How Long Can You Hold Your Breath For? Secrets Revealed!

How long can you hold your breath for?  Remember those games you used to play as a child?  The silly contests with the neighbor kids.  "I can hold my breath long than you can.  No.  I can hold MY breath longer than you can." Once in college I played that silly game where a friend squeezes your neck until you pass out.  It felt like I was out for hours when it was in fact just a few seconds.  Crazy feeling.  Well, watch this video and see the real benefit of  breath holding skills.  Who needs exercise when you can hold your breath.

Happy New Year. For other great videos and humor visit Happy's archives.

Please Vote For the $100 Caption Contest

Read On

Find a New Doctor: The Best Reason I've Ever Heard

Have you ever thought you need to find a new doctor? Sometimes patients and doctors need to part their ways.  Some doctor patient relationships are so good that gifts are exchanged.  Some are so bad that the doctor dismisses the patient from their clinic.

What about the patient who isn't happy with the care they are receiving?  What about the patient who wants to find a new doctor?  Sometimes legitimate reasons exist.  Perhaps the patient and doctor do not agree on the recommended therapies.  When  the patient and doctor do not have the same goals in mind, sometimes it's best for the patient to find a new doctor that can better work with their needs.

Sometimes patients want to find a new doctor for unnecessary reasons.  Frequently at Happy's hospital I have to talk down patients who are upset that their outpatient physician missed the diagnosis or delayed the diagnosis.  What patients don't understand is that delayed diagnosis is often part of the differential diagnostic process.  We do not do CT scans on every patient with shortness of breath looking for pulmonary embolism unless the defensive medicine based local standard says you do.    Some of the best internists in Happy's town are often blasted by patients for not doing their job.  I always defend them and correct patient misconceptions about the poor care they received. 

Sometimes patients feel they or their loved ones were placed in harms way by a doctor's failure to recognize  that an emergency assessment is warranted.    If a patient loses trust in the doctor's abilities, it's time for them to find a new doctor.

I have been fired only a couple times in seven years as a hospitalist.  I have fired two or three patients from my service due to a variety of abusive situations.  But what is the greatest reason I was asked by a  23 year old single mother of three to help them find a new doctor?

"I was pregnant and my doctor didn't know it until after I delivered"

Yes ma'am.  A new primary care doctor is exactly what you need.

Last Grand Rounds of the Decade

Send the decade out with a bang and head on over to the last Grand Rounds of the 2000's

Girl Who Can't Stop Sneezing Diagnosed with PANDAS

Check out this video of a 12 year old girl who can't stop sneezing.    She sneezes 8-12 times a minute for every minute of every hour of every day.  The only thing that makes her stop sneezing is a deep sleep.  Hmm...   Even the hypnotist can't make this girl stop sneezing.  What does the mother say?  She says the doctors think it's an intractible psychogenic sneeze.  What does the expert ENT doc of the day say to the reporter?

"Annie, I just don't think it's a sneeze."

Rule number one of internal medicine:  The most likely explanation is the correct explanation.  If it walks like a duck and acts like a duck, it's a duck.  Watch the video now.  

See other other wild videos on Happy Hospitalist

Midget Jokes Are Funny. I Don't Care What Anyone Says.

Midget jokes are funny .  I think even a midget could appreciate the humor in these jokes.  Two midgets go into a bar, where they pick up two "working girls" and take them to their separate hotel rooms.  The first midget however, is unable to get an erection. His  depression is made worse by the fact that, from the next room, he hears his friend shouting out cries of . . .

"Here I come again! ONE, TWO, THREE UGH!"  "Here I come again! ONE, TWO, THREE . . .UGH!"  This goes on ALL NIGHT LONG.  In the morning, the two met up at breakfast, the second dwarf asks the first, "How did it go?"

The first mutters, "It was embarrassing.  I just couldn't get an erection."  The second midget shook his head. and said "You think that's embarrassing?

I couldn't even get on the bed

And for the politically incorrect finale?  Here's another funny midget joke:

Every day, a male co-worker  walks up very close to a lady at the
coffee machine, inhales a big breath of air,

and tells her that her hair smells nice.

After a week of this, she can't stand it  anymore, takes her complaint to a supervisor in the personnel department  and asks to file a sexual  harassment grievance against him.

The Human Resources supervisor is puzzled and  asks: "What's sexually threatening about a co-worker telling you your hair  smells nice?"

The woman  replies, "It's Keith. The midget."

Radiology Management in the Outpatient World and Why I'm Glad I'm a Hospitalist

I just got notice from Blue Cross that they will be implementing a radiology management program for all advanced diagnostic imaging services starting in 2010.  The costs of advanced diagnostic imaging (such as CT, MRI, cardiac nuclear medicine) are rising 10-20% per year.

Radiology management companies are an attempt by insurance companies to slow that growth curve. What does that mean if you are a doctor?  Let me tell you how the program will operate.  Blue Cross calls it their Radiology Quality Initiative or RQI, not to be confused with CMS Physician Pay For Performance PQRI.  Here are the details of their radiology benefit management initiative.

Q:  What are the requirements?

A:  All physicians ordering advanced imaging must contact the radiology management company to obtain an order number before scheduling elective outpatient high tech diagnostic imaging services.  The radiology imaging center should verify they have a number prior to service delivery.  Radiology imaging centers cannot obtain the order on behalf of the ordering physician.

Q:  What diagnostic imaging exams are included in this radiology management program?

A:  Outpatient elective CT scans, MRI, MRA, MRM, MRS, PET, fMRI, and nuclear cardiology studies

Q:  What types of exams are excluded in this radiology management program?

A:  All imaging services provided in conjunction with emergency room visits, inpatient hospitalization, outpatient surgeries, or 23-hour observation hospital stays.  These types of diagnostic imaging studies do not require an order number.

Q:  How does the physician obtain an order number from their radiology management company?

A:  There are two ways.  They can either register at the radiology management company's website and follow the online process to request an order number or they can call the provided number.

Q:  What information is not required when submitting a request for an order number from the radiology management company?

A:  CPT or diagnosis codes are not required.  No records need to be faxed.

Q:  How does the program work in practice?

