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Football Times

Mar 1, 2013
Hi everyone
Sometimes I notice 20-30 people on here at a time. Leave a message and please tell me how you found my blog. Just comment at the bottom of this post.

This is coming to you from the future so it stays on top!

Thanks for stopping!
posted by  Mohammed at  21:40 | permalink | comments [85]

Jul 31, 2009
New Blog Web Address
It's time to move to a new blog software! After almost 3 million visitors over the years, it's time to move on to faster and more up to date software.

Feel free to stop by MY NEW BLOG!

The new software allows better and safer moderation of the comment section and reduces comment spam. It has become difficult to keep up with the comment spam! You will all still be able to comment, and it will be much better!

Enjoy the new blog!
Doctoring , General
posted by  Mohammed at  11:42 | permalink | comments [0]

Jun 18, 2009
The Disaster of Emergency Medicine
I was walking through the emergency room a few days ago and saw a patient sitting on a gurney in the hallway drinking pop and eating a sandwich.

Nothing is more irritating than seeing the emergency department being used for non emergent medicine.

If you can breath, walk, and talk..... It's not an emergency! Call your doctor's office and get an appointment.

Unfortunately, the non-emergent use of emergency departments is more common than you think. It's unclear why people abuse emergency rooms, but it happens a lot.

Sometimes it's because the patient does not have insurance and doesn't have a doctor. And patients know that the ER is not allowed to turn them away. So they just go to the ER and get their primary care there.

Sometimes it's because patients don't know any better. They think that they can just go to the ER for all their problems, and that that is normal. Someone please educate these people.

Sometimes they say that their doctor is "booked and can't see me for 2 weeks". So they stroll into the ER to get their urinary incontinence medication refilled.

ER physicians should not be allowed to prescribe medications for on-going problems. Then patients won't go to them. An ER doctor should not have to deal with refilling Viagra or Flomax for a patient.

How do we fix this problem?

Pay primary care physicians more! What? Why? There really isn't a primary care shortage in this country. There is a shortage of pay for primary care. If primary care physicians were paid appropriately, they would have enough office hours and time to accommodate all their patients.

Instead, more and more primary care physicians are leaving primary care, moonlighting as ER physicians, and sub specializing to try and make more money for their time. They want to be efficient.

If a primary care physician can get paid upfront $130 dollars an hour for working in the ER, why would he bother seeing 4 patients an hour, some of which have no insurance, some have insurance, but he has to hire 3 employees to chase down insurance companies, so that he can maybe make $30 an hour, but get paid 90 days later?

It does not make sense.

So he cuts his office hours down to 10-20 hours a week, and goes and moonlights at an urgent care facility, an ER, or as a hospitalist.

With President Obama touting health care reform, he needs to attack the core of the problem. Fix primary care medicine! Pay the primary care doctors for their time, effort, thought process, and care.

The worst thing that Obama can do is to hire cheaper "providers". Not physicians, but "providers".

A provider can be anyone, a nurse, a physician's assistant, a dentist or even a chiropracter. Sure, hiring nurses and PAs to take over primary care medicine may look cheaper, but the long term consequences are more expensive.

When you have a lesser trained "provider" trying to care for people, you get tons and tons of useless consults. We have seen this in hospitals as well as clinics. Over utilization of consultants costs the system more. While a good primary care physician can work up most problems and only consult for difficult cases, a lesser trained provider will consult more often and cost the patient, as well as the system, more on the aggregate. That is bad medicine.

A patient will not get appropriate care until further down the line from a random consultant. Bad medicine!

My advice to Obama: Pay the primary care physicians what they are worth, and you will not have a primary care shortage. You will save patients lives, ensure better outcomes, as well as have a healthier population in general. Stop short-changing the physicians that are on the front lines.

This will also relieve the emergency departments, to handle "emergencies". The vast majority of ER doctors did not go into ER because they want to see sniffles, fungal toe infections, and a thinning hairline. Nor do they want to refill your Viagra.
Doctoring , ER
posted by  Mohammed at  21:18 | permalink | comments [1]

Apr 18, 2009
Windows 7?
I am not sure why, but it seems like less than 2 years after releasing Windows Vista, Microsoft now wants to release Windows 7. Prior to Vista, Windows XP had an 8 year run before a new operating system was developed and released.

I downloaded and installed the Windows 7 beta version a few months ago and it has been running on my laptop for 2-3 months now. It runs well and it's not all that different from Vista. When you look at Windows 7, it's a slightly modified Vista.

Of course, if you read the Microsoft Windows 7 development blog, they make it sound like Windows 7 is some new revolutionary Windows that was built from scratch and will change everything about the world of computing.... I don't see it.

I think the problem began when Microsoft radically changed windows with the release of Vista. For about 10-15 years, we got used to Windows 95, Windows 98, and Windows XP. We knew where everything was and how to access the controls and adjust everything. We were familiar with it.

