Cheap Christmas Tree Idea: She's a Beaut Clark

Are you looking for a cheap Christmas tree idea?  We are after spending all our Christmas holiday decoration money on 900 feet  of LED Christmas lights which I  then trekked outside to hang on a beautiful November afternoon.  I should have saved money on Christmas lights by doing what this guy did.  How clever.  I can assure you my display is nothing like this guys amazing video of  Amazing Grace in techno.  Wow!

Every year we've put together a cheap artificial Christmas tree I inherited with my marriage to Mrs Happy.  Every year except two that is.  One year we bought a real Christmas tree from a local Boy Scout troop.  It wasn't a cheap Christmas tree idea.  But it did help raise money for their needs.

Another year we bought a real Xmas tree from a  national hardware store.  It was a decent tree and a cheap Christmas tree by Boy Scout troop standards.  The real Christmas trees smelled nice and all  but they  got a little messy at times. But we never had anything like this happen to us.

My sister's dalmatian, Lucky,  once proudly entered a friends home for the first time and after seeing a real live Christmas tree, relieved himself   without notice.  Needless to say, my Italian greyhound puppy dogs, Marty and Cooper (beautiful slide show pictures) are much too well behaved to pee on a Christmas tree.

Last year Mrs Happy and I donated our cheap Christmas tree to Goodwill expecting to get a new one in the after Christmas sales to hang all our ornaments.  Well, we apparently forgot to buy one so we're currently without a tree to place our presents.  What presents are we going to buy you ask?  Last year Happy's family  started a new white elephant family gift exchange.  What is our contribution to the pot?  It's a toss up between the vibrating toilet seat and the  surgical elf ears.

1 Hidden Happy

We also send out Christmas cards to all our friends and family, usually a picture of us with our dogs in Santa hats.    Sometimes I even get Christmas cards from patients.  And sometimes I don't, like this patient who won't be sending me a Christmas card this year.

So I'm back to where the story started.  After spending all our money on outdoor Christmas lights and elf ears, we have nothing left for our tree.  So Mrs Happy thought of the best  cheap Christmas tree idea ever.  She's always been a green thumb and creative with out house plants, except the time she accidently put our  bonsai tree on life support.  And this time she has the perfect solution for our   Christmas tree needs.  What's her idea for a cheap Christmas tree?   I present to you Happy and Mrs Happy's cheap Christmas tree idea for 2009.

What do you think?  She's a beaut  Clark.

Hospitalist Programs Take Quality Hospital Care To The Next Level

So you're the CEO of a major hospital organization and you're wondering whether or not hospitalist programs (well respected expert) add value to your bottom line.  I'm here to tell you that only a fool would ignore the powerful contribution well run and well funded hospitalist programs can add to the patient care experience.  Hospitalist programs, with an eye on quality, can add millions of dollars to the hospital's bottom line.

Let's say you've made the wise decision that a hospitalist program will add value to your hospital's bottom line.  You're probably wondering what kind of hospitalist model to implement . Should you have a shift model program with in house hospitalists or a traditional take call from home type hospitalist program?  Should you employ your hospitalists or allow a local or national group of doctors to run  the day to day financial operations of the hospitalist program.

How you implement the financial relationship is up to you.  If you want to know how to staff your hospitalist program, read on for my completely unbiased opinion on hospitalist program staffing.

I've been a hospitalist now for seven years and I can tell you that nothing beats the value of a bed side in-house physician evaluation.  Hospitalist programs have added value  benefits that can't even be reliably measured.  But take them away and patient care suffers.  I tell you this because I live that experience every day I'm available by nursing or physician request to evaluate a patient who isn't doing well.

Dr Centor over at DB's Medical Rants asks the question:  Do Hospitalists really provide better care?  The answer is a resounding yes, not only because hospitalists become experts in the efficient allocation of resources within the hospital walls, but in-house hospitalist programs  also offer often  immeasureable value to  bedside patient care when clinical changes occur.

If you're thinking of implementing a hospitalist program without the in-house physician model, you are going to lose major benefits that your hospitalist program could offer. I present to you  two cases in point.

I was recently notified by nursing staff  that the son of a patient was upset and beligerent, threatening to transfer his father to another hospital because of the terrible care his father was receiving.  What was his concern?  His father was confused.

"He didn't look like this yesterday.  What are you guys doing to him?", he demanded to know.

Unless you are a hospitalist program with in-house physicians, it's unlikely that any physician would be available for a bed side evaluation and discussion with the patient's family. My main concern was obviously that the patient's altered mental status was not a critical change in clinical relevence.  The patient had delirium.  Delirium is an altered state of consciousness. Delirium is always transient and it always gets better, even for the 94 year olds that threaten to sue you.

Some in government consider delirium to be a  never event.  Unfortunately, despite all our best efforts to minimize and avoid delirium, patients will always get confused in the hospital.  Most of my elderly patients will experience some sort of delirium event in the hospital if they are admitted long enough.  Our goal as physicians is to minimize the associated complications with preventative measures.

In the pre hospitalist program days, how would this situation have been handled?  Would the internist drive 10 miles to evaluate their confused patient and talk with an irrate son?  Or would they ask for a neuro consult (CPT 99253, 99254, 99255) and begin the polyconsult process?  I have heard loud and clear from Happy's subspecialists in town that before our involvement in patient care, their lives were inundated with middle of the night convenience consults by primary care physicians for problems that required basic cogitative effort.

My ten minute bedside evaluation and discussion extinguished  the son's angry tendencies.    He now understood why his father was calling for Jesus and dropping F bombs in the same sentence. How do you measure this in patient outcomes?  It's difficult if not  impossible to appreciate the value that in-house hospitalist programs bring to patient care.  This type of quality is rarely measured because it has no measurable standard.  Yet these encounters are a normal daily existence for hospitalist programs every where. 

At the same time, it's important to understand the distinct difference between being in-house for convenience and being in-house for patient care.  When Happy's hospitalist group first started seven years ago, we were being asked to read chest xrays for central line placement by surgeons who had already left the buiilding.  We were being asked to write narcotic prescriptions for patients being discharged by doctors who had already left for the evening.  We were being asked to make death declarations on vented patients we had no involvment with.

We put a quick end to the idea of in-house hospitalists being available as a matter of convenience.   We are not a convenience store.  We are a hospitalist program providing high quality care for the benefit of our patients while playing the documentation games as directed by the Medicare National Bank.  Consider us the Saks Fifth Avenue of the medical subspecialties:  We offer a lot of high quality goods and services but not the convenience of access on every corner.

