The Happy Hospitalist

Garage Door Syndrome: Why Does The Need To Pee Get Worse When I See A Bathroom?

2009-11-22T16:19:00.003-06:00

I know I'm not the only one out there. Garage Door Syndrome describes the sudden urge to urinate triggered by environmental conditions. If I have to pee and I see a bathroom why does my need to pee suddenly get worse? It's almost alien like. I've noticed my need to pee gets worse when I see running water too. Or if I take a container of liquid out of the refrigerator. What's your experience? Do you have your own triggers for urinary urgency?

Clever Comebacks From Nurses

2009-11-22T12:54:00.000-06:00

Being in the healthcare field allows many doctors and nurses to interact with all walks of life. We all deal with the emotional tolls of illness in different ways. Some nurses use clever comebacks to get through the day. Take for example this conversation with a 94 year old female in the midst of decompensated heart failure.

Sunday Novemeber 7th, 2009

Patient: It looks like I'm missing church today

Nurse: Don't worry, you might be able to make it later this week.

Now that's a clever comeback.

Prison HealthCare: I Feel Really Greasy

2009-11-22T07:00:00.004-06:00

Did you know that all prisoners have a right to free prison healthcare when under the control of local , state or federal authorities? They may lose their right to freedom, but they gain an unlimited right to free prison healthcare.

Often times, the healthcare prisoners receive vastly exceeds what which many hard working private business owners can afford for themselves or their employees. Even with employer assissance, out of control healthcare inflation threatens the affordability of even basic catastrophic plans by ordinary Americans.

This does not apply to prisoners, who have unlimited access to prison healthcare. With that in mind, let me tell you about a patient I once had. He was a 37 year old unemployeed construction worker with an antisocial personality. He presented to the hospital with a surgical ankle fracture obtained in a bar fight Unfortunately for him, when the cops arrived he was found to have a warrant out for his arrest.

But fortunately for him, his surgical ankle fracture now became an economic liability for Happy's prison healthcare system. By being in police custody, my patient would get his entire hospital stay paid for by my hard earned tax dollars. Perhaps his run in with the law was a blessing in disguise.

But what did he decide to do instead? My bar fight peep posted bond that day. He left against medical advice to "get the Hell away from the cops" who were required to cuff him to the bed and remain in the room at all times. Little did this pleasant man know that had chosen to wait just one day to post bond, Happy's tax dollars would have paid the entire surgical bill of his bar fight escapade.

I felt just a little greasy that day. Did I have a moral obligation to tell him he could have had his necessary surgery for free had he waited just 24 hours to post bond? Considering his decisions had nothing to do with concerns about cost, I felt no obligation. None of the nurses felt inclined to tell him either. Why should they? He's a grown man able to make grown up decisions. If he wants to leave AMA because he doesn't like cops, that's certainly a grown up decision he has chosen to make.

While the state treasury was protected from pillage by an irresponsible man with a capacity to make his own bad medical decisions, I felt a twing of greasiness that day knowing that had he known about the prison health care rules, he may have changed his tune, and perhaps decided to stay, once again invoking FREE=MORE.

What do you think? Would you have told a man that his surgical ankle fracture could be fixed for free if he just waited a day to bond out? Or would you let him make his own adult decisions independent of his insurance status and let him live with the consequences of his adult actions.

Fix Physician Compliance And Documentation Guidelines Immediately

2009-11-21T07:00:00.025-06:00

Let me guess. Your doctors won't follow the rules and you are a hospital in trouble with CMS compliance. Or perhaps you're a doctor at risk for losing your hospital privileges because your physician documentation is placing your hospital at risk for losing their accreditation status. Whatever the case may be, physician compliance with ridiculous documentation rules and regulations will always be a difficult road to pave.

At Happy's hospital, the current CMS compliance guideline hysteria revolves around two issues. I put the first to rest with an explanation about physician food and drink at the nurses station. The second issue, the signing, dating and timing of verbal orders within 24 hours, is a mystery to me.

Not only has the order already been dated and time and signed by the nurse, and verified by read back, but CMS compliance guidelines require physician documentation to counter sign, redate and retime the order within 24 hours. I can assure you that in my last seven years of clinical hospitalist medicine, I have never seen a single case of patient harm due to the lack of a counter signature, redate and resign in 24 hours. If you tell me the lack of a counter signature within 24 hours impairs the quality outcomes of my patients, I will immediately fight for universal acceptance. Unfortunately, 99.9999999% of all orders given will have been completed by 24 hours. The clinical relevance of this 24 hour compliance guideline is a mystery to me.

What this policy does is take away precious time from understaffed nurses who are now required to hunt down doctors who may be in surgery or who may be in clinic or who may be sleeping to sign off an order that has already been implemented. Nurses, in addition to all their other stretched duties, must now play baby sitter to physician documentation and physician compliance requirements to meet the ridiculously obtuse CMS compliance guidelines.

With such an effort being made to meet the standards of physician compliance and documentation at Happy's hospital, I learned the other day, what the fruits of these labors have brought. A labor intensive one month audit has discovered just how much physician documentation has improved and just how far Happy's physicians have to go before CMS compliance guidelines have been met.

I'm all about quality care. So it came with great excitement when our internal audit discovered a 10% improvement in the 24 hour counter signature requirement. With such a rigorous effort being placed on physician documentation and compliance I had to wonder how many lives Happy's hospital physicians have saved by improving their 24 hour counter signature rate by 10%. With tens of thousands, perhaps hundreds of thousands, maybe even millions of orders in that one month period, I would expect a dramatic improvement in mortality and complication data for that month. Was there a statistical reduction in mortality or complications?

I wouldn't know because no one has run the data. And no one has run the data because no one cares. It's not about saving lives. It's about keeping your accrediation with CMS compliance guidelines. And that means getting physician compliance and physician documentation in line with the hospital's priorities, no matter how ridiculous they are.

You can fight the policy tooth and nail, but an unaccredited hospital is a bankrupt hospital. So how do you get your physician documentation and compliance to align with CMS compliance guidelines mandated from the Medicare National Bank?

Most nurses have pockets full of safety scissors and alcohol wipes. Starting next week at Happy's hospital, nurses will also be required to purchase their own tool belt to carry one of these hospital issued Dewalt 18V cordless power drills. I learned of this plan after investigating the discovery of a cordless power drill sitting at the nurses station.

Ultimately, the decision came down to how powerful the drill had to be. After hours of relentless debate between the 12V or the more powerful 18V drill, the committee members finally concluded that because of the high density of hard headed physicians at Happy's hospital, only the 18V drill would be powerful enough to drill some sense into the docs.

There you have it folks. Your solution to the lack of physician documentation with CMS compliance guidelines is not to implement baby sitting nurses trying to hunt the doctors down. You just need to provide them with the appropriate weapons to drill some sense into their docs.

Nurse Violence Against Doctors

2009-11-20T12:20:00.005-06:00

You've heard of patient violence against nurses. You've heard of patient violence against doctors. You've even seen doctor violence against patients. But did you know that nurse violence against doctors is running rampant in this country? Nurses are the perfect group of professionals likely to go Rambo. They're overworked. They're underpaid. They're placed in the middle of unfixable situations with unstable patients and demanding doctor personalities every day.

I'm concerned about an encounter I had with a nurse the other day. So much so that I'm considering contacting the authorities for protection. Could this be the beginning of a sweeping epidemic of nurse violence against doctors?

Nurse: Happy, Mr Smith is driving me nuts. If you stop his Ativan, so help me God I'm going to kill you.

Or am I over reacting?