When Vista came along, it rearranged where certain things were and gave things a new look. Plus a fancy Aero interface. Don't get me wrong, I have 64 bit edition Windows Vista Ultimate running my top dog computer, and it is a huge upgrade to Windows XP, but people weren't ready for the shock and change.

People enjoy change, but they are comfortable with familiar things, that was the problem.

Couple that with the Mac vs PC campaign that Apple put on the airwaves, and people started disliking Windows Vista without even knowing what it is. They just thought it was awful and didn't like it.

If you look at the Mojave Experiment Mojave Experiment, where people who never used Vista before were told this is Windows "Mojave" the new upcoming Windows platform, everyone loved the new Mojave windows. Later they found out that they were using Vista not Mojave.

It's obvious that people just didn't like Vista due to the marketing campaign and public buzz. It became cool to not like Vista.

Having used Vista since it's beta releases and up until now, it is an awesome operating system. By far the most stable, secure, media savvy, and speediest system I have ever used. Although, my 64 bit Windows XP system was probably a hair faster, what Vista can do is far more advantageous than a few nanoseconds difference in speed.

My Vista is running on an all 64 bit platform with Intel 2 Core Quad 2.66 Ghz system with 8 GB of RAM on an ASUS motherboard with an NVDIA SLI Chipset. Also my graphics card is the NVDIA GeForce 8800 GT for all those powerful graphics and games. You just can't beat this system.

Windows 7 seems like a slightly improved Vista. They changed the way the Start and Taskbar look and work. Sure, they look and work better, but that isn't too exciting. I don't know too many people who would upgrade and pay another $300-500 dollars to get a nicer more functional taskbar. That seems insane.

Of course, Windows Vista is Windows 6.0 (in the actual numbering scheme). Win XP was 5.0. Windows 95 was 4.0. Then you have Windows 3.1 which was the 3.0 version of Windows.

Windows 7 is not the Windows 7.0. In fact, it's just Windows 6.1. All the drivers and software that work on Vista, now work on Windows 7, since it's the same version number.

This also leads me to believe that Windows 7 (or 6.1), is only a minimal improvement to Windows Vista (or 6.0), even though they say it is a major change.

I think Microsoft is really doing this to eliminate the bad stigma that goes with the "Vista" name, since it's been dragged through the dirt. Windows XP users who hated Vista will hate 7. People who quickly adopted Vista and love it (like me) will not notice a huge difference when they go to 7.

I can see the commercials on TV now, the young Mac guy asking the older, frumpy PC guy,

"Hey, why'd you change your name?"

"What do you mean?"

"Why are you calling yourself 7 now?"

"I'm a new man, I am 7, that old guy is gone."

"Hmm, that's funny, you look like the same guy that I knew last year who was called Vista."

"No, I am 7!"

"Ok, call yourself whatever you want."
posted by  Mohammed at  11:10 | permalink | comments [0]

Apr 1, 2009
Jay Cutler and Josh McDaniels
The Jay Cutler and Josh McDaniels saga has been brewing, and I have been trying to avoid making any public statements one way or the other, but I think it's time to discuss this situation.

Yes, I was shocked when Mike Shanahan was fired. Not just shocked. I was depressed. When Denver lost at Carolina, then at home to Buffalo (thereby giving San Diego the opportunity to play for the AFC West title at San Diego in the final week of the season), I knew it was over for the Broncos season and playoff hopes. The loss to Buffalo was demoralizing. Our defense was non-existent.

Did I think Shanahan would get fired? No. Last year, Bowlen said that "Mike can coach here for as long as he wants." Bowlen is a classy, first rate owner, and Shanahan an amazing first rate coach. After 14 years in Denver and a $14 million dollar mansion that Shanahan built, no one thought it'd happen.

Bowlen interviewed plenty of prospects. Garrett from Dallas, Raheem Brock, a few others and Josh McDaniels. Of all of them, I preferred Josh McDaniels. He was an unbelieveble record setting offensive coordinator, who has worked on the defensive side as well. Plus, he came from New England, and they know how to win.

None of Bill Billicheck's coordinators ever made great head coaches, but of all the interviewees, he was by far the most impressive. We've seen Romeo Crennel, Charlie Weiss, Eric Mangini and a host of others all fail and not really do much. But press conference after press conference, McDaniels was extremely impressive.

I watched every interview and every press conference that McDaniels gave to the Denver media and I was extremely impressed. At age 32, he is mature and knows his football. He reminded everyone of a young Shanahan when he was hired. Shanahan was also in his 30s when Bowlen named him head of football operations.

