Human Factor in Medicine and Life.

Despair.

2011-10-03T21:04:00.000-04:00

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"

Unknown.

Blog you later.

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

She cried, good Luck with needle stick!

2011-09-22T21:11:00.001-04:00

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.

Conundrum of Consultation.

2011-09-19T10:43:00.002-04:00

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.

Dante’s Inferno.

2011-09-13T00:24:00.002-04:00

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.

Three Things You Want In Future.

2011-04-11T17:45:00.007-04:00

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.

Chinese Curse

2011-04-04T23:18:00.001-04:00

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”.

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.

Snooki Or Not To Be....

2011-04-03T16:59:00.001-04:00

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…….

Great……….

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.

Cost Share Program by Blue Cross Blue Shield.

2011-03-10T17:28:00.001-05:00

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.
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Human Factor. Sepsis

2011-03-09T08:17:00.002-05:00

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.

Sepsis. Hospitals, Mind Your $$$.

2011-03-06T22:31:00.002-05:00

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?

Sepsis Protocol.

2011-03-02T20:10:00.001-05:00

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.

Love Bugs And Medical Myths.

2011-02-28T21:00:00.002-05:00

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.

Weekend Mortality

2011-01-29T22:05:00.000-05:00

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"

Skins.

2011-01-27T12:30:00.002-05:00

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.

Hospital Food..... Yummy.

2011-01-17T23:22:00.000-05:00

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.

Selfless Acts Have Better Compensations.

2011-01-13T23:31:00.000-05:00

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.

End Of Life Issues.

2011-01-10T23:56:00.005-05:00

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.

Supersize Me!

2011-01-09T22:20:00.002-05:00

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.

Monro-Kellie Doctrine And My Father.

2011-01-04T16:28:00.000-05:00

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.

Music Is In The Silence Between The Notes.

2010-12-27T22:15:00.000-05:00

Music is in the silence between the notes. Just imagine even the most renowned symphonies would be just noise if there was no pause between the notes. Life is just like that. If there is no sorrow, joy would not mean any thing. If there is no tragedy, happiness would be meaningless.

If some one would remain euphoric all the time you would call him insane, if someone is always sad, you would think that he is "depressed". Life requires balance, that could only be achieved if you experience both spectrum. Sometimes it requires a touch of the other side to cherish what you have. Some people only realize what a blessing good health is, until they come out of an illness.

There is a short Urdu story by Azad. There was this man who found out that there is a place where you can go and trade ones worst problems. He went there and traded his chronic colic pain for bad arthritis. On his way back he realized how difficult it was for him to walk with this new ailment. .He had no choice in the end but to return and get his old ailment back. They say that no one gets more than their share of bad luck, not an ounce more than they could tolerate, I guess it is true, maybe it is adaptation or I just hope that it is not Karma!

I write this because in the past one week I admitted two patients, both with foot pain. One person got an amputation the other had a simple infection. Surprisingly both were stoic. I made it a point to ask both of them today how come they never had a complaint. They both said it could have been worst!

Blog you later.

About the picture: Curves and different shades caught my eye in this frame as I was walking towards this building in DC.

Irony!

2010-12-18T15:49:00.000-05:00

Few years back I received a call from a lawyer in North Carolina. He was calling to find out if I wrote a letter in favor of an inmate. I knew the patient but I never wrote a letter on his behalf.

I asked him to fax the letter to me. It was a most interesting letter. The letter basically stated that this former patient of mine should be released from jail due to health reasons. I wish if this was as simple to get a "get out of jail" card from a doctor. My letterhead was forged using my business card and interposing the image on a copy paper. The terminologies and language in the letter were flawed and the context was way too simple.

I called the lawyer back and told him that I am not the author of this letter. He laughed and said he thought so. Out of curiosity I asked him what is he convicted of.

He replied "forgery".

Blog you Later,

About The Picture: I took this picture of a picture at Hirshhorn Smithsonian art museum by Tomas Struth of Pergamon Museum, Berlin.

Enough with Made Up Statistics.

2010-12-16T13:08:00.000-05:00

46% of all statistics are made up.

I come across various times in a day when I am quoted statistics of some sort like "26.5% of patient develop heart failure after a single meal containing excessive salt" or "12.45% of medical errors are due to physicians".

I remember during my fellowship I was doing a breast biopsy. That was was my second biopsy procedure, my first biopsy was a success. The patient asked me how many have you done. I replied "lets put it this way I have been successful 100% of the times". She was pleased for a short time until I told her that this is my second time!

Sometimes I am amazed at the recall people have with these numbers. Now I am not so bad with recalling the numbers but some of my colleagues are just too amazing. So naturally I decided to make a note of these numbers and started to check these figures. I was amazed that 46% of the times these were wrong.

So remember for next time, 46% of statistics are made up................ including this one :)

Blog you later.

Statistics are human beings with the tears wiped off. ~Paul Brodeur, Outrageous Misconduct

About the picture: 100% Downtown.

I Need Money For Weed.

2010-12-15T00:23:00.000-05:00

Hardly a day passes by when I don't have to admit patients with drug related problems. I have seen almost all kind of complications ranging from anoxic brain injuries after Ecstasy use to brain abscesses after IV drug use. Acute myocardial infartions from cocaine to aortic aneurysms after meth. Addicts of all ages from 18 to 79 years olds, people from all socioeconimical backgrounds.There are already enough problems, why create some more. I wrote about this issue here in the past.

On my last call I admitted 9 patients, six of those were drug related issues. These admissions are more complicated as some of them are suicide attempts and some psych issues. Few of them are brought in by police and they are admitted for medical clearance, they later require transfers to psych facilities which are not easy to find.

Anyways just another day in paradise.

