The Daily Apple™© Volume 3, Number 3

The Daily Apple™© Volume 3, Number3
September 29, 2014

PGY 42, Day # 91

On Dodging Bumblebees and Wildflowers

Now it does not matter much, since summer has come and gone and fall is here.  The grass is still green, but growth is slow and the flowers are almost gone.  Leaves are turning all shades of bright and some shout for attention, "Look here!", "Look at me!", "I am the brightest!" ... can you hear their colors screaming out against eternal blue skies?  The brilliant colors speak in a hushed amber glow, but some leaves shout out, before they fade and fall ... flutter and fall gently to the ground in still, sweet, warm air, kindled by the waning Autumn sun.  Calm ... silence, broken by laughter, pleasant conversation and birdsong is Heavenly.  Leaves weave and dance their final path to the ground ... soon to be frozen and covered with a wintry white blanket of snow.  A few grapes (17 to be exact), blueberries and two apples are yet to be harvested.  Yes, that's right, two apples.

The blueberry crop was good this year and I know why the grapes are sparse: severe pruning.  But the apples?  Two apples on a tree that gave me more than a bushel a few years ago?  Two apples?   That is my entire 2014 apple crop and I wonder why so few?  I want to blame it on spring rain.  Is it true?  Is it just a tired old tree? Is this why the many blossoms dropped unfulfilled to the ground?  Is it simple pollination failure, or part of a more global problem?  As my mind wanders through these questions wondering if this is part of colony collapse disorder (CCD)?

Winter was long, hard and brutally cold.  Spring was late, but explosive.  Green burst into view shortly after the mid May full moon and appeared to display faster early growth than I had ever seen.  Within two days, the scene was quickly transformed from drab brown and gray to a fluorescent glow as the buds on the trees burst rapidly into pale soft yellow-green leaves.  By the seventh day after the full moon, early flowers were popping, new growth was nearly fully formed and the grass was growing like wild.  It was time to get the lawnmower out.

When I cut the grass, my first focus is to make a paths to blueberries, grapes, apples and compost pile, and to cut a ring around the house and field, for tick abatement.  One more thing: avoid the wildflowers, bumblebees, honeybees and other hymenoptera.  Children laugh ... even my full grown children and many adults laugh at the sight of my "botched" lawn and missed patches of "weeds".  Yes, my lawn does not meet the normal suburban neighborhood standard, the standard fairway pattern, or any other standards of lawn care.  But, it does make sense.  This is why.

I have been doing it for years.  By dodging wildflowers, bumblebees, honeybees and other hymenoptera, I encourage growth of the wildflowers and give the bees a place to feed.  My hope is that the honeybees and bumblebees will flourish as do the wildflowers and that my "crops" will flourish with them.  This year, I saw one honeybee, many bumblebees, assorted hymenoptera and a single hummingbird.

We can only hope that "botched" lawns will become fashionable in the near future along with other more comprehensive efforts to reduce consumption, toxins, pollution and the ravaging of our planet.  My suspicion is that honeybees are sentinel animals and CCD is a reflection of environmental decline.  Autism rates are up as well, and recently published research suggests a link between autism and maternal exposure to insecticides during pregnancy.  Wild animal populations are down as well.  Can you see the dots?  Try connecting them.  Let's take care of need and boycott greed.  Time to wake up and grow the flowers.  There is NO NEED for arbitrary profit over people.  Let's try cooperation over competition.  And, slow down ... smell the flowers, while we still have flowers to smell.  Recycling plastic bottles is necessary, but not sufficient.

Have a sweet day.