Shanahan's job was simple. Take a group of future Hall of Famers in Elway, Terrel Davis, Shanon Sharpe, Rod Smith, McCaffery, Gary Zimmerman and a host of others and take them to the next level. Over the hump. After installing his QB friendly West Coast Offense, and a bit of luck in finding Terrel Davis, and the new zone-blocking scheme... they one the first super bowl against Favre and the heavily favored Packers. The following year they nearly went undefeated, rushed for 2008 yards by Davis and 2476 total yards including playoffs and Super Bowl for their second title in a row.

Elway decided to retire. If he would have stayed, even in just a leadership capacity, even if he got injured in game 1, just on the roster and on the sideline, they would have probably won three in a row, something no team has ever done. That didn't happen.

Shanahan alienated the locker room by naming Griese the starting QB, when Bubby Brister had already filled in for Elway the year before and was 4-0 as a starter.

The Broncos and Shanahan spent the next 8-10 years trying to find another franchise quarterback.

In 2006, Shanahan drafted Jay Cutler, who took over from Jake Plummer. In 2005, the Broncos hosted the AFC Championship game with Plummer at the helm. But he blew the game reverting to the old Plummer and throwing interception after interception. Although, prior to that game he had a long streak of not throwing interceptions. Shanahan adopted to Plummer's strengths and got him under control.

In the 2006 pre-season, we all watched Cutler in amazement. He played at Vanderbilt. Every single week was a struggle to win (just like the NFL). He was named the SEC offensive player of year multiple years and played against tough SEC opponents.

Cutler wowed everyone with his arm strength and ability to make every single throw (and then some). In college, he threw a legendary pass to Earl Bennett 84 yards in the air from Cutler's hand to Bennett's. In the air! Not after the catch.

Everyone knew it wasn't long before people in Denver would be clamoring to see him play. The Broncos started 2006 7-1 with a defense that hadn't allowed a TD in all of those games. They were winning. Then came a slump. A four game losing streak, which sent Plummer to the bench.

In his first game against Seattle, Cutler was awkward, but Marshall made some amazing after the catch TD runs. Denver lost. Cutler continued to improve. Then he threw the 67 yard bomb to Javon Walker with such zip, that many people said they have never seen a ball travel 67 yards faster than that one.

His legend grew and Plummer was eventually let go. In 2007, he played well and got better at the West Coast Offense. It;s usually in year 3 that most QBs get it. The defense was awful, and Denver ended up 7-9.

In 2008, Cutler was lights out. The first three games they came out blazing scoring 38+ points in each game. People began comparing them to the 2007 Patriots (Josh McDaniels record setting offense), but the defense was awful, giving up nearly 38 points each game as well. Especially to San Diego (the fumble) and to New Orleans (the missed Gramatica field goal). You could argue they should have never won those games.

They collapsed towards the end, while the 4-8 San Diego Chargers went on to beat Denver for the AFC West title. Shanahan gets fired, and we are looking for a new head coach.

Cutler is asked questions by the media and he states it's a mistake that Shanahan was fired and perhaps his opinion should have been sought prior to firing the head coach. A little weird, but Cutler has always been brutally honest and always says what's on his mind, to his own detriment.

Josh McDaniels is hired. Everyone applauds this hire. The best candidate out there. You could also argue that this was similar to when Shanahan was hired. A great quarterback, great receivers, need some help at the RB position, but the offense was set. Similar to what Shanahan inherited. The offense didn't need tweaking. The defense however, was the worst in nearly every category and had an awful 2 year run.

McDaniels hires Mike Nolan (a 3-4 guy) to fix the defense, and everything looks like it's working out. Denver fans are happy, the owner is happy. Everyone is looking forward to the playoffs in 2009.

Problems start
Rumors start floating around that Denver is trying to trade Cutler. Cutler hears of this through the media and makes some ill advised comments about "I play for my team mates, not the coaches. But hey, if they trade me, they trade me." He has always been brutally honest and sounds shocked. It also seems that his ego is bruised. Rightfully so. He just had a pro bowl season, broke every one of Elway's and Plummer's single season, single game records, and now tehy want to trade him? Didn't make any sense. Cutler was probably under the impression that he is safe, and the new regime would work on fixing the defense.

Did Denver actively try to get Matt Cassell, or did they just listen to various offers for Cutler? As a team leader, your job is to improve your team, and you should listen to all offers. Whether Josh just listened to offers or was actively pursuing Cassell is unclear. But it doesn't matter. Everyone can understand that the relationship between an offensive coordinator and his quarterback is special and since the McDaniels offense is different, you could understand why he wanted his guy. Does McDaniels have to clear everything through Jay? No, of course not. He is the coach, not Jay.

Bus Cook, Jay's agent (famous for the McNair and Favre off-season fiascoes), decides to stir the water. He and Jay announce that Jay wants to be traded. Josh McDaniels asks to meet with Jay. And finally, when Jay has time, he goes to meet Josh. Josh reiterates that he will do whatever it takes to improve this team, yada, yada, yada... and Jay and Bus decide that tehy don't appreciate these comments.