About the picture: This gentleman was at Times Square, I had to give him a dollar for this picture.

Illusions Of Healthcare, Uninsured.

2010-12-07T20:40:00.002-05:00

I have two young patients, both with cancers. They need surgery, chemotherapy and radiation, and they need it now. We have a diagnosis and plan, unfortunately we can not implement it. The kind of surgery they need, we are unable to perform those at our hospital. I can not transfer them anywhere because they are UNINSURED. So they are stuck in limbo.

In this day and age where we are the most powerful nation in the world but some of our own do not posses some basic needs. I spent a lot of time talking to different hospitals but I am still waiting for an answer. So naturally I am frustrated.... this is quite an illusion of care. Maybe tomorrow is going to be another day.

About the picture: Luray Caverns, Virginia. There is water at the bottom of this particular shot which reflects the roof and gives you an illusion.

Super Doctor.

2010-12-06T22:04:00.003-05:00

I was talking to a fellow physician and he inquired “how many patients do you see in a day” I said “maybe around 20”. He smirked and replied “20 ONLY! I can see around 40 in a day and still have time to hit some balls”. Hmmmmm....... there is something fishy here at Smallville.

Few years ago I used to work for this company; I had no option but to see a huge number of patients. Sometimes my census would be around 40 or so. I remember one day that I got 26 new admissions. I took care of them all along with the patients who were already on my list. By the end of the day I was a tad confused. When nurses would call it would take me a moment to recall a patient. I would have to think twice so that I don’t confuse a chest painer with a GI bleeder.

You can see a lot of patients but I think it is not fair to the patient. As I always say it is just not about billing. You can not provide adequate care when you are breezing through your list. The goal is not just to see them but to make the right decisions. One way to see them would be to call 20 thousand consults and let other doctors make decisions for you or you can try to see them like you should and spend your whole day ……. and night seeing them all.

Devil is in the details…. If you are detail oriented and if you have a good system in place, then you decrease your chance of error. Believe me it is going to happen… you will make an error (Murphy’s Law) but the difference is the gravity of error.

So what is the magic number, various factors play a role when you consider the right number of patients to see. If you have midlevel support or you have residents, than you can probably see more but that is not the case for most of us. I think 15-20 patients per day is a fair number in a 12 hours shift in a hospital setting. I read this article sometime ago at Today’s Hospitalist, it nicely breaks down various situations vs census of patient accordingly.

I call these doctors Super Doctors. It is like "look! It's a bird. . . . It's a plane. . . . No....It is a SUPERDOCTOR!” No patient can really identify what breezed through them. But just remember it takes only one kryptonite to bring down the mighty.

About the pic: Not Krytonite, it is a Topaz at Smithsonian Museum at DC.

Birthday Party and "I Have A Sick One"

2010-12-05T21:43:00.003-05:00

Birthday is supposed to be your day, you enjoy, relax and have fun with your friends and family. Statistically and according to my personal observation, people who have the most birthdays usually live the most.

Few days ago I had mine, somehow it doesn't look kosher if you try to take a day off. My birthday started a little early with a page from ER around 2 in the morning. They gave me routine greetings and put me on hold for some major announcement. Soon I was talking to a fellow physician who said those dreaded 5 words "I have a sick one". When you hear something like this you know you better get up and get ready. Someone is heading to ICU.

I drove to the ER, dodging few deers (Yes real deer!) and reached there around 3 in the morning. This lady was really sick, she literally decided to throw the book at me. She saved all known critical medical problems for me specially for this day. That took few hours to stabilize. At the same time I was informed that a turkey gulper is waiting for me. Around thanksgiving I usually see one or two who decide to gulp a turkey without utilizing the mastication process which results in a turkey stuck in limbo in the esophagus. Anyways patients kept on pouring in for the rest of the day without showing any sensitivity that it was my birthday.

Later I went to the wound care center where my office manager Debbie was kind enough to bring this cake,

due to lack of resources I had to use a scalpel to cut this cake. The rest of the day passed by pretty fast. I came home around 6 pm, pretty fatigued for the day but it was lovely to see my family and have a great dinner.

PS: No wounds were harmed while utilizing this particular scalpel.

Flu Shot, Did You Get One?

2010-12-02T02:51:00.003-05:00

According to CDC (Center for disease control), flu 2010-2011 season started in October and it will peak in January. Current recommendations are that everyone above 6 months of age should get the vaccine. This year you don't have to get a separate vaccine, this year vaccine includes protection against 2009 H1N1, H3N2 and influenza B virus.

I got my Flu shot early last month at the hospital cafeteria, I was ambushed as I was on my way to get some food. Unfortunately my wife and our two daughters were not so lucky. So as we got out of the plane at Washington Dulles Airport, we saw a kiosk right near the baggage claim, personals over there were offering free Flu vaccine. My wife got a shot and the little ones got nasal sprays. Children were overjoyed when they figured out that they will get a "mist" rather than a shot.

Anyway I like this campaign, it is very effective and convenient. Don't forget to get your shot.

21% Medicare Cuts and Air Tran.

2010-12-01T01:37:00.001-05:00

Some of my blogs get published at other online websites like here at KevinMD.com; I saw a number of comments at one of my recent post which I originally published it here. Some of these comments were thoughtful, some very critical and some very amusing. I would like to mention few here.

“I had a plumber come to my house to snake out a blocked sewer line. Two guys showed, and it took them an hour to do the job. The bill? $100.00 plus the cost of a new wax seal for the toilet bowl. You can’t say hello to a doctor for that kind of money.

“Which is why they make about 500% more than plumbers on average. And they make that regardless of whether the job they do is phenomenal or not.”

