I received a call from a pharmacy today regarding a prescription I had written the day before. I had discharged the patient with a prescription for a medication called Librium - a pill that would help him with his alcohol withdrawal symptoms. The pharmacist told me that I had to get a "pre-authorization" from his insurance company as the medication wasn't on the formulary.

Now - I am a hospitalist. That means that I don't have an office, a secretary, or a receptionist. I only see patients in the hospital and they return to their primary care physician once they are discharged. We don't usually do the pre-authorizations of meds since it takes quite a bit of time. This patient's doctor was on vacation so I offered to do it. After trying to patiently wait through the automated menu, finding no options that were pertinent to the situation, I selected "0" to try to speak to a human being...unfortunately, this just started the menu over again.

I was getting pretty frustrated at this point - so I called the pharmacy back and prescribed an alternate medication, one that is also commonly used and prescribed. About an hour later I received a call back from the pharmacy - that drug also needed a "pre-authorization." So I asked, "exactly how much does the medication cost?"

"Six dollars and thirty-eight cents."

"You are kidding--right? I just spent about 45 minutes of my time, and yours, trying to get an insurance company to approve a drug that costs $6.38?"

This was actually becoming laughable! In an effort to just settle this and get on with caring for my patients, I asked if they could just send the bill to me. I was then informed that they did not have an agreement with the hospital for billing. "No," I said, "bill me personally, not the hospital." At this point it was worth the $6.38 just to get them off my back!

Well - this caused a bit of concern. They had to check with the manager. So - I gave them my cell phone number and got a call back about an hour later. They couldn't bill me but I could give them my debit card number - which I did.

I am sure that I am not the first doctor to pay for a patient's prescription. I know of many doctors, nurses, and social workers who pay for patients' medications, food, gas, taxi rides, and even give rides home to patients and families. The system is screwed up but the people who provide the care will keep doing what is right.

And--before you blame the "big insurance companies" for their incompetence, this patient was insured by Medicaid.

        

Probably the last thing you want to think about when planning a trip is the possibility of getting sick or having an accident while you are away from home. Practicing medicine in a tourist destination has given me a new perspective on the "what-ifs" of travel. "What if I get really sick?" "What if my husband/wife/mother/father/child is seriously injured while we are far away from home?"

Serious injuries and illnesses while on vacation can have devastating effects, both emotional and financial. There may be major delays in returning home, requiring flight changes and prolonged hotel stays. In some cases, patients may require medical supervision during a flight which can cost up to tens of thousands of dollars...typically NOT covered by insurance. While these types of situations are not too common, others we see nearly every day.

Margaret had just arrived in our town from the Midwest the day before, a 12 hour flight. She had noticed a rash on her leg for a few days before she left home but didn't seek medical attention. At 83 years old she had her share of medical problems. By the morning after her arrival she was so weak that she wasn't able to stand. Her daughter noticed that the rash had worsened and now involved most of her leg and thigh. It was bright red and very warm and tender. She was brought to the Emergency Room where she was diagnosed with cellulitis and needed to be admitted to the hospital for intravenous antibiotics.

Although Margaret was a spry 83 year-old, she was not able to tell us what medications she was on, or what medical problems she had. She had brought along her medications in a weekly dispenser, but had no list of what those medications were. Because it was after-hours in her hometown, we could not call her doctor's office or pharmacy. Eventually our pharmacist was able to identify the pills, but this caused a delay in her care and potential risk to the patient since we didn't know what her other medical problems were.

Here are a few tips for healthy traveling - especially for those with chronic medical conditions:

--keep an updated medication and allergy list with you at all times and give a copy to your traveling companion as well.

--ask your doctor for a copy of your "problem list" from your records, or keep your own list, including ongoing medical problems and all surgeries, procedures, and complications you have had.

--check with your health insurance to see what is covered when you are out of town or out of the country.

--consider travel insurance if you have chronic medical conditions that require frequent hospitalizations.

--do not travel if you are not feeling well!

--ASSUME that something could happen and you would NOT be able to give your own history.

--make sure you have more than enough of your medications with you in case your return is delayed.

--do you have a Living Will or Advance Directive? Bring it with you!

        

The practice of medicine is not as dramatic as some might think. Television dramas depict scenes of chaotic trauma and rare diseases with either heroic or tragic endings. I have to say, my days are generally mundane. Don't get me wrong - I am often rushed and harried, trying to balance patient care with paperwork, admissions with discharges, and patient needs with reality. Every once in a while I am reminded that my efforts might actually make a difference - a life or death difference.