Milk The Prostate Not Milk IN The Prostate. Incredible Error Of Judgment

2009-11-20T08:52:00.003-06:00

Sometimes sexual experimentation can land you in the hospital, especially if you don't know what you're doing. Take for example the young couple in love who heard that if you milk the prostate, also known as prostate massage, you can make your man's junk larger than normal. To learn more about this couple, continue reading.

What is the prostate used for? The prostate provides a vital role in male reproduction by giving nourishment and protection to sperm as they pass out the ejaculate.

Milking the prostate is usually a medical process. The prostate can be accessed by inserting a finger in the male or shemale rectum with the patient bent over. Access to the prostate is achieved with approximately two inches of entry (make sure you lube up doctor) and sweeping the finger toward the stomach. How big is the normal prostate? It's often described as the size of a walnut. But they can become quite large, leading to obstructive problems urinating. Benign prostatic hypertrophy, or BPH as it's known, is a condition most men get with age.

I used to do quite a few prostate exams back in my outpatient clinical years. It takes a lot of practice to know exactly what you're feeling or think you're feeling. I haven't done one in the seven years of hospitalist work, nor do I ever intend to do one again. That's why God made urologists and other outpatient doctors. If my inpatient needs a prostate exam, they're getting a urologist evaluation.

I remember my first year of medical school quite clearly. My anatomy professor taught all of us how to milk our own prostate. I went into that day a boy. I came out a man. And I never looked at my medical school professors the same ever again. These are the real life lessons we learned in medical school.

Now that we've established how to access the prostate, I suppose you're wondering why anyone would want to milk the prostate. The medical prostate exam is called the digital rectal exam. There are many medical reasons reasons for milking the prostate. The most common reason for prostate massage is to evaluate the presence or absence of prostate nodules, a clinical marker for prostate cancer, which is the most common cancer in America (excluding skin cancer).

Some doctors still milk the prostate as therapy for prostatitis, or an infected prostate, although the therapeutic benefits are controversial.

One other interesting medical application for prostate massage involves our friends in the animal kingdom. In animal husbandry, electroejaculation involves the placement of an electrical probe near the nerves of the prostate to stimulate the production of semin for reporductive purposes. It can also be used in humans with paralysis associated sexual dysfunction.

But what about our young curious couple in love? How did their milking of the prostate turn out? Let's just say he ended up in the hospital. As physicians we hold an enormous asymmetric foundation of knowledge. One benefit of longitudinal patient relationships with outpatient physicians is the opportunity to understand which of them have the educational foundation, the mental capacity and the motivation to understand their disease process.

As physicians, I am constantly educating my patients on the need to quit smoking. I assume nothing as to their understanding of the ravishes of tobacco. As for our young couple in love, their lack of education is a shocking testament to the realities of the misinformed patient.

Go read all about this most extreme case of milking the prostate ever.

Information On Asthma Every Patient Should Know

2009-11-19T19:23:00.001-06:00

I'm about to give you some critical information on asthma every patient should know. Number one: Don't Smoke. Number two: If your asthmatic child has low oxygen levels, don't go home, go to the hospital. Number three: Never underestimate the value of asthma teaching. I present to you the following video, critical information on asthma every patient should know.
*
*
*
*

That is some good asthma humor.

Growing A Bonsai Tree : From Do Not Resuscitate To Full Code

2009-11-19T14:44:00.000-06:00

Bonsai is the art of aesthetic miniaturization of trees. With that in mind, I have just one thing to say: Mrs Happy and I are the poster children for growing a bonsai tree without success. How did I get involved with bonsai trees? We had the opportunity to play host to mama and pappa Happy earlier this summer. After a two week stay, mama Happy mailed us a beautiful bonsai tree as a gift.

I had no idea there was such a big market for buying bonsai trees. There are thousands of sites proclaiming to have the best bonsai trees known to man.

Mrs Happy has done a great job of greening up our home. Her plants always seem to thrive. In the seven years we've been together, I've never seen one die. I certainly couldn't do it. How do women always remember to water the plants?

I was excited about growing and caring for a bonsai tree. I remember seeing them on the Karate Kid. I imagined myself trimming it with a tiny scissors, perhaps plucking a few leaves here and there in a meticulous display of perfection.

Our bonsai tree gift came in a box by US mail. I had no idea buying bonsai trees online was even possible. Mama Happy wanted us to send her back a picture of what she bought online (picture left). It turns out she was a little disappointed in how it looked. I thought it looked fine. Mrs Happy and I have no experience with growing a bonsai tree. But,.if you look on the internet you can find many web pages proclaiming excellence in how to grow bonsai trees.

The directions said to keep it moist. How much do you water a bonsai tree? Enough to keep it from dying. That's how much. This bonsai tree came in a pot with a hole in the bottom that allowed the water to seep out. It didn't have a pot pan so we stuck it in the sink after watering.

The next day we went on a weekend vacation. Rule #1: If you're growing a bonsai tree, do not leave it unattended for a weekend. After we returned, we noticed all the leaves had dried up. Without a pot pan all the soil dried up and our beautiful bonsai tree shriveled up with it.

For weeks that darn tree lay on our kitchen counter shedding leaf after leaf. I held out hope that the tree would survive. I considered whether buying bonsai trees online was such a good idea. Perhaps the tree was half dead when we got it. I contemplated buying another bonsai tree to replace our dead one.

Instead we waited. We kept watering our tree with all our hearts, hoping for some signal of life. And then it happened. One day we say a green shoot. First one stalk. Then another. Then a few leaves showed up. Soon our happy little bonsai tree had multiple signs of life. We were ecstatic. After thinking for weeks that our little buddy was gone, our heart break turned to joy. We reversed our bonsai's do not resuscitate status and made him a full code.

We trimmed the dead branches to give life to the sprouting leaves. We watered diligently. We never took our eyes off it. Mama happy and company will be coming to Happy's castle in just a few short weeks. I know she was disappointed with the way her gift had looked out of the box. I hope she understands that our little buddy is making a fighting effort to get back to its glory days. He just needs some more tender loving care and a water bowl for our pot.

Prilosec and Plavix Interraction Gets Second FDA Warning

2009-11-19T08:24:00.003-06:00

Back in January 2009 I blogged about the possible deadily Plavix Prilosec interaction. Prilosec is an over the counter proton pump inhibitor (PPI). It inhibits the production of stomach acid, which helps reduce heart burn symptoms. It is also used to treat stomach ulcers or peptic ulcer disease. Plavix is an expensive super aspirin, or antiplatelet medicine who's mechanism of action reduces platelet aggregation by irreversibly blocking ADP receptors on the platelet surface and preventing activation of the GPIIb/IIIa receptor complex.

Earlier this year retrospective analysis suggested that people talking Prilosec and Plavix had a statistically significant increase in major cardiovascular events.

This week the FDA confirmed those warnings.

Omeprazole inhibits the drug metabolizing enzyme (CYP2C19) which is responsible for the conversion of clopidogrel into its active form (active metabolite). The new studies compared the amount of clopidogrel's active metabolite in the blood and its effect on platelets (anti-clotting effect) in people who took clopidogrel plus omeprazole versus those who took clopidogrel alone. A reduction in active metabolite levels of about 45% was found in people who received clopidogrel with omeprazole compared to those taking clopidogrel alone. The effect of clopidogrel on platelets was reduced by as much as 47% in people receiving clopidogrel and omeprazole together. These reductions were seen whether the drugs were given at the same time or 12 hours apart.

In the same report the FDA indicates concerns regarding other Drug-Plavix interactions because of their inhibitor effects on CYP2C19.