“I don’t know about finances but patients are much more likely to say thank you after I teach them to SCUBA dive than after I save their kid’s life. They are also much more likely to pay their fees to the scuba shop for certification than they are to my office for vaccination of their infant.”

Well I can answer some of their concerns but I will leave it for everyone else to make their own inference.

I recently traveled through Air Tran, I took a picture of this pretzel packet, I found the text very amusing and very practical on the other hand.

It is a possibility that with recent fear of 21% cuts to Medicare payments, we may just not have problems with finding treatment for our elderly, just like it takes forever for Medicaid patients to get an appointment. But we may also find little brochures in hospitals and doctors offices with similar language.

You Think You Got It Bad.

2010-11-29T23:51:00.002-05:00

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.

2010-11-28T22:23:00.000-05:00

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.

2010-11-17T21:27:00.001-05:00

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.

2010-11-14T21:01:00.001-05:00

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.

2010-11-11T22:19:00.002-05:00

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.

2010-11-10T20:39:00.000-05:00

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.

2010-11-09T21:41:00.000-05:00

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.

2010-11-05T23:03:00.000-04:00

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.

2010-11-03T19:49:00.001-04:00

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.

2010-11-02T21:32:00.000-04:00

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....

Lemon Tarts.

2010-10-31T22:11:00.001-04:00

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.

1928 Cell Phone?

2010-10-28T22:12:00.001-04:00

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?

Tele Neurologist. Specialist On Call.

2010-10-27T23:59:00.003-04:00

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.

2010-10-27T00:57:00.003-04:00

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.

What If Walls Could Talk?

2010-10-26T01:48:00.001-04:00

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.

2010-10-26T01:19:00.001-04:00

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.

A New blood thinner in 50 years. Dabigatran.

2010-10-20T07:35:00.002-04:00

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.

Doctors Are In For The Money!

2010-10-18T22:46:00.003-04:00

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!

Charity Waters.

2010-10-17T00:52:00.003-04:00

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 31^st 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 32^nd 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.

Hatred. Tyler Clementi.

2010-10-14T12:36:00.004-04:00

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.

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

2010-10-12T21:15:00.000-04:00

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

2010-10-12T21:03:00.002-04:00

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:

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

2010-10-11T21:49:00.001-04:00

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.

2010-10-11T00:16:00.002-04:00

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.

Healthcare Reform Bill.

2010-10-08T23:57:00.000-04:00

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.

Camel Jockey

2010-10-07T22:24:00.001-04:00

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.

Is Compassion A Mutant Gene?

2010-10-06T23:45:00.001-04:00

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.

Female Is A Woman Not An Electric Connector.

2010-10-05T21:51:00.001-04:00

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.

Empowered Patient, Myself.

2010-10-04T15:38:00.005-04:00

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.

International Health service Corps (IHSC)

2010-09-29T22:54:00.000-04:00

I came across an interesting article in New England Journal of Medicine September 2010 issue. “An International Service Corps for Health —An Unconventional Prescription for Diplomacy” by Vanessa Bradford Kerry, M.D., Sara Auld, M.D., and Paul Farmer, M.D., Ph.D.

We are all aware of Peace Corps. Dr. Bradford Et al proposed a concept of developing a program based on providing health care assistance to international community. This could benefit various countries. In almost all disasters United States is one of the leading countries to provide major contributions to affected countries. If we have this in place, it would make a better and more effective way to combat major illness and disasters.

Articles states,

“To break the cycle of poverty and disease, we believe that the United States should create the equivalent of a Marshal plan for health. A program that would train and fund both local providers and US health care professional to work, teach, learn and enhance the health care workforce and infrastructure in low income countries. We envision this program as an International Health service Corps (IHSC)”.

It also elaborates that one third of the world population survives on less than $2 a day; there is a loss of 4.6 million lives annually from AIDS and TB alone, along with deaths of 6 million children who die before the age of 6 from preventable diseases.

IHSC could have collaboration with other countries, any where there is a disaster, like the

Haiti

earthquake, we can contribute in a quicker and more effective way.

Physicians and nurses could be provided with incentives including loan forgiveness and scholarships, which could make this program more appealing.

In short I think this is a great prospective and has a great potential.

About the picture: I used a 70/300 Nikon lens to take this shot just after sunset.

Predator.

2010-09-28T22:06:00.005-04:00

You can not judge a book by its cover, nor can you be always correct about first impressions. You are also expected not to judge a person. You are also taught to give a second chance. This is all true but we are humans after all and we all are guilty of doing everything opposite of what I just said. The argument would be that the intrinsic potential of a person never changes, an eagle would always be an eagle and a vulture would be a vulture. Can you change the true nature of a person?

I often see inmates at the hospital who are brought to us for various problems. I have seen some who have swallowed blades so they can get out of jail for few days to people who have sliced their hands with broken door handles. You deal with them just like you deal with any other patients as per Hippocratic Oath. Along the same lines I always try not to find out what brought them to the slammer in the first place.

Few years ago I saw inmate in the hospital. He was shackled to the bed with two guards around him. He had an ovoid face, wrinkled skin far beyond his age. He had gentle and deep eyes; he was taller than most and touching mid sixties. He was dressed in not so ever modest hospital gown. Ironically his handcuffs and ankle restraints appeared to be brand new. I found him civil and pleasant to talk to. He appeared to be well versed and informed about his condition. I got a sense he must be a college graduate the way he was able to formulate his thoughts with the use of proper lingo.

I saw him for couple of days before I was informed by a staff that he was incarcerated after being found guilty of raping a 6 or 7 year old and then choking her to death. The girl was a kin!

Being a father of 2 girls; it is difficult to isolate your emotions in these situations. I saw him the next day with a straight face. I asked my patent question “Sir is there any thing else I can do for you?” I discharged him in the next few days.