If you want high quality hospitalist groups for convenience, you are going to be disappointed in your ability to retain high quality doctors to provide high quality care.  Boundaries must be established with nursing staff and physicians in the community as to the appropriate use of hospitalist program services.  Calling critical lab values to the hospitalist, that were ordered by the oncologist, is a convenience problem which involves  education at the nursing level.  Calling the hospitalist at 3 am for a   preoperative clearance   history and physical examination  on a  25 year old with a wrist fracture requires education at the physician level. 

Bedside  evaluation is an invaluable asset of in-house hospitalist programs.  Just the other day I was asked to evaluate an 87 year old female patient at three in the morning  with a painful right arm after falling out of bed ( a never event).  Under pre hospitalist program days perhaps the at home internist or family medicine doctor or even  the home call hospitalist would order an xray of the arm , and an orthopaedic consult for good measure.

What did I do as a partner in an in-house hospitalist program?  In the interest of patient care, I did a bed side evaluation.  I listened to her heart with my broken stethoscope  in need of repair and realized she was clinically in rapid atrial fibrillation. At 3:35 in the morning, I documented 35 minutes of critical care work under  CPT E&M 99291, initiated a diltiazem drip for the  acute treatment of rapid atrial fibrillation and transferred her to a higher level of care.  Oh yeah, I also evaluated the arm. 

Nursing records documented the tachycardia starting two hours previously,  but they failed to make the connection as a change in  hemodynamic status.  What would have happened to her had I not been available for a bedside evaluation for a swollen arm that led to the important diagnosis of atrial fibrillation?  I don't know.  Perhaps nothing would have happened to her.  Or, perhaps she would have decompensated into a rapid response team clinical event. If the at home internist didn't come to the bedside and a bad outcome ensued from the rapid atrial fibrillation would they be negligent of failure to diagnose?  Or would this be considered a complication of illness and age. 

This is the type of quality care you can expect from having establishing in-house hospitalist programs running the show with defined parameters that weed out the convenience characteristics of having in-house physicians from the real patient care responsibilities. If you want to take your hospital to the next level in all measurable (and immeasurable) standards, you need to get yourself an in-house hospitalist program and set your hospital free from the constraints of 19th century standards.

LINK TO E/M POCKET REFERENCE CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital:  (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic:  (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high definition view

For more information on current hospitalist compensation visit

• Hospitalist salary compensation survey for 2010 (SHM/MGMA) based on 2009 data.
• Hospitalist subsidy/support payments for 2011 (based on 2010 data)

Eliminate Junk Mail Forever: Clever Tricks Of The Trade On How To Stop Junk Mail

Want to know how to stop and eliminate junk mail forever?  Well,  it's going to take a national effort.  Just today I had 15 pieces of mail.  Twelve of those pieces were junk mail.  From credit card offers to unsolicited catalogues and magazines, it seems impossible to eliminate junk mail.  I know it's not likely that we can end junk mail forever.  There will never be a day with no more junk mail.  But what if reducing junk mail  was a possibility?

What if these companies had an incentive for stopping junk mail cold in its tracks?  I received an  email below reporting on how to stop junk mail from over taking your home.  If you want to know how to stop getting junk mail and take back your home read on.

Happy's kitchen gets overrun with junk mail on a weekly basis. In seven years as a hospitalist physician I have found once I am on a mailing list for a recruiter or a throw away journal, it will be impossible to stop getting junk mail or eliminate junk mail forever.  Don't EVER give out your email address or home address to the booth people at the Society of Hospital Medicine meetings.

If I could end junk mail today, Mrs Happy would be a very happy woman.  But I can't.  What is my junk mail removal system?  I rip the credit card offers in half and I dump everything else into a recycled brown  paper bag to cart down to the local recycling drop off point.

Not anymore.  Now I'm hoping the rest of America will join me and take back our mailboxes.  If you want to stop getting junk mail and eliminate junk mail forever, we're going to have to make them think twice about their unsolicited requests.  Here's how you stop and eliminate junk mail forever:

When you get 'ads' enclosed with your phone or utility bill, return these 'ads' with your payment. Let the sending companies throw their own junk mailaway.  When you get those 'pre-approved' letters in the mail for everything from credit cards to 2nd mortgages and similar type junk, do not throw away the return envelope.  Most of these come with postage-paid return envelopes, right? It costs them more than the regular 41 cents postage 'IF' and when they receive them back.  It costs them nothing if you throw them away! The postage was around 50 cents before the last increase and it is according to the weight. In that case, why not get rid of some of your other junk mail and put it in these cool little, postage-paid return envelopes. 

One of Andy Rooney's (60 minutes) ideas. 

Send an ad for your local chimney cleaner to American Express. Send a pizza coupon to Citibank. If you didn't get anything else that day, then just send them their blank application back!   If you want to remain anonymous, just make sure your name isn't on anything you send them.  You can even send the envelope back empty if you want to just to keep them guessing! It still costs them 41 cents.  The banks and credit card companies are currently getting a lot of their own junk back in the mail, but folks, we need to OVERWHELM them. Let's let them know what it's like to get lots of junk mail, and best of all they're paying for it...Twice!   Let's help keep our postal service busy since they are saying that e-mail is cutting into their business profits, and that's why they need to increase postage costs again You get the idea !

What do you say folks.  You want to eliminate junk mail forever?  Join me in reducing junk mail in our homes by mailing it back to them in their prepaid postage envelopes.  End junk mail today.  Instead of making the weekly trip to the recycling spot, simply use the US postal service as your junk mail removal system.  Stopping junk mail one house at a time.

Or another option is to add your name to the Do Not Mail List.

Quit Smoking For Good Or You'll Get Cross Eyed (A Case History With Stop Smoking Pictures)

You only get one chance to quit smoking for good before it's too late. So quit smoking today before you too succumb to the cross eyes.  Once the cross eyes attack, irreversible damage may be done.  Little is known about this rare side effect of smoking. Even less is known about treatment options for smoking related cross eyes.

I had only  heard of smoking related cross eyes once as a resident in training.  That person quit smoking for good the very next day. For some people, money is not an issue even if it costs them six million dollars to smoke.  Even if they turn into a vegetable.   Apparently, the thought of never again seeing straight  was enough to make them quit smoking for good that very same day.  What kind of smoking cessation methods did they use to quit smoking without the side effects of quitting smoking? 

