beyond the body

Headache or Heartache?

...OBSERVATION...

the positive people aren't the ones talking about positivity. they're too busy being positive to know otherwise. they just are.

...

your truth:

each experience of truth is actual. how it's said and used makes it a lie.

the last laugh

Since inception, rivals prevail as inescapable agitations in collective advancements. Rivals defy time in their incessant vie for the upper hand, the last laugh.
Take note of some of the most enduring rivalries:

Cats versus Dogs
Whatever State U versus Whatever State A&M
the Thirsty Kidney versus the Swamped Heart

Now consider a timeless pair and resolve who’s laughing.

MD gives RN Patient Care orders
RN-Hospital CEO gives MD the following orders:

1. Patient Care
2. Check and ensure that the warmers are working
3. Log code carts' inventory – restock any and all missing items
4. Check and if needed replace all 20-lbs air tanks

If empty,
a. disconnect the tank from the wall
b. go to the storage center to gather another tank
c. haul the tank back to the delivery room
d. hoist the tank into the holder
e. reconnect the tank to the wall

5. Do the same for all 20-lbs oxygen tanks PRN
6. Do the above in 4 delivery rooms and the OR
7. If in use, do 1-5 in the isolation delivery room
8. Report to the nursing station & provide the name of on-call neonatologist
9. Vacuum the call room

November 2024

simplifying life

Today’s communication trends favor minimalism.

Truncating two or more syllable words down to one is fashionable. (Ex: session → sesh.)

Diametrically, while more and more words are minced into grunt-size, simple concepts are contorted into clunky philosophies. Like the monosyllable trend, these philosophies should be simplified and restored to their nascent simplicity.

Here’s a start:

Emotional Intelligence = maturity
Self-awareness = introspection
The Optics = self-consciousness

Take The Optics for example.

What does that really mean?

Basically, it is a matter of minding others’ perspectives. Perspectives that bother us are opinions to which we grant import. In other words, we surrender to other people’s opinions about our person.
Succumbing to others’ opinions about our person is the crux of self-consciousness. Once we surrender to self-consciousness (Fear’s most proficient sniper), all our experiences and interactions are filtered through destructive lenses. Suddenly, harmless inquisitions become hostile interrogations. Somehow a helping hand transforms into a footprint on the forehead. We are armed, spry and ready to defend in the absence of an attack. Such is the power of The Optics.

So why not let go of The Optics and simply understand it as self-consciousness. (Now, be armed, spry and ready to defy Fear’s sniper.)

If we can minimize our consciousnesses solely to a task or job, we can fight the good fight – that is, if we must fight … something.

Bottom Line:
As we evolve into caveman grunting, why not allow the rest of our lives to be just as simple

August 2024

read it? for what?

Reading a text with more than 2 lines may be asking for too much …

hey Doc, this is the ER.
You can just text me the

discharge meds if you busy

and not able to do the note

right now.

DOC

Yeah. i’m busy with an

emergency delivery. i was able

to rx the prednisone before the

delivery so you just need to rx

the ointment and drops.
rx: art tears ophth ointment—

apply thin layer at bedtime,

cover with patch.
rx: art tears eye drops q2 prn

while awake

prednisone as well?

Should someone download AI-READ-FOR-YOU text messages?

April 2024

caves and gods

the policy: As the NICU is closed, no persons younger than 35-weeks gestation shall be admitted.

Should a 35-week or younger baby be delivered, the baby must be transferred. Unfortunately, the mother must remain in the delivery hospital. She does not transfer with her baby.

Sense: to avoid separation of mother and preemie, it is ideal to transfer prior to delivery.

The OBs strictly adhere to this policy.

the problem: What does one do when the chief complaint is not related to labor?

the pressure:

Given the likelihood that a person can begin labor at any time, hospitalists have been coached to spark the transfer of an under-35 weeks' gestation patient to a higher level of care. Therefore, when an ER doc approached the admitting hospitalist about a 28-weeker with gastroenteritis, the hospitalist quoted the baby policy.
The ER doc escalated the matter to the on-call Med-Peds doc, who highly recommended transfer. The ER doc countered, stating that he could not find an accepting facility. Med-Peds recommended expanding the search beyond the immediate area.

