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Monday, October 3, 2011


She was middle age, sitting up on a hospital bed. She was still like a statue and very disheveled. She was trying to appear strong but the flow of tears were a dead give away. Maybe her inability to control her emotions was compounding her despair and frustration. 

She was again admitted with another suicidal attempt. When we started to talk she opened up and said "I always felt the desire to end it all" she paused for a second like she was trying to find the right words then she said very softly,
"when I was 8, I used to take cold baths in winter and stand outside the house, hoping I may catch pneumonia!. 

Just imagine, 8 years old and so much pain to bear! 

"I love walking in the rain, 'cause no one knows I'm crying" 

Blog you later.

About the picture: I shot this inside Doge's Palace. To me it depicts despair.

Thursday, September 22, 2011

She cried, good Luck with needle stick!

She cried not that she was stuck, she cried because I was stuck with her needle.

Sometime back I saw her initially in the ER, around 4:30 in the morning; she was a young girl, a high risk IV drug user who was septic. She was in shock, confused and burning. Her anxious father was pacing nearby; I was afraid that he was going to pass out any time.
I provided not much comfort to him when I told him that she was in septic shock and that she has a guarded prognosis.

She initially refused a central line placement but after much debate she consented but only if my other colleague in the ER would do it. Maybe she found my ER attending to be more comforting. I spoke with the ER physician and she obliged and placed the line.

The next 24 hours were tough for her, but utilizing the 6 hour and 12 hour sepsis bundles we were able to stabilize her. I was questioning a vegetation on her heart valve. During a transesophageal echocardiogram, cardiologist saw an artifact in the atrium. Assuming that this could be the central line, we pulled back the line and the artifact on the echo disappeared. Viola… no vegetations.

As I was almost done with securing the line I stuck myself. For a second my mind went blank, thinking about the significance of this needle stick from a very high risk patient. Naturally I started to think about my wife, my daughters and our baby who is on the way. All the statistics about needle stick started to resonate ….. risk of transmission after HIV infected blood 0.3%, risk of Hep B 30% and Hep C 10%....

Initially I was very angry at myself, I didn’t know what her status was, I should have been more careful, I should have double gloved or ….. done something else. For a moment I felt anger towards her too, though I knew it was not her doing.

As I was desperately washing my hands, squeezing as much blood as I could, she found out and started to cry. She tried to reassure me by saying “I do share needles but I always clean them”…. not much of a comforting thought.

In the middle of this suddenly a sense of calm came over me, I found peace with myself and with her, and I thought for a second and said “it is not your fault that I stuck my self, though it shows that how our actions can affect other people lives.”

I started the HIV prophylaxis, I need testing in 6 weeks, 12 weeks and 6 months. These medications were not easy to take and there were lots of them.

She walked out of the hospital, determined not to use again and plans to go to rehab, she was doing wonderful. On her way out she winked at me and said “good luck”.

So what is the lesson from this?........Sepsis Bundles work!….

Blog you later.

PS: About the picture, I saw this in field's museum in Chicago. Myth is that some diamonds bring bad luck. So it is a good thing that I do not own this rock.

Monday, September 19, 2011

Conundrum of Consultation.

Few years ago a fellow physician asked me to see a patient. When I asked him why he said “STP”,  he chuckled and said “for STP, share the pain”.

As a hospitalist, medical consultation is one of the essential components of our work. Various specialists require assistance in areas which are beyond the scope of their expertise. So, an orthopedist may want a hospitalist to manage infections or diabetes or a cardiologist wants us to evaluate a patient for abdominal pain. The reasons could vary. Some are from orthopedist, some from cardiologist etc….. 
They vary from atypical chest pain to coagulopathy. Most of them are very appropriate and we love to tackle medical problems of all sorts. But then there are some consults which are called for all the wrong reasons.

Interestingly when you look at the reason for consult, mostly it is a very vague reason like “medical co- management”. However, at times when you ask the nurse the reason is entirely different.

