Suffering As A Screening Criteria For Palliative Care Referral

The total pain1 and total dyspnea2 models can be expanded into a model of the multidimensional suffering of patients experiencing serious or life-threatening illness3. These models describe symptom burden in terms of associated physical symptoms and loss of functioning; psychological impact and its effect on emotion, coping, or adjustment; social impacts on identity, role, and relationships; and spiritual impact on coping, existential distress and meaning.

This suffering model has the potential of being a screening criteria for referral to specialist palliative care based on suffering rather than disease state. A hypothetical paradigm to empower patient self-referral might be:

• Does your disease or its symptoms feel intolerable or make you feel debilitated, weak, or fatigued to an unbearable extent?
• Does your disease or its symptoms cause you to feel sadness, fear, or anger to such an extent that it impairs your functioning?
• Does your disease or its symptoms cause you to question your personal, professional or familial identity or role?
• Does your disease or its symptoms cause you to question your beliefs or cause your beliefs to be unsupportive?

If you answered yes to any of the above questions, would you like to see a team that deals exclusively with diagnosing, managing, treating and preventing this kind of distress?

If they answer yes referral to specialist palliative care team should follow. Just a thought.

References

1. Dame Cicely Saunders
2. Curr Opin Support Palliat Care. 2008; 2(2):110-3

3. www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=312.300

Tucking In

In the era of shifts rather than calls, the art of "tucking in" a patient is being neglected.  In the past this generated pages to wake you up but now it generates unneeded business for your colleague who is covering for you.  When the "night float", "nocturnist" or "nocturnalist" is getting paged for a sleeping pill, acetaminophen, or a laxative you are getting a reputation of being lazy, short sighted, and a person who wastes clinical temporal resources.  While your therapeutic regimen may treat the patient, their symptoms do not spontaneously alleviate as soon as the medications hit the blood stream, there is a temporal lag.  In addition, your patient may develop new complaints only peripherally related to their presenting diagnosis.  Imagine, if you will, being a traveller trapped in a hotel room, that you forgot your luggage, and you have to call the front desk for permission to get up to use the lavatory.  This is the powerlessness experienced by patients, who may need trivialities to feel better but have to have a doctor's order to get them.  It is critical to see to the diagnosis and intervene but it is a necessity to see to your patient's comfort as well.  By nature, "tucking in" a patient uses adjunctive measures, medications that the benefits of comfort do not outweigh the risks of side effects, adverse reactions, or worsening the hemodynamic status of the patient.

Rate Controlled Unidirectional Gastrointestinal Motility

People don't like vomiting, nurses like it less than anyone else.  People also like a semblance of bowel regularity and consistency, too much and too little are both subject to complaint, a complaint that is geometrically proportional with age. Symptomatically treating nausea, vomiting, diarrhea, and/or constipation does not solve the problem, your diagnostic inquiry and therapeutic intervention must still proceed.  Where I trained ondansetron was the front line antiemetic of choice, however it can only be given twice in one day.  Therefore a breakthrough or back-up agent such as prochlorperazine, promethazine or metoclopramide is a good idea.  If their nausea and emesis is due to a systemic response to ischemia or infection, the management of the the cause will fix their symptoms, the time delay in improving cardiac perfusion and treating that urinary tract infection will be covered by anti-emetics.  If the nausea and vomiting are due to obstruction or ileus you will be better served with a nasogastric tube to low intermittent suction than just anti-emetics, alleviating the distention and pain which may or may not help the actual problem does help their symptoms, without hiding that massive amount of intestinal content that is just waiting to be ejected when their vomiting centers come back on-line.  Lastly, look the side effects of analgesia, opioids are notorious for causing nausea and vomiting, sometimes simply switching your analgesic regimen will help.
On the back end, people like a "normal" bowel routine.  Once the rate, composition, and volume changes they get concerned and want action.  Constipation must be excluded from ileus or obstruction.  In constipation you still have gas and no other symptoms aside from the abdominal discomfort.  Physicians' are the leading cause of in-hospital constipation, we make people take their iron supplement, PPI, and we fluid restrict them.  We address their pain needs without looking out for opiate-induced bowel dysfunction.  Once your sure it's constipation and not its malevolent cousins ileus or obstruction, you can always work on their bowels with bisacodyl, milk of magnesium (MOM), magnesium citrate, or enemas.  If they have kidney disease avoid the magnesium and phosphorus and try lactulose.

Feed Me

I just waxed poetic about this the other day.

