Painless Jaundice....

Was reviewing some charts to sign earlier, and signed one from a patient I saw recently. Middle Aged, slender female presents with painless jaundice. Finally came in, because her daughter noted that she was "pretty yellow". My heart sunk as I read the complaint, cause I know the most likely cause before I even enter the room. I go into see her, and examine her. Non smoker, no abdominal pain to palpation, no distention, significant dermal jaundice, and scleral icterus. Her daughter and her begin to ask about potential causes, and I explain that the most likely cause is an obstructive process of the biliary duct system, and that generally, if it is painless, that it has been a slow progressive process. We discuss bilirubin, and the cycle bilirubin goes through in the body, albeit in laymens terms. They ask what the causes can be, and I explain that the most likely cause is malignancy. I also explain, that it is not the ONLY possibility, that occasionally, a chronic pancreatitis can cause these symptoms, and I have seen one patient with painless jaundice that ended up having Hepatitis A. I explain the need for the CT scan.....


5cm mass in the pacreatic head. UGH. I hate these conversations. I go into the room, close the door, and sit down with the patient for awhile. I explain the findings, explain the most likely cause, but that it would need to be confirmed with an ERCP. I explain that they can hopefully place a stent when they perform the ERCP, and this should definitely improve the jaundice. I call her primary at home, even though it is the weekend, and she appreciates the call. The patient leaves, and even though I know that it is part of the job, I tell the RN to give me five minutes, and I go back, sit in the office, and take a deep breath.

Life sucks somedays.

Lobbyist for a day....

Well, I've had numerous meetings with various politicians to discuss health policy issues, but I've never tried to sell some legislators on a SPECIFIC legislative bill.

I kinda feel dirty, but I am ashamed to say that I liked it......

Physician Assistant Concerns

Well, I have been reading some of the blogs here in the blogosphere, and one theme seems to remain constant. That is, PA and NP bashing, on many of the physician blogs, not all of them mind you, but many. This concerns me, I am likely taking a leadership position within our national academy soon, and I am curious as the rationale behind this. So to all physicians reading:

1. HAVE you ever directly worked with and utilized a PA or NP?

2. IF yes, do you feel that the care they provide is substandard, and if so, HOW? and can you provide data to support that assertion?

3. If no, then I am wondering how you can objectively even comment on the situation.
Do you feel threatened by midlevel providers? Do you simply not like the concept? Do you feel that they provide bad care? NOTE IF YOU ANSWER YES, you MUST provide data/studies to support that.

I'm just trying to understand, cause the health system is on the verge of collapse, a recent survey of medical students indicated that only 2% plan on entering primary care. CMS reimbursements are dismal, and the largest generation in the history of our young country is on the verge of retirement.

So, if you want to eliminate midlevel providers, what would be your answer? How would you provide care to all those people?

Basically, I am pretty tired of reading all the bullsh*t PA bashing without a shred of credible data to back up those concerns. If you have studies and or data to show poor care, then let's see it......

Thought so.

Critical Care not long ago.

Working in the critical care section a few weeks back, and seeing amongst other things, a natural gas exposure who was VERY concerned that he had symptoms consistent with carbon monoxide poisoning, and had very obviously been researching this on the internet. Well, it turns out, it was a small gas line rupture outside of the home, and there was a small increase in Methane within the home. He presented complaining of dizziness, HA, tingling/prickliness in his distal extremities, and an inability to concentrate. There was NO detectable CO within the house per the gas company. Also, seeing a patient I had known from my orthopedic days, who had presented with a TEN day history of bradycardia, that began at the end of a viral URI, and had persisted. He could not obtain an appointment with his PCP, and therefore decided to come to the ED.....Good thing..he was in 3rd degree heart block with an elevated troponin. So, I'm in the middle of discussing the case with the CCU fellow, when BAM.....doors open, paramedics bringing a STEMI in. Went into see the patient, and quickly summoned my attending, as they were nonoriented, hypotensive, and were displaying an agonal breathing pattern. Attending asked me what I thought about intubation, and I quickly answered yeah, and asked for propofol, and etomidate. RN gives the meds, and I grab a miller blade, and a 7.5 ET tube, a little trouble seeing the cords, but the attending quickly gives some crichoid pressure, and BAM, there they are. Tube is in.

