PGY 39, Day #150
This was a moderately busy week in the ICU. As usual, the tug of the "holiday vortex" and the "game vortex" made it more difficult to get things accomplished. But, let us not dwell on skeleton crews and limited surge capacity. We got the job done, and I am now, again,recovering from lack of sleep for a few days.
Topics discussed on ICU rounds this week included:
1. If you don't know what you are doing, STOP & ask for help.
2. If you don't know what you are talking about, STOP your mouth & ask for help.
3. If you don't know your limits you are dangerous.
4. When dealing with families on matters of life and death, always err on the side of life. "When you put the right things on the menu, patients and families are more likely to make the right choices." You can quote me on that!
5. Hypotension and Shock: Diagnosis and Treatment
6. Supraventricular Tachycardia management in the critically ill patient
7. Traumatic Intraparenchymal Hemorrhage
8. Acute Respiratory Failure from upper airway obstruction: Diagnosis and Treatment
9. Intractable Seizures: Diagnosis and Treatment
10. Brain Protection Strategies and Targets
11. Subarachnoid hemorrhage: Diagnosis,classification, prognosis, Hunt & Hess, HHH Rx
12. Criteria for Nosocomial Pneumonia & Diagnosis of Pneumonia in General
13. Thorazine for fever
14. Breathing & Circulation: Oxygen Content, Oxygen Delivery, Oxygen Consumption, CO2 Production, CO2 Clearance. "Oxygen is overrated & Perfusion is underrated: The importance of perfusion in critical care" you can quote me on that one too.
15. Acute Respiratory Failure: Diagnosis, Treatment, Non invasive therapies, invasive therapies, endotracheal intubation, sedation, analgesia, neuromuscular junction blockade, initial ventilator settings.
Please contact me if you have any questions.
Enjoy!
Dr. Mike
Monday, November 28, 2011
Wednesday, November 23, 2011
Mission: Healing November 23, 2011
PGY # 39, Day 145
GOOD NEWS!
FYI
The ORIGINAL Stress Management Workbook by Aronson and Mascia is now available in electronic format through Amazon.
This book, that we originally wrote and published in 1981 is still useful and relevant. The electronic version is a useful addition by making it readily available to a world audience at a low price. I will be working on a New Edition of The ORIGINAL Stress Management Workbook this year.
http://www.amazon.com/dp/B006BIR5TO
Enjoy & Contact me if you have any questions.
Later today, or tomorrow, I will update on discussion topics in the ICU for this week.
Dr. Mike
GOOD NEWS!
FYI
The ORIGINAL Stress Management Workbook by Aronson and Mascia is now available in electronic format through Amazon.
This book, that we originally wrote and published in 1981 is still useful and relevant. The electronic version is a useful addition by making it readily available to a world audience at a low price. I will be working on a New Edition of The ORIGINAL Stress Management Workbook this year.
http://www.amazon.com/dp/B006BIR5TO
Enjoy & Contact me if you have any questions.
Later today, or tomorrow, I will update on discussion topics in the ICU for this week.
Dr. Mike
Friday, November 18, 2011
Mission Healing: November 18, 2011, Children & Their Parents
PGY 39, Day # 140
My goal for today? Post this DRAFT OF Children and Their Parents for review, comments and criticism. In that regard, I will do what I can do ... as I work through this technology ... bit by bit. And, I do need other eyes to look at this critically and to give me feedback. But, IT as it is in my LOW TECH ZONE does not allow me to post the whole book for reasons that are explained in the PS below.
Nevertheless, if, perchance, people want to BUY this book, I will make it available for purchase ASAP with all proceeds going toward the New Health Development Institute. What is the Health Development Institute? A Non Profit Health Care Organization that I set up more than 20 years ago. Alas, it is time for HDI to be reborn ... perhaps as a Health Care COOPERATIVE?
Ultimately, I expect (with the help of as many people as I can find) we can resume operation of the Non Profit Health Development Institute; originally started as a teaching arm for Patients and Families I served while running my private Family Medicine Practice in Bridgton, Maine before 1989. Always looking for help with to take care of the enormous needs of The People, and the Non Profit COOPERATIVE model is the only one that makes sense to me.
Buona Fortuna e ciao per ora!
Enjoy!
Dr. Mike
PS. OMG, this is much more difficult than I thought it would be. The only way I can put this up here is by going from PDF to JPEG and loading one page at a time as JPEG files. Uggggg! It is painfully slow.
PPS. Maybe some IT people out there can help me figure out a better way.
PPPS. HELP!
PPPPS. Until I get some help it will go up just a few pages at a time ... as I get the time to do this from the LOW TECH ZONE.
