PGY 39, Day # 366

PGY 39, Day # 366

Back in the SICU again

This is my transitional week; my last week of ICU duty for PGY 39, and the start of my first week of duty for PGY 40. That means we have the short timers now and newbies to start on July 1 ... house staff that is.  In other words, the more experienced interns and residents will move up a notch, while the interns move in.  This transition is always exciting

A few observations/thoughts/teaching points from rounds  ... these reflect my collective experience ... not just this week's events.

1. Monster Healthcare Organizations (as well as other corporations and governments) generate momentum and inertia that is dependent upon size and responsiveness. Like Giant Ships (eg. Titanic) they have a tendency to "stay the course" for many reasons, not the least of which is the failure to have accurate "sensors" in and on the front lines and they lack facility to change direction. In other words, they loose their sensitivity to the people they are serving and the servers (providers), get preoccupied with and distracted by things that are essentially phobias, impose top down "solutions" to non problems, increase burdens on front line providers, interfere with quality front line care and, basically, miss the mark on many opportunities to improve care quality and outcome.  Basically, they lack the ability to move smart and fast.  Electronic Medical Records are a perfect example of new technology that was imposed top down without proof of effectiveness and safety.  This technology consumes between 25% and 50% of front line provider time, and that takes away from patient care time.  Scribes can eliminate the time wasted on computers, but the safety and effectiveness of first generation EMRs is yet to be determined.  My bet is that drastic changes in form and function will be mandated in the near future.

2. Benchmark Quality "Standards", lower the quality of care, by justifying mainstream levels of performance. In other words, mainstream performance becomes a standard by default. This is dangerous in healthcare, where optimal performance and outcome is always the goal and mainstream performance may well be substandard. Disinguishing comparative benchmarks from true quailty measures is a serious problem that can only be addressed through solid scientific research.  This research should take the form of Continuous Quality and Performance Improvement measures that review 100% of care provided and examine the impact (outcome) of changes in practice, new techniques and technology.  The goal is to optimize patient care constantly and to raise the bar continuously.  That is the only way to provide the best possible patient care at all times.

3. Causes of vascular injury in trauma

4. Need for and Implementation of Continuous Quality and Performance Improvement Process to Measure Outcome: Provider Role

5. Need for Advanced Directives to prevent unnecessary and inappropriate care

6. Comparison of Morphine and Hydromorphone, cost, effectiveness, dose, side effects

7. Arterial and Venous Gas Embolism

8. Brain and Spinal Cord Protection Strategies

9. Nosocomial Pneumonia, Colonization, Transmission and other assorted issues related to Ventilator Associated Pneumonias and Hospital Acquired Pneumonias

10. Targeted Strategies for Patient Care and Organ Preservation in the ICU

As I was about to leave the hospital tonight, during a conversation after evening rounds with my night coverage resident ... one of the more experienced and competent residents on service ... about patient care and teaching, and the fact that this is "a labor of Love", and stating, "It is a good thing I love what I do."  We both laughed about the difficulties encountered in teaching and providing services, and I think he got the point that I reiterate on a regular basis. Specifically, "there is not enought money in the world to make this right."

I have to give it up now, and try to get some sleep.  On call, but the coverage tonight is solid, and tomorrow will be a Long Day! 

PGY 40, Day 1 meets PGY 1, Day 1!  LOL ... we will see how that goes.

Love to all!

"Love is the Power, Care is the Mission, Safety and Optimal Care are the Goals and The Hippocratic Oath is our Guide."

You can quote me on that.

Dr. Mike

Life is Love™©

StepWisely®™©

Reflections on PGY 39

PGY 39 Day # 359

As this Post Graduate Year 39 draws to a close, I have a few minutes to think ... before I resume my Critical Care Duties at 8 AM on Monday, June 25, 2012.  Next week will close PGY 39 and open PGY 40 ... the significance of which is ... to be determined.  However, there are some absolutely predictable events because the most experienced residents will move up a notch and the new interns will come in to start from scratch.  That means, the burden on the faculty will increase as soon as the shift takes place.

From my perspective as a "player-coach" in the front lines of the Critical Care arena, this is the most challenging time of the year. This is the peak of "trauma season" for many reasons, not the least of which include warm weather, increased outdoor activities, increased tourism (more population at risk), recreational drug/alcohol use and many more ... combine that with the weakest house staff and things can get a bit ... difficult, or worse.

On the larger front, it is time to take inventory ... to look at the year and make plans for the future ... which will include working at Geisinger in Danville, PA. This will start in Critical Care and we will see how things go from there.