A:  The ordering physician office submits an order request through the radiology management's internet application or through the call center.  The provider's office will then be guided through an interview process where the member and ordering physician information, diagnosis, symptoms, exam type, and treatment/clinical history is requested.  If the information provided meets the radiology management  clinical criteria and is consistent with Blue Cross medical policy, the physician will then be guided to select an imaging provider where the imaging study will be performed and an order number will be issued.  If all criteria are not met and additional information or  review is needed, the case is forwarded to a Registered Nurse (RN) who uses additional clinical experience and knowledge to evaluate the request against clinical guidelines.  The nurse reviewer has the authority to issue order numbers in the event that he or she is able to ensure that the request is consistent the with the radiology management company's clinical criteria and Blue Cross policy, when applicable.  If an order number still cannot be issued by the nurse reviewer, the case is forwarded to a Physician Reviewer (MD), who contacts the ordering physician directly to discuss the case and diagnostic imaging guidelines prior to issuing the order number.  The physician reviewer will issue an order number based on a review of information collected and or through discussion with the ordering physician.  If the request does not meet the radiology management company's clinical guidelines, the request will be recorded as having received an order number without meeting clinical criteria.

Q:  How long is the order number valid?

A:  60 days.

Wow.  I don't know where to begin. Obama promises everyone will have insurance.  How long can this madness last before you have to  find a new doctor as they drop out of the work force.    I have no idea.  The 60 day  requirement is interesting to me as a hospitalist.  I often have follow up CT scans ordered for three to six months down the road to follow up a small pulmonary nodule or adrenal mass.  According to Blue Cross, I would have to call the radiology suite 30 days after my patient is discharged and schedule the CT scan.  That ain't gonna happen.  Not in a million years.

What about those folks who need a follow up scan within  60 days? For example, what about the  diverticulitis patient with an abscess that needs a follow up CT scan in 2-4 weeks?   I don't even know what insurance my patient has, let alone what radiology management portal to log in to or what radiology center the patient will use as an outpatient.  If my patient needs preauthorization for an outpatient scan that I am ordering in the next 60 days, either the floor clerk will be trained to do it, or the patient's primary care doctor is going to arrange it.  I'm going to stay out of that loop.

I called Blue Cross and spoke with a nice lady who made it sound like the program was a wonderful addition to patient care.  I asked her if they had plans in place to remove doctors who show a pattern of clinical compliance.  Nope.  No plan.  I asked her if they had data suggesting what percentage of doctors were prescribing advanced radiology imaging that didn't follow clinical guidelines.  She had no idea.  I asked her how much money they expected to save.  Not a clue.

In fact, this effort to save money will do what PQRI has done.  Nothing.  It nibbles at the edges while the train full of health care dollars plows full speed ahead.  Stop nibbling at a broken system and change how you play the game.  The reason doctors order so many radiology tests is not because they don't know what they are doing.  They know very well what they are doing.  They order lots of radiology tests because they don't have time to cogitate because you pay so poorly for your cogitative services.  Doctors order a lot of radiology tests because they don't want to be charged with negligence in a failure to diagnose suit.  They order a lot of tests because patients demand answers in this Me and Now world we live in.

Doctors don't order a lot of radiology tests so they can subject themselves to obstructive radiology management corporations.

I'm not going to play these games.  At some point, either the insurance companies will have to start paying more money for the overhead and time commitment given to doctors through  their cost control measures or the patient will have to spend their time with preauthorizing their own scans.

The big question is when will physicians just stop and say no.  When will they walk away from the headaches imposed by third party insurance rules.   With this additional obstruction imposed by radiology management companies, I for one am glad I'm a hospitalist where all I get to do is practice medicine.  It's also another reason how bundled care initiatives would remove the administrative burden from the backs of doctors just trying to do the right thing.

Free Medical Care For Terrorists While Good Samaritans Go Bankrupt

(HNN)  Umar Farouk Abdul Mutallab lay in a University of Michigan Medical Center hospital bed in Ann Arbor, Michigan getting treatment for injuries sustained during an alleged attempt to blow up Northwest Airlines Flight 253 over Michigan airspace.  The FBI held guard as Mr Mutallab received his free medical care to treat severe burns sustained during his alleged terrorist attack.

President Obama responded to this attempted act of terrorism from his pool side vacation villa in Hawaii:

"Does the guy have insurance?   Me and my Democratic friends in Congress will make sure every terrorist has free medical care as long as I'm in office.  I will make it my mission to provide free medical care to those who cannot provide for themselves.  If you're a terrorist, you can count on receiving excellent free health care under my watch"

When asked to respond to allegations of free medical care for terrorists, George Bush responded:

"I told you guys before.  If the guy doesn't have insurance, just send him to the ER.  Now leave me alone.  Dick and I are goin' turkey huntin'."

A firestorm erupted after citizens learned of the free medical care provided to terrorists in this country while the two heroic passengers were left to fend for themselves.  The good samaritans who sustained injuries during their restraint of Mr Mutallab learned they will be billed thousands of dollars to cover the cost of hand x rays and bandage supplies during their emergency department visits.

One heroic passenger explained:

 "I don't have insurance.    The airline said they aren't responsible. They said I did  what I should  have done as a decent human being.  The government said they aren't responsible. They said I should have bought my own health insurance."

When asked to confirm these obscene reports, Obama agreed.

"Here's a man who should have had insurance.  I'm going to make it my mission as President to make sure every man, woman and child buys their own insurance.  Had my policies of change  already been implemented,  this man would have already bought his own insurance to pay for injuries he sustained combating terrorism.   It's about making sure Americans share responsibility for their health care."

While under federal custody, alleged terrorist Mr Mutallab will get unlimited health care services, paid for by the federal government.  Secretary of Health and Human Services Kathleen Sebelius confirmed these allegations.

"As long as Mr Mutallab continues to require in-patient medical care, we will pay full price for his care", she said.

In other news, The University of Michigan Medical Center was thrilled to be named the first Center of Excellence by the Obama Task For Force For Free Terrorist Medical Care   A spokesman for the hospital, who wished to speak on condition of anonymity, explained:

"We love having this federal quality designation status.  With Medicare and Medicaid payment rates falling quickly, we can't sustain our daily operations. At least Obama's terrorist health care policies offer us the hope and change we so desperately seek in a declining reimbursement environment.  It's about time somebody paid full price for our services.    We are thinking about opening satellite clinics and are working closely with Al Qaeda to become their hospital of choice for international medical tourism.  We plan on opening up the Al Qaeda center for Excellent Terrorist Health Care which will be fully funded by monies paid back by the TARP fund."