© Michael F. Mascia, MD, MPH
My goal for today? Post this DRAFT OF Children and Their Parents for review, comments and criticism. In that regard, I will do what I can do ... as I work through this technology ... bit by bit. And, I do need other eyes to look at this critically and to give me feedback. But, IT as it is in my LOW TECH ZONE does not allow me to post the whole book for reasons that are explained in the PS below.
Nevertheless, if, perchance, people want to BUY this book, I will make it available for purchase ASAP with all proceeds going toward the New Health Development Institute. What is the Health Development Institute? A Non Profit Health Care Organization that I set up more than 20 years ago. Alas, it is time for HDI to be reborn ... perhaps as a Health Care COOPERATIVE?
Ultimately, I expect (with the help of as many people as I can find) we can resume operation of the Non Profit Health Development Institute; originally started as a teaching arm for Patients and Families I served while running my private Family Medicine Practice in Bridgton, Maine before 1989. Always looking for help with to take care of the enormous needs of The People, and the Non Profit COOPERATIVE model is the only one that makes sense to me.
Buona Fortuna e ciao per ora!
Enjoy!
Dr. Mike
PS. OMG, this is much more difficult than I thought it would be. The only way I can put this up here is by going from PDF to JPEG and loading one page at a time as JPEG files. Uggggg! It is painfully slow.
PPS. Maybe some IT people out there can help me figure out a better way.
PPPS. HELP!
PPPPS. Until I get some help it will go up just a few pages at a time ... as I get the time to do this from the LOW TECH ZONE.
Children and Their Parents: A Parenting Guide to the First Six Years
V 1988 Update 2011
Revised 2011
© Michael F. Mascia, MD, MPH© Michael F. Mascia, MD, MPHA MESSAGE FROM THE AUTHOR FOR PARENTS & OTHERS WHO CARE FOR
CHILDREN
This book is designed to be used in conjunction with your baby's personal physician.
In other words, we do no want you to rely on this text without guidance from a
licensed medical doctor. Also, the author expects that you will seek immediate
medical attention for all emergencies through your local doctor or local emergency
medical services.
With that in mind, it would be wise for the users of this book to:
1. Find a personal physician whom you trust, and who can help guide you and your
baby through this journey called life. Check his/her credentials and qualifications!
2. Know when to get help for an emergency
3. When in doubt, if your baby is sick, assume you are dealing with an emergency
4. Learn the signs and symptoms of a medical emergency
5. Know how to contact and get help for an emergency
6. Further instructions with regard to "Finding and Using Your Personal Physician"
will be found in several locations including, but not limited to:
a. Future editions of CHILDREN AND THEIR PARENTS
b. The NEW Stress Management Workbook
c. drmikeihs.blogspot.com/
d. Other electronic and paper publications based upon & included in the StepWisely
®System from Infinity Health Solutions & Michael F. Mascia, MD, MPH
ALSO, WE WELCOME ALL FEEDBACK OF ANY KIND ... COMMENTS, CORRECTIONS
AND CRITICISM FROM OUR READERS ARE WELCOME, AS THIS IS A WORK IN
PROGRESS, & IS NOT A FINISIHED PRODUCT.
Thanks for your help,
Dr. Mike
Michael F. Mascia, MD, MPH
Children and Their Parents: A Parenting Guide to the First Six Years
V 1988 Update 2011
Contact: For EMERGENCIES CALL 911, or your local EMS
For information, comments & questions, go to
ATTENZIONE!
REITERATION
DO NOT SKIP THIS PAGE!
Just in case you skipped this message the last time
READ IT THIS TIME!
YES, IT IS IMPORTANT
DO YOU HAVE A TRUSTED MEDICAL DOCTOR FOR YOUR BABY YET?
Monday, November 7, 2011
Mission: Healing November 7, 2011 Inexperienced Provider Tips
PGY 39, Day 129
For INEXPERIENCED PROVIDERS
If you are new in the ICU, no matter what level of training, medical student, nursing student, new graduate, intern, resident, or just a neophite in the ICU, here are a few pointers that will keep you and your patients out of trouble.
Based upon the following rule: "PRIMUM NON NOCERE" (First Do No Harm) here are your top three rules
1. If you don't know what you are doing, STOP!!!! ... DO NOTHING and ask for help.
2. If you don't know what you are talking about, STOP!!!! ... SAY NOTHING and ask for help.
3. If it is an emergency, CALL FOR HELP, use FIRST AID, ACLS, ATLS and PALS till help gets there.
Ciao e buona fortuna!
Have a nice day.
Dr. Mike
For INEXPERIENCED PROVIDERS
If you are new in the ICU, no matter what level of training, medical student, nursing student, new graduate, intern, resident, or just a neophite in the ICU, here are a few pointers that will keep you and your patients out of trouble.