Theoretically: if your acuity level 1 hospital (with no NICU or trained staff) has a brain bleed in the ER, do you suddenly now accept them when the facility is incapable of managing acute cerebral hemorrhages? No, you expeditiously expand your search to 50 or 100 miles out – wherever.

The ER doc didn’t agree.
The ER doc escalated the matter to his ER lead, who in response contacted the Hospitalist Site Leader. The hospitalist lead contacted the Med-Peds doc, who reiterated the endangerment of two lives, should labor ensue. During that discussion, the hospitalist lead received a text from the ER lead.
The ER lead informed the hospitalist lead that all was well now– his hospitalist “caved.”
Relieved, the hospitalist lead said, “Oh well.” To resolve the matter, he planned to include both the ER doc and the Med-Peds doc in an email to express the Med-Peds doc’s concerns.
The hospitalist lead never sent the email.

Fact: the hospitalist crumpled under the pressure of Administration.
Fact: Administration are humans too and capable of flawed rulings.
Fact: the Hippocratic Oath permits full license to assert the authority needed to ensure all providers practice safely and correctly.

the pertness:

Go back to the ER doc.

It was later learned that the ER doc’s text to his lead divinely concluded:

"patient with no chance of going into preterm labor needing admission"

Sense: who has the authority to determine whether someone has “no chance” of going into labor – none of us.
Technically: that’s like someone saying another person has no chance of dying
Fact: simply being pregnant makes a patient capable of labor at any time, especially in a 28-weeker with an acute medical condition.
Fact: any medical condition is a risk factor for preterm labor.
Fact: a pregnant woman with gastroenteritis has an even higher risk for preterm labor.

February 2024

don't ask, don't tell??

The Case:

HIV positive mother with an undetectable viral load gives birth to her second child. Both children were born healthy and HIV negative. Like the first born 4 years prior, the second child will complete a preemptive 6-week AZT treatment course.
The father, her husband, does not know that mom is HIV positive. The father does not know that both of his children were exposed to HIV and had/will complete AZT treatment.
Mom gave strict orders to the medical team to uphold her privacy, to comply with HIPPA.

The Conundrum:

Issue 1: Since October 6, 2022 the 21st Century Cures Act (Cures Rule) requires unrestricted patient access to all electronic Protected Health Information (ePHI) under HIPPA.I

The medical team is legally required to document everything (that the father can access).

Issue 2: Medical Standards of Care requires uncompromised professional practices.

a. The medical team must provide required care including AZT treatments (while the father is present … in the room … most of the time).

b. Mom wants to breastfeed; however, given the unresolved controversy abounding HIV medication toxicities the team must reach a shared understanding regarding the risk and whether to proceed (while the father is present … in the room … most of the time).

c. Given the AZT treatment, blood draws to monitor the baby’s liver function is required (while the father is present … in the room … most of the time).

Issue 3: Typically, mothers are the only parents to whom medical teams defer all decisions as well as surname determination.

Mom gives strict instructions not to present the birth certificate until the immediately before discharge to prevent the father’s opportunity to sign and therefore later access any medical records.

The Confusion:

How do you protect mom’s HIPPA rights without compromising care of the dependent?
What are you allowed to lawfully omit under confidentiality?
Is there an ethical breach with such omissions of disclosure to the father, the husband?
Had the father asked, the team would have to answer truthfully.
Is this simply a “Don’t Ask, Don’t Tell”?

September 2023

knocking out the pain(tient)

Nurse reports a marginally low potassium for a CHF patient.

