The Level 2 Inpatient Encounter

Ever what a doctor needs to type for a 20-minute inpatient visit? Here's what it took me:

(Note: my poor typical skills are evident in the repetitive pounding on the "Delete" key...)

-Wes

P.S.: Here's the data from a carefully-conducted "study" on age vs. typing skills I conducted some time ago.

Care Pathways and Their Kin

Transitions of Care in Heart Failure, Circulation Heart Failure, January 2015

Living in Washington DC Brochure

(Getting 50% of Liquor - Courtesy Harringtonandselves.com)

(Choosing a Medical Specialty - Courtesy Surgical Sciences blog)

-Wes

Another MacGyver Moment in Pacemaker Implantation

Installing a permanent pacemaker or defibrillator has become commonplace event in cardiology these days.  These devices implanted in a patient are comprised of two main parts: the lead(s) and the pulse generator.  After installing the leads in the heart and connecting them to the pulse generator, the lead and pulse generator assembly are then placed beneath the skin in a small subcutaneous (or in rarer cases, submuscular) "pocket" that is created surgically.  Considerable care is taken to cauterize bleeding vessels when the pocket is created.  To facilitate visualization of these occasional bleeding vessels deep within the created pocket, I prefer to use a surgical headlamp to direct the light deep within the pocket cavity rather than relying on a conventional overhead surgical light.  I have found that headlamps have helped me limit my incidence of post-operative pocket hematoma development.

So as things have had it, I seem to have a knack for attracting every eighty- or ninety-plus year old who needs an emergency pacemaker on the weekend when I'm on call, and this past weekend was no exception.

So the team was assembled and the pacemaker implantation equipment readied.  They knew I liked a headlamp, so they dug deep into the recesses of their inventory to pull out their only headlamp that appeared to be from a bygone surgical era.  Being pressed for time, I couldn't argue and had to make due, but knew that this headlamp might not be very reliable, especially as I saw how the headlamp's fiberoptic cord was secured to the light source that generated about as much light as a few well-lit candles by a cumbersome spring-loaded Rube Goldberg contraption.  As I placed the headlamp on my head, and tightened the plastic strap that housed the headlamp to my head, I needed a backup plan in case the light failed.

Would I have to use the overhead light and make do, or might there be another way? 

I needed another MacGyver Moment.

That's when my on-call staff team came up with a brilliant, simplified idea:

iPhone to the rescue!

-Wes

(PS:  This device is experimental and has not been approved by the FDA.  Use this device at your own risk.    If you experience headaches, nausea, difficulty with concentration, or an erection lasting for longer than four hours, discontinue use of this device and contact your doctor immediately.  I have no commercial interest in this device.  Also, since the headlamp still worked this weekend, no workaround was needed for the patient, but something tells me we might be getting a new headlamp soon.)

Data Plan Health Care Shows Promise

CHICAGO - Citing mounting health care costs, electronic note bloat, and concerns with the quality and quality of Big Data, IBM, Apple, and EPIC Systems recently announced a new initiative to totally revamp US health care by offering health care services by data plan. The health care initiative was recently discovered in a little known section of the Patient Protection and Affordable Care Act (ACA) that changed portions of the U.S. Tax Code.

Under the new system, the brainchild of prominent Chicago physician-turned-health care entrepreneur Henry Throckmorton, MD, patients will purchase an initial 250 megabytes of data space on the EMR for all their health needs for $250 per month.  “It’s cheaper than most current cell phone service," Throckmorton explained. "When patients exceed their data allotment, health care ceases until patients purchase an additional data storage plan." Expansion data plans come in Bronze (250 M Bytes), Silver (500 Mbytes), Gold (5 G Byte), and Platinum (10 GB) storage increments.

Rollover plans for family members are also offered for those nearing the end of life.

“Health care systems that promise to limit the use of macros, dot phrases and cut-and-paste tactices have a real competetive advantage over competitors insensitive to the patient's data needs!” Throckmorton explained. "This system finally puts health care incentives in the right place.”

But Roger Wilco, spokesperson for America’s Health Insurance Plans (AHIP), the national trade association representing the health insurance industry, seemed less enthusiastic. "This is preposterous! Who do these flowery internet types think they are? Don't they realize there are advantages to more middle men in health care? How are we supposed to get our cut of the money?"

Dr. I.P. Knightly of Urocare Health System in Beaverton, New York, seemed less concerned about the middlemen and appreciated the improvements he's seen in patient care:  “Because I document everything on the EMR, including phone calls, results and work schedules, patient are less likely to call so I get a good night’s sleep!”