Oh Dr. Sandman Bring Me a Dream...
Sleep is a valuable therapeutic tool.  People want to be "knocked out" a lá the late Michael Jackson to get that good nights' rest and get better.  However the layman does not understand that the medications we use as sleep aids can easily push one over into respiratory depression and failure.  On the flip side, a little sleep deprivation can move the recalcitrant patient toward discharge because they sleep better at home.  Hospitals are loud, obnoxious places.  You have a new, equally ill room mate, an open door to a lit corridor, you often times have things stuck to or in your body, you're probably tethered to some who's-is-what-is-it, you have apnea, telemetry, and bed alarms going off, and vital signs being checked at all hours of the night and labs drawn at other times.  IV pumps are loud and voices carry in the halls of healing.  Patients are not allowed to rest and do not feel in control.  This leads to an upset person when you preround at the crack of dawn.  Thus sleeping aids, which don't actually improve sleep but do make people forget that they woke, may be of benefit.  However only use them when you are sure that there is no other reason keeping the patient awake such as pain, anxiety, or delirium and that by giving them a respiratory depressant you will not precipitate respiratory failure.
First trim tethers such as IV fluids, Foley's, and NG-tubes.  Also get rid of alarms you don't need, like the telemetry and apnea alarm on your comfort care patient.  Eliminate unneeded lab draws and foster communication between nurses and patients so that evening vitals can be done before the patient decides to go to bed.  Consider non-chemical adjuncts to foster sleep such as no naps and increased activity during the day, turning the television off at bedtime, switching their phones off, or finding them some boring reading material.  Limit caffeine intake in the later part of the day.  Controlling pain can help with sleep, so make sure you have an adequate analgesic regimen in place.
Where I trained our formulary advocated zolpidem.  This is the pill that one of my nurses referred to as "the pill that turns my sweet 80+ year old patient into a psychotic nudist".  Benzodiazepines can also be used, either long or short acting, but benzo's are known to cause delirium, more so than zolpidem.  Diphenhydramine can also be used but is also deliriogenic.  Generally, if a patient is on benzodiazepines and not sedated I continue them to prevent withdrawal.  If the patient insists that diphenhydramine is the only thing they can take for sleep, give a small dose a try.  But neither of these medications are "goto" drugs for the sleeping aid naive.  Haloperidol is a good choice if their insomnia is due to hyperactive delirium.

The DIE-t Order

The start of a new academic medicine year reminds me of the initial shock of being a 'tern.  My first rotation was ambulatory medicine and I had recurrent waking nightmares about a patient presenting to the clinic with chest pain.  That initial day in ambulatory clinic the first patient simply wanted his medication explained and the second a refill.  Feeling saucy I was ready for the third until he said, "I have chest pain".  With that I ran from the room, forgetting further history or physical, and called my attending to staff, which sounded something like this: "The patient has chest pain.  In the thorax.  You know, in the chest area.  It is painful, in his chest." Awed by this clinical marvel, my attending sighed and took over, tempted to administer a benzodiazepine or a swift slap to the back of the head of the hyperactive intern.
My next rotation was the ICU, where experienced nurses carefully took us by the hand and shepherded the "intensivist interns" away from too much stupidity, tactfully paging me when they needed a critical intervention of acetaminophen or an antiemetic while deferring the more mundane ventilator adjustments and anxiolysis to the attending.
My third month was on the floors at the VA.  On-call.  With a suboptimally motivated or interested senior resident.  The resident had vanished before shift change leaving me to face a barrage of sign-offs and nursing shift change.  My first solo decision was...the diet order.  Never has a physician faced such consternation and mental gymnastics as I did when making this pivotal decision.  I thought back to my clinical nutrition rotation and pondered the need for enteral versus parenteral nutrition.  I weighed his medical problems, each one indicating a specific diet.  The nurse, patience fraying as the minutes ticked by finally threw me a clue with the infamous, "Well last time he was here he had a regular diet". Sold! One regular diet order coming up.
In medicine you need a system for making decisions, all of them are important but some are more important than others.  Some of them need to be made right now and some of them can be made later.  Americans are obsessed with food.  Obesity epidemic being corpulent evidence of the same.  Patients with intractable abdominal pain or who have just been told that a myocardial infarction has destroyed the pumping ability of their heart are more concerned with getting that next megaburger with ubër fries and a diet Coke then the next diagnostic and therapeutic step.  Been vomiting all day after eating? Family says feed her.  Had a stroke and with each meal starts hacking and turning cyanotic? Family says he can't get well if he doesn't eat.
This oral fixation drives nursing to page as soon as the diseased hit the floor, regarding the diet order.  Regardless of the vital signs, presenting complaint, operative or procedural needs the first thing I usually hear is "Can they eat?"  Despite a chronic history of "just say no" I still get the question.  Patients are usually blessedly monosyllabic while they eat, making it a perfect time to get a history or for nursing to get done.  However, food or withholding of the same is a therapeutic decision and should be made after  the physician has determined the problem and the solution for the same.  If there is no aspiration risk consider limited ice chips, patients are much happier if they don't have a dry mouth.  Unless they have been given a large dose of insulin or other anti-hyperglycemic medications, skipping one meal or even a whole days worth (as long as they are adequately intravenously hydrated) has never killed anyone.  If they did you would have a case report of hyperstarvation.
So how do you decide the diet order?
First decide if they can or cannot eat.  They cannot eat if they have a condition that will be worsened with intake or they will have a procedure the next day.  Typically they can eat up until midnight if they are having a procedure or operation.  Conditions that preclude intake are neurological insults (e.g. stroke, aspiration pneumonia) that have caused or increase the chance of aspiration, nausea ± emesis, abdominal pain of suspected gastrointestinal origin, blood coming out of the esophagus or rectum, a blood glucose > 400 mg/dL, and recent surgery or procedure until cleared by the surgeon/proceduralist.
Next choose their diet, basically look at their health problems and choose, e.g. hypertension = 2 g sodium, heart disease history = cardiac (trumps hypertension), diabetes = diabetic, both = cardiac diabetic, on dialysis = renal, hyperkalemia = restrict their potassium (which there is an abundance of in salt substitute, tomatoes, oranges, and bananas).  If they forgot their dentures, puree it.  If they have diet restrictions from the nursing home continue them.  If they have been losing weight, no liver disease, and cancer has been excluded or if they have low serum protein and albumin add some CIB shakes.  When in doubt about the calories ask a dietician to see them, when in doubt about the consistency ask the speech therapist to see them.  The longer you think they are going to live the stricter the diet needs to be.  The octogenarian with advanced cancer probably doesn't need to worry as much about her A1c as the newly diagnosed type I diabetic.
If they cannot eat you will need to come up with some form of nutrition other than the meager benefits of D5*.  As a rule of thumb, three days without food should be the temporal trigger for initiating some form of nutrition.  Always use the gut first if you can, consider a Dobhof for tube feeding if they cannot swallow with consideration for a PEG-tube (G-tube) if they are still deemed unable to swallow.  Be aware that neither tube decreases aspiration risk.  Sometimes the stomach needs to be bypassed and a GJ-tube can be used.  If the etiology of the NPO status precludes enteral feeding, i.e. a gastrointestinally-based intraabdominal etiology, consideration toward parenteral nutrition via a PICC or central line must be undertaken.  With either tube feeding (TF) or total parenteral nutrition (TPN) a dietician consultation is highly recommended.