Nurse: Oh, by the way, she reports pain in the swollen leg.
Doc: Oh, she has Tylenol ordered. Did you give it to her?
Nurse: Did you want to give something stronger, Doc?
Doc: Well, you should try Tylenol first. We should prove that the Tylenol is not working before we try something stronger, don’t you think?
Nurse: [Pause] Oh, all right.

The nurse never calls back during the remaining 5 hours of doc’s shift. Either Tylenol got the job done, or the nurse simply waited for the next hospitalist’s shift to get something stronger.

– Wait, if the nurse could wait over 5 hours for a narcotic, then the patient’s pain could not have been that bad.

Typically, if pain is unremitting and uncontrolled, nurses will not rest until it is properly managed.

So, what was that nurse actually hoping to treat, and, more importantly, why?

April 2023

call the bluff

Patient’s “facts”:

40-year-old with lupus – seen Rheum in the past with initial labs needing follow up (never followed up)
History of ulcerative colitis with colonoscopies – none consistently confirmed UC
History of sickle cell – 3 separate hemoglobin electrophoresis performed in 3 separate years, all normal
On prednisone – no idea who started it or why
Now has avascular necrosis of the hip due to prednisone
On chronic narcotics for arthritis from the sickle cell … or … maybe the lupus

Hospital’s facts:

Hospitalized for intractable for nausea and vomiting with abdominal pain
Has an outpatient GI appointment for endoscopic ultrasound
Known drug seeker with symptoms that never improve, requiring higher and higher narcotic doses

It is time for discharge.

Nurse reports that the patient doesn’t want to remove the mid-line (IV) until she leaves; her ride will come mid-afternoon.

Doc has stopped all IV meds. Doc instructs the nurse to tell the patient that there is no need for the line or IV meds.

An hour and a half later, Nurse reports that the patient vomited 50ml in front of him then requested IV Dilaudid. The patient refused Zofran and Phenergan but will accept IV Dilaudid with an IV Benadryl chaser.

Doc says no. Doc counters with IV antiemetics and oral narcotics.

Patient refuses the counteroffer and refuses to remove the pic until IV Dilaudid with IV Benadryl is given.

Doc says, “Fine. Don’t take out the line. She will be discharged.”

Shortly after, she left the hospital … without the line.

December 2022

sometimes you just got to sell it

A 48-year-old mountain climber injured his leg and required surgical repair of a fracture. His post-surgical course was complicated by a DVT. He had no prior medical conditions or significant illnesses. He educated himself about DVT risks, recurrences and sequelae (pulmonary embolism, PE).

Since, he became hypervigilant about any funny feelings anywhere in his body.
Months after healing, he noticed swelling in his leg. He talked it over with the doc, who saw minimal swelling and reassured him that there was no reason for pause. During that conversation, he disclosed that he had chest pain for which he sought the ER. The CT scan was negative for PE. The subsequent scans for the other three visits were negative. He also talked about an endocrinologist who monitors his asymptomatic, normal thyroid.

Although he did not return to the ER a fifth time, he frequented his PCP’s office with chest pain complaints. His PCP finally referred him to a cardiologist. The cardiologist found mild (at best) coronary calcifications. Costochondritis appeared the leading culprit.

After several continual courses of incidents, his medical team were able to complete a comprehensive assessment. The gentleman had numerous stressors that manifested physically as pain. Apparently, he tensed his muscles to pain akin to a myocardial infarction.

Since this diagnosis (perspective), the gentleman managed his symptoms within context and spent his life beyond pain.

September 2022

burn out the whole for just the one

the event:

At 7:00 AM Doc starts his rounding shift by printing his list. The weekend coordinator alerts him with a text message warning, “I may need to assign patients to your list from Team 3. Dr. Skip called out today." Enraged, Doc pauses his perusal of an already exhaustive list of patients to await the redistribution.

Doc recalls the time he had to cover a night shift for Skip – a COVID-19 frontline doc who feared the frontline then stopped working for a month. Dr. Skip is a habitual paid sick-leave caller. Skip has skipped out of shifts for common colds, minor headaches, tummy aches, mild UTIs (treated with cranberry juice and rest) and inundation.