All of sudden, the CCU fellow, who was also there to discuss my OTHER guy, says there is a weak thready pulse, quick bedside US demonstrates little to no RV motion, and severely diminished LV function. Within 30 seconds, Vfib. Shocked three times, two minutes apart with CPR, given Epi, MG, and Amiodarone. Recovered a BP and pulse, with a rhythm, by now, the CCU sttending is there, and the decision is made to quickly take her to the cath lab.....

Would you believe, her cath was normal?

Anyone else with any ideas on what could cause SEVERE ST elevation in the anterior and lateral leads, and sudden onset Vfib, with a normal catheterization?

That is EM medicine folks......similar in some respects to anesthesia...many minutes of routine patient examinations, punctuated by a few moments of excitement.

Interesting case

Had a younger patient present a while ago, had been in a high speed MVA the day before. Had been seen at an outside facility, and was evaluated thoroughly including negative CT scan examinations of C-spine, Head, and Abdomen/Pelvis. He was discharged with a prescription for pain meds, but was unable to fill them as his/her car was destroyed. Patient presented with increasing and worsening pain, primarily in the left shoulder, and left chest wall. Stated that toradol had worked well for him in the past. As it had been last given almost 24 hours previously, was given an additional dose of 60mg IM with excellent pain relief. Discharged after negative xrays and satisfactory exam, and told to fill existing pain med script, and follow up with primary care.

2 days later patient presents again to the ER, this time in ARF. Creatinine is in the mid 2 range upon admission. Admitted to the hospital, worked up, creatinine rose to the low 4's, but with good care and with being hydrated adequately, had complete resolution of ARF. Got a subsequent somewhat terse e-mail from one of the hospitalists regarding usage of toradol, and how it "should never be given in the ER, because of numerous cases like this", and how I caused thousands of dollars in extra expenses. I politely replied that I was aware of the potential nephrotoxic effects of toradol, but that the incidence of these events was very low, somewhere around 1%. I asked them to provide data to support their assertion. It is always possible that there are studies available that I am not aware of. As much as I try, you simply cannot read every single medical study that comes out. I also sent the case to Departmental Peer Review.

Bottom line was that after a thorough literature search, the incidence of ARF with toradol administration was 1.04%, and with the administration of narcotics.....1.37% So the committee concluded that my care was completely in line with current practice parameters, and that toradol posed no severe risk of nephrotoxicity. I was vindicated.

This all occured a couple of years ago, but was an interesting experience.

Funny Patient Encounter

SO, I am working not long ago, and have a middle aged female present with chronic LLE pain, I am completely slammed and have 8 patients in my hallway. She states that she has had numerous visits with her primary care, as well as a PM&R doc and an orthopedist regarding this pain which has persisted for 8 weeks.

Me: So this pain has persisted for 8 weeks, correct?

Patient: Yes...

Me: So what has changed today, what made you present to the ER?

Patient: well, the pain is still there, duh

Me: But the pain has been there for 8 weeks, correct?

Patient: yeah

Me: so what changed?

Patient: I don't understand.

Me: that's okay.

Patient: Aren't you going to fix it?

Me: Fix what?

Patient: whatever is causing my pain?

Me: You will likely need a more extensive workup in the clinic setting ma'am.

Patient: But can't you operate on it?

Me: On what?

Patient: My back or leg, or whatever is causing my pain.

Me: Right here?

Patient: yeah.

Me: Ma'am, I'm trying to understand what has changed in your pain pattern, so that I can better understand why you are here, and what might be going on.

Patient: Well, nothing has changed, and I want answers.

Me: So the pain is the same.

Patient: Yeah, but I'm tired of it.

Me: Well, I need to be honest with you, we might be able to offer slightly better pain management, but you've had an extensive workup, and we will likely not find out what is causing your pain tonight in the ER.

Patient: Why not?

Me: Because this is a complex problem, and the symptoms you are describing sound neuropathic in nature. You have also had multiple imaging studies and visits elsewhere, with negative findings so far.

Patient: I don't understand.

Me: Ma'am, we will provide better pain management and a follow up with our primary care clinic. Unfortunately, at this hour (10pm) this is the best I can offer you now.

For the record, she was pain free upon presentation. Her pain was a burning, "shooting" pain down her leg that only occured sporadically. She had no loss of bladder or bowel control, and no weakness or loss of sensation on exam. Long tract signs were negative. Negative SLR, No spinal midline tenderness.

