Fruits Of Our Labors (Picture of the Spoils of Victory!)

Here's a picture of the fruits of our labors.  Well, not really my labors.  This was all Mrs Happy's laboring.  And we have the fruit to prove it with this gifted assortment of fruit from Edible Arrangements and this cute newborn breastfeeding pose.  

How Fast Does the BiliBlanket Work? Not Fast Enough!

What is a BiliBlanket and how fast does it work?  The BiliBlanket is a special light vest that newborns wear 24 hours a day if their bilirubin levels get too high.  Somehow, it accelerates the elimination of bilirubin from the baby's body.  In the old days, you just stuck an orange baby in the windowsill.  These days, you order a BiliBlanket and have a home health care nurse come out every day for a weight check and bilirubin level.  

Thinking back to my medical school days, bilirubin is a byproduct of metabolism from the breakdown of hemoglobin.  It is metabolized in the liver and can be excreted through stool (as direct bilirubin) or water soluble indirect bilirubin (peeing it out).

Jaundice of the newborn is very common.  Often the jaundice (the orange color as a result of a build up of bilirubin in the body) resolves on its own as the newborn baby's immature liver catches up with the metabolism.   End stage alcoholics turn orange because their liver is incapable of metabolizing bilirubin and their levels rise in the blood stream and take up shop in the skin.  That's why you give them lactulose to make them poop out their hepatic toxins when they get encephalopathic.  It's the same concept for jaundice of the newborn.  

 But why do babies get jaundiced after a couple of days?  Bilirubin is eliminated by stool and urine.  Often premature babies are too weak to maintain a stable and rising weight and are unable to keep ahead of the bilirubin elimination needs.  So being an underweight or premature baby is a risk factor. So is bruising.   Our Zachary had  a big bruise (Mrs Happy pushed him out in the occiput-posterior (OP) position, without an epidural) on his head. Yikes! His blood reabsorption couldn't be handled by his immature liver while trying to metabolize the breakdown of  fetal hemoglobin that kept him going inutero.  

Often, as is the  case with Zachary, with an elevated bilirubin, the newborn will fall asleep at the breast and will be unable to maintain a stable and rising weight.  In the case of Zachary, that means we continue to finger feed him.    Mrs. Happy gives him ten minutes on each breast and then cuts him off to prevent him from expending unnecessary calories in a diminishing return of calories to effort ratio.  Then she pumps for an additional ten minutes while I feed him 30 cc (one ounce) of her previously pumped milk with my finger in his mouth to simulate a nipple.  

He's now seven days old.  His April 21st, birth weight of six pounds twelve ounces bottomed out at six pounds, two ounces, a drop of nine percent.  He has now gained 4.5 ounces in the last three days.

His BiliBlanket was started Tuesday, April 26th at a bilirubin level of 17.4 after an April 25th level of 16.5.  What's dangerous about bilirubin?  If the levels get too high, bilirubinemia can cause long term central nervous system damage called kernicterus (I'm thinking back to my second year of medical school here). 

Our levels have dropped steadily in the last three days.  Was it due to the BiliBlanket or just a maturing liver?  Who knows.  I do know that Blue Cross Blue Shield pays for a home health care nurse and the BiliBlanket therapy and daily lab draws.  They are currently requesting all health care records from the midwife clinic for the entire pregnancy and are refusing to pay for progesterone levels drawn in October of last year that were drawn to guide progesterone therapy during Mrs Happy's pregnancy because the   ICD code used was  ovarian dysfunction.  This is a common code for infertility and they don't pay infertility benefits under our plan.   

I'm pretty sure they're going to lose that position  as being pregnant constitutes a state of fertility.   Oh yeah, and they claim to have a "back log" in claims. Six months?  Give me a break.    The only loser here is the lab waiting for their payment.  Makes we want to follow my own HSA tips and rack up a healthy serving of FREE=MORE now that my $3500 deductible has been fully met for the year and I have zero copays for all services for the rest of the year, including medications.  Maybe I'll even get that MRI of my back for good measure as a way to say thank you for processing all our claims in good faith.    Maybe now is a good time to go back and get another 50 treatments of electrical stimulation shoulder physical therapy to max out my 60 visits a year that I am allotted.  It turned out I had a posterior labral tear.  Of course, they are all medically necessary.   Because, you know.  Everything is medically necessary.

After three days of being tied to an electrical outlet for 24 hour BiliBlanket jaundice therapy, Zachary's level dropped from 17.5 to 14. 5 to 12.5 and he is now free to roam around the home as of a couple hours ago.  

I felt like we were running a make shift hospital at our home. Here's a picture of the home health care nurse getting the bilirubin sample from a heel stick. In case you were wondering, I didn't ask her if I could take her picture, and she didn't seem to mind.  

