RVs jamming the road and people trying to move into RV camps. I had a patient once who was 93 years old, he drove all the way from Maine, and here I am, not even half his age and I try not to drive to the other end of the town.

Winter season has some very interesting dynamics. Especially patients who come from Canada, some of them get conned into buying travel insurances which get them nothing here. On the other hand some Canadian insurance would send a chartered plane with flight crew to pick their patients who need only a colonoscopy or even a cardiac catheterization.

You see a significant increase in your census; I realized finally that we are in the “season” when I ended up admitting 14 patients just last night and at least 35 pages. I have a love hate relationship with my pager; can not live with it and can not live without it.

Not so long ago some physicians in this area used to go on long extended vacations each summer, they worked as seasonal workers.

Anyway,  so for the next 5 months life is going to be very interesting....