Don’t take me wrong, most of the times physicians need assistance like if someone is septic, they want a hospitalist or intensivist to take over the case. If someone has brittle diabetes, they want an opinion for better glycemic control. But some times the consult could be just STP (share the pain) or just indifference. At times  referring physician just want someone else to do their scud work. 
However, regardless of nature of the consult you would almost always find this statement at the end of dictation “Thank you for allowing me to assist you in this very "interesting patient”"

I will give you some very “interesting” consults I have received in the past few years.

-      A nurse called me for a consult for “medical co management”. I asked her what the story is? Apparently patient was very belligerent towards the attending physician. After the attending physician left patient wanted to leave against medical advice.  Nurse called the attending physician; he did not want to be bothered. When she asked for further direction, he said lets call for a hospitalist consult. That left me very perplexed. What am I suppose to do, get a couch, asks the patient to lie down and provide behavioral counseling?

-        I was called for diabetes management on a chest pain patient. When I came down to evaluate the patient I found out she was a 91 year old lady with hospice for terminal lung cancer. Apparently EMS brought her to the hospital while they were on their way to hospice house from nursing home. In the ambulance she started to moan. EMS thought it was a good idea to stop at the hospital. ER physician decided to admit this hospice patient.  On the whole scheme of things diabetes was the least of her problem. I spoke with the family and transferred her back to hospice.

-        Sometimes the consult is called because the surgeon or a refereeing physician does not want to perform medication reconciliation or discharge paperwork; we are consulted for “hypertension”, when patient is on a hint of diuretics for hypertension. They just don’t feel like doing it I guess.

Now on the other hand I would rather be a consultant on some cases than being the primary attending. Few years ago I was called to admit a 42 year old man with chest pain due to a thoracic aortic dissection. After ER physician finished presenting the case I asked him “do you think I have some divine connections, if you want I can come down and pray for this patient at bedside, as I am surely not a cardiothoracic surgeon and you want someone who can crack open his chest”.

Sometimes when I am being consulted I feel transiently important, it is good for my ego that they want my opinion. On the other hand I think we need to have very clear and defined reason for consult, not just “co- management”. This would not only improve care but also clearly focus on the specific issues which need to be addressed. Like the other day I saw a patient for “co-management”. Later found out that the physician was concerned about the side effects of a certain medication. I missed it completely as this was not mentioned nor conveyed to me at any time.

I can see how we need to improve communication from our side. This is an ongoing project at this time.

PS: About the picture: This is not a magic ball. Inside Vatican Museum.

Tuesday, September 13, 2011

Dante’s Inferno.

Nine Eleven.... always brings a feeling of dread, though it has been a decade now. 

In Dante’s Inferno, when Dante along with Virgil started to descend deeper into hell (Inferno), they observed Contrapasso, best explained as symbolic punishments, best suited for one's sin. A kind of a poetic justice. 
For example a con man in hell would be reassured that he will be served a full meal, when he would become hungry, he would be served with putrid and rotten food. A murderer will be kept alive for eternity, where he would only wish every second for death to relieve him from his agony.

If there is hell, what would be the punishment for our deeds? Let’s assume if we are not …..Umm….. not adequate. Not just adequate but negligent, if I may say so ... pernicious to others! So those guys who crashed the planes, what should they get in Dante's Inferno?

I have been in a hiatus, working on my book, busy with work etc and ... OK, have you ever come across a situation when someone calls you after a long time and you try to provide some lame excuse of being really busy? And when they ask you what you have been up to? You reply sheepishly “nothing much”.  
Well, I will not give any excuses, I will stop while I am ahead.

Just some random thoughts...

PS: I wrote few words last year on Nine eleven here. Took this picture around the same time.

Monday, April 11, 2011

Three Things You Want In Future.

 Today was a very special day. I have been invited for talks before but this was the best.

I went to my daughter’s class to talk about what I do. The teacher has invited parents to come to the class and talk about what they do for a living.

When I arrived at the school there were 17 children eagerly waiting. I talked about what Hospitalist are and what hospital medicine is about? I also informed them about wound care and hyperbaric medicine. I asked for any volunteers with any “boo-boo” for demonstration. One 7 year old volunteer with an ant bite came forward,  who I readily discharged from my service after prompt therapy.

All in all it was a lovely experience.