I want my kidney BACK!!!!

Wow...I've seen some nasty divorces, but this might be the strangest request I've seen.....

http://www.newser.com/story/47376/hubby-wants-kidney-back-in-divorce.html

A doctor is demanding that his soon-to-be ex-wife return his donated kidney—or at least the $1.5 million he says the transplant is worth—as the pair divvy up their assets in a divorce, Newsday reports. Richard Batista says his wife jumped into bed with her physical therapist just two years after the transplant and then filed for divorce, the New York Post reports, though the therapist denies the charge. Either way, it's unlikely he'll get compensated, since the kidney was a gift—organs can't be legally bought or sold—and it's now hers.


Just wow.

Out of the mouths of babes

My daughter is my world....my light, my angel....

SO, today, I am tired after working until midnight, and am dropping her off early this morning when she is asking about bringing in some toys with her. I explain to her that she can bring ONE toy with her today, as it is toy day. She wants to bring three....we have a little stand off, but I start to carry her in with her one toy, and she looks at me and asks "Daddy, why no more toys?", and I say, "because those are the rules sweetheart".......

Her response at age 2 and a half....

"THAT SUCKS DADDY".....

My mouth is gaping open, and I am trying to think of something else so I don't laugh and encourage this new vocabulary. Hmm....I think I might be in trouble.

Fast Track Disasters

So, I thought I might post a series on fast track disasters. These are patients that presented with relatively mild complaints, and/or were overlooked by triage, and were put back into fast track, but ended up being pretty sick.

First case:

35 year old caucasian male with a complaint of "cellulitis". H/O Multiple Myeloma on immunosuppression. Patient states that his left elbow is quite reddened and swollen. Now, apparently triage was being manned by monkeys, as no one noticed his pressure of 90/45. OR his pulse rate of 126. Closer examination revealed full elbow ROM with only slight pain at the extremes of flexion. supination and pronation full without pain. Posterior elbow has a definitive infected Olecranon Bursitis, but looking closer, the rash encompasses his ENTIRE RUE. From the axilla down to his wrist, worse posteriorly, but present even circumferentially. I'm starting to get a little nervous now, but feeling at least a little better, after a BP recheck shows 100/50
I immediately order Zosyn, and a 1 liter bolus, look at our critical bed situation.....D*mn, only ONE bed left over there. Time to talk with my attending, I briefly discuss the case with her, and she is, as a new EM doc, a little scared as well. We talk to the charge nurse, and ask that another nurse come over for one to one care with q 5 minute vital checks, and while this is being arranged I am calling the Hem/Onc fellow. We chat briefly, and are both in agreement that he needs ICU care. I call the ICU, and speak with the fellow, and subsequently the attending there. They agree to accept the patient, with Hem/Onc being the primary service. We arrange for an Ortho consult when the patient reaches the floor. He was out of Fast Track within 45 minutes after arrival. Immunosuppressed Multiple Myeloma patient in early septic shock was how I coded that.

I thought briefly about taking the last critical bed, but the fact that his BP was climbing slightly, and that he was still mentating, and functioning okay, made me re-assured that with close one to one nursing care, and a rapid transfer to ICU care would be okay in FT. I simply didn't want to take the last critical bed from a level one MI (STEMI) or a level 1-2 trauma.

Anyway, that is just one of several postings to come about fast track disasters.

Etomidate in sepsis??

Ya know, I do some sedation on a regular basis, for dislocation or fracture reductions, cardioversions, intubations, etc.etc. One of my favorites besides propofol, is etomidate and versed. However, for a long time, we have been cautioned against using etomidate in any patient with suspected infection, such as elderly patient with respiratory distress that could be secondary to pneumonia or sepsis. This warning has been based on an older study that showed increased mortality in patients with sepsis who had also recieved etomidate, this is thought to be due cortisol production suppression and a blunting of the ACTH response. Etomidate does cause both of these effects, however, this is a transient effect. Per Ron Walls, MD, "there has been no credible study that goes against using etomidate in septic shock and...the greatest service we can do to our patients is to conduct the large, high quality trials needed to base our clinical practice on truly robust evidence."

