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Messing with my clock again: SPRING AHEAD??? What?

2012-03-11T09:27:00.005-04:00

PGY 39, Day #254
MESSING WITH MY (BIOLOGICAL) CLOCK AGAIN:
Part 2 Spring ahead?

One hundred and twenty-five days ago, they told us to move the clock back one hour, and now they are telling us to move it forward one hour? Makes no sense to me. To whom does it make sense? Is it a business decision? Why do we do this to ourselves, and what should we do to adjust when they "Mess with our BIOLOGICAL CLOCK?

It takes weeks to recover from/adjust to the clock change, and the loss of an hour's sleep. My recommendation is that you go to sleep "early" for several days to weeks, till you notice that your biological clock has synchronized with the change in the mechanical clock. My November 7, blog post (below) explains the fundamentals of circadian rhythm and the references will give you ALL the details.

Have a great day and StepWisely(R).

Dr. Mike

>>Monday, November 7, 2011
Mission: Healing November 7, 2011 Messing With The Clock
PGY 39, Day 129

THEY ARE MESSING WITH MY (BIOLOGICAL) CLOCK AGAIN:
AKA, I am Falling Behind Again

There is a natural rhythm to life and the universe, and that rhythm is synchronized. As a part of that system, animals (yes, including humans) have day-night cycles called circadian rhythm. This rhythim dictates many fundamental physiologic functions ... most notable of which are the day-night/sleep wake cycle.

(Reference link: http://www.nigms.nih.gov/Education/Factsheet_CircadianRhythms.htm)
(For Detailed Scientific Evidence see:The Clocks That Time Us by Moore-Ede, Sulzman and Fuller)

In other words, our natural rhythm, or biological clock is dictated by day and night, light and dark, or, in other words, SUNSHINE! Every time we arbitrarily "change the clock", we are "messing with" COUNTLESS HUMAN BIOLOGICAL CLOCKS, because our CLOCK TIME is NOT SYNCHRONIZED with SUN TiME. That is CRAZY! Why ON EARTH (:-)) would we not synchronize our MECHANICAL CLOCKS with the SUN? Stupid!(?) We have always done it that way? NO ... that is not at all true.

Disregard of facts about our circadian rhythm and the sun might have been excusable 100 years ago, but today, it is absolute nonsense. What effort would it take to keep the clocks all around the world synchronized with the sun? Very little extra effort. What would the cost be? I have no idea, but the benefit, I am certain, would be enormous with regard to human well being and performance.

Who benefits by maintaining the status quo? Frankly, I don't know. It seems as if this clock changing nonsense is just one of those "we have always done it that way" sort of things. Isn't it TIME for us to be SMART about Clocks, Sun rhythm and circadian rhythm? Let's start a move to synchronize mechanical clocks with the sun ... it would be good for our natural rhythm. I think the music would sound better, and, besides, what do we have to loose?
StepWisely(R) and have a good day.

Dr. Mike
PS. IF, there is some reason why machine time MUST be different from SUN TIME, or EARTH ROTATION TIME, then, at least give us both times on every clock.
PPS. And, for the advocates of this clock change nonsense, explain yourself, please!
Posted by Dr_Mike_IHS at 9:25 AM
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Michael F. Mascia, MD, MPH President: Infinity Health Solutions (C)All Material is protected by copyright law
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Mission: Healing January 25, 2012

2012-01-26T00:13:00.002-05:00

PGY 39, Day 208

Take home message: Never ... that's right, NEVER cut corners in health care. The only exception to this rule would be triage in a disaster situation. In that case, resources are allocated to those who are likely to "make it". Surge capacity and disaster preparedness should be a routine part of hospital structure and function, but it generally given lip service and window dressing to save on costs.

Doing the Right Thing: The Right to Do VS the RIght Thing to Do

How many times have you heard or seen the words "I have done nothing wrong" flowing repeatedly from the mouths of those accused of wrong doing? Well, they seem to be fairly common words from my perspective. A Google search today came up with many pages reflecting the frequency of the phrase. Check it out ...

http://www.google.com/search?q=%22I+have+done+nothing+wrong%22&ie=UTF-8&oe=UTF-8&hl=en&client=safari

What are the jokers who spew these words actually saying? My translation is this: "I really don't care what you think, I have no guilt or remorse (I have no conscience), and have not been proven guilty of breaking any law." While it may be a fact that many of these speakers of innocence are not (yet) proven guilty of misbehavior after further scrutiny, or in a court of law, and some may truly be innocent. And, what are they thinking? These folks rarely talk about the thought process that enables them to do things that they have the right to do, or can do, even though they are not doing the right thing. Why the disconnect? No conscience? This common statement of innocence, "I have done nothing wrong", belies the shady behavior that is absolutely wrong, but may be easy to get away with in the dark, or when in a powerful position. If you don't catch them and prove it in the light of day, or in court, they can and do get away with it ... and they will continue their misbehavior till forced by law or others to quit. Hence the need for transparency. I see transparency as a (perhaps poor) substitute for honesty (including intellectual honesty) and integrity, because the later two are so uncommon. In any case, what are these self proclaimed "inocent" people thinking? What kind of examples do these people (in leadership positions) set for the rest of us and for our children? My observations, based upon personal experience, reading and formal training, lead me to several conclusions ... which are simply the start of a long, ongoing conversation on Doing the Right Thing: honesty, integrity and transparency.

To do The Right Thing, or not to do The Right Thing? That is the question. Or, What is the price of your Integrity?

Why is it that so many seem to have difficulty recognizing the difference between right and wrong? Why is this line so blurry? Is it really blurry? Is that a matter of convenience? Is it greed? Why is it that so many seem to think it is OK to do whatever they want, as long as you don't get caught? These are questions that used to perplex me, but not so much any more. The disconnect between word and deed is very common. In fact, this disconnect is so common as to be ordinary, not extraordinary. What is it about? What can be done about it? Let's look a little deeper.

Generally, it is about a lack of personal integrity, and a willingness to cut corners on "the right thing" (ethics, morality and sometimes legality) for personal gain. This is, regrettably, very common. What is the price of your integrity? Will you cut corners to keep your job? When your boss pushes you to do something that you know is not right, are you going to do what he/she says, or risk loosing your job? I have seen this sort of stuff regularly during my years of life and work. Let's look at some examples that I have seen over the years during my medical career.

There is always an "excuse" for the bad behavior!

Example A: Hospital Excuses for Bad and Self Destructive Behavior

Around 1985 there was a malpractice "crisis". In other words, around this time, it became difficult for some physicians to get malpractice insurance. So, when some doctors went "bare", some hospitals went nuts. Driven by fear (self protection) that their own personal assets would be at risk, some hospital administrations and boards refused to change their policies to allow uninsured docs to keep working in their hospitals (wrong) while other hospitals "did the right thing", and changed their policies so that the doctors could continue to care for patients. In this example, "Doing the right thing" benefits the patients and the hospital by allowing patients to be cared for in their own community, and by keeping hospital revenue up to par. So, what is behind the flawed thinking in this case? Fear of personal financial risk originated in the administration and spread to the board of trustees of the "wrong" hospital. So, fear trumped reason and drove the hospital to do the WRONG THING. What else could these "WRONG" hospitals have done? StepWisley(R) and come up with a rational strategic plan for dealing with the problem in cooperation with the physicians.

Example B: Hospital Plunges into Mediocrity to Keep Control; AKA Blowing a Hole in the Bottom of Your Boat to Save the Ship

This is a beauty! Following the malpractice crisis talked about above, the following misbehavior was noted. A hospital administration and Board of Trustees recruited a marginally competent young surgeon from a nearby residency program to lessen the power of the competent, well respected surgeon who routinely filled the hospital with patients. Guess what happened? Young New surgeon (who was an operative from a competing hospital) torpedoed the ship! Ultimately, his efforts failed and he torpedoed himself, but for several months, hospital occupancy was at an all time low. What had been a very busy and well run Non Profit organization was failing, because the Administration and Board of Trustees was unable to work properly, could not support its medical staff and could not accept the proper authority of the medical staff. From that point on, the hospital slipped and ultimately needed a bailout from/merger with a larger hospital about 40 miles away. So, the the local community lost control and quality driven by the local community.

Example C: Department Chairman "cuts corners" and gets away with it

In this example, a Department Chairman walked away from his supervisory role with residents and actually left the hospital while he was supposed to be supervising. This behavior was so outrageous, that it came to the attention of proper authorities. During the investigation that followed, he admitted to "cutting corners" but he was able to slip out of any disciplinary action. How he got out of it, I don't know, but I don't think he ever made that mistake again. The real question is this: How could justify the behavior ... how could he conjure up a thought process that would twist such blatant misbehavior in such a way as to think it was acceptable?

Example D: Hospital Stupified by Y2K ... a prolific excuse for bad behavior among hospital administrators.

This situation was noted when I arrived to take a new position in the Summer of 1999. The preoccupation with Y2K nonsense by hospital administration was so outrageous as to be comical, but it consumed all their energy, and the consequences were not funny. The situation was so bad that we could not get attention for any real front line problems, and that repeatedly put patients at risk. We could not get proper equipment and we could not get the hospital to address any problems. To combat this stupidity, we were forced to take pictures of faulty equipment and we threatened to supply videos to the local TV stations, if they did not take proper action. When the hospital safety officer was presented with our documentation "book" that was prepared for the next JCAH visit, he flipped through it with a stone face and, at the end he said, "Can you loose the pictures?"

Example E: Department Chairman Refuses to Acceopt a Solution to His Problem

Perplexing at best, this guy asked me to help solve a problem that threatened to destroy the integrity of and quality of care in HIS Department. I did the job over several days by working with the entire faculty, came up with a solution acceptable to all and handed it to him in a nice neat package. He then said, "We are not going to do this." Shortly thereafter, he was replaced, and OUR solution has worked smoothly for more than 10 years. What was he thinking?

Example F: Katrina Stories (before, during and after Katrina)

Example G: The "Financial Crisis" Bad behavior today that use the the current financial situation as an excuse

Example H: Department Chairman Doing things "because he can" (get away with it?)

To be continued ...

Mission: Healing January 6, 2012

2012-01-06T09:35:00.000-05:00

PGY 39, Day #189

White Dawning

This morning dawns cold and white,
light snow falling.
Flakes float gently through windless gray skies,
forest's green and brown,
landing gently ...
a thin blanket on frozen ground.
Peering through glass, safely warmed ...
wood stove and hot coffee bring children's laughter,
as they play on my mind ...
catching memories of cool flakes,
melting on my face and tongue.

Have a great day!
Dr. Mike

Mission: Healing December 26, 2011

2011-12-26T22:14:00.000-05:00

PGY 39, Day 178

The Christmas Holiday Vortex was pulling hard this past week, but despite that and the skeleton crew, we were able to stay on TARGET and on task in the ICU. Patients and families were well cared for, and they always appreciate the good care. How can we do it? Focus on the mission ... mission integrity and mission adhesion, facilitated by our team development tools. The message to the team is simple, Sick Patients Take no holidays and there is no room to cut corners on the Critical Care Mission ... EVER ... not for one second of any day ... NEVER cut corners on patient care or patient safety!

A message for PATIENTS & FAMILIES and INEXPERIENCED CARE GIVERS ... before I get into the meat of our work discussion ...

Please, I beg PATIENTS and FAMILIES to make sure their wishes are known, because this work is very intense ... and it requires our dedication to PRESERVATION of LIFE and limb. It is shameful to waste resources on people who do not want us to do our best to fix what we can fix. If you don't want critical care ... PLEASE don't let yourself, get to the ICU. Make sure your family knows you DON'T WANT the hospital and especially ICU care. There is nothing worse from THIS experienced intensivist's point of view than to have families start to waffle on a care plan before a proper therapeutic trial has been carried out. Advanced directives are useful, but they are rare, and they are VERY RARELY SPECIFIC. IF in our best judgment we are carrying out the patient's wishes, let us carry on until we are sure ... absolutely certain that we are doing what is in accordance with our Critical Care Mission. Please don't undermine our mission.
And ... as for inexperienced care givers ... plaese stay out of it. In other words, please leave these decisions to the EXPERIENCED MEMBERS OF THE TEAM. Let the Experienced Providers determine what is a proper trial of care. If you don't know what you are doing, do nothing and get help. If you don't know what you are talking about, say nothing and get help.

This is a reiteration of my big picture teaching this week.

What is the Critical Care Mission?

Preservation of Life, Limb, Organ and Vital Human Functions in accordance with the wishes of the patient, and with the intent to serve the best interest of the patient at all times.

In that context, and in the context of the family, the Intensivist and his team of care givers, must include the family in the team, and should relentlessly strive to achieve the following Goals and Objectives as soon as is possible:

A. GOALS: NOW = UPON ARRIVAL

SIMULTANEOUS and RAPID (within seconds to minutes)

-Resuscitation,

-Preservation and Restoration of

-Perfusion, Oxygenation and Ventilation to

-Optimize preservation of Life, Limb and Organ function

-Recognize and treat coexisting diseases, precipitating illnesses and/or injuries

B. OBJECTIVES:

SIMULTANEOUS and RAPID (within seconds to minutes) EVALUATION & TREATMENT to

1. Optimize cardiac output and end organ perfusion

2. Oxygenate the blood

3. Remove carbon dioxide from the blood

4. Deliver oxygen to Tissues, Organs/cells

5. Remove carbon dioxide, metabolites and toxins from Tissues, Organs/Cells

(organ priorites are a. Heart, Brain/CNS, Lung b. Kidneys c. All others)

6. Diagnose and Treat the Precipitating Illness/Injury

7. Restore Vital Functions and Optimal Physiology (total organism) ASAP (within minutes to hours) to Prevent and Limit Limb and Organ Damage As Much as is possible and as rapidly as possible (minutes to hours)

8. Prevent complications of Illness, Injury and Treatment as much as is possible (from start to finish)

9. Promote optimal recovery and restoration of normal function through rapid mobilization and rehabilitation as soon as is possible.

10. Restore patient to normal, productive and creative life, as much as is possible (To srart As soon as is possible ... and to continue as long as is necessary for days to weeks to months to years), and to help the family throughout this process.

Toward these ends, we have developed a comprehensive set of check lists designed to help facilitate team care of the sickest patients in the care of teams with varying levels of knowledge, skill and experience. Our Check Lists, all part of the StepWisely(R) System include STOMPP(TM) & STOMPPIT(TM) The Strategic Targeted Operations Management for Patient Protection Integration Tools to promote Optimal Patient Care Through Teamwork. This

Comprehensive checklists includes:

TARGETS and GUIDELINES to Promote

1. Family Integrity, Participation, and Protection - FIPPs(TM)
2. Patient Integrity Protection & Preservation - PIPPs(TM)
3. Patient Organ Specific Protection & Preservation Guidelines POPPs(TM)
4. Targets for Organ Specific Protection, Preservation & Treatment Strategies (Generic and Disease Specific) - TOPPs(TM)
5. General for ALL Pateints Prophylaxis - GAPPs(TM)

I have been using these check lists to help keep the care teams on Target for the last few years. The less experienced find them particularly helpful in light of the many distractions that are rampant and increasingly complex. Focus on the patient and on patient safety. When in doubt go see the patient ... don't rely on the record, or the documentation for decision making, but rely on reevaluation of the patient. The less stable the patient, the more time you should spend at the patient's bedside.