All things considered, we have a health baby boy with ten fingers and ten toes and he's so dog-gone cute.  I feel greaty empathy for the parents who feel trapped by their newborn's illness that prevents them from being free.  I can't even imagine trying to manage newborn ostomy covers and bags.  Now that would take the patience of a Saint.  

Newborn Breastfeeding Pose (Cute Picture) of Zach Having A Big Mac Attack.

It's not every day you get to see a cute newborn breastfeeding pose. We caught Zachary here at one day old eating what we think he thinks is a Big Mac.  It's a Big Mac Zach attack.  We'd better be careful though.  Before we know it, we'll have a Zachary collection of   before and after fast food pictures.

Looks like I've got a little education to do on my hands.

Hospital Photo/Picture and Video Policy For Patients: Snap First, Ask Questions Later

Now that smart phones have become a natural extension of most Americans,  phones that can take a picture or video on the go  and send it out instantly  to social networks such as Facebook and Twitter or email them to hundreds of contacts in just a few seconds, I found the hospital that Mrs Happy delivered in asking for a little  courtesy in return.  Or is it?

I took lots of pictures and videos at the delivery.  It never once occurred to me to ask anyone for permission to snap pictures and video in our room if an employee happened to be in a spot I was trying to photograph. 

What do you think?  Is it etiquette to ask or is getting photographed just part of the job in hospitals these days.  Patients have HIPAA.  What do employees have?  Or should they need anything at all?   I wouldn't mind getting photographed or videod.  It wouldn't even occur to me to care about it.

Wall Mounted Hospital IV Pole Falls, Cracks Open Richard Wallace's Head In Indianapolis Hospital.

The hospital is a dangerous place.  I point you no further than to the wall mounted hospital IV pole that fell on 74 year old patient Richard Wallace, causing a life threatening intracranial hemorrhage at St Francis hospital in Indianapolis, Indiana.    

The injury occurred as the patient's bed was being raised, causing the head of the bed to push an infusion pump right off its wall mounted IV poll and fall on the elderly man's head.  This is but one more example of the many known and unknown dangers lurking in your hospital.

Who would have thought that wall mounted hospital IV poles could be so dangerous?  The hospital says they have now switched to the free standing hospital IV poles. Of course, you trade one potential mechanism of injury for another.  These free standing poles can just as easily tip over without careful evaluation.  

If you really dig deep and think about the whole scenario, in many cases, having the wall mounted hospital IV pole fall and critically injure the patient is probably the most humane way to die in this day and age of doing everything, for nothing.

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.

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

How Do Italian Greyhounds Do With Newborn Infants and Kids?

Marty and Cooper have been with us for almost eight years.  Last week, we welcomed the newest addition to our family, Zachary.  How do Italian greyhounds do with newborn infants and kids?  Italian greyhounds are a sensitive breed.  They get their feelings hurt quite easily.  They need lots of love and attention.  So it didn't surprise me that they were a little depressed the day we brought Zach home.  

But as you can see in this next day picture, they quickly bounce back.  Marty is known as our hugging Italian greyhound.  Nothing has changed, except that now our Iggys have to share the real estate with Zachary.

That's OK.  There's plenty of room for everyone.

Here's another picture describing how Italian greyhounds do with new babies (cute!).   For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

Dirty Diaper Early Warning Detection System (Picture)

Mrs Happy and I are in the process of training Marty and Cooper to be our dirty diaper early warning detection system. We're almost there.

Hospitalist Xtranormal Video: Good Nuggets of Humor at a Sick Hospital

Here's some good Xtranormal humor about being a hospitalist at a sick hospital. Hospitalists who allow this to happen to themselves have no one to blame but themselves.  Remember, you are a hospitalist.  The hospital is going to need you more than ever to survive the economic tsunami coming their way.

This is how not to run a hospitalist program.

brought to you by Sick Hospital.


Click on this link here for other gut busting  Xtranormal medical videos (and non medical too).  

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.

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

Three Little Sleepy Heads: Italian Greyhound With Baby Zach (Picture)

Handicap Bathroom Rating System Redefined (Picture): The Bariatric Rating

America's handicap bathroom definition has officially left the train depot for the next station. In America, we are entitled to life, liberty and the pursuit of happiness.

Oh yeah, and bariatric rated bathrooms. I snapped this picture of a bariatric rated "handicap bathroom" at the hospital Mrs Happy delivered Zachary

A part of me feels for folks who struggle through life outside their home in search of a toilet adequate enough to do their thing. Bathrooms and toilets simply aren't made to hold the weight or size of 300, 400 or 500 pound people and neither are the hospital toilets.

Part of me wants to believe these bariatric rated bathrooms are for the oversized pregnant women on the floor. But the rational side in me knows otherwise. America is fat. And we have the bariatric rated handicap bathrooms to prove it.

Next stop: Braille toilets.

Happy's Little Easter Egg

Here's Zach at 2 days, 4 hours, 32 minutes and 12 seconds old.  

