The Happy Hospitalist

Effective Acne Treatment Causes Emotional Scars As Accutane Is Pulled From The Market

2009-11-08T11:44:00.002-06:00

The physical scars will be nothing compared to the emotional scars that will haunt the children. I recently read that the effective acne treatment Accutane was pulled off the market this summer quietly ending access to an excellent and effective acne treatment for millions of self conscious teens and young adults. Accutane, or isotretinoin as it's known, was used to treat severe nodular acne.

It turns out that Accutane was linked to inflammatory bowel disease, and other side effects resulting in thousands of lawsuits. It spent twenty five years on the market embroiled in controversy

Approved by the Food & Drug Administration (FDA) in 1982, Accutane has been the subject of controversy for years. It first garnered attention in the late eighties for causing severe birth defects. It has also been known to cause psychiatric problems, and has been linked to hundreds of cases of suicide in the United States. Accutane has also been associated with problems of the liver, kidneys, central nervous system, and pancreas, as well as the cardiovascular, musculoskeletal and auto-immune systems.

Now apparently it was the inflammatory bowel disease link that did it in with millions of dollars lost in just a handful of lawsuits, with thousands of lawsuits still pending. The company claims that this effective acne treatment was pulled not due to lawsuits, but rather due to increasing competition from pharmaceutical generics.

Roche notified the U.S. Food and Drug Administration today that it was withdrawing Accutane after a “reevaluation” of its product lines showed it faced serious challenges from generic competitors, company officials said in a statement.

I feel bad for the kids whose lives will be forever traumatized by the emotional scars left from their severe nodular acne. This effective acne treatment, whose benefits far outweighed the risks for millions of pimply teenagers for their severe nodular acne has been banished by a legal profession that chose to ignore the great benefits lost forever.

As with any medication, one has to outweigh the risks and benefits of therapy. Every medication I prescribe can cause serious or even life threatening side effects when used as prescribed. One day perhaps the millions of kids left with emotional scars because an effective acne treatment for their severe nodular acne was pulled from the market may someday sue the company for pulling a product that could have prevented their emotional scars. Perhaps that will be the future gravy train for lawyers, once they've forced all drugs off the market.

These Swine Flu Maps Are Really Cool

2009-11-07T11:05:00.004-06:00

A reader asked me if I knew what the swine flu maps were showing these days. I got word recently that the H1N1 swine flu maps in Happy's region had reached a plateau. I did a little searching and found an excellent database for swine flu maps. It is a project by Dr Henry Niman using technology from Rhiza labs and Google

You can zoom in and click on individual regions on this swine flu map to get a better idea of what's going on locally with H1N1 penetration.

Several other cool swine flu maps can be found here as well.

Paralytic Ileus Wins Man 75 X Rays

2009-11-07T06:00:00.006-06:00

Which is worse, having a chronic paralytic ileus or getting 75 x rays of your belly? I'm not sure which is worse. But that's what one patient of mine has endured over a 15 month spana. Seventy five abdominal x rays. That's five x rays a month, every month, for 15 months. In addition, he's had 8 CT scans of his abdomen and pelvis to evaluate the paralytic ileus he's had since he moved to Happy's town from Los Angeles. If my memory serves me right, that is the equivalent of about 2000-3000 xrays.

And how many admissions has he had for paralytic ileus or bowel obstruction or partial bowel obstruction (what ever the doc of the day wants to dictate)? He's had 26 admissions to the hospital for paralytic ileus in a fifteen month span. That's incredible. Twenty six admissions for paralytic ileus. And every one of them is the same. Nasogratic decompression, fluids and time.

At this point, I think the obvious needs stated. Medical managment of his paralytic ileus has been a complete failure. The Merck Manual gives a concise summary for paralytic ileus. You can't get admitted to the hospital 26 times and call this quality medicine. The only other person that comes close to this kind of medical failure in my experience is the lady who got 9 CT scans for her lung disease.

So what are we to do about this man's paralytic ileus? I'm pretty sure his paralytic ileus isn't do to something like a jellyfish bite. And I'm pretty sure his paralytic ileus isn't do to a giant mesenteric lipoma. I'm not sure what is. But I am sure giving him more radiation is not the answer.

Was Vicarious Traumatization Responsible For The Fort Hood, Texas Massacre by Nidal Malik Hasan?