If you have questions, or want more details, respond to this blog, or email me @ Dr.Mike@ihealsolutions.com and I will get back to you as soon as I can.

Buona Fortuna!
Enjoy!
Dr. Mike

Mission: Healing December 20, 2011

2011-12-20T08:21:00.000-05:00

PGY 39, Day # 172

ICU Rounds details will follow as the week emerges. A few thoughts will have to suffice for now.

Perfusion is the MASTER of Critical Care ... the MASTER of organ preservation, protection and resuscitation ... the MASTER of healing.

STOP THE MADNESS(TM) Rational Cost Containment
StepWisely(R)
STOMPP(TM) & STOMPPPIT(TM) tools to promote mission adhesion, team development and optimal patient care.

More on the blog as soon as I can get to it.

Think about it and have a great day!

Dr. Mike

Mission: Healing December 12, 2011

2011-12-12T11:19:00.000-05:00

PGY 39, Day 164

Ask the survivor?

It has been know for decades that patients can't survive after traumatic cardiac arrest "in the field" despite the best of care. In other words, if you have an accident or significant injury from any cause, if it is severe enough to cause your heart to stop, and to require cardiopulmonary resuscitation, you are probably dead. And, then there are the exceptions ... the occasional patient who survives, despite the fact that they "should have been dead."

Recently, an article published in one of our medical journals looked at the cost and outcome of treating patients who "should die" as a result of their trauma.

http://www.ncbi.nlm.nih.gov/m/pubmed/21986740/

According to this study, which involved the authors examination of trauma patients' CHARTS retrospectively (after the care was given), of the 294 trauma patients who should have died, only one survived despite treatment (0.3%) and required "long term care". The TOTAL cost of treating these patients was stated to be $3,852,446.65, or $13,103.50 per patient. They considered treatment of these patients to be a "violation" of guidelines and conclude that "no loss of neurologically intact survivors would have resulted had strict adherence to the guidelines been maintained."

Wow ... pretty harsh and rigid conclusions, but are they correct? Not so fast!

Here are my recommendations:

1. Ask the survivor! What is his or her current status?
2. Examine all trauma registries with regard to similar data?
3. Examine all survivors who "should have died" and see how they differ from the group at large?
4. Do a prospective randomized trial?
5. Examine the details of each case identified in the study and determine weather or not any of the care provided could have been improved?
6. What else? I always forget something. Please comment

Medical care should not be wasted on dead patients, but it is precision early care that dictates survival. How many patients were saved and are doing well, because VERY AGGRESSIVE CARE was provided in the field? Scoop and run is probably the best once an airway is established. Despite this "study" my opinion stands: When in doubt, err on the side of life & when you are dead, you are dead. So ... the problem remains ... how to determine death ... and especially how to determine who of the critically injured will die despite the best of care? In the meantime ... until we can answer these questions properly, err on the side of life, so people who have the potential to survive and live a good life don't die unnecessarily.

StepWisely(R) and have a nice day!

Dr. Mike

Mission: Healing December 5, 2011

2011-12-05T11:59:00.022-05:00

PGY # 39, Day 157

During my Family Medicine years, I noticed that a small percentage of the population (5-10%) is HIGHLY motivated to TAKE CHARGE OF THEIR PERSONAL and FAMILY HEALTH & WELL BEING. The Stress Management Workbook was written for these people in 1981 and originally published by Appleton Century Crofts. Since then, many have copied our work (some plagerism, I am sure), but none have made it better. NOW, you can get The ORIGINAL Stress Management Workbook by Aronson and Mascia in electronic format through Kindle books @ Amazon.com for less than half the original purchase price. This is very exciting to me ... to think that this book is now readily available to a world wide audience ... is truly phenomenal.

http://www.amazon.com/The-STRESS-Management-Workbook-ebook/dp/B006BIR5TO/ref=sr_1_2?ie=UTF8&qid=1323101547&sr=8-2

Also, I am happy to announce that David, at Voltage Design

http://voltagenj.com/

is helping to set up chats for those who buy the book. Wow, the wonders of modern technology! To think that you can get this book and support for use anywhere in the world is truly amazing.

If you have questions about the book, or any of my blog posts, feel free to contact me through this blog, or by email @ Dr.Mike@ihealsolutions.com.

Have fun and be careful.

Ciao for now and have a great day.

Dr. Mike

Mission: Healing November 28, 2011

2011-11-28T21:54:00.002-05:00

PGY 39, Day #150

This was a moderately busy week in the ICU. As usual, the tug of the "holiday vortex" and the "game vortex" made it more difficult to get things accomplished. But, let us not dwell on skeleton crews and limited surge capacity. We got the job done, and I am now, again,recovering from lack of sleep for a few days.
Topics discussed on ICU rounds this week included:

1. If you don't know what you are doing, STOP & ask for help.
2. If you don't know what you are talking about, STOP your mouth & ask for help.
3. If you don't know your limits you are dangerous.
4. When dealing with families on matters of life and death, always err on the side of life. "When you put the right things on the menu, patients and families are more likely to make the right choices." You can quote me on that!
5. Hypotension and Shock: Diagnosis and Treatment
6. Supraventricular Tachycardia management in the critically ill patient
7. Traumatic Intraparenchymal Hemorrhage
8. Acute Respiratory Failure from upper airway obstruction: Diagnosis and Treatment
9. Intractable Seizures: Diagnosis and Treatment
10. Brain Protection Strategies and Targets
11. Subarachnoid hemorrhage: Diagnosis,classification, prognosis, Hunt & Hess, HHH Rx
12. Criteria for Nosocomial Pneumonia & Diagnosis of Pneumonia in General
13. Thorazine for fever
14. Breathing & Circulation: Oxygen Content, Oxygen Delivery, Oxygen Consumption, CO2 Production, CO2 Clearance. "Oxygen is overrated & Perfusion is underrated: The importance of perfusion in critical care" you can quote me on that one too.
15. Acute Respiratory Failure: Diagnosis, Treatment, Non invasive therapies, invasive therapies, endotracheal intubation, sedation, analgesia, neuromuscular junction blockade, initial ventilator settings.

Please contact me if you have any questions.
Enjoy!
Dr. Mike

Mission: Healing November 23, 2011

2011-11-23T11:33:00.000-05:00

PGY # 39, Day 145
GOOD NEWS!
FYI
The ORIGINAL Stress Management Workbook by Aronson and Mascia is now available in electronic format through Amazon.

This book, that we originally wrote and published in 1981 is still useful and relevant. The electronic version is a useful addition by making it readily available to a world audience at a low price. I will be working on a New Edition of The ORIGINAL Stress Management Workbook this year.

http://www.amazon.com/dp/B006BIR5TO

Enjoy & Contact me if you have any questions.
Later today, or tomorrow, I will update on discussion topics in the ICU for this week.
Dr. Mike

Mission Healing: November 18, 2011, Children & Their Parents

2011-11-18T18:50:00.000-05:00

PGY 39, Day # 140

My goal for today? Post this DRAFT OF Children and Their Parents for review, comments and criticism. In that regard, I will do what I can do ... as I work through this technology ... bit by bit. And, I do need other eyes to look at this critically and to give me feedback. But, IT as it is in my LOW TECH ZONE does not allow me to post the whole book for reasons that are explained in the PS below.
Nevertheless, if, perchance, people want to BUY this book, I will make it available for purchase ASAP with all proceeds going toward the New Health Development Institute. What is the Health Development Institute? A Non Profit Health Care Organization that I set up more than 20 years ago. Alas, it is time for HDI to be reborn ... perhaps as a Health Care COOPERATIVE?
Ultimately, I expect (with the help of as many people as I can find) we can resume operation of the Non Profit Health Development Institute; originally started as a teaching arm for Patients and Families I served while running my private Family Medicine Practice in Bridgton, Maine before 1989. Always looking for help with to take care of the enormous needs of The People, and the Non Profit COOPERATIVE model is the only one that makes sense to me.
Buona Fortuna e ciao per ora!
Enjoy!
Dr. Mike
PS. OMG, this is much more difficult than I thought it would be. The only way I can put this up here is by going from PDF to JPEG and loading one page at a time as JPEG files. Uggggg! It is painfully slow.
PPS. Maybe some IT people out there can help me figure out a better way.
PPPS. HELP!
PPPPS. Until I get some help it will go up just a few pages at a time ... as I get the time to do this from the LOW TECH ZONE.

Children and Their Parents: A Parenting Guide to the First Six Years
V 1988 Update 2011
Revised 2011
© Michael F. Mascia, MD, MPH© Michael F. Mascia, MD, MPH
A MESSAGE FROM THE AUTHOR FOR PARENTS & OTHERS WHO CARE FOR
CHILDREN
This book is designed to be used in conjunction with your baby's personal physician.
In other words, we do no want you to rely on this text without guidance from a
licensed medical doctor. Also, the author expects that you will seek immediate
medical attention for all emergencies through your local doctor or local emergency
medical services.
With that in mind, it would be wise for the users of this book to:
1. Find a personal physician whom you trust, and who can help guide you and your
baby through this journey called life. Check his/her credentials and qualifications!
2. Know when to get help for an emergency
3. When in doubt, if your baby is sick, assume you are dealing with an emergency
4. Learn the signs and symptoms of a medical emergency
5. Know how to contact and get help for an emergency
6. Further instructions with regard to "Finding and Using Your Personal Physician"
will be found in several locations including, but not limited to:
a. Future editions of CHILDREN AND THEIR PARENTS
b. The NEW Stress Management Workbook
c. drmikeihs.blogspot.com/
d. Other electronic and paper publications based upon & included in the StepWisely
®
System from Infinity Health Solutions & Michael F. Mascia, MD, MPH
ALSO, WE WELCOME ALL FEEDBACK OF ANY KIND ... COMMENTS, CORRECTIONS
AND CRITICISM FROM OUR READERS ARE WELCOME, AS THIS IS A WORK IN
PROGRESS, & IS NOT A FINISIHED PRODUCT.
Thanks for your help,
Dr. Mike
Michael F. Mascia, MD, MPH
Children and Their Parents: A Parenting Guide to the First Six Years
V 1988 Update 2011
Contact: For EMERGENCIES CALL 911, or your local EMS
For information, comments & questions, go to
http://drmikeihs.blogspot.com/
http://www.ihealsolutions.com/
email dr.mike@ihealsolutions.com
https://twitter.com/#!/Dr_Mike_IHS

ATTENZIONE!

REITERATION
DO NOT SKIP THIS PAGE!
Just in case you skipped this message the last time
READ IT THIS TIME!
YES, IT IS IMPORTANT

DO YOU HAVE A TRUSTED MEDICAL DOCTOR FOR YOUR BABY YET?

© Michael F. Mascia, MD, MPH

Mission: Healing November 7, 2011 Inexperienced Provider Tips

2011-11-07T17:38:00.000-05:00

PGY 39, Day 129

For INEXPERIENCED PROVIDERS

If you are new in the ICU, no matter what level of training, medical student, nursing student, new graduate, intern, resident, or just a neophite in the ICU, here are a few pointers that will keep you and your patients out of trouble.
Based upon the following rule: "PRIMUM NON NOCERE" (First Do No Harm) here are your top three rules
1. If you don't know what you are doing, STOP!!!! ... DO NOTHING and ask for help.
2. If you don't know what you are talking about, STOP!!!! ... SAY NOTHING and ask for help.
3. If it is an emergency, CALL FOR HELP, use FIRST AID, ACLS, ATLS and PALS till help gets there.

Ciao e buona fortuna!
Have a nice day.
Dr. Mike

Mission: Healing November 7, 2011 Messing With The Clock

2011-11-07T09:25:00.001-05:00

PGY 39, Day 129

THEY ARE MESSING WITH MY (BIOLOGICAL) CLOCK AGAIN:
AKA, I am Falling Behind Again

There is a natural rhythm to life and the universe, and that rhythm is synchronized. As a part of that system, animals (yes, including humans) have day-night cycles called circadian rhythm. This rhythim dictates many fundamental physiologic functions ... most notable of which are the day-night/sleep wake cycle.

(Reference link: http://www.nigms.nih.gov/Education/Factsheet_CircadianRhythms.htm)
(For Detailed Scientific Evidence see:The Clocks That Time Us by Moore-Ede, Sulzman and Fuller)

In other words, our natural rhythm, or biological clock is dictated by day and night, light and dark, or, in other words, SUNSHINE! Every time we arbitrarily "change the clock", we are "messing with" COUNTLESS HUMAN BIOLOGICAL CLOCKS, because our CLOCK TIME is NOT SYNCHRONIZED with SUN TiME. That is CRAZY! Why ON EARTH (:-)) would we not synchronize our MECHANICAL CLOCKS with the SUN? Stupid!(?) We have always done it that way? NO ... that is not at all true.

Disregard of facts about our circadian rhythm and the sun might have been excusable 100 years ago, but today, it is absolute nonsense. What effort would it take to keep the clocks all around the world synchronized with the sun? Very little extra effort. What would the cost be? I have no idea, but the benefit, I am certain, would be enormous with regard to human well being and performance.

Who benefits by maintaining the status quo? Frankly, I don't know. It seems as if this clock changing nonsense is just one of those "we have always done it that way" sort of things. Isn't it TIME for us to be SMART about Clocks, Sun rhythm and circadian rhythm? Let's start a move to synchronize mechanical clocks with the sun ... it would be good for our natural rhythm. I think the music would sound better, and, besides, what do we have to loose?
StepWisely(R) and have a good day.

Dr. Mike
PS. IF, there is some reason why machine time MUST be different from SUN TIME, or EARTH ROTATION TIME, then, at least give us both times on every clock.
PPS. And, for the advocates of this clock change nonsense, explain yourself, please!

Mission: Healing November 4, 2011 Business of FLU SHOTS

2011-11-04T11:06:00.000-04:00

PGY 39, Day 125
Yesterday I wrote about Flu Shots in my piece about the Business of Medicine

http://drmikeihs.blogspot.com/2011/11/mission-healing-november-3-2011.hthtml

Today, a few more comments on the Busines of Flu Shots

PICKING THE RIPE & LOW LYING FRUIT

Today, I asked Mr. Google a few more questions and this is what I found. It appears as if Walgreens, CVS and Target are all in the BUSINESS OF FLU SHOTS. Walgreens and CVS claim to provide them "every day" with some variation on the language regarding every store.

This looks like an effort to select and pick bits of $$$ (fruit) from the $$$ tree called THE BUSINESS OF MEDICNE. These are the "lowest lying & ripest of fruit" available from third party payers. Of course, the patients would be expected to pay the difference between what is covered and what is charged, except for Medicare.

Think about it, and tell me if I am wrong.

Have a great day!