Later in the day, the weekend coordinator apologizes, “… I can’t believe Dr. Skip called off 15 minutes before the shift.”

The next day, the primary coordinator learned that Skip called off because he simply did not feel ready for the shift at 6:45 AM. Skip was not prepared for a shift he had known about over month before.

the matter:

Whether Skip has veritable medical issues, his proclivity to ditch his shifts must be weighed against the impact of his absence. His habit disrupts the entire hospitalist program. If Skip has mental infirmities, the same consideration for others applies.

No matter the issue, everyone else pays for the one who never pays others in return.

the question:

How do you solve a problem like Skip?

Accommodation

Should the Site Leader assign Skip fewer shifts with fewer responsibilities to prevent burning out the rest of his docs? Would Skip feel cheated out of his RVUs?

Furlough

Does Skip need a sabbatical and the team a new hire?

Termination

If Skip cannot reliably perform his job, should he be released to find a job he can perform reliably? Would Skip dare cry discrimination given evidence of flighty negligence?

May 2022

healing's secret ingredient - perspective

The concept “mind over matter” has proved itself on occasions too numerous to count. The mind, the perspective, dictates the outcome. If so, is it unrealistic to expect the mind to overcome a matter so debilitating or so painful that it commands every thought? Is it more realistic to expect a prescription to settle the matter?

Prescriptions have a reputation of being slightly more effective than a bandage in most illnesses. Still, they are easy to write and quick to issue. They act as distractions until the body heals (or determines its fate for) itself. Prescriptions also act as constants imparting a sense of control through pill rituals.

Whether taken or ignored, the daily (hourly, etc.) decision to ‘pill’ or not is a ritual in itself. Rituals are routines. Routines are deliberate acts. Deliberate acts are controlled choices. Controlled choices are independences. Independence is power.

Now, if that power stems from constant distractions, is that power an illusion? Does it matter?

If the desired end is contented perspective regardless of the state of the physical body, no. If the desired end is contentment throughout the entire being (mental, physical, emotional), yes.

Does that mean deny individuals their prescriptions to prove mind over matter true once again?

Well, that depends on the individual. When an individual derives (often subconsciously) satisfaction from health visits, hospitalizations, pharmacy trips and pill bottles, denying him such constants will worsen his outlook. Here mind over matter triumphs unconventionally. Even if his physical health improves, he may not recognize such, because his thoughts are fixated on a notion of lost control, lost power. Thus, no healing occurs.

Then again … ironically…

how powerful can he be when he requires a ritual to empower him?

February 2022

manufactured humans

Physical reconstruction for cosmetic comforts is the now the rule rather than the exception. In fact, convenience store alterations of the face and body are a blink away. This day’s Evolution has changed its consciousness: Nature is just an opinion. Nurture is a humored consideration. Procedures determine the person.

These ruling procedures have created a blurring of cultures with a precision nature had not amused. This mechanical miscegenation has defied bloodlines, creating doppelgangers among continents using spears, shears, stiches and substances. It has created an artificial ethnicity – Manufactured Humans.

Manufactured humans, superficially, could appear as trend enthusiasts. Public figures determine which features are attractive; then, enthusiasts seek to epitomize them. On a deeper plane, manufactured humans may be weighing matters of self-control or self-confidence. – Or both, self-control of self-confidence. Apart from certain professions that rely on the physique, the pursuit of physical reconstruction is declared a personal venture solely for the pleasure (approval) of oneself.

If manufactured humanness means oneself controlling one’s confidence, that confidence will withstand ridicule and rejection. For instance, if Guy is obsessed with his outfit, but no one remotely acknowledges it, Guy will still obsess over his garments with the same zeal he felt before presenting it. If Guy’s feelings waned in the absence of positive attention, was Guy’s obsession real? Likewise, if no one praised a person’s physical reconstruction, would that person remain pleased or would that person reconstruct the reconstructed until he is praised? Reconstruction upon reconstruction whispers artificial confidence.

