What IS Kaiser?

From the comments to another post:

What is Kaiser? What does it mean? Why is that doc so limited in what he does? Does it make his job better? Are all docs in CA Kaiser? Does Kaiser make people healthier? Do Docs enjoy working with /for Kaiser???

Just trying to get up to speed on this real world stuff. thanks,
Suzanne

Well, now, what an opportunity to educate, but not to flame Kaiser (or Suzanne).

First, here’s their very nice website, and now it’s your turn, gentle readers, to tell us the good, bad and other, from whatever your viewpoint.

Daily Weights, and other senseless acts of hospitalization

InstaPundit’s spouse is in the hospital, apparently for evaluation and treatment of arrhythmic heart disease. The hoped-for ablation couldn’t happen, so now they plan placement of a pacer / AICD. I presume that’s why she’s still an inpatient, but don’t know for sure.

This morning he asked, reasonably, why it’s necessary to wake up patients all night long. Yes, vitals can be important, but his objection was to a 5AM “daily weight”. Shrinkette has given a well-written, objective rationale, along with personal experience doing the weighing. Also, Alwyn is on the job from Code:theWebSocket with the nurses’ outlook.

I’m going to point out the other side: orders like this (occasionally) are done ‘just because’. Heart failure is the most common reason to obtain daily weights, as the tale of the scale is very sensitive to fliud retention, and it’s simple and predective enough it’s taught to patients as an at-home screen to adjust diuretics.

However, sometimes patients get admitted to the Cardiac Unit and get Standard Orders, and it’s easy to check a box for daily weights whether that data point is really useful or not. (Data is what you make of it, and I’m not saying this is the case here, I’m just explaining a contrary view). Docs don’t actually DO these weigh-ins, so we don’t know exactly when it’s done, but when rounding on patients docs are going to want the numbers so they can act on them. Rounds will be early, as there’s an office full of patients to be seen today. (Please note, this is from my past experiences as a med student / intern / resident. I’m now happily only in the ED, and none of this impacts me, except for checking the boxes on the ‘standard orders’).

So, it might be necessary, and it might not. Wouldn’t hurt to ask the doc on rounds if that’s really something she needs.

InstaPundits’ latest: he helped his wife scrub her chest with betadine to get ready for her pacemaker insertion. Wow, what a vivid image of a couple sharing their mortality, hope, faith and trust.

Here’s for all the best for his wife and his family.

I talked to a Colleague from Another Universe

at AAEM the other day. He was a year ahead of me at my residency, and he’s a terrific, personable guy. He also works in Another Universe From Me (koff – Kaiser – koff).

While in the Exhibitors’ Area I ran into my friend, and we discussed our opinions on some things we’d seen: wound cleansing apparati and ultrasound gadgets.

The first sign we were from Alternate Orbits: my question about wound cleaning thingos, the latest-greatest saline-squirters.
Me: this’ll help my techs get wounds cleaner, faster. Wounds are terrifically challenging, and they bill well.
Him: no billing, no collections. Wounds closed by PA’s.

Me: (attempting to recover the awkwardness) We do a decent number of sonos in my ED, mostly FAST scans, the occasional EVUS.
Him: “We’re basically residents. If we had a sono they’d just say ‘do a sono and call us back’, so it’d just increase my work”.

It’s weird to meet people from other worlds. I wish him well, and pray our worlds never collide.

Cox-2’s: They’re BAACK!

CNN.com – FDA panel: Keep Vioxx, Celebrex, Bextra on market – Feb 18, 2005

WASHINGTON (AP) — The popular painkillers Celebrex, Bextra and Vioxx all pose a risk of heart trouble, but should be available to those who need them, advisers to the Food and Drug Administration said Friday.

The panel strongly favored keeping Celebrex on the market, split over Bextra and favored Vioxx — which is currently not on sale — by a vote of just 17-16.

“The data is very compelling,” Vioxx is substantially worse than the others, meeting chairman Alistair J.J. Wood of Vanderbilt University School of Medicine said.

The panelists voted 31-1 to keep Celebrex on sale and, after a revote, favored Bextra 17-13 with two abstaining.

I’ve read that some patients with severe arthritis were devistated when Vioxx was pulled, willing to trade an increased risk of heart disease for daily mobility.

Now, who’s going to prescribe these? Not ER docs. My guess it’ll be rheumatologists, and some internists with a long history with a patient, and even then, with billboards up with ‘Lawyer’ and ‘Vioxx’ in close proximity, restraint will be the order of the day.

An Unexpected Influence: Reader Letter

This was emailed to me recently, and I have the writers’ permission to publish it, with names changed to protect, well, whatever.