In the end I asked them if there were any questions or comments, here are some fine examples;

  • “My sister kicks me at night, can you do something about it”.
  • “My granny has a metal in her hip. Does she need any thing?”
  • “Do you also treat cats and dogs?”
  • “I know how you become a doctor, you go to med school”.
 The best thing is my daughter thought I was awesome! You  can’t beat that.
Blog You Later.

About the picture: My 6 year old daughter was asked what three things you want to do in future.
So if you look at the picture, she scratched 1- Fly 2- Talk to cars. Before what she wrote above. 

Monday, April 4, 2011

Chinese Curse

I took care of an elderly lady once. She was brought to the hospital by police after someone reported elder abuse. She was found in her room in diapers only. There were only crackers in the room. Apparently she was locked in the room by her family member; she was kept in diapers, as it would be “easy” to care for this way. She was fed mostly crackers and water. There were no sheets on the bed as it makes it easy, no sheets…. No cleaning.

When I saw her in the room she was eating grapes…… her bed side table was full of food. She was voraciously devouring her food. It was embarrassing to see her eat like that but on the other hand I was also glad that she could eat. She would not talk to me as every time I would ask her a question, she would give me an evil eye and continue to gobble something else…… grapes, lots of them I remember the most from that moment.

The sad part was that even after all that she did not complaint about her family member who did this…. only a mother can protect her child like that.

This event reminded me of a story from my childhood. There was this little kid, he was asked by her mother to go to the bazaar and buy the cheapest plate from a thrift store. He asked why mother? She said “this is for your grandmother as she breaks all the new stuff; I don’t want to waste money on a new plate”. This child went to the bazaar and came back with two old dirty plates. She was surprised and asked him “why two plates my dear?” and he said “one for granny and …. one for you when you are that age”.

In South Korea, a couple is being charged for murder after their baby daughter starved to death while they went out to play an online computer game. Sadly the game was about nurturing a virtual girl as she grows in a virtual world. What an irony.

It has been a famous Chinese curse, may you live in interesting times. I hope not too interesting.

Blog You Later.

About the picture:I spotted this presidential rabbit outside White House, hoarding something.

PS: Correction, obviously that is not a rabbit, I am not sure what I was thinking. LOL.... thank you Ann.

Sunday, April 3, 2011

Snooki Or Not To Be....

To be or not to be---that is the question. Whether ‘tis nobler in the mind to suffer. When Shakespeare penned these words in Hamlet I am sure, that he was not thinking of Snooki.

I am not sure how many of you are familiar with the infamous Snooki, the star of “Jersey Shore”. She has made quite a name for herself in so many ways. To top it all she wrote a new book too.

I read this most interesting news the other day; she was invited to be a guest speaker at Rutgers University. Now the amazing thing is that she was paid $32,000. She was voted by students to get an invite.

During her talk she was full of wisdom and insight regarding this perplex thing we call life. She pondered on various subjects from fist pumping to laundry and tanning. I will take the liberty to quote one historic pearl from her speech,

                              “Study hard but party harder”.

When you Google Rutgers University, the first hit you get about this esteemed New Jersey University is

Rutgers, The State University of New Jersey, is dedicated to advanced learning, creating knowledge and contributing to the growing vitality of the state…….

All jokes aside it is fine and dandy that you want your students to have all kinds of exposure. In all fairness the next speaker is 1993 Noble Laureate in literature , Toni Morrison. She will be speaking to a jam packed stadium audience.  She is known for her eloquence, role of black women in society and her contemporary style.

The only problem is she is getting paid two thousand dollars less than our party hardy girl. I think our Beloved is getting the short stick…. again!

Blog You Later.

About The Picture: That is JFK at a monument in Tampa, not to be mistaken for a Snooki quote.

Thursday, March 10, 2011

Cost Share Program by Blue Cross Blue Shield.

Aspirin for headache.... 30 cents, medication for cough……. $3, antibiotics for flu…… $40. Being treated at some of the top notch hospitals.... an extra $1000. They say all good things in life are free, as long as you are not going to a hospital.