2009-11-06T14:01:00.005-06:00

KevinMd MD discusses the role vicarious traumatization may have played in the Fort Hood massacre by Nidal Malik Hasan, a physician who opened fire on his fellow soldiers.

One reason may be so-called compassion fatigue, also known as vicarious traumatization or secondary traumatization. According to the Psychiatric Times, the condition is defined as “indirect exposure to trauma through a firsthand account or narrative of a traumatic event. The vivid recounting of trauma by the survivor and the clinician’s subsequent cognitive or emotional representation of that event may result in a set of symptoms and reactions that parallel PTSD (e.g., re-experiencing, avoidance and hyperarousal). Secondary traumatization is also referred to as compassion fatigue and vicarious traumatization.”

Wow. I'm shocked. What this sounds like to me is a doctor going crazy. Did he get vicarious traumatization because his patients had a hard life story to tell? When my patients tell me stories of their difficult lives, I find them interesting and intriguing. I find they add an element of excitement to an otherwise routinely unexciting doctor process. I don't find myself turning into Rambo.

I've had my fair share of vets tell me about the battles they've fought. A few have described in vivid detail the gunshot wounds or the stabbings that scar their body. And yet, I've never felt like putting a cap in anyone's head.

Hot Air gives their opinion on the matter, and I bet you can tell what their thoughts are.

So then, in order to avoid the terrifying realities of war, he unleashes the terrifying realities of war on a bunch of people. Lovely. Since that article was published yesterday, there are dozens more that seem to be trying to diagnose PTSD once removed, suggesting that the trauma he heard about while engaging in patient care “infected” him as well. We can’t know that right now, though anything is possible. But I will return the favor (with equally invalid medical credentials) and diagnose the media with Factitous Disorder by Proxy.

If I were a bettin' man, I would guess that our mass murdering physician had some other underlying diagnosis that, like most physicians out there, he hid from his family, friends and medical community. Things are not always as they seem.

The H1N1 Swine Test is About 15-60% Sensitive

2009-11-06T14:00:00.008-06:00

How sensitive is the H1N1 Swine test? A reader asked me that question. I was told a few weeks ago that the H1N1 swine test was between 15-60% sensitive. A Pretty big range. Which means if you have the H1N1 swine flu, 15-60% of the time the H1N1 swine test will be positive.

That doesn't seem like a great screening test, does it? The reader told me the tthought the test runs about $500 and isn't covered by insurance. I have no way of verifying this or not. If that's what the test runs, I'm shocked. At Happy's hospital, we screen for the flu by doing a nasal swab and checking for influenza A/B. H1N1 is an influenza A virus. If the patient is positive for influenza A, we make a presumption of H1N1 swine flu. The sample gets sent to Happy's state lab and that's were further testing is performed (or at least it was, I don't know if they still are).

If you have the symptoms of the flu as an outpatient, would I pay to have myself tested? I'm not sure I would. As I discussed with Mrs Happy's symptoms, the Tamiflu costs around $90 for a five day course, much cheaper than confirming the test.

Should we be checking patients being admitted with flu symptoms or should we just start them on Tamiflu. I don't know the answer to that. I think having a positive flu test would force us into isolation measures to protect other hospital patients and employees. But I'm not sure if a negative test with flu symptoms would prevent me from isolation precautions anyway.

I haven't come across this situation yet.

Leaving Against Medical Advice and The Physician Responsibility

2009-11-06T12:00:00.004-06:00

When a patient decides they are leaving against medical advice what responsibility does the physician have to their care? When I was a resident in training, and even early on in my position as a hospitalist, I would get a call from the nurse that Mrs Smith was demanding to leave the hospital against medical advice. I would tell the nurse "Fine. Let her go. I'm not her father." I would tell the nurse to discharge Mrs Smith with no medications and leave it up to them to find follow up.

I would suspect this is a prevalent attitude for many hospital and emergency based physicians. I've seen it over and over again. And I still see it today. Many doctors and nurses feel obliged to let grown men and women make poor decisions. However, being a grown man or woman able to make poor decisions is apparently not enough to keep a doctor for being sued and losing that lawsuit because a patient chose to make poor decisions. Here's a case report on leaving against medical advice and their bullet points at the end

Discharge AMA does not absolve the physician of responsibility for poor outcomes; as always, good clinical care and careful documentation are of paramount importance.