It's unclear if Bus was using this situation and applying bluff pressure on Denver trying to get the Broncos to re-sign Jay for an extension and a bigger contract. After all Jay will make $1 million this year. And the new backup they signed Simms will make $3 million. Jay and Bus put up Jay's properties for sale, to show that they are serious.

Josh goes to the owner's meeting and tries to fix the situation and says that Jay is our quarterback and they want him. Interview after interview, he wants Jay and wants to meet with him and iron things out. They tell teams to stop calling them about a trade.

For ten days, there is quiet and the story fizzles out and dies. Everyone thinks that Jay and Josh must have resolved their issues.

Suddenly late night March 31st, owner Pat Bowlen announces that they have been trying to get a hold of Jay for the past 10 days, and Jay has been ignoring Bowlen and McDaniels and that he is going to trade him. A local radio host in Denver talks to Jay, and Jay says he is "puzzled" by the situation. Bus Cook and Jay Cutler later release a statement stating that they have no comment at this time.

Are they truly shocked? Who is lying? The story doesn't add up.

Josh and Pat say that they contacted Cook and made an appointment for Jay to speak with Bowlen, and Jay never called. Could it be that Cook never told Jay? Jay says he never got any calls. The Broncos say they have phone records that show they tried calling many times. Is Bus Cook screwing Jay over trying to land a payday?

It's hard to know who to believe. I think Bowlen saw what Cook was capable of last year with Favre and the year before with McNair, and didn't want a media circus in Denver. If Cook was bluffing about the trade to try and get a bigger contract for Jay, Bowlen called his bluff. Maybe that's why Jay is puzzled. Cook was probably reassuring him that they'd resign him to a bigger contract and it would all end.

Jay has always said he'd be at the voluntary workouts in April. In fact, Jay said he already had his car and belongings shipped to Denver. Is this true? Or damage control? Bus probably doesn't want Jay to look bad and try and raise his price and market value by saying that he was already making plans to go back to Denver, and this was Denver being mean to his QB. Did Bus sign any QBs from this draft class? No. Does he need media attention? Is he posturing to get some of next year's QBs? Who knows. At the expense of Jay Cutler's career? Wow.

If Jay is sent to Detroit, his career is likely over. Does anyone ever remember any Detroit QBs?

Or, he may turn the franchise around forever. A first round QB will cost Detroit about 30 million guaranteed, while Cutler has 3 years on his contract and is only making 1 million this year, he is proven, has 3 years under his belt. He could probably deliver 8 wins on his own. That's basically what he did in Denver. When Denver's defense held opponents under 21 points, Cutler was 13-1. Overall he is 17-20, and in 2008, his best year, he was 8-8.

Cutler is obviously a very gifted, strong, talented quarterback. He has the "it" factor, he has what it takes to win in the NFL. He can produce tons of yards and TDs. He is an instant upgrade to almost every team in the NFL except Manning's Colts and Brady's Patriots.

The only knock on Cutler has been his attitude and demeanor in press conferences and when things aren't going well. At the post-game press conferences he is always pouting, looking up, doesn't want to be there, chewing gum, and an overall ass. But we can live with that if he produces on the field.

Is he a cry baby? He is 25 years old. Had the year of his life. And they wanted to trade him for a one year wonder who hasn't played since high school. He has a right to be upset. Be he should have shut up, and let this whole thing play out first. His job is to play for the coaches, not have the coaches run every move by him. What should Kyle Orton, Jason Campbell and other QBs be doing now that Cutler is rumored to be going to their city? Should they be crying? Should they be sensitive? No. This time of year, lots of rumor fly around. Just shut up, show up, and play ball.

The only scenario really that keeps Cutler in Denver is if he decides that Bus Cook is toxic and decides to fire him as his agent. If it's true that Denver has been trying to reach him, and Cook has been blocking communication or not passing the word on to him, then Cook should go. But it's hard to believe that in today's internet and television world that Cutler didn't know that his boss (owner Bowlen) who pays him, and coach were trying to reach him. Unless he was in Mexico on some long vacation and left his cell phone at home turned off in an attempt to clear his mind and lay low. But there are all these supposed text messages that have gone back and forth (unless that was alie too).

Is that plausible? It's possible. But who knows what really happened. I have no reason to doubt Bowlen when he says he tried to communicate with Cutler and has not been able to. Although, he did say we were told by "his agent" that he no longer wants to play for Denver.

I'm not sure why anyone wouldn't answer phone calls from his boss or coach. It's bizarre, and if it's true.... he is really out of control.

Because the facts don't really add up, there is probably more to the story that we may find out some day.