To put this into perspective, the writer and I have never met.

What Would GruntDoc Tell Me To Do?

Or, Mrs. X?s little boy Billy learns not to be afraid of looking stupid.

Short story, (the other day) I felt like crap, borderline nausea all day, upchucking a little but not a lot which I blamed on coffee (caffeinated, ran out of de-caf so I borrowed some of the ?leaded? stuff from my wife, I?d forgotten how jittery caffeine can make you.)

Finally, around 20:00, I decided to go to bed and sleep it off. Laid down, felt pressure in my chest, not much, but noticeable, shortness of breath, sweating profusely in seconds. Sat up, pressure eased, not much, but was lighted headed. Laid down again, got the same result, more pressure, more breathing problems, and sweating, lots of sweating.

At that moment two thoughts and two questions went through my head.

Thoughts
I?m 50ish, 20 lbs overweight, the only exercise I get now is walking the dog and all available data indicates I?m a candidate (maybe prime candidate) for a heart attack.
I KNEW I was experiencing at least 2 or 3 classic symptoms of a heart attack.

Questions
Should I do something about it? I didn?t want to look stupid, embarrass myself yadda, yadda, and yadda. It?s not that bad, I can?t be having a heart attack blah, blah, blah, and it?s only 2 or 3 symptoms, deny, deny, deny, and,

What would GruntDoc tell me to do?

[Read more...]

Grand Rounds Submissions

In the mail:

I’m hosting grand rounds next week, but I’m afraid people might have a little difficulty finding me. I’m now on a group blog and, even if submitters knew to come to me, my email is not listed on the page. Anyway I was wondering if some of you wouldn’t mind, sometime this week, posting a reminder with my email address
(trentmcbride_gk8155@yahoo.com). It would be much appreciated.

Consider it done!

AAEM Day 3

Nice to see old friends, one of the reasons to attend meetings.

Learned: Just get the CT, get the MRI if you think you need it (individual case problems guide, obviously).

Don’t write “Obese” on the chart, record height and weight, let the reviewer do the math. As the speaker said, “Your jury will be made up of non-tall, non-thin people, and they’re gonna hate you!”. Noted.

San Diego traffic is painfully dense, doubly so when it rains. We wanted to go visit my brother tonight, and in One Hour we’d moved less than two miles toward the Interstate. Cancelled, local dinner, back to the hotel.

Not much from today. Not that there’s nothing to get, just me.

Why did the TSA keep one of my shoes?

I flew to Orange County airport a couple of days ago. As with all air travel now, I was subject to the usual scrutiny applied to air travellers: ignominious searches of everything, needless or not.

This includes my checked baggage, as confirmed by cute shiny “Inspected by the TSA” stickers on the American Airlines generated routing tags.

When I got to the hotel, I unpacked and found myself light one shoe, and the belt held within it. I know I packed it, and that it made the trip to the airport. So, it was lost while in the forced trust of the TSA.

It’s not all that much, as shoes go: a black, inexpensive loafer (with a cheap, brown woven belt within: I’m packing like the Queer Eye guys suggest!). So, it’s not a huge loss, except that I’m going to professional meetings in brown shoes wearing a black belt. Trust me, this is a crowd that won’t notice.

Anyway, it’s annoying. Keep a lookout for a DFW TSA person wearing one black loafer, wearing a brown belt. If you find such a person, let me know.

I emailed the TSA using their ‘customer service’ form, inquiring as to the whereabouts of my belongings entrusted to them. I’m holding my breath for a reply.

AAEM Day 2

Day two, things I’ve learned / observed:

Todays’ lectures were good overall, but were uncoordinated, to the point we got the same info several times. (That’s not all bad, we’re ER Docs and repetition is our Friend).

Most people’s Powerpoint presentations are fair, on bad backgrounds. I no longer want to look at speckled-blue backgrounds with yellow type. And, if your graphics look funny on your monitor, they’ll be indecipherable when shined on a big screen.

Don’t read your slides to us: use the bullet points to emphasize what you want to say (something I’m guilty of).

Don’t apologize either for your talk or your slides. We’re paying to hear you and what you know/teach. Do it!

Octreotide
can be used as a therapeutic agent in some types of bowel obstructions (it’s an ‘off label’ use). News to me, and I need to learn more.

10% of caucasians lack the enzyme to convert codeine into morphine, the active metabolite. (Aside: It doesn’t matter: 97% of my patients report codeine doesn’t work for them, making me wonder about the enzyme and its prevalence). (The rest are allergic to it).

Nurse speakers have WAY too many certification acrynoms following their names. This is one of those things that’s probably profession-specific, and the more certs a nurse has the better in the nursing world. However, it’s jarring to see a dozen-plus random consonants after a presenters’ name.

