ACP Hospitalist

Monday, February 8, 2010

Medical News of the Obvious

Again this week, the mainstream reporters are doing our job for us. Newswise brings us reports of "an unmet need to study what might seem obvious: Gay kids will be pushed around." Researchers, published in the Journal of Adolescent Health, attempted to fill that need by surveying thousands of kids to learn that the very few who identified themselves as homosexual (less than 2%) or bisexual (0.5%) were also more likely to be bullied than the blend-in-with-the-crowd heteros.

In other news of those mysterious little miniature humans, it turns out that kids don't take themselves to the dentist. "About 86 percent of children whose parents had a dental visit during the preceding year had a dental exam, compared to about 63 percent of the children whose parents hadn't," HealthDay reports. What, that other 23% couldn't get it together to call a cab or hitchike to the dentist's office?

Labels: medical news of the obvious

Airplane Medicine: What Happens When You Answer The Flight Attendant's Call For A Doctor

This post by Liam Yore, MD, originally appeared at Better Health.

Rounding at 37,000 Feet

Anyone who has flown long-distance flights has heard the call: "If there is a doctor on board, please identify yourself to a flight attendant." But it's impossible to understand how that call induces the urge to flee to the lavatory and hide unless you are one of those unfortunate few who are on the hook, which is to say that you are qualified to respond, but you really really don't want to.

But gee, I can hear you think, Aren't you an ER doctor? Isn't this sort of thing second nature to you? Don't you revel in the adrenaline and glory? Well, yes. But, first of all, there is the performance anxiety thing. I'm used to working with a very small audience. In economy class, there may be 300 people watching me try to do my thing, and I'm just not used to that many people being in the exam room--and I know they are very interested in what's going on.

Also, being an ER doc, I am terminally paranoid, and over the Atlantic Ocean there's just no easy way to differentiate the Very Bad Things[tm] from the more common complaints which occasionally represent Very Bad Things[tm]. So that also is anxiety-provoking. And then there's the potential that things might turn bad, and then it's a flog to run a code in the limited space available.

Click on the "More" link to read the full post.

So, on Olympic Air, somewhere over the mid-Atlantic, the dreaded call goes out. I cringe and try to sink deeper into my seat, hiding my face behind my magazine. Finally, seeing that nobody else responded, I gave a deep sigh and pushed the call light. It was a 60-70ish guy in First Class with abdominal pain which radiated through to his back.

Great, I thought to myself, It's an aortic aneurysm. (See? I told you I was paranoid.) But his belly was soft with no pulsatile mass, good femoral pulses, and clinically, I thought the pain was much more suggestive of a kidney stone. I gave him some ibuprofen and said I'd check on him later.

I tried to sleep, but maybe an hour later, the attendant approached me again ... there's another patient for you. Sheesh. This is an older fellow with a history of heart disease who has epigastric pain and nausea. How the hell am I supposed to tell heartburn from angina over the Atlantic? I asked the attendant if there was a defibrillator on board, thinking maybe I could at least look at the ST segments, but the Greek-speaking attendant seemed to not understand the question. I mimed shocking someone with paddles, and his eyes got very big, but then said, no, they didn't have anything like that.

The patient said he has had typical chest pain with his heart attacks and this felt much more like his stomach. Then he threw up and felt a little better. I rooted through the medical kit and found something which looked like Greek meclizine and gave it to him. I checked on the first guy and he said he felt a lot better.

A couple of hours later, they roused me from a deep sleep (this was an overnight flight), to apologetically tell me that there was a third passenger in need of attention. Oh. My. God. This elderly lady was having trouble breathing and they had gotten an oxygen mask on her. Well, her lungs were clear and her pulse was normal and she seemed really panicky and her traveling companion said she had been under a lot of stress and hated to fly. So probably a panic attack. I told the flight attendant to keep her on oxygen for another half an hour (purely for placebo value) and told the patient in my most authoritatively reassuring tone that she would be feeling better by then. I then checked on the kidney stone (sleeping) and the nauseated fellow (much better, thank you). I went back to the galley and hung out with the crew, drinking coffee for half an hour, then went back to the panicky lady who had in fact experienced a miraculous recovery.