Dr. Mike

References:
1. On Seasons: http://en.wikipedia.org/wiki/Season
2. On Lawns: http://mda.maryland.gov/SiteAssets/Pages/fertilizer/MDAProLawnCareManual6.24.13.pdf
3. On Hymenoptera: http://en.wikipedia.org/wiki/Hymenoptera
4. On Colony Collapse Syndrome: http://www.nytimes.com/2014/09/29/us/the-head-scratching-case-of-the-vanishing-bees.html?emc=edit_th_20140929&nl=todaysheadlines&nlid=65359995

That Just Goes to Show You: Time Flies

The Daily Apple™© Volume 3, Number 2
June 4, 2014

PGY 41, Day #331

That Just Goes to Show You ... There is Always Something and Time Flies

When I use that common phrase and especially when I add "There is Always Something", Gilda Radner and her character Roseanne Roseannadanna from Saturday Night Live come to mind.

http://en.wikipedia.org/wiki/Roseanne_Roseannadanna

Then, a smile comes over me and, given enough pause, a bit of out loud laughter erupts.  AKA LOL.  If you are over 40, you probably know of her and, if not, check her out.  Your heart and soul will be better for it.  Then on to serious business.  Yes, humor and laughter are useful healing tactics, but, eventually, we get back to action required.

My point?  As PGY #41 draws near to a close, I must apologize to my followers for the limited number of blogs posted here this year.  My excuses?  Patient Care, Teaching, Administration, Family Care and Veritas Health Care.  Yes, most of my "free time" has been spent working and writing for the nonprofit Veritas Health Care

http://www.veritashc.org.php53-9.dfw1-1.websitetestlink.com/

and the Veritas Health Care blog

http://www.veritashc.org/blog/

Please join us at Veritas Health Care.  We are the NONPROFIT Veritas Health Care and if you care about health care and want a platform and springboard to help Build Better Health and Health Care you might want to sign up.  We continue our efforts to Build Best Practices and to Optimize Quality and Performance Improvement through application of our available tools.  We are happy to show you how to use our tools to promote and optimize personal health, family health, community health and health care.  We are local and global.

Also, when time permits, I will add teaching points to both blogs.  This may create some overlap, but the spectrum of knowledge and skill required for optimal self care knows no boundaries.  In other words, I am willing and able to teach anyone who is motivated to learn.  So, with that in mind, please forward specific questions or comments on any Health and Health Care related subjects.

Thanks for caring.

Dr. Mike
Michael F. Mascia, MD, MPH

Busy at Our Nonprofit Veritas Health Care (VeritasHC.org)

The Daily Apple™© Volume 3, Number 1
April 1, 2014

Wow, PGY 41 is rapidly disappearing, but we have made considerable progress over the year.  What is it PGY 41, Day #275 in my medical career?

Veritas Health Care, our nonprofit, is now a little over one year old and we are moving along in the process of Building Better Health Care through Cooperation and Cooperatives.

Please Join us @ Veritas Health Care through

http://www.veritashc.org

Check our latest Veritas Health Care blog post "For the Health of It"

http://www.veritashc.org/for-the-health-of-it/health-volume-2-8-stuff-case-1-b2-lens/

For the Health Of It™©, Volume 2 #8: The Stuff We Do, Case #1, Through the B2 Lens - See more at: http://www.veritashc.org/for-the-health-of-it/health-volume-2-8-stuff-case-1-b2-lens/#sthash.GAwnuTao.dpufHelp us to build better health care.

Have a sweet day.

Dr. Mike

PS. The Daily Apple™© will continue to reflect our work at Infinity Health Solutions and Veritas Health Care

Pulmonary Edema

The Daily Apple™© Volume 2, Number 10
October 3, 2013


The questions below were posed last month in association with a Lecture on Pulmonary Edema given by me to the residents, fellows and medical students on the Critical Care Service at Geisinger Medical Center.  If you would like to see the lecture, email me.

Oh, yes, by the way, I am required by Geisinger to tell you that the opinions expressed are strictly mine and based on the latest evidence ... in every sense of the term.  None of this is the opinion of, supplied by or belongs to Geisinger in any way.  Yes, I do share the information with Geisinger as a part of my Clnical, Administrative, Teaching and Research obligation.  In other words, I work for Geisinger.

And ... Please Join us @ Veritas Health Care www.VeritasHC.org to Help Build Better Health Care


Introduction to Pulmonary Edema

Pulmonary Edema is, fundamentally, excess water in the lungs and this extra water interferes with normal lung function.  There are three fundamental pathophysiologic mechanisms that underlie pulmonary edema and they help us to group the pathology we find in clinical cases.  Pulmonary edema may be found in patients with normal pulmonary vascular pressures (NPPE or Normal Pressure Pulmonary Edema), high pulmonary vascular pressure (HPPE or High Pressure Pulmonary Edema), or a combination of the two (MPE or Mixed Pulmonary Edema).  These mechanisms help us distinguish and define the causes and proper treatment options.  All treatments are therapeutic trials and patients must be monitored closely to verify effectiveness, or change treatment, if ineffective.  Always go back to the patient (not the record) to verify effectiveness.