Tomorrow, the Main conference begins. More later!

Spousal Wisdom

Speaking with the wife, while deciding who should sit in the middle seat:

(me): “You’re going to wind up sitting next to some old guy, who wants to tell you his life story”.

(wife): “Yes, and it’ll be you”.

Ouch! Game, set and match!

Rudeness

“Rude people suck” was the statement, and though that’s not a particulalry gentle way to put it I agree wholeheartedly with the sentiment. That the statement is itself rude is one of the ironies of life.

By rude, I mean the following definition (via Answers.com):

1. Lacking the graces and refinement of civilized life; uncouth.
3. Ill-mannered; discourteous: rude behavior.

Like most people, I encounter the majority of rude behavior at work (after all, once we’re through with school we can associate with, or more precisely dissociate ourselves from, rude and obnoxious people. As I work in a ED, I expect people to be under stress, perhaps not tempering their speech in ways they might under better circumstances.

The difference between rude people and those who are rude ‘due to the moment’ is that rude people show no remorse for their behavior, while regular, decent folks will recognize a line was crossed and apologise, in one way or another.

Then we get to the heart of the matter, at least for me, which is what to do with / about the deliberately rude patient. The rude family I can deal with, usually just by exclusion (waiting room = penalty box). The rude patient is a challenge both personally and professionally, to everyone on the staff.

(An aside: if you’re rude as a family member of the patient you’re doing your loved one a disservice. We’re all pros and will do our jobs, but avoiding you, and therefore the patient is only natural. It won’t result in bad care, but it can become a vicious cycle of avoidance, ‘nobody is coming in to check on him’, etc).

I believe somewhat in Karma, more in the “what comes around goes around” sort of way, and realize life will exact a revenge on boors far exceeding my ability, but it’s hard to remember that when someone who needs your help calls you a string of four letter words.

I and some nurses were discussing this recently, and the theme of the discussion was that the rude behavior of our patients would get them denied service in pretty much any other place (merchandise return desks excluded, more’s the pity). The rest of the discussion involved why people feel free to be abusive to us, and we decided it’s because they can. They know we cannot throw them out or deny service because of rude, obnoxious behavior, we have to do our best even when they’re at their worst.

Perhaps you have another reason, or better yet a meaningful way to deal with rudeness?

AAEM 11th Scientific Assembly, Day One

I’m at the AAEM Scientific Assembly, roughing it in La Jolla, CA! I’d link to the program, but it’s horrible .pdf files, and they’re not for the web.

We arrived late, after getting a lot of time to study the I-5 concrete parking lot. I like to fly into John Wayne Airport (SNA) to get to SoCal, as it’s a world better and cheaper than San Diego, and a lot more friendly then LAX. However, it usually means more driving. We, you ask? Yes, for the first time ever I’ve brought my wife to a meeting, and she’s enjoying the vacation, reading and relaxing.

This is my first AAEM meeting, and so far so good. I’m attending a ‘pre-conference conference’ on death and dying issues, required to keep California Licensure (unless you’re a pathologist or a radiologist, opening a whole can of slams). As for first impressions of AAEM, the lectures don’t seem quite as remedial as those of the two ACEP meetings I’ve been to, but time will tell (we’re not to the ‘real’ conference yet).

More to follow.

Harborview EM Program

…has no Emergency Medicine Board Certified instructors? symtym Read it all, but his summation fits the state of emergency medicine:

Max Planck: a new paradigm takes over not when it convinces its opponents, but when its opponents eventually die.

MedBlogs Grand Rounds XXI

Sumer’s Radiology Site

This weeks’ Grand Rounds marks the 21st in the weekly roundup of the best posts of the medical blogosphere. This is the first time that the grandrounds have come to India.

More international goodness, with cartoons. One of which may well stir discussion.

Electronic Medical Records

Today Medpundit gives the latest update in her FP offices’ quest to ‘go paperless’. It’s sobering reading.

Dr. Smythe (pseudonym) there has an upbeat attitude, but is very clear that the changeover is stressing the staff out. It’s good to read.

And it brings up my current gripe with EMR, especially as it relates to EM. To my (limited) knowledge most of the EMR’s out there are just glorified word processors. There’s nothing wrong with word processors, except that they slow practices down, not speed them up.

Additionally, the programming isn’t terribly advanced. Things in the HPI need to trigger automatic exams, etc. Abnormal lab results need to be adressed, and at least suggested in the diagnosis box.

I’m very interested in MedPundit’s trials and tribulations on this issue, and look forward to her next post.