As I transition out from WVU and into Geisinger, I will do my best to develop some links between the two.  But, things like this are not predictable, as Monster Institutions have their own ways of doing things ... for better or worse.  They say that Geisinger is an "institution with a heart" ... we shall see.  I have completed "orientation" there, and, so far so good.  Everyone has been extremely helpful to facilitate the usual credentialing and other preliminary nonsense.  Orientation is always disturbing ... with lots of time wasted.  But, minimal time waste was noted at Geisinger.  By accident, or design ... one can hope by design ... it was mostly one on one, so my specifit concerns could be addressed as we went through the formalities of each "required" piece.  I am optimistic about Geisinger and hope this is a place worthy of my efforts to optimize patient care in as dictated by the Hippocratic Oath.

My efforts to set up The Non-Profit Doctor-Patient Cooperative, will continue. David Mascia and I expect to launch this by the end of 2012.  We have a few tentative board members lined up, but there will be room for more on the Board of Trustees and Founding Members list. 

From the largest perspective, who knows what the future will hold.

Enjoy your day and days, have fun and be careful out there. LEAD with your HEART and DRIVE with your BRAIN!

Life is Love™© so StepWisely®™©

Love and Good Fortune to ALL.

To be continued ...

Dr. Mike

Medical Killing is Just Plain Wrong

MEDICAL KILLING IS WRONG!

Medical Killing is a clear violation of the Hippocratic Oath, it undermines the Doctor-Patient Relationship and it is just plain wrong. Don't let the Business of Medicine and the Politicians enable medical killing!
Below you will find two emails: the first is my respnse to the Care Not Killing administrator, Robert Colquhoun, and the second is the email that prompted my response.  It appears that the movement to enable medical killing is growing, and this is a very dangerous policy for many reasons.  Read the emails below to get a better understanding, and let me know if you have any comments, or questions.

Dr. Mike
dr.mike@ihealsolutions.com

From: "Michael F. Mascia MD, MPH" <masciam@aol.com>
Date: June 14, 2012 12:30:33 EDT
To: CNK Administrator <administrator@carenotkilling.org.uk>
Subject: Re: Vote NO on poll, respond to articles

Hello!

This is the complete title/author info on the MUST READ book to see how we are allowing the mainstream to slip into the Nazi mode ... AGAIN!
It is a compelling and nauseating read.

The Nazi Doctors: Medical Killing and the Psychology of Genocide

Robert Jay Lifton

Thanks for your help.

I will try to tweet/blog on this soon.

Interesting that I just put out a Tweet #quote yesterday about Killing ... as there is never any justification for intentional killing.  With rare exceptions ... perhaps someone like Hitler being the exception ... oddly enough.  Now ... with greedy and selfish people pushing the mainstream for profit over people ... we see this surge again with all sorts of excuses for the bad behavior.

Doctors should NEVER participate in KILLING for ANY REASON.
That said, there are some triage situations, and some allowing people to die in dignity ... which is clearly distinguishable from, and not to be confused with active killing. Abortion to save the mother of an unborn baby perhaps being the most extreme example. But, many can't make the distinction, as their minds are clouded with all sorts of nonsense.

That's why the Hippocratic Oath has stood the test of time ... despite the fact that many have messed with it over time including Hitler's people ... it always come back to the original, wise document +/- that serves as a foundation for our work.

It is time for Doctors to restore the Doctor Patient Relationship and this must go against the grain of the Business of Medicine ... which is clearly on a very bad path ... bad for Patients and Doctors.

Let me know if you need any other contact information.

Ciao for now,

Dr. Mike
Michael F. Mascia, MD, MPH
President
Infinity Health Solutions
dr_mike_ihs @ twitter

MFM@IHS ip
On Jun 14, 2012, at 6:55, CNK Administrator <administrator@carenotkilling.org.uk> wrote:

Dear All,

The next few weeks are shaping up to be extremely busy on the euthanasia front as pro-euthanasia activists are gearing up for a new assault on the media, the courts, the medical profession and Parliament.

The pro-euthanasia lobby has begun its campaign in earnest with three articles in the British Medical Journal which aim at neutralising medical opposition to euthanasia.

Please respond and comment on the articles below on the BMJ website:

Raymond Tallis, chairman of Healthcare Professionals for Assisted Dying, argues that medical institutions should take a position of studied neutrality on assisted suicide: http://bit.ly/M6rUBX
Tess McPherson, tells the story of her mother who died from cancer last year: http://bit.ly/LG9VmX
The journal’s editorial by Fiona Godlee, ‘supports’ call for assisted suicide: http://bit.ly/OGdjz7 Vote NO on the opinion poll on this page (scroll down on the right).