Mr Mutallab expressed a new found excitement about his prospect for free medical care for the rest of his life.   

"Here I was trying to destroy America with my bombs.  I had no idea they gave away their health care for free. This EMTALA thing is great.   I'm going to tell all my friends about the wonderful land of FREE=MORE."

Copyright original story from the Happy News Network

Bad Parking Video: How Not To Park Your Car

This is some bad parking in this video folks.  Some people just shouldn't be driving.

Snowed In? What's Your Hospital Policy?

This  Christmas snow storm of 2009 had me wondering about the snowed in hospital policy at Happy's hospital.  If you can't get to the hospital, you can't get there.  It's as simple as that.    While I had Christmas off, I was back at work for the expected post Christmas rush of patients who delayed evaluation until after the holiday.  

I'm lucky.  My street is on a city bus route.  Which means I am one of the lucky few who will never be snowed in for more than a day.    But what about all those folks who don't live on a bus route or a major city arterial?  What about the folks who live in the country?  What about all those folks who have that old rear wheel drive Mustang or the Neon with a five inch clearance?  What about all the hospital workers who can't get to the hospital because they can't get out of their driveway?  What should they do about being snowed in?

A major clearing snow type of snow storm would wreak havoc on the daily operations of a hospital.  If the maintenance crew can't get there, they can't shovel the parking lot.   If the janitor can't clean the room, new patients can't be admitted.  If the nurses and doctors and respiratory therapists can't get to the hospital, then patients can't get admitted and the hospital must divert patients or face issues with  emergency department throughput. In a world where hospital margins are tight, any loss of business from snowed in workers can mean a month of financial ruin for the hospital's bottom line.

With that in mind, I found myself wondering:  What is the snowed in  policy at Happy's hospital?  I made some phone calls and discovered we have an expanded network of crazy volunteers who thrive on the adrenalin rush of dangerous driving on icy and snow packed roads.  They'll pick you up and take you home if your little 1994 Neon can't make it out of your driveway.  Two of Happy's partners got picked up.  I learned that multiple nurses  not only got picked up, but spent the night in the hospital due to impassable roads. 

While we often think of a major snow storm as placing community bound people at risk for lack of access emergency services,  many people forget about a blizzard's effect on hospital workers.  While the rest of America eats turkey and ham on Christmas Day, hospital employees and doctors are braving the elements to care for patients in a business that never closes.  Not having a snowed in hospital policy can mean the difference life and death for patients.

A major snow storm can rise to the level of importance as a mass casualty event.  It's important to have snowed in policies in place to prevent hospital operations from shutting down and placing patients at risk for lack of services. The irony here is that small town hospitals that rely on Happy's hospital for a higher level of care probably have fewer issues with employees being snowed in.  If you live in the country,  you have a truck.  It's as simple as that.

So, what's your snowed in hospital policy?

How To Be Happy In Life: Five Rules To Live By By Tiger Woods

If you want to be Happy in life, you must follow these five rules to live by from Tiger Woods.

1. It's important to have a woman, who helps at home, who cooks from time to time, cleans up and has a job.
2. It's important to have a woman, who can make you laugh.
3. It's important to have a woman, who you can trust and who doesn't lie to you.
4. It's important to have a woman, who is good in bed and who likes to be with you.
5. It's very, very important that these four women do not  know each other.

Find out how to be happy in life

Christmas 2009 Winter Snow and Ice Storm Was a Day of Danger, Excitement and Snuggies

The winter storm of Christmas 2009 is going to be remembered for years to come. I haven't seen anything like this in years. Between the unbelievable winds, the massive snow drifts and the feet upon feet of snow, 2009 will be known as the year Santa almost can celled his trek south. We had one heck of a winter storm in Happy's neck of the woods.

I'm sure anyone who was affected by this mammoth winter storm has their own stories to tell.  After Marty got dressed up, it was time to brave the ice storm brewing outside.   I haven't seen ice like this in a decade or longer.   After the ice came the snow.  Lots and lots of snow.   Mrs Happy and  family braved the winter weather to meet up with  our family up north.  We had a wonderful Christmas Eve.   We all gathered for snacks and cider.  Between the Snuggies, the Slankets and Cudlees being exchanged, everyone stayed warm on that cold winter night.

On Christmas Day, we again headed north for round two of our Christmas celebration.  On the way we tried to help a couple poor folks stuck on the road in their neighborhood, but they didn't have a way from me to hook up my tow rope.    So Mrs Happy and I drove the women and children to their house and the men got help digging from some friends.

At the Christmas celebration, we discovered that Santa Claus had brought along a Wii for our niece.  Marty and Cooper played with their  new voice activated stuffed pig and rooster.  And I learned you can plug your iPhone directly into your  television with an iPhone-TV video cable adapter.  And to think, ten years ago this month I was getting my first cell phone.  The only thing it could do was act like a cell phone.

All of this was fun and dandy, but the real excitement didn't start until the end of Christmas 2009 when Happy drove his SUV  into a five foot snow drift in a ditch.  We flagged down a passing pick up truck to help bail us out.  After ten or so attempts to pull us out, our tow rope snapped. This nice man then pulled out his own and proceeded to try another ten times, finally pulling us out from the side of the road. I have no idea where he was going or how quickly he was trying to get there.   I offered to give him what cash I had on me ($30 bucks).  But he wouldn't take it.  Merry Christmas he said.

Yes, I think it's about time to schedule another trip to Hawaii.  I hope everyone's Christmas was safe in what has turned out to be known as the winter storm of Christmas 2009.

Update:  I backed black beauty into my driveway last night for an easy get away to work this morning.  To see where I was going, I opened my passenger window.  Oops.  I forgot to close it last night.  Got into the SUV this morning with a 6 inch snow drift inside the entire back seat.  This Christmas 2009 winter storm turned out to be a memory for the ages.

$100 Christmas Caption Contest

$50 Amazon gift card goes to the best caption out there for this picture (thank you Toby for your excellent cookie skills).  I will  also donate $50  to the winner's  nonprofit charity of choice in their honor.  Mrs Happy and family will pick the top three captions through Christmas and you guys get to vote on the winner.    Have a safe and Happy Christmas holiday.