These include: cimetidine, fluconazole, ketoconazole, voriconazole, etravirine, felbamate, fluoxetine, fluvoxamine, and ticlopidine. Since the level of inhibition among other PPIs varies, it is unknown to what amount other PPIs may interfere with clopidogrel. However, esomeprazole, a PPI that is a component of omeprazole, inhibits CYP2C19 and should also be avoided in combination with clopidogrel

What do we do now? Here are some key clinical points to consider:

Is taking Prilosec in the morning and Plavix at night OK? The answer is no. The two should be avoided if you don't want to increase your risk of a major cardiovascular event.

Should all proton pump inhibitors (PPIs) be avoided in patients taking Plavix? The FDA does not have data yet to support that statement. However, if other PPIs work through the same cytochrome system, I think the answer would be obviously yes. If I was a patient on Plavix I wouldn't take any PPI until I had more data showing safety.

Should other acid suppression medications such as H2 blockers or antacids be avoided in patients taking Plavix? Other than Cimetidine (Tagamet), the answer is no. These drugs are not known to affect the efficacy of Plavix.

As medicine becomes more complicated, relying on your friendly neighborhood pharmacist to flag potentially deadily drug interactions will be key. Implementing office and hospital based red-flag pharmacy systems also becomes important for the safety of patient care. There are simply too many interactions to be memorized and remembered on a daily basis.

The other alternative places you, the patient, in control of your own safety. As I often say on The Happy Hospitalist, the best solution to avoiding deadly drug interactions is not to put yourself at increased risk of developing life limiting and disabling disease that require medications in the first place. That means lifestyle modification will always be the key to your health care salvation.

Real Time Search Engine Optimization WIth The Help Of Wade Boggs

2009-11-18T20:08:00.005-06:00

If you want a peak into the intriguing world of real time search engine optimization, as seen through the eyes of Google Analytics, take a look at my recent post regarding Wade Boggs Carpet World. It sounds like a strange post but I did it with the intent of experimenting with real time search engine optimization known as SEO.

I was watching 30 Rock on television when I heard Tracy Morgan speak that phrase of words above five times. Out of curiousity, I Googled it quickly and realized there was no information on it except someone's Twitter message two minutes previously. So I wrote a quick post with the title "What is Wade Boggs Carpet World" asking the world what the answer was. Almost immediately, within a minute or two I had a sunami of visitors. Over 300 visitors in less than two hours. My post was #1 for that search phrase.

For a brief period of time that phrase was the 68 most common search term of the hour on Google. But I also know that my post feed is pulled by a program from the Wall Street Journal Health blog, which carries a higher page rank than I. That means when my post feed is pulled by the WSJ blog and posted on their page, their page outranks mine and Google devalues my original post. The next day, my post disappeared off the front page for that search phrase, and the WSJ was ranked #3 for that search string. By now, several other pages had played the SEO game. WIth my #1 ranking gone, I was still getting quite a few hits from misspelled versions of that same phrase.

Tonight, five days later, my post is back in the #1 slot for that phrase. What I find particularly interesting is that almost 70 different versions of the same phrase landed people one my blog. See the table below. Look at all the wrong spellings that brought people to Happy's little happy place in the internet. I have other popular posts, which even after more than a year, continue to generate traffic. That's search engine optimization for you.

It's no wonder how the Google search engine and a little search engine optimization can make or break a business who's lifeline depends on gaining a spot on page one of a Google search.

For any other bloggers out there, do you have any pages that generate specific interest month after month? And if you're using Google Analytics, how do you find it helpful?

For me, I find it fascinating.

1.	wade boggs carpet world	330	55.00%
2.	wade boggs carpet	68	11.33%
3.	wade bogg's carpet world	40	6.67%
4.	wade bogs carpet world	27	4.50%
5.	wade boggs carpetworld	16	2.67%
6.	wade bogg carpet world	8	1.33%
7.	wade boggs' carpet world	6	1.00%
8.	wade carpet world	6	1.00%
9.	boggs carpet world	5	0.83%
10.	wade boggs carpet store	4	0.67%
11.	wayde boggs carpet world	4	0.67%
12.	what is wade boggs carpet world	4	0.67%
13.	"wade boggs carpet world"	3	0.50%
14.	30 rock carpet world	3	0.50%
15.	30 rock wade boggs	3	0.50%
16.	wade bog carpet world	3	0.50%
17.	wade boggs 30 rock	3	0.50%
18.	wade boggs's carpet world	3	0.50%
19.	wade bogs carpetworld	3	0.50%
20.	"wade boggs carpet"	2	0.33%
21.	carpet world	2	0.33%
22.	wade bogg's carpetworld	2	0.33%
23.	wade bogg's world	2	0.33%
24.	wade boggs carper world	2	0.33%
25.	wade boggs carpet worlds	2	0.33%
26.	wade boggs carpets	2	0.33%
27.	wade bogs carpet	2	0.33%
28.	wade bogs carptet world	2	0.33%
29.	wade bogs crpet	2	0.33%
30.	wade carpet worls	2	0.33%
31.	"carpet world"	1	0.17%
32.	"wade boggs carpet world	1	0.17%
33.	30 rock "carpet world"	1	0.17%
34.	30 rock wade bog's carpetworld	1	0.17%
35.	30 rock wade boggs carpet world	1	0.17%
36.	30 rock, carpet world	1	0.17%
37.	boggs carpet	1	0.17%
38.	carpet wade boggs	1	0.17%
39.	carpet world tracy	1	0.17%
40.	how towade boggs carpet world	1	0.17%
41.	plug wade bogg's carpet world	1	0.17%
42.	tracy carpetworld	1	0.17%
43.	wade blogs carpet world	1	0.17%
44.	wade bog carpet	1	0.17%
45.	wade bog's carpet world	1	0.17%
46.	wade bogg caroet	1	0.17%
47.	wade bogg carpet	1	0.17%
48.	wade boggs capert world	1	0.17%
49.	wade boggs carpect world	1	0.17%
50.	wade boggs carpert	1	0.17%
51.	wade boggs carpert world	1	0.17%
52.	wade boggs carpet "30 rock"	1	0.17%
53.	wade boggs carpet workd	1	0.17%
54.	wade boggs carpet worl	1	0.17%
55.	wade boggs carpet world 30 rock	1	0.17%
56.	wade boggs carpet world hair	1	0.17%
57.	wade boggs carpet world tracy	1	0.17%
58.	wade boggs carpet world wade boggs carpet world wade boggs carpet world	1	0.17%
59.	wade boggs carpet world world	1	0.17%
60.	wade boggs carpet worls	1	0.17%
61.	wade boggs carpetting	1	0.17%
62.	wade boggs carpte world	1	0.17%
63.	wade boggs world	1	0.17%
64.	wade bogs	1	0.17%
65.	wade boogs carpet world	1	0.17%
66.	wade] carpet world	1	0.17%
67.	wadeboggs carpet world	1	0.17%
68.	wadeboggs carpetworld	1	0.17%
69.	wades boggs carpet world	1	0.17%

It's Not The Lion Lady. It's Not Plastic Or Cosmetic Surgery Addiction. It's Much Worse.

2009-11-18T15:59:00.004-06:00

We've all seen stories about patients with horrible plastic or cosmetic surgery addiction. No matter what cosmetic or plastic surgery they have done, it's never satisfying enough. The Lion Lady seen here is a sad case of plastic and cosmetic surgery addiction gone wild. She has progressively changed her appearance over a fear of abandonment from her husband. Many experts believe that body dysmorphic disorder is to blame for plastic or cosmetic surgery addiction. Does the Lion Lady have body dysmorphic disorder? I have no idea. I know that anyone who believes they must undergo multiple surgeries to find inner satisfaction with whatever they are seeking must have some form of psychiatric pathology present. Is it body dysmorphic disorder? I don't claim to be an expert, but I suspect it is. It's the same kind of skewed self image and clouded reality that afflicts young women with the eating disorders anorexia and bulimia.

