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

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

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.

Tick Season Again: One more reason to avoid tick bites

The Daily Apple™© Volume 2, Number 6

Saturday, June 15. 2013
PGY 40, Day #350

Tick Season Again: One more reason not to get tick bites ... Red Meat Allergy

I found at least one of the nasty creatures on me each day this this week.  Fortunately, none of them had stared feasting on me.  Nevertheless, it is a reminder that this is the time to be especially careful about ticks and the troubles they can cause.

It is is not bad enough that they are nasty creatures that can transmit Lyme Disease, and a long list of other infectious diseases (below), tick bites are now found to be associated with RED MEAT ALLERGY.  So, if you did not have enough reason to protect yourself from tick bites before, you can now add the risk of red meat allergy to your list. 

That's right, you have one more reason NOT to get tick bites.   New science has emerged from researchers at the University of Virginia the associates tick bites with RED MEAT ALLERGY, including, but not limited to life threatening anaphylaxis.  The symptoms of red meat allergy usually occur several hours after eating the red meat, because the offending agent, alpha-gal is most abundant in animal fat, so absorption is delayed.

Beware tick bites!

Have fun and be careful out there.  StepWisely®™© with us and Go to Health™©

Dr. Mike
Michael F. Mascia, MD, MPH

REFERENCES

CDC LIST OF TICK BORN DISEASES:

• Anaplasmosis is transmitted to humans by tick bites primarily from the blacklegged tick (Ixodes scapularis) in the northeastern and upper midwestern U.S. and the western blacklegged tick (Ixodes pacificus) along the Pacific coast.

Babesiosis is caused by microscopic parasites that infect red blood cells. Most human cases of babesiosis in the United States are caused by Babesia microti. Babesia microti is transmitted by the blacklegged tick (Ixodes scapularis) and is found primarily in the Northeast and upper Midwest.

Ehrlichiosis is transmitted to humans by the lone star tick (Ambylomma americanum), found primarily in the southcentral and eastern U.S.

Lyme disease is transmitted by the blacklegged tick (Ixodes scapularis) in the northeastern U.S. and upper Midwestern U.S. and the western blacklegged tick (Ixodes pacificus) along the Pacific coast.

Rickettsia parkeri Rickettsiosis is transmitted to humans by the Gulf Coast tick (Amblyomma maculatum).

Rocky Mountain Spotted Fever (RMSF) is transmitted by the American dog tick (Dermacentor variabilis), Rocky Mountain wood tick (Dermacentor andersoni), and the brown dog tick (Rhipicephalus sangunineus) in the U.S. The brown dog tick and other tick species are associated with RMSF in Central and South America.

STARI (Southern Tick-Associated Rash Illness) is transmitted via bites from the lone star tick (Ambylomma americanum), found in the southeastern and eastern U.S.

Tickborne relapsing fever (TBRF) is transmitted to humans through the bite of infected soft ticks. TBRF has been reported in 15 states: Arizona, California, Colorado, Idaho, Kansas, Montana, Nevada, New Mexico, Ohio, Oklahoma, Oregon, Texas, Utah, Washington, and Wyoming and is associated with sleeping in rustic cabins and vacation homes.

Tularemia is transmitted to humans by the dog tick (Dermacentor variabilis), the wood tick (Dermacentor andersoni), and the lone star tick (Amblyomma americanum). Tularemia occurs throughout the U.S.

364D Rickettsiosis (Rickettsia phillipi, proposed) is transmitted to humans by the Pacific Coast tick (Dermacentor occidentalis ticks). This is a new disease that has been found in California.

   REFERENCES FOR TICK ASSOCIATE RED MEAT ALLERGY:

http://uvamagazine.org/research_and_discovery/article/ticked_off_carnivores/

http://online.wsj.com/article/SB10001424127887324634304578537203916053308.html

REFERENCE FOR PREVENTION AND TREATMENT OF LYME DISEASE

http://cid.oxfordjournals.org/content/43/9/1089.full

CDC LYME DISEASE LINK

http://www.cdc.gov/lyme/

Drinking and Thinking?

