Dear Colleagues and Friends,
Today is the most important day in the history of Buffalo since the British burned it to the ground on December 30, 1813. This is the day of the NFL Draft. If you have been reading the newspapers or listening to the radio, you would think that the draft tonight is the most important event in our history. Will we finally draft the quarterback of our dreams?
Speaking of drafting, if you had to draft a first lady of the United States, wouldn’t Barbara Bush be the first pick. She showed us how to live and how to die. If there was ever a role model for palliative care, she would be it.
The Internal Medicine Residency training draft, i.e. match, was successful again this year. A full complement of excellent new interns will be starting in July. On the other end of the program, our graduating residents have been accepted into fellowship programs in infectious disease, cardiology, neuro–critical care, and heme/onc. They will be spread from Boston to Texas. Congratulations to them and their teachers.
Special thanks goes to Dr. Mark Jajkowski, who just completed his tenure as President of the Catholic Health Medical Staff. Dr. Donald Largo from Mount St. Mary’s is the incoming president.
Documenting nutritional status and malnutrition remains a challenge for us. The insurers continue to hammer us on this. To meet that challenge the nutrition department has drafted a new section in Soarian called the Nutrition Committee Note. The insurers are refusing to accept our Registered Dietitians’ notes as documentation of malnutrition. They insist that a note be specifically stated in the provider’s notes. Now you can copy and paste the dietitian’s notes into your progress notes. Hopefully this will resolve the issue. It may seem like a moot point, but the economic impact for the system is huge.
Can you believe that new cases of influenza are still being diagnosed in WNY? I guess we are still getting evil Draughts. True or false? A patient, who gets admitted from a nursing home, and who has the flu, and is treated with Tamiflu, can be sent back to the home if stable on day 3 of the 5 day course of Tamiflu? The answer is No. The patient will not be allowed back until the entire 5 day course is finished.
Recently the Bioethics Committee discussed a difficult hypothetical case. A patient was deemed to be mentally incompetent for making big decisions. There were no family members nor Health Care Proxy. The patient had impaired cardiac function, and was at high risk for ventricular arrhythmias. The patient would not wear telemetry leads or a LifeVest. The ethical question was whether or not the patient should be restrained in order to keep the leads or LifeVest on. Without these, unrecognized fatal ventricular fibrillation could occur. Forcing the patient to wear the leads or LifeVest could detect the arrhythmia and save the patient. The decision of the committee was that it was more appropriate to let the patient die without restraints then to induce suffering and potential death from the restraints per se. What do you think?
Making the diagnosis of sepsis remains a problem. In the past “Sepsis 2” criteria were used. This centered around documenting an infection, hemodynamic instability, and elevated lactic acid levels. In 2017 the Surviving Sepsis Campaign suggested drafting “Sepsis 3” criteria instead. Whether we clinicians agree or not, and many of us do not, the insurers are aggressively mandating this. The basic difference between the 2 sets of criteria is that in the latter there must be evidence of organ dysfunction due to the inflammatory effects of sepsis. There are diagnostic criteria with names like SOFA (Sequential Organ Failure Assessment)and q SOFA (the” q” stands for quick), etc. To utilize these tools just keep in mind that one has to look for changes in respiratory rate, mentation, hypotension, increased bilirubin, thrombocytopenia, and an increased creatinine or decreased urine output.
One last thought on the Draft and Medicine, if a person gets drunk and has a bad hang-over from too much beer, should they be diagnosed with “Draft vs. Host Disease?”
Norman J. Sfeir, MD
Associate Chair of Medicine
Sisters’ Hospital