Is Santa Claus Real? How Prove To Your Kids Santa Was In Your House And Raise Money For Charity

Have your kids been asking you that dreaded question:

"Mommy. Daddy. Is Santa Claus real?"

It's time to answer that question and prove once and for all to your kids that Santa Claus is real.  Your children deserve an honest answer.  Of course Santa Claus is real. But just telling them Santa Claus is real won't remove the doubt from the minds of millions of children who's friends are telling them otherwise.  You need a photo of Santa Claus in your house.

"Daddy.  My friend Jimmy said his big brother told him Santa Claus wasn't real.  He's just a phony."

Well dad.  What are you going to say to your son Frankie?

"Frankie.  Santa Claus is real.  You just have to trust me on that."

Who's Frankie going to believe?  Little Jimmy who's big brother told him Santa is a fraud?  Or is Frankie  going to believe a dad who says "Trust me son.  I'm your father".  My bet is on Jimmy.

Kids these days want evidence.  They live in the prove me world.  The only way you're going to prove to your little twelve year old Frankie that Santa Claus is real is photographic evidence.  The kids these days, they're all into video games and iPods with their applications and their You Tube videos and their phones with their cameras and their texting.  No kid is going to believe a father anymore who just says "Trust me son.  I'm your father."

You're going to have to talk the talk of a 2009 kid.  And that means show them the E-V-E-E-D-E-N-S-E.  You're going to have to produce a bona fide real honest to God picture of Santa Claus invading your home to put to rest the "Is Santa Claus Real?" question.  How are you going to do that? Have I got some news for you.  Happy has  has teamed up in an exclusive deal with Santa Claus.   He won't let you see him in person (something to do with an acne problem), but he will let you snap a photo proving he was at your home.

Between now and Christmas if you purchase a photo for your kids proving once and for all that Santa IS real and he was at your home, Happy will donate 100% of the proceeds he generates to the Make-A-Wish Foundation to help keep dreams alive for children all across America.

What are you waiting for.  Answer that question "Is Santa Clause real?"  once and for all.  Put the mystery to rest.  Click on the Santa graphic  to get started today and bring joy and Christmas cheer to your child's heart.

No middle link this time, just your hidden Happy.  Only six more to go for your money.  And I'm going to make it easy for any of you still following or playing along.  No more middle links.  You've suffered enough.  The next 6 Hidden Happys will either be found by a search from my search engine (I will tell you), or by following just one link.  In this case, there is no link to follow, so search for a cool Christmas dog video and you'll find hidden Happy 7. 

Merry Christmas and Drive Safe

Mother Calls 911 Because Son Won't Stop Playing Video Games and Go To Bed

I can't make this stuff up.  This is your America, where cops are parents and Senators are doctors.  Why would any mother ever call 911 because their child won't stop playing video games? What did the officers do?  They persuaded the child to obey his mother.  I'm actually quite surprised he wasn't taken to the emergency room for a hospitalist to admit him for an overdose of Grand Theft Auto.   And here is another one of the strangest 911 calls ever.  

Always Wash Your Hands After Touching A Patient: Mystery Liquid?

Always wash your hands after touching a patient. You just never know what they've been touching.    I shook a patient's hand the other day and was surprised with a transfer of some unidentified wet substance.    I have no idea what the liquid was.  Any guesses?

Third Party Insurance Rules Make You Pull Your Hair Out

I have yet another example of how third party insurance rules obstruct efficient patient care. I was asked to see a patient with fibromyalgia who was asking about about the drug Lyrica she heard about on television (one example of how direct to consumer marketing increases health care expenses).  Lyrica is about the only medication approved by the FDA to treat fibromyalgia.  I don't know if it really works or if it's just an expensive placebo effect.

Maybe  fibromyalgia is all in your head, and that's why this medication works.  I don't really care.  I know it's FDA approved, which means it has more going for it than most pharmaceuticals used for off label purposes.  At least doctors who prescribe Lyrica for fibromyalgia aren't going to get charged with homicide for prescribing medications for unapproved reasons. 

I notice my patient has Medicaid preauthorization, the ultimate third party insurance nightmare.  Medicaid has strict rules about what can and what cannot be prescribed without preauthorization.  Preauthorization is the third party insurance method of choice to control costs.  It is a series of roadblocks used to prevent physicians from providing the care they believe is in the patient's best interest. Third party insurance use of preauthorization is  a time consuming, mentally draining and frustrating experience.   Third party insurance rules force physician offices to spend hours on the phone everyday  defending their medical decisions on behalf of patients.  This uncompensated time is one of the major reasons why primary care is dead.

As a hospitalist I rarely have to worry about thousands of third party insurance rules, medication formularies or preauthorization problems.  Every drug I need as a hospitalist is available. Any x ray or or cardiovascular scan I need is at my fingertips.    I rarely know what insurance my patient carries. Every insurance has their own formulary.  I try and pick generics to use for discharge.  I try and pick the cheapest drugs.  I am not fooled by claims of superiority between this ACEi or that, this statin drug  or that, this PPI or that.  Only a rare patient requires that extra expense of a brand name drug which is often ten, twenty or fifty times greater than their generic counterpart.

Patients occasionally  bounce back for hospital readmission because they couldn't afford to fill their medications.  I once readmitted a patient with pneumonia because Happy's partner discharged them with an unaffordable $200 course of antibiotics.  I was thinking a couple $4 drugs from Walmart could have prevented that.   I often find myself battling this problem with doctors who write for expensive statins, inhalers or blood pressure medications which I know will never be filled. The homelss guy on the street isn't going to fill his Ramipril or his Brovana.  The unemployed construction worker isn't going to fill his Crestor or Avandia.  At some point in the discharge process, common sense should prevail. 

For my Medicaid patient, I wanted to know whether third party  insurance rules required preauthorization for my Lyrica prescription.  So I called the patient's pharmacy.  And what was I told?  I was told that I couldn't get this information without having an actual script written and the actual medication filled.  Only then could the Medicaid carrier tell them if my Lyrica required preauthorization.