Nursing and medical students seem torn, however. While some see benefits to shorter notes, some like Tim Allen, MD, a hard-working fourth-year medical student from Roanoke, VA, sees other challenges “I’m still trying to understand ortho notes that no longer contain the critical information fields like the patient’s full name, VIP status, research status, and a complete review of systems. How's a guy supposed to understand what ‘Silt @ t/s/s/sp/dp’ means?”

Market analyst Rebecca Solomon of Lock, Stock and Barrel Equity Partners noted "Apple, IBM and EPIC are quickly gaining market share from more conventional insurance policies. The concept has also resonated with the Department of Health and Human Services because of the cost savings seen from fewer data-hungry imaging studies being ordered."

Mobile partnerships with AT&T, Verizon, and T-mobile are planned in the next fiscal year.

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 -Wes

P.S.: If you thought this press release might be real, even for a second, consider why.

When Media Doctors Play Doctor

After George W. Bush's recent controvertial stent placement, news organizations were hot to jump on the media buzz created by a former President's health issues. Perhaps the funniest moment of all came from Fox News' proported medical "A-team" member, Marc Siegel, MD.

Dr. Siegel is an internist by trade, and when internists are handed a cardiac stent to open on TV, the ensuing moments were something to behold:



The special moments begin a 2 minutes into the video where Dr. Siegel attempts to open the stent packaging (even resorting to using his teeth 22 seconds later). After failing, he hands the package back to the anchorwoman who hands the challenging packaging to her TV crew to open.

Once the package contents are returned to Dr. Siegel, he remains baffled and displays the stents flush port to the TV audience as the stent.

Sorry, but it rarely gets better than this on TV...

-Wes

Mad Honey Poisoning Causing Arrhythmias?

Could the honey from bees cause cardiac arrhythmias?  At least one European Heart Society abstract, already fed by press release to the "inter-Webs," suggested it could:

Dr. Ugur Turk, from Central Hospital, Izmir, Turkey, reports on the cases of a 68 year old father and 27 year old son who were both admitted to the Izmir emergency department at the same time with symptoms of vomiting and dizziness. Surface ECGs revealed both patients to have complete atrioventricular block and atrial flutter with slow ventricular responses.

When a history was taken both father and son reported that their breakfasts over the past three mornings had included high amounts of honey from the Black sea region of Turkey. This information immediately triggered Turk and colleagues to consider that their patients could be suffering from 'mad honey poisoning'.

Mad honey poisoning occurs after people consume honey contaminated with grayanotoxin, a chemical contained in nectar from the Rhododendron species ponticum and luteum. Grayanotoxin is a neurotoxin that binds to the sodium channels in the cell membrane, maintaining them in an open state and prolonging depolarisation.

"It's like the effect of cholingeric agents, and results in stimulation of the unmyelinated afferent cardiac branches of the vagus nerve which leads to a tonic inhibition of central vasomotor centres with a reduced sympathetic output and a reduced peripheral vascular resistance,"says Dr. Turk, "This in turn triggers the cardioinhibitory Berzold-Jarisch reflex which leads to bradycardia, continued hypotension, and peripheral vasodilatation."

Mad honey poisoning generally lasts no more than 24 hours, with symptoms of the mild form including dizziness, weakness, nausea, vomiting, excessive perspiration, hypersalivation and paraesthesia. Symptoms of the more severe form include syncope, seizures, complete atrioventricular block and even fatal tachyarrhythmias (due to oscillatory after potentials).

While no specific antidote exists for grayanotoxin poisoning mild cases can be treated with atropine and selective M2 muscarinic receptor antagonists; while for the more severe form treatment options include temporary pacemaker implantation, and vasopressor agents.

Heh.  Maybe that explains why the "honey badger don't care."  Especially since the testing of the honey consumed by the two individuals only tested for the presence of Rhododendrons and not grayanotoxin.

-Wes

Are the Blackhawks Causing Heart Attacks?

Maybe:



"No more overtimes, okay?"

-Wes

h/t: The Toronto Sun

Happy Mother's Day

From Tom's Burned Down Cafe, Madeline Island, WI

-Wes

Psychology's New Adjustment Disorder

You can see it in their eyes as they dart left and right, up and down.  Their hands make rapid, self-flagellating movements over their chest, hips, buttocks.  Their pulse quickens.  Cold beads of sweat rise across their upper lip and forehead.  Their breathing is shallow at first, then builds, gradually, to a large sigh.  Inaudible words are whispered and the individual appears agitated, often pacing in circles as they speak.

They stop.  They frantically look about, rechecking pockets, coats, desktops, and even peer under the keyboard.  Their thoughts circle, pupils constrict, palms moisten, and mouth goes dry.  

Then, as fast it came, nothing.  They try to stay calm but the damage is done. A blank stare descends as they look toward somewhere in space, as if every hope, every friend, every loved one, is lost.