Mrs Happy and I decided he's thinking about what the heck he got himself into. I've got a picture at 2 days, 4 hours, 32 minutes and 56 seconds I took that I'll share next.

Who Is The Happy Hospitalist?

Zach wondered after all these months.

I'm sure there are some good bedtime stories about The Medicare National Bank in there somewhere.

Welcome Happy Zachary To The World. Our Third Bundle Of Joy

Happy Zachary was born April 21st, 2011 at 1:01 pm at 37 weeks. 6 lbs 12 oz. 10 fingers and 10 toes and hungry as a horse.
Before Zach at just under 37 weeks

After Zach at 37 weeks

We can't wait to get him home to play with his two big brothers, Marty and Cooper. We are thinking about signing out AMA.

Fourth Year Rotations To Take In Medical School To Prepare for Internal Medicine or Hospitalist Medicine Career.

A second year medical student reader asked me to comment on what rotations to take in medical school to prepare for an internal medicine or hospitalist medicine career.

I am a second year medical student, very interested it practicing the art of Hospital Medicine, and I was wondering if you had any advice/comments on any specific electives to consider to help prepare me for an Internal Medicine residency.

Great question.  As is standard in most medical schools, your third year will be defined for you with a nice healthy serving of clinical rotations in bloodless surgery, pediatrics, internal medicine, obstetrics and gynecology, family medicine and psychiatry.   If your education was anything like mine, you will have some limited elective options within each core curriculum clinical rotation.   They are first come first serve as spots will be limited.  Don't stress too much about these options.  Anything will do. 

But your fourth year is filled with electives of your choosing.  What is my advice for picking clinical rotations in your 4th year if you are planning on doing an internal medicine residency in preparation for a career in hospitalist medicine?

1. Radiology.  It was a "posh" rotation in my day.  But you still get to see some crazy stuff like the tortuous aorta,  severe scoliosis and  bilateral hydrophrosis, from a foley catheter.    Plus, you'll get pretty good at reading chest x-rays.   You won't read your own CTs and MRIs in the real world, but you can get a good sense of what you're looking at on rounds and you can impress all the nurses who will think you're smarter than you are as you scroll  up and down through the images while consuming food and drink at the nurses station.  Image is everything.  Right?
2. Electrophysiology cardiology.  Why EP cardiology?  At my institution, as a fourth year medical student, I got to "read" every EKG in the entire hospital for an entire month.  I saw some pretty unusual EKG/ECG patterns during that month.  To this day, I still remember nuggets of info that I carried past my internal medicine residency into my life as a hospitalist. For example, sinus tachycardia does not need a beta blocker.  Ever.  
3. Gross Anatomy.  This had to be one of the hardest educational experiences of my life, as a first year.   Nothing can prepare you for the incredible  onslaught of information you have to pack into your brain in that first week of medical school.  As a fourth year medical student, deeply inflicted with medical student syndrome, our 4th year elective gross anatomy rotation consisted of looking at a cadaver for three days and then writing a paper about the experience.  Come to think of it, I never did get that paper written.  To this day, I still can't figure out how I got an A that month.  Oh, yeah.  Everybody got an A.  Now I remember why I played golf that month.  
4. Rheumatology.  It helped that Happy's rheumatologists were pretty smart.  I gained a new perspective on horses and zebras.  I learned to never ask for an inpatient rheumatology consult because, as you'll soon discover,  the answer is never lupus.  I discovered fibromyalgia is all in your head.  Oh wait, that was from my family medicine rotation.  All the rheumatologists make it very clear that fibro is outside their scope of practice.  Systemic fibromyallergia?  Now that's a disease  for the hospitalist to tackle.  
5. Anything outpatient.  Doesn't matter what you do.  At all costs, avoid lengthy inpatient rotations where you're in the hospital until midnight every night.  Why?  Because all your fiends did and they're at the bar hanging out eating chicken wings while the ID doctor finds great joy in pimping you about the appropriate treatment for a UTI at 9 pm on a Saturday night.  Stupid Happy.  Stupid Happy.  Stupid Happy.  What were you thinking?  If that happens to you, feel free to suggest choramphenicol as the appropriate treatment, but only after you've matched in your residency slot.  Now that your residency work hours are restricted to banker's hours, there's no need to abuse yourself.  If you want to abuse yourself, volunteer to shadow a surgical intern and offer to do all their grunt work when you're done by noon on your Mon-Thurs dermatology rotation.
6. Dermatology.  Speaking of dermatology, I know of no other field where you only have to remember two medications: a steroid cream and an antibiotic cream.  If you remember this advice, you'll get an A+.  Plus, if you become a hospitalist, you'll understand why any inpatient dermatology consult will alway's result in the same answer.  If it's wet, make it dry.  If it's dry, make it wet.  In either case, they'll get an order for a  steroid cream and an antibiotic.  
7. Research.   Remember, you're paying tens of thousands of dollars in tuition to play golf that month.  Make every round your best round ever.  You might even be able to deduct your new golf clubs as an educational expense.  Though I'd talk to your accountant about that first.  This is not tax advice.  But it is medical education advice. 
8. Do a second month of research.  Your handicap has a few more strokes to go before the big spring scramble.  
9. Take a month of sick leave, or get pregnant and take a month off for maternity leave.  I think both, if they aren't already, will be available to you by the time you become a fourth year medical student.  Because you've been working too hard for two years and America thinks it isn't fair.  