I can understand that psychiatric illness would drive a man or woman to seek such drastic changes. The brain works in mysterious ways as witnessed by Jill Bolte Taylor's Stroke of Insight video, a fascinating look at how the mind changes one's perception of reality.

One other celebrity known for his addictive personality was Michael Jackson. In addition to being a prescription drug addict, many tabloids have speculated about the late Michael Jackson's cosmetic surgery addiction that morphed his body into a shell of its former self. This MJ video is a stunning representaion of Michael Jackson's Evolution from Thriller to the present day. Just imagine what Michael Jackson would have looked like without surgery.

But none of this matters. Because I'm not here to talk to you today about the Lion Lady. I'm not here to talk to you about cosmetic or plastic surgery addiction. I'm not here to talk to you about Michael Jackson's addictive personality. I'm here to show you the worst case of addiction to surgery I have ever seen. He's not famous like Michael. He isn't a socialite or a celebrity. He's just a simple man who arrived recently to Happy's hospital domain, fresh of the the East Coast Greyhound in seek of greener pasteurs. He has undefined mental illness with borderline and dependent personality traits. And he thrives on the attention he seeks and receives by playing the sick role with a passion for surgery. He truly is a surgical addict. But, I don't place blame squarely on this man's fake shoulders. I'm also convinced his surgeons are equally addicted to surgery as well.

Man was not engineered to undergo seventy-two surgeries and invasive procedures in a fifteen year period. That's right. I said it. Seventy-two episodes of anesthesia induction and operative intervention in fifteen short years. That's almost five surgeries a year. You want to talk about complications of surgery? I don't think it's humanly possible to undergo seventy-two surgeries without having an expected surgical wound infection, a deep venous thrombosis or an episode of antibiotic associated clostridium difficile colitis. At some point, a never event is going to kill him. The only question is, will it be at Happy's hospital who will we choose to blame?

Will you blame the patient with their mental illness and personality traits that drive doctors to the pathway of least surgical resistance? Or will we blame the surgeons, the ones who are supposed to earn the big bucks for doing what no other doctor can do: cut and think. What I see here is a lot of cutting and no thinking. The surgeon who took out his ruptured appendix got it right. The surgeon who took out his gallbladder may have gotten it right.

The orthopedic surgeons that scoped his joints forty-seven times over a fifteen year period would appear to my trained eye to be committing a massive Medicare fraud, cloaked under the protection of medical necessity and driven by fear or greed or both.

I am stunned by this patients course of medical history. Stunned not only by the patient's willing complacency to use surgery as his comfort food, perhaps clouded by their desire to be loved. But also by the willingness of my fellow surgical colleagues to bypass their ability to think.

In cases like this, it's easy to see how surgical addiction can cloud both sides of the knife.

Winnie The Pooh Swine Flu Hilarious New Picture

2009-11-17T16:52:00.011-06:00

You've all seen this famous Winnie The Pooh Swine Flu cartoon . I've blogged about the the H1N1 swine flu pretty extensively. I described our frustrating H1N1 IVF swine flu experience. I talked about my swine flu vaccine side effects that really scared me. I showed you some really cool swine flu maps from around the world. I even linked to the shocking swine flu pregnancy experience in Australia. Happy's local experts told me how sensitive the H1N1 swine test was. At one point I even argued about Happy's swine flu hospital policy and the rationing that could occur with a widespread pandemic with limited resources. I talked about data showing H1N1 swine flu patients on statins had a lower mortality, suggesting that a possible side effect of statins was flu protection.

With all the serious talk about H1N1 swine flu, it's nice to peek at the lighter side of swine with these hilarious Winnie The Pooh Swine Flu depictions. I especially liked the photo to the right sent to me by a Happy reader. What we have here is a good 'ole fashioned Winnie The Pooh Swine Flu mutany. Now that is some good humor.

10% off all nursing uniforms with coupon code "hospitalist1"

Is Patient Noncompliance A Marker For Emotional Spousal Abuse?

2009-11-17T12:42:00.001-06:00

Like Mrs Happy says to me: If you act like a child, you should be treated like a child. I recently discussed my efforts to help an uncontrolled diabetic accept responsibility for her actions. The husband defended the immature actions of his wife, and blamed me for treating her like a child. In retrospect, I believe I was woefully misguided.

It never occurred to me that patient noncompliance might be a marker for physical and emotional spousal abuse. But make no mistake about it. Patient noncompliance is not a marker of the abused. It is the sign of the abuser. The response by this reader made me open my mind to that very possibility

poppydot Yesterday 05:47 AM

My husband has had uncontrolled diabetes now for over 10 years. Yes I do believe that I should divorce him. I've done everything imaginable to help him. When I first found out he had diabetes, I went to the cupboards and threw out everything that he couldn't have. I said to the children, if dad can't have it then no one can. They agreed. But he didn't. He yelled and ranted and raved, threw things etc till it became unbeareable, once his prescription ran out for blood pressure tablets etc, he just didn't bother going back for his check up and to get more meds. I still carefully watch what he eats at home, but I have no control over what he eats while away. From what he tells me (boastingly) he eats rubbish and as much as he likes. It's sad. He no longer has any good teeth, but won't go to the dentist. He has trouble with his vision, but won't get his eyes checked out. He constantly has this sweet sickening smell about him, ketones. If he injures his legs, there's no longer any feeling in them so the bleeding goes unnoticed. He has "little" pains in his arms, chest and legs. Perhaps these are the last warning signs he will have before I find him DIB. I was so worried that I would report to his Doctor every 2 weeks, just so the Doc got an update of my husbands diabetes. In the end after 6 years I gave up. My husband also refuses to have a much needed hip operation, this should have taken place 5 years ago, there is no longer any ball left on his femur neck joint so much so that his right leg is 4 inches shorter than the left. Now after his 10 years of uncontrolled diabetes I have had enough. I told him last January that if he didn't start looking after himself and controlled his diabetes that I would stop sleeping in the same bed. That didn't work and I still sleep on the lounge 10 months later, maybe just as well as he's started to "leak" in bed now. I'm tired... tired of trying to help... tired of worrying.... tired of being here and tired of being married to him... tired of trying to make our home happy again. I've begun to dislike spending time with him and I've started to resent him for not trying to take care of himself or think of the consequences of his actions. How can you help someone who just won't help themselves....who won't help his children and yet gives away $50,000 from our homeloan to someone he doesn't know? Maybe I'm just crazy for thinking that I can help him in some small way....

It never occured to me that a patient would willfully entertain being noncompliant with medical therapies as a way to exert control over their spouse. It's almost as if patient noncompliance is a variant of emotional spousal abuse.This type of relationship dynamic is malignant to the core.

Patients who are willing to sacrifice their own health and prosperity with malignant noncompliance should be considered abusers. They are abusers because of the intentional emotional spousal abuse they inflict on their loved ones.

Malignant noncompliance patients are not patients who don't care about themselves. In fact, if you think about it, this form of patient noncompliance is a highly selfish act. Every day I see pregnant women smoking their little child's life away. I see stroked out hemiplegic mothers and fathers who lay in their own poop and drool with the stench of cigarette smoke permeating through everything they touch. I see Type I diabetics on the brink of death, leaving their children without a parent.

These are not patients to be pittied. They are abusers for the emotional pain they willfully inflict on their loved ones.. The abused need to be separated from this environment of emotional spousal abuse. I feel sorry for this woman's story. I feel nothing for the abuser; this diabetic who is inflicting pain and suffering on his loved ones with his willful patient noncompliance.

Perhaps it's time to recognize patient noncompliance as an act of abuse and start screening the spouses of noncompliant patients in an effort to discover whether emotional abuse is being inflicted. Only then can the real patients seek the help they need.