Questions Posed


Pulmonary Edema: Back to Basics QUESTIONS for interactive discussion and debate
September 2013 Geisinger Talk by Michael F. Mascia, MD, MPH

masciam@aol.com and Dr.Mike@ihealsolutions.com

©IHS Michael F. Mascia, MD, MPH Pulmonary Edema v972013

1. What is Pulmonary Edema?
2. What is Edema (oedema): Transudate vs Exudate?
3. What are the Symptoms of Pulmonary Edema?
4. What are the Clinical Signs of Pulmonary Edema?
5. What are the Causes of Pulmonary Edema?
6. What is Noncardiogenic pulmonary edema?
7. What is Cardiogenic Pulmonary Edema?
8. What is the pathophysiology leading to pulmonary edema: Cardiogenic vs Noncardiogenic vs Mixed?
9. How can you confirm your clinical diagnosis?
10. What is the treatment of Pulmonary Edema?
11. Is it cost effective?
12. What is the expected outcome after treatment for pulmonary edema?
13. What is the evidence to support your answers?
14. What is optimal cost effective care in Pulmonary Edema?


Have a great day and StepWisely®™© with us @ihealsolutions, Infinity Health Solutions and Veritas Health Care


Ciao for now,


Dr. Mike
Michael F. Mascia, MD, MPH

One More Thing on EMR Flaws, Dangers: Why Patients First?

The Daily Apple™© Volume 2, Number 9
August 29, 2013

Technology Failed Again.  That reminds me to remind you about the need for redundancy, when it comes to HIT stuff.

When thinking about EMR<>EHR<>HIT stuff and designing better HIT systems ... remember this.
Wall street went down on (Thursday, August 22, 2013)

  http://dealbook.nytimes.com/2013/08/22/nasdaq-market-halts-trading/?nl=todaysheadlines&emc=edit_th_20130823&_r=0

but, nothing happened.  A few guys made less money?  There was a delay in trading ... so what?  Who cares?  If I were one of those trader guys, I would have hiked out of the office, grabbed a cup of coffee, walked down to the river, felt the sunshine and watched the water run by.  "Call me when things are back up and running."  But, in my business, I can't do that.

There are few things in life during which time is critical.  In fact, time is usually irrelevant.  But, in the spectrum of life, health, healthcare and death, the natural history of injuries and diseases dictate some of the critical moments in life.  So, chill when you can ... drink the coffee and smell the roses.  And, recognize those things that require immediate attention ... true emergencies.

In other words, there are certain illnesses and injuries during which minutes ... even seconds of delay in proper diagnosis and definitive treatment may result in permanent cell damage, organ damage, loss of limb, or loss of life.  The diagnosis and treatment of these conditions is CRITICAL CARE ... That's my day job.  In this business, there is no excuse or time for "systems down".  In other words, we have to be ready to take care of these sorts of problems 24 x 7 with or without technology.  That is the simple truth.  Veritas!

During Katrina, ALL SYSTEMS WERE DOWN within a few hours and they stayed down for days to weeks.  In the immediate aftermath of Katrina, we had NO RECORDS on many patients, some of whom were critically ill.  Direct care Patient<>Physician<>Provider prevented many disasters in our hands.

Intermittently, every electronic record and system I have used has failed.

Intermittently, every piece of technology I have ever used has failed.

Conclusion:  There is no such thing as failsafe.  But, we can build redundancy into EMR<>EHR<>HIT Systems that will generate smart cards and "hard copy" intermittently, at a frequency to be dictated by the "situation" the patient happens to be in at the moment.  If "the patient" is in the hospital, or the Intensive Care Unit, hard copy of the EMR/flow sheet should be printed out at least every 8 - 12 hours. At the push of a button, the "system" should generate a smart card and paper summary for each patient.  In critical situations, attach that summary and smart card with all essential data, at least a problem list, to name tag that hangs on the patient's neck.  That way, the patients and the folks on the front lines with the patients who are responsible for their care will have a little something to help them get some background information.  And, the folks who receive them will also have something to go on.  Add this capacity to the design of any robust EMR<>EHR<>HIT System.  Just my opinion.