*The amount of kcal (Cal) per liter of D5W = 5000 mg/dL x 3.4 kcal / g x 1 g / 1000 mg x 10 dL/1 L = 170 kcal/L.  Thus a patient receiving 150 mL/hr of D5 NS would receive 170 kcal/L x 150 mL/hr x 1 L/1000 mL x 24 hours = 612 kcal per day.  As the average caloric intake per day ~2000 kcal this is a starvation "diet" and catabolic.

The New Magic

Perhaps inspired by Z Dogg MD's A Muggle's Guide to Med School I'm drawn to the parallel that modern medicine although seemingly steeped in scientific rigor and experimentally verified practice is still the same witch doctor shamanism that attempted to prognosticate disease since time began. Incidentally time was invented simultaneously with medicine for billing purposes. Rather than tea leaves we have tests, instead of augeries we use electrocardiograms to try and divine not only what is currently wrong with our patients but what is going to happen to them in the future. Each specialty owns its own oracles, which they use to bitterly confuse the initiates of medicine, the residents, and baffle the hedge wizards such as myself, the general internist. Here are some of the specialists go to tricks:

Cardiology: Electrocardiogram (EKG)

Both American and European cardiological societies (Circulation 2007, 116:2634-2653) are quite clear on this: myocardial infarction is defined by an elevation in cardiac markers, particularly troponin, with suggestive symptoms (i.e. chest pain) or electrocardiographic changes (actually that's just one definition there are others). Specific EKG changes such as new ST-elevations or new LBBB need acute cardiac catheterization as does non-ST elevation MI with continued pain. The argument that because the EKG is normal or "nonischemic" that this presentation is not related to cardiac ischemia cannot be validated until subsequent cardiac markers are negative, four to eight hours later. Although if you do suspect cardiac disease, check them sooner as you may be able to detect a positive trend. Remember too that an EKG is a snippet of time, if the patient is asymptomatic at the time, the associated electrocardiographic event may never be recorded on the EKG, particularly in cases of paroxysmal arrhythmia. It just goes to show that an EKG with diagnostic findings need to be corroborated with further diagnostic testing and that a pristinely, normal EKG has about as much association with mortality as tea leaves do. It also shows that telemetry, if it can be correlated with episodes of symptoms,` may increase or decrease the likelihood ratio of a cardiogenic etiology.

Critical Care: Arterial blood gas (ABG)

The ICU is essentially a place for one or both of two things: ventilators and vasopressors. Thus if the patient is in some form of shock to the ICU they go. You don't need an ABG to diagnose shock, although a PaCO₂ < 32 mmHg is one of the systemic inflammatory response criteria, and would be useful but not necessary to diagnose sepsis. Elevated lactate > 2 mmol/L and not the pH is criterion for severe sepsis. The decision to intubate can and should be made independent of the blood gas (Manual of Emergency Airway Management), how the patient appears clinically in terms of work of breathing, airway protection, and level of consciousness is a better indicator of requiring invasive positive pressure ventilation. The ABG allows you to assess response to mechanical ventilation and to make adjustments that the patient's body is, hopefully transiently, physiologically unable to do. Thus the arterial blood gas is a powerful tool for assessing how a patient is currently doing and how they have responded to interventions, it does not clinch the diagnosis of shock nor is it the tool to decided whether or not a patient should be intubated.

Endocrinology: Cortisol

No laboratory result is more nebulous than the cortisol level. Although a random cortisol level < 3 ug/dL is highly suspicious for adrenal insufficiency and > 10 ug/dL is unlikely to be adrenally insufficient, further testing using ACTH stimulation is often required to delineate if they actually have adrenal insufficiency. To the endocrinologists chagrin corticosteroids have usually already been given, dexamethasone being the one that shouldn't confuse further diagnostic testing. The amount of ACTH to administer and the time to wait superimposed on the reality that the timing of drug administration to lab draw is seldom accurate makes the subsequent determination of the result a question fraught with perils, particularly when the results make adrenal insufficiency less likely but the administration of stress dose corticosteroids resulted in a marked clinical improvement. This may be why the administration of corticosteroids without checking serum cortisol level is part of the Surviving Sepsis Campaign.