Greatest Tooth Fairy Letter Ever

2009-11-17T00:16:00.003-06:00

We've all heard about the Tooth Fairy. But what I saw tonight was the greatest Tooth Fairy letter ever. And it just happens to come from Mr and Mrs Happy's niece. Sydney, our niece, had been hiding it under her pillow for the last two days, waiting patiently for the Tooth Fairy to pick it up. Read below how precious this Tooth Fairy letter really is. I think it says volumes not only about the innocence of childhood but also about what an incredible responsibility a mother has to teach her daughter how to grow up to be an honest adult. Her mother is doing a fantastic job if you can't tell. In case you have a problem reading the picture this best Tooth Fairy letter ever says:

Dear Tooth Fairy

I found my tooth siting in a jar but I had already given it to you..... .....so if you would still like it back here you go and I will take no money. Mom sais it is rude. PS and oh one question. Are you a girl or a boy (circle one). Love Sydney (Tooth placed in capsule attached to letter)

I can't ever remember writing a letter to the Tooth Fairy. But I can remember pulling my teeth. We used to tie them to a door knob with dental floss and slam the door shut. That's how you take a tooth out. I specifically remember feeling the gapping hole in my gums and watching them bleed. And then thinking how cool the roots of the tooth looked. Perhaps this was my first experience with the wonders of science.

I think the going rate for the Tooth Fairy back in the late 1970's was a quarter or two per tooth. How much Tooth Fairy money is at stake now? Sydney got $5 for her tooth.

I'm telling you, if you think health care is expensive, what about Tooth Fairy inflation? A $0.50 tooth in 1980 should be worth $1.29 in 2008 dollars. So $5 represents significant Tooth Fairy inflationary pressures. It's no wonder working families are having problems making ends meet. The Tooth Fairy is taking all their dough. Perhaps a government takeover was in order.

Obama had grandiose plans to role out his Tooth Fairy economics and bring America back to productivity and growth. His plan? To limit the income stream of the top twenty-five Tooth Fairy executives in this country. What Obama didn't plan on was their mass exodus. Those who once led the vital Tooth Fairy industry abandoned ship and with that sinking ship went the loss of millions of dollars for poor children everywhere. Where did all these Tooth Fairy executives go? Why, they went to work for Santa, of course.

Once the executives realized they could make triple the amount working for Santa, the Tooth Fairy business collapsed and millions of poor children forever lost their only source of income. What once earned them $5 a tooth was now only a $1 and all the Tooth Fairy Stimulus in the world couldn't bring it back. Thus is the nature of government intervention in private Tooth Fairy industry. The more the government gets involved, the worse they will make it.

Once the Tooth Fairy is gone and your baby teeth have retired, it's important to protect your adult teeth from the traumas of daily life. I've chipped numerous adult teeth playing sports, mostly basketball in my younger years. I even lost part of a tooth diving off a diving board. I've tried to repair them with dental bonding on several occasions but the bonding never lasted. So I just gave up as it wasn't worth the hassle.

What can you take away from all this Tooth Fairy talk? Protect your children's childhood. Be a great parent to your child. Teach them well. Always wear sports mouth guard equipment. And believing in Tooth Fairy economics will leave you broke and dependent on others to save the day. Perhaps this Tooth Fairy letter here was written by every tax and spend Congress and President who feels your money is rightfully theirs. If you believe that your government can fix your problems, then you must believe in the Tooth Fairy too.

Is Having Sex In The Hospital A Legal Defense To Initiating Hospital Discharge Planning?

2009-11-16T11:57:00.000-06:00

When I initiate final hospital discharge planning, I am making a clinical judgment that the patient is safe to leave the monitored confines of the hospital system. Hospital discharge planning begins on the day of admission.

Good hospitalists are always thinking in their minds how to get the patient safely discharged in the quickest, safest and most efficient way possible.

Sometimes the patient wishes to leave against the medical advice of the physician. Sometimes they refuse to leave at the advice of the physician. And sometimes the physician and patient agree it's time for the next level of care.

But how do you as a physician know to pull the trigger and initiate the final hospital discharge planning process in a manner consistent with quality care? How do you know when it's safe to write the order for discharge? A certain number of my patients will always bounce back into the hospital. The frequent flyer club is alive and real. Whether it's the natural progression of endstage disease or issues with medical compliance or access issues which result in readmission, it doesn't really matter. The best way to prevent preventable readmissions is to have system processes in place that maximize success with the hospital discharge planning process.

So I have to ask the question: Is there a defining patient characteristic which guarantees safe discharge from the hospital and guarantees complete immunity from prosecution should a bad outcome occur?

That answer is yes. Here's a text I got from Happy's nurse coordinator on the scene of the crime:

Happy, the nurses told me your abdominal pain patient in room 503 was having sex last night. They walked in on her. Do you think it's safe to discharge her this morning?

The answer to that question would be a resounding yes. If you're well enough to have sex in the hospital, you're well enough to have hospital discharge planning initiated immediately. Looking down the road, I think the patient's actions opened up the hospital to liability. I wonder if this patient will sue the hospital for pregnancy related complications due to ongoing alcohol and tobacco abuse. It would appear to me that getting pregnant in the hospital would be considered a hospital acquired never event. No patient should ever get pregnant in the hospital. Perhaps this will require a smack down by the Joint Commission on par with the crime of the century of not dating and signing verbal orders within 24 hours.

If your patient is having sex in the hospital, you can mark my word, hospital discharge planning should be initiated immediately.

Medical School Education: Is It Hard To Get Accepted?

2009-11-15T23:31:00.008-06:00

The short answer is yes. One of the most difficult processes an undergraduate student can undergo is the application experience for medical school education. The requirements are difficult for a reason. Medical school education requires highly motivated individuals with highly intelligent academic capabilities and highly competitive personalities to survive the rigorous educational process. Medical school is not easy. It's brutal, even for the most gifted of students. Not because the material is harder than other post graduate training programs. But rather, the volume of information is like nothing an undergraduate student can ever prepare for. It is nothing like nursing school. It is nothing like PA school or NP school or pharmacy school or PhD school. It's medical school and it's in a class of its own.

The road to a medical school education starts with the first day of college and continues until that acceptance letter arrives in the mail.

What are the minimum requirements to apply for a medical school education? Unless things have changed in the last 15 years, most medical schools don't require their students to complete an undergraduate degree. Most medical schools only require ninety credits or so of a universal basic science curriculum, which includes such classes as organic chemistry, physics and biochemistry. However, due to the highly competitive nature of medical school education, I wouldn't plan on getting accepted without completing your undergraduate degree.

By the way, there is no such thing as majoring in premed. When you see sportscasters announcing that the quarterback of the football team is majoring in premed, just remember no such thing exists You can't get a degree in premed. Imagine getting a degree in prenursing. It just doesn't exist.

In addition to completing the core basic science curriculum, the medical school education applicant must also take the MCAT, or the Medical College Admission Test. Once these objectives are completed, the only thing left for an applicant is to pay the application fees, complete the personal statement and hope for an interview.

Here are some words of advice. If you have poor undergraduate grades and poor MCAT scores, your probability of being accepted for a medical school education in an accredited medical school is very poor. Save your application money. You are going to have to accept that as your reality. Perhaps you could apply to something less rigorous if you desire a field in health care.

Medical schools do not think highly of applicants who didn't excel in their undergraduate experience. They want highly motivated, highly intelligent, highly competitive applicants and they want their institution to reflect that standard. What kind of grades and MCAT scores do you need to get accepted? Plan on at least a 3.7 grade point average and a 27 or higher on your MCAT scores. Here's a list of all schools with their average GPA and MCAT scores. My acceptance into medical school in 1996 was delayed a year after my 3.7 grade point average in Chemistry and a 23 MCAT score improved to a 29 MCAT on my second attempt.