Recently Blue Cross Blue shield of Massachusetts introduced Hospital Choice Cost-Share Program. It is based on a system of High Cost hospitals and High Value hospitals. This year it was determined by CMS that all hospitals met the quality bar in Massachusetts

So these hospitals were than classified on the basis of cost meaning High Cost versus High Value hospitals. If you choose this program and if you decide to go to “high cost hospital”, you will end up with a higher co pay after their deductible. So far I hope this is not too confusing.

OK here goes, various hospitals charge different amount for the same services. So let’s say for a certain test one hospital charges you $1000 and another hospital charges to $600 for the same service. If you choose a Higher Cost Hospital you will pay your standard deductible + $450 co pay, for a lower cost hospital you pay only your co pay. However, if you go for the same test again within a year, for a Higher Cost Hospital you will pay $450 co pay, for a lower cost hospital you pay zero dollars. If you choose this program your premiums would not hike as much for next year.

Now if you decide to see the top 15  providers in Massachusetts, you would have to pay a higher out of pocket expense almost $1000, including hospitals like Brigham and Women’s Hospital, Harvard and University of Massachusetts Hospital (UMASS). Not so for Beth Israel Deaconess Hospital, Harvard (BIDMC) which was considered to be a low cost institute. I can relate to these issues as I saw it first hand when I was working at BIDMC and also at UMASS.

What impact this would have nationwide is still yet to be determined. I think if this becomes a trend with other insurance agencies and Medicare too, it may result in a paradigm shift in the way some hospitals do their billing. As we all know hospitals bills are not an easy thing to deal with regardless of what insurance you have. I wrote about this issue here (Bankruptcy, You Could Be Next).

Blog You Later.

About the picture: My very first day at UMASS many many many years ago.

Wednesday, March 9, 2011

Human Factor. Sepsis

 I recently received this email from a follower regarding sepsis,

I read your blog regarding the necessity of urging hospitals to develop a protocol as a preventable measure in the early detection of sepsis in a patient. 

You blog rings very true to my family and as we buried our mother last month.  A victim of sepsis.  She was scheduled to be released from the hospital within the next two days, when the hospital realized at that point that her overall condition had started to rapidly deteriorate.

We are at a loss as to the hospital's late discovery about the severe infection our Mom had detected and the hospital's seemingly either misguided or complete misunderstanding of the early signals for sepsis”.

I think this is occurring more than we anticipate. One way to prevent this from happening is to have a good screening system in place. Patients should be screened for SIRS (Severe Inflammatory response syndrome) not only in the ER but also on the floor with the change of shift. As we know, SIRS is the initial phase of sepsis followed by Sepsis, Severe sepsis, Septic shock and finally multi-organ failure.

SIRS consists of

1.      Heart Rate more than 90/min.
2.      Respiratory rate more than 20/min.
3.      White blood cell count more than 12000 or less than 4000.
4.      Temperature less than 36 degrees or greater than 38 degrees.

A number of hospitals are implementing this screening protocol. I hope we should be able to do that too. I will keep you posted as we move along.

Blog you later.

About the picture:  Big Island while I was lava hopping. Temperature around 1,200 °C. 

Sunday, March 6, 2011

Sepsis. Hospitals, Mind Your $$$.

As we are talking about sepsis here

In a recent study published at Archives of Internal Medicine, it was concluded that just because your institution can throw more money for sepsis protocols does not mean that it will result in decrease mortality.

Considering some of the bigger institutes has spent millions of dollars in creating these protocols. This means from hiring full time nurses who only responds to sepsis codes to hiring big consulting firms to establish and run these programs.

It was unclear from the study that why some institutions do better even without higher expenditure but with lower mortality rate.

Something to think about.

Blog you later.

Round Rainbow by Olafur Eliasson at Hirshorn Collection. Did you get it?

Wednesday, March 2, 2011

Sepsis Protocol.

 Sepsis is a condition which causes derangement in cardiovascular compartments, problems with inflammatory and hematological processes, which is due to an infection or injury resulting in severe morbidity or even mortality.

There is a “Surviving Sepsis Campaign” led by European Society of Intensive Care Medicine, international Sepsis Forum and Society of Critical Care Medicine. The goal is to decrease the mortality associated with sepsis syndrome.