That should cover all your months for you.  Any questions?

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.

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

Attitudes About Psychiatry? There's a Poll For That.

Some psychiatrists want to know your attitudes about psychiatry, psychiatrists and psychiatric patients. Go take their poll through the link provided.   As a hospitalist, I'd have to say, many of my admissions have at least one psychiatric diagnosis and many  have a stable supratentorial process that helps define their infratentorial hospital presentation.  And our medical-industrial complex is not equipped, funded or trained to mesh the two together.  Me included.   Not even close.

Make Sure You Keep Your Patients Satisfied

at this week's patient centered Grand Rounds presentation where you'll find the best of the Internet's medical offerings.  

Common Sense Quotes: I Heard A Good One Today

Here's a great common sense quote I heard today.

Common things are common.
Rare things are rare.
Common sense is rare.

What happened to all the common sense in this world?

There's plenty more where that came from.  

Quote Junkie:  Enormous Quote Book: Over 3000 Quotes From Several Hundred Of The Most Famous People In The History Of The World




On a side note, I've also been told by a partner of mine that this book below is a must read.

Heaven is for Real: A Little Boy's Astounding Story of His Trip to Heaven and Back

Does Medicare Pay For An Ambulance Transfer? Yes And No, Only If...

I learned something the other day about Medicare and coverage for ambulance transfer. Did you know that Medicare will pay for medically necessary ambulance transfer from the hospital to a skilled nursing facility,  but they'll only pay for the first twenty miles.  At least that's what I was told. 

I recently tried to transfer a patient to a nursing home, I mean a skilled nursing facility, but was told the family could not afford an ambulance transfer for their mother's broken hip because the facility was was more than 20 miles away and any mileage past 20 miles would be paid for out of pocket.  So they dumped her into the back of an SUV and off they went. 

I haven't really come across this before. Has anyone experienced this 20 mile CMS ambulance limitation before?

Largest Atrium Ever (We're Talking Heart Here).

Having a big heart is one thing.  Having big atria  are another.  The two atria are the small chambers of the heart, one of which contains the sinus node, responsible for the origination of the heart beat.  When the atrium enlarges, the patients faces a higher risk of sustaining an unfixable atrial fibrillation.

So it doesn't surprise me that my patient in atrial fibrillation had atrial enlargement of 8.1 cm on cardiac echo.    That's huge and it is  probably the largest atria I'll ever see.  For a cardiologist, this is probably a Holy cow moment.  I'm not sure what the urologist equivalent is.  That would be an interesting conversation , none the less.

I'm sure.

Go here for my other record clinical findings. 

Italian Greyhounds Discover the Baby Shower Loot (Cute Video)

Mrs Happy returned home yesterday with a pile of baby shower advice cards and an SUV full of baby shower gifts.  Not more than a minute expired before Marty and Cooper tried to make these gifts their own.  Enjoy this cute video of our Italian greyhounds discovering the baby shower loot.   What did the baby get?

Because the video contains music recognized by YouTube, an advertisement is automatically displayed.  Simply close the ad for full enjoyment.

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

Advice Cards For New Mommy Baby Shower Reveal the Best Advice Ever For New Mothers (and Good Humor Too)!

Mrs Happy went to a baby shower with the local family yesterday. She brought home an SUV full of baby goods for baby Zachary. There was so much baby stuff I didn't even know existed.  I wonder how kids used to survive without all this stuff, that Marty and Cooper were convinced was all for them. 

Mrs Happy also brought home a bunch of  advice cards for the new mother to be. Mixed within the numerous advice cards filled out by all the participants at the shower was probably the best advice card of all. 

What was the best advice revealed from these new mommy advice cards?

Don't rely too much on others advice.  

I don't care who you are. That's good advice and good humor.

For some more really great mom advice humor, visit the classically hilarious Xtranormal video Why I Can't Make Mom Friends.  You'll laugh your head off. 

Snap Into A Slim Jim, For Puppies: $16/Pound For Dried Chicken.

Remember those Snap into a Slim Jim commercials of years past with macho man Randy Savage?  You couldn't turn on the television without seeing his commercials or ring up your total at any big box store or convenience shop without being tempted to buy a couple of those individually wrapped  nitrite sticks.

