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I've decided to document some reflections on my work as a hospitalist. Plenty of things to talk about! I work regular medicine floors, as well as our step-down unit. We have a nice collection of problems with different organ systems here...
Somatic doctors have a somatic bias. Specifically, a bias towards doing what comes with dollars attached, it may seem sometimes. You may feel this particularly when your patient has an uncommon problem - like let's say hiccups 24/7 for several weeks. It would seem that doctors sometimes go out of their way to fit the uncommon case in terms of what they encounter much more frequently, like GERD, hiatal hernia, gastroparesis, dysphagia... You'd think that gastroenterologists would have the most expertise to find the solution for an uncommon issue like the persistent hiccups, but the reality doesn't always play out as expected. If they do their procedures, but don't provide a solution and the patient continues to have hiccups that don't let them sleep, you're back to square one. The thought that you "ruled out many GI pathologies", maybe even diagnosed esophagitis in the process (common enough, but not an avenue to fix the presenting complaint), doesn't get you anywhere useful.
Baclofen fixed the problem, and this didn't come from the gastroenterologist. These hospitalizations sometimes make me doubt the usefulness of consults more broadly...
Communication is one of the key skills in hospital medicine... In medicine in general, of course, but it seems to me that hospital medicine more than many subspecialties that get to focus more on the organ-specific signs, symptoms, and chart review.
Some patients can't speak. There may be many situations with different reasons. Some can't communicate at all, others just can't speak. And there are those that can speak with you if only the right provisions are made. We account for this with patients whose first language is not English by providing interpreter services in many hospitals, most often phone interpreter and at times even in-person interpreter services. But did you know that patients with tracheostomy on ventilator without a speaking valve can also potentially speak if you partially deflate the cuff. This may need to be done by your respiratory therapist, and only temporarily because the ventilator will likely start beeping over the low volumes.
To me, this has made a huge difference. Lip reading attempts are not the same, even if you're very good at it, I find. Don't be one of those doctors that skips over an opportunity to have an actual conversation with your patient who is likely having a lot of emotional turmoil from being in this situation!
Some patients have tubes. Some came with them, some got them in the hospital. Most have at least one tube in a vein, many have one in their urinary tract or gastrointestinal tract. Breathing tubes are common - for me now usually through a whole in the neck and called "tracheostomy," as I don't work in an open ICU setting anymore, meaning patients on a regular oral endotracheal tube (ETT) are generally in an intensive care unit, under the care of one of the pulmonologists or cardiologists.
Tubes may solve important problems, but they also cause problems, and generally the longer they are in, the more problems they cause. Infections are inconvenient to life-threatening scary for anyone with long-term tubes, for example.
I've had to think less often about leaking aroudn tubes, but this is still surprisingly common - especially stomach feeding tubes ("PEG tubes", probably because of the stress from stomach acid in the area), and - I've learned this today - especially in chronically malnourished patients.
Wait, you might say, isn't the feeding tube there to prevent this exact problem? Well, tissue metabolism is a complex affair... I can't claim to be an expert in this, but can attest to that chronic bedbound, tube-fed patients with severe neurological impairment generally don't have normal levels of albumin in their blood, and by inference not normal protein availability for regular tissue maintenance. I assume that not stressing your organism and not using your muscles at all (or only very little) doesn't entice the body to spend energy on building high quality proteins for tissues like muscles and connective tissue.
From my reading, the problem with leaks around the PEG tube has a lot to do with the poor nutrition status (rather than the tube size), likely contributing to the tissue retreating where the foreign body of the tube runs. The inevitable small movements that any tube will do with movements probably have a part in this, too.
Interestingly, one patient had this and a leak around the urinary catheter, too. I would assume the same mechanism being at play - tissue quality too poor to maintain a tube firmly in place in one place tends to be a general problem.
Acidic blood is bad... how bad depends on the severity, the time course, the cause, and the response to treatment. Under normal circumstances, the body maintains a pH tightly in the range of 7.35 to 7.45. The lungs and kidneys are the main contributors. With diabetic ketoacidosis, a severe metabolic derangements in patients with diabetes who don't produce or take enough insulin, a pH of less than 7 is considered severe (there are other parameters to look at, too, like the HCO3- for example). Generally, my own heuristic is that pH above 7.2 to 7.25 may still be fair - mostly based on the fact that I may be able to try some treatments to bring it fairly close to the normal range within a few hours. Under 7.15 to 7.20, this is generally more difficult. This is also the severity where several resources suggest supplementing the alkalotic buffer sodium bicarbonate, if the cause is metabolic (that is a lack of bicarbonate - HCO3-! - in the metabolism).
If the acidosis is severe and is due to insufficient breathing, problems are likely afoot. Sometimes ventilation with a face mask and 2 different pressure levels (BiPAP) can help release more CO2 from the lungs and reduce the breathing-related component of the acidosis. If this is tried with no improvement, this is a very dangerous situation.
If a patient is struggling to breath and other measures don't suffice, it's time for endotracheal intubation and mechanical ventilation - that means inserting a tube through the mouth into the trachea, and then connecting the tube to a machine that manages the air movement for the patient. It is always better to intubate when the impaired breathing is clear than to wait until the breathing fails completely - because then you don't have time and you might be dealing with a cardiac arrest while scrambling to insert the breathing tube. Not good!