Based upon the following rule: "PRIMUM NON NOCERE" (First Do No Harm) here are your top three rules
1. If you don't know what you are doing, STOP!!!! ... DO NOTHING and ask for help.
2. If you don't know what you are talking about, STOP!!!! ... SAY NOTHING and ask for help.
3. If it is an emergency, CALL FOR HELP, use FIRST AID, ACLS, ATLS and PALS till help gets there.
Ciao e buona fortuna!
Have a nice day.
Dr. Mike
Mission: Healing November 7, 2011 Messing With The Clock
PGY 39, Day 129
THEY ARE MESSING WITH MY (BIOLOGICAL) CLOCK AGAIN:
AKA, I am Falling Behind Again
There is a natural rhythm to life and the universe, and that rhythm is synchronized. As a part of that system, animals (yes, including humans) have day-night cycles called circadian rhythm. This rhythim dictates many fundamental physiologic functions ... most notable of which are the day-night/sleep wake cycle.
(Reference link: http://www.nigms.nih.gov/Education/Factsheet_CircadianRhythms.htm)
(For Detailed Scientific Evidence see:The Clocks That Time Us by Moore-Ede, Sulzman and Fuller)
In other words, our natural rhythm, or biological clock is dictated by day and night, light and dark, or, in other words, SUNSHINE! Every time we arbitrarily "change the clock", we are "messing with" COUNTLESS HUMAN BIOLOGICAL CLOCKS, because our CLOCK TIME is NOT SYNCHRONIZED with SUN TiME. That is CRAZY! Why ON EARTH (:-)) would we not synchronize our MECHANICAL CLOCKS with the SUN? Stupid!(?) We have always done it that way? NO ... that is not at all true.
Disregard of facts about our circadian rhythm and the sun might have been excusable 100 years ago, but today, it is absolute nonsense. What effort would it take to keep the clocks all around the world synchronized with the sun? Very little extra effort. What would the cost be? I have no idea, but the benefit, I am certain, would be enormous with regard to human well being and performance.
Who benefits by maintaining the status quo? Frankly, I don't know. It seems as if this clock changing nonsense is just one of those "we have always done it that way" sort of things. Isn't it TIME for us to be SMART about Clocks, Sun rhythm and circadian rhythm? Let's start a move to synchronize mechanical clocks with the sun ... it would be good for our natural rhythm. I think the music would sound better, and, besides, what do we have to loose?
StepWisely(R) and have a good day.
Dr. Mike
PS. IF, there is some reason why machine time MUST be different from SUN TIME, or EARTH ROTATION TIME, then, at least give us both times on every clock.
PPS. And, for the advocates of this clock change nonsense, explain yourself, please!
THEY ARE MESSING WITH MY (BIOLOGICAL) CLOCK AGAIN:
AKA, I am Falling Behind Again
There is a natural rhythm to life and the universe, and that rhythm is synchronized. As a part of that system, animals (yes, including humans) have day-night cycles called circadian rhythm. This rhythim dictates many fundamental physiologic functions ... most notable of which are the day-night/sleep wake cycle.
(Reference link: http://www.nigms.nih.gov/Education/Factsheet_CircadianRhythms.htm)
(For Detailed Scientific Evidence see:The Clocks That Time Us by Moore-Ede, Sulzman and Fuller)
In other words, our natural rhythm, or biological clock is dictated by day and night, light and dark, or, in other words, SUNSHINE! Every time we arbitrarily "change the clock", we are "messing with" COUNTLESS HUMAN BIOLOGICAL CLOCKS, because our CLOCK TIME is NOT SYNCHRONIZED with SUN TiME. That is CRAZY! Why ON EARTH (:-)) would we not synchronize our MECHANICAL CLOCKS with the SUN? Stupid!(?) We have always done it that way? NO ... that is not at all true.
Disregard of facts about our circadian rhythm and the sun might have been excusable 100 years ago, but today, it is absolute nonsense. What effort would it take to keep the clocks all around the world synchronized with the sun? Very little extra effort. What would the cost be? I have no idea, but the benefit, I am certain, would be enormous with regard to human well being and performance.
Who benefits by maintaining the status quo? Frankly, I don't know. It seems as if this clock changing nonsense is just one of those "we have always done it that way" sort of things. Isn't it TIME for us to be SMART about Clocks, Sun rhythm and circadian rhythm? Let's start a move to synchronize mechanical clocks with the sun ... it would be good for our natural rhythm. I think the music would sound better, and, besides, what do we have to loose?
StepWisely(R) and have a good day.
