CAUTION

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

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

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

PS: About the picture.

What About Bob!

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

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

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

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

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

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

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

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

PS: About the picture.

Disease Management System.

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

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

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

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

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

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

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

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

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

About the picture: A new day.

Bring your own measuring cup.

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

I was suspecting either statins, hepatitis or alcohol.

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

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

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

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

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

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

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

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

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

And the reason is;

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

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

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


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

Tele-Intensivist.

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

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

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

And again I thought that we were done.

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

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

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


PS: About the picture. Room full of consultants.

Healthcare Being Sequestered!

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

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

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

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

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

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

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

Please change Diet orders. Mediterranean diet

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

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

I hope I won't get into trouble.

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

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


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

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

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

Buddhist temple, Kyoto, Japan

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

Keeping an eye on me.

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

Bird One

_DSC0419, a photo by At_a_tangent on Flickr.

Yahoo Dome, Kyoto. HDR version

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

Huddle, Multidisciplinary Rounds.

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

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

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

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

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

2- House nursing supervisor.

3- Floor supervisors (optional).

4- Physical therapy and occupational therapy.

5- Dietary.

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

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

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

9. Pharmacist (if they can).

Our team has so far improved,

1- Potential early discharges and transfers. 

2- Plan of care for the day.

3- Identify needs for patients.

4. Improve work flow and delegation of tasks.

5. Improve core measure compliance and power plans. 

6. Improve documentation. 

7- Contain cost per case.

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

Hiroshima, A Hard Stop.

A hard stop is something you can absolutely not do after a certain point.  I believe as far as nuclear arsenal is concerned we should have had a hard stop on August 6^th, 1945.

We were in Koyoto for few days; we were debriefed regarding our Kaizen project in Fukoaka.  Dr Rippe, Dr Nunez and I decided to make a quite round trip to Hiroshima. We took a bullet train and ended up in Hiroshima.

I wanted to visit this site since I wrote a blog here almost two years ago regarding a patient of mine who was in Hiroshima.

As soon we entered the Hiroshima Peace Park, it felt like the bomb was still hovering over you rather then something which has happened almost 70 years ago. 

Sometimes you can almost feel the sounds of tortured spirits screaming and begging you to stop their anguish, your mind starts to play tricks on you, you can smell bodies burning and seeing charred skin. As you continue to walk you finally come across ground zero, the prefectural Hall that now lies in ruins.

My friend Ramone was in so much anguish, he could not even finish the museum.

In the end you wonder what has changed since then? Our course remain unaltered. Auschwitz, Bosnia, Rawanda and 9/11….

About the picture:  The picture shows a shadow left behind by radiation heat rays. The shadow is of a person who was sitting 250 meters from the hypocenter, waiting for the bank to open. It never did!

Toyota Production System. Part 3.

Kaizen project at Showa Industry.

Our 2 teams spent 5 grueling days at the Showa Tekko plant in Fukuoka. This particular plant produces all kind of equipment, from air conditions to vacuum boilers. Some of their cooling equipment is as large as a small building.

Our project was to Kaizen (Improve) their production line. They produce a certain model of air conditioner. Our task was to reduce overtime of their workers without any change in their production capacity.

We utilized Toyota Production principles as I have mentioned before. We divided our team into 2 sub teams. 

We observed three different operators.  First operator was involved in the assembly,  second was  the inspector and third operator was involved with packaging.

Our goal was to reduce the total TakTime. We started with standard flow chart and measured their timings. Caroline White was our team leader and she did a remarkable job leading our team.

We came up with some great ideas. Dr. Nunez and Ruth Hemphill suggested a U shaped module for the inspector work station which reduced his walking time significantly, my team suggested to eliminate waste (Muda) from packaging and add value to the operator’s time by assisting other colleagues.

Our patients are not cars, but on the other hand we do have a line, a line in the ER. Different patients presenting with different problems like a production line, where you may have a Camry and the next could be a Highlander.

Our goal is to have a standard work for these problems so that all operations run free of defects/medical errors and our quality remains top notch/improved survival.

Toyota Production System. Part 2.

Toyota Production System Training.  Part 2.

Kaizen, it is all about improving a system, any system. This course,  Gemba Kaizen, is about learning skills to improve efficiency as you decrease Muda (waste) associated with work.

There are few key concept one need to comprehend as you learn more about Toyota Production systems.

-       Jidoka: it roughly translates to “Automation with a human touch”. So whenever there is an equipment malfunction, the machine stops immediately that prevents it from producing defective products.

-       “Just in time” approach: Any process produces only what is needed by the next process in a continuous flow. It helps with producing only what is needed, when it is needed and in the right amount.

Using these principles Toyota mass-produces automobiles utilizing the philosophy of Jidoka and “just in time”. These vehicles are of exemplary quality, long lasting and up to the par for the customer.

Few days ago we spent our day at the Toyota museum. It was a very interesting experience. Museum has tow major pavilions. One is about textiles/Looms and the seconds part is about Automobiles.

Toyota name is so synonymous with cars that few people know that their initial business was manufacturing automatic looms.

This was the first time I observed a museum as a student rather than a spectator. Our goal was to observe Toyota Lean manufacturing and Toyota production system and later describe that process to the group with a brief sketch.

About the picture:

Picture 1- First circular looms designed by Sakichi Toyoda.

Picture 2- This  is my sketch. I was impressed by the automotive pavilion where they tested different metals, improved their design, they went to the source to get better materials and design and at the same time kept safety in their mind. 

I was never good at sketching!

Kaizen. Toyota Production System.

Very interesting day at the Toyota museum. I was amazed by the way this organisation has integrated lean principles in every process.

Their humble beginnings from a loom machine production company to the largest automotive sale company in the world.

More to come later.

Toyota Production System.

I am attending a course, Toyota Production System in Nagoya, Japan. I am very excited to learn some new skills in regard to this system. For the next 2 weeks I am here in the land of the rising sun, hopping from one city to another. We have our Value stream map ready to present and as some of you may have guessed, our project in Sepsis-error proofing. Details later.

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About the picture: I saw this gigantic spherical structure today as I was walking along with my group around the museum of Science, looks alien.

Top Ten Things.

I was recently invited as a keynote speaker at our hospital for our staff and nurses dedication day.

This is part of my speech.

Top ten list of things I appreciate the most of the staff and nurses.

1-  Thank you for loaning me their pens.

2-    Being redundant, you save more medical errors than I can count.

3-    Making it a great place to work everyday.

4-    Thank you for being passionate about your work. Some people mistake that their eventual goal is to make lots of money, the focus whould be directed towards your goal.

5-    Thank you for not hanging up on us in the middle of the night even If you hear us snoring on the other end.

6-    Thank you for smiling even on your worst day.

7-     Thank you for your compassion and sensitivity.

8- Thank you for using two point restraints.

9-Thank you for charting and bearing with administators, directors and doctors.

10- Thank you for deimpacing and giving fleet enema and kayexalte.

In the end I would like to thank God for letting me prescribe Haldol and  thank you from the bottom of my heart for everything you do."

About the picture: Nothing to say today.

Despair.

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.