Of course, no such smoking cessation method exists, unless of course you quit smoking right now using this magical method.  There will always be side effects of quitting smoking.  The question is, how much is the smoker willing to accept in the pursuit of quitting smoking for good?  The only way a smoker can expect to quit smoking for good is to accept quit smoking withdrawal symptoms as part of the detoxification process. 

Quitting smoking withdrawal symptoms can be managed, much like they can in an alcoholic withdrawing from their alcohol.  What defines a smoker as an addict?  All smokers are addicts if they meet three or more of the following criteria:

• build tolerance with escalating doses
• smoking more than usual
  
• withdraw after stopping
• continue to smoke despite desire to quit
• spent a lot of time in pursuit of cigarettes
• rearrange their life around smoking
• continue to smoke despite health hazards

Most smokers could probably meet all seven criteria at one point or another in their lifelong climb up the corporate smoking ladder of disease.  Smokers who deny their addiction are at an especially high risk of contracting the devastating cross eyes.

Which brings me back to my own family experience.  I learned on Thanksgiving that my sister-in-law, one of the 20% of smokers nationwide, and the mother of the tooth fairy child, has contracted smoking related cross eyes.  Mrs Happy and I are devastated.  She must quit smoking for good.  She must quit smoking today.

As a physician, I know what's in store for her future if she isn't willing to accept that quitting smoking withdrawal symptoms are part of the addiction recovery process.  If she can't accept quitting smoking side effects as part of the road to recovery, then all the quit smoking pills in the world won't help her break her addiction.  Quitting smoking withdrawal symptoms will always be present. That's the nature of addiction.  The question for the addict becomes, are they willing to quit smoking for good despite the pain and suffering?  A pain and suffering they must be willing to endure if they want to avoid the life altering cross eyes.

Mrs Happy and I fear she is headed for a career in the circus if she doesn't find a smoking cessation method that works for her.  There is no time to waste.  Our worst fears have been realized.  I blog often about the side effects of smoking, but I've never discussed the cross eyed phenomenon, mostly out of a fear of mass hysteria.  Now it's time to lay it all out.  The problem is a matter of national security.  As President of the United States, Obama is placing his health and our country at risk for smoking   and he too must find his methods to quit smoking before it's too late.

I want you all to know, while I am gravely concerned for my sister-in-law's future, there is hope on the horizon  with her efforts to quit smoking.  She has procured the electronic cigarette and searched the  underground market for a three month supply of  free Chantix.

As you can see in these pictures, her quitting smoking withdrawal symptoms have strangled her sanity.  In just three hours of tobacco abstinence, she developed a severe  case of uncombable hair syndrome, an ominous sign that she needs to quit smoking for good.  She needs to quit smoking today.  Quitting smoking side effects often include a desire to eat everything in sight.  So I wasn't sure if her attempt to eat the Chantix box was due to a hunger pain or due to patient education issues.  She might even have other methods to quit smoking that I know nothing about.

In just three years her addiction to cigarettes has turned her  from a beauty queen on the beach into a cross eyed, crazy haired circus midget  looking for her next nicotine fix.  Sister-in-law, if you're reading this, remember today is the day you quit smoking for good.  It's too bad the smoking vaccine isn't available yet.  So take your quit smoking pills as directed.   Make sure your electronic cigarette is fully charged at all times and rid your body of the toxic cesspool infesting you and all your loved ones around you.

I won't even charge you for my quit smoking advice.  It's now or never sister. Today is the day you quit smoking for good and see straight once again.

UPDATE:  Chantix lawsuits, here we come.  

The Checkout Line After Thanksgiving Proves The Recession Is Over

I snapped this picture while waiting in the checkout line at Shopko during the greatest recession in more than 50 years. Based on the number of people waiting in this checkout lane, I'd say the recession  is over.

What did I buy you ask? Over 900 feet of LED Christmas lights for a steal of a price.

Did you do the post Thanksgiving shopping marathon? And if so, what time did you wake up? And what did you buy?

CMS Physician Pay For Performance (PQRI): My2008 Experience And Everything You Need To Know

It's official. Happy has now earned his CMS physician  pay for performance PQRI Bonus for 2008, a direct deposit into Happy's bank account. PQRI stands for Physician Quality Reporting Initiative.  How much was my PQRI Medicare pay for performance bonus for calendar year 2008? A $2,500 check written out directly to Happy by the  Medicare National Bank.  CMS gives a wonderful overview of the history of PQRI .  PQRI is the Medicare pay for performance program for physicians that was initiated by Congressional mandate in the latter half of 2007.   Doctors had an opportunity to earn back 1.5% of their gross Medicare collections for 2008 (increased from 1% in 2007 which the government calls a bonus but which I call legalized theft) by submitting a grotesque amount of quality performance paper work to the Medicare National Bank. It's one giant PQRI guideline game.

PQRI reporting is currently voluntary, but legislation in future years will certainly mandate reductions in payment for not submitting data, all but making this program a punitive standard.  Many physicians failed to meet the requirements to get paid under CMS pay for performance program guidelines in the latter half of 2007, the first year for PQRI measures.
EMR Comparison

Successful software implementation starts with choosing the right system. This  checklist contains over 50 of the most important features to look for when evaluating:

• electronic medical records
• medical billing software 
• scheduling software
• technology, security and certifications

Download now and get started today Other useful information is available at my EHR Resource Center.

After discussing concerns with my CPT medical coding company, I learned why PQRI  was a dud for many physicians in 2007.  It was the government's own fault. Imagine all the hard work, overhead, time and frustration that must have been encountered simply to get back 1% of their gross Medicare collections.  It's no wonder why many doctors won't accept Medicare anymore.  You get what you pay for.   As a result of the governments misdoings, they did end up paying an additional 3,900 physicians an average of $860 a piece.

So who's playing and winning the CMS pay for performance game?  It turns out in 2007 less than 1/3 of physicians feel like battling the PQRI requirements.  That doesn't surprise me, considering the average PQRI bonus payment for the second half of 2007 was just around $600.   In Happy's group alone, I was the only physician of almost twenty that successfully navigated the incredibly obtuse PQRI reporting rules of 2007.  I blogged about my first experience with PQRI and showed you the data card we used in our first attempt to capture all the PQRI data.  You can see how complicated this process was. (We reported on four PQRI measures)

With the inaugural year (2007) behind us, how did Happy's group do for 2008?  I have heard that only Happy and two other physician's earned their PQRI reporting pay for performance for 2008. It's almost 2010 and I'm just now learning my 2008 PQRI  CMS pay for performance fate.  Who here thinks it's OK to pay 2008 money in the last month of 2009?

