Turn off E-Babysitter. Children And Television

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.

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.

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.

 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

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?

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.

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.

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.