Dr. Mike
PS. IF, there is some reason why machine time MUST be different from SUN TIME, or EARTH ROTATION TIME, then, at least give us both times on every clock.
PPS. And, for the advocates of this clock change nonsense, explain yourself, please!
Friday, November 4, 2011
Mission: Healing November 4, 2011 Business of FLU SHOTS
PGY 39, Day 125
Yesterday I wrote about Flu Shots in my piece about the Business of Medicine
http://drmikeihs.blogspot.com/2011/11/mission-healing-november-3-2011.hthtml
Today, a few more comments on the Busines of Flu Shots
PICKING THE RIPE & LOW LYING FRUIT
Today, I asked Mr. Google a few more questions and this is what I found. It appears as if Walgreens, CVS and Target are all in the BUSINESS OF FLU SHOTS. Walgreens and CVS claim to provide them "every day" with some variation on the language regarding every store.
This looks like an effort to select and pick bits of $$$ (fruit) from the $$$ tree called THE BUSINESS OF MEDICNE. These are the "lowest lying & ripest of fruit" available from third party payers. Of course, the patients would be expected to pay the difference between what is covered and what is charged, except for Medicare.
Think about it, and tell me if I am wrong.
Have a great day!
Dr. Mike
Yesterday I wrote about Flu Shots in my piece about the Business of Medicine
http://drmikeihs.blogspot.com/2011/11/mission-healing-november-3-2011.hthtml
Today, a few more comments on the Busines of Flu Shots
PICKING THE RIPE & LOW LYING FRUIT
Today, I asked Mr. Google a few more questions and this is what I found. It appears as if Walgreens, CVS and Target are all in the BUSINESS OF FLU SHOTS. Walgreens and CVS claim to provide them "every day" with some variation on the language regarding every store.
This looks like an effort to select and pick bits of $$$ (fruit) from the $$$ tree called THE BUSINESS OF MEDICNE. These are the "lowest lying & ripest of fruit" available from third party payers. Of course, the patients would be expected to pay the difference between what is covered and what is charged, except for Medicare.
Think about it, and tell me if I am wrong.
Have a great day!
Dr. Mike
Thursday, November 3, 2011
Mission: Healing November 3, 2011 Business of Medicine
PGY 39, Day 125
Today, I stopped at Walgreens to pick up a few things. As I pulled into the parking lot, I noticed several flimsy signs reading something like ... Free Flu Shots ... in bold. As for the fine print ... if you have Medicare Part B. So, being the curious guy that I am and seeing that I just put the blog up on "FLU SHOTS" yesterday, and, since I had a few minutes, I commenced an investigation ... follow the $$$ and report for the blog. Little did I know that this would end up being quite an exercise. Who am I kidding ... it is exactly the bumbling third party nonsense that I would expect.
First, I buy my stuff and pay for it ... 10 minutes ... a few items ... no problem. Then I go to the pharmacy and ask them about the flu shot. Specifically, I asked for a brochure, which the pleasant cash register lady and asked her how much they cost. She asked, "Do you have medicare?", I said, "No" (do I look that old?) and she sheepishly told me $31.99 while she went to the Walgreen website to find and print the scoop on the inactivated vaccine that they offer.
So, I come home and continue my snooping on the COST of the vaccine and the reimbursement from Medicare part B. First, I ask MR. Google, "What is the cost of influenza vaccine?" and this is what I get ... PERFECTION from CDC! It is the current price list for all vaccines.
http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm
So, the cost for the inactivated Influenza vaccine is a max of about $14/dose in the private sector, but the range is from less than $8/dose to about $14/dose.
Then I check with Medicare to see what the reimbursement rate is for the Flu Vaccine. Good luck with that ... it is a wild goose chase. Check for yourself, and see if you can find what they pay. Let me know if you find it.
http://www.medicareinteractive.org/frames.php?URL=http://www.cms.hhs.gov/AdultImmunizations/Downloads/0506vaccreimburs033006.pdf
Here again, multiple third parties are involved ... $, $$, and $$$ ... caching!
Then I check the Walgreen website for fine print about other insurance. There, availability and co-payments apply and I find that they work with some other third party with regard to the administration of the vaccine. So, let's guess they make $5 - $ 10 for each dose given on their turf. How much is that? LOTS of money! I would like to know exactly what they make on the draw and the immunization itself.
So, in the process, they draw people away from their Docs and into the BIG BUSINESS MACHINE ... THIRD PARTY ... party $ after $$ party $$$, Business of Medicine makes money on the BACK OF THE DOCTOR-PATIENT relationship.
Sickening!