I have a vivid memory that just before discharge he complained to me about neck pain, it was an effort for me not to ask him “Sir, do you think your pain is more than the girl you choked, is it more than what she must have endured at the last few seconds of her life”.

I have always believed that nothing is absolutely bad nor anything is absolutely good. This incident is one of the times when I questioned my philosophy. What do you think?

About the Picture: I took this shot of Tyrannosaurus rex, largest land predator of all times at Field Museum, Chicago, however, man maybe the worst.

Alien Factor and United Nations.

2010-09-26T21:57:00.002-04:00

I saw a post today by a friend of mine, Abbas who resides at the border of Italy and Austria. Pretty far away from here. But the post was about things which are much farther than earthly distances. It is about new frontiers, where no man has ever gone before.

Today is a historical day; united nations have appointed a first contact for any aliens who may decide to drop by. A Malaysian astrophysicist Ms. Ottman has been nominated to perform this job. She recently stated “The continued search for extraterrestrial communication, by several entities, sustains the hope that some day humankind will receive signals from extraterrestrials”. She further states "When we do [make contact], we should have in place a coordinated response that takes into account all the sensitivities related to the subject. The UN is a ready-made mechanism for such coordination.” Ms. Othman is currently head of the UN’s little known Office for Outer Space Affairs (UNOOSA).

Wow I like this UNOOSA’s “beam me up Scoty” job. But I do have some questions. How do you qualify for this job. As you may have guessed by now I am not an astrophysicist but I have been a Trekkie all my life along with my big brother (Yes I confess). So I wonder first and foremost how do you get this job. Do you need past experience of alien abduction or dealing with aliens, if you do, how you can prove it. Second what is the tenure for this job, do you get fired if you have no alien contact in the first 10 years of your job. Third, how is your job performance measured? Talk about job insecurity.

Well all jokes aside this is forward thinking. Prepare for everything. So power to Ms. Ottman.

I remember this intriguing quote from book Contact by Carl Sagan, when little Ellie inquires from her father about existence of life out there, he says “Well, if there wasn’t, it’d be an awful waste of space.”

So you must be wondering what this has to do with medicine. Nothing!

About the Picture: Getting ready for a job interview.

Have a Seat Please.

2010-09-24T23:38:00.002-04:00

Physicians who sit down during a hospital patient visit are perceived as spending more time with patients versus who stand. A study conducted at University of Kansas concluded these results after reviewing data from 120 visits.

Physicians who took a seat were thought to spend five minutes with the patients; where there actual time was just over a minute. Physicians who stand up during the visit spent 1 minute and 28 seconds and they were perceived as spending 3 minute and 44 seconds. Doctors who sat down were believed to be spending 40% more time with patients than standing up.

So next time have a seat.

About the Picture: Some street artist caught my attention. Specially the one on the right. It is exhausting work. Cough up some money next time please, will ya!

Kaizen

2010-09-23T23:49:00.000-04:00

I was invited to be a content advisor for a Kaizen training program. Toyota production system is known for following Kaizen. It refers to a system which constantly works to improve various processes; this could be implied to business, production lines or health care. Training involves all employees from CEO to security. Organizations like NASA to hospitals are using the core philosophy of Kaizen and lean principles. I was able to attend some of it but what I heard and what I have read in the past was most interesting.

Kaizen demonstrates a strong desire to eliminate Muda, a Japanese word for wasteful or non value activity. If you look at the way we do work, there is a lot of duplication in what we do. From my perspective nurses ask all the same questions to the patient as we do. Past medical history of a patient is not updated in medical records. We invent the wheel all over again when we admit an old patient. There is a lot of Muda from where I see it.

This whole week I have been seeing people running in black vest, working on small projects other than their usual duties. One of the ideas one staff member came up was to implement a color coded patient census board. Like red denoted 100 % census and yellow 75%. This helps with early discharges and other planning involved.

The five main principle of Kaizen are

§ Teamwork

§ Personal discipline

§ Improved morale

§ Quality circles

§ Suggestions for improvement

Kaizen Way, a book by Robert Maurer deals with applying Kaizen principles on a more personal level. You may find it an interesting read.

About the Picture: Port Canaveral, Florida.

Pain Clinics and Chill Pill Mills.

2010-09-22T22:21:00.000-04:00

Recently I attended a presentation by an Interventional Pain management physician, Dr Maulik B. Some of the facts that he stated were mind blowing. I also read this article in Time magazine.

Some of the facts are stated below.

In Broward County, Florida there more pain clinics than burger joints. There are 115 pain clinics in the county versus 70 burger franchises.
18 out of the top 25 Oxycodone prescribing doctors are in Broward county.
Deaths related to prescription drug use rose from 2,780 in 2006 to 3,750 in 2008.
Pain Clinics can be run by doctors who are not citified in pain management.

I personally have seen patients being prescribed 360 tablets of Oxycontin along with Valium and Soma. The street value of 10-20 mg of Oxycontin is 70-80 dollars. Just imagine if someone is prescribed 100 tablets of Oxycontin, that is straight $7000.

People are driving all the way from Tennessee to make a quick buck. When I initially moved to Florida, I remember that there was a clinic which was busted after authorities noticed that they had a sign outside that said “We prescribe Vicodin and Percocet”

I admit patients everyday with excess prescriptions for narcotics. I remember a case when I admitted a 21 year old young man with respiratory failure after a narcotic overdose. He was later placed on life support after being diagnosed with anoxic brain injury. His girlfriend used to visit him with their cute 2 year old girl. I used to feel bad about this little girl that she will miss out on her father. He died and 8 months later I admitted the girlfriend with similar presentation. She also died in the next few weeks. That little girl must be very lonely tonight.

So my friends this is the human factor in medicine and life.

