Let us put the dialysers out of business

Never occurred to me why when we talk of Heartmate 2 and all that chutzpah, is there no such implantable device for the kidney.

Cleveland Clinic gets $3 million to create artificial implantable kidney

Maybe there might be an implantable MARS system for the lliver too!!

F.D.A. Studies Band Surgery for Less Obese - NYTimes.com

Interesting read about bariatric surgery in the NYT.

F.D.A. Studies Band Surgery for Less Obese - NYTimes.com

Think of the symptomatics-anyone who is obese and has symptoms- OA I guess is symptomatic obesity, or OSA- which everyone will have. So then suddenly 1/3rd of all Americans, including all those brobdignagian American football stars will qualify. Of course there is no debating the lack of a middle path- weight watchers and surgery are 2 extremes. One often feels stuck when managing obese patients who have no quick fixes than disciplining themselves. Lifestyle change often is a life changing event and not many want or are able to do that.

We know about the effect of bariatric surgery and the resultant weight loss on not just medical problems- I mean imagine coming off diabetic medications-, but also factors like mood- improving depression, as well as paradoxically, an increase in suicide risk!! But have you read the fine print in Love Bailey on dumping syndromes and other miscellaneous post gastrectomy complications?!! People do not appreciate how dramatic the weight loss can sometimes be- I have taken care of people who eat 1 cracker for breakfast, 2 for lunch and a few sips of juice for dinner which consists of a few raisins!!!! And lose 1o0 lbs or so in few months. One of my colleagues once presented a case of Wernicke's encephalopathy in a patient after bariatric surgery- aptly titled as "loss of weight and loss of gait" because the patient would just not eat anything at all. Surgical complications exist of course, and quite often the obese with COPD, OSA, CAD, CHF are poor candidates for surgery anyways given all the end organ damage which has already set in. One is stuck thinking as to where to start to remedy this lardaceous mess. I guess addressing it before it assumes gargantuan proportions is an option....but then...suddenly everyone's in. It is tricky ground..one has to loop before taking this leap of faith.

Technology Can Get Freaky | MakeUseOf.com

Wonder what wireless fidelity might be?!!

Technology Can Get Freaky | MakeUseOf.com

Classic Gas

Saw the most awesome X ray I have ever seen- 40 something guy with MR and hydrocephalus who keeps swallowing air. Also gets opiates for an ankle fracture and is immobile from it. So guess what shows: a hugely distended stomach, small bowel distended as well; colon is at least 20 cm in size with a Chiladiti sign.

It sounded like the Rime of the Ancient Aviator:
Air , air everywhere, and all our planes did float
Air air everywhere, watch his belly bloat!!!!

Obviously I cannot reporduce the image due to privacy concerns etc- but it is coming at a journal near your library soon.

equanimates

How the morbidly obese lady who wore skin hugging jeans 4 inches below her Brobdingnagian rump and ringlets of gaudy colors tearing her pinnae apart ,and wetpaint for lipstick with jello in her hair and 12 inch high heels became a sorrowful, troubled, aching, short of breath person who sighed and panted to breathe her bellows to carpopedal spasm and funny perioral feelings; and sighed and fluttered her eyes, depressed her lateral canthi to convey a 9/10 pain that was sharp and localized to her tender chest wall and came from the heart.

How this transition happened once she wore the peekaboo hospital gown , how she donned the sickness role of a troubled soul whom misery had struck a machete on after disability had sapped the energy off , seemed clear to me when, once "ruled out"- this perversion of American medicine- she got her percocet, dressed up, painted her nails, took her cellphone and hollered, " Sebastian, get your f#@*ing ass here to fetch me."

Simbly put.....

"How the hell can you see 70 admissions in a day", Debangshyu exclaimed

"Abbe you did medical school in Delhi na?"

"Woh to we used to present cases and get our term completion done through friends. Koi ward shard work nahi kiya"

My first experience at "floors" in a typical hospital in the US was with Dshyu who oriented me to other culture shocks including rounding by the podside and not the bedside, dispo decision making pushed by case managers, the mirth of Dilaudid, the christianity of equating pain management with deliverance from suffering, nursing homers and other gomers.

"You get capped at 10 for the day?" I had exclaimed. Solid maja hai babu.....I had thought. Kaamchoron ka desh hoga.