How did the rest of the country do with PQRI CMS physician pay for performance for 2008?  The government paid out 92 million dollars to 85,000 physicians.  Another 70,000 physicians tried to play the game and failed.  Not one penny received.  This represents about a 15% participation rate, with only 7% or so of physicians nationwide earning back what was legally stolen.  This represents a pitiful 55% success rate for PQRI in 2008.  The average physician received   a little over $1,000.  The highest paid PQRI physician earned $98000 for their PQRI physician pay for performance efforts.  The states with physicians receiving the most PQRI pay for performance money were Florida and Illinois with 7.5 million and 6 million dollars respectively.

With a horrible 2008 PQRI CMS  physician pay for performance now behind us, there is hope for Happy's colleagues yet.  We made some drastic changes to our methods of collecting the data with the hopes of having universal success for the 2009  CMS PQRI pay for performance.  My hope is that Happy's colleagues will finally succeed in winning the PQRI physician pay for performance game of 2009 that has generated nothing but annoyance for many physicians at their lack of success. 

Unfortunately, the whole PQRI CMS physician pay for performance is not about quality.  It won't even be about saving money for the Medicare National Bank.  It's about collecting data and documentation to perpetuate  support for the government bureaucracy  This is just a game.  A game you just have to know how to play.  If you want to know how well you played the game here are your options to learn about your pay for performance PQRI 2008 status:

Providers can access their confidential feedback reports at the Tax Identification Number (TIN) level by visiting the secure PQRI portal athttp://www.qualitynet.org/pqri.  Trained Help Desk staff will assist providers with accessing their feedback reports at 1-866-288-8912 or atQnetsupport@sdps.org.  Support is available on Monday through Friday from 7:00 a.m. to 7:00 p.m. Central Time.  In addition, individual professionals can access their feedback reports by contacting their Part A/Part B MAC at its Provider Contact Center.

What does PQRI hold for physicians in 2010?  A fact sheet for the 2010 PQRI CMS physician pay for performance is available for review.  The legalized theft and payback option is set for 2% for both the 2009 PQRI that is finishing up and the 2010 PQRI pay for performance season.  There are no Congressional mandates to continue the program past 2010 at this moment in time.

You can read all about the FAQs on the CMS physician pay for performance website.

Venous Embolism (Saddle Pulmonary) Crazy Presentation As Massive Pleural Effusion

The differential diagnosis for pleural effusions is quite broad, but one of which must always include pulmonary venous embolism.  Pleural effusions are the accumulation of fluid in the pleural space.  What is the pleural space?  The pleural space is what separates your lungs from your chest wall.  It allows your lungs to expand and contract with every breath and not get stuck on your musculoskeletal organs.

Pleural effusions are most commonly  divided into two broad categories:  transudative or exudative.  In general terms, transudative pleural effusions are a volume issue and exudative pleural effusions are a disease specific issue.  In even more general terms, exudative=bad and transudative=good.  Volume issues such as heart failure and poor nutrition are  classic causes of transudative pleural effusions.  Cancer, pneumonia, auto immune disorders  and pulmonary venous embolism are classically associated with exudative effusions.

What are the criteria for determining if a pleural effusion is transudative or exudative?  The Light criteria describes pleural effusions as exudative if one or more of the following criteria are met

1. a pleural fluid:serum protein ratio > 0.5
2. a pleural fluid:serum lactic dehydrogenase (LDH) ratio>0.6
3. a pleural fluid LDH>200

It came somewhat as a shock to me when this 52 year old male presented to the hospital in acute hypoxemic respiratory failure after telling his wife that he felt short of breath for the last three weeks.  Here is a picture of his xray.  As you can see his pleural effusion was consuming most of his left lung parenchyma.  Even stranger was the fact this guy had a negative CT of his chest just two months prior, when he presented to the hospital with atypical chest pain.

To go from a normal CT scan of your lungs to this in just two months, and no other acute problems is a first for Happy.  It became quickly apparent that an elevated D-dimer and bloody pleural effusion was unlikely to represent a transudative process, such as heart failure.

Further pulmonary venous embolism evaluation and diagnosis (CT angiogram of the chest) confirmed the presence of massive saddle  pulmonary venous embolism.  What was the source of this man's thromboembolic disease?  Of course, his venous emboli came from his massive, asymptomatic and clinically unapparent deep venous thrombosis of his right leg.  From groin to ankle a large deep venous thrombosis consumed his leg.  Yet he had no symptoms.  He had no  swelling.  No pain.  No nothin'.

This makes for some interesting legal discussion for patients who may feel failure to diagnose an asymptomatic deep venous thrombosis before the clinical life threatening pulmonary venous embolism represents negligence on the part of the physician.

I forgot to mention that this man had a history of a pulmonary embolism five years prior, so pulmonary venous embolism was #1 on my list of the differential diagnosis, despite the terribly unusual presentation for pulmonary venous embolism this would represent.  I would consider this a long tail presentation of a common medical condition.    I've seen pleural effusions from pulmonary emboli before.  But I've seen never them like this before.

This case also shows how important the history and physical examination is in developing the differential diagnosis. And why you must always be on your guard for unusual presentations of common disease.  Something that the intensity of medical school and residency training turns just another provider into doctors.

Hourly Rounding By Nurses: Turning The 4Ps of Nursing Into 5Ps

I recently learned that Happy's hospital is initiating hourly rounding by nurses.   Apparently there is research behind hourly rounding to show it is effective in increasing patient satisfaction, increasing nursing satisfaction, increasing quality by reducing fall rates as much as 60% and decreasing the number of call lights by 40%.

How does this magical hourly rounding work?  It's based on the 4 P's of nursing:  Pain, Potty, Position and Periphery.  This is not to be confused with the 4 P's of marketing:  Product, Price, Place and Promotion.

I read now that there is actually a script for which nurses should memorize when introducing themselves in the hourly rounding role:

"I am here to do rounds.  How is your pain?  Do you need to use the restroom?  Do you need help to reposition (or get up, or get back to bed, or whatever the activity is)?"  Once all that is complete, the nurse should make sure the call light, telephone, TV remote, bed light, bedside table and tissues are within the patient's reach.  Then tell the patient, "Is there anything else I can do for you?  I have time now while I am in the room.   Also, someone will be back in about an hour."