How ridiculous is that?  I can't even check to see if my patient's third party insurance will pay for the medication before the patient tries to pick it up.  What a terribly inefficient system third party insurance has become.   What are my options here?  I wrote the script.  If the pharmacy won't fill it without preauthorization, which is only known at the point of sale, then the patient either gets their medication or they don't.  If it requires preauthorization, good luck finding me.  I'm either gone or I'm off service.  Perhaps I'm in Hawaii.

The only solution as I see it is to contact the primary care doctor.  Man am I glad I'm a hospitalist.  Where I'm free to practice without the constraints of third party insurance rules that  make you want to find a specialist in hair restoration for women.

Pot Humor Post of the Day, And How To Bill For Pot Humor

Whenever drugs are involved in a patient's hospital admission, the outcome is either craziness or comedy.  Methamphetamines and cocaine seem to be the popular drugs of choice requiring admission. These people are usually angry and agitated.  However, it seems like pot humor always adds a little touch of the unexpected to an otherwise boring admission.

Read On

Let Us All Come Together

For Grand Rounds, this weeks best medical offerings.

Bizarre Rituals Land Boy In the Hospital With Needles In His Heart and Lungs

Just when you think you've seen it all, along comes a month long series of bizarre rituals involving a brick laying Brazilian stepfather, two inch blessed sewing needles, a lovers quarrel and the Afro-Brazilian religion Candomble.

These bizarre rituals landed a boy in the intensive care unit after surgeons successfully removed four of the sewing needles from inside the toddler's thorax.  While four of these needles were removed, over thirty needles remain embedded in the child's body.  Two lovers have been arrested, although no charges have yet been filed. 

I haven't seen any patients hospitalized as a result of bizarre insertion of needles, or any other objects in one's body.  I linked previously about a lover's misguided attempt to stimulate the prostate.  I suppose that could be considered an unintentional bizarre ritual.

Or perhaps there are the nurses fired for posting sex rays on their Facebook page.  I suppose anytime a patient shows up in the emergency department with an object in their rectum, bizarre rituals would head to the top of my differential diagnosis.

Or how about the meth addict who told me the bizarre rituals she uses to cure her cotton fever.  No people.  Injecting tap water into your veins is not a cure for meth related fever.  It's crazy what bizarre rituals people will believe out there.

Maybe you prefer to partake in bizarre Christmas spirit rituals by getting permanent surgical elf ears.  Whatever the case may be physicians have the opportunity to see the medical side of bizarre rituals gone bad.

What are some of the craziest rituals you've seen in the office or hospital?

Is Getting What You Want Part of the Physician-Patient Relationship?

Dr Kevin had a nice piece on how to make the doctor visit more tolerable and respectful to patients.  A reader by the name of A. Medici left a comment mocking me and my blog (I'm not sure if Dr Kevin pulled it from his blog, but I got it in my email).  so here it is:

Happy, don't let that crowded waiting room puff up your already inflated ego. No, it doesn't necessarily mean you're doing everything right.  The main reason an unhappy patient might still be there cooling their heels 2 hours past their appt. time is because they have no choice about their providers.  Since you dismiss this thread as hilarious and would direct any unhappy patient to take their business elsewhere once again validates your blanket scorn of patients. Like the ones you routinely mock in your blog.

 My response?  This reader has a misdirected anger at Happy.  I don't have a waiting room, first of all, which makes me believe this reader speaks not of what they know.  And I don't scorn patients.  I discuss personal responsibility in the entitled economic world we live in.  I talk about the ultimate economic doom living life as an entitled American will do for our country.   I have no scorn for patients.  I could care less if they smoke  get fat, watch TV all day and live a life of entitled slobbery.

What I do care about are the people who expect others to support their expectation of cradle to grave support for the poor choices they made in life.  I do care about the obviously unsustainable economically disastrous path our nation has chosen to take, bribed by the promise of FREE=MORE from politicians in the business of protecting their own entitlements.  

If you don't like my blog, don't read it.  If you don't agree with my position, I'm sorry to tell you you're just wrong.  Go read something that allows you to bury your head in the sand makes you feel good about the FREE=MORE world being embraced by this country.

My words of advice to those complainers in life.  Don't sweat the small stuff.  Everyone has their own tolerance level for the unimportant stuff in life, even Happy.  Every day is a new lesson in life.   This reader appears to me to have a low threshold for being annoyed.  If the doctor calls you by your first name instead of by your title, you might care while other people may not.  If I tried to live my live pleasing everyone, nobody would be happy.   As a doctor, I am there to provide excellent care in an honest and open environment.  Some people only want to read about sugar plums and snow angels and choose to ignore the reality we find ourselves in.

If you don't like your doctor for whatever reason, find another doctor.  If you can't find another doctor within 40 miles, move to a place that has more doctors.  If you  can't move, be prepared to accept the result of your choices in life.  Your third party insurance company pays your doctor for a 99213.  Your insurance company does not pay your doctor to call you Prince Medici.  If you want your doctor to do as you say, be prepared to pay extra for that right to be pampered.   If you can't afford to pay for service, be prepared to accept what  you paid for.  Third party medicine does not pay for service.

Like I said in my post at KevinMD, a busy office is doing everything right, it just may not be right for you.  The solution to the problem then becomes obvious to the neutral bystander.

Asthma Dyspnea, COPD Dyspnea and the Use of Narcotics: A Case Presentation from a Marathon Runner with Severe Refractory Asthma

Asthma dyspnea (or COPD dyspnea) can be a debilitating symptom.  What is dyspnea you ask?  The American Thoracic society defines dyspnea as

a term used to characterize a subjective experience of breathing discomfort that consists of  qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factor and may induce secondary physiological and behavioral responses

I have had several brief episodes of dyspnea in my life, usually related to a  viral illness.  But I  know I can't even begin to know what severe dyspnea feels like.  I do, however, see it every day as a hospitalist.  Usually my patients have end stage COPD, a disease of smoking (and occasionally other causes such as alpha-1-antitrypsin deficiency).  They usually have terrible air trapping in their lungs and have difficulty finding the energy for their next breath.

It's terrible to watch a conscious COPD patient struggling to get their next breath.  Short of intubation, or biPAP, there isn't a lot of other mechanical interventions we as doctors can do to alleviate COPD dyspnea.  Once the lung tissue has died, you can't replace it.