A couple of years later I was on the other side,dressed in scrubs and an unnecessarily long apron/labcoat, stetho stylishly strung around syringomyelic shoulders, specious wrinkles on my forehead complaining that "no, I cannot take a fifth now"

Dr Terry was amazed too, like Dshyu- how can you take 70 admissions in a day. (As was Gawande when he wondered in his NEJM article about how a general surgeon could see 36 patients in 3 hours)

I had to tell them that admitting 70 patients with one ailment, with one page HPI and one page orders, no 15 line past medical history and EMR to dig records from, other hospitals to get records faxed from, no baby boomers seeking immortality and no oligocerebral nonagenerian grandaunts of HuffPo/Grey's Anatomy educated smart grandnieces with every joint fixed every coronary stented, every nephron dialysed and every orifice scoped into made it infinitely less work than the 10 of the above kind I admit here.

Yeh kya hai- MI, fir-lepto, uske baad- OPC poisoning, next malaria, next - stroke, PICA; agla- interesting hai- cord case; next- woh bhi clinic ke liye rakha hai VSD/PS. And kone wala HIV as usual with crypto men. He has cutaneous crypto- thats interesting too.

Pneumonia was simple CAP, troponin leaks were probably missed because you don't follow a set and treat initial presentations, cardioembolic stroke from Rheumatic valvular heart disease was at least 1-2 per admission and monsoon masala with Crystalline Penicillin, Artesunate and /or Doxycycline made things so easy.Of course, there's zillions of miles to go- if only there were more resources.There were situations where you just held your hands or grit your teeth in frustration for a life lost and how little you tend to value it, or not give attention to when you have to see such large numbers of people everyday. But as Gawande observed from an outsider's eye,it is still a victory of sorts given the odds. I would like to see what a doctor from the west would have done in Nanded.

Like watching a movie on bioscope I always used to think that one person always had one ailment and there was nothing around that influenced how I as a provider needed to remedy him/her of that single ailment. And then life goes on. I thought that this was an extension of the law of parsimony or Occam's razor to the general way of life and order of things.

But like this case from the NEJM shows, this thought process restricted my vision to within the bioscope. Why would I even look for drug induced lupus when I have temporal arteritis to satisfy my diagnostic nosiness and keep my maaz quiet. Why ever with the former system of tending to the basic complaint would I even bother if an ANA sticks its nose out obnoxiously.

Well if you have the tests to play with, (and the monetary fortitude to order them)- it is a different story. I need to reeducate myself that a person with MAC pneumonia can have Wegener's granulomatosis and HNPCC and liver disease related to HBV which also caused PAN related stroke and a neuropathy, heroin related nephropathy, Arnold Chiari malformation besides a Klippel Trenaunay which is poor last one on impressive the PMH list. All these were diagnosed by different specialists at different expensive insurance/Medicare billed visits- whatever could be upped fixed nipped tucked stapled opened up or closed is done. And now the patient comes to see me!!

If I use what my older system of training taught me- treat what the patient comes to you for, I might get ticked off for ignoring all this excess baggage that the person carries. Billing, after all depends on the number of diagnoses you put in. Again, I need to rule out PE somewhere, rule out MI some otherwhere; have to write a 4 page HPI, get records from other hospitals, contact family, discuss code status, print out ordersets for DM, ACS, heparin ordersets, look at the huge medication list to see what we can keep and what we can omit and finally call all the guys who did the hardware and wiring previously as well to consult.

Thats equal to 10 patients in back home.I think what I want to do- treat what the patient comes in for - should have been done before all this piled up.No one would have faulted me for keeping things simple, so you wouldn't have had to build that big resume of PMH and ordered that ton of investigations and dictated lengthy dictations which one needs to rummage through now.

The wisdom of life consists in the elimination of non-essentials. The consumption society has made us feel that happiness lies in having things, and has failed to teach us the happiness of not having things.It is truly a joy to focus on one thing at a time, not having to build an absurdly lengthy list of differentials and work up to rule out numbers 10-11 and 12 on that list. And it is a joy when life behaves that way . But that is, or may not be the truth. Rules of common things occurring commonly might not necessarily be true when you confront the individual patient who says that chest hurts. It depends on how you want to heed those rules.

Now: House: Each one of these conditions is about a thousand to one shot; that means that any two of them happening at the same time is a million to one shot, Chase says the cardiac infection is a ten million to one shot which makes my idea ten times better than yours.Get a calculator run the numbers."

Chase: "We'll run the tests."

In another world, in another time: "Every human being is the author of his own health or disease" ...so the Buddha tweeted.

To say no....

Posting a link to a recent article from the NYT. I like the point of giving the people all the information- they are more likely to say no if they know.

It is always so interesting to read the Comments btw.