Drinking and Thinking
April 13, 2013

LoveLife IS Love™©,
Whimsical Words With A Serious Meaning

On a Spring Morning in Maine

Are you thinking,
an alcoholic beverage.  No.
I am drinking ...

Hot coffee, it is, as is usual for me this time of day,
for me to drink and think and,
to tell what my sense and senses say,
as I sit in my cozy seat and sip this warm, delicious mix.
It is a fix,
for me to watch through kitchen window,
this, another day grow out of darkness,
a joyful pleasure and good way to spend some leisure,
giving my two cents
and say,

This morning Snow, White, I tweet these words

"Today, white. Yesterday's snow, clouds +ice -new blanket spread around on trees & ground, &crystals bending branches. Still now, Love." U?M

and think, "this is too short. And, besides, on Twitter, everyone talks and nobody listens.  So, what is the point of words on twitter? Then again, there are a few I know ... have come to know through Twitter ... who are real people and solid friends ..."

So, my reasons unfold,

"These words resonate with some. Few, but enough hearty souls and courageous, as they speak out as well.  It is good to know and to share words from the heart, to know you are on this earth, myy kindred spirits."

and as I sit and think about it all,
clumps of snow begin to fall,
and drip from trees.
A brighter sky now warming,
the ice begins to sparkle in sunbeams,
this crystal splendor soon to be ... gone
as it is, time passing and thoughts so fast and words so slow,

"and writing such a distraction from being ...the page is not real ... here and now ... words, there are never enough of them to tell the story, but it is just another form of expression, as is life ... and every step taken ... expression of self"

Sunbeams, within each droplet an infinite rainbow sparkles

"Life IS Love and precious ... not to be wasted ... on the greedy.  Reciprocity is the rule, Love and tough love.  Am I trying to convince myself?  There are others I know who live by this simple rule.  The only reason we are here on this earth is to Love and be Loved in Return."

Shadows in the sunlight,
and, you know,
warming, melting, dripping,
dropping water from the trees
turning brown and green before my eyes.
Drooping leaves and branches,
bouncing up from under the melting snow and ice.
There is no breeze.

"It is nice"

A bird, birds, birdsong.

"How is it that they can find the feeder after it has been gone so long.  Within a day they found it."

They flutter by the steel gray sky,
and yet, they sing
to each other?

"Is this Love?"

I wonder what this day has in store for me?
Have a great day!
StepWisely®™©, Take the Best Care™© of Yourself and those in your charge.  Have fun and be careful.
Dr. Mike

Why are Hospitals Dangerous? The Business of Medicine

The Daily Apple™© Volume 2, Number 4

Wednesday, March 6, 2013 PGY 40 Day #249

The Daily Apple™© Volume 2, Number 4

From Dr. Mike & Infinity Health Solutions

www.ihealsolutions.com  

Why are Hospitals Dangerous? The Business of Medicine

Why are hospitals so dangerous?  Is this a new problem, or worsening of an ongoing problem? How do we fix it?  This is my take on the subject.

During my career, I have watched the Medical Profession fall into a trap driven by The Business of Medicine.  Yes, that's right, it is all about money.  When I started, it was not easy to do the right thing for patients, but we did it.  The Medical Profession, the Art of Medicine and the Doctor-Patient Relationship were important considerations at that time.  Now, for many reasons, dwarfed by the focus on money and business, the Doctor-Patient Relationship has been sold out to the Business of Medicine.  Let's take a brief look at the problem and the fix.

Patient care has never been and will never be perfect, so Quality and Performance Improvement (QIPI) have always a part of what we did to take stock of errors and bad outcomes.  At the start of my career, QIPI generally took the form of Peer Review and Morbidity and Mortality (M+M) reviews.  The traditional reviews of adverse outcomes were strictly medical, mostly confidential and Peer Review has generally been undiscoverable as well.  These processes were not strictly scientific, because they only looked at the cases that surfaced.  Generally they focused on deaths and major adverse events which were perplexing or major errors.  We all learned from these case conferences and, having been actively involved from the start, I learned how to turn the QIPI process into a scientific way of monitoring quality and outcome of care, and how to make care better and best.  So, I have been watching Quality and Outcome in healthcare from the start of my career and I have watched the deterioration over time.  This is what I have seen.

