Dante’s Inferno.

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. 

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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.

 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

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”.

In 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....

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.

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

 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 $$$.

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.

 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.