The flight crew was very nice and gave me a free bottle of champagne as a gift. And I swore I would never again admit that I was a doctor on an airplane flight.

The time in Greece was lovely. We started off on the island of Kos, Hippocrates' birthplace, and I got a cool T-shirt with the Hippocratic Oath on it, in Greek. As it happened, that was the only clean garment I had for the flight home (this time on Delta). This time we made it most of the way across the Atlantic before the call came for a doctor. I waited and waited and nobody else responded. Finally I decided that I couldn't very well walk around with the fricking Hippocratic Oath on my chest and not help out, so I gave in and rang the bell. As I stood up, I saw an elderly man about 10 rows in front of me, standing in the aisle in the tripod position, labored breathing, gray and sweating. That must be my patient, I thought. He doesn't look good. He couldn't tell me anything (too short of breath), but his traveling companion cheerfully informed me that he had had a heart attack only two weeks ago, and just got out of the hospital with congestive heart failure and had a pacemaker put in.

Oh, is that all? His pulse was about 150, way too fast, and his blood pressure was also very high. When I asked, he nodded "yes" that he was having chest pain. I figured that most likely he had gone into an irregular heart rhythm as a consequence of his heart failure and the low oxygen pressure in the cabin. I got out the defibrillator and moved him to an empty seat in business class because I figured that if he was going to code, I wanted room to work it. He looked that bad. I rooted through his med bag (a cornucopia of heart meds) and gave him aspirin, nitro, lasix, and metoprolol. And oxygen, of course. Then I went to talk to the pilot. We were two hours out from JFK, he said, but we could get down just a bit sooner by landing at Halifax, Nova Scotia. I tried really hard not to let the knowledge that I had a connecting flight affect my decision-making. Tough decision. Finally, I said that I thought he could make JFK but we should expedite it. I heard the engines spool up as the pilot accelerated the plane. So I sat up in first class with him to keep an eye on him (The wife eventually joined me when I didn't return to our seats in coach), and he progressively improved. His pulse came back towards normal with a second dose of metoprolol, and by the time we landed (almost 40 minutes early) his color was much better and his breathing was a lot easier. I wrote up a little report for the paramedics/ER, and after the fastest landing and shortest taxi I have ever had, the medics bustled him off the plane.

Again, the flight crew was really nice (and almost pathetically grateful, which was appropriate, since an unscheduled landing would be just about the end of the world to them). They took my business card and promised me a "nice little something." Lord knows what that'll be--probably a fruit basket. It was rather a pain in the butt, but at least the guy really needed me, and it was gratifying to see him get so much better. And I have resolved that from now on, I will fly with an iPod in my ears, cranked up so loud I cannot hear a single overhead announcement ever again.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: guest post, humor

Patients Value Personal Recommendations Over Online Doctor Ratings

This post by Toni Brayer, FACP, originally appeared at Better Health.

The organizations that rate hospitals and doctors have proliferated as the Internet has become mainstream over the past five years. I'm sure you have seen some of these: U.S. News & World Report, Consumer Reports Health, Health Grades, Leapfrog, Hospital Compare, America's Best Doctors and 100 Best Hospitals. My local magazine lists the "top doctors" along with full-page paid ads and promos that are very compelling. The questions is, do consumers care? Are these rating agencies really steering people toward top quality in health care?

Each of these agencies and organizations that "rate" have different measurements and criteria for their choices. The top rankings do not necessarily relate to quality outcomes. The Medicare data are two years old. Different treatments and conditions are judged, so a "top" hospital in one area may be a loser in another.

Even the mortality rates for acute myocardial infarction (heart attack) that were in the top 50 hospitals in U.S. News & World Report were misleading. One third of the ranked hospitals were outside the best performing quartile based on mortality and four of them were within the worst performing quartile.

Where can a patient go to find out the outcomes of a hip replacement? What if I want to know the infection rate and the number of hips that require "re-do"? How can I find out information about my surgeon? How many has he/she done? Do they track outcomes one year after surgery?