Source: Ron Walls, MD; Annals of Emergency Medicine 2008;52(1):13-14

For myself, until this is sorted out, I will continue to use propofol in adult patients who are considerd possibly septic, and ketamine in children.

FWIW, before anyone asks, YES, at our instituion, the PA's can perform the sedation, as long as the attending is aware of what you are doing. Some attendings like to be present, others only want to know if there is a problem.

Long Swim Day

Ughh, Hard to believe it's been a week already, my workout plans entail swimming four days weekly, but today was my LONG swim day.

4500 meters. 3 miles. almost 2 hours in the pool...

I'm a tired boy.

Started with a 500m warmup....just to get loose, slow and easy. Then, ramped it up with intervals of 50m hard, 100 easy. After that, did a pyramid starting with 25 on 10 seconds, then up to 200m, and back down. After which, did some "total immersion" drills, and kickboarded for a little while. then 2000m continuous at a moderate to intense pace, and then 200 meter cool down.

Now I have to go run a short 3 miles today too.....Going to sleep well tonight.

Primary Care Shortages...

We've talked about MLP utilization, we've discussed hospital bed shortages....but now I think we need to talk about one of the biggest hurdles/problems in american medicine today.

We've discussed various issues with healthcare here, and recently I have been talking about the problems with simply enacting or instituting nationalized healthcare....NOTE, I am not saying that we should not eventually do this, as it is probably eventually needed, BUT, we need to do this slowly.....

Keep in mind that it took TEN years for Japan to re-work their healthcare system and provide nationalized healthcare.....TEN YEARS. And their society is much smaller and more homogenous. Recent estimates I've seen have suggested that it will take close to 20 years for a nationalized health plan to truly be implemented and function well. And it must be a multi faceted approach that addresses other problems as well.

Here's one:

http://www.usatoday.com/news/health/2008-11-18-doctor-shortage_N.htm

Primary care doctors in the United States feel overworked and nearly half plan to either cut back on how many patients they see or quit medicine entirely, according to a survey released on Tuesday.

And 60 percent of 12,000 general practice physicians found they would not recommend medicine as a career.

Eleven percent said they plan to retire and 13 percent said they plan to seek a job that removes them from active patient care. Twenty percent said they will cut back on patients seen and 10 percent plan to move to part-time work.

Now, imagine adding an additional 49 million patients to this system???

And add to that, that a recent survey of 1200 medical students indicated that only, ONLY 2% were planning on entering primary care......2%....we need that to be closer to 30%, at least.

Thoughts?

American College of Clinicians...NP and PA

So I got my renewal reminder for the ACC in the mail today. The ACC for those of you not familiar, was created a few years back by a group of NP's and PA's (Bob Blumm among them, whom I know from the Academy) in order to foster a more collaborative atmosphere and to encourage a partnership between the two groups. I think their aims are admirable, so I usually send in my check.

It reminds me however, how often I am asked to explain the differences between the two, both at policy meetings, and by patients and even MD's (who should know this)

I will start by saying that I hold no personal grudge against NP's, hell, I supervise two of them in our group.

There are however, some substantial differences between the two.

Educational Degree:

PA's Master's level for the most part, there are still some baccalaureate programs remaining, and I believe one or two certificate programs.

NP's Master's mandated now, however, the NP leadership has now mandated that the Doctor of Nursing Practice degree (DNP) be the entry level degree for the profession.

Educational Structure:

PA's Based on the medical model. All schools must meet stringent criteria, and be accredited by the APAP. There is ALWAYS one full didactic year, followed by one full clinical year. We are told that we get the "meat" of medical school, essentially the 2nd and 3rd years. As I have not been to medical school, I cannot qualify this statement.

NP's All over the place, there is no nationally based criteria for NP school structure, and many have a mix of didactic and clinical hours, but do not seem to follow any pattern, hence there are sometimes serious questions regarding their educational model.

Board Examinations/CME:

PA's Licensed by the state medical board, we have to fulfill the same requirements as the MD's....50 hours of CME every year, and we have to take our boards over again EVERY six years. Most MD specialties require boards to be taken every x number of years, most are every ten.

NP's Licensed by the board of nursing, they have to fulfill the minimum CEU requirements for their state. They take a state based NP board exam only once. They do not ever have to take their boards again, and as their board exam is state based, there is wide variability on the testing that actually takes place.