About the picture: Happy M & M seen in New York.

Medicare Cost and Million Gazillion Dollars.

2010-09-21T21:34:00.002-04:00

Recent new estimates from US government reported a 17.3% increase in health care spending as compared to the previous year. This is the largest jump in half a century. 2.5 trillion spent on healthcare was 134 billion more than last year. These are very huge numbers, beyond my comprehension. The way I see it they will continue to grow.

How we contribute to this cost, is best explained in the words of a patient I recently admitted.

ER called me regarding a patient who was unresponsive. She was in her late eighties. Patient had a comprehensive work up including labs, chest x-ray, EKG, cardiac enzymes and CT of the brain. These entire series of tests were predominantly negative.

When I saw her on the floor she struck me as all gray, her hair was all gray, skin ashen and face pale; like a flower dying slowly. She was still not responding to any commands, I saw that there was an order for a MRI of the brain and carotid ultrasound. After examining her I reviewed the records in the chart from the nursing home and among other things there was a DNR (Do Not Resuscitate) order in the chart.

I called the son and he asked me, what his mother was doing in the hospital. I told him about her grim status. He informed me that she was always good to him, he was her favorite. She had started to deteriorate once dementia started to set it. Now she had been non verbal for a year. She was like an empty shell. He decided to enroll her in hospice a year ago. I assured him that I will call hospice. Within few hours hospice saw the patient, I cancelled all pending labs and test and she was transferred to nursing home with hospice.

Hospice patients just want to be comfortable, they do not want any heroic measures or any further diagnostic test. Even within twelve hours of her stay in the hospital, Medicare will be billed probably more then 15 grand, excluding bills from EMS etc. All of this could have been saved if someone had paid more attention to her code status at the nursing home, ER or on the floor.

The sad part is not just the cost of care but taking the opportunity away from some loved one to die in peace rather than dying with tubes coming in and out of you.

About the picture: I shot this at my backyard.

White Board R’ Us. Part II.

2010-09-19T21:57:00.002-04:00

This blog is a continuation of a previous posting “White Board R’ Us”. I wrote earlier regarding utilization of white boards in patient’s room. It is a very simple and one of the most effective tools to improve communication. This is based on a study conducted by Dr Sehgal at University of California.

It has been over a month since I have been using this medium to convey the plan of care to the patient. I just use simple layman language. It starts with my name, date, their diagnosis and plan for a particular day.

So like for the patient above, I jotted down on the board that he will be getting steroids for a rash, antibiotics for a skin infection and an ultrasound to check for a clot in his arm.

Patients seem to be more informed about their diagnosis and plan. They are more appreciative and they know what is coming to them later in the day. I usually do not use the white board if the patient is confused or being discharged home.

I will keep you posted as this is work in progress.

Viagra (Niagara) Falls.

2010-09-18T23:10:00.001-04:00

Sleep, the final frontier where few doctors have gone before.

As a physician you learn to compromise on a good night sleep. While on-call you get phone calls of various nature at all odd hours of the night. Just recently I received 24 pages from 11 pm till 7 am. So you can imagine the quality of sleep one gets.

Every doctor has a plethora of stories regarding the calls we receive during a given day or night. Ninety percent of these calls are appropriate and the rest, I better not say any thing. I will give you samples of few remarkable calls I have received during nights in the last few years.

· 4 AM, call from a nurse, “Doc, I just want to inform you that patient has dark urine”, I inquired “you mean patient has blood in urine”. Nurse, “No, It is just dark yellow in color”. I replied, “Please keep a very close eye on it, if it turns blue let me know”.

· 5 AM, last month from a nurse, “We just want to tell you that patient is allergic to Diovan and he is on Labetalol”. I asked, “Is he on Diovan?”. Response, “No”. I was speechless and sleepless after that.

· 2 AM a nurse from ICU: “I just want to inform you that patient has a critical BUN level of 3”. My response, “STAT transfuse 2 units of BUN”.

· 5 AM during residency: Code beeper goes off: I ran to the patient’s room. Code team was at bedside. I touched the patient, he is cold and stiff but I was still asked to run a code. Of course I refused for obvious reasons; rigor mortis never responsive to resuscitation.

· I was called during my first year of training by nurse around 3 AM for medication for headache. I gave her the quick orders while in an attempt to catch a quick 2-3 hours sleep before going back to the ICU rotation. In the morning the same nurse told me that she did not give the medication I ordered. She told me that she heard me say, give 1 tablet of Viagra. She was unsure so she called the pharmacy to find out if there were any indication for Viagra for headache, they told her that there were none. She gave the patient Tylenol instead and notified me in the morning.

I strongly believe that in a hospital setting a dedicated nocturnist, can improve safety and decrease errors related to “burn” effect.

About the picture: While walking in New York.

CPOE vs. CAPTCHA vs. Diabetes.

2010-09-17T20:27:00.000-04:00

You must be wondering what is CAPTCHA? This is an acronym which stands for “Completely Automated Public Turing test to tell Computers and Humans Apart". This is a combination of different letterers and numbers you see at websites for security and prevents spam.

Regardless of how fail-safe our security is; you will always need a human interface. Or maybe it is my intrinsic desire to be superior to computers.

I have been a strong supporter of CPOE (Computerized Physician Order Entry) as you may have read it in my previous post “I Stole A Cow”. Recently I came across a Leapfrog study. Leapfrog group partakes in reducing medical mistakes and try to improve quality of care. There has been several studies in the past regarding safety and reduction of medication errors. However, a recent study conducted at 214 hospitals using a simulation tool missed one half of non fatal appropriate warnings and missed one third of fatal order errors. Now this is something to think about.