Believe me, you cannot get this information. Period.

Patients are becoming more savvy about health care choices, but research suggests that rankings have little influence over those choices. "The primary care physician is still the leading source for patients seeing specialist physicians and the opinions of referring physicians remain the leading factor for an individual patient choosing a hospital," according to a JAMA perspective article.

For that reason it is important that patients have a choice and have transparent information on their primary care physician. Selecting a physician is done mainly by word-of-mouth and availability. The consumer Web sites where patients can rate doctors are imperfect, but without better ways to get information, more patients are looking there as they select a doctor.

We still don't know if the 5-star doctors are just nicer or if they are clinically better.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: guest post

Medical News of the Obvious

You know a study's obvious when the news article covering it begins "Just in case the world needed more evidence on the matter..." We totally second the HealthDay reporter's opinion, and welcome her to our subspecialty of journalism. The link between exercise and good health--most recently and most frequently uncovered by the Archives of Internal Medicine--has become such a MNO staple that we're considering banning it from our coverage. If even HealthDay knows it's a given, perhaps we need to devote our energies to highlighting some less-obvious obvious news.

Labels: medical news of the obvious

In case you missed it...cognitive impairment is under-recognized

A recent JHM study found that hospital staff often don't recognize cognitive impairment in patients age 65 and older. This was especially true for patients on the younger end of the spectrum, and those with more comorbidity.

Of the 424 patients (43%) in the study who were cognitively impaired, 61% weren't recognized as such by ICD-9 coding. Interestingly, there was no significant difference between patients with documented and undocumented cognitive impairment as far as mortality, length of stay, home discharge, readmission rates, incidence of delirium, or receipt of anticholinergics. One troubling finding: a significant number of patients with cognitive impairment received anticholinergic medication, even though it's not recommended for patients with any type of CI.

The researchers also found that 38% of elderly patients with cognitive impairment had at least one day of delirium during their hospitalization. The patients with delirium had higher death rates (9% vs. 4%), were less likely to be discharged to home (75% vs. 31%) and stayed in the hospital longer (9.2 days vs. 5.9 days).

For more information on spotting and treating delirium, see this ACP Hospitalist article from last June.

Labels: cognitive impairment, delirium, in case you missed it

Unintended Consequences: When Hospitalists Become Too Popular, Costs Rise

This post originally appeared at Better Health.

It's the fastest growing "specialty" service in medicine: hospitalist medicine. These are the doctors who limit their practice to the care and management of patients admitted to the hospital. It has been wildly popular because it adds a shift-like work schedule to medical care for physicians while supposedly preserving their personal life. It also moves patients through the hospital faster, shortening length of stays. As one of our more esteemed hospitalist bloggers likes to boast: it's a "WIN-WIN!"

At least until the hospitalist service gets too busy.

It seems now that hospitalist services are limiting the number of patients they admit per day in response to their overwhelming "popularity." It's something akin to capping resident medical student ward services--they stop accepting patients when their census gets too full. I learned this today when a patient I was trying to manage with heart failure was just not turning the corner and needed to be admitted for more aggressive inotropic therapy.

Finding an admitting physician becomes an interesting exercise when the patient's primary care doctor no longer admits to the hospital (or is on vacation as was the case today) and the hospitalist service is no longer accepting patients because they're "capped" and you're trapped in a busy clinic.

What becomes the pop-off valve? You guessed it: the Emergency Room. Even though the patient absolutely, positively does not need the Emergency Room.

So much for cost savings.

It appears hospitalist services are increasingly finding themselves overwhelmed with admissions and the promise of a reasonable lifestyle can be assured by either limiting the number of patients admitted to each hospitalist or hiring more of them. But new hires are becoming tougher to justify in this "do more with less" economic time in medicine. As a result, it appears existing hospitalists are quickly finding they've hit the peak speed of their clinical-care gerbil wheels.

In a 1999 National Association of Inpatient Physicians (NAIP) survey, 25% of hospitalists were at risk for burnout, and 13% were in fact burned out. While these burnout rates were significantly lower than those documented in similar surveys of intensivists and emergency medicine physicians at the time, others suggested that this rate could increase as the field matured.