Gastroenterology: Rectal exam and fecal occult blood testing

The rectal exam is the most avoided exam there is, the reason for which is presumably related to provider discomfort and the time it takes. It is only clinically important when it is not done. The rectal exam is touted in the work-up of gastrointestinal bleeding, but is only useful if frankly positive, i.e. active bleeding is observed, indicating that bleeding is most likely rapid and/or in the distal colon. A negative fecal occult blood test does not eliminate gastrointestinal bleeding. A positive test indicates that there is blood in the gastrointestinal tract the source is unclear and swallowed blood from another source is not excluded. In fact Intern Med J. 2010 Feb;40(2):107-11 claims that "there is no place for FOBT in an acute hospital setting."

Hematology: Peripheral smear

The peripheral smear are the tea leaves of the hematological world. For the work-up of too much or too few platelets, red, or white blood cells it is the go to test of choice for board examinations, usually with an attached image for our interpretation. While diagnostic in some conditions and helpful in directing clinical decision making in others it is no longer a convenient test. A long time ago in a hospital far, far away residents and fellows performed peripheral smears on the floor. They drew their own blood, prepared their own slides, and viewed them under the microscope. They had clinical information within minutes. In today's hospital peripheral smears are prepared in the lab, reviewed by the pathologists every second Thursday of the month, and finally obtained by the hematologist for a second look. That makes this test more mysterious to the generalist because we don't do it and less diagnostically useful due to the time lag.

Infectious Disease: Gram stain and culture

The potions and poisons of infection are a world with constantly evolving diagnostic results, starting with the Gram stain, followed by the quantitating and qualifying the bacterial type, and finally determining the susceptibility to antibiotics. Testing after antibiotic administration nullifies the accuracy of results, and some infections leak so few bacteria, i.e. endocarditis, that not two sets but three sets of blood cultures are drawn. Unfortunately empiric therapy must be initiated prior to the test results, and even if those results are negative, patient's often improve while antibiotics are on board whether due to them or not is unclear. Antibiotics have a recommended duration, three days for uncomplicated urinary tract infection, and weeks for osteomyelitis, endocarditis and line infection. Once committed to a diagnosis we are committed to a course and the attendant complications of multi drug resistance and C. difficile diarrhea. Oft touted clinical markers of infection such as fever or leukocytosis are not exclusive to infection. As we grow older our febrile response weakens, meaning that an elderly person without a fever can still be septic and bacteremic but treating the marked leukocytosis of CLL with antibiotics is well amusing to our specialist colleagues.

Nephrology: Urine analysis

The urine analysis, the tea leaves or at least the result of them, is the bedeviling test of renal disease. Unfortunately the urine analysis is nonspecific for severity of disease. Furthermore the results are affected not only by what portion of the stream the urine is obtained but the time between acquisition and analysis. The versatility of the urine analysis decreases the worse the renal function becomes. Woe to he or she who obtains the UA in ESRD while in the anuric patient the urine analysis impatiently awaited by the nephrologist isn't going to change anything, there's no pee for them to see.

Neurology: Magnetic resonance imaging of the head

Unless of course the patient has the wrong type and collection of metal in the the wrong location in which case the test of choice is the CTA. Prior to tomographic imaging, neurology used carefully elicited signs to diagnose the diseases neurological. Thus neurologists nearing retirement these days amuse themselves by diagnosing the disease and pinpointing the lesion (Lateralize! Levelize! Localize!) before the imaging can get done. They then sit back and chuckle at our wonder at their acumen. With the advent of three dimensional brain and spine imaging, the need for superior exam skills decreased and reliance on the imager for diagnosis has increased.

Oncology: Biopsy

Despite the cases where endoscopists and radiologists have put their reputation on the line by saying, prior to any pathological data and with minimal clinical data, "looks like cancer", heavens be merciful to anyone who pages the oncologist with the right story and subjective evidence but no pathology. Unless the pathology is back, after being confirmed at a tertiary center, it is not cancer to the cancer doc! In their defense, no cancer will kill before the pathology is back, if it does the disease was so advanced chemotherapy would not have made a difference anyway. Also treatment regimens are titrated to the diagnosis, so pathology is important for directing therapy and prognosis.

Pulmonology: Pulmonary function test (PFT)

In the diagnosis of obstructive versus restrictive lung disease and for the establishment of chronic obstructive pulmonary disease (Global Initiative for Chronic Obstructive Lung Disease) the pulmonary function test is key. However they are performed on patients at their baseline to obtain measures of severity of chronic disease and aren't usually available in-patient. Also PFTs never get better, given the limited therapeutic options we have for pulmonary disease, we don't manage the disease so much as try to decelerate its decline. So with the knowledge they have a chronic problem, we have little evidence to know who will need merely some nebulizer treatments, who will need intubation, and who will die. But still the pulmonologists will ask for or refer back to the PFTs obtained at a time of relative pulmonary stability.