When I started in practice, the immunizations were generally given as a part of a well visit or follow up visit for a chronic medical problem, and they were a part of a comprehensive & individualized health care plan for each patient. Cost of the vaccine and the administration would have been perhaps double the cost to us. But, more importantly, it would have been part of a larger effort to address each patient individually with regard to their total health care needs. In the current scenario, each thrid party contributes to the fragmentation of care, the "disintegration" of care and the cost of care. It is a pathetic and unnecessary state of affairs. That's why I am an advocate for Non Profit Doctor Patient Cooperatives to CAP the BUSINESS OF MEDICINE take all third parties out of the picture and return to the DOCTOR-PATIENT RELATIONSHIP to the realm of OPTIMAL PATIENT CARE and PATIENTS FIRST.
Let's fix it!
Do the right thing and enjoy!
Dr. Mike
Today, I stopped at Walgreens to pick up a few things. As I pulled into the parking lot, I noticed several flimsy signs reading something like ... Free Flu Shots ... in bold. As for the fine print ... if you have Medicare Part B. So, being the curious guy that I am and seeing that I just put the blog up on "FLU SHOTS" yesterday, and, since I had a few minutes, I commenced an investigation ... follow the $$$ and report for the blog. Little did I know that this would end up being quite an exercise. Who am I kidding ... it is exactly the bumbling third party nonsense that I would expect.
First, I buy my stuff and pay for it ... 10 minutes ... a few items ... no problem. Then I go to the pharmacy and ask them about the flu shot. Specifically, I asked for a brochure, which the pleasant cash register lady and asked her how much they cost. She asked, "Do you have medicare?", I said, "No" (do I look that old?) and she sheepishly told me $31.99 while she went to the Walgreen website to find and print the scoop on the inactivated vaccine that they offer.
So, I come home and continue my snooping on the COST of the vaccine and the reimbursement from Medicare part B. First, I ask MR. Google, "What is the cost of influenza vaccine?" and this is what I get ... PERFECTION from CDC! It is the current price list for all vaccines.
http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm
So, the cost for the inactivated Influenza vaccine is a max of about $14/dose in the private sector, but the range is from less than $8/dose to about $14/dose.
Then I check with Medicare to see what the reimbursement rate is for the Flu Vaccine. Good luck with that ... it is a wild goose chase. Check for yourself, and see if you can find what they pay. Let me know if you find it.
http://www.medicareinteractive.org/frames.php?URL=http://www.cms.hhs.gov/AdultImmunizations/Downloads/0506vaccreimburs033006.pdf
Here again, multiple third parties are involved ... $, $$, and $$$ ... caching!
Then I check the Walgreen website for fine print about other insurance. There, availability and co-payments apply and I find that they work with some other third party with regard to the administration of the vaccine. So, let's guess they make $5 - $ 10 for each dose given on their turf. How much is that? LOTS of money! I would like to know exactly what they make on the draw and the immunization itself.
So, in the process, they draw people away from their Docs and into the BIG BUSINESS MACHINE ... THIRD PARTY ... party $ after $$ party $$$, Business of Medicine makes money on the BACK OF THE DOCTOR-PATIENT relationship.
Sickening!
When I started in practice, the immunizations were generally given as a part of a well visit or follow up visit for a chronic medical problem, and they were a part of a comprehensive & individualized health care plan for each patient. Cost of the vaccine and the administration would have been perhaps double the cost to us. But, more importantly, it would have been part of a larger effort to address each patient individually with regard to their total health care needs. In the current scenario, each thrid party contributes to the fragmentation of care, the "disintegration" of care and the cost of care. It is a pathetic and unnecessary state of affairs. That's why I am an advocate for Non Profit Doctor Patient Cooperatives to CAP the BUSINESS OF MEDICINE take all third parties out of the picture and return to the DOCTOR-PATIENT RELATIONSHIP to the realm of OPTIMAL PATIENT CARE and PATIENTS FIRST.
Let's fix it!
Do the right thing and enjoy!
Dr. Mike
Wednesday, November 2, 2011
Mission: Healing November 2, 2011 on Influenza
PGY 39, Day 124
FIRST OF ALL
If you don't have a Doctor whom you trust, get one! If you don't know how, contact me and I will give you guidance. She or He should be able to guide you in the right direction.
AFTER YOU HAVE YOUR DOCTOR, CHECK THIS OUT with your DOC!
There seems to be a bit of confusion regarding "the flu" and the influenza vaccine, and that is quite easy to understand. It is very confusing, because the bug confuses everyone ... it keeps changing.
