SHM 2010 Day #2 "Hospitalists...the 2010 National Champions"

Plenary Session
The plenary session started with the winners of the abstracts for this year, that asked the following questions:
Does hospitalist care change one year post discharge increase readmission or use of health care resources? Actually decrease in any emergency department visits but not frequency, if they start going to the emergency department they keep going. Also decreases MD office visits, but no difference in post-discharge hospitalization. The researchers hypothesized that hospitalists have an increased use of home health

What does disclosure do to liability? i.e. what is the effect of transparency?
Yes it improves (decreases) claims, time to resolution with a 53% decrease in liability costs

The final presentation was an innovation in health care, in this case ensuring safe discharge of homeless patients using a respite program. Which of course begs the question if respite programs might be used for patients with homes to decrease readmissions.

NIPPV in acute respiratory failure
Inspiration actually places inward pressure on external airways while internal airways expand. Examining the hysteresis curve at the ends where maximal changes in pressure have minimal changes in volume is comparable to filling a balloon, the most difficulty is at the beginning and end of filling of the balloon.

Positive pressure ventilation

• Decreases venous return
  
• Decreases RV stroke volume and increases LV filling volume
  
• Decreases work of breathing
  
• Improves gas exchange
  
• Unloads heart
  

CPAP improves oxygenation
PSV improves ventilation
BiPAP = CPAP + PSV

Entry criteria

• Able to protect airway (anatomic + neurologic)
  
• Stable hemodynamics
  
• Absence of MSOF
  
• Cooperate with NIPPV
  
• Compatable facial anatomy
  
• Can tolerate insuflation
  

NPPV Predictor of Success

• Youth
  
• Low APACHE score
  
• Cooperative
  
• Moderate hypercarbia, PaCO2 > 45 mmHg
  
• Mild acidosis
  

NPPV in COPD (Cochrane Database Syst Rev. 2004;(3):CD004104)

• PaCO2 > 45 mmHg
  
• Decreased mortality and LOS
  
• Works well for modern COPD exacerbations
  

NPPV in decompensated left heart failure

• Decreased ICU admissions, if started in ED
  
• 50% reduction in need to intubate
  
• Widely accepted for ADHF
  
• If PaCO2 normal use CPAP not BiPAP
  

Other indications of NPPV

• Immune compromised patients (Intensive Care Med. 2002 Sep;28(9):1233-8)
  
• Hypoxemic respiratory failure (Crit Care Med. 2004 Dec;32(12):2516-23)
  
• Pneumonia with manageable secretions
  
• Asthma exacerbation (Cochrane Database Syst Rev. 2005 Jan 25;(1):CD004360)
  

Clinical pearl: Status asthmaticus with normal ABG is either not that sick or about to crash.

Preoxygenation before intubation
Am J Respir Crit Care Med. 2006 Jul 15;174(2):171-7
Critically ill patients have ~30 seconds before they become hypoxic versus nearly 5 minutes in healthy adults. Effective bag mask ventilation is difficult, thus BiPAP studied before intubation: higher preintubation SpO2, smaller dip in SpO2, fewer severe desaturations.

Postextubation Respiratory Failure
N Engl J Med. 2004 Jun 10;350(24):2452-60
NPPV is an effective bridge post extubation far longer before reintubation. NPPV prevented reintubation only if instituted BEFORE the onset of respiratory failure.

Airway Obstruction?
Sometimes if rapidly reversible cause NPPV can "stent" open an airway

Initiation

• Early is Better (Intensive Care Med. 2002 Dec;28(12):1701-7)
  
• Moderate severe respiratory distress
  
• pH < 7.35 and PaCO2 > 45 mmHg
  
• RR > 25
  

How do I know if it's working?
Chest. 2000 Mar;117(3):828-33

• pH, PaCO2, and LOC if these do not improve in 1-2 hours, it will probably not improve
  
• 48-72 hours total trial
  

Mask Type

• Face mask is more effective
  
• Nasal mask/pillows are more comfortable
  

Complications

• Discomfort
  
• assure: rjuy to nose, the. eye
  
• sinus pain/congestion
  
• mild gastric distortion
  
• Barotrauma is uncommon
  
• Adverse hemodynamic reactions uncommon
  

Common Hematologic Emergencies and Consults
Thrombocytopenia, defined as platelets < 150000