"Doctor, are you okay?"

"Oh,  I'm sorry.  Acute Rectangle Deficiency...."

 "... I think I left my cellphone at home."

-Wes

Gruntdoc: Talk Like A Healthcare Management Robot

Via Gruntdoc, Richard Winters, MD nails healthcare management speak. 

Click the button there and you can become a healthcare management robot, too!

-Wes

Study Maybe

Zdogg MD has some competition from the University of Maryland School of Medicine Class of 2015:




Heh.

Thanks to a cool $10 million dollar grant available from he AMA, perhaps (music) video production will become the next new prerequisite for medical school.

-Wes

In Case We're Not Here Tomorrow,,,



The 2012 Phenomenon


... it's been nice knowing you.

-Wes

How A Sudden Cardiac Arrest Survivor Handles the World Cup

It's a story as incredible as it is incomprehensible: On 17 March, 2012, a world-class soccer player from England, Fabrice Muamba, has sudden cardiac arrest (SCA) on a European soccer field.  The audience and remaining players stand stunned as CPR is initiated (video here).  An automatic external defibrillator (AED) is applied to his chest.  Two shocks from the AED are delivered on the field, another as he was carried to the ambulance nearly five minutes later, and 12 more shocks were delivered on the way to the hospital.  None of them worked.  Ultimately, 78 minutes of CPR were performed before the sixteenth shock miraculously restored sinus rhythm.  He then underwent therapeutic hypothermia, and, just as incredibly, awakened neurologically intact some time later.  He later undergoes implantation of an implantable cardiac defibrillator (ICD) as secondary prevention against future sudden cardiac arrest.

Fast forward just three months later.

Yesterday, England's soccer team reached the quarter finals of soccer's World Cup tournament against Italy.  In a hard-fought match, time ran out after 90 minutes of play with the score tied 0-0.  To advance to the semi-final match, a shoot-out must decide the victor. 

The air is tense.  The world watches in anticipation.  Mr. Muamba, also watching it all, can only sit and watch as his country's players take the field.  So what does he do?

He sends a Tweet containing a joke and a picture of his remote monitoring device for his ICD:

https://twitter.com/fmuamba/status/217002769578590208/photo/1

(No, the device pictured does not "charge" his ICD)

It was the humorous mark of a champion who is indeed happy to be alive.  Sadly, England lost to Italy in the shootout and although we have yet to learn if Mr. Muamba required the use of his device yesterday as a result, we certainly learned a lot about the character of the man and the remarkable efforts of the medical team who made this remarkable story possible.

-Wes

h/t: C.G., a faithful reader.

The DSM-Tw: Handbook of Twitter Personality Types

In an effort to assist the American Psychiatric Association with the publication of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) expected in May, 2013 it seemed only appropriate that a DSM-Tw (Twitter) supplement be provided to help classify newly emerging personality types on Twitter.  After all, the third and final (really, the FINAL) comment period for the DSM-V criteria ends June 15th!

292.891 Caffeine-induced disorder: Newscycling Disorder - chronic obsession with Tweeting main stream media news stories.  For instance, all topics that have an association with medicine are cited: even acne studies.   Diagnostic finding:  first to tweet the story so that others will "retweet" their tweet, as if it was their own.  Gaining followers is the name of the game, so they occassionally venture off on tangents, like American Idol, Justin Bieber or Venus in front of the sun.

787.62 Elimination Disorder: Encopresis with constipation and overflow incontinence, Cynic - chronic obsession with snark.  No matter what get's posted, they'll counter with a cynical comment.  Post something snarkier, they'll lose sleep at night until they quip with another one-liner that beats yours.  Yeah, suck on that one. (Discussions are underway to consider re-filing under "313.815 Conduct Disorder: Oppositional Defiant, Cynic")

307.213 Separation Anxiety Disorder of Childhood: The Pollyanna - They can never be nice enough.  Really.  If it isn't nice, it won't be mentioned, retweeted or fav'd.  But if it's about flowers, kitty cats, or the like, count on a high resolution picture link to Flickr or Photobucket.

301.811 Narcissistic Personality Disorder: The Narcissobsessive - They love themselves and they love Twitter.  So they tweet anything and everything.  A diagnostic feature: tweets-to-followers ratio typically exceeds 50:1.  Coffee shops, diners, movie themes are common topics.

297.32 Shared Psychotic Disorder, Boy (or Girl) Wonder Professional - Typically very sincere, advocates for a cause.  Well-liked by the Twitterverse.  Happy to share your tweet or there's.  Folds their underwear.

300.112 Conversion Disorder: #Hashtagger - One word tweet like "loser" with an attached concatenated hashtag like #runswithscissors.