For now, it seems that Bus Cook has probably screwed up Cutler's career for a while in an attempt to make some more money and bag some media attention and a few QBs from next year's class. Denver fans love their QBs, especially ones like this. He had a good thing going. Unless he fires Cook and flies to Denver immediately to redeem himself, he is done. Bowlen is not going to deal with a media circus.
General , Sports
posted by  Mohammed at  20:19 | permalink | comments [0]

Mar 30, 2009
Patient Family Types
It seems like no matter where you go around the country, no matter which hospital, which clinic or which ER, you always have the same type of family members. Here is a humorous look at some exaggerated family types.

The Normal Family:
This is the family we all love. When their loved one is ill in the ICU, they ask questions, try to understand what is going on, and are very appreciative of what everyone is doing to help their loved one. This is the family type we all love and is usually the most common type of family.

The Expert Family:
This is the family that always mentions that they have 5 doctors in their family and wants everyone from the janitor to the CEO of the hospital to know. I'm not sure how they think this will change the course of their loved ones disease, but they think that it may change outcomes.

The False Expert Family:
This family always mentions that they have 5 doctors in the family, and when you finally meet them it turns out one is a podiatrist, one is a chiropractor, one is a dentist, one is a PhD in engineering, and one is a pharmacist. The actual "experts" are all very nice and interact professionally, but that doesn't seem to bother the few family members that aren't "doctors" from mentioning that they have doctors in the family eight hundred times per day. No one is sure why they keep mentioning this, they just think they'd get better care if they did.

The Litigators:
This type of family always talks about suing the hospital and suing the doctors that are taking care of their loved one, even when their loved one is receiving the best care. Of course, this type of behavior may result in worse care for their loved one as all the doctors go into, what I call "cover your ass" mode of practice and start treating the chart not the patient.

We all know what cover your ass means in medicine. Order the extra test, the extra CT scan, the extra lab test, just to make sure it isn't something else that is rare that may be missed. This is not what I am talking about.

This mode of cover your ass care seems to be different. The primary doctor will start adding more and more consultants (experts in various fields of medicine) to help spread the malpractice wealth. If they are going to sue, they sue a whole host of doctors, the less one doctor takes a hit. Can it be that all these experts were wrong? Of course not. It'll probably be thrown out of court or never make it to court. If it does, all these experts can't possibly be wrong. Just look at how good the chart looks!

So what's wrong with that? Lots.
You start seeing every expert offerring an opinion and deferring to another expert. You see, "Restart coumadin if ok with cardiology." Cardiology comes by and writes, "Hold coumadin for now, get head CT and restart coumadin when ok with neuro." Nerology comes by and says, "MRI/MRA head and neck, may restart coumadin if ok with GI." GI comes by and says "May restart coumadin after EGD and if ok with heme/onc." Heme comes by... and you get the picture. You start seeing a lot of charting and not much really being done to fix the patient. And eventually, said patient dies.

Advice.... don't start threatening with lawsuits! Period! This will just prolong and slow down the process of healing. (and they may never heal) This is the surest way to insure that your loved one won't get proper care.

The Loud Family:
This is the family you can hear from a mile away! Before they even make it up to your floor, you know they are coming. They're harmless and funny as hell, but man, they are loud! This family is usually fun to talk to and always have funny stories to share. A lot of times though, suddenly the ICU staff will start enforcing the "2 visitors per room" rule. While everyone else has five or six people visiting, this family suddenly is told that the limit is two.

The Know it All:
This family usually starts off as a normal family; very appreciative of the wonderful care and very happy with everything in the hospital, until the Know it All shows up. The Know it All may have some medical background, just enough to be dangerous, and they start making comments to this seemingly normal family about how everything is being done backwards here.

"Back at my hospital they'd never use that type of IV tubing" or "How come the did the EGP before the colonoscopy?" They don't even realize that's it's an EGD. They just spew medical terms and sound informed to the rest of their family.

The Know it All is usually some distant relative to the family and the family barely knows them, but they seem informed, and the family starts getting fired up. They start asking questions that they think make sense when it really doesn't. The poor doctors and nurses answer their questions without being condescending and they try to be as polite as possible. The family starts thinking that they know more than the nurses and doctors because the Know it All says so. The family will eventually push the Know it All to the forefront and have them start asking questions the next time the doctor shows up,

"Doc, how come she is on 8 different pressors?"

"Mam, there isn't 8 pressors, and she is only on 2."

"Why did you guys give her packed red cells instead of albumin?"

"Her hemoglobin is low and albumin doesn't provide any benefit, let alone fix hemoglobin."

"Why aren't you guys following the latest guidelines?"

"Mam, what guidelines are you talking about?"

"From the IDPRC, for sepsis."

"I am not familiar with that organization and we always follow the sepsis guidelines."

"Why haven't you guys transferred her to a better hospital."

