I'm just back in Rural after several days in San Francisco where I attended the Care of the Hospitalized Patient, co-sponsored by UCSF and the Society of Hospitalist Medicine. In an attempt to render my note-taking as paperless as possible I used Adobe Acrobat Pro to annotate the PDF files corresponding to each lecturer's slides. This gave me an excuse to drag my MacBook everywhere and keep Twitter open for the entire conference. What resulted was a line-by-line report of the conference, which has been kindly featured on Clinical Cases and Images as an example of using social media such as Twitter to share information about curent medical practice with one's colleagues. In total, I tweeted 192 times from the conference. Here's a selection of the top tweets:
DAY ONE
ruraldoctoring
Going to bed. CME meeting starts tomorrow.
ruraldoctoring
OK, now that I'm up before 6am, going to this CME seems like the dumbest idea in the world.
ruraldoctoring
Finally arrived at SHM meeting after sweaty sprint up 16% grade San Francisco hills.
ruraldoctoring
Think I've passed my stress test--no chest pain. Near-syncope a few times, but no chest pain.
ruraldoctoring
#SHM: We now move on to talk by "neurohospitalist" S. Andrew Jacobson.
No such animal has ever been sighted in Rural.
ruraldoctoring
#SHM: European SITS-MOST study suggests tPA can be effectively
implemented in non-referral hospital settings safely. Gotta read it
myself.
ruraldoctoring
#SHM: UCSF Stroke CT protocol: 1)noncon brain + 2)CT Angio from Ao arch
to Circle of Willis, 3)CT perfusion study, 4)Post-contrast CT.
ruraldoctoring
#SHM: "A lot of you work at these stroke referral centers." Ah, not.
ruraldoctoring
#SHM: tPA decisions will probably be made on basis of perfusion
patterns in near future, after identifying areas of salvagable tissue.
ruraldoctoring
#SHM: Post-stroke management must include permissive HTN--up to at
least 220/120 unless tPA is planned. I knew this but the struggle!
ruraldoctoring
#SHM: Post-stroke management must include permissive HTN--up to at
least 220/120 unless tPA is planned. I knew this but the struggle!
ruraldoctoring
#SHM: I will say they choose excellent speakers for this meeting. Good
thing, otherwise I'd be sitting with 700 other bored hospitalists.
ruraldoctoring
#SHM: Oh, and btw, I *am* using Acrobat Pro to annotate PowerPoint PDFs provided by speakers. It works.
ruraldoctoring
#SHM: Now talking about CA-MRSA pneumonia. Yes I've seen it, even in Rural.
ruraldoctoring
#SHM: Ah, the UCSF physician's demeanor. The brisk confidence, the
articulate and slightly self-mocking humor. I'd forgotten.
ruraldoctoring
#SHM: Discussing reasons for readmit after pneumonia hospitalization:
<H.S. educ, unemployed, COPD, CAD. Target intensive d/c
instructions.
ruraldoctoring
#SHM: Now we're talking about my favorite hospitalist problem: Delirium.
ruraldoctoring
#SHM: "Delirium: A Stress Test for the Brain." I like it.
ruraldoctoring
#SHM: "We don't think about [encephalitis] often enough." I do! Or at least I think I do.
ruraldoctoring
#SHM: "When the EEG begins to look like the EKG, things are not normal."
ruraldoctoring
#SHM: Discussing need for urgent EEG, even if this requires transfer to another hospital. Trying not to laugh.
ruraldoctoring
Because, in Rural, I think the neurologists do maybe 2 inpatient EEGs at my hospital a year. OK, maybe 5.
ruraldoctoring
#SHM: I love that this hotel has WiFi. I just wish they had switchplates at every seat. Battery at 26%.
ruraldoctoring
Back from lunch break, went with some friends and had to tackle that 16% grade again. Feeling a bit...exhausted.
ruraldoctoring
Found a seat at the back next to an electrical outlet, so MB receiving
urgently-needed transfuson of battery juice.
ruraldoctoring
Breakout session: "Sedation and Ventilator Pearls" is my choice this
afternoon. Who'da thunk it would be so important for an FP to know?
ruraldoctoring
Mostly a bunch of internists at this meeting, but I know there must be some renegade FPs out there.