Objective data is everything. If you don't have the scores, they won't take you and nothing has changed in almost 15 years.

However, acceptance into a medical school education starts well before you take your MCAT. It starts in your first semester of your freshman year and it never lets up. If you want to get accepted into a medical school education program, you can never let up your guard. A grade of D or F in any class, but especially a core curriculum class will weigh heavily against your odds of acceptance. Bad grades are highly frowned upon. If you chose to party instead of study for the big test, you have nobody to blame but yourself. And you can't take it back. You have to live with the consequences of your actions.

Your best chances for getting accepted into a medical school is to apply to your state university. Most state institutions have rules in place that give preference to their instate residents. They want instate residents, whom they are subsidizing with state tax dollars, to stay in the state and practice medicine. The amount of tax dollars the state will eventually collect from these doctors will dwarf the amount of money they provided in state funded subsidies. The real winner here is the state's tax coffers, thousands of times over.

Your other best chance to get accepted into a medical school education is to be a minority. If you are a minority and you study hard and your credentials are equal in every way to a nonminority, your chances of getting accepted are pretty much guaranteed. Due to affirmative action laws in many states, minorities have an advantage based solely on the color of their skin. Is this right or wrong? It is what the law says it is. I personally don't believe anyone's accomplishments should be judged based on the color of their skin. But many states say they should be. If you're smart enough to compete for a slot in medical school, you should be judged on your merits and nothing else. Nothing else should matter.

By now you've spent three years of undergraduate work meticulously studying and staying competitive. You've aced your MCATs and you've written an excellent personal statement on why you want to help people and prevent greenhouse gases and do mission trips in the African jungle. You've paid your application dues and now you wait.

If you have rock star numbers, be prepared to get multiple interview requests. But remember, unless you are an incredible genius with a 4.0 GPA and 12's on your MCATs don't waste your money applying to out of state university systems. Like I said before, they play favorites with their own. And if you aren't planning a future in academic medicine, don't worry about not getting into an Ivy League school. The medicine they teach is the same medicine you learn at State College University. Plus you're spending a lot of money to name drop. It won't earn you any extra money from the Medicare National Bank.

If you have average to good competitive scores, stay inside your state institutions, or private colleges for your medical school education. But remember, the private colleges are going to cost you at least double. Perhaps $50,000 a year or more a year in tuition and living expenses.

Once you get an interview, I have just one word of advice for you. Be happy. If you have competitive scores, what will separate you from the other competitive guy is not only how you dress but how you act. If you carry yourself well, make eye contact and act interested you will separate yourself from the rest. It always helps to be good looking too. Hell, if babies prefer attractive mothers, it's not hard to imagine the professor of anatomy wanting eye candy as well.

Once you get accepted be prepared for nothing you've ever experienced. I assure you, no matter how much you believe you are prepared, you aren't. Not even close. Medical school education changes you from day one. You'll be in for the wildest ride of your life.

A wise man once told me that internalizing all the information in medical school is like trying to take a drink from a fire hose. I’m beginning to think he was right.

Hospitalist Benefits Extend To The Emergency Room

2009-11-15T10:31:00.000-06:00

Not only do hospitalists make hospitals millions of dollars for their hospital, they keep their emergency room doctors happy and improve emergency department throughput. It's no wonder hospitalists are the fastest growing speciality in this country and why hospitalist salaries continue to grow (more on that soon).

The Government Is Reporting Medicare Fraud Three Times Higher Due To Illegible Physician Signatures

2009-11-14T15:17:00.003-06:00

How widespread is Medicare fraud? The government is now reporting Medicare fraud rates almost three times higher than previously accounted for, at 47 billion dollars this year. How could Medicare Fraud triple in a year? The answer is simple. In an effort to be more honest with data collecting, Obama ordered the new accounting into effect. All part of the hope and change we always hear about

It's not clear whether Medicare fraud is actually worsening. Much of the increase in the last year is attributed to a change in the Health and Human Services Department's methodology that imposes stricter documentation requirements and includes more improper payments — part of a data-collection effort being ordered government-wide by PresidentBarack Obama next week to promote "honest budgeting" and accurate statistics.

And what are some of those increased requirements as they relate to the reporting of Medicare fraud? Yes folks, the legibility of the physician signature. Now that Obama's administration has decided to play games with reporting Medicare and Medicaid fraud, their next step is to reduce the fraud from a make believe 12% to a more palatable 9%. Of course, that still represents a more than doubling of the baseline Medicare fraud.

According to the report, the Bush administration from 2005-2008 reported improper payments of roughly 4 percent in the fee for service program, or about $17 billion total in 2008. Government officials at the time, however, typically did not consider a Medicare payment improper if the medical documentation was incomplete or a doctor's signature was illegible. Since these were flaws that ordinarily bar payment, that methodology drew complaints from government auditors that the figures were understated.

I haven't written an legible signature since my first day of medical school. After signing my signature, I would suspect over 100,000 times since I started clinical medicine, my doctor signature is nothing more than a line, a one inch by one inch diagonal line. Now that the Joint Commission has cracked down on the dating and timing of verbal orders that have already been dated and timed once by the nurse, I simply do not have time to offer the chart a legible signature. Instead I offer the chart my doctor identification number, which is becoming more illegible every time I am forced to duplicate unnecessary documentation. I fear to think what my Medicare documentation will look like as I close in on 200,000 signatures.

Perhaps Obama would like to consider my 45 minutes of intensive care work to be fraud because he couldn't read my signature? Perhaps if he simply asks me if the documentation is mine I would tell him yes. Instead, we have more economic games that won't fix anything.

It appears to me that Medicare is going to save 10 billion dollars by not paying physicians who have illegible signatures. I have just one thing to say. If Medicare and Medicaid stop paying physicians for work done because their signature is illegible, there wouldn't be a doctor in this country that collects money for work provided. Find me a physician with a legible signature and I'll bet you they aren't an MD. Perhaps they are a nurse practitioner in disguise. But give them 40 years to catch up in the signature work load and they too will one day be banned from earning a living by taking care of the old and the poor.

Starling Birds Dancing In An Amazing Display

2009-11-14T14:22:00.001-06:00

This is cool. 300,000 starling birds dancing in an amazing display of unity (video below). I saw something like this the other day in my area, but it was no where near as large is this collection. What do you think keeps all these starlings from knocking each other out as the dance through the air?

Funny Dog Cartoons: It's Been Three Months Since I Licked My Balls

2009-11-14T12:24:00.000-06:00

That is some funny dog cartoon humor

What Percentage Of Americans Smoke Cigarettes And Other Interesting Facts

2009-11-13T12:11:00.001-06:00

What is the percent of Americans who smoke cigarettes you ask? Well, The rate has been dropping since the 1960's when the percentage of Americans who smoke cigarettes was about 66%.

Fast forward to today and you'll find that number has dropped to about 20%. In 2007, the percentage of Americans who smoke cigarettes was 19.8%. Public health officials hoped this marked the beginning of a long term trend below 20%.

But that number has flattened and has slightly risen in 2008. The CDC's Morbidity and Mortality Weekly Report released yesterday indicates that the percentage of Americans who smoke cigarettes has risen to 20.6% in 2008 after dropping to 19.8% in 2007.

It is interesting to note a lot of the blame of smoking is placed being poor, yet some of the data would suggest otherwise. Here's a chart of the percentage of Americans who smoke cigarettes as it relates to their sex, education and poverty level. Hispanic women represent some of the poorest people in our country as a population, yet their rate of smoking is only 10.7%, far less than the overall percentage of Americans who smoke cigarettes.