Will leaving against medical advice negate insurance coverage for the patient? Dr Gott chimes in by scolding a physician for telling an elderly lady just that.

DEAR READER: The social worker who saw you in the hospital was absolutely correct. The doctor does know better than to behave that way. He should also know that Medicare and other insurance will cover hospital care even if the patient leaves against medical advice (AMA).

But what about the outcomes of patients who leave against medical advice?

The significantly increased risk of readmission among general medicine patients who leave hospital AMA is concentrated in the first 2 weeks after discharge. However, it is difficult to identify which patients will likely be readmitted.

As a resident, I rarely got any legal education on patient care issues. I know for a fact I never got any education on the legal ramifications when I discharge a patient leaving against medical advice. A few years back I did a little research on what is expected of physicians when patients are leaving against medical advice.

That research changed my attitude about how to deal with patients choosing to leave against medical advice. I used to let them go and leave it at that. But now, I will take the time to discuss Mrs Smith's concerns about continued voluntary hospitalization. Often patients can be convinced to stay when presented with the facts of their care and care plan, as I did the other day with an old man who was out of control. If Mrs Smith still chooses to leave after discussion, I document that Mrs Smith has the capacity to make poor medical decisions for herself and that she understands the risks and benefits of leaving against medical advice including the high probability of death or disability.

Once I am convinced that Mrs Smith has the capacity to make poor medical decisions and understands the consequences of those choices, including long term death and disability, I discharge her just like I do any other patient. And I bill her as a discharge code (CPT 99238 or 99239) just like I would if she was leaving with my blessing.

If she needs a prescription for pneumonia, she gets a prescription for pneumonia. If she needs a heart pill, she gets a script for a heart pill. She gets the same care as if I was discharging her with my blessing. Many physicians falsely believe that by formally discharging Mrs Smith, they are approving of the discharge plans. That couldn't be farther from the truth. By formally discharging Mrs Smith in her leaving against medical advice manner, you are protecting yourself against charges of abandonment and failing to provide standard of care upon discharge. Many subspecialists will refuse to see Mrs Smith on follow up after she leaves against medical advice believing that seeing her would increase their liability for practicing medicine on a patient who's actions increase the likelihood of a bad outcome. Again, that couldn't be farther from the truth.

I will discharge Mrs Smith just as if she was leaving with my blessing and I will clearly document that I oppose her decisions but recognize her right for leaving against medical advice. Patients in the hospital have the opportunity to refuse therapies and evaluations at anytime. Leaving the hospital is no different.

But what if I don't think a patient has the capacity to make their own medical decisions and they still feel like leaving against medical advice? I have been told by my psychiatry service several years ago that because the patient was admitted to a medical wing and because they came in voluntarily I have no legal grounds to force them to stay, even if I believe they lack the capacity to make their own medical decisions. I have no legal basis to prevent them from leaving and in fact I could be charged with some sort of unlawful imprisonment charge if I tried to keep someone in the medical wing against their will.

My duty at this point, if I believe the patient leaving against medical advice lacks the capacity to make their own medical decisions, is to let them leave the confines of the hospital, but to contact the police department to pick the patient up the moment they step foot outside the hospital doors.

Today's Hospitalist had a great review earlier this year. Who tends to leave against medical advice?

And a body of research has identified several characteristics common in AMA discharges. These individuals are often young, male, have Medicaid or no insurance, come from a low socioeconomic class, or have a history of substance abuse.

Thankfully the against medical advice crowd is not a large one. AMedNews reports that only about 2% of hospitalized patients end up leaving against medical advice.

About one in 50 patients leaves the hospital early, disregarding the doctor's orders. These patients are three times more likely to be re-hospitalized within a month, according to a recent review of more than two dozen studies since 1970 that examined the phenomenon of "self-discharge."

As a medical physician, I have been told I have no authority in Happy's state to hold someone in the medical floor against their will, regardless of their mental capacity to make sound decisions. They have to be picked up by local authorities and transferred to a psychiatric hospital for a medical hold, or the police department must place an emergency protective custody (EPC) on the patient which allows a physician/hospital to hold the patient for up to 48 hours in Happy's state before a judge declares intentions for further court ordered confinement or not.

If your patient is leaving against medical advice, take my advice and formally discharge them. You will save yourself a lot of potential trouble in our world where every bad outcome is someone else's fault and our legal system encourages an incredible lack of personal responsibility.

