Friday, January 25, 2013

Day 223 - big dogs, big journals, big fun

Ever notice how nobody ever says "Is it cold enough for you?" but "Is it hot enough for you?" is commonly said. I wonder why not and why. In case you were wondering, it is cold enough for me. Maggie wouldn't mind it if it were colder, however. Today Maggie and I went to visit my friend Joni and her dog, Talaigh (said "Tally" like tally ho). Talaigh is a 90 pound Great Pyreneses with long white fur and a playful temperament. At first Maggie was afraid of her and kept trying to hide behind me, but soon she began boxing with Talaigh and then they began playing with toys together. Maggie seemed to have figured out there was no way she could muscle toys away from Talaigh so instead she would distract her and then swoop in to steal them. It was adorable. A funny thing is that she will defer to Kita who is significantly smaller than her and Talaigh deferred to her. Good luck understanding the canine brain. We had lunch and they had playtime. A good time was had by all.

In addition to lunching, I breakfasted with Patrick at D2 which was very nice. I called my new friend and fellow traveler in AML land and he is doing well. I don't remember if I blogged about it, but the induction chemo is supposed to run without interruption for 7 days. They're very serious about the without interruption stuff; you're supposed to keep it going even in the shower. Fortunately for me, there was a pharmacy delay and for one very pleasant hour, there was no cytarabine to infuse for me so I was able to run into the shower without my annoying companion. Evidently something like this happened for him too so he was feeling quite clean and spiffy when I called.

I have a few good articles to recommend. The JAMA from Jan 23/30 is about readmissions and has one article I really liked about Diagnoses and Time of Medicare Readmissions. It turns out that the peak day for readmissions for AMI, CHF and pna (pneumonia was feeling left out without a three letter acronym) is day two after discharge with an almost imperceptible decrease in readmissions every day after that to day 30 which was the end of the study. People with CHF and AMI are most likely to be readmitted with CHF. People with pna are most likely to come back for pna, then CHF. There is no real difference between which diagnoses people come back with in which part of the month. This says if you could eliminate CHF readmissions, you'd be very successful. I remember in residency having it made very clear that you have to find the cause for every CHF exacerbation. I wonder if people dig down further into the CHF readmissions and sort out why the people came back: dietary indiscretions, med mixups or non-compliance, infections, new cardiac events, arrhythymias, etc. My guess is that would be a much harder study to do and even harder to do right because it would not be automated data and it requires a good H and P for each readmission. I think that might be where the real explanation is. The December 13 NEJM had two really great articles that described in narrative form what it was like to be in a flooded and failing hospital: how they dealt with patients, no water, etc. and also what it felt like. One of the articles talks about how "Bellevue was empty of patients--probably for the first time since it opened its doors in 1736." I remember thinking when I was a resident about how I was part of an unbroken chain of doctors taking call all night that stretched back for generations. I imagined us all holding hands in a chain back into a past where I thought the records had probably even been lost and it made even the difficult nights feel a little more, well,  sacred. It seems like something is really lost when a hospital has to close even briefly, but it also seemed like the people who did their jobs or whatever jobs needed doing while the hospital was flooded really did a good thing for their hospitals.

For all of us for tomorrow I will wish for the chance to do good things.

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