ruraldoctoring
The RT presenting the ventilator portion of this talk is the same man who taught us as med students.
ruraldoctoring
#SHM: Daily interruption of sedation in vent pts a "huge effort for
nursing staff." Agree, but we still have to do it to shorten vent time.
ruraldoctoring
WiFi cutting in and out of this room.
ruraldoctoring
#SHM: Standing room only here in the Vent Pearls workshop.
ruraldoctoring
#SHM: I feel sorry for this speaker, this is not an easy topic to make "sexy."
ruraldoctoring
#SHM: Does it say something about our hospitalist practice that most of what I'm hearing is old hat?
ruraldoctoring
#SHM: Here comes the fun stuff--RT has powered up the demonstration vent and it is beeping. A familiar sound.
ruraldoctoring
#SHM: Not that ventilator alarms should be a familiar sound, but they are.
ruraldoctoring
#SHM: UCSF apparently uses nice, state-of-the-art ventilators with elaborate laptop LED readout.
ruraldoctoring
#SHM: In Rural, we have the wind-up, Fisher-Price variety of
ventilator. Our intensivist calls them "sacks of roachsh*t."
ruraldoctoring
#SHM: Surprised by some of the questions here. I was expecting to be the most ignorant person in the room.
ruraldoctoring
#SHM: But I have discovered here that many hospitalists do NOT manage
ICU patients--enough intensivists to take that out of their hands.
ruraldoctoring
#SHM: Learning about plateau pressures! I've always wanted to understand plateau pressures!
ruraldoctoring
#SHM: I'm so cool--I'm hand-drawing vent flow graphics into
PhotoStudio, a simple image-editor I got with my Canon flatbed scanner.
ruraldoctoring
#SHM: We really, really need vents with graphical readouts in Rural.
Last time intensivist wanted plateau pressures, we had to send out for1
ruraldoctoring
#SHM: Feeling grateful for the existence of good respiratory
therapists. I work with some, and you probably do too. Pat them on the
back.
ruraldoctoring
#SHM: Just had 30 minutes of whirlwind plateau pressures, auto-peep,
increasing expiratory time--all stuff I wanted to know about.
ruraldoctoring
#SHM: Back in the Grand Ballroom. The one and only Bob Wachter, M.D. is about to speak....
ruraldoctoring
#SHM: Wachter's talk: "Patient safety eight years after the IOM report on medical errors."
ruraldoctoring
#SHM: OK, maybe I missed something, but why do people leave their BT
earpiece on while they sit in a conference room? Are they taking calls?
ruraldoctoring
#SHM: Regarding regulation of H/C entities: "We used to be
underregulated, now we're overregulated." Draws parallel with Wall
Street.
ruraldoctoring
#SHM: Good point: CMS mandates more concerned with quality of care than
safety. Safety initiatives rely heavily upon self-report.
ruraldoctoring
#SHM: Now Dr. Wachter is talking about "never events." Talk about a hot-button topic.
ruraldoctoring
#SHM: UCSF now has 2hr weekly root-cause analysis meeting, ever since
"never event" requirement. Imagine having to go to that mtg weekly...
ruraldoctoring
#SHM: Wachter on P4P for safety: "It is more attractive to pay less for errors than more for safety."
ruraldoctoring
#SHM: Dr. Wachter rates healthcare regulation over clinical IT when it comes to efficacy in reducing errors.
ruraldoctoring
#SHM: Telling hilarious story about implementing computerized
decision-making tools to improve safety & then residents totally
derail them.
ruraldoctoring
#SHM: Dr. Wachter now talking about failure of accountability in "no
blame, the system is broken" RCA approach. I agree.
ruraldoctoring
#SHM: Risk of "no blame" is perpetuation of circling the wagons around bad HC providers.
ruraldoctoring
#SHM: Bob Wachter: "We've taken the issue of individual accountability and put it in the "Too Hard" box."
