Administering high doses of drugs like Epinephrine, Atropine, and Vasopressin has become the standard of care for Advanced Cardiac Life Support. In theory, it makes sense to “jump start” the body by giving extra-high doses of stress hormones. We all know of a case or two when the patient “came around” after some Epinephrine or Atropine. How much evidence is behind this practice? Not too much.

According to the paper published in JAMA, IV drugs during life support do not improve long term survival (survival to hospital discharge) or the neurological outcome. Short term survival (survival to ICU admission), though, was better when IV drugs were given.

Is it really surprising? Not if you think about it. If it takes an industrial dose of stress hormone to bring somebody back, the degree of the physiological derangement is likely too profound for the patient to survive to discharge. Unless there is an identifiable and correctable cause of the cardiovascular collapse, IV drugs, no matter in what doses, will unlikely change the outcome. Giving IV drugs might buy you some time to try to stabilize the patient, and that would be the argument to continue the current practice.

This is a single-center study with all it’s inherit limitations. More evidence is needed before the change of practice is considered. Meanwhile, the business as usual – push those drugs to jump start the body.

Several Physician Types You Might Encounter in the Hospital

The Hospitalist movement is a relatively new development, yet it is becoming increasingly popular. Hospitals of every size are introducing hospitalist programs to provide inpatient care. Even though, there are multiple benefits to having a hospitalist team in your institution, there is one obvious drawback – the patients, for the most part, are unable to choose the treating physician. Instead, the patients are usually randomly distributed at the morning report. From a patient perspective that means that they will get “stuck” with whoever is on that day.

There are several types of inpatient physicians that I have encountered in my practice.

Here they are:

The Academician
This physician has a tremendous amount of theoretical knowledge and is able to give you a lecture on any given topic in medicine. Unfortunately, all this knowledge does not always translate into good patient care. The “human aspect” of medical care often irritates and annoys these physicians. This type of doctor does better in an academic practice.

The “Nerd”
This doctor enjoys his/her work and strives to provide excellent care for the patients. He is always excited to talk about an interesting medical case or problem. This type of a doctor tends to overmanage the patient by trying to address every single issue before discharge. For this reason, the patients often stay longer in the Hospital since “there is just one more thing to fix before they go home”. In general, the “nerd” spends a lot of time in the patient room and is often being involved in conversation not directly related to the patient’ medical condition. This takes a lot of time and often makes for very long rounds for this doctor.

Mr/Ms Efficiency
This kind of a doctor knows what he or she is doing and tends to concentrate on the most important issues. If the patient is admitted with pneumonia, there is no reason to order an MRI for chronic back pain since it could be done as on outpatient. This type of doctor tends to redirect the conversation with the patient while taking the medical history. Sometimes, it is necessary to interrupt the patient if the conversation is going nowhere. Despite all of this, the patients usually are quite satisfied with their care since things are being done quickly and efficiently. The patients are in and out of the Hospital which is good for the patients and the bottom line.

The OCD
This Doctor takes everything personal. Unexpected adverse outcome might cause a significant amount of stress for this physician. Patient care is excellent but at a cost of personal distress and even marital problems for this doctor. This doctor is always late to leave the hospital which adds even more problems. There is always something going on and the inability to flip the switch and go home makes this physician miserable.

The “Lone Ranger”
This kind of a doctor is suited best for working night shift. Routine rounding and interaction with the patient and the family is not his thing. If the hospitalist program has one or two of those physicians, developing a nocturnalist program may be a good idea.

The Slacker
This type of a doctor is simply dangerous. The physician does not really know what he or she is doing and doesn’t really care. The notes are often unreadable and pretty much useless. It’s a total nightmare to assume care of the patient after this physician signs off the service. Often, the patient will tell you more about what is going on than the sign-out from this doctor. The patients are often kept in the hospital longer just so that somebody else can discharge them once this doctor is off the service.