Freddie had seizures most of his life. At age 57, he wasn't always compliant with taking his medication. So when he was brought in to the emergency department with seizures, it was not a surprise. But these were worse than before - they didn't stop. It took hours before we were able to get them under control. He had to be heavily sedated and placed on a ventilator to assist his breathing. After several days the seizures were controlled, his sedation was lightened, and the breathing machine was able to be removed. His family was ecstatic.

But this wasn't the end of the story. Something still wasn't right. He was so restless and agitated, he could not stop moving. He developed a high fever along with a rapid heartbeat, and a very high blood pressure. None of the tests could reveal what was wrong. He was given more sedation without relief. He was started on antibiotics but the fever continued. None of his medications were known to cause these symptoms. For over 48 hours, Freddie didn't rest. He had to be restrained just to keep his IV in and give needed medications. Time was running out.

We don't have the luxury of specialists at this small hospital. As a member of the world's largest online community of physicians, I sometimes post questions to assist with interesting cases. So - out of desperation, I posted this case. Faster than I could have gotten a specialist on the phone, I had the input and opinions of a dozen specialists from all over the country. Based on one neurologist's recommendation, the following morning I tried a medication that would either confirm or rule out a very unusual and dangerous disorder known as Neuroleptic Malignant Syndrome.

Within 1 hour Freddie was asleep...he was resting! I honestly couldn't believe it! His fever went away, his heart rate and blood pressure returned to normal, and he was calm. The very next day he was eating, talking with his family, and walking in the halls. This was dramatic! That website saved this man's life.

As physicians, we have to always be willing to ask for help. The internet has made it much easier to find help, no matter the day or the hour. Through professional networking sites such as Sermo.com, we can exponentially expand our access to specialists all over the country and keep up on the latest trends and innovations. 

Freddie and his family are grateful.

        

    You may have all heard the collective sigh of relief that spanned the ocean after the feared Hawaiian tsunami fizzled out. Whew! While we should all be grateful that there was no injury or damage to our island home following yet another tragic earthquake, the "Monday morning quarterbacks" were quite vocal. The grocery stores, restaurants, and local gathering places were abuzz with criticisms of the authorities who ordered evacuations of the coastal areas. Roads were blocked off, stores were closed, and events were canceled. An inconvenience? Yes. A disruption in routine? Definitely. Over-reaction? Certainly not!
    In hospitals, we take similar measures to avoid potential "disaster." Your chance of getting a hospital-acquired infection following a routine surgical procedure is pretty low - but we take all measures necessary to prevent it...because an infection could be life-threatening and cause potential disaster--one patient at a time. Patient safety involves standardizing procedures and processes to prevent needless injury and death. While there are some things we have no control over, we have to take control over those things we can to ensure safety and save lives.
    We have no control over the weather, earthquakes, or tsunamis--but we can make predictions based on education, experience, and mathematical calculations--just as in medicine. No one really knew how big the tsunami would be and we are grateful that it was only a 3 foot wave. But the process worked. There was no panic. The evacuations went smoothly. The Walmart parking lot was even turned into an impromptu tailgate party...in true Hawaiian spirit!
Mahalo to those who worked so hard to keep us safe.

        

    As I sit here waiting for the next wave of the tsunami to hit my home island of Hawaii, I can't help but think of how this can serve as a lesson in life. We just returned from a cruise vacation/seminar in the Caribbean - ready to get back to life as usual. We awoke this morning to the tsunami warning sirens and news of yet another tragic earthquake. 
    Our first thought was of our own safety and that of our "family" - our 2 dogs who have spent their vacation at "doggie camp" (aka: the resort). We knew they would be safe there, even with a significant tidal wave. Our only way in and out of our area however, was along the ocean. I was concerned about the traffic and being able to get back home if we did venture out, but we had at least 4 hours before the first wave was predicted to hit.
    So - we ventured out. There were already some roadblocks set up but they assured us it was okay to be on the road. The ocean was calm, the beaches empty, and the usual few walkers and runners were noticeably absent. There were many cars on the road, given the early hour of 6:30AM. The grocery store parking lots were packed, the lines at the gas stations were already forming. 
    We were relieved to get our tired pups and get them home, safe and sound. Although we have to put up with a few inconveniences, we will be fine. Our home is just above the official tsunami evacuation zone, so no worries of having to evacuate. Although we have only lived in Hawaii for less than a year, we are very aware of the innate dangers and vulnerability of living on an island. We are at risk for tsunamis, earthquakes, volcanoes, and hurricanes. If harbors or airports are damaged, we may be cut off from "civilization" for days or weeks. We keep plenty of water, food, and batteries on hand.
    This serves as a reminder and a lesson to be prepared, individually and as a family, a community, and as a nation. We must take care of ourselves first. If we are not in good health--physically, emotionally, and financially, we cannot take care of others. I would not be able to do my job of caring for patients if I was not healthy and prepared personally. It is also important to act responsibly so as not to put others at risk. Inevitably someone will try to "surf" the tsunami - putting rescue workers at risk and diverting needed resources elsewhere.
    Expect the usual, but prepare for the unexpected. Aloha.

