Blog | Monday, November 28, 2011

Hospitalistin'


Keep the big picture in focus
People should be admitted to the hospital because they are sick enough to have an increased chance of dying relative to those going home. My overall patient-by-patient "mission statement" is: Find the diagnoses and offer treatment options that decrease acute mortality and chronic morbidity through efficient and high quality care. Offer palliative care options when such treatment is medically futile or does not provide significant gains in the quantity to quality of life balance. The patient needs to be looked at as a gestalt of both data and intuition regarding the level of acute injury inflicted on the substrate of a certain level of chronically damaged protoplasm.

I have to explain to my patient and their circle that based on what I think is going on, will the treatment options available improve their lives and do those benefits outweigh the risks of that treatment. If not, pursuing aggressive treatment of the untreatable is a study in futility, and palliative care options should be introduced.

Understanding the worst case scenarios, is in my opinion, more valuable to both provider and patient than painting a rosy picture of the future. It is important to foresee negative outcomes to know what to test for and what you may need to treat, but without either you or the patient losing sight or hope of positive outcomes. Positive outcomes do not necessarily mean a cure, it may mean pain control, dignity, and even a peaceful death.

Sweat the details
A good internist is a scared internist: worried about what has happened, concerned about why the current state of their patient is different from before, wondering how complications can occur in the future. We take a microscope to abnormalities, trying to tease out if this is incidentally benign or malignant, wondering if this is evidence of disease or simply a normal perturbation.

Hospitalists must be the diagnostic laser, making light-speed decisions about what to pursue and what to defer as well as carefully convey to outpatient follow-up. We must carefully dissect subjective complaints and objective data using the scalpel of evidence-based criteria and a wealth of subspecialty guidelines.

We must thin out the electronic medical record of redundant or inaccurate diagnoses while updating it with new history. The patient's medication list is not simply the medications they are prescribed but those they are actually taking and when they are taking them. A hospitalized patient demands an agent, their hospitalist, who manages nutrition, hydration, electrolytes, medications, and ancillary therapist evaluations while requesting appropriate specialist consultation and preventing adverse events such as deep vein thrombosis, falls, and delirium. We must take a collection of prior documentation to weave a history, amalgamate in-patient events, tests, and consults as daily progress notes, and then meticulously sift all of this into a timely, complete discharge summary.

Achieving hemodynamic homeostasis
I consider "vitals" to be an acronym for Verify If They Are Living Still. In general most hemodynamically regular people are euthermic with a heart rate between 60 and 90 beats per minute, breathing 8-16 times per minute, have a systolic blood pressure greater than 100 mm Hg and less than 160 mm Hg, and saturate greater 92% on room air. If they don't they are either (1) acutely sick with a physiological response, (2) chronically sick and at their (albeit abnormal for the majority of the human population) baseline, or (3) weird.

Acutely ill humans should have a positive response to appropriate therapy, that is there vital signs approach normal, and negative one to inappropriate therapy. That being said, people die even despite the most optimal of treatment decisions, and people live despite our best unintentional attempts at killing them. You have to determine whether the population mean abnormal vital sign(s) are an indicator of acute pathology or simply evidence of chronic but stable disease.

Returning the patient to basal levels lab result rubor
People are often admitted because of the density of red (abnormal) test results they have. Although abnormals should be recognized they should also be placed within the context of their chronicity and severity.

Some patients have bloody diagnostic tests at baseline. An elevated white blood cell count can be due to chronic lymphocytic leukemia, dehydration, stress, or infection. No matter what we as physicians do, it is unlikely that no matter what we do acutely we cannot change the leukocytosis of CLL. Antibiotics do not treat dehydration or stress, but not treating a pneumonia with its associated leukocytosis is tantamount to medical crime.

Similarly a volume depleted patient may have a CBC in the black, volume contraction hiding their basal anemia, just because they are less in the red, doesn't mean they are any less sick. An elevated creatine in a patient on dialysis has an impressive crimson hue but generates little therapeutic inertia compared to the same value in someone without previous kidney disease.

No matter what intervention is undertaken, the patient with end-stage renal disease will never be in the black when it comes to creatinine, if we waited for this value to normalize before discharging the patient, they would serve a life sentence. As hospitalists we must find with the intent to treat the scarlet letter of abnormal but accept the chronic unchangeable crimson that will show up on some diagnostic tests. We can only attempt to restore our patient to the baseline they had before and hope to prevent the next decompensation as best we can.

ACP Member Mike Aref, MD, PhD, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging. This post originally appeared at his blog, I'm dok.