Rheumatology: Inflammatory markers and nearly anything prefaced with anti-

When the signs and symptoms make no sense, the cause is either rheumatologic or psychogenic. Autoimmune and connective tissue disease are diagnosed with inflammatory markers and multisyllabic serum tests starting with anti- (i.e. anti-double stranded DNA antibody or anti-phospholipid antibody). After a battery of these tests, which are oft repeated because of their poor sensitivity and specificity the rheumatologist will arrive at some equally multisyllabic diagnosis (i.e. systemic lupus erythematosus or granulomatosis with polyangiitis (Wegener's)). And then they prescribe corticosteroids.

What is a poor wizard to do?

Hospitalistin'

Keep the Big Picture in Focus
People should be admitted to the hospital because they are sick enough to have an increased chance of dying relative to those going home. My overall patient-by-patient "mission statement" is: Find the diagnoses and offer treatment options that decrease acute mortality and chronic morbidity through efficient and high quality care. Offer palliative care options when such treatment is medically futile or does not provide significant gains in the quantity to quality of life balance. The patient needs to be looked at as a gestalt of both data and intuition regarding the level of acute injury inflicted on the substrate of a certain level of chronically damaged protoplasm. I have to explain to my patient and their circle that based on what I think is going on, will the treatment options available improve their lives and do those benefits outweigh the risks of that treatment. If not, pursuing aggressive treatment of the untreatable is a study in futility, and palliative care options should be introduced. Understanding the worst case scenarios, is in my opinion, more valuable to both provider and patient than painting a rosy picture of the future. It is important to foresee negative outcomes to know what to test for and what you may need to treat, but without either you or the patient losing sight or hope of positive outcomes. Positive outcomes do not necessarily mean a cure, it may mean pain control, dignity, and even a peaceful death.

Sweat the Details
A good internist is a scared internist. Worried about what has happened, concerned about why the current state of their patient is different from before, wondering how complications can occur in the future. We take a microscope to abnormalities, trying to tease out if this is incidentally benign or malignant, wondering if this is evidence of disease or simply a normal perturbation. Hospitalists must be the diagnostic laser, making lightspeed decisions about what to pursue and what to defer as well as carefully convey to outpatient follow-up. We must carefully dissect subjective complaints and objective data using the scalpel of evidence-based criteria and a wealth of subspecialty guidelines. We must thin the electronic medical record of redundant or inaccurate diagnoses while updating it with new history. The patient's medication list is not simply the medications they are prescribed but those they are actually taking and when they are taking them. A hospitalized patient demands an agent, their hospitalist, who manages nutrition, hydration, electrolytes, medications, and ancillary therapist evaluations while requesting appropriate specialist consultation and preventing adverse events such as deep vein thrombosis, falls, and delirium. We must take a collection of prior documentation to weave a history, amalgamate in-patient events, tests, and consults as daily progress notes, and then meticulously sift all of this into a timely, complete discharge summary.

Achieving Hemodynamic Homeostasis
I consider vitals to be an acronym for Verify If They Are Living Still. In general most hemodynamically regular people are euthermic with a heart rate between 60 and 90 beats per minute, breathing 8-16 times per minute, have a systolic blood pressure greater than 100 mmHg and less than 160 mmHg, and saturate greater 92% on room air. If they don't they are either (1) acutely sick with a physiological response, (2) chronically sick and at their (albeit abnormal for the majority of the human population) baseline, or (3) weird. Acutely ill humans should have a positive response to appropriate therapy, that is there vital signs approach normal, and negative one to inappropriate therapy. That being said, people die even despite the most optimal of treatment decisions, and people live despite our best unintentional attempts at killing them. You have to determine whether the population mean abnormal vital sign(s) are an indicator of acute pathology or simply evidence of chronic but stable disease.

Returning the Patient to Basal Levels Lab Result Rubor
People are often admitted because of the density of red (abnormal) test results they have. Although abnormals should be recognized they should also be placed within the context of their chronicity and severity. Some patients have bloody diagnostic tests at baseline. An elevated white blood cell count can be due to chronic lymphocytic leukemia, dehydration, stress, or infection. No matter what we as physicians do, it is unlikely that no matter what we do acutely we cannot change the leukocytosis of CLL. Antibiotics do not treat dehydration or stress, but not treating a pneumonia with its associated leukocytosis is tantamount to medical crime. Similarly a volume depleted patient may have a CBC in the black, volume contraction hiding their basal anemia, just because they are less in the red, doesn't mean they are any less sick. An elevated creatine in a patient on dialysis has an impressive crimson hue but generates little therapeutic inertia compared to the same value in someone without previous kidney disease. No matter what intervention is undertaken, the patient with end-stage renal disease will never be in the black when it comes to creatinine, if we waited for this value to normalize before discharging the patient, they would serve a life sentence. As hospitalists we must find with the intent to treat the scarlet letter of abnormal but accept the chronic unchangeable crimson that will show up on some diagnostic tests. We can only attempt to restore our patient to the baseline they had before and hope to prevent the next decompensation as best we can.

Laws of Thermodiagnostics

A tongue in cheek application of the Laws of Thermodynamics as applied to medicine:

0th: If two diagnostic findings support a third, then they must support each other. No single diagnostic finding has ever made a diagnosis, it is a careful process of combining and comparing data that makes it possible to reach a diagnostic conclusion. Look at what your "facts" are, the diagnosis with the most "facts" supporting it is most likely the right one. Of course, facts in medicine are not as concrete as we would like to make them seem as demonstrated by false positive and negative results.