DAY TWO
ruraldoctoring
Another 6am wake-up call. Waiting for coffee.
ruraldoctoring
#SHM: Arrived a conference venue after scaling only one vertical block.
ruraldoctoring
#SHM: WE are having clinical problem-solving workshop this morning, AKA Stump the Internist.
ruraldoctoring
#SHM: Internist on the hot spot is doing admirable job of talking
through a case he is being confronted with this morning.
ruraldoctoring
#SHM: (Am I terrible to suspect the conference organizers for having
snuck the internist-on-the-spot clues about this case?)
ruraldoctoring
#SHM: When your consultant says "All of those options are
reasonable...." you know s/he's about to tell you why you're wrong.
ruraldoctoring
#SHM: Zebratalk: discussing Legionella, Cocci, Histo, Blasto.
Relatively uncommon but not rare, and classic InternistSpeak.
ruraldoctoring
#SHM: I used to believe IM doctors were the ultimate in medical
intellect. Today's discussant is a classic ex off Internist as
Diagnosician.
ruraldoctoring
#SHM: What's rarer than a zebra? Lymphomatoid granulomatosis. We're
entering Where the Wild Things Are with this case.
ruraldoctoring
#SHM: Note to med students who hate getting pimped: I get the feeling
that this very articulate and meticulous discussant got pimped a lot.
ruraldoctoring
#SHM: Re: shotgun treatment. "The issue of observing is easy on PowerPoint but hard to do in the hospital."
ruraldoctoring
#SHM: I knew it! We were given red herrings during this case! Now the pt is back with 2nd presentation!
ruraldoctoring
#SHM: Big historical clue: pt has always lived in a Midwestern
battleground state...something having to do with fungal exposures.
ruraldoctoring
#SHM: Slide: "A Diagnostic Test Was Sent." Oh hahaha.
ruraldoctoring
#SHM: OK, battleground state clue was also a red herring. Pt drove down
I5 in California through the Central Valley, so she has....
ruraldoctoring
#SHM: ...pulmonary cocci followed by cocci meningitis. Classic IM red
herring/we figured it out/isn't medicine cool case.
ruraldoctoring
#SHM: On to "Using the Literature to Make Tough Decisions and a Few Other Things."
ruraldoctoring
#SHM: OK, current speaker is going to criticize reliance upon UpToDate,
upon which I could not survive daily life in medicine.
ruraldoctoring
#SHM: Case: 78F melena&fatigue. Obv LGIB. EGD planned then
cancelled when she dev unstable angina. Cardio won't cath while
bleeding...
ruraldoctoring
#SHM: ..GI won't scope with angina. Speakers suggest we go to PubMed
for primary sources to support argument for GI to proceed w/endo.
ruraldoctoring
#SHM: "UpToDate is great for textbook problem, but not as good for two
or more concurrent problems." OK, this is true, I'll admit.
ruraldoctoring
#SHM: The fact that these speakers have the time to sit around and
compare UTD to PubMed head to head = academic medicine.
ruraldoctoring
#SHM: I appreciate the info at this meeting, but there is a definite
disconnect between urban/academic and my rural hospitalist needs.
ruraldoctoring
#SHM: Presenting case of cardiac myxoma causing Ao embolic occlusion.
"You present this pt at your weekly hospitalist case mtg." Riiiiight.
ruraldoctoring
#SHM: Now they're presenting examples of Googling for Diagnoses.
ruraldoctoring
#SHM: Emphasis on Google to help determine whether an interesting case
is worth writing up (e.g. few or no other cases published).
ruraldoctoring
#SHM: How often do I ask myself, "Should I write up this case?" About as often as I snake the drains in my sink.
ruraldoctoring
#SHM: Take-home point to using EBM in clinical practice: suck it up and
use PubMed instead of just being a UpToDate slacker.
ruraldoctoring
#SHM: Break! Recharging MacBook. Sitting on the floor in the front of
the conference room like a geek, but at least recharging.
ruraldoctoring
#SHM: OK, onto Dermatology Topics in Hospital Medicine.
ruraldoctoring
#SHM: Conference room plunged into darkness so we can look at pretty color slides of gnarly skin eruptions.
ruraldoctoring
#SHM: We're looking at slides of Stevens-Johnson and toxic epidermal necrolysis. Extra gnarly.
ruraldoctoring
#SHM: "The key issue is to consult your dermatologist right away." And
just who would that be? We have one derm who consults & rarely.
