E-day

While walking back from work this evening, something struck me as being remarkable. I spent an entire day seeing patients in my clinic from 9 AM to 5 PM without once needing to use a pen! And I realized that because I forgot to carry a pen with me this morning and didn't miss it once in the day.

Many hospitals and clinics are incorporating electronic medical records including charting and prescribing. Notes are completely electronic, communication between nurses, front-desk staff and physicians is via electronic messaging, referrals and prescriptions are also e-scribed and e-signed. With the security of a provider's password, a lot of important communication and therapy is taking place. It didn't strike me as amazing till I realized that I didn't need to sign a single prescription or hand-write a single instruction note for a patient today. Everything was printed and/or sent electronically.

While it makes health information relatively easier to access and circumvents the need to develop special skills to decode physicians' scribbling, there is almost always an excess of documentation and mandatory tags that follow the note that sometimes buries the real essence of a physician's note. The Center for Medicare and Medicaid (CMS) has announced special incentives for practices and clinicians who demonstrate "meaningful" use of EMR. It is believed that it will make documentation lighter (no paper), cheaper in the long run (perhaps), more transparent, increase sharing among different providers that in turn can decrease medical errors and deaths. For instance, when seeing one of my geriatric patients who has moderate dementia and does not remember his or her allergies, EMR makes it almost impossible for me to prescribe a medication he or she is allergic to. Without EMR, a provider who missed reviewing the allergy list on some specific page of a thick paper chart could easily prescribe a medication that can eventually lead to wasteful emergency room visits and unnecessary admissions. That is one of several ways in which EMR hopes to reduce medical errors and improve health care delivery.

One of the cons of EMR for physicians is the learning of computer skills and smart ways to document efficiently. For some, EMR documentation may need them to stay longer at work in the evening. Also, it may result in lower patient satisfaction if the physician seems too busy with typing on the computer as he or she speaks with the patient, and this may ironically result in lower online 'health-grades'.

Best city to live in?

I am definitely not talking of Philadelphia, in the suburbs of which we currently reside. I am presently attending a national conference in Vancouver, Canada, a place I have heard a lot about, but am getting a chance to experience first-hand only now. In fact, other than the United States, this is my first entry onto foreign soil. I have not even started the tourism around here, but I already seem to like the vibes I am getting. Neat and clean, friendly people, great downtown and restaurants. I do not hear much about crime yet, but I am sure it cannot beat Philadelphia and Camden, amidst which we are nested currently! In fact, Vancouver and neighboring Calgary are among the best cities to live in according to several sources I have read. Forbes in 2008 ranked it number 4 (with a quality of life index of 107.4) behind Vienna, Zurich and Geneva, and it is the only North-American city in the top ten.

So far, I was impressed with free luggage trolleys in the airport (unlike $5 ones at Newark), $70 rental for 4-days on our mid-size car (unlike $70 for one day in Detroit, America's car city) and from medical standpoint, far less visible obesity than many places I have been to. I haven't picked up on the nuances of the Canadian accent yet, but the personalty of the city and its people have impressed me much. More later!

One Last Wish

"You want to be connected to this machine though you may never come off it or be able to talk or eat anything?" My patient connected to a ventilator and with multitudes of wires and connections all over her body, looked me in the eye and nodded her head. I looked at her in frustration and bafflement.

This was a patient of mine who was in the Intensive Care Unit (ICU). She had extensive lung cancer which had spread to other areas of her body. Her best survival at this point was 6 months, only if she remained free of infections. Yet, she wanted to remain attached to the ventilator, and did not want comfort care or end of life discussions. I was unable to understand her need to being awake with an uncomfortable machine connected to her, not being able to eat, not being able to talk, and living in a nursing home. 'Such people are a complete waste of resources', I fumed inwardly.

As we frantically searched for a ventilator facility to transfer her to, she developed more complications - an infection of her bowel, potentially needing surgical evacuation. The surgeons we consulted balked at the thought of operating on this patient with such a poor prognosis. They recommended medical therapy and we prayed that the infection would wall off with the antibiotics we were giving. Through all this my patient had to bear multiple abdominal exams on an exquisitely tender abdomen, multiple CT Scans, nutrition through deep IV lines and their changes. Once again, end of life care was approached as we were skeptical she would pull through. The family of my patient, comprising of 5 sisters and a brother staunchly supported her decisions. And my patient, through all this, while mournfully staring into my eyes each day as I examined her, remained strong in her wishes to remain on the ventilator machine.