1st: You cannot win — A physician's diagnostic performance can be of one form (i.e. specific or sensitive) or another, but cannot be both. If you rule out a lot of different etiologies without ever ruling one in you are highly sensitive but not specific, and your patient still doesn't know what is wrong with them. If you always get positive results to your diagnostic inquiries you are highly specific but not very sensitive, and you are probably missing some disease in other patients because of missed testing.

2nd: You cannot break even — A negative diagnostic work-up does not decrease morbidity or mortality, while a positive one always increases both. Just because you didn't find a pathophysiological reason for a presentation doesn't mean that you didn't miss something or that your patient is any safer from future insults. Confirming a diagnosis simply means that you have named the disease and they now have the same increased risks as others with that disease as well as those from related or unrelated future insults.

3rd: You cannot leave the game — Absolutely false results must be worked-up, as there are no absolutes in medicine. Even the most spectacularly sound medical reasoning for explaining a false positive or random incidentaloma means nothing without further testing to corroborate that reasoning. Missed diagnoses kill, maim, and get doctors sued.

Ten Eyes for Looking at Disease

Hypothesis: All disease is caused by some combination of

I Injury (caused by an exogenous agent, this would include hemorrhage)

I Inflammation (caused by the human organisms response to injury)

Y Immune (caused by under, over, or inappropriate response of the human self-defense mechanism)

I° Infection (caused by an exogenous microbial vector)

I Ischemia (caused by lack of blood flow)

i Inadequacy (caused by mechanical failure)

Aye Incompetence (caused by physiological failure, heart failure would presumably fall in both)

I Intoxication (caused by poison)

I Iatrogenic (caused by doctors)

¿ Idiopathic (caused by an unclear reason that is not included in the above, the cop-out)

When it is about the heart, it is all about relationships

Let us start our tale with little Ms. P who has a relationship with the broad shouldered Mr. QRS. In a normal stable relationship (NSR), Ms. P is always accompanied by Mr. QRS. They plan to go to weekly dance classes with some other partnered friends, but it's difficult with the sometimes early and other times late Sinus Arrhythmia. The Sinus Exit Block couple are always punctual when they make it, but sometimes skip a dance class or two with no warning, only to be there punctually next time. The hardest folks to do any planning with is the Sinus Arrest couple, they not only miss classes they never get the time right on the next one, arriving early or late.

Relationships can be challenging, like when Ms. P's ex-boyfriend Pac (Premature Atrial Contraction) drops in. He wants to hang out with P and reminisce about old times, messing up the lovebirds orderly schedule. The same thing happens when one of Mr. QRS' old frat brothers from the PVC (Premature Ventricular Contraction) house crashes their place for the weekend.

However relationships can also have more serious discord or blocks between them:

• A first degree block places some distance between the two lovers, but still they remain together.



• A second degree type I block is demonstrated by P and QRS Wenkebach who grow steadily further apart until QRS cheats and P dumps the bum, but she forgives him and takes him back only for the cycle to repeat.



• The more dastardly second degree type II occurs in the relationship between P and QRS Mobitz II, where despite the illusion of a stable relationship, QRS gets drunk, cheats, and they break up. P is still a forgiving lady and takes him back, but the scalawag QRS will do it again.



• Divorce, or the third degree block, has complete disassociation between P and QRS

The thin and rhythmless rapper A fib has so many ladies (his P's) that he is only erratically spotted. He is not to be confused with the equally anorexic hip hop artist A flutter who usually dates only twins and triplets. Neither one of these artists jams should be confused with the sudden vibrant beat of the techno SVT, he brings a rapid rhythm that looks almost sinus. Rumor has he too has an eating disorder. Everyone knows a player like their friend Mat (Multifocal Atrial Tachycardia), he's got a different P every week.

Not so for the amphetamine and steroid abusing loner V Tach, no Ps for him in his destructive quest. He used to be a founding member of the all male deathmetal band V Fib, but they were too chaotic even for him.