I would suggest that being poor is not the causative force for smoking. More likely, it's the cultural dynamics that make one a smoker or not a smoker. The fact that hispanic women, some of the poorest people in this country smoke at half the rates of the general public is a testament to cultural dynamics over economic status as the basis for high smoking rates among the poor.

Plus, I look at the data and see that 70% of poor people don't smoke. To me, that says far more about the relationship between smoking and being poor than does comparing the percentage of Americans who smoke cigarettes in poverty than out of poverty. I would suggest that the poor smokers have more in common culturally with non poor smokers than they do with other nonsmoking poor people.

Millions of people die every year from smoking cigarettes. Some people like to argue that smokers die younger and cost less money to society. I completely disagree. If you look at the big picture, they are a net economic drain to social resources. When you combine, age velocity with managed health care expectations, net consumption and net production over a wide range of parameters and the massive benefit of the economic compounding of delayed health care consumption, smokers are a massive net negative in economic value to society. The best public healthy policy is to make smoking an economic hardship.

And the best policy for that is through raising the price of cigarettes. Dr David gave us a peak at state cigarette tax rates. The best way to reduce the rate of smoking is by making it an economic burden for those that choose to engage in it.

Missouri ($.17)

Mississippi ($.18)

Virginia ($.30)

Florida ($.339)

North Carolina ($.35)

Louisiana ($.36)

Georgia ($.37)

Alabama ($.425)

North Dakota ($.44)

West Virginia ($.55)

Idaho ($.57)

New York City has the highest tax rates in the country, at $4.25 per pack. Chicago, Illinois is only one step down from that at $3.66 per pack.

The CDC also reports that many of the states with the lowest percentage of Americans who smoke cigarettes are also the same states with the most aggressive indoor smoking bans. Smoking bans work, not only to protect the innocent public from the harms of second hand smoke, third hand smoke, and fourth hand smoke, but also to encourage all smokers, the most of whom want to quit (the graph is the ratio of former smokers to ever smokers) , to finally make the effort. One drug company will even give you the free stop smoking medication Chantix for free if you are too poor to pay for it. With all the free resources these days, being unable to afford help is no longer an excuse for not quitting. The issue becomes whether you want to quit and that has more to do with the culture that surrounds you.

What percentage of Americans smoke cigarettes based on the state they live in? The highest rate of smoking by state can be found in West Virginia and Indiana at 26%, with Kentucky, Missouri, Oklahoma and Tennessee close behind.

The lowest rate of smoking by state is Utah by far with only 9 percent of residents describing themselves as current smokers. But don't let Utah fool you. Residents in Utah are also the largest consumers of pornography. Perhaps that's because none of their men have smoking related erectile dysfunction.

As we move forward with the transformation into government subsidized health care for all the burden of smoking related disease will continue to be buried under the entitlement mentality of American politics. The current bills being debated do nothing at all to slow the rate of health care inflation. All they do is guarantee that Americans who make terrible lifestyle choices will be given the opportunity to pay the same for their health care as those that sacrifice daily through hard work and sacrifice to maintain their body's temple in the best shape they can. At current trends, even the wealthiest upper middle class will be unable to afford any type of premium option based on social solidarity in a race to the lowest common denominator. Eventually, once the government rescues us in Stage IV, we will have solidified our storms on the horizon and wonder what hit us when it all comes crashing down in a blaze of glory.

If you are a smoker, don't let the promise of government health care comfort you. You will be rejected once the time is right. It's already happening across the ocean as governments realize they cannot sustain the current health care budgets of their entitled masses.

But heavy smokers, the obese and binge drinkers who were a drain on the NHS could be denied some routine treatments such as hip replacements until they cleaned up their act.

When the tough choices have to be made, when America wakes up to realize they can't pay for all care all the time, those who chose to make poor decisions will pay the price. If you don't believe this will happen to you, I suggest you keep puffing away in denial. You'll find that only about 20% of your fellow Americans will feel your pain.

If you are poor and you think you've tried everything, you can try Chantix for free. What do you have to lose?

What Is Wade Boggs Carpet World?

2009-11-12T21:02:00.004-06:00

I'm watching 30 Rock and I heard Tracy Morgan plug Wade Bogs Carpet World. What was that all about? Apparently it's all about the hair. See the video obtained from my comment below. Nice plug Tracy. That's some good humor.

Hanging Christmas Lights Outdoors Without Getting Divorced

2009-11-12T12:14:00.005-06:00

It's that time of year again for hanging outdoor Christmas lights. You want some tips on how to get through this holiday season hanging Christmas lights without getting divorced? Read on.

Mrs Happy and I have a long standing agreement. Rule #1 to avoid divorce: She decides what they'll look like and I put them up. You can read about the interesting history of hanging Christmas lights here. I can only assume that Christmas lights migrated outdoors as a natural extension of the Christmas celebration.

Seven years ago as a new homeowner, I got my first experience for hanging outdoor Christmas lights. I remember it clearly. Full of excitement and anticipation, I found out just how expensive these strands of lights could be. I probably spent several hundred dollars that first year collecting a small army of C9 Christmas lights that I expected to last for years (see picture below). Do you know the history of C9 Christmas Lights? They were first introduced by General Electric in 1927.

My first experience ever hanging these C9 Christmas lights would make any trauma doctor salivate. I was invincible that year, up on the roof with brisk winds and steep grades dangling in positions man was never meant to dangle. It's a miracle I didn't fall and kill myself. Rule #2 to avoid divorce: Man should not place himself on the trauma service in the interest of holiday spirit. That was my first and last year of hanging outdoor Christmas lights with stupidity. No more dangling over the edge for me. I should have done what my neighbor did and rent a cherry picker.

That was just the beginning. How little did I know about how expensive hanging Christmas lights would become. These things were made of glass and were easily broken. Bang the strand of lights against the ladder and they shattered immediately. They were hot and they consumed a lot of electricity. Check out this neat Christmas lights electricity cost calculator. My first year of hanging Christmas lights cost me over $150 in electricity. I was not prepared for that. Rule #3 to avoid divorce: Your holiday light extravaganza should not bankrupt the family budget. If you're spending too much on electricity, just stop it, or switch to the new LED bulbs, which may break your budget in other ways.

I also found that the C9 Christmas lights burned out quickly. Within a week I found myself replacing individual bulbs. It seems like all Christmas lights are made in China these days. So it doesn't surprise me that quality is an ongoing issue.

Rule #4 to avoid divorce: Put the lights up when it's nice out. Take 'em down when it's nicer. It makes for a wonderful family experience. If it's cold out and the wife has to freeze while she helps you, you're asking for trouble. Nobody likes to hang Christmas lights when its cold out. I remember a few years ago the pain was unbearable. This year we've had had an unusually warm November. Mrs Happy and I have succeeded in hanging our Christmas lights barely a week out of Halloween, a record for us. I noticed many of my neighbors have instituted rule #4 to protect the sanctity of their marriage as well. Or they've hired someone to come and hang their Christmas lights for them (now that's just wrong). We thought about turning them on now, but there seems to be an unwritten rule in our neighborhood that lights go on only after Thanksgiving. What do you think, too early yet?

Seven years was a lifetime ago for hanging Christmas lights. That was before LED Christmas lights made it big. LED Christmas lights claim to last thousands of hours before going dead. However, I'm pretty sure these claims don't include the wiring that comes with them. I have spent hundreds of dollars through the last few years upgrading our lights to the environmentally happy LED Christmas lights. These things are much more expensive, sometimes 10x the cost, but they use 80-90% less electricity. My hope was that if I spent more on the front end, I would save in electricity costs on the back end. Plus I think they look cool. Unfortunately, over the last few years, I have discovered that these LED Christmas lights don't last as advertised, mostly because the wiring is still unsatisfactory and because they're still made in China, the quality is nothing to cheer about. Rule #5 to avoid divorce: If you're upgrading your lights to save on electricity, you're not going to come out ahead. They don't last as advertised.