Dr. Mike

Mission: Healing November 3, 2011 Business of Medicine

2011-11-03T17:11:00.001-04:00

PGY 39, Day 125

Today, I stopped at Walgreens to pick up a few things. As I pulled into the parking lot, I noticed several flimsy signs reading something like ... Free Flu Shots ... in bold. As for the fine print ... if you have Medicare Part B. So, being the curious guy that I am and seeing that I just put the blog up on "FLU SHOTS" yesterday, and, since I had a few minutes, I commenced an investigation ... follow the $$$ and report for the blog. Little did I know that this would end up being quite an exercise. Who am I kidding ... it is exactly the bumbling third party nonsense that I would expect.
First, I buy my stuff and pay for it ... 10 minutes ... a few items ... no problem. Then I go to the pharmacy and ask them about the flu shot. Specifically, I asked for a brochure, which the pleasant cash register lady and asked her how much they cost. She asked, "Do you have medicare?", I said, "No" (do I look that old?) and she sheepishly told me $31.99 while she went to the Walgreen website to find and print the scoop on the inactivated vaccine that they offer.
So, I come home and continue my snooping on the COST of the vaccine and the reimbursement from Medicare part B. First, I ask MR. Google, "What is the cost of influenza vaccine?" and this is what I get ... PERFECTION from CDC! It is the current price list for all vaccines.

http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm

So, the cost for the inactivated Influenza vaccine is a max of about $14/dose in the private sector, but the range is from less than $8/dose to about $14/dose.

Then I check with Medicare to see what the reimbursement rate is for the Flu Vaccine. Good luck with that ... it is a wild goose chase. Check for yourself, and see if you can find what they pay. Let me know if you find it.

http://www.medicareinteractive.org/frames.php?URL=http://www.cms.hhs.gov/AdultImmunizations/Downloads/0506vaccreimburs033006.pdf

Here again, multiple third parties are involved ... $, $$, and $$$ ... caching!

Then I check the Walgreen website for fine print about other insurance. There, availability and co-payments apply and I find that they work with some other third party with regard to the administration of the vaccine. So, let's guess they make $5 - $ 10 for each dose given on their turf. How much is that? LOTS of money! I would like to know exactly what they make on the draw and the immunization itself.

So, in the process, they draw people away from their Docs and into the BIG BUSINESS MACHINE ... THIRD PARTY ... party $ after $$ party $$$, Business of Medicine makes money on the BACK OF THE DOCTOR-PATIENT relationship.

Sickening!

When I started in practice, the immunizations were generally given as a part of a well visit or follow up visit for a chronic medical problem, and they were a part of a comprehensive & individualized health care plan for each patient. Cost of the vaccine and the administration would have been perhaps double the cost to us. But, more importantly, it would have been part of a larger effort to address each patient individually with regard to their total health care needs. In the current scenario, each thrid party contributes to the fragmentation of care, the "disintegration" of care and the cost of care. It is a pathetic and unnecessary state of affairs. That's why I am an advocate for Non Profit Doctor Patient Cooperatives to CAP the BUSINESS OF MEDICINE take all third parties out of the picture and return to the DOCTOR-PATIENT RELATIONSHIP to the realm of OPTIMAL PATIENT CARE and PATIENTS FIRST.

Let's fix it!

Do the right thing and enjoy!

Dr. Mike

Mission: Healing November 2, 2011 on Influenza

2011-11-02T23:11:00.000-04:00

PGY 39, Day 124

FIRST OF ALL

If you don't have a Doctor whom you trust, get one! If you don't know how, contact me and I will give you guidance. She or He should be able to guide you in the right direction.

AFTER YOU HAVE YOUR DOCTOR, CHECK THIS OUT with your DOC!

There seems to be a bit of confusion regarding "the flu" and the influenza vaccine, and that is quite easy to understand. It is very confusing, because the bug confuses everyone ... it keeps changing.
BUT ... there are some fundamental rules that have not changed over the years. This CDC document

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0729a1.htm

covers the whole story, and the recommendations have not changed since last year. Their reasoning for expanding the population to be immunized is covered in this document. I recommend that you study it, if you are NOT high risk and you need to decide weather or not to get immunized. If you ARE HIGH RISK, and have NO CONTRAINDICATIONS, you should be immunized for sure. Keep in mind that my conclusion is based upon the fact that I see the casualties who end up in the Intensive Care Unit ... not a good way to spend your days, if avoidable, eh?

TWO TYPES OF VACCINE: INACTIVATED & LIVE ATTENUATED
From the CDC DOCUMENT

"TIV contains inactivated viruses and thus cannot cause influenza. LAIV contains live attenuated influenza viruses that have the potential to cause mild signs or symptoms related to vaccine virus infection (e.g., rhinorrhea, nasal congestion, fever, or sore throat). LAIV is administered intranasally by sprayer, whereas TIV is administered intramuscularly by injection. LAIV is licensed for use among nonpregnant persons aged 2--49 years; safety has not been established in persons with underlying medical conditions that confer a higher risk for influenza complications. TIV is licensed for use among persons aged ≥6 months, including those who are healthy and those with chronic medical conditions (Table 1). During the preparation of TIV, the vaccine viruses are made noninfectious (i.e., inactivated or killed) (8). Only subvirion and purified surface antigen preparations of TIV (often referred to as "split" and subunit vaccines, respectively) are available in the United States. Standard-dose TIV preparations contain 7.5 mcg HA antigen per vaccine strain (for children aged <36 months) or 15 mcg of HA antigen (for persons aged ≥36 months) per vaccine strain (i.e., 22.5 mcg or 45 mcg total HA antigen). A newly licensed higher dose TIV (60 mcg per vaccine strain or 180 mcg total HA antigen) was approved recently for persons aged ≥65 years (Fluzone High-Dose, Sanofi pasteur)."

WHO IS HIGH RISK:

FROM THE CDC DOCUMENT

"Vaccination to prevent influenza is particularly important for persons who are at increased risk for severe complications from influenza or at higher risk for influenza-related outpatient, ED, or hospital visits. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to the following persons:

all children aged 6 months--4 years (59 months);

all persons aged ≥50 years;

adults and children who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus);

persons who have immunosuppression (including immunosuppression caused by medications or by HIV);

women who are or will be pregnant during the influenza season;

children and adolescents (aged 6 months--18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection;

residents of nursing homes and other long-term--care facilities;

American Indians/Alaska Natives;

persons who are morbidly obese (BMI ≥40);

HCP;

household contacts and caregivers of children aged <5 years and adults aged ≥50 years, with particular emphasis on vaccinating contacts of children aged <6 months; and

household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza."

STILL CONFUSED?

You will have to study the whole document and ask for guidance. Feel free to ask me questions and send your comments.

Buona Fortuna & Ciao for now,

Dr. Mike

Mission: Healing November 2, 2011

2011-11-02T21:24:00.000-04:00

PGY 39, Day 124

StepWisely(R)
Improve Quality First = IQ First(TM)
The First Ten Steps To Rational Cost Containment = provide the Best Possible Care that will fresult in the best possible outcome.

for PROVIDERS in the Intensive Care Units

These tips are based upon my years of experience taking care of critically ill patients. They are especially designed for inexperienced doctors, medical students, nurses, patients and their families, and to help promote Integrated Quality Team Based Care ... STAY ON TARGET to optimize patient outcome and minimize adverse impact on families and loved ones.

1. Engage the Family: The Family is an ESSENTIAL Part of the Care Team
2. DEFINE ADVANCED DIRECTIVES based upon the PATIENT'S Wishes and in conjunction with the Family ASAP (When there is no family, whomever is responsible for the patient needs to be involved, if possible)
3. Use STOMPP*(TM) and the STOMPPIT*(TM) ATM Team Development Tools to help engage ALL Team Members in the definition & clarification of goals and objectives.
4. Restore ALL end organ perfusion RAPIDLY
5. Restore perfusion to organs at risk ASAP by all means necessary
6. Optimize ALL end Organ and Organ System preservation strategies using STOPs*(TM) (Specific Targest for Organ Preservation)
7. Enable Damage Control, if necessary
8. Enable Specific & Definitive therapy ASAP
9. Check END POINTS & STOPs for ALL therapies FREQUENTLY**, especially with regard to restoration of PERFUSION and achievement of DEFINITIVE THERAPY
10. Change the CARE PLAN/TREATMENT PLAN FREQUENTLY on the basis of weather or not your current plan is working & KEEP ALL TEAM MEMBERS in the loop.

*STOMPP, STOMPPIT & STOPS are familiar to the medical students, interns and residents I teach regularly. Contact me, if you want further information about these Patient Care Tools.
**FREQUENTLY in the ICU means at least hourly and sometimes continuously
Do the right thing and ENJOY!
Dr. Mike

Mission: Healing November 2, 2011

2011-11-02T18:25:00.003-04:00

PGY 39, Day 124
For FAMILIES of Patients In the Intensive Care Unit

Here are a few pointers based upon my observations while caring for patients in the ICU over the years.
First, For Families and Loved Ones
StepWisely(R)
Improve Quality First = IQ First(TM)= Best Outcome = Best Care = Most Cost Effective Care = Best Practices

The First Ten Steps to Rational Cost Containment(TM) (RCC)

For Families of Patients In the Intensive Care Unit
1. Trusted Doctor: You must have Faith and Confidence in the physician(s) who take care of your family member, friend, or significant other. If you do not trust the people you are dealing with, arrange for a transfer of care to another facility, or doctor, or both.
2. CARRY OUT THE WISHES OF THE PATIENT: Make sure you have advanced directives that are based upon the wishes of the PATIENT, not your wishes, or the wishes of another family member. Do not impose your beliefs upon the patient. Do the RIGHT THING for the patient.
3. TEAMWORK: You are a member of the team. Find out how you can help. Ask what you can do to help. It is NOT HELPFUL for you to interfere in the care of the patient by spending too much time at the bedside. Ask the Doctor and the Bedside Nurse, what you can do to help when you are at the bedside.
4. Take Care of Yourself. You can't help if you are exhausted or in the way. Get some sleep. Identify your preference (if any) for religion and religious support. When the situation is critical get these folks involved.
5. Designate one or two members of the Family who are the primary representatives and spokespeople for the family. You will be responsible to coordinate information sharing with Family and Friends
6. Do not disrupt care: It is not helpful to have any DRAMA at the bedside
7. Write down your questions and the names of the people who are members of the care team
8. Make sure you understand the care plan
9. Review the care plan with the Critical Care Team Every Day and whenever changes are made
10. CONTACT INFORMATION: Give your contact information and GET the contact information for your care team.

Let me know if you want me to elaborate on any of this. Next will come a piece for PROVIDERS and I promised some guidance regarding influenza.

Questions or comments, contact me.
Dr. Mike

Mission: Healing October 18, 2011

2011-10-18T09:50:00.001-04:00

PGY 39, Day 110

Children and Their Parents

This book was originally composed and written by me in 1985, for CHILDREN AND THEIR PARENTS as part of our Non Profit Child Development Project, run by our Non Profit Health Development Insititute in conjunction with Northern Cumberland Memorial Hospital (at the time, a Non Profit Hospital in the town of Bridgton) and partly funded by the State of Maine. Although the book was never comnpleted for widespread distribution, it is available @ cost of production. Again, I will put Bits By Bit up on the blog for commentary and to facilitate development of a NEW Edition. Forgive the CRUDE Draft and recognize the value of the content, if you will.

Thanks for your help.
Enjoy!
Dr. Mike

Fundamentally, nothing has changed since the book was written. Think about what you read here and send feedback. Remember, it was originally written as a Child Development Guide for Children and Parents, under the assumption that Parents are not born with optimal Parenting Skills. Therefore, we saw it as our goal at the time to work with parents as a team ... to help them develop their parenting skills. Our target was reduction of child abuse and neglect, which is still, and I suspect will always be a worthy cause ...

Mission: Healing October 18, 2011

2011-10-18T09:02:00.000-04:00

PGY 39, Day 110
Relaxation is one of fundamentals of Stress Management.
This video, if you focus on the sound and the falling water, is very relaxing. Although brief, it will help most to relax and it can be repeated. Try it, you might like it.
http://youtu.be/zrIwQlri07A
Enjoy & Happy Tuesday!
Dr. Mike

Mission: Healing October 17, 2011

2011-10-17T09:42:00.002-04:00

PGY 39, Day 109

More words from The NEW Stress Management Workbook
from Dr. Mike. The latest (electronic) version is designed for use with The Original Stress Management Workbook and will be put up here BIT BY BIT ... in pieces for your review. New stuff will be in parentheses, in order to distinguish between NEW additions and the ORIGINAL version.

The NEW*

STRESS

Management

Workbook

new & revised

action plan

for

taking control of your

life and health

*Designed for use in conjunction with your family doctor and The Original Stress Management Workbook

Michael F. Mascia, MD, MPH

Preface

(from our Original Stress Management Workbook, published in 1980. These words were carefully chosen at the time of our original writing. They ring true today, in a New Millennium... more than 30 years after they were written ... and I dare say, these words will likely remain true ... into the foreseeable future. I will expand on this preface for the New edition, but for now, to avoid confusion, I leave it as it was written and published in 1981. Keep in mind, that, if you are an individual who wants to TAKE CHARGE OF YOUR LIFE AND HEALTH, think carefully about these words, StepWisely(R) and join me ... walk with me ... as I create, Bit by Bit ... The NEW Stress Managment Workbook. I welcome your participation and feedback. Enjoy! Dr. Mike

Michael Frank Mascia, MD, MPH October 17, 2011)

The twentieth century has been marked by tremendous advances in

the theory and practice of medicine. Phenomenal scientific and tech-

nological discoveries have found their way into medical practice. Peo-

ple have grown to expect certain seemingly miraculous results from

the institutions and providers of medical care, and often, the expec-

tation is that the "impossible" can be achieved.

There is, however, increasing popular awareness that modern med-

icine cannot perform miracles despite the available science and tech-

nology. Professionals and laymen alike are learning that advances in

medicine, however dazzling, cannot make up for life styles that breed

pathology. Life style is now being recognized as a major factor in the

development of many of our modern medical problems. General atti-

tude and behavior are clearly linked to the individual's health status.

Moreover, most medical problems seem to occur more frequently with

increasing stress, and environmental exposure appears to be a factor

in most illnesses. Expectations appear to have an effect on health and

well-being. Such varied problems as cancer, cirrhosis of the liver, mal-

nutrition, pancreatitis, ulcers, high blood pressure, headache, food poi-

soning, voodoo deaths, and others appear to be influenced by both

internal and environmental factors, both emotional and physical.

Professionals and laymen are beginning to realize and teach that

the individual has a great responsibility in the promotion of his own

health and the prevention of his own disease. The concept of self-care

is steadily gaining acceptance. People are beginning to realize that

they have control over certain factors that affect their health and well-

being. But although these concepts are being accepted more readily,

the methods for their application and general use have not been widely

available.

THE STRESS MANAGEMENT WORKBOOK is designed for the

individual who takes the concept of self-care seriously and wants to

do whatever he* can to promote his own health and well-being, as well

as take advantage of the best that modem medicine has to offer.

Although the book can be read rather quickly, the material is de-

signed to be implemented gradually and thoughtfully in conjunction

with advice from your personal physician. It is expected that your

initial planned changes may take up to two years or more to institute.