These are just a few “extreme” types of the doctors you will encounter in the inpatient setting. This “classification” is based on work ethics and attitude towards patients. These are not meant to address doctor’s personality traits. Doctors, like everybody else, could be classified as whiners, complainers, angry type or even psychotic.

In reality, most of us represent a mix of the types described above. We all have a little bit of everything (yes, even lazy type) and different parts of our personality come up depending on the circumstances. Well, it’s like that saying: “Nobody is perfect”.

A 60 year old male with a known history of metastatic renal cell cancer was transferred to our hospital with an intracerebral hemorrhage. He had known metastatic disease to the brain and developed a DVT. He was started on Lovenox for anticoagulation and proceeded to bleed into one his brain lesions. I thought this posed an interesting question about what is the evidence regarding anticoagulation in the setting of brain mets.
The current recommendation IS to anticoagulate DVTs in the setting of primary brain tumors and metastatic disease that has a low propensity to bleeding.
In order to discern which metastatic diseases have a low propensity to bleed, it is easier to state which have a HIGH propensity to bleed: melanoma, choriocarcinoma, thyroid carcinoma and renal cell carcinoma. If a patient is suffering from brain metastases from one of these conditions and develops a DVT/PE, the recommendation is to not anticoagulate these patients and to place a permanent IVC filter. Some authors have stated that if there is a single brain lesion associated with one of the above cancers and that lesion is resected and the person develops thrombosis then aspirin should be used.
In the above mentioned patient, the literature would not have supported anticoagulation in this patient. In the end, this patient did received a permanent IVC filter. He does have some visual field defects associated with his cerebral hemorrhage.

Recently a women in her late 40s presented to our hospital with a complaint of reduced exercise capacity and "heavy legs". Her only medication was her birth control pill. Her evaluation revealed a large thrombosis that orginated in her IVC just below the level of the renal veins and extended down into both of her femoral veins.
It is well documented that oral contraceptive pills (OCPs) increase the risk of thrombosis in women. Oral contraceptives are one of the most commonly prescribed pills the world and I think it is worthwhile to review what the risk of thromobis is.
There is no hard and fast data to say exactly how much OCPs increase the risk of thrombosis. Hematologists I have spoken with say that there is an increased risk that increases with age. Obviously there is an even greater risk in women with thrombophilia. Meanwhile there is certainly no evidence that every women who wants to use an OCP should have laboratory testing for thrombophilia. We also know that this risk increases with tobacco abuse.
Of course there are also many benefits of OCPs including desired birth control and reduction in ovarian cancer.
Overall I think we need to be reminded to advise our female patients of the risk of thrombosis with OCPs. We need to do a thorough personal and family history to look for anything that might suggest a thrombophilia. We should also be ready to investigate these women when they complain of anything that might suggest they have developed a thrombus.

I have an idea how to save billions of dollars in healthcare costs. Start serving alcohol to selected patients while they are being treated in the hospital. I am being absolutely serious. Every day I am seeing patients developing complications from alcohol withdrawal. Usually, the patient is admitted for a scheduled or an urgent surgery. Many patients tend to understate their level of drinking, and on a day 2 – 3 after the admission they go into an alcohol withdrawal. Alcohol withdrawal is not a mere inconvenience. It could be quite severe. Many patients end up being admitted to an Intensive Care Unit. Some patients could even have seizures. Going into an alcohol withdrawal will significantly prolong the hospitalization and will increase the cost tremendously. I figured, that if I am taking care of at least one patient a day, on a national level it will add up to billions of dollars.

You might ask: “So, now we are going to have drunk patients in the hospital?” Well, yes. For many patients who drink alcohol on a daily basis, this becomes a “requirement” for a normal functioning. Some people could even be productive while being…you guessed it – drunk. Alcohol withdrawal, in contrast, could be a severe or even lethal condition. I saw people trying to jump out of the window while going through Delirium Tremens (DT). It is not unusual to require five or six people to hold a patient in DTs down while a sedating medication is being administered. Sometimes, despite an industrial dose of sedatives, we have to put the patient on a ventilator and administer sedation via a continuous infusion. So, to answer your question, I would rather have a “drunk” patient than a patient going through DTs.