Practice:

PA's Generally, although not always, much better at procedural medicine, and much better at acute care (ICU's, ER's, Surgical specialties).

NP's Generally, although not always, much better at preventative medicine, and patient counseling, as well as geriatric nursing home care.

Bottom line is, there are differences between us, it is important to recognize these, but also to work together.

I do have a problem with the NP pursuit of the DNP degree as their entry level degree, as they are creating a potential legal minefield for themselves. I have 3 friends who are PA's that have PhD degrees as well, and not a SINGLE one of them will identify themselves as "Doctor" to patients. They don't even have the PhD listed on their clinical nametags, as it is simply NOT worth the potential confusion. I know that I am finishing my Doctoral degree now, and I will follow their example. I can see everything being fine for the NP's until something goes wrong. Which it will, when you practice medicine, as an NP, PA, MD, DO, CRNA, CNM, etc.etc., if you practice long enough, you will have complications and/or bad outcomes. It's just a statiscal reality, and I can see a defense attorney having a FIELD day with the DNP degree. "So, (snidely) DR, was the patient aware that you do not in fact, have an MD?....before you answer that, WHERE did you go to medical school? Where did you complete your residency....DR?, I mean you are ABSOLUTELY SURE that the patient was aware that you are not, in fact, an MD? How could they be so sure, I mean after all, you call yourself a DR, you are treating the patient, are you not?"

And that would likely end badly. So, to any NP that reads this, it is not a slam, merely a concern. I would like to see us both flourish........

(PS.......you should have to re-board too.....dammit)

This is just sickening.....

I have a two and half year old daughter....this just breaks my heart. There are some truly evil people in this world, and this must be one of them. I mean, he hasn't ever seen the kid, finds out he needs to pay child support, and then kills him....an innocent little child. This is the kinda guy that I would LOVE to have alone in a room for a few hours...show him the true meaning of the word PAIN......

http://news.yahoo.com/s/ap/20090104/ap_on_re_us/new_orleans_child_killed_6

Dusty Guitar

Ahhh...looked at some of my old beauties last night. Haven't picked up any of them for some time. I actually played guitar for what seems like forever, I started as a teenager, and then alternated between bartending gigs, and playing in heavy metal bands to pay my way through undergrad. Haven't heard a song in a LONG time that made me want to play again..but then I heard this song:



Well, sat down to learn to play it, and right away, I knew he was playing in a different tuning. SO I started with a drop D....then tried DADGAD......but NO.....he's playing it in a DROP C......dayyyumm. Took me about an 2 hours to figure it all out, but a good hour of that was changing the strings (locking tremolo) and then figuring out the tuning. Definitely like this tune.....

Hospital Bed Shortages

I thought perhaps a discussion of the availability of hospital beds and, secondarily, resources, might be apropos this evening. This is extremely important in light of discussion of 47 million uninsured americans beginning to use health resources if and when "Universal Healthcare" becomes a reality. Most people in this country are not aware of the bed shortages, and difficulty finding placement that occur daily. Most people operate under the assumption that if you are very ill, you can present to your hospital, and be admitted for further care there. Well, not necessarily.

http://content.healthaffairs.org/cgi/content/full/22/6/40

"After nearly two decades of concern about excess inpatient capacity in U.S. hospitals, the business media and some industry observers are beginning to suggest that some hospitals are near their capacity limits in providing patient care.1 Concerns have arisen especially about emergency services and the increased frequency with which hospitals have gone on emergency department (ED) diversion (requesting that ambulances bypass their EDs) in recent years.2 Some studies suggest that ED diversion might be the most obvious sign of more widespread capacity problems in certain hospitals. In particular, some hospitals may go on diversion because their ED is crowded with patients who are boarded there because regular floor and intensive care unit (ICU) beds are full.3
These issues have generated discussion in public and private policy circles largely because of impending demographic changes as the baby-boom generation enters retirement and needs more health care. Should the United States now be considering increased investment in hospital capacity? The Health Care Advisory Board recently suggested that based on a moderate-growth scenario, hospital in-patient days will rise 3.5 percent each year through 2010, which implies the need to increase inpatient bed capacity by 40 percent.4 Also, a 2003 study of the Chicago health market, commissioned by its local hospital association, suggested that 4,500 more beds (approximately a 20 percent increase) would be needed there by 2020.5"


