Healthcare delivery as seen by the patient/family

This past Friday, grandpa V had a cardiac arrest. He was a very vibrant 89-year-old with many medical conditions. He was resuscitated, intubated and transferred to the hospital emergency department. We drove down friday night to be at his bedside in a Delaware ICU. We take care of such patients all the time. This was one more chance for me to be on the other side and see how the healthcare system works or does not work. I saw from a family's perspective what drives outcomes and patient/family experience. I hope the wonderful treatment we got was not because I was a physician. There were many things that worked well.

Communication: The emergency department physician and the attending cardiologist both got on the phone to update me as I was driving down I-95. They were open to ideas, and they started hypothermia protocol at my suggestion. The interventional cardiologist also called me before the procedure to explain the rationale and the risks.
Access: The nurse and the ICU allowed family visiting, and gave frequent updates. Doctors and nurses were available a phone call away.
Caring: The hospital sent a comfort cart with coffee, juices, muffins while we were at the bedside vigil. small touch, goes a long way. It showed that they cared.

So, inspite of a bad outcome--death, the family was pleased with the care provided at the ICU in Delaware and will always be grateful to the wonderful nurses, physicians, and the hospital staff for taking such good care of grandpa and us.

I relearnt my lessons.

What is a patient centered practice?

Patients are why we all are here. That is obvious. However, in the last few years, the concept of patient-centered medical homes have emerged. These are primary care practices that meet certain criteria listed below:
PCMH 1: Enhance Access and Continuity
PCMH 2: Identify and Manage Patient Populations
PCMH 3: Plan and Manage Care
PCMH 4: Provide Self-Care and Community Support
PCMH 5: Track and Coordinate Care
PCMH 6: Measure and Improve Performance

Although this is geared towards primary care, our office does have some primary care component and the model also makes sense for specialty care.
PCMH content and scoring details are found at NCQA website.
We can start by establishing registries of our patients with asthma, COPD, sarcoidosis, lung nodules, OSA.
We can also identify high-risk patients- based on their disease severity and psycho-soical factors.
Finally, getting a superb office EMR will let us become more patient-centered and do continuous quality improvement.

Understanding Lung Shadows

All of us come across chest xray or a CT scan report on our patients that mention infiltrates or nodules. Other times they mention a mass, or ground glass opacity. Let us try to understand the basics of these radiographic descriptions.

Infiltrate: generally describes a haziness in the part of lung that is denser than normal lung- it could often be seen in pneumonia. There are other conditions that can cause infiltrates- such as atelectasis (compressed lung segment).

Nodule: a density or opacity that measures less than 3 cm is called a nodule. It can be single or mulitple; it could be subcentimeter or more in size. Nodules are scary because we always worry about them being from cancer. We never want to miss a nodule patient in follow up. Many nodules turn out to be benign, from scar, or granuloma ( old infection). We need to closely monitor the nodule to make sure it is not growing in size. Depending on the size or the risk factor of individual patient, we may decide to either closely follow it by serial CT scan, or send patient for biopsy, or send the patient for thoracic surgery to take the nodule out surgically. Missed lung cancer in a patient with nodule is a high risk to our practice.

Mass: is generally a dense, 3 cm or more density, and it generally is concerning for cancer. Rarely pneumonia, or rounded atelectasis can mimic a mass. A mass usually needs urgent consultation followed by biopsy.

Have you come across other radiographic term that has puzzled you?