One day, I noticed a man sitting at her bedside and a wan smile on her face. I had stayed late that day and asked the nurse next to me who the man was. The nurse told me that it was my patient’s boyfriend who visited her everyday at this time. After he left I walked in and asked my patient somewhat brusquely: "What does he think seeing you in this condition everyday?"

She signaled to me to get a sheet of paper and in rambling handwriting wrote: "That is my boyfriend of 18 years, whom I can’t imagine a life without. I have had this cancer for 5 years but I came here because I could not breathe anymore on my own. I would have died if you had not placed me on this machine. I know I can’t make it on my own. By staying on this machine if I can get to see my love even one more day, then it’s worth it. I am not ready to leave him just yet."

I was sobered. I felt apologetic about my attitude. Even as I tried my best to get her to a ventilator facility, my thoughts were more mature. Young physicians like us sometimes forget that people are complex individuals and they have a personality beyond their disease. The reasons behind human decisions are manifold, some of which we don’t necessarily understand. Our job is not to coerce patients into our way of thinking or disagree with their decisions, but to continue to make our patients as comfortable as they can be. Just as we respect the wish to die and provide comfort care for people with a terminal diagnosis, we need to respect those who want to fight death and live beyond all reason.

Jai Ho!!!

Hurray! He did it! A billion prayers answered. An Indian composer wins the prestigious Golden Globe best composer award for the first time. It's ARR's tribute to India and Indian music. I was lucky to catch the live presentation of the 66th annual Golden Globe awards on TV last Sunday and all the anticipation ended in jubilation. I was so proud to see the entire audience, the who's who from Hollywood and from other film fraternities around the world, give an impromptu standing ovation to our "Mozart of Madras" as he walked up the stage to get his award. And then each time a Slumdog nomination or award was announced, the inspirational song "Jai ho" played in the background.

I would not say that Slumdog Millionaire is Rahman's best work. It very well ranks with the top music he has produced in the last 15-16 years. But he needed this film to catapult himself and India to a global level of recognition. In fact, in the 2 days since the GGs, I have heard at least 4-5 people I work with, actually evincing interest in his work and talking about his music for the film. I think that is simply remarkable. Soon, they will be able to pronounce his name well too! (They called him AR Roman or some such thing at one of the award ceremonies.)

2008 was indeed a fantastic year for ARR. Before we could have enough of one album, he came up with another chartbuster. Jodha Akbar, Jaane Tu Ya Jaane Na, Ada, Yuvvraaj, Ghajini, Slumdog Millionaire... wow! And what a way to start the year! I can see many more awards coming his way in the next few months. An Academy award too perhaps; watch out on February 22, 2008. Another billion prayers for the musical genius please!

And from reading a million news articles on ARR in the last 2-3 days, I can tell you somethings that you probably didn't know:

That Shahrukh Khan was offered the part of Anil Kapoor as the host of the 'Who wants to be a millionaire', but refused because he was busy with Om Shanti Om. He apparently regrets it now! First, he missed Lagaan, and now this.

The award winning song "Jai Ho" was composed by Rahman for Yuvvraaj, as a song for Zayed Khan's character. Subhash Ghai felt that it did not suit the movie, and agreed to let ARR use it for Slumdog instead.

Mallfluenza

That's right! Fatigability, severe joint pains, headache, dizziness, feeling of impending doom.... I had all these symptoms this afternoon as I returned home after a 4-hour shopping mall outing with my wife. I believe the 'pleasurable' excursion was long overdue, and we were initially excited to find what great deals everyone has been talking about. But what a way to begin a year!