Over time it has become progressively more difficult to focus on the patient first and the Doctor-Patient Relationship.  At this stage, third parties have so much control over the profession, that it is virtually impossible to stand for patients, because the Profession and the Doctor-Patient Relationship have been hijacked by third parties that hold the money.  If a doctor stands up for patients and, in the process slows "the line" down, he or she becomes the identified problem.  The "real problem" gets lost in the shuffle.  Now, the business people drive Doctors to "perform" and that often puts Profit over People.  As the money holders push Patients into "product lines" and Doctors into "line workers", the human factors and rough edges are dismissed, and corners are cut for the sake of "efficiency".  That translates into running patients "through the mill" as fast as possible to "save money". 

Nothing wrong with saving money, right?  But, think about it and look at the facts.  In fact, when we "save money", it does NOT go back to patient care, it goes to third parties who care only about profits and bonuses.  Consequently, the bottom line is this: corners are cut, quality of care goes down, people are hurt and third parties get more money.  That money comes out of the pot that should be used to improve patient care, and goes into the pockets of corporations, share holders, executives, managers and other folks who do not care for or about patients. 

This background sets the stage for deterioration of patient care in hospitals.  As corners are cut and fundamentals are ignored, the most vulnerable of the vulnerable, our patients, become the victims.  Pushing for speed over quality under the guise of efficiency and "cost containment" has interfered with good old fashioned basics of quality patient care.  Generic 'benchmarks" have lowered quality by creating a group think mentality that reinforces bad care as acceptable.  Why? Since we look at hospitals as they compare to each other, standards are lowered to "we are all bad together" levels, instead of reaching up for better and best care.  Hospital QIPI programs are sluggish, disconnected from front line providers, not transparent, dysfunctional at best, and do not come close to the scientific scrutiny required to build the best possible care.

What's the fix?  Objective QIPI and Improve Quality First (IQ First™©).  StepWisely®™©, IQ First™©, Rational Cost Containment™©, Top 10n Targets™© and STOMPPIT™© are each parts of our QIPI Tool Kit™© .  Our Quality Improvement systems are designed to engage Doctors, other care givers, Patients and Families in the processes of improving patient care from the front lines of Patient Care.  When Doctors and Patients unite to drive the QIPI process, we will make hospitals and other health care providers as safe as can be ... we can make each one of them the "best" in the context of the community in which they live.

Join us.  Let us help teach you how to make your hospital stay safe and your local hospital "the best".

Please comment on this blog, or email dr.mike@ihealsolutions.com

Dr. Mike

The Daily Apple™© Volume 1, Number 4

Wednesday, December 26, 2012

The Daily Apple™© Volume 1, Number 4

The Daily Apple™© Volume 1, Number 4

From Dr. Mike & Infinity Health Solutions

www.ihealsolutions.com

December 26, 2012 PGY 40 Day #179

BLUEBERRIES ARE GOOD FOR YOU TOO!

Take the Best Care™© of YOURSELF ...

What Can You Do To REDUCE Your Risk of a Motor Vehicle Crash?

Take Ownership for Self, Family Members, Passengers & Others on the Road: Be Responsible

In The Daily Apple™© we “use The Stress Management Workbook, to help maintain order and perspective in what has become an extraordinarily complex and fragmented “business of medicine”. Recently, I have been asked to create a blog post on safe travel tips. So, that leads me to this

StepWisely​®™© Check List:

Step One: Take the Best Care™© of YOURSELF

Top 10n Targets™©: To Promote Motor Vehicle Safety & Prevention of Motor Vehicle Crash

