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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.