Just entering a mall, any mall, small or big, causes some blurring of my vision. All covered with artificial lighting, a really jarring combination of colors and styles. The miles and miles of walking and turning into aisles. Don't even ask about the pressures of finding the best price between stores and amongst the heaps of clothes, shoes and bags. The irritating banners all over the place, one bigger than the other; but each less informative than the other. One said: "all items $4.99 and up", with the latter two words in small print, about 1/100th of the size of the first three. Another shouted: "Up to 80% off". Then the BOGO scam: Buy One Get One deals. I sincerely sympathize with store managers who arduously scale up prices to 200% one day prior to the sale only to give the gullible shoppers half-off. And if you're finally done with your selections, at the check-out counter, would they ever forget to ask you to enroll for their credit card if you want another 15% off? One generous lady even wanted my e-mail id so she could send exciting offers about the latest bath and body products. I courteously declined.

All this prompts me to go on the internet for all my shopping needs and urges. Already, I shop for electronics, books, some groceries and sometimes shoes and clothes online. You can often make the best decision in lesser time, be certain of good quality by reading customer reviews before purchasing, compare prices at different stores and have it delivered at home comfortably.

Memsahib

"First impressions are lasting impressions". Or perhaps, "Don't judge a book by its cover". From our first experience at this Indian restaurant in Baltimore, MD, the second statement wins handsomely. As we strolled through the streets of Inner Harbor Downtown looking for a nice place to dine, we were not greatly impressed by the shady streets and parked old cars around Lexington Street. But a first-rate experience awaited us when we least expected it.

The usher-waiter was genuinely courteous. The seating was splendid and comfortable, the decor inside was ethnic and soothing. The menu at dinner was exquisitely unusual. You get to choose one of two starters, one of three main course options, one of two dessert options, then tea and papad. No extensive looking menu-cards like some other places where you get different vegetables in similar tasting gravy. I don't particularly remember what I liked the most, but the bhelpuri, the nan (bread), the kheer were all very well-made. And then we felt like eating some yoghurt (not on the menu), they got me some just like that, and did not even bill for it! To top it off, they had a huge display screen (check the picture below) that streamed some of the latest Hindi film songs, that more than quenched my thirst for Bollywood chartbusters. Overall, easily the best Indian dining experience in the USA so far for me. So don't forget to include it in your travel plans to Baltimore.

Nutrition and Malnutrition

From being Indian, the only malnutrition I knew is protein-caloric under-nourishment with kwashiorkor, protruding bellies and skinny, sickly limbs. But from living in America, the only malnutrition you need to know is protein and caloric overloading, protruding bellies and oversized hips and thighs. It is omnipresent, almost taken for granted. Less known is the fact that obesity has the potency to kill like cancer from smoking does. The current generation will be the first in history to NOT outlive their parents.

Last week, a 44 year-old male patient in the Intensive Care Unit succumbed to death after suffering from a fever of 101-103F for 15 days. He had an abscess on his buttock that was being treated with multiple antibiotics. There were 6-8 specialists on the team who were trying to decipher the source of his fever, day after day, week after week. He was on the lung ventilator, heart monitor, urinary catheter, feeding tube, peripheral intravenous and central venous lines and several cooling blankets. His 'numbers' kept creeping downward, with his kidneys, heart and liver also showing signs of deterioration. We could have sent him to a University or tertiary center for multi-disciplinary care. Why were we all so helpless? It was his weight: 520 lbs. He wouldn't fit inside any CT scanner in the area. Not in our hospital, not in our city or the state. Perhaps only 2 machines are available to accommodate such a size in the entire US: Mayo clinic, MN and some South Carolina university hospital. We even called the Philadelphia Zoo to find out if they had a scanner they used for large animals. Finally, due to our inability to determine the cause of his fever, we had to let him go. Each of his last days was a mixture of hope for a miracle and despair and frustration, for the family and the medical team.

You probably know that 66% of US is overweight (defined at Body Mass Index >25) and almost half of those overweight can be classified as obese (BMI>30). Here are some startling facts about obesity you might not know:

In 1963, the average 10-year-old American boy weighed 74 lbs; girls 77 lbs. Today, the same boy weighs 85 lbs and the same girl weighs 88 lbs.

Obesity is linked to the top 10 causes of death, depression, absenteeism (school and work), lower marriage rate and lower income potential.

Only 2% of children consume a “healthy” diet (as defined by the US Department of Agriculture) on a daily basis.

25% of American teens drink 4 colas a day!

20% of all ‘vegetables’ consumed in the United States are french fries and/or potato chips.