""Throughout the book we have used such constructions as "the individual... he" solely

for the economy of language. Our usage of personal pronouns is not, in any way, intended

to imply any connotation of sexual role discrimination.

(Maybe in the new version, we will use "she" instead of "he" for "economy of language"?:)

Ciao for now.
Dr. Mike

Mission: Healing October 17, 2011

2011-10-17T08:10:00.000-04:00

PGY 39, Day 109

A "poem" ... probably just better called a "few words reflecting the dawn" promised and started several days ago ... when Fall was Dawning on Me ... written in Maine.
The photographs below are from New Orleans and Florida. Have a happy day.
Dr. Mike

Fall Dawning on Me

Out of Darkness,

This Morning Dawns with Cotton Candy Skies ...

Magical

Fluorescent Trees Glow ...

Mesmerize

Shouting in silence ...

First shades of red, then yellow and green

Scream,

"Look at me", "No, me", No, me. I am the brightest!",

they "say", shouting in loudest colors,

fighting for attention against eternal pink-blue skies.

She called me out for this glowing feast,

into the cool crisp air, morning dew, soft moss and grass

cold ... feet ...

glide slowly down to earth

Eyes ... and up again

now drifting slowly ... "ahh" ... "apple tree",

red, ripe fruit gently bending branches,

easy reach, yes, "pick the ripest one"

Wet, cold ... "rub to dry ...

and shine"

"bite" a crunching sweetness ...

deeply chilling thoughts

Awaken ... chilled ... shaken ...

I

quickly go inside.

Happy Monday!
Dr. Mike

Mission: Healing October 13, 2011

2011-10-13T14:29:00.000-04:00

The Stress Management Workbook
Bit By Bit: The NEW Stress Management Workbook
Click the link above to View a free Introduction posted via Twitter.
Eventually, I will figure out how to go live with it.
Give me feedback and I will do my best to make sure that your questions are answered in the NEW edition.
Dr. Mike

Mission: Healing October 12, 2011

2011-10-13T02:40:00.000-04:00

The Stress Management Workbook
An action plan for taking control of your life and health
http://www.ihealsolutions.com/thestressmanagementworkbook.php

As promised, I am starting to post bits and pieces of the book, as I see the needs are great and the book is available and ... why not? Enjoy and contact me via my website, or email at dr.mike@ihealsolutions.com,
if you want a copy of the book. Electronic copies are not yet available "officially", but I do have paper copies & can put electronic copies on a disc for those who want it that way.
So, this will be a work in progress on the blog ... with The NEW Stress Management Workbook taking shape as I put pieces of the original Stress Management Workbook out here on my blog, with additions, links and commentary on the Original.
Ciao for now,
Dr. Mike

PS. Always remember that I expect you will use this guidance in conjunction with your personal physician.

PPS. For emergencies, go through 911 or your local Emergency Room/Emergency Services.

PPPS. Over time, I will help you figure out how to
a. establish a relationship with a good doc &
b. figure out how to get the care you need when and where you need it.

From the original cover published by Appleton Century Crofts.
Drs. Aronson and Mascia retained the copyrights.
New Comments will be put in parentheses

(from the front cover)

An Appleton Book

The

STRESS

Management
Workbook

action plan for

taking control of your

life and health

StephenAronson, PhD

Michael F. Mascia, MD, MPH

(From the back cover)

The STRESS

Management Workbook

numerous and varied as its causes. The Stress Management Workbook is a unique, complete

guide to recognizing the factors that are evoking stress - at home, at work, in school, and in

your relationships with family and friends. Once you've identified what's causing you to

experience stress, you've taken the first big step toward overcoming it!

The questionnaires, checklists, and self-evalution tools you'll find throughout the book will

helpyou to measure your personal reactions to stress and to develop a stress management plan

that is tailored to your day-to-day needs. The authors teach you how to use such time-proven

stress management techniques as meditation, exercise, deep muscle relaxation, diet, and

self-hypnosis.

Other features include:

STRESS - You're bound to experience it at some point in your life. Its symptoms are as

• An "Integrated Model of Health and Disease" - which helps you to pinpoint the physical and

emotional effects stress can have on your well-being.

• Diet guidelines - You'll learn which common foods can ease or increase the symptoms of

stress.

• Practical stress management exercises that you can fit into your busy schedule.

The stress Management Workbook combines the best of modern medical information with

realistic self-help techniques. As the authors emphasize, a certain amount of stress in your life

is normal and healthy. This book simply shows you how to find and keep the perfect balance for

you - so you can enjoy life to its fullest!

About the Authors*(see updates below each author)

Stephen Aronson, Ph.D. is a licensed psychologist with more than 10 years' experience as an

organizational development and training consultant - to schools, summer camps, corporations,

and government groups. He has taught psychology at the university level throughout the

country. His professional interests include the development of communication skills, and

team management.
(*Dr. Aronson has continued his work in Portland, Maine for the many years since this book was originally published, and he will be invited to help me with certain sections of The NEW Stress Management Workbook.)

Michael F. Mascia, M.D., M.P.H. is a Board Certified Family Practitioner with a private medical

practice in Bridgton, Maine. He has taught Family Medicine in major medical schools, and is

actively involved in the research and development of stress management techniques. Dr.

Mascia is a diplomate of the American Board ofFamily Practice, and a member of the American

College of Preventive Medicine and the American Academy of Family Practice. He received his

M.D. and M.P.H. degrees in 1972 from Tulane University.
(*After 14 years of rural Family Medicine, Dr. Mascia returned to the University of Maryland and The Maryland Institute for Emergency Medical Services Systems for further training in Anesthesiology, Critical Care and Hyperbaric Medicine. Since then, he has taken teaching and leadership positions in several academic institutions including SUNY in Syracuse, New York; Tulane University, in New Orleans, Louisiana; and West Virginia University, in Morgantown, West Virginia. While caring for, teaching about and researching the sickest of patients, Dr. Mascia has continued his interest in and use of Team Development & Stress Management principles and strategies to optimize teaching and patient care.)

Drs. Aronson and Mascia have worked together, conducting stress management workshops for

corporations, government groups, and individuals.
Appleton-Century-Crofts / $8.95 0-8385-8696-1 (the original price from 1981)

(*Drs Aronson and Mascia worked together in Bridgton, Maine for 14 years and continue to collaborate on this work.)

Mission: Healing October 11, 2011

2011-10-11T06:49:00.000-04:00

PGY 39, Day 103

Should we call it the HIT Parade?
Easy now, don't jump on the bandwagon. Think first; jump later? Think and walk? Better yet, StepWisely(R)

This is my latest comment with regard to Health Information Technology flaws and fixes.

Happy Monday! I will try to post on your blog (DONE http://biomedres.blogspot.com/2011/10/more-on-hits-impact-on-dr-patient.html?showComment=1318263890772#c2930562617135789482) and will go to my blog as well.

Thanks again for including me in your conversion(s). It is good to know that some are thinking (actually thinking) about doing the right thing in regard to HIT.

BUSINESS OF MEDICINE vs PROFESSION OF MEDICINE vs HEALTHCARE

Regrettably, as with all things medical over the last couple of decades, there are many (THIRD PARTIES) out there who would be happy to take some $$$ out of this pot ... without regard to impact on patients and patient care. In other words, most (if not all) of these systems are a great source of income for the vendor and I venture that ALL would FAIL the scrutiny of cost benefit analysis, if they were in the mix of new products and services being examined. DON'T give them the money! Make them prove that it is worth it!

But, everyone has (without good reason) jumped on the HIT train ... and it is being pushed full speed ahead ... before the tracks are laid. Sure, I like the data to play with, but is it worth compromising patient care to get it? And, the prices you are paying are a RIP OFF!

My advice? If you don't want to waste money on HIT, 1. Don't buy anything before you test it! 2. Better yet, make it yourself and run pilots before you spread it around like fertilizer ... cough ... cough ... sputter. 3. Don't waste your time negotiating with 3rd party HIT vendors. Make them prove their systems by loaning trial hardware and software for testing on site!

Seems as if Governments are in a good position to help develop a SECURE INTERNET that runs parallel to, but separate from the existing hardware and software. Over this INTERNATIONAL HEALTH NET, Personal Health Information could be shared (Standardized Data on OPEN SOURCE SOFTWARE that each patient and provider has) between providers and patients anywhere in the world. Open source, Non Profit COOPERATIVE makes the most sense, because NOBODY should profit (over and above a reasonable wage) from Healthcare. Like ($$$) banks, the information would be held by each patient and provider, but not in central data banks.

Just my opinion:)
To be continued ...
Dr. Mike
Michael F. Mascia, MD, MPH
dr.mike@ihealsolutions.com"

T

Mission: Healing October 9, 2011

2011-10-09T11:21:00.002-04:00

PGY 39, Day 101

Thinking about Steve Jobs, and my brother Peter. Good men, lost to the world, but lives lived well.

V2

Sunny Day

Silent ...

Sunbeams Spotlight Shimmering

Leaves

Flutter ... dance in gentle breeze ...

soon to be naked trees.

Some, radiant dressed, scream for attention ...

about to drop their cover.

Reflecting ...

rhythm, autumn's amber glow ...

crystal blue skies ...

eternity.

Seasons ... men ... women ... come and go,

cricket, squawking bird, rustling squirrel,

each endless solo

squall and swan song sung ...

to no avail,

sensing ... warm, sweet, calm ...

days savoring seasons' fruit ...

moments pale.

Watching, wondering how can it be?

The inchworm ... tiny thing,

efortlessly dangling ... floating ...

up ... down ... side to side ...

on a sparkling string ...

nearly invisible.

But, that is just a distraction.

Have a Happy Sunday and Do The Right Thing!

Dr. Mike

Healing: Saturday, October 8, 2011

2011-10-08T10:56:00.000-04:00

PGY 39, Day 100
This morning, I wrote these words and sent them out on twitter, as I was enjoying my morning coffee. Just a few moments on a Saturday morning ... awake moments of meditation. Try it. You might like it.

10/8/11 10:47 AM
BEING ... Warm sun, hot coffee, birdsong, blue skies, sweet air ... leaves sparkle ... glow ... dancing in the gentle breeze ... is.
Dr.Mike

Mission: Healing October 7, 2011

2011-10-07T13:06:00.000-04:00

PGY 39, Day 99

Fall Rhythm ...

Hushhhhh ... the only sound in this sweet air ...
and a few notes ... birdsong ... chipmunk rustling ...
gently drifting through trees ...
green leaves flutter and dance ...
Submission.
Sunbeams,
burning through flesh, take the chill out of bones,
and spotlight the brilliant ones screaming for attention ...
standing out among the forest's green, gray and brown.
Ahhhhhh ... being ... this is ... an intermission.
Summer's swan song over,
sweet day's calm,
silent blue skies give a hint of what was
and
what is to come.

Happy Friday!
Dr. Mike

Mission: Healing October 7, 2011

2011-10-07T11:10:00.000-04:00

PGY 39, Day #99
Business of Medicine: More on Problems With Health Information Technology ...

These are comments on a HIT bloggers reflections regarding my Top Ten HIT Problems Post from a few weeks ago ...
Some day I will figure out how to link all this together, so that it can be followed.

Thanks for including me in your conversation. I take it that in the UK your HIT is non proprietary and Government property?
As a front line provider & proponent who has dabbled in EMR creation and relational data bases for ... how long have they been available? ... I am continually struck by the inadequacy of proprietary EMR products available in the US. And, I can only conclude that the proprietary model is the major barrier to eliminating the flaws ... or is it Ego? Money/Ego? Money vs Ego? Money & Ego ...
Anyway, no matter what the causes, I strive to set up a Non-Profit Doctor-Patient Health Care Cooperative, and think that the HIT problems can be resolved as a part of the Mission. The objective would be to find a group of IT people who will work together with me to create the ultimate open source HIT platform. I can do it on paper ... I just can't do it electronically.
It is interesting to note that the HIT people look at me as if I have two heads when I tell them that their product is not good enough, because it gets between us ... between the Doctor and the Patient ... and takes time away from my patient care time. They just don't get it. I should not be surprised, right? HIT people think that interacting with a computer is natural, right? Prove me wrong.
Well, like it or not, I have watched technology chip away at the Doctor Patient Relationship and nursing time ... bit by bit over the years. Now, it is simply madness ... And, while it may not make a difference ... in certain scenarios where care is irrelevant and people will get better anyway (most clinic patients), it is a serious problem in the ICU, or in the OR to have 25 - 50% of physician time spent on computers. This is foolishness! Especially today ... in an era with availability of such sophisticated technology. Doctors and nurses spending precious patient care time on computers? This is CRAZY, not NORMAL! NOT RIGHT and NOT ACCEPTABLE. If I only had a chance to talk with Steve Jobs ... I am sure he would have seen the value of fixing this problem. Ah, well ... it is what it is.
Right now, as it stands, we could instantly solve the HIT interphase problem and help reduce unemployment by hiring scribes to serve as the interphase between Doctor and Patient ... one for each patient in the ICU and one for each patient in the OR. (Do what you like in the clinic.) This would work as an instant stop gap measure while we push to bring this monster around to a technology that is friendly to the Doctor - Patient relationship and Nursing care of the patient.
To be continued ...
Dr. Mike
dr.mike@ihealsolutions.com

Mission: Healing October 7, 2011

2011-10-07T02:31:00.000-04:00

PGY 39, Day #99
As usual, I am thinking ... always thinking more as I recover from my week of patient care and sleep deprivation. Delayed processing of the events of the week and examination of my emotions ... a trick I have learned over the years to keep emotions out of my interactions with patients. This works for patient care, but I am sure it drives everyone else in my life crazy.

Anyway, lately I have been thinking that I need to start posting some of my Stress Management strategies & some pages from the "Stress Management Workbook: An Action Plan for Taking Control of Your Life and Health". I wrote it with a Psychologist friend & co-worker (Stephen Aronson, PhD) to help worried well patients get healthy and stay healthy. More than half of my Family Practice patients (I did Family Medicine for 14 years before Anesthesiology & Critical Care) were suffering from stress related disorders, and, even though less than 10% of the folks were motivated to "take control" of their own health, I thought it was a worthy endeavor. The book was written in 1979, and published by Appleton Century Crofts in 1981, and ... low and behold, it is still sound and relevant. I have threatened to publish an electronic version and to write a new edition for years, and, maybe I will just have to start posting the updates in the blog.

The fact is, that little has changed with regard to the fundamentals of Stress & Stress Management, but I can update the book with new and emerging problems since the original publication. Not much needs to be added, but there are some issues that deserve special attention for the New Millennium. Specifically, I will update the immunization section, add a sections on AIDS, and bits for some of the newer global issues and worries such as terrorism, financial instability and disaster preparedness. Also, an electronic version should enable strategically placed live links for references and easy user updates.

Hopefully, I can get some feedback and interaction from my Twitter Followers, Facebook Friends and Blog Readers, so that I can fine tune the New Edition to make it particularly relevant and helpful. What do you think?