Causes

• Artefact
  
• Dilution
  
• Sequestration
  
• Decreased production
  
• Increased consumption
  

Essentials of work-up

• Review blood smear
  
• History of blood transfusions
  
• Hypersplenism
  
• Bone marrow biopsy
  

"Washout phenomenon"
Platelet count < 50000 would be equivalent to about 15 units transfused

Congenital hereditary thrombocytopenia
Bleeding out of proportion to platelet count and often associated with platelet function deficit (gray platelets, Bernard-Soullier, vWF deficiency Type 2B)

May Hegglin Anamoly
Diagnosed by peripheral smear and associated with MYH9 mutation

Other causes of thrombocytopenia

• B-12 deficiency
  
• Alcohol abuse
  
• Leukemia
  
• DIC
  
• ITP
  
• TTP/HUS
  

Drug-induced thrombocytopenia
Heparin-induced thrombocytopenia (Chest. 2005 Feb;127(2 Suppl):35S-45S)
Diagnostic gold standard: Serotonin platelet loaded assay, however platelet factor 4 assay more commonly available. Hospitalist should support and promote efforts to eliminate heparin flushes. HIT can cause both arterial and venous thrombosis. Fondaparinux can be used to treat (unlabelled use).

Platelet GP IIb-IIIa inhibitors may cause sudden severe drop in platelets (N Engl J Med. 2004 Jan 15;350(3):232-8)

Idiopathic Thrombocytopenic Purpura
Increased bone marrow megakaryocytes. Thrombocytopenia + mucosal based bleeding have increased chance of intracerebral hemorrhage. RFVIIa limits ICH volume in ITP.
Treatment

• 2/3 corticosteroids
  
• 2/3 IV Ig
  
• 2/3 anti-D immunoglobulin (may cause DIC in elderly patients)
  
• 2/3 splenectomy
  
• 2/3 danazol (associated with some virilization and increased hepatic dysfunction
  
• TPO mimetics increase megakaryocyte production of platelets

?H. pylori positive associated with ITP more true in Asia than the US

Thrombotic Thrombocytopenic Purpura
The classic pentad of microangiopathic hemolytic amenia, neurological abnormalities, fever, renal failure and thrombocytopenia is nearly useless clinically. Instead:

• Schistocytes
  
• Elevated LDH
  
• ADAMTS13 inhibitor
  
• vWF multimers
  
• No anticoagulation abnormalities and negative D-dimer
  

Treatment is plasma exchange and corticosteroids

Disseminated intravascular coagulation
Too much thrombin generation or too little down regulation in thrombin or points along the cascade. Induced by sources of tissue factor and is an acquired syndrome characterized by intravascular activation of coagulation leading to end organ damage. Associated with sepsis, trauma, malignancy, obstetric complications, vascular disorders, toxins (snake bite), and immune disorders (severe allergic reactions or transplant rejection). Treatment:

• Treat the underling cause
  
• Heparin anticoagulation
  
• Platelet transfer after anticoagulation
  
•  FFP/cryoprecipitate
  
• ATIII concentrate
  
• Activated protein C concentrate
  

Antiphospholipid Ab syndrome
J Thromb Haemost. 2006 Feb;4(2):295-306
Think of this diagnosis in a pregnant woman presenting with stroke and has a history of recurrent spontaneous abortions. These patients must be anticoagulated, bridge with heparin, eventually target INR > 2.5 with warfarin. If recurrent thrombosis add aspirin.

VTE and postthrombotic syndrome
Deep vein thrombosis is 15-25% associated with cancer and carries 7% mortality. Thrombolytic therapy has not been shown to improve overall mortality.

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.

How To Eyeball A Patient

Gestalt View

As you walk into the room is the patient appear sick or not sick? Distressed? Obtunded? Comatose?

ABCs

Does the patient oxygenate and perfuse?

Vital signs

What are the specific numbers, how was it assessed, and does it correlate with the picture above?

Diagnostics

Find abnormalities. That's really what you are paid for. Some people always have high creatinine or low hemoglobin or whatever, so don't focus on the population mean abnormalities, focus on the patient's abnormalities.