"What is it that you think they will do differently?"

And so on and so forth. The Know it All is toxic to a situation. They are usually stubborn and too misinformed for their own good. Logic and reason doesn't work with the Know it All. It's like having Terrell Owens or Tiki Barber in your locker room. They are cancerous and things start turning bad.

Sometimes you just have to appease the Know it All. Most humans highly value the feeling of feeling important. Everyone wants to feel important. It's the ultimate feeling. If you can find a way to make the Know it All feel important, then you can win these battles. You have to make them feel important and "consult them" (not really consult them, but make them feel a part of the decision making process). You may have to educate them subtly, "As you are well aware, and I am sure they do this at your hospital, albumin in most cases, is useless." Get them on your side somehow. Have them talk to the family and calm things down. Try to get them to be your ambassador.

If all else fails, "You're right, we should transfer her to a better facility." At least you get them out of your hair!

The Religious Zealots:
This family is overly religious. If not overly religious in general, they are overly religious about something. Sometimes it's blood products that they won't accept, sometimes it's heparin, sometimes vaccines, sometimes coffee... who knows. But they always blame God.

Reasoning with the Religious Zealots requires a lot of maneuvering. A lot of times they don't want to withdraw life support on their 120 year old grandmother who has been brain dead and on a ventilator for the past 40 years growing out every resistant bacteria, fungus, and some things we haven't identified yet, because, "God will take her when he wants her."

You have to be careful, and if you aren't the religious type, just levae it alone. You could always try, "Well God tried to take her so many times, but you guys keep insisting that we do our best to resuscitate her and she always makes it." Or, "Is this how God wants his people to live? Let her go to be with Him and enjoy heaven." Just be careful.

There are a few other family types which I will add soon. Stay tuned....
Doctoring , Residency
posted by  Mohammed at  20:02 | permalink | comments [0]

Mar 30, 2009
HgbA1c to diagnose diabetes
Finally, the American Diabetes Association and a few international diabetes organizations have agreed to allow the use of HgbA1c to diagnose diabetes.

HgbA1c is a better test since, wide swings don't affect it, you don't have to go on an 8 hour hunger strike, acute illness or current administration of steroids doesn't affect it, much more stable and standardized test.

What if you have sickle cell disease and have an abnormally high HgbA1c? You can use the old method of a fasting glucose, or get a fructosamine test (which gives you a two week average).

Before 1997, you had to do an oral glucose tolerance test to be considered "diabetic". In 1997, they changed the guidelines and all you needed was a fasting glucose over 126 (why they chose such a high number I don't know, should be 100).

Of course, after the 1997 change to a fasting glucose of 126, a lot more people who were previously "not diabetic" suddenly became "diabetic". Which is good and bad. On the bright side, you now know you have a serious issue and need to address it. On the bad side, it probably shocked some people.

The committee has already decided that they will allow HgbA1c to be used, the question is where will the number be set? Is it going to be 6.5? Or 5.5?

At 6.5%, you are diabetic. Normal people (who are not diabetic) never have a HgA1c over 6%. In fact, most non-diabetics run in the low 5s.

If you set the number at 5.5%, you have a whole host of people now that will be considered diabetic that previously were told "you are borderline diabetic". This is great, because finally doctors will start treating these people early.

Hopefully, this new standard will spur physicians to start treating diabetics sooner and sooner with metformin (for type 2 diabetics) and delay the complete failure of the pancreas for as long as possible.

The problem in type 2 diabetics (90% of all diabetics) is insulin resistance. Your cells are resistant to insulin, so your pancreas make more of it, to overcome the resistance. Metfromin sensitizes your cells to insulin and allows your cells to use your insulin more appropriately and your pancreas can take a break and not have to make so much. Hence, saving your pancreas!

I am interested in seeing what level they set this at. Of course, smart doctors know that unless your HgA1c is less than 6 (and usually a lot less), you have a problem, and should be on metformin.

The American Diabetic Association already has a calculator on their website that translates fasting sugars to HgA1c values:

As well as other resources:

Doctoring , Residency
posted by  Mohammed at  19:46 | permalink | comments [1]

Mar 30, 2009
Polypill solves all problems
It's on the news again, a 5 in 1 pill that can cut heart attack and stroke risks by 60-80% (depending on who you read) if taken once a day.

Imagine 5 generic drugs in one pill. Brilliant? The pill will contain asprin, a generic statin (presumably simvistatin), 3 blood pressure medication (my guess is low dose hydrochlorothiazide, a generic ACEI, and probably a low dose beta blocker).

Lots of studies have been done and it sounds like a good idea. Compliance wouldn't be an issue since people take it once a day. They tried coming out with this about 5 years ago, and it lost the PR battle.

Since they are all generic, this pill could cost a small amount. A month supply should be no more than $10-30 dollars at most.