1.   DO Take this check list with you. O

2.   DO NOT drive if impaired in any way. O

3.   DO Take a Co-Pilot if possible.  O

4.   DO NOT DRINK ALCOHOL/TAKE ANY DRUGS and drive.  O

5.   DO BUCKLE SEATBELT & USE CHILD SAFETY SEAT BEFORE YOU GO. O

6.   DO NOT TEXT and drive. O

7.   DO NOT drive if SLEEPY.  Pull over and NAP  O

8.   DO GET an IGNITION INTERLOCK, if FAMILY MEMBER has an ALCOHOL Problem O

9.   DO have a SOBER BUDDY at all times if U Plan to PARTY O

10. DO TAKE the KEYS from any IMPAIRED PERSON & NEVER LEAVE HIM/HER ALONE O

This link has more use ful facts from CDC.

http://www.cdc.gov/motorvehiclesafety/impaired_driving/impaired-drv_factsheet.html

Wishing you Safe and Peaceful Holidays.

Dr. Mike

PS. Email dr.mike@ihealsolutions.com or comment on this blog, if you have any suggestions, or questions.

The Daily Apple™© Volume 1, Number 2

The Daily Apple™© Volume 1, Number 2

From Dr. Mike & Infinity Health Solutions

www.ihealsolutions.com

   

December 2, 2012 PGY 40 Day #155

Yes, in Volume 1, Number 1, I promised to “use The Stress Management Workbook, to help maintain order and perspective in what has become an extraordinarily complex and fragmented “business of medicine”.  So, let’s do it.  Here you go … the first few pages of The “Original” Stress Management Workbook, with exception of format & tweaking to fit the blog, unchanged.  If you want a copy, contact me directly by email at Dr.Mike@ihealsolutions.com.

 

                             

                               To our families

Preface

The twentieth century has been marked by tremendous advances in

the theory and practice of medicine. Phenomenal scientific and technological

discoveries have found their way into medical practice. People have grown

to expect certain seemingly miraculous results from the institutions and providers

of medical care, and often, the expectation is that the "impossible" can be achieved.

There is, however, increasing popular awareness that modern medicine

cannot perform miracles despite the available science and technology. Professionals

and laymen alike are learning that advances in medicine, however dazzling, cannot

make up for life styles that breed pathology. Life ·style is now being recognized as

a major factor in the development of many of our modern medical problems. General

attitude and behavior are clearly linked to the individual's health status. Moreover,

most medical problems seem to occur more frequently with increasing stress, and

environmental exposure appears to be a factor in most illnesses. Expectations

appear to have an effect on health and well-being. Such varied problems as cancer,

cirrhosis of the liver, malnutrition, pancreatitis, ulcers, high blood pressure,

headache, food poisoning, voodoo deaths, and others appear to be influenced by both

internal and environmental factors, both emotional and physical.

Professionals and laymen are beginning to realize and teach that the

individual has a great responsibility in the promotion of his own health and the

prevention of his own disease. The concept of self-care is steadily gaining acceptance.

People are beginning to realize that they have control over certain factors that affect

their health and wellbeing. But although these concepts are being accepted more

readily, the methods for their application and general use have not been widely available.

THE STRESS MANAGEMENT WORKBOOK is designed for the

individual who takes the concept of self-care seriously and wants to do whatever

he* can to promote his own health and well-being, as well as take advantage of the

best that modern medicine has to offer. Although the book can be read rather quickly,

the material is designed to be implemented gradually and thoughtfully in conjunction

with advice from your personal physician. It is expected that your initial planned

changes may take up to two years or more to institute.

_________________________________________________________________________

*Throughout the book we have used such constructions as "the individual ... he" solely for the economy of language.

Our usage of personal pronouns is not, in any way, intended to imply any connotation of sexual role discrimination.

December 2, 2012 Addendum:

NB: Please read this book carefully and use in conjunction with your trusted Family Doctor.  This book is not intended to treat any medical emergencies and is not a substitute for your doctor or any other healthcare provider.  The Stress Management Workbook is designed to help you take The Best Possible Care™© of yourself, and to help you achieve optimal health & wellness.  It takes time to reprogram; to bust a lifestyle that breeds pathology and to build a lifestyle that breeds health, wellbeing and wellness.  Be patient. Be strong. You can do it.  We are here to help.

Join us.  StepWisely® & Go to Health™© Michael F. Mascia, MD, MPH