Artificial confidence may not be an inherent trait in artificial ethnicity, however. Like all manufactured entities (buildings, cars, shoes, etc.), regular upkeep against Nature is required. Repeated reconstruction may just be the manufactured humans’ key to cosmetic survival.

Manufactured humans are a rising cosmetic culture that redefines notions of being, that unifies physical forms, that imparts a sense of self-control, and that challenges self-confidence.

October 2021

nothing billable for loneliness

She says she has pain. Her review of systems is positive. Upon palpation, she has pain disproportionate to the stimulus … everywhere. She says she is too weak to walk. She says she can’t keep any food or liquid down.

– But –

Aside from the wincing, she looks fine. All vitals and tests are normal. And, she can’t stop chatting. Since stepping into the room, you have learned about her first pet, first boyfriend, first girlfriend, first husband, first wife, first fight, first hospitalization as well as her last pet, last boyfriend, last girlfriend, last husband, last wife, last fight and last hospitalization. Most times during her storytelling she remembers to yelp in pain or gasp for air. Sometimes she forgets.

You stand there, watching her lips tap and part with tireless lightning speed.

Somehow, you manage to get out of the room.

Then, you manage to admit that there is nothing wrong with her.

– But –

How do you manage to not admit her?

June 2021

illness - thrills or chills

There are some tricky diagnoses out there, like fibromyalgia, complex regional pain syndrome / reflex sympathetic dystrophy and vocal cord dysfunction. Those diagnoses require an extensive rule-out process before ruling in. To this minute, science cannot place a firm finger on how and what these conditions are. Skeptics think science is wasting its time on such things. Proclaimers harp on science for not proactively answering the unanswered. Whether plausible, those diagnoses are out there, and they mean something to some people – and they aren’t going anywhere.

So, that means clinicians have to put up and shut up. The only thing left to do is decide if it is a thrill (attention-seeking manipulation) or a chill (an atypical affliction) then proceed as if it were real: order the labs, order the imaging, order the procedures, order the treatments. Hope that something billable pops up to give to your employer. Hope that something credible shows up to tell your patient. Hope that the body will just stop its mischief so that you won’t have to deal with such mysteries again.

If hope fails you, may luck be kind during all that verbal finessing you must perfect until time, circumstance or coincidence liberates you.

May 2021

swallow or spit it out

Completely independent, physically fit 68-year-old Mr. Mann slipped and crashed onto loose, wet tiles. He required surgical treatment for his right femoral neck fracture. Prior to the injury, Mr. Mann enjoyed biking, swimming, hiking and jogging.

Surgery was horrendous. The procedure was complicated by osteonecrosis. Core decompression was first attempted. Mr. Mann followed the expected recovery course and was discharged to rehab by day four. During physical therapy two days later, Mr. Mann crumpled to the floor in pain. Right leg swelling and induration at the incision site sent Mr. Mann right back to surgery. In addition to worsening necrosis, an infection and DVT had blossomed. Mr. Mann now required a hip replacement. Unlike the first procedure, Mr. Mann’s post-anesthesia recovery lasted nearly four hours. This time, his hospital recovery course was protracted and (seemingly) never-ending.

Mr. Mann was a ghost of himself. He greeted no one and refused to respond to any questions. He ate very little, if at all. He ignored the television, his cell phone and greeting cards. Mr. Mann devoted his attentions to the floor, the bed and his “no good” leg. He did not express any intention to harm himself or anyone else. He did not exhibit any erratic or psychotic behaviors.

Clearly Mr. Mann was depressed. The consulted hospitalist was advised by the case manager, the nurse, the nurse supervisor, the surgeon, the surgical physician assistant to start a SSRI or get the psychiatrist to do it.

Question: should Mr. Mann throwback a happy pill or talk about his feelings and possible solutions?

Wait – Talk? Who has that kind of time? Pop the pill.

April 2021

the medicine beyond the body