Posts by Tracy Cardin

Mother Knows Best

My 85 year old patient was brought in from home.  She was cachectic, contracted, minimally responsive to questions, covered in multiple decubitus ulcers on both hips, both knees, both shoulders, and her sacrum.  She had polymicrobial sepsis-bacteremic with two different organisms. She was, in fact, dying. Despite her profoundly debilitated condition,  her son, who cared for her at home wanted "everything" done.  So she was placed on IV fluids, antibiotics, received an infectious disease consult, had a tunneled line placed, was started on TPN etc., etc.  The medical team had a family conference, but could not dissuade the family from the aggressive plan of care to "do everything."  An ethics consult was called.  No decisions to change the plan of care were made.  Ultimately the patient did improve somewhat, but she was stuck in the hospital as it was felt to be "unsafe" to discharge her home, without hospice level…

Low Hanging Fruit

I just finished reading the soon to be published JHM article called "The highest utilizers of care: individualized care plans to coordinate care, improve health care service utilization, and reduce costs at an academic tertiary care center" by Mercer et al. Using a multidisciplinary team of volunteers including members from hospital medicine, ER, psychiatry, ambulatory care, social work, nursing and risk management,  individualized care plans were developed for high utilizer patients.  These patients had multiple co-morbidities, or concomitant psychiatric illness or substance abuse issues.  This team took the top 24 patient utilizers and developed individualized care plans and loaded them into the EMR. With this change, they saved money.  They saved hospitalizations. They reduced readmissions by about 60%.  But they didn't really reduce ER visits.  But that is actually the most interesting part.  Because it means the patient's behavior didn't change.  The PROVIDER'S did. I had the opportunity so talk…

Bad to the Bone

I came to hospital medicine from the land of pulmonary/critical care. I had spent ten years dealing with septic shock, respiratory failure and acute renal failure. I had intubated, withdrawn life support, placed central lines, performed thoracenteses, and even placed a couple of chest tubes. I had changed tracheostomy tubes, I ran codes. In short I was a critical care bad ass. I thought I was hot stuff. But I tired of critical care, so I went to hospital medicine. And died. Just died on the vine. It turns out that the skill sets necessary for critical care are different from those that are required for inpatient care of general medicine patients. So despite a DECADE of inpatient care in a 24 bed ICU, I was woefully unprepared for hospital medicine. I felt like the stupidest bad ass in the world. Because I was! I tell you this for a…

The Shield

Recently I received an elderly patient who had been transferred from another hospital where she had been admitted for two weeks. The pertinent information about this patient is that her son, a doctor, a pathologist, had arranged the transfer. The worst thing to have is a patient with a doctor for a relative. No, the worst thing is to have a patient with a doctor who is a pathologist for a relative. I had already heard from the night doctor about how difficult and “micro-managey” the son was, how he walked around the hospital wearing his stethoscope (...pathologists don’t use stethoscopes). So before I even saw the patient I was aggravated and loaded for bear, filled with a bit of self-righteous anger. I was going to “set some limits” with the son. I was not going to let him take over her care. When I complained about the situation, before…

People, Why Are We Fighting?

If my last post used the words of the brilliant Marvin Gay, today's post reflects Mick Jagger's  ultimately vain and ineffective plea for non-violence at Altamont in 1969, when a group of Hell's Angels, acting as security, brutally murdered a concertgoer feet from where The Rolling Stones were performing. A colleague of mine was telling me about a very ugly exchange on an anesthesiology message board between an anesthesiologist and a CRNA.  You can check it out here: www.topix.com/forum/med/anesthesiology As I read it my first reaction was one of dismay, as well as disbelief.  The complete deriding of an entire class of professionals (CRNAs) by a physician colleague is wrong on so many levels.  It is never ok to decide that an entire class of anyone exemplifies a typical set of characteristics, not race, not religion, nor professional designation; it's simply offensive and ignorant. Should I go online and flame…
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