Dr. Mike

Mission: Healing October 3, 2011

2011-10-03T19:05:00.000-04:00

PGY 39, Day 95
Recovering from another week in the ICU. This was a moderate week, in the sense that we had a strong care team and a patient population that did not exceed our capacity. In other words, we did not have to stretch beyond capacity at any time during the week and all patient care, teaching, research and administrative objectives were met. it is not uncommon that some unimportant things have to be put off, so that patients can get the care that they need.
For obvious reasons, patient care details can't go in here, but I can and do talk about my goals, objectives and methods ... patient care, teaching, research and administration. Patients and Patient Safety always come first in my book. Toward that end, I have developed some tools that are designed to keep inexperienced Doctors and Nurses on target with our Mission: optimal patient care. These are all part of the StepWisely(R) System that I have been using over the last few years.
Previously, I have given you bits and pieces in this blog and through twitter. Here is a bit more ... will expand on it over time.
STOMPP(TM)IT = Strategic Targeted Operations Management for Patient Protection & Preservation Integration Tool: A tool to keep the team on Target with the Optimal Patient Care Mission. This team development tool is a series of check lists that helps the members of the team to stay FOCUSED on the CRITICAL GOALS AND OBJECTIVES that are most likely to result in a good outcome. They include General Patient Goals and TOPS(TM) (Targeted Organ Protection Strategies) that are patient & organ specific. In other words, they are designed for the management of each patient on the basis of each patient's specific needs. While I can't be specific about any real patients, over time, I will give theoretical examples of how these are used in the care of each critically ill patient.
That's all for now ...
If you have specific questions, you can contact me by email @ dr.mike.ihealsolutions
Ciao for now,
Dr. Mike

Mission: Healing for Kids

2011-09-24T22:04:00.000-04:00

If you look through these images you will see a few of the
Life is Love(TM), StepWisely(R) Whimsical Words For Kids ...
Simple Messages for Healthy Kids. These are the Simple of the Simple for Little Kids
Soon we will put them in a collection for Parents and Children ...
Part of the StepWisley(R) System for Healthy Kids and Families
Enjoy!
Dr. Mike

http://twitter.com/#!/Dr_Mike_IHS/media/slideshow?url=http%3A%2F%2Fyfrog.com%2Fkjof7rj

Mission: Healing for Kids, StepWisely(R) & Life Is Love(TM)

2011-09-24T21:42:00.000-04:00

Life Is Love (TM): Whimsical Words With A Serious Meaning for Kids, part of the StepWisely(R) System for Individual and Family Health Development

Mission: Healing September 24, 2011

2011-09-24T20:56:00.000-04:00

PGY 39, Day # 86

Medicine by the Numbers is Painting an Unacceptable Picture ... Strike that

Medicine by the Numbers: Painting an Ugly and Unacceptable Picture of Money and Profit Over Patient Care

These are not new thoughts for me, but, rather recurrent thoughts ... triggered by my observations on the front lines of patient care ... and the picture gets worse ... and worse with every passing day. With every passing day, it gets harder and harder for the front line providers to give the best possible care. It is a struggle to say the least, and the bottom line is this: The Business of Medicine DOES NOT equal The Profession of Medicine and The Art of Medicine, and therein lies the problem. Business guys want to earn money, and Doctors want to ... and are obliged BY OATH to take care of patients. So, as I see it, the Profession of Medicine ... the Doctor Patient Relationship ... has been hijacked by the Business of Medicine, so patient care providers are only valued in so much as they can generate $$$ for the business. In other words, the Business Guys are riding on the backs of patients and providers (AKA the Doctor-Patient Relationship), driving the Doctor-Patient Relationship toward the MONEY, skimming off the top (30-60%) and Patients are falling through the cracks, because their health care needs are not being met. It is Ugly, Unacceptable, Unethical, Immoral and probably, if not illegal, on the edge of legality.

But these Business Guys do have excuses for their bad behavior, and they are protected by corporate structure from the bad outcomes that they produce in the process of driving the line toward greater "productivity" and pushing providers into situations that result in cutting corners and lowering quality. What do Business Guys know about quality patient care? Nothing! Do they care about patient care? No! They care about the bottom line, profits, bonuses, money in their pockets and corporate profits ... that is their business.

I have posted a Top Ten Target ( TTnT(TM)) Solution List in the past, and I will post it again in my new blog, but for now, I will share the piece posted on my website blog ... in November 2008. As you review this post, keep in mind one simple fact: The Business of Medicine DOES NOT EQUAL The Profession, Practice and Art of Medicine. Therefore, The Business of Medicine DOES NOT & CAN NOT PROVIDE for optimal patient care.

"By Dr. Mike Nov. 26, 2008 at 11:10 pm EST (Updated Nov. 26, 20

08 at 11:10 pm EST)

Medicine by the Numbers is Painting an Unacceptable Picture

Do you remember those “Paint by the Numbers” kits we used when we were kids? Have you ever used one? Have you seen the results? Sure, on the cover they show a masterpiece partly completed to perfection by the numbers.

Then, you or your child eagerly rips the kit open in anticipation and rushes to create your own copy of the masterpiece. You paint away by dutifully dipping your brush into each little container and carefully applying each color in the proper spot … yes, “according to the numbers.” After hours of careful work you have finished … ah … and you hold your finished product up to stare in admiration … only to find that you have created something that, at best, only grossly resembles the masterpiece. The finished product is most likely gross; a very disappointing and poor representation of the real masterpiece upon which the kit is based.

When I stand back and look at the products we deliver in American medicine today, it is only rarely that I see a true masterpiece … the work of a master craftsman. Frankly, I am often grossed out by what I see. Why? Currently, American Medicine is done “by the numbers.”

What do I mean? Modern American medicine is driven by reimbursement and not by patient needs, so many patients fall through the cracks. Hospitals and other care systems have clearly been forming their organizational structures and operational strategies based upon the “return on investment” and other production principles … the same business systems that drive factories, assembly lines and factory workers. Nothing against return on investment, production principles, business systems, factories, assembly lines and factory workers, but the model simply does not work in healthcare.

When I started working as a Critical Care Anesthesiologist at Tulane University Hospital in 1999, it soon became apparent that patients were being treated like hamburgers in a fast food chain, and I often said, “They treat patients like hamburgers … as if they were all the same … as if they all needed the same treatment for the same diagnosis.” I would say, “Imagine trying to run an airline … with 100% special need customers. It could not be done. But, each patient is a special need customer. Patients don’t fit into the cattle herding and hamburger production models, and that is one of the reasons why many hospital administrators have no understanding …

(CONTINUED(C)MFM@IHS)"

This outrageous situation can and must be fixed. I will share my "Open Letter to President Obama" that I posted soon after his election, so you too can see my suggestions for moving back toward a more health and healthful health care system.

To be continued ...

Dr. Mike

Mission: Healing September 16, 2011

2011-09-16T11:40:00.000-04:00

PGY 39, Day #78

More on Obesity: A Reiteration of Facts - Eat Well and Move

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6005a1.htm?s_cid=rr6005a1_e&source=govdelivery

The surprising fact is that the causes & the solutions are simple, clear and intuitively obvious. However, the facts have been obscured by wishful thinking and cultural trends that are driven by $$$. These trends have become part of childhood programming and the fabric of our institutions. These must be driven back toward basic human needs and provision of proper services to meet those NEEDS ... not desires, or wishful thinking derived from God knows where.
I will elaborate over time ... again ... and again ... as the fundamentals have not changed, nor will they ever change. Focus on the nature of the beast!

Have a Happy Friday!

Dr. Mike
PS. I will try to link this to my last post on obesity.

Mission: Healing September 15, 2011

2011-09-15T11:29:00.000-04:00

PGY 39, Day # 77

Today's Whimsical Wake Up

The pouring rain was roaring,
but sleep called me back.
Then to my surprise,
sun poked me in the eyes,
and said,
"You better get out of bed!"

Happy Thursday!
Dr. Mike

Mission: Healing September 14, 2011

2011-09-14T09:56:00.000-04:00

PGY 39: Day 76

Last night, Silence broken ...
A symphony ...
Crickets sing summer's swan song,
heralding today's sweet sunshine.

Happy Wednesday!

Dr. Mike

Mission: Healing September 11, 2011

2011-09-11T11:15:00.000-04:00

PGY 39, Day 73

The Moment

Morning Sunbeams Warm

Birdsong and crickets fill the cool breeze

Swinging trees

green leaves sparkle,

dance and sway with a "Hushhhhh" ...

Ah, Sweet Moment ... Eternal

Memories, first fond ... warm wishes, dreams and desires penetrate ...

then fade into darkness, heartache and misery.

Memories for those who suffer, and have suffered,

at the hands of men and in the name of God.

HAVE A GREAT DAY! & StepWisely(R)
Dr. Mike

Mission: Healing September 9, 2011

2011-09-09T10:12:00.001-04:00

PGY 39, Day #71
The Obesity Pandemic

A few introductory words on Obesity would be in order ... absolute fundamentals that can be used with some certainty.

StepWisely(R), folks.

1. Obesity is a serious problem with serious adverse health consequences.
2. The number of obese people is increasing (both frequency and prevalence are increasing).
3. We are hard-wired for obesity by the time birth (genetic capacity for obesity at conception)
4. Programming for obesity starts at the time of birth and some might argue at the time of conception
5. continues through preschool years and
6. is reinforced in schools.
7. Reinforcement of the obesity program continues into the world of work, play and recreation.

To COMBAT OBESITY:
8. MOVE MORE = Motion is good & we are made to move = MOVE MORE
9. EAT LESS = Too much food is bad = EAT LESS
10. EAT WISELY = smart foods only: high in nutrient value/low in "empty calories" = EAT WISELY

Here again is a link that will bring you to reliable and required background reading.

http://www.cdc.gov/obesity/defining.html

To be continued ... as a part of our StepWisely(R) series.

Dr. Mike

Mission: Healing September 6, 2011

2011-09-06T10:28:00.000-04:00

PGY 39, Day # 68

More on Stupid: Moron, Stupid!

Some might ask, "What brought on this ranting about stupid?", or "Why now?" Well, I am not sure, but it seems to me that my Katrina Flashbacks, brought on by Irene ... seeing that Irene is about 6 years behind Katrina. And, my experience with Katrina was summarized as "an exercise in stupidity." So, clearly, I have been thinking about this for quite some time, and I have written some about it, but kept those writings to myself. Perhaps they needed time to mature ... time to be nurtured and grown, and I needed time to get comfortable with the idea of giving birth to such thoughts. In any case, now, because of the modern wonders of technology, we have reached the stage where my thoughts can be typed and published for world distribution ... in a matter of seconds. That is amazing! That is smart! That is the opposite of stupid ... which brings me back to more on stupid.

What is the Worst Kind of Stupid?

Clearly there is a Hierarchy of Stupid Human Behavior. I would rank Stupid Behavior on the simple basis of how many people are hurt by the consequences of the stupid thoughts and actions of a particular individual.

So, for example, stupid decisions by individuals, organizations, NOLA, LA and federal leaders before Katrina (during the days, weeks and years before) resulted in bad things for many people, as well as injury and deaths for some. Clearly ... some of the issues were beyond the control of those in power on the day the storm hit, but that's no excuse for bad thinking and behavior as the storm approached, eh?

Another example might be Hitler ... he is a good (?, well, he was not good, but he is the perfect example of, perhaps the pinnacle of the stupid triangle) one to use as an example, because he mesmerized the German people and many around the world with his nonsensical wishful thinking, then duped these people into carrying out his evil mission for fear of retaliation of one sort or another. I am sorry to say, that Hitler was only able to carry out his mission, to the extent that he caused so much pain, suffering and death around the world, because early in his regime he bought the Medical Profession in Germany. (Read "The Nazi Doctors" by Robert Jay Lifton for insight into how Hitler duped the Doctors.) I dare say that, had "Nazi Doctors" resisted ... had they not fallen in line with Hitler, they could have brought him to a halt before he got his machine going. "It is what it is", to quote Machiavelli, and as history tells us the story unfolded, Hitler, for whatever reason(s) was able to carry out his STUPID (pure selfishness? psychopath?) mission ... to an extent. It has been done by Hitler and the world still lives with his fallout. So, I do put him at the top of the stupid list ... at the pinnacle of the stupid triangle ... Hitler, a man who wanted to dominate the world at any cost.

As you look around at today's world leaders, how would you rank them? Hmmmm ...

And, in your daily life, looking at yourself, and others around you, where do we ... where does each of us fit in the stupidity ranking? Tough thoughts ... look in the mirror first ...

Move Away From Stupidity: Do The Right Thing

Enough on Stupidity, at least for now, because there is no longer any need to wallow in it. We now have instant access to the world with words and deeds. Each and all of us (at least most) have the ability ... the capacity to think clearly and to express ourselves in a positive, creative and (not stupid) productive way. Not yet, but soon, virtually all humans will have the freedom to speak to the world directly ... and in seconds. Now, those of us who do have freedom can spread good words and deeds that resonate with humans everywhere.

Yes, the common ground is there ... for us to love and be loved in return, to care and be cared for, and to keep the world on the positive track of freedom, mutual respect and dignity. Our instincts are (animal) survival instincts (selfish), but we have the capacity to be much better than that. It can be done, and now, we have easy access to large numbers of people throughout the free world, so building a critical mass of people who want to do the right things should be relatively easy. We no longer have any excuses, we have freedom to speak and act properly in our own space and in the world community within seconds.

The energy required to move away from our instinctive (selfish, stupid) behavior is significant, but the rewards are great. First ... self control comes first and then a willingness to help others. Once these things are done ... helping those around you ... one at a time ... family, then community, state, nation and world. Yes, now that the world is much smaller ... we now have the tools to break out of mundane survival routines and to live and love and grow each other. Let's do it together! Let's DO THE RIGHT THING! LIFE IS LOVE(TM)

Thank about it, and let me know what you think.

I will start posting bits and pieces of "The Stress Management Workbook: An action plan for taking control of your life and health" on this blog, if I can figure out how to do it. Some might find it useful. Even though we originally had it published 30 years ago, it is still quite relevant. After all, the fundamentals never change.

Have a nice day.

Dr. Mike

Mission: Healing September 4, 2011

2011-09-04T21:13:00.000-04:00

PGY 39, Day #66

Talk about *Stupid?

Sure, some are offended by my use of the word, stupid. But ... why? It is a perfectly fine word, and it describes some of the most common human behaviors. I know,I know ... I too was raised thinking it is not right to use the word, with the frequent admonition; "Don't call anyone stupid. That is a bad word." I think it is because, as kids, when we learned the word, it generally implied a personal attack on one of our "friends" and the implication was that whomever we were calling "stupid" had a congenital or acquired form of stupidity; as in low intelligence or brain damage ... something permanent. But, that is only one of many possible uses, and the word is actually very rich with meaning and potential applications.
I generally prefer to use the word to describe behavior that occurs when the particular person is in a stupor, as in NOT congenitally stupid and NOT stupid because of any permanent disability, but stupid, because they are under the influence of something causing distorted thinking, or less than optimal thinking, or lack of thinking. Temporary stupidity, or stupor, generally implies reversibility and that the individual sometimes has the capacity for normal thinking. It implies decision making and behavior based upon less than the full thinking capacity the particular individual has when the mind is clear.