News flash: At least at some hospitals, it looks like we're there.

References:
Robert M. Wachter, MD; Lee Goldman, MD, MPH. The Hospitalist Movement 5 Years Later. JAMA. 2002;287:487-494.
Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001 Mar 26;161(6):851-8.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: guest post, health care cost, health care reform, heart failure, hospital costs, staffing

Ruppy

The following post is from Jamie Newman, editorial advisor to ACP Hospitalist:

Have you heard about Ruppy?

Jump on a plane to South Korea. Take one red sea anemone and one cloned beagle, mix some genetic material together in a fibroblast--shaken, not stirred--and you get a puppy that fluoresces under UV light. Do a Web search image for Ruppy and you'll see the glowing dog (or click here).

Strange but true.

And what, you ask yourself, does this have to do with hospital medicine?
(Go ahead and ask yourself now.
Really, I mean it, ask.)

Next time you are sitting in a meeting, trying to get two groups to work together and you hear "The cultures are too different!" or "This isn't going to work"-- just say "RUPPY!"

Ruppy. If you can mix a Cnidaria with a Canis, then anything is possible.

Labels: hospital medicine, Jamie Newman, Newman's notions, Ruppy

ACP Hospitalist hosts Grand Rounds on February 16, wrapping up the best of the medical blogosphere. Send your submissions to acphospitalist@acponline.org by this Sunday for consideration.

Contact ACP Hospitalist

Send comments to ACP Hospitalist staff at acphospitalist@acponline.org.

Blog log

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

db's Medical Rants
Robert M. Centor, FACP, contributes short essays contemplating medicine and the health care system.

Everything Health
EverythingHealth is designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Getting Better with Dr. Val
Getting Better is the continuation of Dr. Val Jones' previous blog at Revolution Health. It is devoted to helping people understand health issues from a balanced, scientifically sound perspective.

HealthHombre
A roundup of health policy news drawn from a database of hundreds of Web sites.

Interact MD
Michael Benjamin, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

Kevin, MD
The alter ego of Kevin Pho, ACP Member, is the closest thing to royalty in the medical blog world.

LSUHSC-S Medical Library Evidence Alert
Major guidelines, systematic reviews, meta-analyses and/or major reviews by national and international organizations.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by a doctor.

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American College of Physicians: Internal Medicine — Doctors for Adults ®

Related ACP Resources:

Internal Medicine 2010
for Hospitalists

ACP Hospitalist

Monday, February 8, 2010

Medical News of the Obvious

Friday, February 5, 2010

Airplane Medicine: What Happens When You Answer The Flight Attendant's Call For A Doctor

Thursday, February 4, 2010

Patients Value Personal Recommendations Over Online Doctor Ratings

Monday, February 1, 2010

Medical News of the Obvious

Friday, January 29, 2010

In case you missed it...cognitive impairment is under-recognized

Tuesday, January 26, 2010

Unintended Consequences: When Hospitalists Become Too Popular, Costs Rise

Monday, January 25, 2010

Ruppy

Contact ACP Hospitalist

Previous Posts

Archives

Blog log

American College of Physicians: Internal Medicine — Doctors for Adults ®

Related ACP Resources:

Internal Medicine 2010 for Hospitalists

ACP Hospitalist

Monday, February 8, 2010

Medical News of the Obvious

Friday, February 5, 2010

Airplane Medicine: What Happens When You Answer The Flight Attendant's Call For A Doctor

Thursday, February 4, 2010

Patients Value Personal Recommendations Over Online Doctor Ratings

Monday, February 1, 2010

Medical News of the Obvious

Friday, January 29, 2010

In case you missed it...cognitive impairment is under-recognized

Tuesday, January 26, 2010

Unintended Consequences: When Hospitalists Become Too Popular, Costs Rise

Monday, January 25, 2010

Ruppy

Contact ACP Hospitalist

Previous Posts

Archives

Blog log

Internal Medicine 2010
for Hospitalists