        

        According to the American Heart Association, over 2 million Americans have a disorder called atrial fibrillation. Many never have symptoms and may only become aware of it when an irregular heartbeat is found on a routine examination. But atrial fibrillation is so much more than just an irregular heartbeat.
        The atria are the 2 small  upper chambers of the heart that pump blood into the ventricles--the large lower chambers that pump blood out of the heart. When the atria fibrillate, or beat irregularly, serious problems can develop.
        The blood in the atria becomes stagnant because it is not pumped out effectively. Small clots can form and travel to the brain, causing a stroke. About 15-percent of strokes occur in people with atrial fibrillation. This risk can be lowered with the use of a blood thinner, or anticoagulant medication. The medication warfarin (Coumadin) is most effective at preventing stroke in patients with atrial fibrillation - but the side-effects and risks, such as bleeding,  must be considered along with the benefits of this drug. 
        Atrial fibrillation can be treated or prevented in several ways. In some cases the heart can be restored to a normal rhythm using medications or an electrical shock to the heart called cardioversion. Sometimes more invasive procedures are required to stop or prevent atrial fibrillation including ablation (destruction) of electrical pathways or insertion of a pacemaker.
        Sometimes the heart can beat very fast with atrial fibrillation, potentially causing myocardial ischemia (lack of blood supply to heart muscle) or even heart failure. This requires medication or cardioversion to slow the heart rate or convert it to a normal rhythm.
        Atrial fibrillation is a common heart disorder that can be treated and managed effectively with proper medications and close medical follow-up. There are many options for treatment depending on the individual circumstances and choices.
        

        

        As intense debate continues in Washington, DC over the future of your healthcare, it is more important than ever to take an active role in your own health and the choices that are available to you and your family. Not everyone has a choice in which hospital they use - especially in an emergency. But there are ways to compare hospitals and doctors in your area so that you can make an informed decision when the need arises. If you are planning an elective surgery, or if you have a chronic medical condition that may require frequent hospitalizations, obtaining some information about your choices may give you a more positive experience. 
      To obtain detailed information on specific hospitals, including outcomes for certain procedures, patient safety information, and cost of care, check out www.healthgrades.com. Health Grades is a national corporation that collects, interprets, and provides information on hospitals and physicians to consumers, insurers, and employers. While the information can be very helpful, it must be used only as a guide, since it does not take into account all of the factors involved in successful patient outcomes. 
        Another useful website is www.hospitalcompare.hhs.gov. This site provides information on how well hospitals care for patients with certain medical conditions or those having certain procedures. It also includes results of a survey of patients about the qality of care they received during a recent hospital stay. This site also provides the rate of readmission - how often patients treated at your hospital end up returning within 30 days of going home. 
        These "readmission rates" can be a clue to how well your hospital cares for its patients. Those hospitals with low readmission rates have generally provided good quality care and effective discharge planning. They have communicated the important information that patients and families need to know to be compliant with the plan and get follow-up care in a timely manner. 
        Choosing a hospital is a decision that should not be taken lightly. Do your homework and ask questions. Knowing how your hospital performs can help you to make good decisions about your own care.