In addition to  dead lung tissue while living with   emphysema, a mostly irreversible process, severe asthmatics battle airway spasm and congestion that prevents inhalation of oxygen and exhalation of carbon dioxide.  As the airways contract, the asthma related dyspnea gets worse and is eventually followed by respiratory arrest.

We use bronchodilators.  These are  medications that counteract the spasm of the airways.  These medications include the short acting albuterol and Xopenex.  We also use the longer acting bronchodilator formulations such as Serevent (salmeterol) or Advair (combination inhaled steroid fluticasone and  salmeterol)  and the long acting formoterol or Symbicort (combination inhaled steroid budesonide  and formoterol).

Sometimes we also add a short acting anticholinergic bronchodilator such as ipratropium bromide (Atrovent).  It's used in  combination with nebulized  albuterol (Duoneb) or in combination with inhaler form (Combivent).  Sometimes we'll use the long acting anticholinergic once a day bronchodilator tiotropium bromide (Spiriva) instead.

For acute severe attacks in hospitalized patients, we will also use intravenous steroids (such as solumedrol) in very high doses (125mg IV q 6 hours) and taper the dosing from there, eventually discharging the patient on a two week prednisone taper (usually starting at 40 mg a day).  Some patients with asthma or COPD require chronic maintenance doses of steroids which themselves can come with chronic side effects, which can be as unbearable as the asthma dyspnea we are trying to treat.  Other medications are available as well (such as the leukotriene receptor antagonist Singulair) in the treatment of asthma.

Asthma or COPD related dyspnea can be a very difficult symptom to treat.  Even in patients who aren't hypoxemic, the subjective nature of dyspnea varies from mild and acute to severe and chronic.  We often use inhaled morphine in patients on hospice or end of life cares.  It can be a very effective method to control the agonizing drowning sensations of asthma or COPD related dyspnea.

Breathin' Stephen is a blogger, a patient with severe refractory asthma since birth, a retired respiratory therapist and a marathoner.  A marathoner?  That's incredible.  Instead of rolling over and accepting a disability check with a bold sense of entitled anger, he decided to take control of his life.  I encourage all of you who feel like you got the short end of the stick in life to go read about the power of perspective in your daily life choices.

Will you roll over and die?  Or will you turn your disability into ability.  Stephen has taken his asthma management one step further by initiating Methadone, an opiate used as the treatment of choice for heroin addicts in remission, to control his severe asthma dyspnea.  Stephen is correct in his assertion that many physicians are weary of using narcotics to treat dyspnea.

The drugs can induce respiratory depression and death if not monitored carefully.  In fact, the FDA has recently suggested that physicians be required to undergo additional certification to earn prescribing privileges for class 2 narcotics.  


Would I recommend class 2 narcotics such as Methadone for most patients with asthma dyspnea?  Of course not.   Would some patients benefit with better COPD or asthma dyspnea control?  Yes they would.   However, in this litigious society we practice in, I think most physicians might think twice about  the  off label use of drugs, especially narcotics, when doctors are being charged with homicide for their  unorthodox use.  

Would I prescribe narcotics for use in asthma dyspnea?  Not in a million years.  Not as long as doctors are charged with homicide for off label use of medications. Would I take a class the certify myself?  Perhaps I would.  But I would use that class as a basis for telling patients narcotics are not indicated for migraine headaches.  Narcotics are not indicated for their irritable bowel pain.   Narcotics do not have an FDA indication for asthma dyspnea.  

Perhaps the unintended consequences of health care reform such as  this FDA action  will limit patient access to pain medications and increase the burden of suffering by patients all across this country, including those experiencing severe refractory asthma dyspnea.

I recommend you go check out Breathin' Stephen  (click on the methadone link above) and see what an inspiration he is to patients who chose to turn disabled into abled and his inspiration to help others achieve their dreams.

Should A Mother Tweet About Her Child"s Death Hours Later?

After recently being linked by the New York Times parenting blog, I found this interesting story about  a mother who lost her child to a drowning accident.  Drowning accidents occur thousands of times a year in this country.  In fact, Happy's hospital group was once asked to admit a patient who was a roll over ATV accident that landed upside down in a pool of water.

• Number one:  Roll over accident is a trauma.  I don't admit trauma patients
• Number two:  Accidental drowning is a trauma.  I don't admit trauma patients.

In this case, the child was a simple drowning in the backyard pool.  The child died as a result of their accident.  What did the mother do?  Was she grieving for her loss?  I'm sure she was.  Was she overwhelmed with grief and emotion?  I'm sure she was.

Was she Tweeting about her son's death hours after his accident.  Unbelievably, yes.

An apparent firestorm erupted in the virtual world of Twitter.  Some people called her callous while others defended her as a caring mother searching for help from virtual friends.

In a world where relationships with total strangers can mean as much as they can with close friends and family, it's not surprising some people find comfort in expressing their grief and sorrow with their online community of friends they've never met.

On The Happy Hospitalist, I have my own community of frequent readers who comment.  Some are supporters.  Some are die hard antagonizers.  Some have great stories to tell.  Some are just annoying.   Whatever it is Happy's readers are searching for or offering,  my site is a haven for free speech (minus a few ground rules).

• No cussing
• No insulting Mrs. Happy
• Nothing illegal
• No personal agendas with real names.

Minus these few basic ground rules, anything goes at The Happy Hospital.    The online world can be a powerful force for those who actively seek it.  What do you think?  Should a grieving mother be Tweeting about her son's death hours after the accident? Is that what social online media is all about?

Christmas Dog Clothing for Puppy Angels (and a Dalmatian Dressed as Santa's Elf)

Here's what Christmas dog clothing looks like for Happy's two Italian greyhounds and our  immortal 14 year old cousin Lucky dog.  He's Santa's little elf in this picture (he hates getting his picture taken and tries to avoid direct camera eye contact at all costs).

Lucky is a twice rescued dalmatian who settled into Happy's sister's home a few years ago.    Lucky was recently diagnosed with an adrenal tumor.  After experiencing serious side effects from a trial of the  chemotherapy drug mitotane (severe anorexia and severe weakness), mama and papa Lucky decided to abandon their treatment plans and let old Lucky be free of any further therapy.  I'm happy to report Lucky is back to his cheerful old self and is living his life to the fullest by bringing love and joy to all those around him.  Hang in there Lucky.  Your spirit runs deep.