Should We Be Giving Hospital Stickers To Children?

2009-11-06T10:00:00.007-06:00

What's the deal with hospital stickers these days? I found this sticker laying around in Happy's emergency department the other day. Should we be encouraging children to come to the emergency room and feeling happy and excited about the sticker they get? I'm not sure putting a happy robot on a sticker and proclaiming ones exciting visit to the emergency is the best public health policy. Perhaps we need to take a different course of action before another entire generation of citizens feel obliged to use the emergency department as their sole source of medical care. Perhaps instead of a hospital sticker, children in the emergency room would all get a saline injection in their shoulder. Now that's the kind of memory you want kids to have of their emergency room visit. They should fear the hospital and do everything in their power to stay healthy as adults. Not feel giddy about happy robots on hospital stickers.

Do children get hospital stickers at your facility?

Hospital Shoes And Socks Will Make Or Break Your Night Shift

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

If you don't have comfortable hospital shoes or hospital socks, you might as well call in sick. Having sore feet can really be frustrating during a twelve hour night shift. Forget about annoying pages at 6 am for critical lab potassium levels of 3.2. Forget about the social admit from the emergency room at 3 am. Forget about the healthy 40 year old with a broken arm who needs a hospitalist pre-op evaluation at 5 am. It's all about the hospital shoes and the hospital socks. Comfortable hospital shoes and socks will make or break your night shift experience. Here are some of my requirements for the hospital shoes and hospital socks.

Easy on and easy off: No shoe laces. When I have to go do something from a dead sleep the last thing I want to do is mess around with shoe laces. Slip 'em on and off ye go. That's the number one criteria for my hospital shoe.
Breathability. I've had several pairs of rubber Birkenstocks that don't breath. I didn't know how bad they were until I found a shoe that was able to breath. Nothing worse than hot sweaty feet at 3 am.
Lightweight. Hospital shoes must be lightweight. I don't want to feel like I'm draggaing around a barbell all night.
Flexible. Nothing worse than feeling like you're wearing a lead pipe at 4 am.
Durable. I don't want to buy a new pair of hospital shoes every couple of months.
Buy them on sale. It's for work. Never pay full price for your hospital shoes.
Style: You gotta look cool for granny at 2 am, plus when you do a great job you can always say "It's gotta be the shoes."

I'm currently wearing a slip-on Teva that I bought off the sale rack over a year ago. They have held up quite well, although I just discovered part of the sole breaking apart. Here's a picture of them below. The best $30 I ever deducted as a business expense for hospital shoes.

What about the hospital socks? Until I started running, my socks consisted of buying eight pairs of tube socks for five bucks from Walmart. They were thick and bulky. I never knew what I was missing until Mrs Happy turned me on to the Balega wicking socks. I loved the Smart Wool socks even better but I found their life span less than something to be desired. These Balega wicking socks are incredible. They're comfortable. They're breathable. They're flexible and durable. And they're stylish. They are great for running and excellent to use as hospital socks on the night shift.

Having the shoes without the socks can negate all the benefit you get from comfortable hospital shoes. Here's a picture of my hospital socks.

Just remember. If you want to make it through a night shift in one piece, you have to get yourself some comfortable hospital shoes and hospital socks and put your pager on divert for non emergency pages. So what are your favorite hospital shoes and socks?

Animal Anesthesia Picture With Huge Tubing

2009-11-05T22:21:00.002-06:00

Animal anesthesia is performed at a vet hospital in front of a live audience at the Wild Kingdom in Walt Disney World Florida. I took this picture of the animal anesthesia apparatus they use to knock out the animals. Check out the size of that tubing. Can you imagine how much anesthesia would be required for these animals? And I thought I passed a lot of gas.

The Squirrel Wall Video Says Never Give Up

2009-11-05T10:36:00.000-06:00

This squirrel wall video is really touching. If at first you don't succeed try and try again. Enjoy this piece about never giving up, even if you are a squirrel facing the biggest wall of your life.

It Was The Greatest Night Shift Ever

2009-11-05T06:21:00.002-06:00

Last night was the greatest night shift ever. Why you ask?

1) Every hemoglobin called really was a critical lab value

2) Every potassium called really was critical lab value

3) Not a single call for decreased urine output

4) Not a single call for a social admit

5) Five hours of rarely interrupted sleep

6) Going home a half hour earlier than normal

Now that's the greatest night shift ever. It definately feels better than a no-hitter, because it feels like team Night Happy excelled in all aspects of patient care. Excellent job team. Let's try to make this a habit worth repeating.