ruraldoctoring
#SHM: Very helpful derm review. Makes me think I'm not paying enough
attention to all the "cellulitis" and "infected decub" admits.
ruraldoctoring
#SHM: Now we're on to Adrenal & Pituitary Issues in Hospital
Medicine. Very, very important and hard to grasp (for me, anyhoo).
ruraldoctoring
#SHM: Choice D of multiple-choice pop quiz: "Obtain a neuroendocrine consult." Uh, NOT!
ruraldoctoring
#SHM: On to rheumatology. Cool stuff but we can't get into the meat of the problem in 30 minutes.
ruraldoctoring
#SHM: Discussion of bacteremic spread of septic arthritis makes me realize how lazy I am at daily M/S exam.
ruraldoctoring
#SHM: Regarding vasculitis, spkr using Justice Potter Stewart's quote:
"I know it when I see it." I wonder how Justice Stewart would feel
ruraldoctoring
#SHM: about his words being used for every subject other than its original (pornography).
ruraldoctoring
#SHM: First breakout session: Improving Management of Diabetes in the Hospitalized Patient. Standing room only.
ruraldoctoring
#SHM: Academic wiki project: www.endotext.com --free, downloadable, regularly updated textbook about endocrinology.
ruraldoctoring
#SHM: Dr. Rushakoff, our speaker, can actually pronounce thiazolidinedione easily. rolls right off his tongue.
ruraldoctoring
#SHM: OK, finally a take-home message: nobody agrees on what goal glycemic control in ICU patients should be.
ruraldoctoring
#SHM: "Sliding scale insulin works great if the patient doesn't need insulin."
ruraldoctoring
#SHM: "Giving [preprandial insulin] on time in the hospital is not only
virtually impossible, it is impossible." Yup.
ruraldoctoring
#SHM: Reviewing UCSF's preprinted insulin orders. It looks useful, but
preprinted orders always do. Using them is a bit less useful.
ruraldoctoring
#SHM: "Patient should not be given corrective insulin dose at bedtime."
Exactly. Why I write "for AC coverage only" on my orders.
ruraldoctoring
#SHM: Transitioning from insulin drip to SQ insulin. Not quite what I'm
doing now, but close. Very important topic.
ruraldoctoring
#SHM: For diabetic pt on PO meds only, UCSF uses correctional dose
insulin for 1st hospital day. Oh good, this is what I do.
ruraldoctoring
#SHM: Now covering insulin dose for patients receiving tube-feeds. Yay,
I have to struggle with this one all the time.
ruraldoctoring
#SHM: How to manage insulin in patients receiving steroids: no formula, but adjust prandial dose daily.
ruraldoctoring
#SHM: "It's a lot easier to implement [insulin protocols] in small
hospitals." This is true. Our diabetic management is pretty good.
ruraldoctoring
#SHM: It took UCSF 3 years to implement their current diabetes management protocols.
ruraldoctoring
#SHM: Crappy wifi in new room. Hete for EKG refresher.
ruraldoctoring
#SHM: Reviewing electrically silent MIs. ER fodder.
ruraldoctoring
#SHM: Back in the Grand Ballroom, where WiFi reigns free.
ruraldoctoring
#SHM: We now get to hear what's new in lower GI bleeding.
ruraldoctoring
#SHM: Looking around this room and feeling kinda depressed that there
are 700 docs in this room and not one is in primary care. Incl me.
ruraldoctoring
#SHM: Re: LGIB: "People who continue to bleed are more likely to
continue to bleed." This indeed has been my experience.
ruraldoctoring
#SHM: Rapid purge LGI prep: polyethylene glycol 1 liter q30-45 MINUTES
times 6. "NGT needed in 30% of patients." No kidding.
ruraldoctoring
#SHM: OK, on to Antibiotic Updates--my hospitalist friend is very
excited because her ID consultant only uses dapsone & other
3rd-line abx.
ruraldoctoring
#SHM: Being brought up to date on 5th gen cephalos coming up and +/-
evidence for increased all-cause mortality with cefipime.
ruraldoctoring
#SHM: Learning a lot about the "penem" antibiotics, which I never used to use, but these days--more and more.
ruraldoctoring
#SHM: Current fluoroquinolones are burdened by emerging resistance
patterns--reducing usefulness for hospitalized patients w/sig infxn.
ruraldoctoring
#SHM: Ooooh, my MB battery is down to 6%--lowest I've gotten during active use.
ruraldoctoring
#SHM: Coming soon: lipoglycopeptides, for weekly dosing of deep-tissue MRSA infections. Maybe.
ruraldoctoring
Back from #SHM. Today I covered hospital-related topics in derm, endo,
rheum, GI, ID, and cardio. My brain is full.
ruraldoctoring
So far, my self-assessment at #SHM has been better than expected. I
know more than I thought I did. But I still don't know a LOT.