Well, it looks like America's marketing of immediate gratification has spilled over into the pet world.   I present to you PETSMART's newest fad in pet cuisine:  The individually wrapped, conveniently positioned (in the checkout lane) Canyon Creek Ranch Chicken Tenders dog treat.  They're only  $.99 an ounce.  

I'm just waiting for PETSMART to start their Snap into a Min Pin advertising campaign and roll in the cash selling dried chicken for $16 a pound.

Better yet, if they want to capitalize on America's voracious appetite for immediate gratification and fat, they should market these individually wrapped dog treats as a combo pack with a Slim Jim.    I nominate Randy Savage  together with  Marty and Cooper.  Now that would make an awesome advertising campaign.

Unusual EKG/ECG Pattern (Picture): You Don't See This Everyday.

A  reader sent me this unusual EKG pattern that I'll admit, I've never seen before. Really kind of fascinating.  Any takers on what this unusual ECG pattern is showing us?  The chief complaint was chest pain.

I don't ever remember seeing this example in my travels through learning ECGs.  But if you're interested in a solid foundation, here are your two options.
Rapid Interpretation of EKG's, Sixth Edition
The Only EKG Book You'll Ever Need (Thaler, Only EKG Book You'll Ever Need)

Lawn Mower Rims (Pictures): Aftermarket Chrome Bling (Only Sold In Arkansas, I think)

You know you're a redneck if...

You head out to  buy blinged out chrome lawn mower rims. Now that's a redneck granny with some style.   Next up?  Granny gonna get herself some silver teeth grillz. 

Most Shoplifted Item From Walgreens. You'll Never Guess It...

I'm not sure if this is true or not, or if it's a local phenomenon, but I heard a discussion the other day from a previous Walgreens employee describing the most shoplifted item in their store.  Are you ready for this.....

Hemorrhoid creams and suppositories.

There are apparently a lot of assholes in this world that get rubbed the wrong way.

Medical Student Syndrome Redefined: It's Not What You Think.

Most people think medical student syndrome is the sense of worst case scenario medical students often think about when they experience a symptom related to a disease they may have recently read about.  If you're a med student and you have medical student syndrome, every headache you have is a brain tumor, every leg pain is a sacrcoma and every palpitation is  a life threatening arrhythmia.  

But that's not at all what medical student syndrome is.  Medical student syndrome is the never ending, unrelenting sensation of always doing too much  work and being bossed around on other peoples  schedule.   Happy's hospitalists work with third year medical students doing their internal medicine clinical rotations.  

Here's a comment from a medical student regarding their experience on our rotation. 

This rotation would be better if they let us out earlier. 

 I see not much has changed in 15 years, except, apparently 3 pm is now too late for a day at the medical school office.  

I Can't Hear Anything Out of My Stethoscope (Picture of Failure)

If you tell most old time clinicians that you can't hear anything out of your stethoscope, they'll say you aren't listening.  But I know better.  I know they  don't make stethoscopes like they used to.  I have a Littmann.   It's my second one.  The other one sits dormant in the kitchen cabinets of our new home remodel.  My current stethoscope has been through several surgeries.  It has had on the fly stethoscope repair with a pocket knife after the tubing experienced catastrophic failure.  I also had the  stethoscope eartips replaced after they became cracked and worn out.  The other day, I found myself thinking, I can't hear anything out of my stethoscope.  And sure enough, eartip failure once again.

I'm always amazed at how well these things work, when they aren't broken and just how terrible heart and lung sounds are transmitted when they are.  But I have faith in her.   I think she's got another 20 years left in her.  We'll just have to patch her here and there along the way. 

Home Remodel Before and After 2010-2011 Picture Video Tour (Kitchen-Bath-Dining-Family-Laundry-Office-Stairs)

It has been a long drawn out process, but every thing finally came together beautifully for our home remodel project.  It started out as a partial kitchen remodel and quickly expanded into a full first floor home remodel.  I hope you enjoy your tour through our home with my 2010-2011  home remodel before and after picture/video tour.  

What all did we do?

Laundry room

• new porcelain tile floor
• new door hardware
• all new trim work with corners details
• new hanging cabinet with trim with slow close doors
• new base cabinet with slow close door
• new granite counter top
• new faucet with removable head
• new sink basin
• all new paint
• two new flush mount recessed positional can lights
• Hunter Douglas shade

New "mud room"

• we converted a closet into a coat and shoe depository with custom made carpentry and stain.
• painted walls
• trim work 

Guest bath

• hand scraped engineered walnut wood floor
• new trim with corner details and door hardware
• custom multilevel, multicolored, multitextured, wall paint treatment
• new vanity cabinet with slow close doors
• granite countertop
• granite above mount sink
• modern chrome light fixture
• modern chrome towel and toilet fixtures
• new mirror
• new modern chrome light fixture

