CAUTION

I sat in my car kind of exhausted after admitting 16 new admits. As I turned the engine on I saw the warning on the GPS screen, so it came to me that there should be a warning at the start of a Hospitalist shift.

I changed few things here so if there ever is a warning, it should look like this.

"Admit patients safely and obey hospital rules. Watching your life pass by while spending insane amount of time in hospitals can lead to serious health problems. Place all night orders when completely awake. Some patient data provided by ER doc maybe incorrect. Talk with patients rather than navigating the computer".  Agreed?

PS: About the picture.

What About Bob!

I had a meeting with one of the administrators this week. He told me this interesting story. 

During his rounds in the hospital, he went to see an elderly sweet lady. She was lying in bed, lost in her own thoughts. He introduced himself and inquired if there is any thing he can do?

Our lady was very grateful that a hospital administrator came to her room and he cares enough to ask her if there is any thning she needs. That pleasant conversation went on for few minutes.

Our administrator by then was quite confident that he has created a good rapport with this lady. On his way out he asked "is there anything else I can do for you?"

She looked up at him and said "let me ask Bob" she turned her head towards an emty chair asked "so Bob is there any thing else he can do for us?" 

For the next five minutes she continued to have a very creative discussion with the empty chair and invisible Bob. 

During this time our administrator stood there, very confused and not wanting to interrupt, after she was done she dismissed him.

There are so many lessons to learn from this story but mostly, never sit on an empty chair, you may hurt Bob! ............

PS: About the picture.

Disease Management System.

Andrew Weil is an internationally renowned writer on holistic health and wellness, I recently came across an article about him. 

Mr. Weil says "we do not have a health care system in America. We have a disease management system-- one that depends on ruinously expensive drugs and surgeries that treat health conditions after they manifest"

For details you can read this article. I agree with the idea that our main emphasis is biased more towards the health industry rather than the patient and primary care.

We do not emphasize as much about balanced diet, exercise and prevention as we do about emerging medications coming out soon or the latest and the greatest CT scan on the block. Health industry these days is targeted towards maximising profits.

Recently I overheard one radiologist bragging to the other "I have a 128 slice CT, what do you have?".  

Few months ago I had a pleasure of visiting Dr Shilpa P. Saxena's office during a meet and greet campaign for a new hospital my organization built in the area. 

She was indeed a breath of fresh air. She believes that patient makes better choices when they understand all the factors which lead to a diseased state. She is  the only physician I know who has a fitness centre in her own office. 

In her practice if a patient comes in with high cholesterol, he is not automatically prescribes Statins, but he is prescribed a regimen of work out and exercise. I wrote about obesity some time ago here, I think we need to work on these issues a little more.

I think we need more PCPs to fashion their practices along the same way.

About the picture: A new day.

Bring your own measuring cup.

I recently met a sweet old lady, I think she was in her early eighties. She had abnormal liver functions.

I was suspecting either statins, hepatitis or alcohol.

Considering she may be a a closet drinker. So I asked her "ma'am do you drink alcohol everyday". She looked at me  and said "just 1 glass a day".

I got a little curious and asked her how big of a glass do you use and she said "16 Oz".

I smiled and advised her to shrink the size of her glass from now on.

PS: About the picture: Alcoholic bird versus chips heist.

God give me a "sweet-dream" bacteria, not a nightmare bacteria.

Once there was a bug, it was called Enterbacteriaceae, it was a run of the mill bug (if there are any).
It started to misbehave occasionally, later is became anti social and now it is all out psychopath.

We have a monster of a bug now called carbapenem-resistant Enterobacteriaceae or CRE. Even some of our most potent antibiotics have no affect on this bug. Unfortunately... it is spreading.

Most of us who are healthy would not be affected with this bug but our hospitalized patients or who have weak resistant may succumb to this bacteria.

I am not surprised that Dr Fieded from CDC calls it a "Nightmare Bacteria"

And the reason is;

1- It is highly resistant.
2- It carries a mortality rate of 50% or more.
3- The way it becomes resistant, it can spread this mechanism to other bacterias.

Our other bad boys like, MRSA (Methicillin-resistant Staphylococcus aureus) or ESBL (Extended -Spectrum Beta Lactamase) bacterias, seems like angels here.

Please remember you can decrease your risk by properly washing hands, follow precautions and always judicious use of antibiotics.