Of course there are always the holier-than-thou "ethicists" that say that creating such a pill would reduce the emphasis on diet and exercise. (Cuz we all know that's working!)

If you eat french fries, butter, heavy cream, and pancakes with loads of syrup everyday and pop a polypill... I'm afraid you will still have heart disease and end up with a stroke or heart attack. A pill isn't a substitute for good habits. It may delay some things or offer some protection, but you are ultimately doing yourself in.

We'll see how this pill goes this time around. Who will combine these drugs first and start marketing it? Will they try to make loads of money off it? Will the government start requiring that all people over 50 should be on it or else lose some tax/insurance benefits?

We'll see!
Doctoring , Residency
posted by  Mohammed at  19:32 | permalink | comments [0]

Mar 5, 2009
Aggressive Medicine
Nothing is more disturbing than seeing a patient whose cholesterol is elevated, and hearing that their doctor said to them, "It's ok."

Or seeing a hypertensive patient whose doctor said, "We'll keep an eye on it."

Or a diabetic with sugars running in the 160s and hearing them say, "My doctor said I'm doing well."

Or seeing patients in the hospital with some obvious medical problems that are not being treated aggressively enough by their physicians.

Not being aggressive about treating patients is simply irresponsible on the part of the medical community. You can't tell you patient that a cholesterol level of 243 is ok. It's not ok!

Sure, you can try lifestyle modifications for a few months, but how often does that work?

Ok, so they diet, excercise, lose weight... and their cholesterol is now 217. Is that ok? You have to then aggressively manage their cholesterol.

Cholesterol is not a" lifestyle choices" problem. It's a genetic problem. You were born with these genetics. You can slightly improve them by changing your habits, but not by much.

People don't seem to understand that it's not the amount of cholesterol that you eat that matters, it's the saturated fat in the food you eat that tells your liver to make cholesterol. 85% of our cholesterol is made in our liver, not from intake. Saturated fat is fat that is solid at room temperature (butter, cream, fat on steaks, chicken skin, etc).

What about the uncontrolled diabetic. A doctor sends some routine blood work on a patient and their fasting blood sugar comes back at 106. That's not normal! After an 8 hour fast, no one's blood sugar should be over 100. The doctor's just ignore this number and say, "It's ok, we'll keep an eye on it." Instead of treating diabetes early and preserving their pancreas. That's not right.

How about the hypertensive with a blood pressure of 137/89. Is that ok? For every 20/10 that your blood pressure is over 115/75 your risk of having a cardiovascular event (stroke or heart attack) doubles. So is 135 ok? No!

When talking to friends, family, insurance sales people, or others, they always start asking you questions when they find out your a doctor. "Is my cholesterol good?" "Is my blood pressure ok."

You find out that their doctors told them that a cholesterol of 230 is ok, that their fasting glucose of 111 is ok, and that a blood pressure of 140 is ok. It's not ok!

We owe it to our patients to treat them aggressively and get their numbers down. We don't want to see them in the hospital with half their brain not working or half their heart not pumping.

We are highly educated, highly trained. We have to put this to good use and give our patients good advice. We can't let them be with high cholesterol, high sugars,s and high blood pressures. It's not right. We are better than that.
Doctoring , General , IM , Residency
posted by  Mohammed at  19:30 | permalink | comments [0]

Jan 29, 2009
New Insulin Drip Computer Program
For the longest time, I have been searching for a simple algorithm that will adjust patients blood sugars correctly. Ever since I started working in critical care, I have been longing for a good insulin drip protocol. I finally found one!

For those who are not medically inclined, when a patient is critically ill after surgery or for whatever reason, it is important to maintain tight glucose control. The definition of "tight glucose control" varies based on who you ask and which study you read, but the idea is that their sugars should be under 200 and should be as close to normal as possible, without going too low. Some studies liked sugars between 90-120, others in a slightly higher range.

Critically ill patients, patients with head injuries, patients after surgery, patients who are in a diabetic coma, and even septic patients all need tight glucose control to heal and overcome their injuries and insults. Elevated sugars slow down wound healing, impair brain health in closed head injuries or vascular accidents, and provide for poor infection control in patients with infections.

There are lots of ways to control sugars, but when they are this critical, we usually put them on a continuous insulin infusion through an IV and check their sugars every hour and adjust the insulin infusion (drip) as necessary.

It's this "as necessary" part that gets everyone. How do you know how much to adjust it by? Is it based on how well they respond to the insulin? Or just a guess? Intuition? Experience?

If you had a really good nurse with good intuition and experience you could probably tell her,

"Start the insulin drip at 8 units/hour, check their glucose every hour, and adjust it how you see fit to get their glucose down around 120 or so."

That would be ideal, and at some places, that'd probably work. Hospitals now are becoming more and more strict as to what nurses can and can't do, so they want to come up with algorithms and formulas for nurses to follow when trying to control blood sugars.

