From what I’ve seen, the most lucrative hospitals are those that you don’t typically consider to be academic powerhouses. On the contrary, many of them appear to provide care that is far from excellent. Based on personal observation and unfounded stereotype, I’ve created an action plot of the ultimate medical provider framework (outside hospital):

Update 5/5/09 18:30: I’ve realized that cardiac cath reimbursements aren’t what they used to be. The big revenue generators these days are the imaging modalities, like MUGA scans, and even ABI’s. Having a nuclear medicine lab would help pull in the big bucks.

medicine humor, medicine

Illness drives us to illogical decisions, and that’s one of my pet peeves in medicine. As doctors, we think that we know what’s best for our patients and frown when they disagree with us. We are even trained in medical school and residency to put ourselves into their shoes to help guide our decisions. Yet with such extensive preparation and almost a year of clinical practice behind me, I still am unable to rationalize some of the decisions my patients make.

Last evening I was paged by nursing that one of the asthmatic patients demanded to be discharged from the hospital, at 10:45pm. She was taking multiple anxiolytic agents, along with sedatives. She complained that her wheezing had not improved since admission, and that she “needed” to leave. Earlier in the evening outside of visiting hours, she had a visitor who demanded to meet her in the hospital lobby. When security denied their rendezvous, she threw a fit.  I gave her a standard discussion about leaving against medical advice, and that I did not believe it would be ideal if she left in the middle of the night while she was ill.

Over the next hour, she demanded to speak to me over 5 times. I presented the AMA form that relieves the hospital of any wrongdoing if she left and told her that she could even die with untreated asthma. Around 2am, the nurse notified me that the patient had left the hospital.

I guess she was probably withdrawing from some illicit substance, like a third of my patients predictibly do (I am working at an inner city “Outside Hospital”).  Afterward, I felt disturbingly relieved that my patient had left–I wouldn’t have to write a progress note on her in the morning.

medicine medicine, rant

You’ve probably heard about the outbreak of swine flu in various parts of the U.S. and Mexico recently. We even received a page via the UrgiCare service that one mother believed that her daughter had swine flu today! Talk about mass panic.  Interestingly enough, the swine flu is of a similar in subtype to the flu that caused the 1918 Spanish influenza outbreak (H1N1).  Google has set up a tracker to follow all of the suspected swine cases in North America:

View H1N1 Swine Flu in a larger map

medicine humor, medicine

I’m at the point in my internship that taking overnight call on the inpatient floors is more of a chore than a challenge. We admit patients, and field a few dozen nursing pages that are usually manageable. I walked into call yesterday with my 95 year-old lower lobe pneumonia patient rolling into atrial fibrillation with a rapid response rate of 180. For some reason her blood pressure was also elevated to the 180′s systolic, which isn’t as common in a-fib. The kicker was that she wanted to be full code. Great.

As I was ordering a diltiazem push, an ICU nurse had materialized at the scene–apparently the floor nurses called a rapid-response code (RRT) behind my back. RRT codes are usually called when a patient needs of prompt attention when housestaff aren’t available immediately. I was, however, already at the scene. No time for hurt feelings though–I was glad that help had arrived, especially since my senior resident was nowhere to be found. My brain had already closed down to internal medicine knowledge, as I’ve since mentally moved onto starting ophthalmology residency.

Soon afterward, a cardiologist arrived to evaluate her. We transferred the patient to the ICU later that morning, and started her on a diltiazem drip. She stabilized for the next 12 hours until the evening rolled around. She then became delirious, pulling out her lines, jumping out of bed, and muttering nonsense…all typical of ICU psychosis. As I was redirecting her back to bed a third time, she decompensated, and spiraled down to a rapid heart rate again. She further deteriorated and required intubation.

Daytime soon rolled around, I signed out to the day team. I now have a 95 year-old woman on a ventilator. Great. I wonder what other excitement will be had when I come back on Monday…

medicine medicine

Since a portion of my web traffic originates from the medical community, I’ve decided to provide an update on a web technology that you’ve all probably heard about, Twitter. We see links to Twitter on websites, news links, and even television ads. Just what does this ubiquitous, cute bird do, and what role can he play in the medical field?

Those of you using Facebook are also probably wondering whether Twitter is any different from your Status. Well, the truth is, it’s not. To take a step back, Twitter serves as a one-way bulletin board. You can post whatever you want on it for the world to see, but others cannot write on your bulletin. Your viewer do not require an account on Twitter, nor do they ever have to log in. In contrast, your status page on Facebook can only be viewed by your designated friends.

The strength of Twitter lies in its accessibility. The owner can post links via SMS, website, email, desktop application, or portable application. It is concise, and viewable by the public with any of the aforementioned posting media. Your followers can receive automated updates on your bulletin. Therefore, it is an expedient means of communication.

I first saw the use of Twitter in medicine from Henry Ford Hospital, where they broadcasted updates directly from the OR. This was innovative, because it was a means for the public to become involved in the operating room. Imagine receving real-time updates on the carotid endarterectomy from OR #12:

“The shunt has been bridged!”

“EEG shows activity!”

“The resident calls for the yellow-tails!”

I would certainly try to incorporate the medium in my OR. Twitter’s application can also be extended beyond the OR. You can post updates from the clinic via Twitter.

“Dr. is running late today.”

“Two openings at 4:15pm today. Okay to walk in.”

The key is, of course, not to abuse posts to the extent that your patients become sick of getting updates. There is certainly a fine balance to be had. That’s it. Go to Twitter.com. Open an account. Play with it. In the meantime, you can follow my Twitter, also viewable on the side column. Real-time. Real news. Good stuff. If you have questions, contact me.

Update (4/23/09; 9:07pm): Mayo Clinic has even jumped onto the Twitter bandwagon, holding a webcast presentation on Twittering. Great stuff.

computing medicine, tech