We are taking an initiative to decrease the mortality associated with sepsis and I am part of this team to create a protocol for our hospital. Unfortunately sepsis has not been recognized as we have other conditions like cancer, strokes and cancers. It is imperative to identify this problem early  and manage properly.

These are some facts which everyone should know about sepsis.

-          Sepsis is the leading cause of death in non cardiac ICUs.
-          Severe sepsis causes more deaths than deaths due to colon, breast, prostate and pancreatic caner….. all combined.
-          Mortality due to sepsis almost matches that of a heart attack (Myocardial infarction).

There are several great treatment protocols based on Rivers ET AL study, which basically concludes that early goal directed therapy decrease mortality in septic patients.

We are in the process of creating a protocol based on this study which can suit our needs. However, I feel the problem is not finding the right protocol; the problem is correct and consistent implementation. You can have the greatest of protocols but it would be of no use if the implementation is based on unrealistic expectations or lack of resources.

In the next 15 days we will work on these issues

-          Creation of time line to work on these schedules.
-          Screening procedure to identify sepsis.
-          Procedure to create time zero.
-          Creating code sepsis protocol.
-          Creating a “one click” order for sepsis protocol.
-          Education for medical staff.
-          Evaluation of resources available to reach these goals.

Well it is a good start. Let’s see when we reach there.

Blog you later.

About the picture: During FCCS course.

Monday, February 28, 2011

Love Bugs And Medical Myths.

If you are a Florida resident you can not miss our famous love bugs a.k.a honeymoon flies or kissing bugs or its real name …….Pelica Neartica. Come March and you can see these bugs everywhere in pairs here in Florida. They are an annoyance not only because they are awkwardly stuck to each other but also ruin your car paint when they splatter on it.   You try to remove the corpses for the first few years and then it just becomes a lifestyle. Great caution is required while a riding a bike, as you get a free protein bolus every time you open your mouth

There is a famous urban legend here that these bugs were created by University of Florida to fight mosquitoes. The myth is, that somehow this experiment failed and these bugs got out and spread all over Florida. I actually believed it. So every time I would see these bugs I would curse USF softly. Very recently I found out that USF has nothing to do with this and these bugs probably came through cargo ships in 1940s.

This got me thinking what else I believed in for the longest…..for example I believed…..

-          All post menopausal women should be on hormonal replacement therapy (HRT). Until we found out that HRT increases the chances of uterine cancer.

-          I believed that childhood vaccination can cause autism, a famous study published in “Lancet” , until I found out this January that it was a complete fraud and the study was retraced.

-          I thought all patients with osteopenia needed be on biphosphonates to prevent bone loss …. Until I found out that they can cause significant Jaw bone necrosis.

-     Antonio Moniz was awarded Nobel Prize for Physiology in 1949 for his discovery of lobotomy in  psychosis.  By 1951, 20,000 lobotomies were performed. There was a gradual decline in this procedure… after the discovery of  the miracle drug Chlorpromazaine in 1954. Everybody believed in this med….eventually this too declined after it was found that it can cause Tardive Dyskinesia .. a disorder resulting in repetitive body movements.

Do not think for a second that I am saying that we should not believe in evidence based studies. My point is  that we should keep our inner critique alive at all time. We should maintain our ability to question and never permanently close any doors. I believe the same is true for everything in life. 

There are very few eventualities in life.

About the picture: Not a love bug. 

Saturday, January 29, 2011

Weekend Mortality

Recently there has been a lot of talk about higher mortality over weekends. A British study, published in the Journal of Quality and Safety Care in June of 2010 concluded that there is a seven percent increase in mortality rate for patients who are admitted through the emergency room over the weekends as compared to patients who are admitted over weekdays. This was a large multi-center study conducted at 163 hospitals. 

An other study published at Journal of American Society of Nephrology also concluded almost the same results. The study concludes that over the whole length of hospitalization, mortality risk is 7% higher for larger hospitals and 17% at community hospitals. As you can see this was found to be higher for small hospitals as compared to large hospitals.

Recently I attended a critical care committee meeting. There was a mortality report about our hospital, I was glad to hear that our mortality data for the hospital was not part of this mix.