BUT ... there are some fundamental rules that have not changed over the years. This CDC document
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0729a1.htm
covers the whole story, and the recommendations have not changed since last year. Their reasoning for expanding the population to be immunized is covered in this document. I recommend that you study it, if you are NOT high risk and you need to decide weather or not to get immunized. If you ARE HIGH RISK, and have NO CONTRAINDICATIONS, you should be immunized for sure. Keep in mind that my conclusion is based upon the fact that I see the casualties who end up in the Intensive Care Unit ... not a good way to spend your days, if avoidable, eh?
TWO TYPES OF VACCINE: INACTIVATED & LIVE ATTENUATED
From the CDC DOCUMENT
"TIV contains inactivated viruses and thus cannot cause influenza. LAIV contains live attenuated influenza viruses that have the potential to cause mild signs or symptoms related to vaccine virus infection (e.g., rhinorrhea, nasal congestion, fever, or sore throat). LAIV is administered intranasally by sprayer, whereas TIV is administered intramuscularly by injection. LAIV is licensed for use among nonpregnant persons aged 2--49 years; safety has not been established in persons with underlying medical conditions that confer a higher risk for influenza complications. TIV is licensed for use among persons aged ≥6 months, including those who are healthy and those with chronic medical conditions (Table 1). During the preparation of TIV, the vaccine viruses are made noninfectious (i.e., inactivated or killed) (8). Only subvirion and purified surface antigen preparations of TIV (often referred to as "split" and subunit vaccines, respectively) are available in the United States. Standard-dose TIV preparations contain 7.5 mcg HA antigen per vaccine strain (for children aged <36 months) or 15 mcg of HA antigen (for persons aged ≥36 months) per vaccine strain (i.e., 22.5 mcg or 45 mcg total HA antigen). A newly licensed higher dose TIV (60 mcg per vaccine strain or 180 mcg total HA antigen) was approved recently for persons aged ≥65 years (Fluzone High-Dose, Sanofi pasteur)."
WHO IS HIGH RISK:
FROM THE CDC DOCUMENT
"Vaccination to prevent influenza is particularly important for persons who are at increased risk for severe complications from influenza or at higher risk for influenza-related outpatient, ED, or hospital visits. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to the following persons:
all children aged 6 months--4 years (59 months);
all persons aged ≥50 years;
adults and children who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus);
persons who have immunosuppression (including immunosuppression caused by medications or by HIV);
women who are or will be pregnant during the influenza season;
children and adolescents (aged 6 months--18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection;
residents of nursing homes and other long-term--care facilities;
American Indians/Alaska Natives;
persons who are morbidly obese (BMI ≥40);
HCP;
household contacts and caregivers of children aged <5 years and adults aged ≥50 years, with particular emphasis on vaccinating contacts of children aged <6 months; and
household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza."
STILL CONFUSED?
You will have to study the whole document and ask for guidance. Feel free to ask me questions and send your comments.
Buona Fortuna & Ciao for now,
Dr. Mike
FIRST OF ALL
If you don't have a Doctor whom you trust, get one! If you don't know how, contact me and I will give you guidance. She or He should be able to guide you in the right direction.
AFTER YOU HAVE YOUR DOCTOR, CHECK THIS OUT with your DOC!
There seems to be a bit of confusion regarding "the flu" and the influenza vaccine, and that is quite easy to understand. It is very confusing, because the bug confuses everyone ... it keeps changing.
BUT ... there are some fundamental rules that have not changed over the years. This CDC document
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0729a1.htm
covers the whole story, and the recommendations have not changed since last year. Their reasoning for expanding the population to be immunized is covered in this document. I recommend that you study it, if you are NOT high risk and you need to decide weather or not to get immunized. If you ARE HIGH RISK, and have NO CONTRAINDICATIONS, you should be immunized for sure. Keep in mind that my conclusion is based upon the fact that I see the casualties who end up in the Intensive Care Unit ... not a good way to spend your days, if avoidable, eh?
TWO TYPES OF VACCINE: INACTIVATED & LIVE ATTENUATED
From the CDC DOCUMENT
"TIV contains inactivated viruses and thus cannot cause influenza. LAIV contains live attenuated influenza viruses that have the potential to cause mild signs or symptoms related to vaccine virus infection (e.g., rhinorrhea, nasal congestion, fever, or sore throat). LAIV is administered intranasally by sprayer, whereas TIV is administered intramuscularly by injection. LAIV is licensed for use among nonpregnant persons aged 2--49 years; safety has not been established in persons with underlying medical conditions that confer a higher risk for influenza complications. TIV is licensed for use among persons aged ≥6 months, including those who are healthy and those with chronic medical conditions (Table 1). During the preparation of TIV, the vaccine viruses are made noninfectious (i.e., inactivated or killed) (8). Only subvirion and purified surface antigen preparations of TIV (often referred to as "split" and subunit vaccines, respectively) are available in the United States. Standard-dose TIV preparations contain 7.5 mcg HA antigen per vaccine strain (for children aged <36 months) or 15 mcg of HA antigen (for persons aged ≥36 months) per vaccine strain (i.e., 22.5 mcg or 45 mcg total HA antigen). A newly licensed higher dose TIV (60 mcg per vaccine strain or 180 mcg total HA antigen) was approved recently for persons aged ≥65 years (Fluzone High-Dose, Sanofi pasteur)."