Here's a picture of Marty and Cooper cloaked in their Christmas dog clothing:  a nice warm rabbit tail.  Precious angels they are.  If they aren't snuggling together under the bed sheets they're wrapped in a blanket, or in this case, fur and giving huggles. 

If you'd like to see hundreds of other wonderful pictures of their love, visit Marty and Cooper's slide show in my side bar.  You can also find all their videos on their YouTube channel.

Do you dress up your dogs in Christmas dog clothing?  If so I'd love to see your pictures.  Send your Christmas dog clothing pictures to me at my email in my contact info and I'll post them here for some Happy holiday and Christmas cheer.

Christmas Clogging: It's Not What You Think.

If you Google Christmas clogging, you might find a video showing dancers on a stage.  But not at Happy's house.  We have brought new meaning to the words Christmas clogging.  I have sister Happy, brother-in-law Happy, mama Happy, papa Happy, and Cousin Lucky dog Happy in our home.   Soon to arrive are brother Happy, sister-in-law Happy and nephew Happy to enjoy the Christmas spirit.

And I awake this morning to discover that  two out of four of Happy's toilets are clogged.   And I can assure you, there is no dancing at Happy's home.

How To Help Your Italian Greyhound Survive The Snow and Cold Weather

If you've ever had an Italian greyhound you know they hate the snow.  They hate the cold.  In general they hate the water but ours are starting to discover how fun water can be.  They hate being uncomfortable.  Mrs Happy and I have discovered that Marty and Cooper, our precious little babies, have a very tight range of comfort between 72 and 72.5 degrees Fahrenheit.  Anything below that and they're shivering.  Cooper, our grey Iggy with the white boots, is slightly more tolerant of having cold feet.  But Marty, our little white Iggy with the grey helmet, has no tolerance for snow or cold feet.

Read On

Crock Pot Mom Explains: Just Another Reason Why I'm Not A Lesbian

What is a crock pot mom?  And what does that have to do with lesbianism?  When a crock pot mom discovered the darker side of cooking, here's what we got:

smell alone 

I don't know what to say.  I guess I'm glad I'm not a lesbian.  I'm not sure I could stand the smell of vagina and feet in the same room.   Go read the rest at hooey! critic.  It's hilarious.

On a side note, I can assure you Mrs Happy is not a crock potter.  Nor is she a lesbian.  Nor have we  ever had the smell of vagina or feet in our Happy little castle.

I've Been Linked By The New York Times Parenting Blog

  I guess my job is done.  Should I quit blogging?

Hundreds Attend Global Warming Protest in Littleton, Colorado

With Obama in Copenhagen discussing the future of our world, it's time to give a fair and balanced view of how Americans feel about the issue of global warming.  Check out this picture showing hundreds of angry protesters in Littleton, Colorado protesting global warming.  I'd be angry too if I was them.  Instead of a carbon cap and trade tax, perhaps it's time to implement the breathing tax to save the world and make sure these protesters in Littleton survive for centuries to come.

Cute Italian Greyhound Snuggle Pose of the Day

Here is  Cooper's cute Italian greyhound snuggle pose of the day. What a puppy angel full of love he is.

You can see hundreds of Marty and Cooper pictures in my slide show in my sidebar.

What Is Nursing School Like and How Does It Compare To Medical School?

I've often wondered what nursing school is like.   For a nursing student pursuing a Bachelor of Science in Nursing, the first two years consist of undergraduate requirements.  The last 2  to 2 1/2 years are  nursing school requirements.

The nursing school portion consists of clinical rotations in different fields of patient experiences such as med-surg, pediatrics, obstetrics, a rehab hospital, community health, and intensive care among others. This is similar in some degree to the third year medical school student experience (bloodless surgery, OB/GYN, internal medicine, pediatrics, family medicine, psychiatry).   Generally speaking  a nursing student has one or two patients a day they care for while working closely with an employed nurse and an instructor from the College of Nursing.

After completing two years of  classroom work, the third year medical student generally cares for 2-4 patients at a time.  They complete their history and physical examination by 7 am or earlier (depending on the service)  and join the rest of their team ( other 3-4 medical students, 1-2 interns, supervising resident, attending) in morning report for the case presentation of the day.

How are third year medical students graded on their clinicals?  Medical student are at the mercy of their supervising residents and attendings.  Generally speaking, the residents collaborate with the staff physician.   The students are graded on a bubble sheet with a grade of fail, average, better or excellent.

Medical students in their clinical rotations are graded on such things as  dress and attire, SOAP note writing skills, depth of their differential diagnosis, ability to formulate a plan, and how well they communicate with patients and nurses and other members of the team.  At the end of every rotation, third year medical students must also take the national Shelf exam specific to that clinical rotation.

With all that in mind, I found myself wondering: How are nursing students graded on their clinical rotations?   That was the question I had to answer.  So I  asked a practicing male nurse how he grades his nursing students.  I was shocked by his response.

• 98% of the grade is determined by looks
• 2% of the grade is determined by personality

I had no idea this is what nursing school was like.

Deadliest Day Of The Year Is Christmas???

With 365 days a year, one would think the law of averages would win this battle.  And you would be wrong.  Because there is a deadliest day of the year?  It's none other than Christmas.  Who would have thought that?  Why would Christmas be the deadliest day of the year.

Read On

Family Personality And What It Means In the Intensive Care Unit

Anyone who's ever worked in the intensive care unit knows that family personality plays a big part in how you make it through the day as a hospitalist or intensivist.   Family personality can mean the difference between the patient dying a horrible death or experiencing a death with dignity.

The doctors over at realICU give us a nice list detailing different types of family personality traits that must be acknowledged in the doctor patient relationship.  The doctor must  understand what family personalities they are dealing with so they can manage family expectations.  

The realICU docs discuss seven of these personalities.  One of them is the religious family.  In my experience, the family personality which leans heavily towards the religious spectrum can work either for or against you.  Some religious families want everything done at all costs because only God can take their loved one's lives (and apparently God made ventilators too).  Other families realize that their loved one's time has come at the hands of God and it's time to stop us doctors from preventing  natural death.

I once had a devout family of Mexican Catholics who's loved one was brain dead of a massive stroke.  At only 42 years old, her young life was cut short without explanation.  All clinical data pointed towards clinical brain death, yet this family's internal religious directive was to keep her on life support forever.