However, I can see why this could happen. There are some factors which I can see contributes to these phenomena. 

- Staffing issues,
- Reduced coverage among physicians
- Limited imaging studies.
- Problems with scheduling patients for GI procedures.
- Inability to perform cardiac stress tests.
- Out patient clinics are closed, so there is delay in diagnosing critical health issues.
- Hospital cultures in small hospitals are still managed by physicians who are not full time hospitalist.
(Maybe I am biased here as I am a hospitalist).  

This studies should not be taken lightly, there may be a lot behind this. Do let me know if you have experienced the same problems.

Blog you later.

About the picture: If I am not wrong I think this work was called "Rumors" 

Thursday, January 27, 2011


Every year I see more cases where young adults are involved with either violence, drug complications or reckless acts resulting in various medical dilemmas. 

Newton's third law of motion states that every action has an equal and opposite reactions. This came to my mind as I briefly watched the new show on MTV "Skins". As you may know skin refers to rolling paper (so you can catch the drift), this show is a copy of a British show with the same name.

Los Angeles Times reported this " Nothing more than an R-Rated teen soap minus any truly resonant characters".  Basically the show is all about teens using school as a hang out where they can do drugs, smoke and make fashion statements. Learning is not really a part of schooling as far as this show is concerned. All parents and teachers are imbeciles or out dated and belong to a different world.

My point is this, you are what you grow. I read an interesting article the other day, it was about how your children become what you expect from them. If you have lower expectations they would probably prove you right. However, if you have higher expectations they will likely achieve them. So next time think of them as  Einstein rather than "Jackass".

I guess I am preaching to the choir, I guess we all know that there is a problem, maybe this makes me a boring father, well so be it. The questions is what are we doing about it? What are you doing?

Blog you later.

About the picture:  I like the attentiveness of this child, no matter whatever he is being taught.                         Smithsonian Museum, Washington.

Monday, January 17, 2011

Hospital Food..... Yummy.

I have never met anyone who craves for ever so infamous hospital food. Hospital food is equivocally bad everywhere in the world.... until recently.

I recently visited a local hospital. I came across a menu card there. I would have never guessed that this is a room service menu card for the patients. With a menu like that, you will surely attract a certain kind of patients.

Do see the menu.

Thursday, January 13, 2011

Selfless Acts Have Better Compensations.

There are things in life that are precious and unique; they stare right at your face, however you are completely oblivious to it. Like some folks you meet everyday but never realize who they really are, like the person I mentioned  here (I met Harriet Tubman).

Selfless acts have better compensations. But for the most part you feel much better about things you really don't have to do but you do them anyway. You don't have to hold a door for a stranger but you do, you don't have to smile to a passer by..... but you do and you don't have to say thank you.. Recently I read this story where a Southwest pilot held a plane for a passenger who was flying out to attend a funeral. Pilot found out earlier, as he met the passenger outside the plane, that he was flying out last minute to attend his 3 year old grandson's funeral. Despite being  almost 10 minutes late, he told the passenger "They can't go anywhere without me and I wasn't going anywhere without you. Now relax. We'll get you there. And again, I'm so sorry."

Do you remember this scene from the movie Forrest Gump, when he keeps on bringing survivors from the jungle after his friend Bubba was injured after the bombing. Now that is one great example of what I am saying.

I remember when I was switching my training program from Beth Israel Hospital at Boston, I asked my then program director Dr. Longmaid for a recommendation letter. He said he can do better, he picked up the phone and called the program I was applying to. He said such flattering things that even embarrassed me. But that act is one of the few most cherished  memories of my life. 

So in a very small way I try to do the same every now and than, I let some students do clinical attachment with me. Recently one of the students who worked with me got into a good residency program after I helped him a little bit. It was a joy to hear from him when he recently notified me. Just a small way to pay it forward.

About the picture: I recently found this plant at Haeakala National Park at Maui. It is called silver sword. You may never guess but this little plant can live up to 90 years. 

Monday, January 10, 2011

End Of Life Issues.