Then they mark the hourly rounding checklist.  This process will be a group effort, apparently including RNs, techs, clinical assistants, nurse managers, assistant nurse managers, and even the unit secretary.  At some point other departments, such as PT, OT, RT, etc may assist in the endeavors.

I think hourly rounds sounds like an excellent idea for nurses.  If it decreases their call lights, I don't know how they couldn't agree.  But  I also think the concept holds promise for improving the efficiency of communication between nurses and physicians as well, which can also improve the efficiency of the nurse's daily work flow.  I think I am going to work on adding a fifth P to the hourly rounding.  It's called paging.

Here's how it works.  All floors will page their hospitalist once after the hourly rounds first thing in the morning to notify the hospitalist of any needs related to pain, potty, position or periphery. All necessary prn orders will be obtained at this time and no further pages will be made until the following day's hourly rounding  regarding pain, potty, position or periphery.  After the daily call, the pager will only be available for critical issues.  Turning  hourly rounding 4Ps into hourly rounding with 5Ps  has the ability to take this concept to the next level and reduce the number of pages to physicians  by 99.99999% while simultaneously increase nursing and physician satisfaction by 99.99999999999%.

If the nurses are happy and the physicians are happy and the patients are happy,  then daily rounding with the 5 P's should be established as the standard by which all hospitals strive to meet.   This is a natural extension of the dialysis spa and the hospitel phenomenon and I'm all for any policy that improves quality and satisfaction with one giant magical wand.

Hourly rounds done by 8am.  Pages done by Nine.  Let's get movin' people.

Addendum:  Checklist prompting study adds a 6th P:  Prompting the physician.

Grand Rounds is a Pain In The Ass

But go read it anyway for a peak at this week's Thanksgiving offerings.

Pink Glove Dance For Breast Cancer Investigated By Snopes?

The pink glove dance is even being investigated by Snopes as a fraud. Apparently an email is circulating reporting that Medline, in conjunction with the Providence pink glove dance for breast cancer crew, will donate money, one million dollars, once one million hits on the video are achieved

After watching the video, all I have to say is I want to be the janitor working at that hospital. The whole hospital at Providence St Vincent Medical Center in Portland Oregon is  wearing pink gloves, dancing for breast cancer.  What a great video.   Plus I think it proves one thing.  White men can't dance, unless you're a janitor wearing pink gloves dancing for breast cancer.  That guy's got some moves.

When you're done wearing the pink gloves, make sure you try out the pink stethoscope as well.

Smoking Near Your Apple Computer May Void Your Warranty

The  dangers of smoking keep building.   Did you know that smoking may void the warranty on your Apple computer?  That's right folks.   Not only will your arteries pay the price, so will your computer.

I find this really interesting.  Computer technicians refusing to service the computer because of the toxic residue left by third hand smoke.  What's the basis of their  claim?   Protection under the umbrella of OSHA regulations.

I never thought about OSHA regulations protecting computer technicians from the harmful toxic residue of second, third and fourth hand smoke.  I could certainly see an employee suing their employer if they were forced to work under conditions deemed hazardous to their health against the policies of the regulatory agency there to protect them.

I wrote about nurses refusing to take care of patients who smoke.    I never considered the OSHA angle before.  I would love to see a lawyer tackle this case in court:  A home health care or hospital floor nurse is fired for refusing to take care of a patient in a smoker's home or one who smells of a toxic residue of third hand smoke upon arrival into the hospital and using OSHA safety regulations as their guidelines.

If nicotine is listed as a hazardous material, shouldn't all nurses and any employee who comes in contact with patients who smoke be required to gown, glove and mask for their own safety.  I mean, if you can't have food or drink at the nurses station because of OSHA regulations, shouldn't the nurses be forced to protect themselves from third hand smoke as well?

Remember.  Don't smoke or you and your computer are goners.

Should I Bill A Low Level Admission Code (CPT® E&M 99221) Or A High Level Hospital Follow Up Code (CPT® E&M 99233) For My Initial Consult Request Starting In 2010?

As hospitalists we all get those consults for "uncontrolled diabetes" or "hypotension causing decreased urine output" from a subspecialist who has admitted the patient for something completely unrelated to your consult request.  Often times these are very straight forward consults with minimal effort required.

How do you bill the simple straight forward consults?  Rarely does an "elevated blood pressure" or "elevated blood sugar" consult rise to the level of a 99255 (High level CPT® E&M consult).  I am a big abuser of the level three consult (CPT® E&M 99253, and not 99254).  What are the requirements for CPT® medical coding  a level three inpatient (99253) hospital consult?  They are the same as a low level admit 99221, which are the same as a low level observation admission 99218 which are the same as the same day hospital admission and discharge 99234.

As you can see, you only need four HPI, a two point review of systems not twelve point review of systems, one area from past medical family and social history, six organ areas with two bullets each, and a low level medical decision making criteria.

That makes level three consults very quick, perhaps 20-30 minutes or less.  How many RVUs does a level three consult pay?  Well, according to the Medicare National Bank, a level three 99253 inpatient consult pays 3.18 relative value units (2.27 work RVUs, 0.8 practice expense RVUs and 0.11 malpractice RVUs)

None of this will matter after January 1, 2010 as we all know that Medicare is getting rid of consultation codes.  In the place of consult codes  physicians have been directed to  use the hospital admission codes (CPT® E&M 99221, 99222, 99223) as their initial visit.

I'm here to tell you that if you do that for low level consult codes (99253 or lower), you will lose money.  And here's why.  A high level hospital follow up code (CPT® E&M 99233) is actually worth more in RVUs (2.0 work RVUs, 0.59 practice expense RVUs, 0.06 malpractice RVUs, 2.65 total RVUs)  than the lowest level admission code (CPT® E&M 99221) (1.88 work RVUs, 0.54 practice expense RVUs, 0.07 malpractice expense RVUs, 2.49 total RVUs).

In other words, if you normally bill a level three inpatient consult 99253, once consult codes go away, the equivalent admission code is a 99221.  BUT, the high level hospital follow up code is actually worth 0.16 RVUs more than a low level admission code.  And it's very easy to bill a high level follow up visit as your initial visit in a hospitalized patient, if you know how the E&M system works.