Four Rs of fluids

Resuscitation	Rehydration	Rectification	Regular (Maintenance)
Situation
Shock Decreased blood pressure Increased lactic acid Decreased urine output	Hypovolemia +/- electrolyte abnormalities "Pre-shock" (downtrends in blood pressure or urine output, increasing tachycardia) Diabetic ketoacidosis Rhabdomyolysis Post-obstructive diuresis Hypovolemic acute prerenal failure Pancreatitis	Electrolyte abnormalities +/- hypovolemia Hypovolemic hyponatremia Hypernatremia Hypokalemia Hyperchloremic acidosis	NPO
Choice of fluids
NS LR Albumin Hespan (but numerous contraindications)	Typically composition is directed by published guidelines (as in DKA) or fluids can be formulated by the considerations for maintenance fluids given in the column furthest to the right. Remember that 40 mEq of potassium in a peripheral line has a maximal infusion rate of 125 mL/hr	Hypovolemic hyponatremia 0.9% saline ("NS", 154 mEq Na/L) 3% saline (513 mEq Na/L) Hypernatremia 0.45% saline ("1/2 NS", 77 mEq Na/L) D5 (0 mEq Na/L) Hypokalemia Given normal renal function, assume 20 mEq of potassium increases serum potassium 0.25 mEq/L Hyperchloremic acidosis Assuming mild hyponatremia or normal sodium consider 150 mEq NaHCO3 in 1000 mL of D5 or free water (1)	Based on electrolytes, specifically: sodium, potassium, chloride, bicarbonate, and glucose (and occasionally phosphate) as well as blood pressure. If they are hypertensive consider hypotonic (1/2 NS) rather than isotonic (NS, LR) solutions even if they are mildly hyponatremic. If Na is within normal limits < 140 use NS, > 140 use 1/2 NS If K is within normal limits < 4 add 20 mEq KCl If hypoglycemic or marginally hyperglycemic use the D5 variant of the 1/2 NS or NS chosen above
Rate
20 mL/kg of crystalloid (NS or LR) over 15-20 minutes (thus a pressure bag is needed)	100-1000 mL/hr titrated to whatever volume deficit you are correcting	Hypovolemic hyponatremia The initial rate to correct by 10 mEq/L in 24 hours with NS is by rough calculation 1.35 x wgt [kg] for the rate in mL/hr. If using 3% saline multiply by 0.3 (2) Titrate the rate to serial BMP, if life threatening hyponatremia (e.g. seizures) correction may be more rapid for the first few hours but still < 10-12 mEq/L over 24 hours Hypernatremia The initial rate to correct by 10 mEq/L in 24 hours with D5 is by rough calculation 1.35 x wgt [kg] for the rate in mL/hr. If using 0.45% saline multiply by 2. Titrate the rate to serial BMP, such that the rate of correction < 10-12 mEq/L over 24 hours Hypokalemia Maximal correction via peripheral line is 40 mEq/L in 500 mL NS over four hours or 125 mL/hr Hyperchloremic acidosis As per "rehydration" rates	40-20-10 "rule" (for patients with normal electrolyte hemostatic mechanisms) 40 mL/hr for the first 10 kg 20 mL/hr for the second 10 kg 10 mL/hr for each additional 10 kg
How do you know it's working
Blood pressure increases Lactic acid decreases Urine output increases	Blood pressure, heart rate, and urine output improve ("preshock") Anion gap decreases (diabetic ketoacidosis) CK and renal function improve (rhabdomyolysis) Replace 50% of urine output per hour (post-obstructive diuresis) Urine output increases and renal function improves (hypovolemic acute prerenal failure) Amylase and lipase improve (pancreatitis)	Hypovolemic hyponatremia Sodium corrects by < 2 mEq/L every 4 hours, thus check BMP or I-STAT every 2-4 hours and titrate rate and composition of fluids appropriately Hypernatremia Sodium corrects by < 2 mEq/L every 4 hours, thus check BMP or I-STAT every 2-4 hours and titrate rate and composition of fluids appropriately Hypokalemia Electrolyte correction monitoring at most Q8H Hyperchloremic acidosis Electrolyte correction monitoring at most Q8H	The patient remains hemodynamically stable without electrolyte abnormalities or worsening renal function

1. Assuming NaHCO3 comes in a stock solution of 1 mEq/mL, then [C] = solute osmolarity / solution volume

   = solute osmolarity / (solute volume + solvent volume)

   = 150 mEq / (0.150 L + 1 L) = 130 mEq NaHCO3/L

   In 850 mL of solvent, then [C] = 150 / 1000 = 150 mEq Na HCO3/L

2. Assuming total body water [L] = 0.5 x wgt [kg] (acutally TBW fraction varies between 0.45 and 0.6 depending on gender and age). We want to change the current plasma sodium by 10 mEq/L/24 hours (i.e. the maximum safe change in serum sodium that will not precipitate central pontine myelinolysis) and recall that the concentration of sodium in 0.9% saline or NS is 154 mEq/L, then:

   infusion rate = 0.5 x wgt [kg] x 10 / 154 (L x mEq/L/24 hr) / (mEq/L)

   = 5 x 1000 x wgt [kg] / (154 x 24) mL/hr

   = 1.35 x wgt [kg] mL/hr for NS

   If we are using 3% saline, multiply by 0.9/3 (0.9% / 3%) or 0.3

   In the case of hypernatremia, we know that 1/2 NS is half the concentration of NS, such that if we did a similar infusion rate calculation the denominator would be half what is above, or simply multiplying by 2.

Encephalopathy in a nutshell

Although not the definitive, all encompassing, reasons for encephalopathy/delirium/altered mental status, this short list certainly covers many of the most prevalent causes.

Etiology	Physical Exam	Bedside Diagnostic Tests	History	STAT Diagnostic Tests
"Bugs" Infection	Temperature SpO2 Meningeal signs Lines (vascular, GI, GU)		Headache Aspiration Productive cough Vomiting / Diarrhea Urinary changes	CXR UA and urine c/s Blood c/s Sputum c/s C. difficile toxin
"Drugs" Side effects of and withdrawal from drugs		Naloxone trial	MAR (narcotics, corticosteroids, CNS agents) Review home medications Alcohol/substance abuse
"Lytes" Electrolyte abnormalities particularly hypo- and hyperosmolar states		I-STAT	Ins/Outs	BMP Serum osmolarity
"Plights" Inadequate pain control	Pain scale Abdominal examination	Bladder scan
"Beating" Cardiac arrhythmia and ischemia	Heart rate Blood pressure Jugular venous pulsation Heart murmurs and additional sounds	Telemetry I-STAT Troponin		EKG Cardiac markers BNP
"Bleeding" Acute blood loss	Scleral pallor Rectal exam	Fecal occult blood test I-STAT (ABG also has an H&H)	Recent surgery Anticoagulation	CBC
"Gases" Hypoxemia or hypercarbia Acidosis or alkalosis	Respiratory rate SpO2	ABG	History of hypercarbia Previous ABG
"Glucose" Hypo- and hyperglycemia		Accu-check I-STAT	Diabetes mellitus Insulin or oral antihyperglycemic medications
"Gourd" Intracranial pathology (i.e. stroke, mass effect, traumatic brain injury) Seizure	Neurological examination		Documentation of seizure-like activity without formal history of seizure Trauma History of dementia or seizure	CT head without contrast