Not all the patients should be offered alcohol while in the hospital. It should only be given by a physician order, just like any other medicine. Careful screening and thorough examination will be performed by an admitting physician before the “need” for alcohol is determined.

The concept of “prescribing” alcohol in the hospital is not new. In some places it is still being done. I once asked an older Dietitian about it. The answer that I got was quite surprising. Apparently, we used to give patients alcohol, but stopped doing it. Guess what was the reason? Not what you might think…we just didn’t have a good variety of beverages to suite every taste.

Have you ever declared a patient dead after a prolonged resuscitation, just for the patient to “come back” the moment you stop CPR? It happened to me once when I was a resident.

An elderly patient with severe emphysema was admitted for a COPD exacerbation. He was getting progressively less responsive after he was taken to a medical floor. The patient was likely retaining CO2 leading to a carbon dioxide narcosis.

Eventually, his heart stopped. The code blue was called. CPR was initiated. The breathing tube was placed. The patient was bag-ventilated by a respiratory therapist. The patient was being resuscitated according to ACLS protocol. Pulseless electrical activity (electrical rhythm on a monitor with an absence of heart beat or pulse) was noted on a monitor. Twenty to twenty five minutes into the code – there is still no pulse.

The patient was pronounced dead. CPR was discontinued and bag-ventilation was stopped. A few seconds later – the patient still had a rhythm. What is even more shocking, he had a thready pulse. Resuscitation resumed and he was transferred to ICU.

So, what happened?
Reviewing this case later, we came up with the conclusion that the excessive bagging during the code caused air-trapping in the patient’s lungs leading to a significant Auto-PEEP(PEEP- positive end expiratory pressure, or residual pressure in the lungs after an expiration) and increased intrathoracic pressure (pressure inside your chest). This significantly diminished venous return to the patient’s heart and precluded him from regaining a pulse. Once he was disconnected from the bag, the pressures in his lungs equilibrated allowing for his heart to fill with blood.

In the rush of the moment, nobody noticed that he was being overzealously bagged by the respiratory therapist. Patients with emphysema require a prolonged expiratory time and tend to trap air if not allowed to exhale completely. Excessive bagging can cause air-trapping and Auto-PEEP.

Since then, I often ask to slow down bag-ventilation during a cardiac arrest to allow the patient to exhale by the elastic recoil of the chest.

The patient above did not do well and the family decided to withdraw care.

Modern technology and suicide

Initially, it did not sound like anything unusual. Another patient had tried to commit suicide. The unfortunate combination of an exacerbated depression and loneliness around the holidays and the availability of prescription medications, lead this unfortunate patient to try to end his life. He took multiple tablets of Vicodin (pain killer with opioid analgesic and Tylenol) and Clonazepam (sedative, anxiety medication).

What was unusual about this case is that the patient had, actually, sent his girlfriend a text message with his intentions to commit suicide. His girlfriend acted very promptly and contacted the police.

He was found at home laying in bed. The patient was unresponsive and had shallow breathing. A breathing tube was placed by the paramedic. In the emergency Department the patient was noted to have a very high Tylenol level indicating a massive overdose. The appropriate antidote medication was started immediately. He was discharged three days later with no evidence of any significant liver toxicity.

This case demonstrates yet another example of how modern technology changes all aspects of our lives. Had this patient not texted his girlfriend about his intentions, he most likely would have been dead. Texting has become so ubiquitous that there is even a concern of driving while texting. Just talking on a cell phone in a car is distractive enough; I cannot image how people can text at the same time.

With a rapid spread of other technology including social media like Twitter and Facebook, I will not be surprised that there will be more changes on how we do things in our lives, or death if you will.