I think it's amusing that these same hospitals will let a nurse adjust a norepinephrine drip as she sees fit (which controls your blood pressure and keeps you alive), but won't let her tinker with insulin drips (which doesn't normally kill you).

So the question becomes, can we put that nurses intuition and savvy into an algorithm? Can you legislate common sense? Can the algorithm adapt to variables?

What is the best formula to replicate a nurse or physician's intuition?

You need a formula that not only accounts for the current drip rate, but also accounts for how much the sugar changed. You don't want wide swings in sugars, you want them to slowly, smoothly, and surely, come down to normal and stay normal. You want to adamantly avoid low sugars, and you want to avoid huge swings and drops. Of course, your formula should adjust for increases in sugar as well.

Previous algorithms and formulas I have seen in the past are static. They adjust statically to glucose readings. If a patient's blood sugar is 850, start the drip at 7 units/hour and check sugars hourly. If it doesn't change, increase the drip by some multiplier until it starts coming down.

So if a patient's sugar starts at 850, they start him at 7 units/hour. Nothing changes for a few hours, they keep increasing the insulin drip rate, until say it is 10 units/hour, and finally the sugars start coming down. You keep checking until it gets down to around 120, then you maintain that drip rate. The problem is that the next glucose will be 50 or 60 and is too low. It doesn't dynamically adapt to surroundings.

The insulin drip protocol we have been using at our hospital (the one the residents have been using) seems to follow a static formula. Once the sugars are "normal" the next reading will be way too low, unless the drip rate is cut by 75% or by 50%. I usually have the nurse notify me once we get under 150 or so, so we can dynamically adjust the rate.

If we had a dynamic formula that accounts for the patient's response to the insulin, that would be ideal. Further, it should respond to different values differently. You want slow, smooth control. Not erratic. Your formula should adjust for the change in drip rate and the change in glucose. As well as the rate of change. How quickly or slowly is the glucose changing? Is it going up or down?

In calculus, the rate of change is the derivative. You want an algorithm that adjusts for the rate of change of blood glucose. That would be the ultimate formula.

It seems like the folks at Yale Medical School and hospital found an algorithm that does this quite nicely. Here is a link to their algorithm. It accounts for changes in glucose as well as recommends changes in proportion to the current insulin drip rate. It has some quirks in it, but it works for the average ICU patients that is not a DKA or HHS patient and hasn't had any intracranial accidents.

So we really need an algorithm that works in all situations equally well. You can just tell the nurse follow the "Alo algorithm" and that should be it. regardless of why the sugar is elevated.

Dr. Arcot Dwarakanathan, Endocrinology & Diabetology, who has been involved in every diabetes research study for the past 35 years and who has trained generations of endocrinologists at Chicago's top institutions (the doctor's doctor), and myself decided to come up with an improved algorithm (that is still dynamic, rich, and ubiquitous), and then create a computer program to help nurses follow this algorithm without having to do the math or follow tables or have to look things up.

Of course, there are some programs out there, and their are companies out their that try to market such programs to hospitals for large sums of money. None of the ones I have seen marketed have such a dynamic algorithm. They usually follow a more static formula. Although, they try and make it seem dynamic and self adjusting. None of them works in all situations of hyperglycemia.

Everyone is in a credit and cash crunch, and I have a programming background, so I decided to try and come up with a simple program that will follows our dynamic insulin infusion algorithm.

After spending months with Dr. Arcot Dwarakanathan, we have analyzed various studies, numerous programs, multiple algorithms, and came up with our own algorithm based off the Yale protocol to a certain degree.

The Yale protocol states clearly that it is not intended for someone in diabetic ketoacidosis or other complex medical issues. We wanted an algorithm that will work in nearly all medical conditions, wherein patients require insulin through an IV, including DKA, HHS, steroids, head bleeds, etc.

We spent a lot of time tweaking our algorithm and have come up with what we think is the best dynamic, self-adjusting insulin protocol algorithm, for the following reasons:

1. Slow, smooth insulin control
2. Works in almost all hyperglycemia scenarios (including steroids, DKA, HHS, head bleeds)
3. Self adjusting
4. Dynamic and rich
5. Avoidance of hypoglycemia
6. Quick response to hypoglycemia, if it occurs

Based on this algorithm, I am in the process of developing a computer program for nurses to use to adjust the insulin drip. They input blood sugars and drip rates, the program spits out instructions.

The program is in it's final stages and is ready for testing.

If anyone is interested in testing this program, feel free to contact me by email. Remove the "nojunk" in my address above, and add "com" instead.

Hopefully, this will be the first of many contributions I make to the medical world!
Doctoring , Family , IM , Residency
posted by  Mohammed at  20:27 | permalink | comments [1]

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