Kitchen

• hand scraped engineered walnut wood floor
• all new cherry cabinets with side panel trim, slow close doors and drawers and full extension pull outs
• black straight line door handles
• separate above and below cabinet LED lighting on separate dimmer switches
• six new flush mount recessed positional can lights
• granite counter top with lots of movement
• new granite composite deep, single basin sink with chrome inlay
• new garbage disposal
• new faucet with removable head
• new center island with lots of cherry cabinet storage and granite counter top with etched edge
• all new stainless steel appliances
• trim work around window
• Hunter Douglas window shade
• individually artist signed Italian hand blow glass pendants above island with gold and silver inlays
• broom closet built-ins
• all new paint for walls, trim and doors
• Hunter Douglas shades for French doors

Family room

• same wood floors carried through out
• new stone fireplace
• stained and glazed existing mantle
• all new trim with corner details, 
• repaired sewer pipe
• new door hardware
• new flush mount ceiling fan
• new paint throughout
• new window treatment with Hunter Douglas shades
• new recessed positional can lights 

Hallway/Stairs

• Same wood floors
• all new banister with dark stain, metal/cooper toned ballisters.
• new carpet (previously installed)
• New wall paint and trim work
• New smoked glass entry way chandelier
• new bronze colored hallway lights.

Dining Room

• Artistically painted ceiling with multiple layered tones and textured glaze and LED lighting on a dimmer switch.  
• new paint and trim work with corner details
• New silk drapes around windows with Hunter Douglas shades
• New carpet (previously installed) with water proof antibacterial pad.

New Blogging Office

• new ceiling fan
• new paint and all new trim with corner details
• new carpet (previously installed) with water proof antibacterial pad
• new window treatment with Hunter Douglas shades

Second floor Hallway

• all new paint and trim work with corner details and door hardware 

Plus, I changed out all the light switches with flat sliding on-off switches and all new face plates with hidden screws.  I only shocked my self two or three times.  I learned how to use craigslist and I discovered how expensive the home remodel trades could be.  

It was a long way getting there with lots of dead time spread out over many months.  We changed our minds frequently.  We didn't start with an end in mind.   But here we are.  It's the end.  For now.  We couldn't have asked for a more peaceful tranquility to raise Zachary  and any other babies, adopted or otherwise, that find their way into our home.  I'm blessed to have Mrs Happy as my wife and two angel puppies, Marty and Cooper, looking over us.  

In just about a year, we will be Graced with a brand new grade school just three blocks from our humble home.  We have no desire to move for many years to come.  A wonderful thanks to our designer for an incredible job well done.  He did it all, from start to finish.  And a wonderful job it was.

For anyone living local to Happy, if you're ever in the market for a home remodel, no matter how big or small, feel free to give me a ring or hunt me down at the hospital.   He does it all.  Whether you're looking for a design idea or a full install from start to finish, you won't be disappointed.    I think these pictures speak for themselves.  Enjoy my home remodel before and after 2010-2011 picture video tour

What Is a Physic? Don't Know? Ask Your Grandma, Not Your Doctor

Patients teach doctors every day.  For example, do you want to know what a physic is?  Don't ask this doctor.  Ask your grandmother.

Elderly woman: I haven't had a poop in three days. I need a physic tonight.

Happy:  What's a physic?

Elderly woman:  What's a physic?  How old are you?

Happy:  I just turned 18.  Just kidding.  I'm 38 years old

Elderly woman:  Oh honey.  You're too young to know what a physic is.  Ask your grandmother.

Happy:  I took a year of physics in college, but what is a physic?

Elderly woman:  It's something to help you poop.  Your grandmother would know.

Happy:  Alrighty then.  A physic it is.  I'm going to write an order for a prn physic.

Several minutes later:

Happy: Can you order a physic for the lady in 12 before she goes to her room?   I'm thinking a brown cow enema will do.
Doctor: What's a physic?

Just another one of your typical 3 am hospitalist admissions with Happy.  Still don't know what a physic is?  Ask your grandmother.  What ever you do, don't ask a doctor or nurse.  I suspect even the pharmacist wouldn't know. 

I can appreciate how the lingo changes with time.  What used to be CHF is now acute hypoxemic respiratory failure secondary to acute on chronic systolic heart failure.  Give it 20 years.  There will be no doctors or nurses who know what "CHF" is.  And we'll have patients walking around with no clue about what they have and how to make proactive decisions to prevent complications.    I guess, in that regards, nothing much will ever change. 

Highest HDL Ever: I Don't Think He'll Ever Die Of a Heart Attack

What's the highest HDL ever?  For me it's this cirrhotic alcoholic who presented with an HDL of greater than 135.

This gentleman's HDL level is "desirable".  The way I see things, there's no need to worry about his end stage cirrhosis with all the life threatening sequela that comes with it.  With an HDL that high, his heart will live forever. 

For most folks, the benefits of alcohol reach a dose dependent level rather quickly.  For this guy, perhaps I should tell him to keep drinking.  It's the only thing keeping him alive. 