I was attending a physician staff meeting last night. The speaker pointed out how there is a degradation of clinical protocols with time as new data emerges every year. One prime example is Leuvin Belgium study regarding Intensive Insulin therapy for hyperglycemia. We all jumped and started to mimic these results. However, later we realized that intensive glucose control can lead to increase mortality as shown by NICE-SUGAR and VISEP protocols. Since then we have changed our target numbers for normoglycemia.

My point is, that though we see a significant benefit from utilizing all new protocols, devices and systems. But we should not loose our skepticism. In my heart I am a skeptic, not so much to ask God for an ID card but enough. I believe in this analogy that if one person calls you an ass, don’t worry about it, if two call you an ass, step back and think about it. If three does, get rid of the tail!

Tattoos.

2010-09-15T21:50:00.000-04:00

Teenage is considered to be an age of chaos. You are exposed to various elements, it is an era of change, raging hormones and you are invincible. A friend of mine recently said when your child is a toddler, they are so cute you want to eat them and when they are teenagers you regret why you did not.

Henna (Temporary tattoos) is considered to be a symbol of celebration in eastern cultures. At wedding, girls get together and get very complex intertwined design on their hands and feet.

It was refreshing to see a young teenager Raza the other day. This kid turned Henna into a symbol of joy and utilized this medium to benefit cancer survivors. He is a gifted boy with an artistic approach. He has started offering these design to girls of different ages, and the funds he raises goes to Relay for life which is a volunteer-driven organization for cancer survivors.

Raza could be reached through this facebook account.

About the picture: Henna by Raza, picture over my guitar.

Time.

2010-09-14T23:08:00.003-04:00

Someone inquired the other day, how do I find time to write these blogs. I pondered for a moment and quoted John Maxwell “Each human being has exactly the same number of hours and minutes every day.” We have no more or less time than George Washington or Gandhi. Money can not buy you time nor can you borrow it from anyone. You have to make time Period.

Of course I am not in the same league as these great people, but I try to utilize my time the best way I know. Now suffering from chronic insomnia has its advantages and disadvantages. For the most part I survive with 5 hours of sleep. Anything less makes me cranky.

Isn’t it funny when some friend calls you after a long time. Usually their excuse for not calling sooner is that have been very busy. But after a while when you ask them what they have been up to; their response usually is “nothing much, same ole’ boring life.” So much for being busy!

Time is relative. Not as in the theory of relativity, but as how we see time. We have a very sharp perception of time when we are at home or at work, everything in our surrounding reminds us of time passing by. You are subconsciously aware of time as events happen at certain intervals. You know it is 7 AM because this is the time you go to work, few minutes elapses before the coffee brews, lunch happens at 12 pm, meetings at 3 pm, going back home at a certain time, you exercise for an hour and an hour worth of TV program in the evening etc. etc. However, if you are outside on a beach or in the wilderness our perception is very poor. With no distractions or constant reminders times passes at an exceptionally slow rate. There are no milestones to remind us of the passage of time, maybe just the sun going up and down.

The same thing happens when you are healthy and have no ailments. We experience no reminders of sands of time as long as we are healthy. No back pain after waking up, no prostate problems and no heart attacks. But with age nature starts to call on you with subtle reminders. You start experiencing more headaches, ankle pain, menopause and the list goes on.

Again these are subtle reminders, on the other hand people who suffer from terminal illnesses do not have reminders; they have alerts at the last moment. I have known patients who have asked me this question, do they have another month to live. Just imagine that a person has made peace with themselves that they will not see November 1^st, but they want to live till October 15^th. They can cram their whole life in one month. You can learn the value of time from them. They do not want to waste any time as they are acutely aware of the time wasting them.

Well I had a day off today so I had a lot to think about. I spent a whole afternoon at the library most of the time reading Kissinger by Walter Isaacson; that was not a waste of time.

About the picture: Allegedly the biggest clock there is, but it was out of order that cloudy day.

Wrong Diagnosis.

2010-09-13T20:55:00.003-04:00

“I choose to begin with I am wrong because it is the hardest of the phrases to say and genuinely mean”. Richard DeVos starts his book Ten Powerful Phrases this way.

I was reading this book today; he narrates some of his life experiences and lessons that he has learnt. The phrase “I am wrong” is simple to write but difficult to say. To admit when you are truly mistaken is equally difficult.

I took care of a patient recently. He presented with right upper quadrant pain. His liver function panel was slightly abnormal but his pancreatic enzymes were quite erratic. I obtained a CT scan of the abdomen and a HIDA scan. Considering the clinical picture I was quite confident that this patient has pancreatitis due to gallstones, without common bile duct obstruction.

One of our gastroenterologist and a surgeon were on the case. The GI suggested an ERCP (study to evaluate pancreas and billiary duct), I was confident that ERCP was not needed and urged the surgeon to proceed with laproscopic removal of gall bladder.

During the surgery when surgeon performed a cholanagiogram she realized that there is indeed an obstruction of the billiary duct. Patient ultimately had to go through an ERCP the next day.

I saw the GI doctor the other day, initially I almost considered saying that it could have gone either way but instead I said “I was wrong!”. It takes an effort to accept you are mistaken.

On the other hand it is better to know when you are wrong rather than being wrong and not knowing about it.

About the picture: I entered my room one day and found my daughters trying on my jackets.

Simplify.

2010-09-12T13:00:00.007-04:00

I recently came across an article Simplifying your life from a fellow blogger Doctor John Halamka, Chief Information Officer at BIDMC.

Unfortunately simplifying it self is a complex procedure. You would require a paradigm shift and shed some of the load we carry. As we grow old our culture promotes complexity. At least this article provides us with something to ponder.

It is very inspirational and I have already shared it with few friends of mine. Please take a look at this article and tell me what you think.