Causes?

The causes of temporary stupidity are countless, but here are a few that I see regularly: drugs, alcohol, money, ego, sex, competition, power, selfishness, greed, fatigue, fear, hunger, injury, fever, illness and on and on ... with many of the causes overlapping. And, don't forget that some forms of new onset stupidity may be, or may become permanent. For example alcoholism can cause vitamin deficiency and Wernike-Korsakoff Syndrome, brain damage, organic brain syndromes, seizures and other permanent forms of stupidity. Certain intoxicating and other drugs can do the same thing. Then there are the consequences of the bad behavior that occurs during the stupor: these are generally injuries to the head, or secondary injuries to the brain, after preventable life threatening trauma.

What about animals?

Can animals be stupid? Sure, why not, but, as compared to stupid humans, stupid animals generally don't have the capacity to create large scale chaos and damage when they behave badly, below capacity, or out of character.

Stupid Me!

It was not until I turned 50 ish that I gave myself permission to use the word, stupid. That was the age at which I had become wise enough to know and admit ... wise enough to be willing to accuse and judge myself to be stupid/wrong/dumb. Once I admitted ... that I actually could be ... that I had the capacity to be stupid ... it was easy to see that I had actually been stupid ... not only for a moment, but clearly, I had been through several "stupid years". It was only after that recognition, awareness and acceptance of stupidity, that I was willing to admit that there was such a thing as stupid, stupid is real and that I am not the only one capable of stupid behavior. Let me expand.

*Stupid, the word:

OK, let's examine the word and its meaning.

http://www.merriam-webster.com/dictionary/stupid

The word, stupid, according to Webster and others, (Online & Webster's Collegiate Dictionary & their "New Twentieth Century Dictionary, Unabridged, Second Edition - Deluxe Color") comes to English from Latin and French words (stupidus and stupere) in the year 1541 as "to be benumbed, be astonished". Further, Webster defines stupid as "1.a.Slow of mind" (no causation there), "1.b. Given to unintelligent decisions or acts: acting in an unintelligent or careless manner (recent Congressional behavior), "1.c. Lacking intelligence or reason" (hmmmm ... anybody know any of these kind?), "2.Dulled in feeling or sensation" (ring any bells?), "3. Marked by or resulting from unreasoned thinking or acting" (shocking!)and, "Lacking interest or point" (the decision itself, I presume?)

Well, I have to say, alright then, next question is, "What is the worst kind of stupid?" I have my opinion, but that is for the next installment.

And, for now, think about this; how many of you go from day to day, day after day, week, month and year ... just going through the motions? How many of you take the time to think about what you are going to do short and long term? How many of you have a rational strategic plan? Well, if you don't think about this stuff, does that mean you are being ... ? I am not going to say it.

Oh, and, what if a congressman, or woman were to say certain things, or do certain things, in order to get reelected, even if those words, or behaviors were irresponsible, immoral, unethical & not serving the best interests of the people he or she is elected to serve. Is that stupid?

Think about this; We are herd animals ... yes we humans are herd animals, and when one of us steps "out of line" it is disquieting to the rest. And, of course we do want approval. And, are you afraid to step "out of line" because you fear retaliation? Would you step "out of line" if you were not stepping alone?

Veritas est!

To be continued ...

Dr. Mike

Mission: Healing September 3, 2011

2011-09-03T10:54:00.000-04:00

PGY 39, Day 65

Katrina Flashbacks, brought on by Irene

On this day, 6 years ago I wrote ... these are the words as they appear on the handwritten page

"September 3, 2005
10:09 AM
Lafayette Airport

F****** MORONS (underlined)

That's my bottom line assessment after the last few days we have been through. I thought of Dante's Inferno, but don't know the book well enough to quote it. But, levels of hell from bad to worse continued day after day. This is Day 6; day 5 after Katrina --- what a bitch she was.
Yesterday, I don't really know what time it was, we were evacuated after all the patients, then patient families, staff and staff families. We went out on a Chinook with some of the animal people and the last few came shortly thereafter. So, chopper to NOLA (Armstrong International)Airport then bus to Lafayette (SW Hospital) after a fairly long delay for decontamination ... that is throw away shoes (dammit, my good sandals from Key West), shower, shave, new underwear, scrubs, sandals (foam flip flops), throw away deodorant and toothbrush. Then I got a DT booster and the antibiotics (which I did not take) and they lined us up for busses to a shelter. My nightmare thought was --- the shelter will be the super dome."

Guess I was a little cranky at the time, eh?

Ciao for now,

Dr. Mike

Mission: Healing September 3, 2011

2011-09-03T09:45:00.000-04:00

PGY 39, Day 65

Dawning on me

This morning,
awakened ... sound ...
Silence broken.

Distant thunder rolling over northern hills?

Frequent, loud ... Alarming.

At first, uncertain ...
But, dawn turned to darkness,
Then came rain ...
lightning and thunder,
far, near then gone.

Yes, sure,
She rumbled on.

Now light, gentle rain and peace,
not war.

Dr. Mike

Mission: Healing September 2, 2011

2011-09-02T12:33:00.000-04:00

PGY 39, Day # 64

Katrina Flashbacks ... brought on by Irene ... after which storm(s), some are still suffering the after effects.

On this day, exactly 6 years ago, we were evacuated from Tulane University Hospital ... and the thought of it brings back a raft of bad gut feelings. The "Katrina experience" was a life changing exercise in stupidity ... which I rode through with no "losses" and in good spirits as I continued to do my work. I was able to do this work, because I was with friends and trusted coworkers, and had no worries about my family: all of them were safe, secure, and tucked in far away from the madness in New Orleans. I say, "no losses", but that's a statement worthy of further consideration ... but not now. Clearly, she taught me a lot and I say that I am a Recovering Katrina Refugee, but I was one of the luck ones ... more later ... not now.
Anyway, as I look back on it, it was as if, Katrina, the superior being, had strategically planned a mission to put the worst of human behavior and human stupidity on display ... as if she was thinking, "Let's try this, just to see how stupid these humans are." Well, we all know that She planned nothing. But, She did prove how stupid we can be. Six years ago, after I got out and during my self assigned "debriefing" I wrote a poem about this. Maybe I will post it on this blog some day.

Here are a few quotes, exactly as they were written ... from "Inside Katrina", the story I put together with a Disaster Preparedness presentation, soon after the storm.

"Day 5: 06:54 AM Communication - Sending Signals by Example (Doing)(cont.)

Before we know it, everyone in the place is doing the same thing in the area surrounding their waiting place. Astonishing ... the signal was sent, the mission was accomplished in less than 15 minutes, and everything was neat, including all the empty wheelchairs, stretchers and hospital equipment ... and in order sans loose trash. It dawned on me at that moment ... the importance of leadership sending signals by DOING. All non verbal communication."

Later that day I wrote,

"Note on Friday, September 2, 2005

"Friday 11:49 AM
Now at the airport (NOLA) after our evacuation via Chinook helicopter with most of the animals. Helicopters and pelple pouring in here."

and

"Great sensitivity training for homelessness."

while waiting for busses to take us to shelters.

To be continued ...

Dr. Mike
PS. The whole story is available with photos, assessment, and "Disaster Preparedness Lessons Learned From Katrina" via my website.

Mission: Healing August 30, 2011

2011-08-30T10:17:00.000-04:00

PGY 39, Day 61

FLASHBACKS: Katrina on my mind

On this date 6 years ago I was "Inside Katrina" ... and Irene, well, She reminded me - was I in the right place a the right time, or the wrong place at the right time, or the right place at the wrong time - that I was in the thick of it at Tulane University Hospital on Tuesday, August 30, 2005. This was the day that started with a tapping on my door at 12:32 AM, and a this message: "The water is rising. They say there is a breach in the levee." I went back to sleep ... nothing else sensible to do ... nothing I could do about it ... I went back to sleep, safely locked in my office on a mattress on the floor ... in fact, it was the third floor of the hospital, and I knew that the flood waters could not possibly reach that high. And, as I recall, my vehicle was parked on the fourth floor of the parking garage, or was it the fifth floor? In any case, I knew my stuff and I were safe from the rising flood water, which was ... expected. Yes, this was the day that they decided to evacuate the hospital. After the flood ... after the elevators failed ... after the flood waters started to enter the hospital on the first floor. The stupidity is just outrageous ... still disturbing to think about it. I was there, because I was on call for Critical Care ... for the patients. But, the hospital should have been evacuated before the storm and shut down for the storm. So, I had become a participant in this exercise in stupidity, because of my obligation to and for the patients. In other words, the failure to evacuate and close the hospital before the storm, a storm we had watched and expected for days put hundreds, if not thousands of patients and providers at risk ... not to mention the hundreds of people ... SOM faculty and families (including pets) who put themselves at risk by attempting to ride the storm out at the medical center. So, all in all, the pre storm planning was just plain stupid, and because of this, I was there at Tulane University Hospital on August 30, 2005, when the flood waters rolled in from the broken levees around the Lake. The contrast with Irene is striking ... but, is this just another warning?
To be continued ... MORE REFLECTIONS on KATRINA AND IRENE ...
Dr. Mike

Mission: Healing August 28, 2011

2011-08-28T17:09:00.000-04:00

PGY 39, Day 59 @ 14:46 hours

Irene

Late afternoon darkness ...
as before the night,
comes early today.

Irene brings this,
in waves of wind and rain.

Wind, calm, rain and mist ...
waters pour between
light, gentle breeze, sweet warm, wet air ...

Like spring rain,
She mesmerizes,
pushing in slowly.

Relentless, undaunted ...
a warm and rising tide,lures us ...
children into mother's warm arms and kind smile.

But, She, neither kind nor gentle,
teaches ... all lessons of life and love ...

Naked ... not wishes, desires and dreams ...
not madness, but truth.

Undeniable ... some try to resist, why?
No matter ... none escape.

For the world ... the message is clear.
This Mother's love, not gentle ... but strong ...
wraps around us.

We, in Her tight, wild embrace,
might see ... for a moment,
madness gone and peace in place.

Dr. Mike

Mission: Healing August 23, 2011

2011-08-23T12:55:00.000-04:00

PGY 39, Day # 54
Back into they recovery phase. It always takes a few days for me to take care of loose ends and to catch up on my sleep ... to restore "normal bodily functions" after a week in the ICU.
This week was busy as usual, but not brutal as was my last week in the ICU. My team included two very bright fourth year medical students, a mid level surgery resident, two PGY 2 anesthesiology residents, a mid level OB resident and a surgery intern. Performance was quite good despite the fact that we had, as usual, some very sick patients. Aside from some some routine administrative nonsense (that needs to be eliminated) capacity was not exceeded at any time, as best I can tell. It is still trauma season, and the students are now back in town, so we can get slammed at a moments notice.
But, this week, we had time to talk ... and my focus was on The Healing Mission: Specifically Healing in the ICU. From my perspective Critical Care means Patient resuscitation, prevention of accident or further injury, and protection & preservation of Life, Limb and Organ Function. From that big picture view, I brought the students down into the gritty world of Patient & Family, organism, limb and organ injury and preservation ... then down into the level of cell and molecule ... damage, pathogenesis of injury, opportunities for intervention and the need for precise, rapid intervention. And, I gave them my STOMPP(TM) check lists to help them StepWisely(R) & stay on target in this world of chaos we call patient care.
Key points of discussion included, distractions from the mission and how to stay on target, advanced directives, reasons why families interfere with advanced directives, reasons why families interfere with care, reasons why providers interfere with advanced directives and patient care, team development, including the family in the care team. Then, we dropped down to specific patient and organ injury and injuries, primary injury, secondary injury, progressive injury, prevention of progressive injury, brain preservaion, the vaue of hypernatremia, spinal cord preservation, perfusion and its importance, prevention of complications, cardiac protection and prevention of myocardial ischemia, treatment of acute myocardial injury and MI, renal protection and preservation, ADH, DI, Cerebral Salt Wasteing ... and on and on. Generally, I take a tutorial approach based upon the real patients in the unit, but this week there was enough time for me to give my lecture on respiratory failure. This included, diagnosis, treatment options, prevention of progressive respiratory failure by using non invasive airway management therapies. Then we went on to invasive airway therapies, endotracheal intubation, methods and optimal intubation strategies, early management after intubation, early ventilator management, analgesia and sedation after intubation and prevention of self extubation. I am sure that the students (and the intern) were overwhelmed ... but that is not bad at this stage, because they always work with supervision.
So, now, I take care of loose ends and R&R for a few days ... part of which includes writing this blog ... and other assorted moments of reflection.
Ciao for now,
Dr. Mike

Mission: Healing August 17, 2011

2011-08-17T08:33:00.000-04:00

PGY 39, Day 48
Yesterday, the senior resident on the service said, "I'm bored." after which I promptly said, "Good. That means we are doing our job well." Then, I went on to explain ... "When we do our job properly, there is no excitement ... just good patient care ... even in the midst of the casualties and disasters." The message speaks for itself.
Dr. Mike

Mission: Healing August 16, 2011

2011-08-16T08:03:00.000-04:00

PGY 39, Day 47
Our current critical care team includes one surgery intern, two senior medical students, a second year OB resident, a PGY 2 Anesthesiology resident and a PGY 3 surgery resident.
Yesterday ... a 24 hour day ... rounds went OK. Our patient list includes mostly trauma casualties and a few SAH patients. Discussions focused on TBI and strategies for prevention of progressive brain injury, euvolemia, fluid and electrolyte management, diagnosis of DI, Hypernatremia and the differential diagnosis of hypernatremia, placement of central venous lines by the subclavian route and others. Everyone was pretty much organized by 10 PM and I left shortly thereafter. There were a few admissions during the night, but nothing drastic. The relationship between drugs & alcohol and trauma is STILL striking ... and disturbing ... even after doing this for so many years. Were it not for self abuse, we would have much less work to do.
We will see what today brings.

Dr. Mike

Mission: Healing August 15, 2011

2011-08-15T07:44:00.000-04:00

PGY 39, Day 46
Today I start another week of ICU coverage. Hmmm ... Interns on day 46 and peak trauma season. Will let you know how it goes.
Dr. Mike

Mission: Healing August 11, 2011

2011-08-11T10:33:00.000-04:00

PGY 39, Day 42

Morning Kiss

Shimmering Green Leaves Dance in Easy Winds
and
Dawning Sunbeams ...
Breaking through the shroud of darkness
and
Cool Morning Mist to Kiss ...
warmly and ever so gently ...
to bring another day.
Dr. Mike

Mission: Healing August 8, 2011

2011-08-08T16:13:00.000-04:00

PGY 39, Day 39
This is my latest post (today) to the American College of Physician Executives discussion on why physician leaders are not leading healthcare reform.
Here you go ... Dr. Mike
PS. We need some patients to join us in this effort!