Back to my second year of hanging Christmas lights. I forgot the mention, if you want to spend five hours hanging Christmas lights only to discover that none of them work, make sure you hang them without plugging them in first. That's what I did in my second year of hanging Christmas lights. What a headache that was. Not only did I hang them up in the brisk cold, I had to take them all down, go buy some new ones and then repeat the process all over again. That was a mistake I have never made again. Rule #6 to avoid divorce: Always plug in your Christmas lights and check them before hanging.

Once you've checked all your lights, and made sure everything is working appropriately, you have to accept that something will fail you. Even though you did everything right. Even though you checked every bulb. Even though you carefully devised your extension chord map so all plugs met peacefully in a hidden corner, you have to accept failure. Lights go dead for no reason at all. Rule #7 to avoid divorce: Accept the death of your light strand with grace. At first I was upset when my lights died. I felt like finding the receipt and returning them, but by then the stores only give you the clearance price. It's just better to accept the death of your hanging Christmas lights with grace and move on.

Someday the Chinese will figure out a way to make Christmas lights that last more than a year or two. Perhaps someday, hanging Chirstmas lights will come with a security knowing that nothing could possibly go wrong. Until then Clark Griswold sums it up nicely when he says, "What the....What's going on here".

UPDATE: After a few nights of beautiful C9 glowing up Happy's sky, all my C9 lights went dead. And they've done it three times now. I'm done with C9's. It's the fuse. Those cheap Chinese strands and fuses can't handle the load. So they're all going to Goodwill and I'm going 100% LED from here on out.

Is Emergency Assessment and Medical Care Needed For My Child?

2009-11-11T11:30:00.001-06:00

Your child seems half dead to you, but you're frozen with uncertainty. Are they just being whiny? Is that fever going to pass quickly? When do I know if my child needs an emergency assessment? When do I know if they need emergency medical care?

I recently got involved in just a situation with one of Mrs. Happy's friends. She has a young child, about four years old who came down with a fever a week ago. The child has a history of asthma and a history of supraventricular tachycardia. The child was meandering along doing fine when one day his condition changed.

The mother took her child to his pediatrician saying that the child seemed to be rather weak. He was still having fevers and was now wheezing. At the pediatrician's office the oxygen saturation was found to be about 90-91%. As any physician knows, the oxyhemoglobin dissociation curve drives clinical oxygen management. Once the PO2 drops below 60, the clinical oxy-hemoglobin saturation drops quickly. This is why a 90% oxygen saturation is used as the safe clinical cut off for clinical oxygen assessment. Anything below 90% requires an emergency assessment and emergency medical care should be initiated.

After obtaining a chest xray in the clinic that suggested pneumonia, a shot of antibiotics was administered. The mother was instructed to take the child home and to watch him. If her son was no better the following day she was instructed to bring him back.

Several hours later the child was complaining of a mild headache, was having a bout of diarrhea and was not interested in moving or eating or drinking. He was still wheezing and he was still having fevers. The mother was conflicted. Her physician had told her to go home and basically wait it out. The mother's family was telling her to follow the physician's advice. The cost of of an emergency assessment and emergency medical care was weighing on her. She contemplated taking him to the cheaper urgent care center.

While I hate to give advice without doing a clinical evaluation, some times the obvious needs to be stated. When I heard about how the child was acting, how his oxygen saturations left no wiggle room for safety, how he was complaining of a headache (which could be a sign of low oxygen levels), how he sounded lethargic, how he had a history of asthma and SVT, and how the H1N1 virus was disproportionately affecting the young in adverse ways, Mrs Happy and I recommended that she ignore her physician's advice for watchful waiting and take her child in for an emergency assessment and emergency medical care. I could see no possible way that an emergency assessment would not lead to emergency medical care in the hospital. I suggested the urgent care center would simply recommend transfer to the emergency room for emergency medical care and admission.

I couldn't think of any reason why this child should not have been admitted from the pediatrician's office, as I would have done the same had I been asked to admit the adult version by an emergency department physician.

I thank the Heavens that mother took her child to the emergency department for an emergency assessment and emergency medical care. The doctors took one look at the child and didn't hesitate about admitting him. The next morning the pediatrician acted like the child had a dramatic change in condition, which they didn't (according to mother). That's just pathetic. The red flag symptom in my book was the low oxygen saturation in an otherwise normally healthy child. I would never send anyone home in that condition. Why this pediatrician did is beyond me.

In the hospital, the H1N1 swine test came back negative, but we all know that it's not a very sensitive test. After 48 hours, the child remains hospitalized with hypoxemia, on 4-5 liters of oxygen, IV fluids and antibiotics. We're told the hunt is on for other respiratory viruses, although I'm not sure that finding another virus would change the management. After over a week of fever at home, any antiviral is unlikely to change the course of the disease process. The mother remains distressed. Her experience with the nursing staff has been one of rudeness and borderline incompetence at times. Her trust in her pediatrician appears gone. That's a horrible way to experience the illness of your child.

How is a mother to know when an emergency assessment and emergency medical care is required for their child? Unless the mother has a detailed background in science through nursing or physician level education, few mothers would know anything about an oxy-hemoglobin dissociation curve. Few would know much about what is considered safe and what isn't from a physiology point of view. The point is, you just don't know. If my child had an office oxygenation level of 90% and my child's pediatrician recommended going home, I would find another doctor and go to the emergency department for admission.

As the mother, you have to do what you think is right. That means if you think your child is in danger, you take them in for an emergency assessment and emergency medical care, regardless of what anyone else says, including the physician. For the lay public, often times they are left with Google and their gut instinct to guide them in for an emergency assessment and emergency medical care of themselves or their loved ones when everyone around them gets it wrong. I'm just glad Mrs Happy and I were there to help her do the right thing for her child. We hope he gets better quickly.

ICD 9 Medical Codes From A Radically New Perspective

2009-11-10T11:58:00.002-06:00

What if ICD 9 Medical Codes were not limited to your work life existence? What if the same ICD 9 medical codes that you document in your medical practice were also responsible for documenting your life? Dr Rob gives us a very clever and entertaining look at what life would look like if you had to document ICD 9 medical codes from sunrise to sunset. And just imagine, it's only a matter of time before ICD 9 medical codes are retired in favor of the ICD 10 medical codes, which contain 10x greater number of codes.

7:25

Shower, shave, and get dressed. LACERATION, FACE ICD-873.40

Walk downstairs to find kids sulking and wife frustrated. UNDERSOCIALIZED CONDUCT D/O UNAGRESSIVE UNSPEC ICD-312.10

Try to give her advice. COUNSELING FOR PARENT-CHILD PROBLEM UNSPECIFIED ICD-V61.20

Wife glowers. MARITAL&PARTNER PROBLEMS UNSPECIFIED ICD-V61.10

Say: “We have to leave in five minutes!” in an angry voice. PROBLEMS WITH COMMUNICATION ICD-V40.1

Children glower. FAMILY DISRUPTION D/T PARENT-CHILD ESTRANGEMENT ICD-V61.04

Wife sighs and chides for the tone of voice. COUNSELING FOR PARENT-BIOLOGICAL CHILD PROBLEM V61.23; E/M 99215, ENCOUNTER, ESTABLISHED, HIGH COMPLEXITY

When you look at the madness of ICD 9 medical codes, you have to wonder how we ever got here in the first place. Medical care is no longer about treating patients, it's about documenting ICD 9 medical codes to get paid.