About the picture: Picture taken at Chicago Art Museum.

9/11 Nine Eleven, 8:45 AM. A Minute Before Impact.

2010-09-11T08:45:00.005-04:00

“I remember looking at their faces when they walked in the church…… their faces were so blank almost like a deadened look on their faces. But after a while they talk, and eat, and sit and you’d see them leave smiling”.

Tara Bane

Victim’s wife and volunteer.

Sometimes I wonder what do we have to show for. Is it really all about getting a good education or making few more bucks or collecting some more "stuff" in your life.

What is our contribution? Have we made a difference in someone's life.... if we have than I hope in a good way. Let''s start small, let us make a change in just one life.
Let's talk .....

I wish at 8:45 AM, someone could have talked to them.

About the picture: Badges of workers and volunteers at ground zero on my last trip to New York.

Victim. Where is the SVU?

2010-09-10T16:01:00.006-04:00

It was almost five years ago, when I saw her. I do not think she was white but kind of whitish! She had a little bit of Native American in her. She was in her thirties, taller than usual and one of those quiet type. She always wore a pony tail and had freckles on her face, and she had an infectious laugh which gave her an innocent look. She was jittery and very anxious, biting her nails all the time. She had two children but I can not recall if those were boys or girls.

There was something about her. She always looked scared, like she was watching her back. She was reluctant to be examined when I saw her first. Every time I would examine her she would cringe. I remember telling my wife years later that she looked so scared and anxious that I should have explored the reason behind it a little more closely.

I saw her most of the times for minor ailments like headaches or joint pains. Then I started to notice bruises which she could not explain. She had a big jagged scar on her belly which she explained was from a previous surgery.

One day she came to me with multiple bruises. I was suspicious and asked her bluntly what was going on. She was hesitant initially but finally gave up and started to talk frankly. She came from a family where she was abused as a child. She was divorced; she had no place to stay so she was still living with her ex in-laws. Her ex-husband was physically abusive and whenever he would swing by his parent’s he would have his way. One time he punched her so hard that it caused perforation of her bowels. Just imagine the brute force required to hit someone so hard, that it would burst someone innards. Envisage the desperation and sacrifice on her part to continue to live in this situation so that her kids could have a roof over their heads. She fit the profile of a child who is abused; they have a higher chance to end up in a similar situation.

I was very upset hearing that, I advised her to call the authorities. I told her if she would not then I will. She refused and told me that even if I call them, she will never press charges. I advised her to go to one of the safe houses or shelters around Tampa. To my surprise when I called a couple of places around Tampa I was given a run around. I was so surprised that considering that we see all these ads about resources available to us in news and magazines, when you really need them you can not get them. Every place started with eligibility requirement which she did not qualify for. I even asked a supervisor how much beating would she need before we can get her in one of these safe places. They did not like it. I wonder where the SVU (Special victim units) are.

When she was leaving she was smiling…. what was behind that smile I can only imagine. I never saw her after this episode. Sometimes I wonder what became of her. Her kids should be older now, I hope she is too.

About the picture: I stole this picture over the web. Woman displaced after the flood in

Pakistan

# 7 Life Is Good, #6 "Ciken" Wings.

2010-09-08T22:44:00.006-04:00

This is a detailed account of what I mentioned in an earlier blog My Teachers.

Not so long ago after a busy and tiring day I came back home quite late. We usually sit down with our two daughters at dinner time and either do some fun activity or watch some TV together. Their favorite show is America's Funniest Video. Both my daughters 8 and 6 years old love that show.

When you are a child you are easily amazed, unfortunately it takes more and more as you grow old. I think wonder never cease to exist, however we loose the ability to appreciate it as time fogs our vision as we grow old. It is a precious gift to watch a child laugh for no reason at all.

So as we were watching the show, my 6 year old asked me, "Baba, can we make a funny video too". I asked her why. She said, "If we make a funny video maybe we can send it to

America

's Funniest Video". I assured her we can do it but why should we need to do that. She said, “If they like my video maybe we can win TEN THOUSAND DOLLARS"

"Wow that is a lot of money, what are you going to do with it" I said. She thought for a moment and replied solemnly "I will give it to your hospital". I was surprised because I was thinking she will probably ask to buy some gifts or dolls. Still bewildered I asked her, "why would you do that?"

What she said next would stay with me for the rest of my life. She said ,“Then may be you can spend some more time with us". The decisions I made after that were pretty obvious.

"Nobody on his deathbed ever said, I wish I had spent more time at the office" Unknown.

About the picture: My daughter wrote this note about our family.

One Hero Every Day.

2010-09-07T22:05:00.002-04:00

In a hospital setting, administrators love to work with physicians; they make sure whenever a new system is being formulated and implemented, this is discussed with a team of physicians, as they are also an integral part of success. All physicians work with each other in harmony and synchronicity. Cardiologist never steps on each other toes, radiologist call admitting doctors for any bizarre findings and hospitalist notify the primary about their patient’s update. Physicians discuss their plan of care with nurses and nurses in turn make sure all support staff is conveying the same message to the patient. Nurses keep a direct contact with their assistants, physical therapist etc and they inform each other about any significant changes. And…… by now I usually wake up from sleep and face the nightmare of reality.

There is no “I” in a team. Unfortunately I often feel that there is a desire from everyone to work as a team however adjective never transforms into a verb. We all work in our little domains, administrators do their own thing, physicians after seeing a patient do not see the big picture and nurses immerse themselves more in entering data rather than reviewing what data means.

In every hospital I have worked at, there is a huge void between physicians and administrators. I often feel a free flow of information and mutual trust can reach goals better than “need to know” policy.