And the only place you would have known that is if you are sitting here  reading The Happy Hospitalist

For the last seven years of hospitalist work,  I have frequently written just a hospital follow up code (usually a CPT® E&M 99232 or 99233)  when asked to consult on a patient.  There is no dictation requirement.  There is no complete history and physical exam.  You don't need to meet ALL criteria, just "two out of three".  The documentation necessary to meet a hospital follow up code is less than an admission or consultation code.    And quite frankly, if a patient is hospitalized and you, the  hospitalist ,are asked to consult, 99.999% of the time you could meet the requirements of a level three 99233 follow up visit, no matter what you are asked to consult for.

I have never been denied payment for submitting a hospital follow up code (CPT® E&M 99231-99233) as an initial consultation visit.  I do not foresee the Medicare National Bank declining payment now, simply because the consult codes have been rolled into the admission history and physical codes.

Unless the Medicare National Bank changes the value of RVUs between now and January 1st, 2010, the fact of the matter is that a high level hospital follow up code (99233)  is worth more than a low level admission code (99221) and with less documentation required for follow up visits, it may make sense to do a S.O.A.P note instead of a consultation admission note (99221) for the low level consult requests starting in 2010.  In fact, unless CMS changes the RVU values, doing so will actually pay more.

And I bet you didn't know that.

You can learn more about coding for free in my lectures on medical billing and coding.

Should Marijuana Be Used To Treat Autism Behaviors?

These aren't your grandma's brownies. It appears that parents are now using medical marijuana to control the symptoms of their autistic children.  The American Medical Association is urging federal authorities to reconsider its classification of marijuana as a dangerous drug with no medicinal properties, in alignment with the government's new stance on  federal marijuana laws.  This doesn't surprise me considering all the doctors and lawyers are smoking pot these days.

This video below describes  an autistic child with severe out of control autism behaviors. One would wonder if he has autism schizophrenia.    This ten year old boy was skin and bones  and experiencing severe side effects from his daily handful  of anti psychotic prescription medication.  That is, until he started eating his mother's medical marijuana brownies.  The boy has since gained a lot of lost weight  and his aggressive behaviors have all but subsided.

One psychiatrist argued it was inappropriate to turn young children into stoners.   Are you freakin' kidding me?  The kid has got autism.  He is not going to go buy his own baggie and test it with his buddies.  The proof is in the brownies.

I personally believe all prescription drugs should be legalized, Smoking kills over two million people a year. Alcoholism has its own problems.  As does prescription pain addiction.  Controlling a substance only creates criminals.  It doesn't create addicts.   The Portugal drug experience proves that legalization does not create addicts.  Removing barriers to all prescription drugs would eliminate access problems for the untold silent sufferers who don't have the funds to seek medical attention.  Removing the barriers to all current prescription drugs would also create  strong market based economies to drug pricing.  Dr WhiteCoat also agrees.

I look at this remarkable medical marijuana story in the treatment of severe autism behaviors and am left to wonder if it's only a matter of time before Happy's hospital begins their own medical marijuana program as a viable and accepted part of the rehabilitation process for the old and the sick wasting away in a fog of confusion.

With that said, I know you're all wondering the same thing.   Is the mom counting, "One for you.  One for me.  One for you..."

Oh yeah, and in case you're wondering:   What's the most joints a man has ever legally smoked?  115,000.  That's 10 joints a day, every day, for 30 years.  Damn.

History And Physical Examination: Stop Right There Doctor!

I  remember very clearly as a medical student hearing my attending hammer home the importance of the  history and physical examination.  Everyday I heard the same thing

The history and physical examination is the most important part of patient care

After seven long years of hospitalist medicine, I gotta say my attendings were right.   If you listen to what the patient is telling you, the answer is often staring you in the face. Unfortunately, in this volume driven world of fee for service we live in, time is not on the physician's side.  Most elderly  patients are incapable of separating important medical information from irrelevant medical  information, which can make history taking a very  painful part of being a doctor.  So they just talk and talk and talk.

We are always taught to open up the conversation with open ended questions.   I hate to say it but a lot of  open ended patient history   is complete jibberish.  With that said, I find that most patients will still give you the answer you're looking for if you simply take the time to listen.  It's the physician's job to tweak it out.   My favorite question to ask a patient when I walk into the room is "What's goin' on?"  How they respond says volumes about their disease process.

How about a comprehensive physical examination?  It too can add important diagnostic  information for physicians developing the therapeutic plan.  Whether the complete physical examination makes the diagnosis  or simply corrects a wrong assumption, laying eyes on the patient will always play an important role in patient care.

And even Happy isn't perfect.  I'm sorry to report that I once broke my own rules:

Nurse:  We have a consult for you (CPT 99253, 99254, 99255).  It's a psychiatric patient with knee pain.
Happy:  Did they fall?
Nurse:  Um, yes, I think several weeks ago
Happy:  Will you get an xray of the knee?
Nurse:  Will do.

After finishing up three more admissions, I hunted down the radiologist and reviewed the knee film.  Normal. Then I went to talk to the patient.

Happy:  What's goin on Mrs Smith?

Mrs Smith:  My knee hurts.

Happy:  looking at knee Your knee looks fine.  It's moving fine and your xray is normal.  I don't think there is anything to do about it.

Mrs Smith:  You mean there are no bugs in there?

Happy:  No Mrs Smith, there are no bugs in your knee.

One golden rule of medicine is never to assume anything.  I suppose if I had taken the time to talk to the patient before I ordered the xray I could have saved $200 in facility fees and professional fees from the Medicaid National Bank. Instead I have no skin in the game and someone else pays for it.

Perhaps in an effort to be efficient with my time, I wasted many others.  Stop right there doctor.  The history and physical examination really is the most important part of the evaluation.  I suppose someday when bundled care arrives, these kinds of convenience xrays will disappear as the money gets tighter and the incentive to practice competent and efficient care prevails.

Garage Door Syndrome: Why Does The Need To Pee Get Worse When I See A Bathroom?

I know I'm not the only one out there.  Garage Door Syndrome describes the sudden urge to urinate triggered by environmental conditions.   If I have to pee and I see a bathroom why does my need to pee suddenly get worse?  It's almost alien like.   I've noticed my need to pee gets worse when I see running water too.  Or if I take a container of liquid out of the refrigerator.  What's your experience?  Do you have your own triggers for urinary urgency?

Clever Comebacks From Nurses

Being in the healthcare field allows many doctors and nurses to interact with all walks of life.  We all deal with the emotional tolls of illness in different ways.  Some nurses use clever comebacks to get through the day.  Take for example this conversation with a 94 year old female in the midst of decompensated heart failure.