Is Your Monthly Grocery Bill Smaller Than Your Fast Food Bill?

2009-11-05T06:00:00.003-06:00

If your monthly grocery bill is smaller than your fast food bill, you know you have a problem. The Hungry Addict fell off the wagon once again. His internet banking has shown him the truth. What is his monthly grocery bill and how does his monthly grocery bill compare to his fast food bill? These numbers are shocking.

August Restaurants: $1302.58

August Groceries: $634.45

September Restaurants: $1262.98

September Groceries: $817.88

October Restaurants: $1082.33

October Groceries: $823.06

Truth can be a powerful liberator. Your monthly grocery bill is a powerful indicator for how you choose to live your life. The question now is what are you going to do about it? Will you lay down in defeat with the realization of your actions? Or will you rise to the challenge for yourself and your children.

Why Is Decreased Urine Output Considered A Nursing Emergency?

2009-11-04T22:46:00.007-06:00

To this day, after seven years of hospitalist medicine, I have yet to figure out why nurses from all walks of life consider decreased urine output a nursing emergency. This is an honest question about a real clinical issue that interrupts doctor and patient care issues at all hours of the day and night. Somewhere in the bible of nursing education there must be a law. A law that says any patient producing less than 30 cc of urine per hour, regardless of age or baseline renal function, must constitute decreased urine output, which by default constitutes a nursing emergency.

Are nurses taught that decreased urine output is equivalent to hypotension? Are nurses taught that decreased urine output is equivalent to tachycardia? What exactly is it about decreased urine output that makes them drop what they are doing and call the doctor at 4 am to inform them that Mrs Smith's urine output is only 200 cc for the last eight hours.

Happy: Is the blood pressure normal?
Nurse: Yes
Happy: Is the heart rate normal?
Nurse: Yes
Happy: Is the patient sleeping comfortably?
Nurse: Yes
Happy: Then why did you wake me up from my comfortable sleep?
Nurse: Because she had decreased urine output.
Happy: And why are you concerned about that? What is her creatinine?
Nurse: I don't know. I'll check
10 minutes of searching... catching some more zzz's while waiting.

Nurse: It's 2.5
Happy: Is it different from the day before?
Nurse: I don't know. Let me check
5 minutes of searching...catching some more zzz's
Nurse: It's the same
Happy: How old Is Mrs Smith?
Nurse: She's 92
Happy: What's your concern
Nurse: She has decreased urine output
Happy: Why are you checking her for decreased urine output. Do you want me to discontinue the foley?
Nurse: No, she's having problems getting up.
Happy: So what is your concern for her decreased urine output
Nurse: It's decreased.

At this point I'm banging my head on the night stand.

Happy: You have to understand. Calling me at 5 am because a 92 year old with chronic kidney disease who has decreased urine output as her baseline does not do your education justice. If you're calling me with a concern, you have to be able to explain to me what your concern is. If you don't want to be treated like a robot, then you must stop acting like one. Please. Take an order that says stop checking her urine output, and if your nursing fears tells you to check it anyway, please don't call me unless it's less than 10cc per hour for hummmm, let's go with 8 hours this time.
Nurse: But what if she goes into kidney failure
Happy: She is in kidney failure. As is just about every 92 year old that walks this earth.

I simply do not understand the emergency nursing concerns with decreased urine output. I would love to have some nurses explain to me their thought processes when calling and why they never know what the current or previous creatine or current vital signs are when calling.

Decreased urine output must be interpreted with at least some basic science understanding that all nurses should have received. Urine production is a sign of kidney filtration. When blood flows into the kidney, it passes by a network of glomeruli and tubules that allow the exchange of fluids and metabolites for the production of pee. If you have underlying chronic kidney disease, you will have decreased urine output as your baseline. If you have advanced age, you will have decreased urine output as your baseline.

If you want to call the hospitalist to express your concerns about low urine output in the 92 year old with a baseline creatinine of 2.5, you must at least have the decency to understand why you're calling. Simply stating that it's low and therefore I need to be notified is the robot mentality. It does not do your education justice.

Please, for the love of God, use critical nursing skills when calling decreased urine output. What's important is not where they are at, but rather where they came from.