Half of the physicians do not get along with each other. There is constant bickering about stealing patients and how unethical the other doctor is. Please do not take me wrong I have my moments of bickering too but I try not to. If a primary decides to use another physician to admit a patient other than our group, I try to self evaluate ourselves and see why did this happen, were we doing something wrong or was it a purely business decision from primary care. And if it is, then it is a free country, I believe in free will and enterprise.

I call this overall behavior “Maximum of Minimum attitude” where you do the minimum best among our own domains and seldom cross over. I think we need to put more emphasis on team work. Workshops among all hospital based personals should be encouraged. We need to emphasize on the bigger picture rather than our cocoons.

There need to be one hero everyday rather than one hero all the time.

Blog you later.

About the picture: Memorial altar at St. Paul Church at Ground Zero .

How Do You Like Them Yankees!

2010-09-06T15:54:00.002-04:00

This happened few years ago at another hospitals I used to work at.

There was this emergency room physician who was doing the graveyard shift. It was late at night when he went to the physician lounge to catch the last few minutes of Yankees game. In the lounge he saw two technician working on a 52” Plasma TV. Apparently they were having problems with mounting it right.

Being a nice guy, he helped those guys to take the TV off the wall and move it to the next room and went back to the ER. Those guys were very appreciative and thanked him.

In the morning the staff could not find the TV in the physician lounge. When they reviewed the video they saw the physicians helping the two “technicians” who later loaded this TV in their van and made a quick getaway. Our doctor friend of course was not very happy.

So what lesson did we learn today? Is it a) Do not help strangers. b) Call Security when in doubt! c) Stay away from free food at physician lounge.

The answer is none of the above. It is…...Why watch a Yankee game when you can watch a good Red Sox game.

About the picture: Red Sox and Rays game at Fenway captured by my IPhone.

Message In A Bottle

2010-09-04T02:23:00.004-04:00

Somebody asked me today “why a blog?” I countered “why not”. He said “what if no one reads it”. I replied “so what, think of my musing as a message in a bottle, I almost have no expectations that anyone would ever find it, probably it will be lost in the sea. It may also smash against a rock or maybe it would land somewhere on a castaway island never to be found. But if I won’t float the bottle, it will never reach its destination”. He got irritated and walked away.

I assured my self that at times people do find it; it can not be a total waste of time. People do find tales of joy or maybe tragic moments, sometime maybe a nudge to move on or perhaps someone’s life narration. They may learn to avoid the same mistakes the other person made or discover about things they can relate to. On the other hand if nothing is done then sum of zero is …….

Finally I moved away from the front of the mirror and walked away too……

About The Picture: Lake around my house.

Medicare Cuts And My Plumber.

2010-09-02T23:25:00.003-04:00

So there was a neurosurgeon who called a plumber for a house visit. The plumber arrived and after spending an hour bestowed the neurosurgeon a bill of $500. The surgeon was stunned; he said “Even I don’t charge this much after a surgery”. The plumber stood up, gave him a sly look and said,” well that is why I am a plumber now; I used to be a neurosurgeon”.

I mention this as I was talking to a cardiologist few days ago. He said we are one of the few professions where someone else comes in and informs you how much you will get paid, regardless of what you do. Next time when you have a plumber at your house. try telling him what you want to pay him but do not hold your breath. Unfortunately every year with Medicare cuts we are seeing more and more doctors changing the way they run their practices.

Now we can argue that physicians are still compensated well, but on the other hand they also do a phenomenal job in helping and saving lives. A bureaucrat sitting in his office can decide how much health care institutes and providers will be compensated. However, these bureaucrats do not get up in the middle of the night or drive 80 miles an hour to reach the hospital to save a life. Neither do they have to reach the hospital within 90 minutes because the sooner they perform the procedure, better the outcome. Nor do they perform a cardiac catheterization which literally saves lives. However one thing they will never be able to share, is the sweet feeling of contentment about making a difference in someone’s life. By the way this doctor after spending three hours will get a profligate check of $253.

A plumber was actually at my house this week. He charged me $50 for consultation and $260 for fixing a leak. He was out within an hour. On his way out I did ask him, “Hey were you a neurosurgeon before?”

About the picture: A billboard at 43rd and 7th, NY.

My Teachers.

2010-09-02T00:22:00.006-04:00

I have been blessed with great teachers. They showed me horizons which I thought did not exist. They had an array of personalities and professions. Not all of them were strictly in the academic settings. They varied in age and things they had to offer, at different stages of my life. Like my high school teacher Ms. S, who taught me time management and brought out the best in me. My father, who showed me being a doctor, is more than billing a patient.

My little 6 year old daughter, who taught me what is more important in life, when she asked me to donate money to the hospital I work at, I asked why. She said “so that you can spend more time with me”. My teacher at Beth Israel Hospital/Harvard Dr. Ferris Hall, who taught me that you can not ask for respect, you earn it.

My “singing heart” patient who taught me that you have the power to brighten someone’s day. My supervisor at the carpet cleaner company where I worked in Chicago during my first year in America, who taught never to treat anyone the way you don’t want to be treated.

Our janitor Julie, who spent decades at University of Massachusetts, taught me never to ignore people who help you, with what you do. She said "I feel invisible, people pass by me all day long but never seem to notice my presence". Indeed, she was right when I saw her next day working, she was….invisible to everyone.

I cannot forget my senior resident Kirk MacNaught, who told me once during my intern days when I was in a hurry to make a decision about a patient, “You should never treat a patient like you would not treat your own family member”. Then he continued in his soft voice “can you please stop running around the hospital like a chicken with its head cut off and get back to work”.

I sometimes still run like that. I never claimed that I was the best pupil, I was just lucky to have great teachers. Most of all my patients are the best teachers, who teach me things I could have never learned in any school.

About the picture: I think this does not require any explanation.