WHO IS HIGH RISK:
FROM THE CDC DOCUMENT
"Vaccination to prevent influenza is particularly important for persons who are at increased risk for severe complications from influenza or at higher risk for influenza-related outpatient, ED, or hospital visits. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to the following persons:
all children aged 6 months--4 years (59 months);
all persons aged ≥50 years;
adults and children who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus);
persons who have immunosuppression (including immunosuppression caused by medications or by HIV);
women who are or will be pregnant during the influenza season;
children and adolescents (aged 6 months--18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection;
residents of nursing homes and other long-term--care facilities;
American Indians/Alaska Natives;
persons who are morbidly obese (BMI ≥40);
HCP;
household contacts and caregivers of children aged <5 years and adults aged ≥50 years, with particular emphasis on vaccinating contacts of children aged <6 months; and
household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza."
STILL CONFUSED?
You will have to study the whole document and ask for guidance. Feel free to ask me questions and send your comments.
Buona Fortuna & Ciao for now,
Dr. Mike
Mission: Healing November 2, 2011
PGY 39, Day 124
StepWisely(R)
Improve Quality First = IQ First(TM)
The First Ten Steps To Rational Cost Containment = provide the Best Possible Care that will fresult in the best possible outcome.
for PROVIDERS in the Intensive Care Units
These tips are based upon my years of experience taking care of critically ill patients. They are especially designed for inexperienced doctors, medical students, nurses, patients and their families, and to help promote Integrated Quality Team Based Care ... STAY ON TARGET to optimize patient outcome and minimize adverse impact on families and loved ones.
1. Engage the Family: The Family is an ESSENTIAL Part of the Care Team
2. DEFINE ADVANCED DIRECTIVES based upon the PATIENT'S Wishes and in conjunction with the Family ASAP (When there is no family, whomever is responsible for the patient needs to be involved, if possible)
3. Use STOMPP*(TM) and the STOMPPIT*(TM) ATM Team Development Tools to help engage ALL Team Members in the definition & clarification of goals and objectives.
4. Restore ALL end organ perfusion RAPIDLY
5. Restore perfusion to organs at risk ASAP by all means necessary
6. Optimize ALL end Organ and Organ System preservation strategies using STOPs*(TM) (Specific Targest for Organ Preservation)
7. Enable Damage Control, if necessary
8. Enable Specific & Definitive therapy ASAP
9. Check END POINTS & STOPs for ALL therapies FREQUENTLY**, especially with regard to restoration of PERFUSION and achievement of DEFINITIVE THERAPY
10. Change the CARE PLAN/TREATMENT PLAN FREQUENTLY on the basis of weather or not your current plan is working & KEEP ALL TEAM MEMBERS in the loop.
*STOMPP, STOMPPIT & STOPS are familiar to the medical students, interns and residents I teach regularly. Contact me, if you want further information about these Patient Care Tools.
**FREQUENTLY in the ICU means at least hourly and sometimes continuously
Do the right thing and ENJOY!
Dr. Mike
StepWisely(R)
Improve Quality First = IQ First(TM)
The First Ten Steps To Rational Cost Containment = provide the Best Possible Care that will fresult in the best possible outcome.
for PROVIDERS in the Intensive Care Units
These tips are based upon my years of experience taking care of critically ill patients. They are especially designed for inexperienced doctors, medical students, nurses, patients and their families, and to help promote Integrated Quality Team Based Care ... STAY ON TARGET to optimize patient outcome and minimize adverse impact on families and loved ones.
1. Engage the Family: The Family is an ESSENTIAL Part of the Care Team
2. DEFINE ADVANCED DIRECTIVES based upon the PATIENT'S Wishes and in conjunction with the Family ASAP (When there is no family, whomever is responsible for the patient needs to be involved, if possible)
3. Use STOMPP*(TM) and the STOMPPIT*(TM) ATM Team Development Tools to help engage ALL Team Members in the definition & clarification of goals and objectives.