Dear Doctor H...:
I understand your point of view, but disagree with your conclusion(s). This is a crisis ... and CRISIS = OPPORTUNITY.
If we take advantage of this chaos, put our personal needs aside, stop bickering, put the patients first and develop a united front with the patients, we can drive this whole thing in the right direction.
Millions of $$$ have been put up for development of COOPERATIVE insurance models. We could take advantage of this opportunity by realigning ourselves with our sworn obligation to the patients (The Hippocratic Oath), and joining together with patients to create some smart DOCTOR-PATIENT COOPERATIVES that will favorably compete with the junk that is avaiable out there. Patient needs are great and growing and the money is available, but we are stuck on trying to do things with the old models that don't work and waste too much money on profits, bandaids, categorical programs, low priority items, and bureaucracy. I figure we can reduce waste by 30 - 50% by eliminating the third parties ... the reason for a DOCTOR-PATIENT COOPERATIVE.
My position? It is better to try something new that might fail (or something more like the old thing that worked) than to give up. While most seem to be comforted by wringing their hands in misery, I saw at least three voices in this conversation that appear to echo my opinion. If those of us who agree can get together on this, we can take the next steps that are necessary to move from talk to action. Interested parties are welcome to contact me.
Dr. Mike
Michael F. Mascia, MD, MPH
dr.mike@ihealsolutions.com

Life Is Love(TM)

2011-08-06T21:26:00.000-04:00

https://twitter.com/dr_mike_ihs/status/100013378386407424

MISSION: HEALING, August 5, 2011

2011-08-05T07:49:00.000-04:00

LIFE IS LOVE (TM)

This is a fundamental guiding principle: LIFE IS LOVE(TM) Think about it.

Life without love is pretty much ... well, lifeless. In other words, love brings a dimension to life that is a quantum leap above survival. Don't get me wrong. I understand survival and striving to meet fundamental survival needs, but how much does that take. Human nature pretty much dictates our (animal) need to take care of ourselves first (selfish) but, face it ... how much do you really need ... REALLY NEED??? And, is that all you want for yourself and your kids? How much stuff do you need?
Maybe we can all spend a little more time striving to embellish those things that are special about human beings??? ... SPECIAL!!! Like, creativity, art, music, writing, listening to each other, playing ...

Sure, it is simple, idealistic and, perhaps unrealistic to think that grown people can live life by following this fundamental guiding principle, but not impossible. Sure, our lives are cluttered with all sorts of things that make it seem impossible ... but, it is entirely possible.

Sure, you say, there are all sorts of REASONS WHY "it can't work ... IT CAN"T BE DONE!!!" Well, if you are one of the folks who is saying "it can't be done", you are simply wrong. It can be done and this is one piece of how ... "IT CAN BE DONE!!!"

This is the start of a new series designed for children ... to help them understand the fundamental principle that LIFE IS LOVE(TM) and to help explain to them how to put that principle to work in their lives. Yes, "IT CAN BE DONE!" What is THE RIGHT THING to do and How to FIND AND DO THE RIGHT THING TO DO when there are so many options out there. While the guiding principle is fundamentally Love, the goals of this series include, but are not limited to individual health, public health, community health, world health & safety.

This is, in essence, a Set of Children's First Steps on the path to STEP WISELY(R) on the way to health ... as you are learning and growing your way through this world ... to know that LIFE IS LOVE(TM)

Ciao for now,
Dr. Mike

Mission: Healing August 4, 2011

2011-08-04T10:33:00.000-04:00

PGY 39, Day #35
The Business of Medicine: Follow the money
Health Information Technology: Top Ten Problems

A few days ago, I promised a Blog on the Top Ten HIT problems. Of course, this is just my opinion ... based upon more than 40 years experience in patient care, teaching, administration and research. That is ... experience in a cross spectrum of patient care from primary care to tertiary care and quaternary care ... from primary prevention to treatment ... from home to hospital ... treatment of some of the sickest patients in the nation. Granted, my experience is limited to the East coast. I have not worked west of New Orleans, but, I don't think patients are much different west of the Mississippi. When I started in Medicine around 40 years ago, there was NO technology available to help develop HIT systems. Now, we have all the necessary technology, but Mission: Healing is lost in the race for $$$ by the HIT providers. Ah, yes, greed again. I suggest that the Non Profit Doctor-Patient Cooperative could take this on as one of its tasks.

In any case, this is the way I see the TOP 10 Health Information Technology PROBLEMS today.
Report Card: Overall Score 2/10

1. Interphase: Too Cumbersome and too much time is used interacting with computers.
These machines should make it easier for us to spend more time with and take better care of patients. But, in fact, they interfere with patient care. They take precious time away from patient care activities. In other words, they add non patient care tasks to our daily activities ... far in excess of paper charting. According to my observations and estimates, 25% to 50% of provider time is tied up interacting with the EMR. That's not good.
These Systems should have to pass a risk/benefit test ... like all our drugs and procedures, before they are allowed to enter the Healthcare arena. HIT Providers charge outrageous prices, because they can ... and because they promise to improve reimbursement ... under the guise of better care.
Let's look at cost benefit and design systems to IMPROVE PATIENT CARE FIRST! Improve Quality First! And, while you are at it, prove that you are improving quality. A "from scratch" system would be in order ... without proprietary restrictions.

2. Data Entry: Too Cumbersome
Related to #1 above, but separate, the data entry points should duplicate our clinical flow sheets that have been developed over the last 50 years! Jumping around from place to place for the ease of developers is neither necessary nor acceptable.

3. Data Shareing: Too Cumbersome because proprietary systems don't talk to each other.
We can't add data from outside sources (EG images) very easily, if at all, and, no matter where the data comes from, it is difficult to find, or access some of it.
A Health Information Exchange Network (Health Internet) needs to be established ... preferably by the government. Similar to banking, private HEALTH INFORMATION BANKS kept in Doctors' offices and Hospitals, need to "store" the data, like banks store your money. And, in addition, each patient would have their data and data could be shared among patients and providers with permission ... over the secure Health Internet.

4. Security: Inadequate & related to #3 above
The health record belongs to the patient, so it should be given to the patient in electronic format and shared only via secure Health Internet & and between patient and providers.

5. Ease of USE: Non existent
Outlined above. Some combination of touch screen and voice activated data entry would work best, given today's technology.

6. Time dedicated to machine: Excessive
Outlined above

7. Redundancy: Inadequate In other words, when the power goes out, or the system goes out, the data is not accessible. A flow sheet summary should be printed on a regular basis one for the patient and one for the provider. This was a major problem during Katrina. We had critically ill patients with no patient information.

8. Reliability: Inadequate
Thses systems go down all the time ... for one thing or another. Automatic printing of flow sheets on a scheduled basis (depending upon severity of illness) is necessary and lacking, as outlined above in #7.

9. Comprehensiveness: Inadequate

These systems should be designed for patient care, administration, teaching and research. I will expand on these topics over time.

10. Flexibility: Minimal
The IT people have these systems locked up. (I believe that the EHRGuy was referring to this. Perhaps he will comment on my blog, once I publish it.) They should be simple enough to enable users (admistrative users) to make changes that will make them more specific to particular front line use anywhere in the world.

Mission: Healing August 1. 2011

2011-08-01T21:50:00.000-04:00

PGY 39, Day 32
It has been a brutal week ... lots of casualties. We had a few hours of down time yesterday afternoon, before last night's "bolus" of new trauma patients. I always tell folks to enjoy the down time, because it never lasts long ... always more patients out there. The need is great.

Most are very sad stories for patients and their loved ones. They are truly casualties ... many victims of self abuse ... drugs, alcohol, lifestyles that breed pathology, momentary stupidity and bad decisions. And there are the many "innocent bystanders" who are victims of the fall out from the bad behavior. So sad, but, no time for emotional and big picture considerations during the heat of the moment. But it does take its toll for the patients, the families and the providers ... forever. We are all changed forever.

My focus on defining, treating the precise and most important targets of care is intense ... undivided attention must be given to the patients and their problems to enable precision, timely intervention where seconds and minutes can mean the difference between life, loss of limb, organ damage, or death. That is Critical Care.

Between driving inexperienced people in the right direction, keeping them focused on the key targets, engaging families, avoiding distractions and sleep deprivation, by the end of my week I am all used up.

This is my recovery time ... my time to sleep, decompress and to think about the emotional impact on me & larger picture ... problems and solutions. Always thinking about ways that we can make it better for the patients and the proviers ... the many people who need our services. Healing is a labor of love.

Ciao for now,
Dr. Mike

Mission: Healing July 31, 2011

2011-07-31T08:57:00.000-04:00

PGY 39, Day 31
Predictably busy and not much time to think or play. Happy July!
Beyond capacity ... Problem Solving ... Mission Integrity
Why health care institutions don't address chaos?
Paterns of utilization need to be acknowledged, and surge capacity needs to be built around the needs of the patients served. Why not? It makes sense and $$$ to serve well.
No time to expand now. Will share some of my thoughts and "TOOLS" later this week.
Dr. Mike

Mission: Healing, July 28, 2011

2011-07-28T07:55:00.000-04:00

PGY 39, Day #28
Missed yesterday. Too busy to write. Pushing capacity. Interns are in the thick of it and totally overwhelmed. Time to train up is not put into the staffing formula.
More later.
Dr. Mike

Mission: Healing July 26, 2011

2011-07-26T05:57:00.000-04:00

PGY 39, Day #26
Early Morning Meeting today. Let's see what the day brings. Hopefully, our leadership will not be following congress for tips on leadership skills.
Dr. Mike

Mission: Healing July 25, 2011

2011-07-25T21:52:00.000-04:00

PGY 39, Day # 25
Long day after a short night. Had to take care of some family heal care problems yesterday. Got in late and had a long, productive day in the ICU. Exhausted. More tomorrow.
Dr. Mike

Mission: Healing July 21, 2011 StepWisely(R) #1 Dr-Pt Relationship

2011-07-21T09:59:00.000-04:00

PGY 39, Day 21
Patients First: Patient Safety First - the essence of the Doctor-Patient Relationship
How you can help your doctor to help you despite the Business of Medicine!

Business of Medicine = $$$
Profession of Medicine = Patient Care
The Business of Medicine is NOT The Profession of Medicine

How to Bridge the gap?

The other day I saw a blog ... something about how you can protect yourself when you need hospital care. For some reason that is beyond me, some folks think they can direct themselves, without PROFESSIOINAL MEDICAL guidance ... without a Doctor to find the best hospitals and health care. Of course, some of these folks are selling something.

Well, you can take care of yourself and protect yourself and your family to a certain extent by being smart, but the best thing you can do and the first thing that you should do is to find a doctor you can trust and establish a relationship with that doctor. Yes, the Doctor-Patient Relationship is #1 and still the key Optimal Patient Care. The next question is how do you find a good Doctor with whom you are comfortable and in whom you have confidence? That may be a bit more of a challenge for many reasons.

Regrettably, over the last 70 years (in the US) many factors have contributed to the decline of the Doctor-Patient Relationship, and I have seen things get much worse over the course of my career. The bottom line is this: over the last several decades and especially the last 25 years, the Business of Medicine has put multiple third parties between the Doctor and the Patient and some of these third parties have $$$ as their primary objective. Well, it would be OK, to have money as a primary objective, if pateint care is perfect, but some of these thirds parties will cut corners on patient care and patient safety to make more money(eg, Health Care Providers), or keep their money(eg, Health Insurance Companies). This is where the Doctor-Patient Relationship comes in. It is the responsibility and the sworn duty of physicians to take care of The Patient First and above all else to promote patient safety. This is an obligation that comes with the Hippocratic Oath ... the Oath that most, if not all Physicians take upon graduation from medical school, and this is a serious matter.

This oath creates the foundation of the Doctor-Patient Relationship, and it is essential to providing optimal patient care. Patient Care is never perfect, because the Science of Medicine is not perfect, but the physician's obligation remains and is based upon the best available science. Next, I will ... when I get to some high speed internet access, put the oath in here. In the meantime, think about what I have said and know that it boils down to Do the best thing possible for your patients at all times, do the right thing, and do no harm.

Do you have a relationship with a Trusted Doctor? If not, why not? If not, you need to find one. I will give you some tips here in the future, but for now, when you do see a doctor, make sure he/she graduated from medical school and make sure he/she took the Hippocratic Oath. Ask him/her what it means and how it is important to your relationship.

Ciao for now.
Dr. Mike

Mission: Healing, July 15, 2011

2011-07-15T09:22:00.000-04:00

PGY 39, Day 15
I must confess to being a coffee snob. That means I love coffee, and I have become more and more picky about what coffee I will drink, and where & when I will drink it. When I am working in the OR, I will get up extra early, so I can take the time to make and drink my coffee. For me, it has become an important ritual ... and (with regard to this particular ritual) the ultimate is having the time to roast beans in the evening, grind them in the morning, sniff them and the fresh grind and fresh brew in the morning. Then comes the drink ... nothing like that morning cup, brewed with crystal clear spring water ... sipping it to the tune of birdsong and the sight of morning sun as it cuts through the darkness to dawn on us and show us what this day has to offer. That's the way I like to start the day and it does happen sometimes.
Generally, I don't have the perfect ritual, but the morning coffee ritual is always part of my time for recovery and healing ... time for contemplation and consideration of the stuff of the days before and time for planning this day and the days to come.
So, as this bright and sunny day emerges in the midst of my coffee ritual, as usual, I think about the past, present and future.
Yesterday I spent several hours doing administrative work for WVU. This included Quality and Performance Improvement activity, and some email correspondence with the Dean about a few contentious "issues". Of course, these are confidential matters, so you will not get any details here. But, the point is that several hours of my time were spent doing work for WVU.
Buona Fortuna ... e una bella giornata!
Dr. Mike

Mission Healing: July 10, 2011

2011-07-10T19:57:00.000-04:00

PGY 39, Day #10
I tried to post this on the ACPE website discussion that I had told you about earlier. Today, this one, somehow got lost in cyberspace, and I can't paste into the ACPE discussion, and I am not going to type it in again. The discussion is the hottest spot on the website with over 60 posts and more than 400 views. Keep in mind, these are all Doctors who are (presumably) busy.
This is what I wanted to post ... it is going on my blog instead and I will invite them to view it here.
"Hello, Dr. G:
Thank you for your good words. I am just glad to see this discussion in print, and that it is being sponsored by ACPE. ACPE is showing true leadership by enabling such a conversation. But, I don't really see it as a debate, and I don't see anyone holding back ... even though I am sure that some are afraid to speak for one reason or another.
From the postings so far, I see quite a bit of agreement, but I have also noticed that there are many viewers and only a few "posters". I wonder who is watching and I wonder what they have to say? Hope they speak up.
Nevertheless, although my personal preference is to see PLs and PEs on the front lines with me on a regular basis for many reasons, I don't think anyone said that "practicing full time in patient care" is required to have a "more important or more relevant" opinion. More important than any words or opinions expressed on these electronic pages are the facts that define our success as physicians in meeting our obligations to the patients. In other words, we all know how to talk the talk, but how well do we walk the walk?
To keep us all walking ... perhaps a bit more in synchrony toward meeting our patient obligations, we all need sensors on the front lines. I like real people as sensors ... real doctors and real patients. Short of being the patients. or providers, on the front line, the next best thing is for all PEs and PLs to get out there on the front lines on a regular basis. And, while you are at it, drag the non physician Execs and Leaders out there with you as well. Feel the heat of the battle. Is it so scary, or time consuming to to get out there every once in a while ... to see, feel, smell, hear and touch what is actually going on out there? Is it so hard, that PEs and PLs can't go there? If that is the case, maybe those folks belong in another business.
It is time for us to face the facts that the Business of Medicine has become an out of control monster composed of and driven by an outrageous number of third parties most of which are political, self serving or both. This BUSINESS OF MEDICINE MONSTER, drives us ... more and more away from our sworn obligations to the patients. This monster rides on our backs ... the backs of doctors and patients ... the backs of the DOCTOR-PATIENT RELATIONSHIP. This monster has control, it holds the whip and the leash ... and it is not about to relinquish that control. That is why I see the need for a new paradigm.
But, that will take time and effort ... probably 3-6 months to start and 3-5 years to build an alternative program with long term viability. In the meantime, I will continue to push to get the PEs and PLs out onto the front lines and I will continue to look for and work with & for PEs and PLs who are clearly aligned to helping me to continue to carry out all aspects of my Healing Mission on the front lines and all the other lines for as long as I have something to offer.
My hope is that ACPE will continue to enable this discussion and will help us take the next steps toward developing a new paradigm that will help us all to stay on target with our Healing Mission. With any luck, some of our current PEs and PLs will participate in the process and help us to make it right.
Dr. Mike"

On the Lighter Side ...