Is decreased urine output taught as a vital sign that is engrained into the nursing psyche on the same level as blood pressure and heart rate? Is it engrained as a critical nursing value that must be immediately addressed, regardless of clinical history?

I don't know. I've never gone to nursing school. But remember, if the patient is making urine, the patient has kidney function. How much? I ask the question does it matter on an emergency basis at 5 am? Are their electrolytes critically abnormal? Are they hypoxemic? Do they require increasing oxygen needs? Is their blood pressure low or their heart rate high? Are they tachypneic. These are the values that matter to patient care in clinical medicine.

If you can answer these questions, you have done more to evaluate the patients' current clinical situation than all the urine output calculations you've done on your shift.

From my position as a hospitalist, decreased urine output means nothing when that is the only reason you're calling. Give me the courtesy of understanding your patient's history before you call with your concerns. If you understand basic physiology, your concerns will often be alleviated on their own. All I ask is that you understand why you're calling and why you are concerned. If you can't answer these simple questions, you need some more continuing medical education fast.

With that said, give me a hypotensive 20 year old in septic shock making 5 cc in the last hour and now you're talkin'.

The Exercise Travel Barrier Has Been Solved

2009-11-04T15:00:00.002-06:00

Traveling can put a major crimp into the daily exercise routine. When you're on the road eating poorly having a way to exercise during travel is paramount. Dr Centor describes his one year effort to lose weight. His dedication to exercise has also resulted in a self proclaimed B+ to A- cardiovascular fitness.

He goes on to describe how he hopes to improve on his consistent effort over the last year, hoping to achieve greater than 200 work out days in the next 12 months. The exercise travel barrier is his greatest concern.

So this year I am aiming for >200 days working out. That is actually difficult given that I travel quite a bit.

Dr Centor, travel is not an excuse anymore. In fact, travel gives you the opportunity to experience exercise in fresh surroundings whether it's in the middle of the city or out in the country side. You don't need to be home to run, walk or jog. Whenever Mrs Happy and I go on vacation, we make a dedicated effort to get out and run. The run is in fact part of the vacation now. We look forward to it like everything else on the trip. The different surroundings add an exciting element of change to the daily exercise activity at home.

Besides, if you aren't into scenery or you're too scared to go out in the dark alone, you can alway book a room at the Westin where they offer in room treadmills as an upgrade. Now you have no excuse except the ones you choose to make up. Your exercise travel barriers have been removed. Keep it up. And someday you'll be just like Dick and Rick.

How To Wake Up Your Wife Or Girlfriend

2009-11-04T12:25:00.003-06:00

That's just good humor. Check out the video below on how to wake up your wife or girlfriend. Cause wakin' up is hard to do... After my first year of college, I lived in a house for a summer with seven guys. Three of us worked at the parks department mowing lawns. The boss was difficult to work with. Show up 30 seconds past 7 AM and he's yelling at you.

So one night one of the guys fell asleep early on the couch. It was around 10 PM. We went around to every clock in the house and pushed them forward to 6:30 am. Then we came running down stairs screaming at him to wake up and get ready for work saying everyone had overslept. He jumped out of bed and ran to the shower to get ready. He came running down stairs hair dripping wet in his work cloths scrambling to find his lunch box only to see us all sitting there laughing our asses off.

Don't ever fall asleep in a house full of guys.

Fun Theory And A Piano Staircase Can Make You Exercise Or Recycle Glass

2009-11-04T11:53:00.003-06:00

The Fun Theory says you can get people to change their behavior for the better simply by making the change fun. The following three videos are hilarious examples of how making something fun can change behavior for the better.

First up, how can you use a piano staircase to make people exercise? Here's how:

How do you get people to recycle glass when they get no money for it? Here's how:

How do you get people to put trash in a trash can? Here's how

How would you use Fun Theory?

I'm Addicted To Dog Smell

2009-11-04T11:27:00.000-06:00

I confess. I'm addicted to dog smell. But not just any dog smell. I'm addicted to the dog smell of our very own Marty and Cooper. They are our precious little Italian greyhound angels of love. And they give off the greatest dog smell ever known to man.

When they're wrapped up in a blanket and come out for air, the smell is over powering. It's hypnotic. It's soothing. It's relaxing. Their dog smell is like nothing I can describe. It's an incredibly soothing experience.

