Wednesday, February 24, 2010
Conflics of interest prevent AMA from accurately representing physicians' views
Saturday, February 20, 2010
Thinking about starting a rural hospitalist program?
- Only administrations that appreciate physician billing as a small component of determining success of a program will survive. If your administration believes that physician billing is the most important sign of success and they make their decisions accordingly, the program is doomed to failure.
- Don’t under staff. Many programs try to skimp by. When one doc leaves (and they will), it puts the others on the road to burnout real quick. If you can’t fully staff with enough physicians plus buffer for growing pains and the quitters, then start the program part time. Perhaps no weekends or no nights. Whatever, if you don’t have enough physicians to run the program, it’s doomed to failure from the start.
- Be flexible. The larger your pool of candidates, the more successful you will be in starting the program.
- Keep lines of communication open between docs and administration. Hospitalist jobs are everywhere. Administration in rural America must understand that they don’t run the show, the docs do. Why? because the docs can leave and land a job just about anywhere they want. It’s a buyers market for hospitalist medicine. It will be for quite some time. We are only getting started.
- You’re going to have to pay more than you think. It’s rural. And it’s hospitalist. Think big.
A Hospitalist’s Lament
Thursday, February 18, 2010
Stress Testing
Monday, February 15, 2010
Discontinuation of Mechanical Ventilation
- Adequate gas exchange (e.g. PaO2/FiO2 greater than 150 to 200; level of positive end expiratory pressure (PEEP) less than 5 to 8 cm H2O; FiO2 less than 0.4 to 0.5; and pH greater than 7.25);
- Hemodynamic stability as defined by the absence of active myocardial ischemia and the absence of clinically significant hypotension (i.e., a condition requiring no vasopressor therapy or therapy with only low-dose vasopressors such as dopamine or dobutamine, less than 5 mcg/kg/min); and
- Appropriate neurological and muscular status allowing the capability to initiate an inspiratory effort.
- Arterial oxygenation saturation less than 85-90 %
- PaO2 less than 50-60 mmHg
- pH less than 7.32
- Increase in PaCO2 greater than 10 mmHg
- Respiratory rate greater than 30-35 breaths/minute
- Respiratory rate change over 50%
- Heart rate greater than 120-140 beats/minute
- Heart rate change over 20%
- SBP greater than 180 mmHg, or
- SBP less than 90 mmHg
- Blood pressure change greater than 20%
- Vasopressors required
- (e.g. somnolence coma, agitation, anxiety)
- (e.g. use of accessory respiratory muscles, nasal flaring, paradoxical breathing movements)
Friday, February 12, 2010
Rheumatoid Arthritis Decision Tree
Conditions That Can Adversely Affect SMBG Results
Conditions That Can Adversely Affect SMBG Results
Condition | Outcome |
Patient has poor hygiene. | Failure to wash hands before testing or keep the meter clean can commonly cause errors18 as well as potential contamination.10 |
Test strips are not specific to the meter in which they are used. | A mismatch between meter and strips will produce inaccurate results.10 |
The expiry date on the test strips has passed. | Outdated test strips can produce inaccurate results.10 |
Test strips are exposed to humidity, high temperatures, or strong light; test strip container is left open. | Humidity and high temperatures can deteriorate the enzyme on the test strip that interacts with glucose to produce the result, producing a falsely elevated number.19 |
Test is done at high altitude. | Can adversely affect results, particularly in low temperatures.20 |
Patient does not assess accuracy of new meter or test strip batch using control solution. | The patient should test each new meter and each new package of test strips with control solution. Prescriptions should include control solutions as well as meters and strips.10 |
Patient does not properly calibrate meter as required. | Patients must properly calibrate their meters for each new set of test strips.10 Coding errors can produce inaccurate results that can in turn lead to insulin dosing errors.21 Alternatively, patients can be advised to choose meters with automatic calibration, which significantly reduces the possibility for these types of errors.21 |
Patient has variable hematocrit levels (eg, smokers, patients living at high altitudes, dehydrated patients, or patients with sickle-cell anemia, polycythemia, or end-stage renal failure).15 | Abnormally high hematocrit can artificially depress the glucose result; abnormally low hematocrit levels can artificially elevate the glucose result22; this occurs because the higher concentration of red blood cells blocks the plasma from adequately diffusing through the strip layers.10 |
Patient is receiving a treatment containing a sugar (eg, xylose, maltose, icodextrin, galactose). | Test strips that use the enzyme glucose dehydrogenase pyrroloquinolinequinone or glucose-oxireductase can give falsely elevated readings in patients who are also receiving treatments containing other sugars.23 In rare instances, this has caused death and has been the subject of an FDA warning.24 Not all glucose meters use this enzyme, and the test method used is identified in the package insert for the glucose strips. |
Patient is taking acetaminophen, ibuprofen, ascorbic acid, dopamine, L-dopa, methyl dopa, tetracycline, ephedrine. | These substances (among others) can potentially influence the reliability of blood glucose test results.10 |
Expected Decreases in A1C, Advantages & Disadvantages of Glucose-lowering Medications
- Januvia (sitagliptin)
- Glucotrol and Glucotrol XL (glipizide)
- Diabeta, Glynase, PresTab, Micronase (glyburide)
- Amaryl (glimepiride)
- Chlorpropamide
- acarbose (Precose)
- miglitol (Glyset)
- Tolbutamide
- Tolazamide
- exenatide (Byetta)