PS: About the photo: Dream catchers. 
Disclaimer: Dream Catcher not recomedend for use as an alternate to antibiotics or doctor visit.

Tele-Intensivist.

We are so used to Doctor in a box AKA Tele-Neurologist (prior blog here) these days that it is just a routine to request a Tele Neurology consultation without giving it a second though.

Some of you may be naive to this concept!. So in cases where we need a stat neurology consult and as there is a shortage of neurologist in town, we ask for a tele neurologist consult. A nurse brings a computer to the room and turns the camera on. A neurologist remotely reviews everything and then gives his recommendations.

So I thought that was it, but then came in Tele-Psychiatrist. We went with the flow and started to request them for our suicidal patients.

And again I thought that we were done.

Today I was reviewing some documents and I saw that one of our hospitals have been approached by Tele-Intensivist/Critical care services.

I am at a little loss here, how can they intubate or place lines from hundred of miles away. May be I am still living in the time where if I am a patient I would rather see a doctor in person.

What is that Chinese curse "May you live in interesting times" I think we are.


PS: About the picture. Room full of consultants.

Healthcare Being Sequestered!

President Obama signed forced spending cuts of $85 billion dollars last Friday. There has been a public outrage but it is already too late.

What does this mean for us? just $11 billion dollars spending cut for Medicare.

Yes Sir, Medicare is going to slash away $11 billion in payments to healthcare providers, this amounts to a 2% cut.

All Medicare providers including hospitals, doctors and other allied health services will get the brunt of this order.

It will also effect CDC, American Public health, FDA, Vaccination programs, education programs (HRSA) , substance abuse and Mental health services administration (SAMHSA) and community healthcare center patients.

Imagine this is only one sector, please go and search what is happening to your sector. 

PS: About the picture: Bend a slinky too many times and it will stop springing  back to its original shape.

Please change Diet orders. Mediterranean diet

Each day I admit cardiac patients who end up with a "heart healthy diet".
It may change now!.

The definition of heart healthy diet is evolving as we speak. For a diet to be heart healthy I may have to order some nuts, fish, virgin oil with some red wine.

I hope I won't get into trouble.

A new study published in New England Journal of Medicine defies our conventional beliefs regarding low fat diet to be heart healthy. This new study suggest that Mediterranean diet is more "heart healthy" almost by 30% as compared to a regular diet.

In this humongous study out of Spain, where 7447 individuals were enlisted were shown to improve their heart attack risk by 30%.


Participants were asked to eat white meat like fish, lentils, almonds, walnut and virgin oil. Results are so phenomenal that some of the primary researchers even changed their own diet.

By the way today I bought some nuts on my way back!

PS: About the picture, very visual menu somewhere in Europe.

Buddhist temple, Kyoto, Japan

Buddhist temple, Kyoto, Japan, a photo by At_a_tangent on Flickr.

Keeping an eye on me.

Keeping an eye on me., a photo by At_a_tangent on Flickr.

Bird One

_DSC0419, a photo by At_a_tangent on Flickr.

Yahoo Dome, Kyoto. HDR version

Yahoo Dome, Kyoto. HDR version, a photo by At a tangent on Flickr.

Huddle, Multidisciplinary Rounds.

Finally I was able to successfully roll out Huddle or multidisciplinary rounds at all three hospitals.

So far I have heard great things the way we are conducting these rounds. 

We have a huddle for 20 minutes every day, less than a minute per patient at a specific location in each hospital.

Out team members include everyone who are stakeholders in patient care.

1- Dedicated case manager. (I would appreciate if you can assign a dedicated case manager for all our patients)

2- House nursing supervisor.

3- Floor supervisors (optional).

4- Physical therapy and occupational therapy.

5- Dietary.

6. Core measure/ quality measure person for real time corrective measures for CHF, Pneumonia, AMI etc.

7- Hospital DRG coder. (Again this would take care of any def. in documentation).

8- Mr. Computer, so we can take care of orders during rounds.

9. Pharmacist (if they can).

Our team has so far improved,

1- Potential early discharges and transfers. 

2- Plan of care for the day.

3- Identify needs for patients.

4. Improve work flow and delegation of tasks.

5. Improve core measure compliance and power plans. 

6. Improve documentation. 

7- Contain cost per case.

And the best part is.... it is a lot of fun.