Medications

Will tell you a lot about the protoplasmic substrate (except cancer as chemotherapeutic agents generally don't show up on medication reconciliations) and look out for side effects of therapeutic intervention

USMLE Step I

I have actually taken the USLME Step 1 Examination twice, having failed it the first time, so I have a slightly unique viewpoint regarding this exam. There is a multifactorial explanation/excuse/reason as to why I did not pass, but it did give me a lot of experience preparing for the exam. I do not believe that this an examination that tests basic medical science but rather tests your ability to take a huge multiple choice test. Yes there is a significant amount of information you must know, but rote memorization will not get you through, to quote Goljan (http://usmlestep.com/goljan.htm) you must understand mechanism, not only of the underlying physiology and pathophysiology, on both micro and macro scales, but of the mechanism of the test questions themselves. The resources I found useful for information review were:

Gold Standard Board Review System (http://www.boardprep.net/)
Kaplan On-line lecture series (http://www.kaptest.com/Medical_Licensing/Step-1/View-Kaplan-Programs/Online-and-Supplemental/webprep.html)
USMLE Step 1 Made Ridiculously Simple (http://www.amazon.com/USMLE-Step-Made-Ridiculously-Simple/dp/0940780712/ref=sr_1_1?ie=UTF8&s=books&qid=1241648745&sr=8-1)

The oft touted Step Up (http://www.amazon.com/Step-Up-USMLE-Step-1/dp/078178090X/ref=sr_1_1?ie=UTF8&s=books&qid=1241651240&sr=1-1) and First Aid (http://www.amazon.com/First-Aid-USMLE-Step-2009/dp/0071548963/ref=sr_1_3?ie=UTF8&s=books&qid=1241651203&sr=8-3) were not of great help to me, but if your mind wraps well around such outlines then it may be of benefit.

I split my days into a morning of questions (minimum 100) and an afternoon of lectures. I took at least one weekend day off per week. Approximately every two weeks I would do 8 hours of questions to simulate the exam, out of a book of written examination questions. Make sure that you reverse engineer the questions, I noticed that there were certain types of questions that I missed. I just kept doing the questions until I had done them all right. In all I did over 3700 different questions between all my resources, which included Q-bank, Q-Book, and other test question repositories.

Since then I have been introduced to the Goljan lecture series, while I didn't use them I believe they would be of benefit.

Do not let the cost of a prep course discourage think of it as a $1000 to $3000 investment in your future. You will carry a failure or a low score on USMLE Step 1 for a long time, it is not the end of the world but it will make you work harder for residency and it may keep you from getting your foot in the door.

White Coat Ceremony Talk 2008

I gave this brief talk to the medical students in 2008, I thought it was pretty good:

This is not a white coat.

This is a superhero’s cape; a knight’s tabard; a wizard’s robes. Not convinced? Where else but in comic books and medicine can grown-ups wear the equivalent of pajamas and be taken absolutely seriously. Who else but a paladin or a physician would be on a quest to help people. What else but the magister’s raiment or the white coat symbolizes knowledge and the hope of miracles.

Despite its mystic origins, the white coat is a poor insulator against the freezer they call the cath lab and attracts tomato sauce. It will snag every exposed door handle and makes a barely tolerable pillow. Its carrying capacity is significantly less than the mass and volume of assorted pocket references, peripheral brains, pagers, and diagnostic gadgets required of medical students.

The mark of a physician, however, is not in their sartorial splendor but in their desire to help people through their compassion, intellect, and work ethic. The white coat symbolizes the best qualities of a physician. They are the vestments of medical knowledge and the license to alleviate suffering. They command both power and respect while demanding duty and service. Today these medical students begin their clinical apprenticeship, they become squires to Sir Osler and side kicks to Hippocrates.

These student doctors will find that as soon as they don their crisp white coats that they will be looked to for answers regarding simple analytical diagnosis to the difficult decision of whether to allow a fellow human being a glass of water. From a simple piece of cloth they will be privy to a person’s most intimate secrets and exposed to a patient’s greatest moment of weakness. They will find that no matter how much they load the straining pockets of their uniform they will never carry enough resources to have all the answers.

This coat will be your introduction to clinical medicine, sometimes frightening but always rewarding, it is by interacting with patients as a student doctor that you will learn to be a physician. This white coat is your passport to that experience. Welcome to the most fun part of medical school.