And, HIT guys ... don't look at me as if I have two heads when I tell you these things.  Fix it!

Dr. Mike
Michael F. Mascia, MD, MPH

EMR Flaws and Dangers: Patients First, Not the Medical Record

The Daily Apple™© Volume 2, Number 8
August 9, 2013

PGY 41, Day 40

Electronic Medical Records: Flaws and Dangers

ALWAYS GO TO THE PATIENT FIRST

Here are ten reasons why you & every provider should ALWAYS go to the PATIENT FIRST and NEVER go to the record first, or copy and paste from the ELECTRONIC MEDICAL RECORD (EMR)

1. SICK PATIENTS CHANGE FAST: INTERVAL CHANGES IN HISTORY AND PHYSICAL EXAMINATION WILL BE MISSED

You may miss clinical changes that are important to early diagnosis and treatment

2. THE RECORD MAY NOT BE ACCURATE: THERE MAY BE ERRORS AND OMISSIONS

Previous examiners may have skipped parts of the history or physical examination

3. SOMETHING MIGHT HAVE BEEN MISSED IN THE LAST EVALUATION

The natural history of most diseases includes a preclinical, or undetectable phase, which may or may not be symptomatic. Frequent evaluation of the patient, including repeat history and physical examination is an essential part of early definitive diagnosis and treatment.

4. THE RECORD MAY BE INCOMPLETE

5. YOU MAY BE LOOKING AT THE WRONG RECORD

6. SOMEONE MAY HAVE MADE AN ERRONEOUS ENTRY INTO THE RECORD

7. DISEASES EMERGE OVER TIME: EARLY & DEFINITIVE DIAGNOSIS AND PRECISION TREATMENT MAKES A DIFFERENCE

This is intuitively obvious and proven empirically for several diseases. Follow the data and use your intuition for now. Target: Early Definitive Diagnosis and Precision Treatment

8. THE MORE PEOPLE WHO EVALUATE THE PATIENT (NOT THE RECORD) THE MORE ACCURATE WILL BE THE EVALUATION

Intuitively obvious. Do you need proof? Talk with me and we will do some research to prove it.

9. THE MORE OFTEN THE PATIENT IS EVALUATED, THE MORE ACCURATE WILL BE THE EVALUATION

As in number 8 above.

10. COPY AND PASTE IS CHEATING, PLAGIARISM & FRAUD

Yes, and it is a bad idea to cheat patients and cut corners on patient care. This is a problem that results in suboptimal outcome. Do you need proof for this?

SUMMARY AND CONCLUSION

Sick Patients, especially when critically ill, can change rapidly. The natural history of each disease, the way in which each disease presents in a particular patient (host), the preclinical phase and the clinical presentation can vary dramatically from one -DISEASE<>PATIENT (host)- to another. This is the reason for frequent and repetitive patient evaluations. In other words, frequent evaluation by multiple providers increases the accuracy and speed of diagnosis and proper treatment, and this is the right thing to do for all patients at all times. It is NEVER OK to cut corners on patient care.

Electronic Medical Records make it very easy to cut corners, to go to the record first, to copy and paste, to take the note that someone else wrote, to copy it and paste it in as if it were your note. In other words, if you don't write the note based upon your history and physical examination ... if your note is not based upon your evaluation of the patient, you are cheating the patient. Don't do it! ALWAYS go to the PATIENT FIRST. To copy in paste is plagiarism, fraud and cheating the patient out of best possible care.

At best, the Medical Record, Electronic or otherwise, is an imperfect reflection of the patient. In other words, even if it is a "perfect" record, or a "perfect" EMR, it is limited by our knowledge of the patient at one point in time. Over centuries, the medical profession has learned a few things that are easily undone by the EMR. You in the EMR business? HIT people? Do NOT ENABLE COPY AND PASTE for history and physical examinations and interval notes.