        

        Two new studies reported in this week's New England Journal of Medicine may help us to reduce the incidence of hospital infections. One study took place in six US hospitals and compared the use of a commonly-used skin cleanser--providone iodine--for patients having surgery to chlorhexidine, a less common and more expensive alternative. The chlorhexidine group had a 40% lower rate of post-operative infections.
        The other study was done in Canada and involved patients who were "carriers" of the staphylococcus aureus bacteria. The patients were treated with an antibiotic ointment applied to the inside of their nose for 5 days. They were also told to shower with a chlorhexidine soap prior to their surgery. These patients, compared to a group who received a placebo, we 60% less likely to develop an infection. 
        So - should you shower with chlorhexidine before surgery? There have actually been studies on this and no clear benefit has been shown. However - these new studies would certainly make it seem reasonable for surgeons to recommend it to their patients - especially those who are known to carry the staph bacteria. Many orthopedic surgeons have been advising this for years. 
        Chlorhexidine soap is sold in most drug stores as Hibiclens. Unless you have a sensitivity to the ingredients, it would not hurt, and may very well help...or even save your life.

        

        The day of discharge from the hospital should never come as a surprise. At the time of admission to the hospital a discussion should take place about the anticipated length of stay and planning for discharge should ensue. In most instances a Discharge Planner is assigned to each patient and will meet with patients and families before going home. Some patients may need visits by Home Health nurses or Physical Therapy. Others may need to go to a rehabilitation or nursing facility. There are many options depending on your location. It is important to be prepared before the decision has to be made.
        Discharge from the hospital does not mean that the patient is fully recovered. Patients are discharged when there is no longer any need for acute care hospital services. While this may seem to be financially motivated, there are many other reasons that short hospital stays are best for everyone. As discussed in Chapter 6, prolonged hospital stays increase the risk for hospital-acquired infections and other hazards including medication errors, blood clots, falls, and other injuries. 
        Delayed discharges also create risks for other patients. Hospitals are usually short of beds these days and when discharges are postponed, more patients are forced to wait in the Emergency Department or transfer to another hospital. Some hospitals have “discharge times” that require patients to leave by a certain time. Although this is certainly a cost saving measure, it also allows for time to pick up prescriptions, equipment, and any other unforeseen needs once a patient returns home.
        The discharge planner is usually an experienced nurse or social worker. It is important to maintain contact with this person throughout the hospital stay, especially if the patient is elderly or if there will be special needs after discharge. As the hospital stay progresses, the discharge needs will likely change. With a planned surgery such as a joint replacement, your doctor will tell you the expected date of discharge and can help you to determine whether you can go directly home or if you will need to go to a rehabilitation facility. 
        With an unplanned and unexpected illness, outcome may be uncertain at first but will become clearer as the days go on. There are many people and services available for help with discharge planning but the ultimate responsibility lies with the patient and their family. Some of these services are covered by insurance and some are not. Find out what your policy will cover and anticipate any costs you might have to incur.

 

        

        The decision to provide nutrition and hydration at the end of life is probably the most controversial, and least understood issue in the care of the dying patient.  In our society we think of food and water as the most basic needs of a human being. But in the dying patient the physiology changes and the body may not be able to handle the excess fluids and nutrients. In fact - providing these fluids, nutrients, and medications may lead to harm and increased suffering. 
        At the start of this new year, the nation's Catholic hospitals face a new mandate by the US Conference of Catholic Bishops (http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/01/03/BA321BC2R1.DTL) requiring their hospitals and doctors to "provide life-sustaining food, water, and medicine to comatose patients who have no hope of recovery."  
        Using artificial means of hydration by administering intravenous fluids to dying patients has been proven to be of limited benefit and may even be harmful. Evidence from medical research and experience suggests that it is more comfortable to die without the use of artificial hydration. In previous generations, death was allowed to happen naturally, without intervention. Only recently have we adopted the false concept that dying patients may be starving or thirsty as they near the end of life. 
        Artificial hydration may cause discomfort by increasing respiratory secretions, leading to difficulty breathing and a choking sensation. This often increases anxiety as well. Because the body can no longer handle the excess fluid, there may be accumulation of fluid in the tissues causing swelling of the arms and legs and sometimes the face. Swelling may also occur in the abdomen, called ascites, which makes breathing more uncomfortable. In some circumstances hydration can alleviate symptoms of delirium in dying patients. This benefit may be outweighed by the difficulties associated with maintaining IV access in those who are already agitated or confused.

        In certain circumstances, such as a temporary and reversible illness, artificial nutrition and hydration can be beneficial and help in recovery. When they are used at the end of life they are of little benefit. If the body is unable to absorb and process the food because of illness, forcing nutrition will not prolong life and may, in fact, cause additional discomfort and prolong the dying process.
       Although the article states that "the November decree isn't rigid and leaves room for accommodating patients' wishes," this may make the difficult end-of-life decisions even more complicated for families and loved ones of the dying patient.