Go here for a bunch of other record clinical findings. 

Nursing Home Won't Accept Patients On Sundays? It's Time For Hospitals To Play Hardball.

Anyone who works in a hospital knows  it's darn near impossible to get a hospitalized patient transferred to a nursing home on a Sunday, even if that's where they came from on Friday.   Most of the time, our Medicare patients who can't take care of themselves are transferred to a nursing home so the nurses can do for them that which they can't do for themselves.  Medicare will pay for the room and board of a nursing home for up to 100 days a year if the patient qualifies for skilled nursing facility benefits (SNF).

What does SNF mean? ? It's the 100 day Medicare free pass to the all you can eat nursing home buffet. Once these benefits expire for the calendar year, you have several options.

• Cash in your long term care policy you've been paying on for years
• Time for your family to hide all your assets so you can join the Medicaid National Bank
• Survive at home on your own
• Cough up some cash to go live in an assisted living facility
• Go live with the long lost daughter who shows up on days you hit the jackpot at the Casino's monthly Round Robin Penny Slot Tournament.

Why is it that nursing homes refuse to accept patients on Sundays? I've always been told that they don't have the staffing to accept new SNF admissions on Sundays.  Well, maybe it's time they do.    If I'm admitting patients seven days a week, I should be able to discharge them seven days a week.  That's just good medicine.  Having my patients sit around longer than they need to is expensive, unnecessary and dangerous.

What are some reasons nursing homes won't accept patients on Sundays?

• That their insurance needed to be re-evaluated, even though nothing had changed to prevent coverage. Insurance people don't work Sundays, apparently.
• That they needed their nurse to verify the stability of the patient  even after a board certified hospitalist internist (ME) and a board certified pulmonologist said they were stable for  transfer.  Yes.  A nurse.  A nurse who doesn't work Sundays.
• Theydidn't have staffing for a Sunday transfer. 

Nursing home staffing issues are not my problem.  They are the problem of the nursing home.   Fix your staffing problems or we will eventually find a way to fix them for you. 

All too often my patients will sit in a hospital  all weekend long because the accepting facility does not have reason X, Y, Z to initiate a patient intake process on a weekend or a Holiday.  It's 2011.  Apple gave us the iPad.  It's time nursing homes gave us the Sunday transfer.

I'm sure many hospitals all across this country are dealing with the same weekend patient backlog problem  that I do because their community disposition only operates on a Monday through Friday schedule.  It's time we put an end to that ridiculous standard.  It's time we play hardball and do the right thing for our patients.  Any ideas?

Gas Prices Are Out of Control (Gas Pumping Video)

Gas prices are out of control. I took this video of myself pumping gas on April 7th, 2011. I paid just under $4.15 a gallon. I don't imagine the average American's budget will tolerate such an insult to their budget.  The last time I paid this much for gas, America was in the depths of its greatest recession in 50 years.  Not much has changed, except that gas prices are back where they were when we started this economic disaster that has no end in sight.  

Disney Family Car Decals (Cute Picture): Where Do They Find The Time To Have Sex?

Mrs Happy and I saw this display of cute family car decals with the Disney mouse ears the other day on the back of a family truckster. The only thing I could think of was, where do they find the time to have sex?

And who can afford Disney with seven kids?  Get your own Disney family car decals if you so desire.  

Heart Failure 30 Day Readmission Barriers: The Dude Just Wants Some Salt For His Eggs

This was a classic moment of comical clarity that only comes along once a week.  As you may or may not know, starting in 2013, The Medicare National Bank has promised to take back 1% of all  of a hospital's total Medicare revenue (to increase in future years) if the hospital has a higher 30 day readmission rate for  congestive heart failure, acute myocardial infarction or pneumonia than an as yet undefined acceptable 30 day rate of readmission.

What does this mean?  It means if the government decides that 20% is an acceptable rate for congestive heart failure 30 day readmission, and the hospital has a readmission rate of 25%, the hospital will be told to return 1% of all Medicare revenue for the year, not just their heart failure revenue.

Let's use some hypothetical numbers, shall we?  If a hospital generates $250 million dollars in a year on 25,000 Medicare discharge diagnosis related groups (DRGs)  but only 100 of those discharge DRGs (or $1,000,000) were heart failure in 2013, what would happen if 21 CHF patients returned for readmission  (a 21% thirty day readmission rate) within 30 days for heart failure instead of allowable 20%? The hospital would have to return 2.5 million dollars (1% of their total revenue on all Medicare admissions).  

That one patient that took them from 20% to 21% will cost them 2.5 million dollars.  The hospital would generate one million dollars in CHF  revenue for the year and pay back 2.5 million dollars in penalty.  That's a pretty hefty price to pay considering that hospital profit margins from Medicare have been negative, on average, for most of the last decade. 