I tell Mrs Happy I wish I could figure out a way to bottle it up and take it with me where ever I go. I know there are millions of dog lovers out there who love the smell of their dogs. Don't be ashamed. I know you're thinking the same thing. It's OK. Don't let the dog haters put you down. It's OK to love your dog's smell. Hold your head up and and stand proud. You have nothing to be ashamed about.

Now, time to go smell my dogs.

My Swine Flu Vaccine Side Effects Scared Me

2009-11-04T07:40:00.008-06:00

So I got my swine flu vaccine yesterday at Happy's employee health. And the side effects? After giving the swine flu vaccine, the nurse stepped out behind the drape while I put my shirt back on. I started to experience side effects almost instantaneously. Without warning an uncontrollable pig snorting noise came out of my mouth.

Happy: How long did you say it takes for the swine flu vaccine side effects to show up?

Nurse: Laughing

Happy: Come on. Am I the first person to do that to you?

Nurse: Yep Happy, you're the first.

I learned a couple things though

1) The H1N1 vaccines is free no matter where you get it. She said the federal government is paying for it

2) She said the CDC is recommending the swine flu vaccine even if you think you may have had the real thing already.

Cute Dog Picture For the Fall Season

2009-11-03T21:39:00.000-06:00

What a cute dog picture. That's our cousin Archie being adorable

The Incredible Hoyt Family Motto Is Simple: You Can

2009-11-03T19:04:00.001-06:00

The Hoyt Family story is nothing short of incredible. It's a story about a father and son, Dick and Rick. It's going to make you cry. You had better get the Kleenex out.

Their motto is simple. You can. That's it. Nothing else. Just you can. When you think you've hit a brick wall remember Dick and Rick. Because you can. I only hope one day I can be a fraction of the father to my family that this guy is to his son. My arms applaud you both. You are an inspiration to the world.

Funny Criminals Arrest Of The Year

2009-11-03T16:36:00.003-06:00

The funny criminals arrest of the year goes to to the guy who was arrested for driving drunk in a breathalyzer costume. How can you not feel sorry for this guy? He's never going to live this one down.

Pulmonary Embolism Diagnosis May Be Missed Due To Pigeon Hole Diagnostic Error

2009-11-03T12:48:00.008-06:00

Pulmonary embolism diagnosis often requires a combination of due diligence and independent thought and luck. I can't tell you how many times I've had massive pulmonary emoboli diagnosed in patients without any risk factors or unstable vital signs. But I've also had patients with every sign and symptom conceivable and a high pretest probability who's workup was negative.

I recently had a 96 year old male that was admitted through the emergency room with pneumonia. The hand off was straight forward. My night doc partner took the call for the day docs to come evaluate in the emergency room after morning report was complete.

ED Doc: I've got an elderly man in room six that needs to be admitted for pneumonia.
Night Hospitalist: OK, we'll send someone down there in a bit.

So Happy went to admit this 96 year old man with pneumonia. I took a look at all the data. The nursing home transfer sheet said his oxygen saturation was 78%, improved to 88% on three liters. He had dementia. His history was unreliable.

I took a look at the chest xray and noted the patient to have a basilar effusion on both sides. He also had possible infiltrates associated perhaps with the compressive atelectasis. He had no evidence of jugular venous distension.

At the point of my evaluation he had an oxygen saturation of 100% on a nonrebreather, which is the over compensated oxygen delivery of choice for any ED patient who even looks short of breath from the door way. He appeared to be a pleasantly demented man in no distress.

He was afebrile with a white blood cell count of 13K. He had already received his dose of antibiotic in the emergency room, beating the CMS quality indicator time period by a good four hours. But something just wasn't right.

Why did the guy suddently decompensate so quickly? Why was his infection count basically normal? Why was he afebrile? And why did he have effusions present? I wasn't convinced he had pneumonia , sepsis or any other infectious process going on.

So I ordered the d dimer level. I ordered a BNP blood test and a procalcitonin. Why you ask? These are three excellent blood tests who's negative values help to exclude, with high probability, the likelihood of having disease (great negative predictive value). A normal d dimer level would dramatically reduce the clinical probability of pulmonary embolism. A normal BNP would dramatically reduce, if not eliminate the probability of acute heart failure. And a normal procalcitonin assay would all but exclude a bacterial infection as the source of respiratory failure.