Each note, history and physical examination should stand alone at a point in the timeline of each patient's life. It is a reflection of each physician<>patient relationship at one point in time. Each is personal and unique ... not to be undone by technology or methodology. And, if done properly, Doctor, your notes will be accurate and lead to better and best outcomes in patient care.

Salute! Amore e buona fortuna. It is all about Love. There is not enough money in the world to make this right.

Join us.  Help Build Better Health and Healthcare through Patient<>Physician Cooperation and Cooperatives @ www.ihealsolutions.com  and our non profit @ www.VeritasHC.org

Dr. Mike

Michael F. Mascia, MD, MPH

Eleven Steps: HOW TO FEEL BETTER MORE OF THE TIME AND REDUCE YOUR CHANCES OF A MAJOR ILLNESS

The Daily Apple™© Volume 2, Number 7

Friday, June 28, 2013

PGY #40  Day #363

Take The Best Care™© of Yourself

From Dr. Mike and Infinity Health Solutions

HOW TO FEEL BETTER MORE OF THE TIME AND REDUCE YOUR CHANCES OF A MAJOR ILLNESS 

From The Stress Management Workbook: An action plan for taking control of your life and health

Pages 156 and 157

The last blog post made reference to these pages, so here they are.  These 11 rules will help you get healthy and stay healthy.

Dr. Mike

HOW TO FEEL BETTER MORE OF THE

TIME AND REDUCE YOUR CHANCES

OF A MAJOR ILLNESS

The following list of rules gives you a general summary of what we

think is reasonable health behavior. Review them and keep the list

for future reference.

1.  Awareness of Behaviors You Can Change:

You have control over many factors that may significantly affect your health. Take advantage of the opportunity to learn how your own behavior

affects your health. Strive to change your behavior in such a way

as to promote your health. Learn to differentiate between those

things you can change and those you must accept.

2.  Preparation for Conditioning:

Establish a relationship with a physician whom you can trust. Make sure .you are able to communicatewith your personal physician. Visit your physician annually in order to continually assess your health status. Do not

start an exercise program without a health evaluation and advice

from your physician.

3.  Immunizations:

Be sure you are fully immunized. Diphtheria/tetanus

should be received at least every 10 years. Other immunizations

may be necessary under certain circumstances.

4.  Exposure:

Avoid physical, chemical, and biological hazards in the

environment. This is the essence of risk reduction. Some things

are obviously more hazardous than others depending on your age.

The major health hazards for the 30- to 40-year-old individual

are the automobile, alcohol, smoking, and weapons. There are

other significant factors such as drugs, air and water pollution,

and food additives that have adverse health effects, although they

may be difficult to quantify.

5. Diet:

Learn what you are eating and what you should not be

eating. Food additives, such as flavor enhancers, artificial flavors,

artificial colors, artificial sweeteners, and preservatives, as well

as hormones and antibiotics, are chemicals. Some are known to

be hazardous and others are suspect. These should be avoided. In

addition, excess sweets, starches, and fats should be avoided.

Your diet should contain fresh fruits and vegetables, lean meats,

fish, and low-fat dairy products. Excess salt can be a problem.

Obesity or overweight is a major health hazard.

6. Drugs:

Avoid the use of drugs unless absolutely necessary. All

drugs are potentially hazardous. Their benefit must be carefully

weighed against their danger. Discuss this with your physician.

7.  Exercise:

Develop a regular exercise program and go through

your daily activities in a way that promotes fitness. Exercise, if

done regularly and under supervision, reduces the risk of hypertension

and heart disease.

8.  Recreation and Relaxation:

These two are critical to your sense of well-being. They probably also prolong your life.

9.  Sleep:

When you are tired, go to sleep. Distractions such as television

that keep you awake during your period of greatest evening

fatigue are the single greatest cause of insomnia.

10. Goals and Expectations:

Examine your personal expectations and

the expectations which you have of others very carefully. Make

sure that they are reasonable. If unreasonable, they should be

changed. If you are unable to examine or change them on your

own, seek help.

11.  When and How To Seek Aid:

A serious, or persistent problem deserves prompt evaluation by your personal physician, or, if necessary, the physician who is on call.