2011-07-09T10:09:00.000-04:00

Today, (actually it was Friday) I am OFF! That means, I am goofing off and doing some things that have needed to be done for a long time, like oil change and do it yourself auto maintenance & cleaning. So, after the oil change (6000 miles overdue), I go to the local branch of "megachain" auto supply, to get some fabric/carpet cleaning stuff(there are about 30 to choose from. It takes me a while to figure that out, but pick one that should work and is the least toxic. I actually know what the chemicals are.) & fog light bulbs (they have been out for about 6000 miles, which is not too long in my life. I drive quite a bit.). While at the store,I have the guy run the diagnostics on my "check engine" idiot light, which has also been on and off for about 20,000 miles.(Should I get a tune up?).
Anyway, the funny part of the story is this: I buy the fog light bulbs and carpet cleaning stuff, but and before walking out the door, I made the mistake of asking, "Is this a tough job?" He jumps on the question and instantly (acting as if he knows what he is talking about) proceeds to make it sound like a big production. I don't know if he thought I was too old to get down on the ground and back up again, or what, but he said, "ya gotta put da car up on da lift and ya gotta get on your back and all that." So, I'm thinking to myself, "Hmmm, sounds like a PIA. Maybe I should leave this to the dealer. I can't bring the bulbs to the dealer. O .. boy ..." But, "o boy", I buy the bulbs anyway.
"Perfect conditions!" Warm and dry in the driveway when I get to the house. Carpets and seats clean. Still warm and dry. "To hell with it," I pull out my camping matt, lay it on the pavement and pull out the old bulb and fixture in less than 30 seconds. "OH" ... bulb out in another 30 seconds "OH" ... new bulb in another 30 seconds ... back in place ... another 30 seconds. Same thing on the passenger side ... and they work.
Engine Diagnostics said one of the vacuum regulators also needed to be replaced, so I bought that part. "It is easy. Right on top of the engine." When I checked under the hood, it instantly became clear that it is easier said than done to replace that part. I will give it a shot, when I have a whole day.
Moral of the story ... don't listen to the guy at the counter of "megachain" auto supply, when you need advice about how to replace auto parts.
Dr. Mike

Mission: Healing, July 8, 2011, ACPE Post

2011-07-08T18:31:00.000-04:00

This is my latest post on the American College of Physician Executives discussion regarding, Why Physician Leaders are not Leading Health Care Reform. I am advocating the start of a new paradigm. Specifically, I think it is a good time to start a Non Profit Doctor-Patient Health Care Cooperative. I think I made a couple Executive Physicians angry. What do you think?
This is what I said early this morning ...
"Doctors:
This is a great discussion from my perspective. Why? Because front line docs are talking with Physician Leaders & some are paying attention. Sorry, Dr. Cardinal, but, with all due respect, physician leaders and especially physician executives need to work the front lines. Why? It keeps them honest and aligned with the healing mission.
I have never been there, but I have heard and read that respected Generals work the front lines with their troops and their boots on the ground. They may not man the machine guns, rifles, tanks and other weapons, but they are in there with the troops & they understand the war.
I have not had the honor of working for Geisinger, but I have worked front lines, administrative lines, academic lines, public health lines and research lines in many environments, and in institutions ranging from my own private rural medical practice in Maine, to academic Critical Care Anesthesiology Divisions at SUNY in Syracuse, Tulane in New Orleans & WVUH Morgantown. Maybe Geisinger is different, but I have never seen any PEs or PLs in the Intensive Care Units or Operating Rooms. Closest I have been to a PE was the hug I got from Paul Whelton AFTER evacuation from Tulane, where I had the honor of serving during Katrina and the days that followed ... he was the only one around and i admire him for that. All the others have been ... well, I just don't know where they have been. I only know where they have not been and I do know how it has been on those front lines. I do know that few have been listening.
So, nevertheless, I have begun this PGY 39 still committed to the Healing mission & the oath that I took upon graduation ... on the front lines (and all the other lines) ... still optimistic ... because joy comes from the DOCTOR-PATIENT RELATIONSHIP ... & this is a labor of love. I am still optimistic about the Healing Mission, but not about the "business of medicine". Medicine will survive ... the business of medicine will not.
ACPE is the only professional organization I have ever joined that has been supportive & worth the money. ACPE has enabled my continued growth as a physican-healer-administrator-teacher-researcher. I am wondering if it is an organization that can support us in in the creation of a new paradigm that is destined to survive. I am wondering if it is going to be a part of the solution, or not. We will see. So far, so good ... this dialog is a good start.
Dr. Mike"

Mission: Healing, July 8, 2011

2011-07-08T13:54:00.000-04:00

PGY 39, Day #8. Worked into the morning of the 5th in the ICU. Everything went quite well and now I am in the recovery phase; this time after an 8 day week. During recovery time, I generally catch up on sleep, reflect on the clinical work, tie up the loose ends and take care of my administrative and personal stuff that has to be put aside during the intense focus on leading the SICU team ... to care for the patients.
We had some remarkable and dramatic patient care problems this past week. And, I might add, that the outcomes were remarkably good! That is something to celebrate. When I get back to the unit at the end of the month, I will make a point of telling folks how well they did. We will review the cases in SICU M&M for teaching purposes.
SICU is so intense, that I can't do much of anything other than work with the team to make sure the patient get optimal care. I have designed some tools to help keep inexperienced providers on target with the Healing Mission ... Patients and Patient Safety first. There is so much noise and so many distractions that it is particularly difficult to keep newbies on focus. It can be done ... it is always a tough job ... orchestrating optimal comprehensive care of critically ill patients ... but, it is a beautiful thing when it is done right. Doing the right thing for the patients and families ... despite the obstacles and the complexities ... that is the Healing Mission.
Dr. Mike

Mission: Healing, July 4, 2011

2011-07-04T09:39:00.000-04:00

Happy 4th of July! PGY 39, Day 4
Yesterday brought worries to the surface of the interns. Let's see what today brings. So far, there are no panic calls. Yesterday, there was contained panic.
Dr. Mike

Mission: Healing, July 3, 2011

2011-07-03T08:01:00.000-04:00

Another short night and days blending together. The calendar says it is another day and that tomorrow is a holiday, but this is a block of time: an 8 day week for the patients ... time, virtually 100% of which is dedicated to the patients. We will see what today brings.
I will go in soon ... sooner if they call me for a problem.
Dr. Mike

Mission: Healing, July 2, 2011, PGY 39, Day 2 Continued

2011-07-02T23:36:00.000-04:00

Here it is! My post to American College of Physician Executives discussion from today. We will see what I get for responses.
Dr. Mike
This is PGY 39, Day 2 for me. That means Post Graduate Year 39 (after medical school) for those who are unfamiliar with the term. PGY 39 ... WOW! I remember the day I graduated and the day I took the oath. Things have changed, but I still take that oath seriously.
Running the SICU service with two PGY 1s (AKA interns) and some back up from PGY 2s and 3s. We get the job done despite the distractions. How? Focus on the Mission. What is the Mission? Healing; AKA Patient Care. That is the only way I can keep inexperienced house staff and nurses on target to provide comprehensive quality care.
Do we talk about money? Yes. Do we talk about Quality and Performance? Yes. Do we talk about the needs of the providers? Yes. But, all of the conversations not central to providing optimal patient care are secondary to our talk about specific patients, their needs and the needs of their families and loved ones. We engage everyone in the process of care ... patients, families, docs and support staff ... all the folks who help us care for those patients. They all help us to stay on target with the mission, goals, objectives and the process of providing optimal care for OUR patient. It works ... it is hard work, but it works and it is the right thing to do and it is rewarding. Not for the money, but for the pleasure that comes from doing the right things for these folks who need us. It is about love ... there is not enough money to endure the stupidities that have grown into great obstacles and barriers between Doctor and Patient.
Yes, it all gets harder as the complexities of care grow ... not because patient care is harder, but because increasing numbers of various (removed from the front line) third parties impose more and more tasks and distractions that detract from our efforts to accomplish the mission.
How many of you work the front lines? How many of you feel "production pressure"? How many of you work for a "Physician Leader" who is pushing you to cut corners on Patient Care and Patient Safety for short term $$$ gains and profits? How many of our "Physician Leaders" work the front lines? My bet is that there are very few of us out there. And, how many of us who work the front lines have a significant voice in driving the health care machine that we work in? I suspect very few have a say.
What does that have to do with anything? Get out there and try it ... try breaking away from those closed door executive meetings and get yourselves embedded in the front lines. You might learn something about the needs of the patients and front line providers.
Think about it, and think about this: This is the time for a new paradigm ... or return to the old paradigm. Return to the fundamental practice that is the DOCTOR - PATIENT relationship. Simplify ... get the third parties out. That would save 30 - 60% of each and every health care dollar. If you don't take care of patients, you have no business making decisions about how patient care is provided! Get out! And, those of us on the front lines will have to carry some necessary administrative burdens. Such is life as it should be, in a DOCTOR-PATIENT driven health care system.
I sat at one of my obligatory hospital meetings the other morning. During the usual boredom, I counted the number of people there who rarely, or never take care of patients. They have created a bumbling and very expensive bureaucracy to justify their own existence. What for? To deal with the complexities created by other third parties that never take care of patients. This is the BUSINESS OF MEDICINE and not the PROFESSION OF MEDICINE.
The business of medicine is not equal to, nor does it have the capacity to provide optimal patient care. In other words, the BUSINESS OF MEDICINE does not equal GOOD PATIENT CARE. There are too many gaps and obstacles in the production lines (product line/factory mentality) designed to make money ... forcing doctors to become line workers who work on their patients for the sake of the company. The Healing Mission ... the Human Factors ... are lost in the confusion that ensues when we chase the money.
That approach can never work, because it is designed to make money and not designed to provide individualized care to patients and families. The HEALING MISSION can only be accomplished through the bond between DOCTOR and PATIENT in the context of their FAMILY. Why did we let this happen? We followed the money!
Let's try something different. I believe the time is right for a new paradigm. LET'S START a NATIONAL NON PROFIT DOCTOR - PATIENT COOPERATIVE. Build greed out of it. Cap salaries and eliminate profits. Put all money back into care, and "profits" back into the hands of the members.
My sense is that about 5 - 10 % of the patients we serve are interested in being active participants in their health care. That is a large number of people. And, according to my calculations, that could, over time, create a large enough population base to enable development of a NATIONAL, or INTERNATIONAL NON PROFIT DOCTOR-PATIENT INSURANCE COOPERATIVE that could fund itself for routine care and buy, or create catastrophic back up coverage to be used anywhere.
Idealistic? Yes. Possible? Yes. Anyone interested? Let me know. I need a few good, experienced, dedicated and courageous docs (and patients) who are ready to work with me and to take a step into the unknown for the sake of the patients we all serve ... and for the sake of the profession ... to honor the oath that most of us took upon graduation from medical school. You have little to lose and, perhaps, we all have a little something to gain.
Dr. Mike

MFM@IHS ip

Mission: Healing, July 2, 2011

2011-07-02T08:50:00.000-04:00

Day 2 of PGY 39 will continue, as it has been a night without much sleep ... a continuation of yesterday without distinction. Sickness does not know the clock, or the calendar, so one day blends into the next. We live in the moment ... each moment dictated by the needs of the patients we serve.
Quiet and calm West Virginia morning ... mourning dove, birdsong, cool, sweet air, sunshine and calm for the moment. All reports calm in the house this morning as well. We shall see.
Dr. Mike

Mission: Healing, July 1, 2011

2011-07-01T07:57:00.000-04:00

July 1, 2011 ... another first of July ... 39th year starts today. Could that be right? Yes that is right. This is the start of my 39th year in medicine. I'll think back on that ... reflect on it a bit with the new folks, before we start rounds today. They will be in a frenzy of fear and excitement.
Dr. Mike

Mission: Healing, June 30, 2011

2011-06-30T08:08:00.000-04:00

Yes, this is the last day of the year ... the last day before the new interns start. Well rested this morning, so that should help.
Dr. Mike

Mission = Healing June 29, 2011

2011-06-29T08:08:00.000-04:00

Today, the team will be light. Our senior resident will have meetings for most of the morning and the rest of the folks are going to have to come up to speed. We will see how it goes.
Dr. Mike

Mission = Healing June 28, 2011

2011-06-28T08:16:00.000-04:00

Meetings are pretty worthless these days. They appear to be places where people who don't take care of patients spend their time. So, they (these folks) need to have more meetings to justify their job, aka existence and pay. My solution to that problem is simple ... No clinical work, no administrative work = no teaching work = no pay & no clinical work = no job. Minimum clinical work for health care providers should be 20% of total hours worked.
Most of the stuff discussed in our meeting today could have been done by computers with a little human help. I saw at least three and as many as 10 people at this early morning meeting who virtually NEVER take care of patients. Maybe they should work elsewhere, or in some other business?
Dr. Mike

Mission = Healing

2011-06-27T19:28:00.000-04:00

Today, after rounds, while writing notes, one of our discussions centered around advanced directives ... our own individual advanced directives. As a teaching exercise, I asked one of our residents to bring his advanced directives in order to read the exact language he would use to describe what he wants done in the event of a cervical spine injury with quadriplegia. It's easy to talk about, but not that easy to do. To get the exact language ... the language that will tell providers and especially exactly what you want done under all circumstances. Try it ...
Dr. Mike
To be continued ...

Day Job Doc

2011-06-27T08:03:00.000-04:00

My life has been dedicated to healing.
https://twitter.com/dr_mike_ihs/status/85311009652346880
Let's see what today brings.
Dr. Mike

Testing

2011-06-20T10:18:00.000-04:00

I am just starting this blog thing. Will probably need help to figure it out.
Dr. Mike