I could have admitted her as a pneumonia. She certainly could have it. I could have left it at that. I could have accepted the diagnosis of another excellent physician and proceeded with the management of the patient as one of pneumonia. But I didn't.

I used my clinical experience to tell me that all the data wasn't adding up. When the d dimer level and bnp assay both came back very high and the procalcitonin level normal, I knew that the diagnosis was originally missed. It happens to all of us. Pneumonia was a very plausible explanation. It just wasn't the right explanation, this time. Lawyers would say that a bad outcome from a delayed diagnosis should be compensatory negligence in our current tort system. This is just one common example of why the medical legal process is flawed. Part of the differential diagnosis process requires a failed or delayed diagnosis.

Subsequent studies confirmed the pulmonary embolism diagnosis. A massive saddle embolism.. It also showed evidence of a failing heart pump. I could have been pigeon holed into the diagnosis of pneumonia. This is a major diagnostic error that physicians battle all the time. The herd mentality can pigeon hole doctors into accepting the most popular diagnosis. But taking the time to independently evaluate the data requires an extra step of diligence, every time.

Is it negligence that the diagnosis was missed by the emergency room doctor? Of course not. Missed diagnosis is part of the differential diagnosis process. And no matter how diligent we as physicians are, we are never going to get it right every time. I just happened to get it right this time. Next time, the patient may not be so lucky. Thus is the nature of clinical medicine.

365 Days of Discharge Episode 6

Fibromyalgia Diagnosis Evolves Through Five Important Stages

2009-11-03T08:15:00.002-06:00

Fibromyalgia diagnosis is a diagnosis of exclusion. Don't have anything else wrong with you and you have multiple trigger points? You've got fibromylagia. The rheumatologists had a heated discussion last month about whether fibromylagia diagnosis rose to the level of disease status. A rather interesting discussion indeed. In Dr Kevin's comments a rheumatology fellow left a classic description of the evolution of fibromyalgia diagnosis as seen through the eyes of the medical student all the way to private practice. I highly encourage you to go read it. It's freekin' funny. Here's a peek at the five stages of evolution for fibromyalgia diagnosis:

Stage 4 (Fellow): Sigh, why am I getting another fibro consult. It's not rheumatic--it's a disorder of central pain processing. It's a freaking neurologic disorder mostly related to chronic untreated pain from other diseases or from sleep disorders. Either have the primary deal with it or just to piss off my (neuro) wife, consult neuro.

Consult Neuro. Ha. Now that's good humor

Is Fibromyalgia Real Or Is It An Example Of A Pathoplastic Disease?

2009-11-03T06:00:00.002-06:00

Is fibromyalgia real by the strict definition of a disease? That's the question that was debated last month at the American College or Rheumatology. An interesting discussion was had about whether strict scientific method should be embraced or whether fibromylagia was an example of a pathoplastic condition.

He spent much of his allotted time discussing the phenomenon of how the label we attach to a disease or condition, and how our perception of that disease, changes over time. This mutability of language and perception, and the need that patients and clinicians have to give a name to the cause of illness or distress, what Russell referred to as pathoplasticity, has led to a whole host of loose collections of commonly experienced symptoms to be elevated to the status of disease.

I bet you're wondering what I think. Is fibromyalgia real? I think fibromylagia is all in your head.

Why Are Nursing Student Uniforms White And Why Do They Wear Those White Hats?

2009-11-02T15:44:00.000-06:00

I've often wondered why nursing student uniforms are white. Why is that? I almost blinded myself the other day after jumping into an elevator with eight nursing students all dressed in their white nursing student uniforms. It seems like the worst color to go nursing in.

I'm sure nursing students wonder the same thing. They come to work in a hospital dressed head to toe in white. These same nursing students are managing patient care issues that often involve blood, puke, urine, feces, spit and pus. Why would any training program want their nursing students to wear a color that shows every stain?

And those white hats. Why do student nursing uniforms come with those white hats? These days, none of the American nursing students wear them out in public, except perhaps during Halloween. Occasionally, I'll see Asian nurses or nursing students shadowing their American counterparts in some sort of exchange program. The always seem to wear the white hats. I wonder why that is? I'm not sure what purpose the hat serves.

When I first started working at Happy's hospital, there was a nurse who always wore the white hat. I found it odd, but very retro at the same time. And kind of cool too.I'm not sure what the patients and families think of those old time white hats.

So, does anyone out there know why nursing student uniforms are always white?