4. Restore ALL end organ perfusion RAPIDLY
5. Restore perfusion to organs at risk ASAP by all means necessary
6. Optimize ALL end Organ and Organ System preservation strategies using STOPs*(TM) (Specific Targest for Organ Preservation)
7. Enable Damage Control, if necessary
8. Enable Specific & Definitive therapy ASAP
9. Check END POINTS & STOPs for ALL therapies FREQUENTLY**, especially with regard to restoration of PERFUSION and achievement of DEFINITIVE THERAPY
10. Change the CARE PLAN/TREATMENT PLAN FREQUENTLY on the basis of weather or not your current plan is working & KEEP ALL TEAM MEMBERS in the loop.
*STOMPP, STOMPPIT & STOPS are familiar to the medical students, interns and residents I teach regularly. Contact me, if you want further information about these Patient Care Tools.
**FREQUENTLY in the ICU means at least hourly and sometimes continuously
Do the right thing and ENJOY!
Dr. Mike
Mission: Healing November 2, 2011
PGY 39, Day 124
For FAMILIES of Patients In the Intensive Care Unit
Here are a few pointers based upon my observations while caring for patients in the ICU over the years.
First, For Families and Loved Ones
StepWisely(R)
Improve Quality First = IQ First(TM)= Best Outcome = Best Care = Most Cost Effective Care = Best Practices
The First Ten Steps to Rational Cost Containment(TM) (RCC)
For Families of Patients In the Intensive Care Unit
1. Trusted Doctor: You must have Faith and Confidence in the physician(s) who take care of your family member, friend, or significant other. If you do not trust the people you are dealing with, arrange for a transfer of care to another facility, or doctor, or both.
2. CARRY OUT THE WISHES OF THE PATIENT: Make sure you have advanced directives that are based upon the wishes of the PATIENT, not your wishes, or the wishes of another family member. Do not impose your beliefs upon the patient. Do the RIGHT THING for the patient.
3. TEAMWORK: You are a member of the team. Find out how you can help. Ask what you can do to help. It is NOT HELPFUL for you to interfere in the care of the patient by spending too much time at the bedside. Ask the Doctor and the Bedside Nurse, what you can do to help when you are at the bedside.
4. Take Care of Yourself. You can't help if you are exhausted or in the way. Get some sleep. Identify your preference (if any) for religion and religious support. When the situation is critical get these folks involved.
5. Designate one or two members of the Family who are the primary representatives and spokespeople for the family. You will be responsible to coordinate information sharing with Family and Friends
6. Do not disrupt care: It is not helpful to have any DRAMA at the bedside
7. Write down your questions and the names of the people who are members of the care team
8. Make sure you understand the care plan
9. Review the care plan with the Critical Care Team Every Day and whenever changes are made
10. CONTACT INFORMATION: Give your contact information and GET the contact information for your care team.
Let me know if you want me to elaborate on any of this. Next will come a piece for PROVIDERS and I promised some guidance regarding influenza.
Questions or comments, contact me.
Dr. Mike
For FAMILIES of Patients In the Intensive Care Unit
Here are a few pointers based upon my observations while caring for patients in the ICU over the years.
First, For Families and Loved Ones
StepWisely(R)
Improve Quality First = IQ First(TM)= Best Outcome = Best Care = Most Cost Effective Care = Best Practices
The First Ten Steps to Rational Cost Containment(TM) (RCC)
For Families of Patients In the Intensive Care Unit
1. Trusted Doctor: You must have Faith and Confidence in the physician(s) who take care of your family member, friend, or significant other. If you do not trust the people you are dealing with, arrange for a transfer of care to another facility, or doctor, or both.
2. CARRY OUT THE WISHES OF THE PATIENT: Make sure you have advanced directives that are based upon the wishes of the PATIENT, not your wishes, or the wishes of another family member. Do not impose your beliefs upon the patient. Do the RIGHT THING for the patient.
3. TEAMWORK: You are a member of the team. Find out how you can help. Ask what you can do to help. It is NOT HELPFUL for you to interfere in the care of the patient by spending too much time at the bedside. Ask the Doctor and the Bedside Nurse, what you can do to help when you are at the bedside.
4. Take Care of Yourself. You can't help if you are exhausted or in the way. Get some sleep. Identify your preference (if any) for religion and religious support. When the situation is critical get these folks involved.
5. Designate one or two members of the Family who are the primary representatives and spokespeople for the family. You will be responsible to coordinate information sharing with Family and Friends
6. Do not disrupt care: It is not helpful to have any DRAMA at the bedside
7. Write down your questions and the names of the people who are members of the care team
8. Make sure you understand the care plan
9. Review the care plan with the Critical Care Team Every Day and whenever changes are made
10. CONTACT INFORMATION: Give your contact information and GET the contact information for your care team.
Let me know if you want me to elaborate on any of this. Next will come a piece for PROVIDERS and I promised some guidance regarding influenza.
Questions or comments, contact me.
Dr. Mike
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