Perhaps the question that needs answering is how do we keep that 21st patient from returning to our hospital to ruin everything?  Is it going to be this patient that I actually saw once?

Happy:  You're here with congestive heart.  You have too much fluid in your lungs and we need to help you pee a bunch to get it out.
92 Year Old Demented Guy eating his breakfast:  Can I get some salt for my eggs?

I couldn't stop laughing at the irony here.  This demented old guy just wants to eat his eggs in peace, with a little salt, of course.  He's ended the hospital stay as a full code, despite all compassionate attempts to guide the conversation toward reality. 

Yet, if there are 21 of these 92 year old demented guys living in my community, who love to put salt on their breakfast eggs, and The Medicare National Bank only allows us to have twenty of them, each one of these congestive heart failure men and women are going to cost my hospital $125,000. They will never be able to stay out of the hospital. 

So, what's the solution? 

1. Place a local 10,000% community tax on salt. 
2. Pay the family thousands of dollars to put grandpa into a hospice program.
3. Transfer all heart failure patients to other hospitals. 
4. Change the DRG to "Acute Hypoxemic Respiratory Failure" instead of CHF
5. Implement a large community tax on the  elderly.  Call it the ex-lax tax.  Maybe we can get them to move somewhere else and make them some other hospital and community's problem.  

I think any one of these solutions will do.   Others?

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.

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

Italian Greyhound Wagging Tail to "I Love You Guys" (Cute Video)

Cooper, our seven year old Italian greyhound, loves to hear us say "I love you guys".  Here he is wagging his tail every time I say those words.  For pet lovers, this is cute.  For people who don't like dogs, please disperse.  There's nothing to see here.  

 

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

Handicap Parking Space (Picture): Doctors Acting Badly at the Hospital.

One of my biggest pet peeves is to watch a car occupy a  handicap parking space parked there by someone who doesn't respect their fellow handicapped citizens enough to make sure they follow the rules of etiquette.  

I saw this car parked in a physician spot of a secured entrance parking garage at the hospital.  I saw this car parked here when I arrived at 7 am and I saw it parked there in the same position when I left at 5 pm.  For over ten hours, this individual obstructed a handicap parking space that prevented a disabled individual from accessing the handicap parking spot.  

Whom ever you are,  shame on you.   For other posts about handicap issue

• Handicap bicycle racing (picture)  (Cool!)
• Handicap parking permits for sports cars. 
• Handicap parking spot FAIL! Picture

Straight Cath vs Clean Catch: Don't Waste My Time With Bad Urinalysis Data

After eight years of hospitalist medicine and seeing inaccurate urinalysis results day after day, year after year, I've come to the conclusion that the straight cath vs clean catch debate is not a debate.  If the urine didn't come from a straight cath, I have zero faith in the accuracy of the results.  

I know, I know.  It takes time and effort for a nurse to perform the straight cath.  It's not comfortable for the patient to have a catheter inserted into their urethra.  Plus, with bad nursing technique, one could introduce bacteria into the bladder when performing a straight cath urinalysis.

All that aside, if I'm a physician trying to make medical decisions based on accurate data, then having bad urine results that don't represent the true picture is worse than not having any data at all.  For example, here's a classic case of what I have to deal with day in and day out when trying to make medical decisions on my patients.  Below is a snap shot of three UA results obtained from Happy's ER over two visits.  I'm sure it's the same no matter where you get your care in this country.  The first two urinalysis results came from a clean catch sample of a horribly weak 89 year old female who presented with family complaints of "fever and weakness", both days.  

There are several issues going on here.

1. The patient  got sent home from the ER on Day #1 with a diagnosis of UTI based on a horribly inaccurate clean catch UA.  The final culture returned a verified contaminated sample (greater than three organisms present, which means the sample was too dirty to be interpreted with any accuracy. )
2. I was asked to admit the patient on D#2 for "weakness and fever" after the patient  presented to the ER for the second time in less than 24 hours.
3. I asked that the third urinalysis be performed in the ER as a straight cath sample after eight years of knowledge that clean catch urinalysis is about as accurate as diagnosing a pulmonary embolism on a chest xray.

Ultimately, I showed that this patient did not have a UTI.  In fact, they had a DVT, that I diagnosed in the ER after removing the knee high wool socks the woman was wearing. Just one of the physical exam findings one can find when you properly prepare the patient for exam by taking off their socks (or shoes, or jeans for that matter).   

I have had many moans and groans over the years from nurses questioning why I need a straight cath urinalysis on my 45 year old schizophrenic we are asked to see in the psych floor with "abnormal UA", or the confused 84 year hanging out in the dementia unit with agitation.  

From now until eternity, if I ever have a nurse question why they can't just do a clean catch vs a straight cath, I'm going to refer them here, to my nonrandomized, highly scientific N=1 case presentation.  Or tell them to show me they have received extra training on how to obtain a clean catch UA.  Because the training they currently have isn't cutting it.