I have very mixed feelings about POCUS. POCUS meaning "point-of-care ultrasound". First, the favorable take on what this means compared to regular (radiology-run) ultrasound: an extension of the physical exam, similar to the stethoscope, to answer clinical questions at the bedside and expedite correct decision making.
Nobody (here in the USA - compare to Germany for a different take) wants to take the traditional ultrasound away from the radiology department and the ultrasound (and echocardiogram) techs. Instead, the idea is that we are more pragmatic, don't do a full report, but answer: does the patient have X or not? For example, "X" could stand for:
pleural fluid
heart failure
pneumonia
pneumothorax
urinary tract obstruction
...
With early identification of heart failure and no signs of pneumonia, I may be able to just start and focus on diuresis, rather than being unclear after an ambiguous physical exam and awaiting the results of the echocardiogram and chest CT that might not be back until tomorrow.
That's the ideal.
Second, the less favorable view on POCUS: a fast, but limited study performed by someone who spends most of their time not doing ultrasound, has little or poorly structured training, a lack of quality oversight, and no generally established standards or requirements to store the images and report the interpretation of the findings.
There's a serious problem with knowing the reliability of this diagnostic tool. Ultrasound is generally accepted to be a highly operator-dependent methodology for imaging - unlike CT scans, for example, where the images are pretty much similar, as there is no need to find the best probe position and patient position for best images.
It seems to me increasingly to be a mad idea to have hospitalists do this, when most of us realistically won't do it with regularity, and in the best case probably still less than 15-30 minutes per day. There is little incentive to do more - there aren't any time savings for me as the clinician. And in virtually all situations, you should still get the actual study done by the radiology department (or cardiology for hearts).
I've looked out for opportunities to use POCUS for the last couple of months. There are definitely patients where I'm *curious* "to POCUS" them (people use it as a verb, yes). However, the time pressure and time savings are usually not there, compared to just ordering and then seeing the formal study report... which should be done either way. This situation doesn't compare to the emergency medicine use of the FAST exam, for example, which is very valuable for the early assessment in a time-critical trauma situation, before the patient goes to the CT scan.
I've observed that the incorporation of POCUS in training seems to have become rather established ... but not necessarily in a way that inspires me with the confidence that this is operated by someone who knows how to get good pictures and draw good conclusions from it. For a dose of reality about the uncertainties around this, just look at this nice discussion of IVC ultrasound interpretation and how little is truly established:
I'm wondering if we're on the wrong path here. In Germany, many internists spend quite a bit of time on training on ultrasound pertinent to their specialty, as radiology doesn't do ultrasound there (take it with a grain of salt - I went to medical school in Germany, but haven't done any residency or "Assistenzarzt" training there). It seems to me like a big advantage in the U.S. healthcare system (with all its flaws) that you have doctors like hospitalists that are generalists and get to focus on their communication, thinking, and problem-solving steps which are often what is most needed for patients... and not a different and frankly less complete and probably inferior way of doing ultrasound before the radiology department gets to it.
Don't get me wrong, there may be situations where it actually makes a significant difference to do a quick ultrasound - I just haven't seen them yet, so I think those might be rarer than proponents of POCUS for hospitalists care to admit. One thing that I've experimented with a little which was not part of the POCUS training is jugular vein ultrasound to assess for distension. Regular JVD assessment on exam is fraught with uncertainties and people at times pretending they saw it when they actually didn't, or they saw the aorta pulsating. Ultrasound can show the jugular vein fairly easily, allowing for rather objective determination of the jugular venous pressure and potentially even waveform.
As a Hospitalist, most of my patients are pretty old. I don't mean this in any demeaning way - I love taking care of the hospital medicine patients which often are very geriatric to outright palliative. The older you get, the less well your body functions, and with some patients, the problems piled up to easily fill a couple of pages to discuss everything at play...
All the more startling when I see a young patient (meaning in their 20's to early 30's) who rivals my 80-something year-olds in number and severity of problems. Chronic problems - the bread and butter for a hospitalist like me, especially with their complications and exacerbations - are by definition usually hard to impossible to reverse. It's one thing to accept this in an 85-year old, but someone in their 20's with many severe, chronic problems is a sad thought, mainly because I have a hard time seeing a path for some such patient's to make it another 20 years without dying or severe disability (blindness, loss of limbs).
Optimism and a valient effort to turn things around and work with the patient on reversing or improving the illnesses is definitely worth it, and I hope so much that this patient can prove me wrong about my worst-case fears for them...
Every patient is different. It may not always be on a doctor's mind. We like (and for billing and legal reasons have to) put patients into established categories or labels called "diagnoses" that serve as stepping stones to justify a workup and treatment plan. But the patient isn't just a collection of diagnoses. I don't want to invoke Osler too excessively, but I think he hit the nail on the head on at least this issue.
We internists are certainly no surgeons when it comes to opening bandages and looking at wounds and surgical sites. But compared to my patients, I'm usually the one more eager to look at the wound than the patient themselves. It is interesting, when the reverse happens and I'm the one who feels squeamish while watching the bandage come off relentlessly...
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