SHM 2010 Day#1 "It is NOT Rocket Medicine"

SHM Exhibit Hall
I'm attending the Society of Hospital Medicine's 2010 meeting in Washington, D.C. This morning I toured the Exhibit Hall over a tasty (free) breakfast of fruit and pastry products. I saw the GE Vscan which is a PDA sized ultrasound device that would allow nonradiologist physicians to do simple imaging as an adjunct to physical exam. It does not allow for ultrasound guidance of central line placement but it does allow visualization of the heart (i.e. to look for wall motion abnormalities and pericardial effusions), aorta, liver, kidney and gall bladder. The cost is in the $8000 range for a unit one could slip in a pocket. Later in the day (again over free munchies), I was able to contrast the Vscan with the SonoSite M-Turbo which is about the size of a laptop and with a heftier price tag starting $30000. It appears to be able to do anything that is worth doing with ultrasound.
I also checked out the documentation solutions from Shareable Ink which uses Livescribe technology and custom forms to allow handwritten documentation to be immediately available in an electronic medical record. It also has applications for billing. I got to drive the "robohospitalist" or InTouch Health RP-7 Robot. In addition I spoke to the representatives for PNA FISH which offers rapid identification of certain species of bacteria in particular MRSA and VRE as well as candida differentiation within 90 minutes rather than waiting for 2 days for culture results. This begs the question will the Surviving Sepsis Campaign guidelines change in the future? Also I picked up some articles regarding hyponatremia management using vasopressin antagonists as an adjunct in patients resistant to conventional hyponatremia management.
Of course no conference trip for me is complete without a little bit of shopping so I picked up some books (Evidence-Based Medicine: In Sherlock Holmes' Footsteps by Jörgen Nordenström, The 10-minute Clinical Assessment by Knut Schroeder, and ICU Chest Radiology by Harold Moskowitz) at the Wiley Interscience booth and ordered custom heavy weight cotton lab coats with chef's buttons in orange and blue respectively from On Call Medical Coats.

Plenary Session: Hospitalists are Becoming Influencers of Healthcare Policy
The plenary session began with a panel discussion regarding healthcare reform. The idea of the CMS Development Center whose goal is to decrease cost while increasing quality was applauded warily as a great idea already hamstrung by limited vision. One key area of praise was that it would be allowed to independently contract with companies to decrease costs, i.e. rewarding those whose systems work. Meanwhile, terms like "Super-MedPAC", "bundle payments", "medical homes", and "accountable care organization" flew. I'm not entirely clear on what they all meant (nor do I think any of us are) but these are the tools to provide that higher quality of care at less cost. The models of these are places like Mayo and Geysinger, qualifications for accountable care organizations are in the pipe. The argument was made that hospitals, like major academic centers, are actually potential lobbying groups and need to do so to compete with special interest groups.
The bottom line was that "fee for service" will disappear and in its void remains opportunities and challenges for providing as well as reimbursing healthcare. There will be a change from "profit" centers to "cost" centers that create value in non-value based ways. This was summarized best as we need to limit healthcare, not because we don't care but because rising costs do not provide more care. Medicare the "big dumb payer" sends 33% of it's money to hospitals and another 20% to physicians. By stopping paying for readmits, theoretical we increase a hospital's responsibility for readmissions.
Despite the disagreement with "cook book medicine" the use of "comparative effectiveness" will mandate the usage of evidence-based medicine in healthcare. There was some discussion regarding patient autonomy and the entitlement society, particularly in discussion of patient accountability for their own healthcare. One example of how less insurance drove down costs was in Lasix surgery, since it is mostly out of pocket and not covered demand drove down the price.

Plenary Session: Paul Levy
Paul Levy is CEO of Beth Deacon Isreal hospital and runs a blog called Running a Hospital. He presented a paradox: Doctors are dedicated to alleviating suffering but are the 4th leading cause of death in the U.S. In fact the chance of patients being killed in American hospitals each year was greater than the chance of American soldiers in Iraq during the height of the Gulf War being killed.
Doctors like to finish tasks so they often resort to "work arounds" that transiently solve a single problem and not the systemic issue. Mr. Levy discussed the work of Steve Spear examining the the lean approach to production as applied to healthcare. The lean approach as optimized by Toyota up until recently states that when a worker identifies a problem they call the supervisor who initiates a team to work on it, i.e. "root cause analysis".
Mr. Levy also discussed "transparency" as a management tool, stating that after releasing numbers on central line infection and VAP this helped to decrease these complications without more costs. He also noted that leadership takes audacious statements that cannot be scientifically met.