That is until I used some impromptu religious discussion to convince them otherwise.   I explained that her soul had already left her body.  The only thing keeping her body from following was our machines.  I explained to this religious family personality that I was in fact preventing her from completing her journey.  These were the magic words this religious family needed to hear to do the right thing and disconnect the life support.

I've experienced all seven types of these family personalities in the ICU.  However,  I might add an eight prominent family personality these docs forgot.

Family personality #8:  The non English speaking family.  Nothing beats a room full of twenty family members who don't speak English, with all eyes switching between you and their 7/8 dead grandma.  That's about as hard as it gets.  Discussing death through an interpreter will never be easy no matter how many times you do it.

Grand Rounds Presents A Web Of Intrigue

Check out this weeks neat Grand Rounds presented in Spidey Vision

CT Scan Radiation Exposure Much Worse Than Originally Thought. Predicted Cancer Rates Scary.

It turns out that the CT scan radiation exposure is much larger than was previously thought (and even health concerns with the whole body TSA scanners are starting to crop up).  This is really scary considering how freely CT scans are ordered these days.  A while back the FDA published What Are the Radiation Risks of CT?   See the table below.

 Table I. - Radiation Dose Comparison

Diagnostic Procedure	Typical Effective Dose (mSv)1	Number of Chest X rays (PA film) for Equivalent Effective Dose2	Time Period for Equivalent Effective Dose from Natural Background Radiation3
Chest x ray (PA film)	0.02	1	2.4 days
Skull x ray	0.1	5	12 days
Lumbar spine	1.5	75	182 days
I.V. urogram	3	150	1.0 year
Upper G.I. exam	6	300	2.0 years
Barium enema	8	400	2.7 years
CT head	2	100	243 days
CT abdomen	8	400	2.7 years

1.Average effective dose in millisieverts (mSv) as compiled by Fred A. Mettler, Jr., et al., "Effective Doses in Radiology and Diagnostic Nuclear Medicine:  A Catalog," Radiology Vol. 248, No. 1, pp. 254-263, July 2008.

2. Based on the assumption of an average "effective dose" from chest x ray (PA film) of 0.02 mSv.

3. Based on the assumption of an average "effective dose" from natural background radiation of 3 mSv per year in the United States

Unless otherwise noted, the contents of the FDA Web site (www.fda.gov)--both text and graphics--are not copyrighted. They are in the public domain and may be republished, reprinted and otherwise used freely by anyone without the need to obtain permission from FDA. Credit to the U.S. Food and Drug Administration as the source is appreciated but not required. 

Now it appears these numbers relating to CT scan radiation exposure

 have been severely underestimated due in large part to the higher doses of radiation  being given to patients (I assume because of obesity).  The average CT scan radiation exposure for an abdomen and pelvis exam was not the 8 mSv reported by the FDA , but rather 31millsieverts, with a range of 6 to 90. Ninety millisieverts is equivalent to many thousands of chest X-rays, or the equivalent background radiation of living over a 30 year period.  And you get it all from one CT.

Thirty years of background radiation from one exposure to a CT scan of the abdomen?  That's scary.  With America getting fatter as we speak, higher and higher doses of radiation will be necessary to obtain good looking films.  This can only mean  increasing exposure to potential cancer causing CT scan radiation.

How many cancers are CT scans causing?  Great question.  The study reported in the Archives of Internal Medicine claims that 29,000 cancers will be caused by CT scans performed in 2007 alone, with CT scans of the abdomen and pelvis accounting for just under 1/2 of those future cancers. The younger you are the greater your risk of getting cancer (more years to develop cancer).  Women were disproportionately affected by the risk (2/3) due to the larger number of scans being performed on them.

Here's one scary figure.  The study authors calculate that a one out of every 270  forty year old women undergoing CT coronary angiography will develop cancer.

These numbers are shocking and leave physicians in a catch 22.  With more and more data now coming out suggesting that CT scan radiation exposure  may significantly increase one's lifetime risk of cancer, physicians are left in a no win situation.

Failure to diagnose is considered negligence in our  legal driven medical environment.  If a physician misses a venous embolism in a patient visiting the emergency room and the patient has a bad outcome, the physician will in all likelihood get sued because the standard of care in the emergency room is to do that CT scan.  It doesn't matter how low the probability of having a pulmonary embolism is.  When a bad outcome occurs, the probability is 100% that the CT scan should have been done.  The unknown medical outcome, which is known only after the fact, drives the process of defensive medicine

If John Ritter's wife can sue for 67 million dollars because her husband died of a rare aortic dissection that was missed in the emergency room, only a fool would believe that physicians won't order CT scans to protect themselves from perceived negligence.  Only a fool would believe physicians won't order CT scans to prevent missing a diagnosis that the American public and the legal community wants you to believe is negligence, no matter how low the probability.

In America, the standard of care is zero tolerance for failure to diagnose.  You can thank the legal driven blame game of American medicine for creating impossible standards which can only be upheld by irrational medicine.  Medicine which is practiced in the possible zone instead of the probable zone.

Here's how I see this playing out in the future. CT scan use will actually increase dramatically because of the legal climate in which we practice.  Here's why.   CT scans will eventually come with informed consent warning patients of the risk of cancer from CT scan radiation exposure. With informed consent, the rate of CT scans will actually increase as physicians see patient refusal as their way to protect themselves.

Physicians will simply recommend a CT scan for everyone ( no matter how low the probability of finding something wrong)  and let the patient sign the refusal papers.  That way, the physician is protected from negligence failure to diagnose.  If a bad outcome occurs because the CT scan was not done, the physician can place blame on the patient.  If the patient gets cancer because of a CT scan, the physician can point to the informed consent signed twenty years prior.

It seems silly but this is the only plausible solution for physicians caught in the middle of a legal climate ready to blame them for not ordering CT scans as well as the harm that comes from the CT scan radiation exposure.

This is the ultimate patient centered model of care.  You want to be in control of your medical destiny Mrs. Patient.  Here's your chance to accept the consequences of your actions.

Tiger Woods Video Game New For 2010

Check out the newest Tiger Woods video game coming to stores in 2010.  It's the next greatest offering to add to your  Tiger Woods video game collection.

Watch the video.