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Showing posts from February, 2014

The Hospital Dependent Patient--some people will be in and out of the hospital despite our best efforts to make them well

This week the New England Journal of Medicine published an article by David Reuben MD and Mary Tinetti MD, both academic gerontologists, about patients who are unable to stay out of the hospital. The two physicians study the problems of old people, and are of the opinion that most of these "hospital dependent" patients are elderly. Certainly some of them are, but in my experience a surprising number are just chronically ill, usually also poor and with home situations unequal to their vast medical needs. Drs. Tinetti and Reuben are apparently studying these patients, thinking about solutions and now focusing us on this special population.

Hospitals potentially risk not being paid for patients who return to the hospital with new or persistent diseases within a short time of discharge. (I wrote an article on the history of this several months ago which points out some of the same issues that Dr. Reuben and Dr. Tinetti mention as well as how this fits in with the history of Med…

Requiem for ABC David.

When I first learned to take care of patients in the hospital, as a third year medical student, we used a mnemonic to help us remember what to order when a patient was first admitted. Patients would come in to the hospital from a doctor's office or from the emergency room and the nurses needed a set of orders to know what to do for the patient. The mnemonic we used was "ABC DAVID." This is how it worked:

Admit: to medical surgical unitBecause: diagnosis--Congestive heart failureCondition: guardedDiet: sodium restrictedAllergies: no known drug allergiesActivity (sorry, 2 A's): bedrest with bathroom privilegesVital signs: every 4 hours while awakeInvestigations: chest x-ray, morning labs - chemistry panel and blood countDrugs: digoxin, a diuretic, potassium, a beta blocker, maybe insulin or blood pressure medications, acetaminophen for pain, something mild for sleep, if needed. It worked pretty well. It did allow me to forget certain things that I really didn't wan…

Mammograms don't help--and the dog that didn't bark in the night

In the short story "Silver Blaze" by Sir Arthur Conan Doyle, Sherlock Holmes remarks that it was very curious that when a race horse disappeared and its trainer appeared to have been murdered, the dog was not heard to bark. Dogs are supposed to bark when odd things happen in the night. If they don't, it means something.

Today Reuters commented upon the most recent article in a series over several years showing evidence that mammograms do not reduce death from breast cancer. Although this is not actually a new finding, it is still big news in the US where the wisdom of having regular mammograms is rarely questioned. In my junk email folder I get commentary on the most influential news from medical meetings and journals from organizations such as Medscape and Internal Medicine News, organizations primarily funded by drug and device manufacturers, but also by other aspects of the business of medicine. These organizations successfully take it upon themselves to educate phys…

Sick patients with chronic diseases and the wisdom of Dr. Bernard Lown

I have been doing admitting shifts at a large hospital, as hospitalist. It is flu season, so volumes are large. Even people without the flu are sick. It often happens that way. And they are so very sick!

The thing about the very sick patients I see is that they are generally what might be called "medical train wrecks." They are very sick because they have had interventions over the years that have caused them to be dependent on more medical interventions. In some cases this means that they are alive when they would be dead otherwise, and in some cases medicine has allowed them to make more terrible choices in their lives and be subsequently more miserable than they would have been if forced to face the logical consequences of their behaviors. Often these two stories are played out in the same people. It is hard to take care of these people because they have had so much done to them, have taken so many medications, had so many complications that the landscape of caring for t…