Iona Heath, President of the RCGP, argues that assisted suicide would marginalize the most vulnerable: http://bit.ly/K4scan
Many thanks,

Robert Colquhoun
Administrator

Please come to our symposium in Scotland:
http://www.carenotkilling.org.uk/forms/first-european-symposium/

--
Robert Colquhoun, Administrator
Website: http://www.carenotkilling.org.uk/
E-mail: info@carenotkilling.org.uk
Address: 6 Marshalsea Road, London, SE1 IHL
Phone: 020 7234 9680; Skype: carenotkilling
Registered as a Limited Company in England and Wales, Company No. 06360578
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One more Bit on Love

There is only one reason why we are here on this earth ...
To Love and Be Loved in return.
Get it?
Do it!

Life is Love™© so StepWisely®™©

Never underestimate the Power of Love

The question is this: How do we put this Power to Work for All?

Toward that end, I have been working with a few set this up.


My goal?  By the end of this year ... to set up a Non Profit that will enable and put this fundamental concept to work for the health and benefit of ALL who choose to participate.


I need a few folks, Doctors, Nurses and Patients to contribute and help get this going.  Not looking for money. We don't need money ... we need People.  This is a Cooperative ... Of the People, By the People and For the People.  You can particpate from anywhere in the world.  You give and you get in return.

Looking for ...
Founding members
Board members
Participants
Ordinary folks
to help us.

Let me know ... by email, or by responding to this blog.

Dr.Mike@ihealsolutions.com

Ciao for now, and LOVE to all.

Dr. Mike

Love Tid Bit

Love, An Eternal Moment

I close my eyes ...
you appear ...
Sweet images of you ...

wondering ... why ...

You are the Fire ...
that burns ...
in my ...
Heart.

Never underestimate the power of Love.
Love to all.
Dr. Mike

Critical Care Day 6 of 6

PGY 39, Day 339 I think ... "339" ... "lucky numbers" ... we will see how it goes. My concern is for the patients and families ... not for myself. Sure, fatigue is always an issue, but at this stage, a few hours sleep and an occasional nap will get me through. The units are full ... we have received "bolus" after "bolus" of 3 - 5 patients at a time ... to keep us at capacity. This time of year ... "trauma season" ... is usually busy, but we have "experienced" house staff in June ... before the newbies move in on July 1 ... and the cycle starts again. Ooooo my ... Issues and discussions: EMR goes "down" for "upgrade" ??? Limitations of EMR? Why first generation EMRs interfere with patient care? EMR Flaws Why we need "scribes"? How EMR fails as a research tool? Euvolemia and the "Euvolemia Checklist" Brain and CNS protection and the "CNS Protection Checklist" Resuscitation targets Acute Kidney Injury and more. To be continued ... We can fix the "Business of Medicine" ... one step at a time. StepWisely(R)TM(C) Dr. Mike

Critical Care Week: Day 4 of 6

PGY 39, Day 337 BOOTS ON THE GROUND IN THE FRONT LINES OF PATIENT CARE I see myself as a Taskmaster ... and sort of "player/coach" ... someone who pushes the team toward optimal care of each patient and steps in (when necessary) to make it happen. Toward that end, I am constantly working to define the team, the problems, the solutions, the tasks and the jobs as they must be accomplished for each patient at all times, if we are to accomplish optimal patient care. 1. set and generate goals and 2. objectives (targets) 3. jobs and tasks 4. the care ... develop and coordinate the team and the care plan. Sounds simple ... It is not! Today: we have a new team ... it is June 1, so one senior resident stays and the pharmacy team is unchaanged, but there is a new intern and a new resident, which means that it will take several days ... if ever for the new folks to get up to speed. Consequently, the burden falls on the senior surgical resident and me ... to make sure everything gets done optimally. That is the way it is! Today, I focused on helping the new folks to understand "their job" ... we will see how well they can do it!!! Earlier in the week, these topics came up for discussion in the context of patient care. 1. Advanced Directives and lack thereof 2. Need for definitive care plan 3. Patient and Family as team members 4. Pancreatic Cancer 5. Biliary obstruction 6. Brain Protection 7. Custodial Patients ... what to do when folks can't make decisions and have nobody to make decisions for them??? 8. Pneumonia vs colonization 9. Importance of Perfusion 10.Need for a paradigm shift in American Healthcare 11.Why did you go into medicine? 12.Don't shoot from the hip ... use your brain. 13.Have a reason for everything you do. To be continued ... "This is a labor of love ... Lead with Heart and Drive with your Brain." Life is LoveTM(C) and StepWisely(R)TM(C) Have a great day and be careful out there. Dr. Mike PS. I got some great family feedback today ... always needed and appreciated ... Love for Love ... Always needed and sometimes it happens ... the healer gets healed in the process of healing.