And

"Number of hospitals. These data suggest a consistent downward trend in the number of hospitals from 1975 to 2001. The number of staffed hospital beds also declined between 1985 and 2000, with a small increase in 2001. The number of hospitals declined 14.4 percent from 1985 to 2001, as a result of hospital closures and mergers. The decline in staffed hospital beds between 1985 and 2001 was about 17.5 percent, the result not only of closures and mergers but also of hospitals’ decisions to downsize bed complements or their difficulties keeping beds staffed because of labor shortages.
Hospital use. In relation to hospital use, between 1975 and 1980 admissions rose about 11 percent, and average length-of-stay was stable. This likely influenced the hospital bed expansion observed in this period. After 1980, though, inpatient admissions declined 14.4 percent, as did average length of hospital stay (14.5 percent).

Several factors were instrumental to these changes, including advances in medical technology that expanded the types of procedures that could be provided in an outpatient setting. Further, the introduction of the Medicare prospective payment system (PPS) also contributed, given its payment incentives that encouraged reductions in inpatient lengths-of-stay and a shift of some care to outpatient settings.9 Finally, managed care was a strong force between 1980 and 1995, and health maintenance organizations (HMOs) in particular focused on utilization management to reduce unnecessary hospitalizations and hospital days.10

Some of these trends took an interesting turn after 1995 (Exhibit 1). Most notably, hospital admissions rose 9.4 percent from 1995 to 2001. Despite a decline in average length-of-stay of 0.8 days over this period, average hospital occupancy rates rose to 64.4 percent in 2001. Meanwhile, the growth in outpatient visits continued unabated, rising about 30 percent between 1995 and 2001."

Also, Massachusetts looked at this, and found this:

--------------------------------------------------------------------------------

"http://www.mass.gov/Eeohhs2/docs/dph/quality/healthcare/ad_emergency_dept_analysis.doc

This study found that the most significant driver of ED diversions in the two hospitals studied is the lack of sufficient inpatient capacity. This is supported both by observational data and by stochastic modeling. Capacity shortfalls may result from either an absolute lack of staffed hospital beds, a periodic bed shortage revealed during peaks of demand, or a combination of the two."


Just wondering what others thoughts might, or might not be.

What a shift....

Wow. Moonlighting at another hospital today....what can I say...money talks.

This hospital is a smaller community hospital in one of our rural towns. There is one physician on at all times, and between the hours of 12p to 12a, there is a PA on to help with flow during peak hours.

Today was incredibly busy, saw a great many patients, and some were pretty sick. One of which was a very debilitated old man who came in with a shortened, externally rotated lower extremity which was very obviously a hip fracture. He lived on his own, and had become increasingly confused over the past several months. I think that he must have fractured his hip the night before, as he was still wearing the same clothes from the previous day according to his family, and had an elevated creatinine. Along with a concomitant UTI. Can we say admission. It was a good femoral neck fracture with significant displacement. He'll be having surgery soon....

Also saw a patient who ended up being pretty sick. Had a an elderly female patient who had a syncopal event present primarily for evaluation of her shoulder, as she had fallen on her left side and sustained abrasions as well as pain and swelling at the sternoclavicular border. No SOB, No CP, No neurologic changes. Had some episodic dizziness after recovering from the syncopal event, but felt fine now with no pain outside of her clavicle. I explained to both her, and her family, that the clavicle pain and swelling was one thing, but more concerning was this isolated syncopal event. We needed to rule out more sinister causes for this. EKG demonstrated A-Fib, which the patient did NOT have a history of, exam demonstrated some skin tears, abrasions, and the above mentioned clavicle swelling and pain. Neuro exam was carefully done, and was benign. I ordered a head CT, and this demonstrated an acute SAH with bleeding in to the sylvian fissure and temporal lobe. I explained the significance of this to the family, and the need for urgent neurosurgical consultation. The nurse at this point, comes up to me concerned about his BP which was 95/55. I laughed and said that was perfect. I explained to her, that at this point, I would prefer a slight hypotension, as long as she was perfusing well.

Anyway, add to that, the diverticulitis patient, the 2 year old that needed periorbital suturing, the two chest wall traumas (non penetrating)...and this PA is done tired.

Now I have to go deal with a drug seeker......yay....(rolls eyes)