Venting

November 19, 2008
Abe Friedman, MD

This editorial was stimulated one morning when I saw a patient with congestive heart failure and rapid atrial fibrillation (AF).

This editorial was stimulated one morning when I saw a patient with congestive heart failure and rapid atrial fibrillation (AF). A medical student came over to me and we reviewed the data. I noticed that Digoxin was not one of the medications. I asked the medical student her reasons and she told me her lectures on congestive heart failure and AF stated that Digoxin is no longer an effective inotrope or a rate controlling drug. I must have missed that lecture. Digoxin does have a narrow toxic window, but if we keep levels less than 1.0 ng/mL we are not going to get into trouble. If we add it with other drugs we know that it will control AF and aid in conversion. It is an inotrope and will add its effects to other drugs. Maybe it is a sign of aging or maybe it is a sign of transition but I imagine that we have to tell Sir William Osler and the British housewife that gave him the Lanatus Purpura that their medication does not work. Recall when prior researchers stopped Digoxin in compensated congestive heart failure patients, these patients decompensated. Digoxin, I hope that I do not have to say goodbye to an old friend.

Heparin has been around for a long time. In the elderly, I keep the partial thromboplastin times between 50-60 seconds and watch platelet counts daily and only rarely have I gotten into problems. Note the key point is reducing the dose in the elderly and particularly paying attention to renal function. I use Heparin in unstable angina, ST-elevation and non

ST-elevation infarctions but other drugs are trying to make a big push to remove it. Enoxaprin has been equated with the effectiveness of Heparin, but there has been a problem with bleeding. The bleeding will decrease if we pay attention to the patient’s age and renal failure. Researchers have tried to use thrombin inhibitors, mainly lepirudin, argatroban or bivalirudin. The only one that has been tested is bivalirudin and close attention must be paid to age and renal function. Heparin, goodbye old friend.

Where should we keep the patients blood pressure? We are pounded in tapes, literature and conferences that 140/90 mm Hg may not be the ideal range. In diabetics 130/80 mm Hg maybe the ideal range. Perhaps we may need to get it to 120/80 mm Hg. This seems to change every six months. When treating patients it is imperative to not necessarily rely on blood pressure in the office, but have the patient purchase a sphygmomanometer and evaluate blood pressure at home and at work. If patients cannot afford this, have them come into the office and obtain blood pressure when you are not there. Most importantly, particularly in the elderly, always do orthostatic blood pressure. The control of supine blood pressure should not be at the cost of orthostatic hypotension and syncope. This is not an uncommon event.

We are concerned about the timing in treating myocardial infarctions (MI). I think that it is time that we set up MI centers similar to trauma centers. Avoid politics and economics. If there is a hospital in a reasonable distance that has a 24 hour cardiac catheterization lab ready to go than that is where the patient should be.

Can we have studies that do not have acronyms? I cannot remember acronyms. What did we do before acronyms? At least we knew what the study entailed from its title.

I try my best to follow lipid standards. It is very difficult to get the LDL into the 70s. Most of my population probably is no different than yours, does not exercise, does not follow a diet, is significantly overweight and has a myriad of complaints when we use a statin drug. After I have placed the patient on a statin drug, a fenofibrate, niacin or added ezetimibe, I am thrilled when I can get the LDL close to 70. I am always concerned that with a 78, 89 or 90 that the lipid police are going to arrest me. Once I have the lipids under control, I look at the C-reactive protein and it is elevated. Oh lord, what do I do now? I have searched for higher guidance but it has been very difficult. How many lipid drugs will our patients tolerate?

Would someone please tell the orthopods that they MUST” use warfarin post operatively for hips and knees. It is imperative. In those who refuse I try my best to have the patients at least have venous Doppler’s one week after surgery.

Can we please make the evening news free from advertising medications, different types of surgery or impotence? Is this a marker of our society that we have pills for better sex and operations for obesity? Would someone pinch me? Am I dreaming? Can we stop malpractice attorneys from advertising during the evening news? Dr Jarvik, enough lipid commercials.

My patients will promise to lose weight. I have a wager with them. In six months I want them to lose 10 pounds. If they lose the 10 pounds I will donate $50.00 in their honor to their favorite charity. If they do not, they will donate $50.00 in my honor to their favorite charity. Their charity wins no matter what. In 27 years of practice I have lost this bet 3 times. I am now thinking of paying the patients $1.00 per pound. How did the “COURAGE” population do so well? Maybe they were all aliens or prisoners. What does COURAGE stand for?

I am told by the hospital police, the pharmacy and the Joint Commission of Hospitals I cannot use Latin anymore when writing prescriptions. I cannot use b.i.d., q.o.d., and t.i.d. I must write it out. I am told that this will decrease medication errors. Valere iubere anilitas amiculus.

Has HIPPA gone too far? For the past 12 years my family and I go to a local hospital on Christmas to pass out flowers, candy canes, fill water pitchers and do simple tasks for the patients. I started this because I wanted my children to see that giving is better than receiving. This year everything was stable until we came to the second floor, the detox unit. At this point we were confronted by a new social worker. He told us that we were not permitted to be on the unit or to pass out flowers to the patients. There was a risk that we would know a patient and this would create significant problems for HIPPA. To be honest with you I am not sure what HIPPA stands for, but I know that it has caused significant changes in policies throughout all hospitals. I was not going to allow HIPAA to ruin Christmas, so I simply told the social worker that this has been a tradition for 12 years without complaints and that this may be the only present or visit that some patients will receive. I told him if I am doing something so terrible you can call the HIPPA police and I would be willing to take any sanctions that they deem necessary. First it was Latin now they are trying to take Christmas. I think it is time to call the Vatican. We proceeded into the rooms and gave each patient their gifts.

Stethoscopes: All my residents have them but do not use them correctly, if at all. They do not receive the ausculatory skills from teachers because teachers do not have these skills. I see them examining from the left side of the bed. I see them examining through the patients clothes. It is hard enough to hear heart sounds without having any interface between you and the patient. I am told why use a stethoscope when you can get an echocardiogram?? Auscultation will become archaic when robots are directing care. Most likely the physician will not be at the bed side. There will be no touching and caring by the physician. It will be a technical era and the nurse and physician’s assistant will be the only humans at the bedside.

Am I aging? Absolutely! But yet, I think that I have used different types of practice policies that have resulted in good patient outcomes. We can never stop change or better care but we must become symbiotic with it.

The author would like to thank Jennifer Brown for her technical assistance.

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