So, what's your personality type?  Other personality / behavioral characteristics you'd like to provide?  Time is short!  They need our help!

-Wes

The First Annual Heart Rhythm Society Worst Accepted Abstract Award

As many of us head off the the Heart Rhythm Society's 33rd Scientific Sessions in Boston, MA this week, we leave to see some of the best science of the year in our field.  Abstracts, posters, discussions, Live Case demonstrations, - the whole works - will be there.  Media will cover reports of late breaking clinical trials, the benefits of our new oral anticoagulants, the amazing clinical workings of the subcutaneous ICD, and late-breaking clinical trials filled with fantastic innovations and controversy. 

Sadly, no one will cover the worst abstract that made the cut for the meeting. 

But now, thanks to the entrepreneurial spirit of the blog-o-sphere, the worst abstract of this year's Scientific Sessions can be crowned!!  The criteria for such an award HAS to include the abstract that contributes the smallest amount to our field while demonstrating the worst grammar, the most bureaucratic lingo and, of course, verbosity. 

Ladies and gentleman, I give you the unofficial 2012 Heart Rhythm Society's Worst Accepted Abstract of the Year:

The sentence that clinched it? 

The conclusions:

"Conclusions: The harmonization of endpoint definitions, terminology, and clinical trial design paradigms provides consistency across clinical trial studies that can facility (sic) clinician acceptance of results and the evaluation of safety and effectiveness of devices and medicines for atrial fibrillation."

Congratulations, Abstract # AB35-01!

-Wes

The Red Light

He was an older man, lying head-up in the Intensive Care Unit attached to telemetry and pulse oximetry monitors.  A small plastic cannula irritated the columella of his nose.  He lifted his hand to scratch the area, but the IV tubing in his hand did the work for him sooner than he expected.  He looked at the wall behind him. 

"So far so good," he thought.

A soft knock was heard on the wall outside his room.

"Come in," he uttered.

A bright young woman in a neatly-pressed pant suit entered, carrying a clip board. 

"Hello, Mr. Smith, my name is Sally.  I'm from the Office of Patient Advocacy.  I was wondering if I could ask you a few questions about your stay here in the ICU."

"I don't see why not," he said, straining his head to see the wall behind him once more.  He looked back at her.  "Go ahead."

"How have the staff been here?  Any problems?"

"No!  They've been wonderful.  Really.  Can't say enough about them except 'Fantastic.'"

He quickly looked at the wall again, then tuned back.

"Have the staff been responsive to you when you needed something?" the advocate asked.

"I'll say!  Couldn't be nicer, but the food still needs some work."

She jotted something on her clipboard then looked up and saw the man glancing at the wall behind him again.

"I'm sorry, Mr. Smith, is there something that's concerning you?"

He turned back to her and waved to her to come closer, looking concerned.

"You see that light back there, the yellow one?"

"Yes," she said.

"Well I don't know what it's for, but last night, the guy's next to me turned red and twenty people rushed into his room and beat the poor guy to death."

-Wes

Our New Electrophysiology Annex?

This was spotted by one of our nurse practitioners vacationing in Belize:

Click image to enlarge

Heh.

-Wes

Caption Contest: Taking It to New Heights

Click image to enlarge

Yes, it's a porta-potty and yes, this is the view outside our clinic lunch-room.

Now, you pick the picture's caption.

The winner will be chosen by our office staff later this week. What's the prize? Sorry, our new Physician Payment Sunshine Act limits the prize to bragging rights only.

Good luck!

-Wes

Oops: Transplant Heart Dropped On the Way to the Recipient

... and it was caught on video:



Talk about the "10-second" rule!

Heh.

-Wes

Fisher House Reaches LeapFrog Status

PRWeb (Chicago, IL) – Following an unprecedented first winter snowfall, the Fisher household achieved LeapFrog status attaining complete snow removal by no later than one hour before family members were scheduled to egress the premises. “This represents a landmark achievement by any house in the neighborhood,” says Mortimer T. Schnerd member of the 12-member LeapFrog assessment team. For the second year in a row, not only will the Fisher residence reach the 100-Most Wired Houses milestone, but also reach the US News and World Reports 100-Best Small Houses ranking on the North Shore of Chicago. “I would have also picked up the dog poop in the yard, but that was not in my wheelhouse,” said Westby Fisher, MD, owner of the esteemed home, “It was only through the tireless efforts of the whole family team, that we were able to reach this important benchmark.”

Media inquiries should be directed to the Ms. Sally Smith, Director, RealEstateByDesign PR, LLC, 2 East Park Ave, New York, NY 00221
(800) 555-1234
On Twitter: @WeBeBad

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