Sunday Novemeber 7th, 2009

Patient:  It looks like I'm missing church today

Nurse:  Don't worry,  you might be able to make it later this week.

Now that's a clever comeback.

Prison Health Care: I Feel Really Greasy

 Did you know that all prisoners have a right to free prison health care when under the control of  local , state or federal authorities?  They may lose their right to freedom, but they gain an unlimited right to free prison health care.

Often times, the health care prisoners receive vastly exceeds what which many hard working private business owners can afford for themselves or their employees.  Even with employer assistance, out of control health care inflation threatens the affordability of even basic catastrophic plans by ordinary Americans.

This does not apply to prisoners, who have unlimited access to prison health care.  A reader sent me their account about a patient: 

I feel really greasy, Happy.  He was a 37 year old  unemployed construction worker with an antisocial personality.   He presented to the hospital with a surgical ankle fracture obtained in a bar fight   Unfortunately for him, when the cops arrived he was found to have a warrant out for his arrest. 

But fortunately for him, his surgical ankle fracture now became an economic liability for the  prison health care system.  By being in police custody, my patient would get his entire hospital stay paid for by my hard earned tax dollars. Perhaps his run in with the law was a blessing in disguise.

But what did he decide to do instead?  My bar fight peep posted bond that day.  He  left against medical advice to "get the Hell away from the cops" who were required to cuff him to the bed and remain in the room at all times.  Little did this pleasant man know that had chosen to wait just one day  to post bond, my tax dollars  would have paid  the entire surgical bill of his bar fight escapade.

I felt just a little greasy that day.  Did I have a moral obligation to tell him he could have had his necessary surgery for free had he waited just 24 hours to post bond?  Considering his decisions had nothing to do with concerns about cost, I felt no obligation.  None of the nurses felt inclined to tell him either.  Why should they?  He's a grown man able to make grown up decisions.  If he wants to leave AMA because he doesn't like cops, that's certainly a grown up decision he has chosen to make.  

Great perspective!  If he asks, "Will my insurance pay if I leave against medical advice (AMA)?", the answer is yes. Though, it wouldn't be the prison health system.

What do you think?  Would you have told a man that his surgical ankle fracture could be fixed for free if he just waited a day to bond out?  Or would you let him make his own adult decisions independent of his insurance status and let him live with the consequences of his adult actions.

Fix Physician Compliance And Documentation Guidelines Immediately

 Let me guess.  Your doctors won't follow the rules and you are a hospital in trouble with CMS compliance. Or perhaps you're a doctor at risk for losing your hospital privileges because your physician documentation is placing your hospital at risk for losing their accreditation status.  Whatever the case may be, physician compliance with ridiculous documentation rules and regulations will always be a difficult road to pave. 

At Happy's hospital, the current CMS compliance guideline hysteria revolves around two issues.    I put the first  to rest with an explanation about physician  food and drink at the nurses station.  The second issue, the signing, dating and timing  of verbal orders within 24 hours, is a mystery to me. 

Not only has the order already been dated and time and signed by the nurse, and verified by read back,  but CMS compliance guidelines require physician documentation to counter sign, redate and retime the order within 24 hours.  I can assure you that in my last seven years of clinical hospitalist medicine, I have never seen a single case of patient harm due to the lack of a counter signature, redate and resign in 24 hours.  If you tell me the lack of a counter signature within 24 hours impairs the quality outcomes of my patients, I will immediately fight for universal acceptance.  Unfortunately, 99.9999999% of all orders given will have been completed by 24 hours.  The clinical relevance of this 24 hour compliance guideline is a mystery to me.

What this policy does is  take away precious time from understaffed nurses who are now required to hunt down doctors who may be in doing bloodless surgery or who may be in clinic or who may be sleeping  to sign off an order that has already been implemented. Nurses, in addition to all their other stretched duties, must now play baby sitter to physician documentation and physician compliance requirements to meet the ridiculously obtuse CMS compliance guidelines (just like the CPT medical coding requirements).

With such an effort being made to meet the standards of physician compliance and documentation at Happy's hospital, I learned the other day, what the fruits of these labors have brought.  A labor intensive one month audit has discovered just how much physician documentation has improved and just how far Happy's physicians have to go before CMS compliance guidelines have been met.

I'm all about quality care. So it came with great excitement when our internal audit discovered a 10% improvement in the 24 hour counter signature requirement. With such a rigorous effort being placed on physician documentation and compliance I had to wonder how many lives Happy's hospital physicians have saved by improving their 24 hour counter signature rate by 10%.  With tens of thousands, perhaps hundreds of  thousands, maybe even millions of orders in that one month period, I would expect a dramatic improvement in mortality and complication data for that month.  Was there a statistical reduction in mortality or complications? 

I wouldn't know because no one has run the data.  And no one has run the data because no one cares.  It's not about saving lives.  It's about keeping your accrediation with CMS compliance guidelines.  And that means getting physician compliance and physician documentation in line with the hospital's priorities, no matter how ridiculous they are. 

You can fight the policy tooth and nail, but an unaccredited hospital is a bankrupt hospital.  So how do you get your physician documentation and compliance to align with CMS compliance guidelines mandated from the Medicare National Bank?

Most nurses have pockets full of safety scissors and alcohol wipes.  Starting next week at Happy's hospital, nurses will also be required to purchase their own tool belt to carry one of these hospital issued Dewalt 18V cordless power drills.    I learned of this plan after investigating the discovery of a cordless power drill  sitting at the nurses station. 

Ultimately, the decision came down to how powerful the drill had to be. After hours of relentless debate between the 12V or the more powerful 18V drill, the committee members finally concluded that because of the high density of hard headed physicians at Happy's hospital, only the 18V drill would be powerful enough to drill some sense into the docs. 

There you have it folks.  Your solution to the lack of physician documentation with CMS compliance guidelines is not to implement baby sitting nurses trying to hunt the doctors down. You just need to provide them with the appropriate weapons to drill some sense into their docs.

Nurse Violence Against Doctors

You've heard of patient violence against nurses.   You've heard of patient violence against doctors.  You've even seen doctor violence against patients.  But did you know that nurse violence against doctors is running rampant in this country?  Nurses are the perfect group of professionals likely to go Rambo. They're overworked.  They're underpaid.  They're placed in the middle of unfix able situations with unstable patients and demanding doctor personalities every day. 