When I saw my first patient die, I was in shock. I knew that some will die but you are not really ready until you see one. You will never forget your first one, that always stays with you. When my first patient died during medical school;  a young guy around forty. He died from complications of Endocarditis. He was fine in the afternoon, talking about his family and what he does, when I came back in the morning he was gone. I was shocked beyond words. Unfortunately with time and age you get used to it. We adapt and move on but still end of life issues are difficult to deal with, even for the most experienced doctors.

I wrote about the role of hospice here earlier. But there is a transition, a process which ends up with hospice or no code status, but this process starts when a physician starts talking about end of life issues.  

During my training at UMASS, we were taught to always inquire about the code status at the completion of history and physical. This included either a Full code, DNR (do not resuscitate) or CMO (comfort measures only) status. However , most of the time this discussion is delayed until it is too late in the game. 

Some of the pitfalls I see in this matter are:

1- Physicians are a little weary about inquiring the code status. There may be a certain level of apprehension as they think that the patient may loose confidence in them if they ask this question. 

2- Patients may get angry as we all know that we will never die.

3- Often I hear physicians asking patients "do you want us to do everything". In this scenario physician assumes that the patient does not want to die.  Information is not carried to the patient properly and the patient makes a vague statement "yes", But the question is yes to what? However, code status is entered in the medical record as Full code.

I am not saying that I am an expert in this issue. Usually this is how I ask them after I am finished with history and physical that "I would like to ask what I ask all my patients, what are your wishes in case your condition deteriorate, I don't want to do any thing which is against your believes and wishes". 

You need to ask the patient how they feel or understand about their condition, otherwise it becomes a one sided discussion without giving the patient an opportunity to discuss their perspective.

If they decide to be DNR, then I go over various options which a person can choose from refusal to blood transfusions to refusal of basic CPR or intubation.

It is important to give patient time after each statement for two reasons a) It gives times for the information to sink in and b) it gives physician some time to read patients reaction and some space to to maneuver words to soften the impact.

All in all this is a very important process and physicians need to be more proactive about this process.

Blog you later.

About the picture: I woke up at 5 am to run to Na' Pali coast, Kauai when I saw this sunrise at the beach.

Sunday, January 9, 2011

Supersize Me!

 Recently I came across an article by Dan McGinn of Harvard Business Review he mentioned a study by Brent McFerran of  University of Columbia. The study was conducted at a restaurant where certain menus were first suggested by a thin server, later she wore a “fat suit” and suggested the same menu to a different set of people.

36% decided to go with suggestions from the “thin waitress”, however, 59% opted to go with the obese waitress.

The researchers concluded that the reason people went with the obese server because they could identify with her.

Conclusion: Restaurant should hire servers with a higher weight dimensions.

About the picture: I found these "fried eggs" at Luray Caverns in Virginia.

Tuesday, January 4, 2011

Monro-Kellie Doctrine And My Father.

Alexander Monroe hypothesized in 1783 that brain resides in a confined box. Total volume of the brain remains constant and it is incompressible. Any time there is an increase in the volume of this box it will directly increase intracranial pressure and will compromise either one of the three contents; brain, cerebrospinal volume or blood.  Later George Kelly confirmed this observation in 1824.

Our memory is like that too. We only have a finite memory, our recall is limited. We only remember the most pertinent things. Stress plays a major role in memory loss, sustained stress cause damage to hippo-campus, which is essential for learning and memory. When we forget essential details during stress, that is due to Cortisol, which may also cause confusion in trauma and crisis. Maybe after delivery mother's develop some short term memory loss.... otherwise women may never want to be pregnant again.

My father taught me so many things. He practiced Medicine for almost 50 years, a very astute clinician.   When I was growing up, I had to wear a tie even in 1st grade. It took me a while to master the knot properly but he never gave up on me. My parents were visiting me some time ago and we were going out  for dinner. My mom came to me and asked me to help my dad. I went to his room and I found him standing in front of the mirror holding a tie with a look of confusion. I asked him what is wrong. He said I don't know how to tie a knot. I looked at him and remembered all the times when I had the same look when I was young. I tied his knot and we went our way.

They are visiting me this month. When I look back, I wish I be as caring and a good father as he has been to me all my life.

Blog you later,

About the picture: Still going through the museums.