I'm concerned about an encounter I had with a nurse the other day.  So much so that I'm considering contacting the authorities for protection.  Could this be the beginning of a sweeping epidemic of nurse violence against doctors?

Nurse:  Happy, Mr Smith is driving me nuts.  If you stop his Ativan, so help me God I'm going to kill you.

Or am I over reacting?

Milk The Prostate Not Milk IN The Prostate. Incredible Error Of Judgment

Sometimes sexual experimentation can land you in the hospital, especially if you don't know what you're doing.  Take for example the young couple in love who heard that if you milk the prostate, also known as prostate massage, you can make your man's junk larger than normal. To learn more about this couple, continue reading.

What is the prostate used for? The prostate provides a vital role in male reproduction by giving nourishment and protection to sperm as they pass out the ejaculate. 

Milking the prostate is usually a medical process.  The prostate can be accessed  by inserting a finger in the male or  shemale rectum with the patient bent over.  Access to the prostate is achieved with approximately two inches of entry (make sure you lube up doctor) and sweeping the finger toward the stomach. How big is the normal prostate?   It's often described as the size of a walnut.  But they can become quite large, leading to obstructive problems urinating.  Benign prostatic hypertrophy, or BPH as it's known, is a condition most men get with age. 

I used to do quite a few prostate exams back in my outpatient clinical years.  It takes a lot of practice to know exactly what you're feeling or think you're feeling.  I haven't done one in the seven years of hospitalist work, nor do I ever intend to do one again.  That's why God made urologists and other outpatient doctors.  If my inpatient needs a prostate exam, they're getting a urologist evaluation.

I remember my first year of medical school quite clearly.  My anatomy professor taught  all of us how to milk our own prostate.  I went into that day a boy.  I came out a man.  And I never looked at my medical school professors the same ever again.    These are the real life lessons we learned in medical school.

Now that we've established how to access the prostate, I suppose you're wondering why anyone would want to milk the prostate. The medical prostate exam is called  the digital rectal exam.  There are many medical reasons reasons for milking the prostate. The most common reason for prostate massage is to evaluate the presence or absence of  prostate nodules, a clinical marker for prostate cancer, which is the most common cancer in America (excluding skin cancer).

Some doctors still  milk the prostate as therapy for prostatitis, or an infected prostate, although the therapeutic benefits are controversial. 

One other interesting medical application for prostate massage involves our friends in the animal kingdom.  In animal husbandry, electroejaculation involves the placement of an electrical probe near the nerves of the prostate to stimulate  the production of  semen for reproductive purposes. It can also be used in humans with paralysis associated sexual dysfunction.

But what about our young curious couple in love?  How did their milking of the prostate turn out?  Let's just say he ended up in the hospital.  As physicians we hold an enormous asymmetric foundation of knowledge.   One benefit of longitudinal patient relationships with outpatient physicians is the opportunity to understand which of them have the educational foundation, the mental capacity and the motivation to understand their disease process.

As physicians, I am constantly educating my patients  on the need to quit smoking.  I assume nothing as to their understanding of the ravishes of tobacco.  As for our young couple in love, their lack of education is a shocking testament to the realities of the misinformed patient.

Go read all about this  most extreme case of milking the prostate ever.

Information On Asthma Every Patient Should Know

I'm about to give you some critical information on asthma every patient should know.  Number one:  Don't Smoke.  Number two:  If your asthmatic child has low oxygen levels, don't go home, go to the hospital. Number three:  Never underestimate the value of asthma teaching.   I present to you the following video, critical information on asthma every patient should know.  That is some good asthma humor.

Growing A Bonsai Tree : From Do Not Resuscitate To Full Code

Bonsai is the art of aesthetic miniaturization of trees.   With that in mind, I have just one thing to say: Mrs Happy and I are the poster children for growing a bonsai tree without success.    How did I get involved with bonsai trees?  We had the opportunity to play host to mama and pappa Happy earlier this summer. After a two week stay, mama Happy mailed us a beautiful bonsai tree as a gift. 

I had no idea there was such a big market for buying bonsai trees.  There are thousands of sites proclaiming to have the best bonsai trees known to man.  

Mrs Happy has done a great job of greening up our home.  Her plants always seem to thrive.  In the seven years we've been together, I've never seen one die.   I certainly  couldn't do it.  How do women always remember to water the plants?

I was excited about growing and caring for a bonsai tree. I remember seeing them on the Karate Kid. I imagined myself trimming it with a tiny scissors, perhaps plucking a few leaves here and there in a meticulous display of perfection.

Our bonsai tree gift came in a box by US mail.  I had no idea buying bonsai trees online was even possible.  Mama Happy wanted us to send her back a picture of what she bought online (picture left).  It turns out she was a little disappointed in how it looked.    I thought it looked fine. Mrs Happy and I have no experience with growing a bonsai tree. But,.if you look on the internet you can find many web pages proclaiming excellence in how to grow bonsai trees.

The directions said to keep it moist.  How much do you water a bonsai tree?   Enough to keep it from dying.  That's how much.  This bonsai tree came in a pot with a hole in the bottom that allowed the water to seep out.  It didn't have a pot pan so we stuck it in the sink after watering.

The next day we went on a weekend vacation.  Rule #1:  If you're growing a bonsai tree, do not leave it unattended for a weekend.  After we returned, we noticed all the leaves had dried up.  Without a pot pan  all the soil dried up and our beautiful bonsai tree shriveled up with it.

For weeks  that darn tree lay on our kitchen counter shedding leaf after leaf.  I held out hope that the tree would survive.  I considered whether buying bonsai trees online was such a good idea.  Perhaps the tree was half dead when we got it.  I contemplated buying  another bonsai tree to replace our dead one.

Instead we waited.  We kept watering our tree with all our hearts, hoping for some signal of life.  And then it happened.  One day we say a green shoot.   First one stalk.  Then another.  Then a few leaves showed up. Soon our happy little bonsai tree had multiple signs of life. We were ecstatic.  After thinking for weeks that our little buddy was gone, our heart break turned to joy.  We reversed our bonsai's  do not resuscitate status and made him a full code.

We trimmed the dead branches to give life to the sprouting leaves.  We watered  diligently.  We never took our eyes off it.   Mama happy and company will be coming to Happy's castle in just a few short weeks.  I know she was disappointed with the way her gift had looked out of the box.  I hope she understands that our little buddy is making a fighting effort to get back to its glory days.  He just needs some more tender loving care and a water bowl for our pot.