DAY THREE
ruraldoctoring
#SHM: Back in the Grand Ballroom. Took a cab this morning--luxury.
ruraldoctoring
#SHM: Ordering the Right Neuroradiology Study--excellent topic. I can
never remember which kind of MRI (con/noncon) to eval encephalitis.
ruraldoctoring
#SHM: Now I finally understand the difference between brain MRI with
contrast vs. MRI with diffusion weighted images.
ruraldoctoring
#SHM: Learning the correct spinal level MRI to order for different neuro deficits. Very, very helpful.
ruraldoctoring
#SHM: Now we're hearing about Clinical Controversies in Medical
Consultation--i.e., more evidence to use in surg comanagement.
ruraldoctoring
#SHM: New ACC/AHA preop guidelines: only need to stress test pts with
poor funct capacity, 3+ predictors of cardiac mort, & hi-risk
surgery.
ruraldoctoring
#SHM: Reviewing 2007 ACC/AHA guidelines for when a recently
post-cardiac stent pt can undergo electively-times surgery.
ruraldoctoring
#SHM: Bottom line: not too soon! Wait at least 4 weeks after plain metal stent, 6 months for drug eluting stent.
ruraldoctoring
#SHM: Never mind th 2006 ACC/AHA beta-blocker recommendations. Reserve
BB for pts already on, or hi-risk pts going to vascular procedure.
ruraldoctoring
#SHM: However, regarding statins--use them early, use them often. Even
consider in intermediate-risk surgery for pt with risk predictor.
ruraldoctoring
#SHM: Endocarditis prophylaxis--reserve for mech valves, prior
endocarditis, hx cyanotic heart disease, heart transplant
w/valvulopathy.
ruraldoctoring
#SHM: 2007 ACCP guidelines for holding coumadin--only AFib pts with
multiple comorb dx and older mechanical MVs need briding heparin.
ruraldoctoring
#SHM: On to Workup and Management of Vertigo--woo-hooo!
ruraldoctoring
#SHM: Geez, vertigo is a tough topic. Anything that takes us into the vestibulocochlear complex is tough.
ruraldoctoring
#SHM: This lecture on vertigo is moving so fast I'm getting vertiginous just listening to it.
ruraldoctoring
#SHM: Just covered a case of basilar artery thrombus diagnosed late. Scary.
ruraldoctoring
#SHM: On to Update on Interventional Cardiology. My rural version of
this would be "How to Get Your Cardiologist to Intervene."
ruraldoctoring
#SHM: @drval Or it could be "How to Manage the ACS Patient When the Cardiologist Won't Intervene." Now THAT would be useful.
ruraldoctoring
#SHM Good. Now I can argue we should be using glycoprotein IIb/IIIa
inhibitors as well as Plavis in all my pts who don't get cath'd asap.
ruraldoctoring
#SHM: So far, this talk is NOT about interventional cardiology but
about 2007 ACC/AHA guidelines for UA/NSTEMI, which I already know.
ruraldoctoring
#SHM: OK, I take it back. Now we're talking about in-stent restenosis
vs. stent thrombosis and how this influences duration of Plavix rx.
ruraldoctoring
#SHM: Bottom line: Duration of Plavix post-PCI depends on nature of
lesion, type of stent, and pt's ability to commit to long-term Plavix.
ruraldoctoring
#SHM: Showing a cool fluoro video pre/post successful stenting of "widowmaker" LAD lesion.
ruraldoctoring
#SHM: Coming down the pipeline: more drug-eluting stents (pharma
getting in on the money), perc AV/MV replacement for non-OR candidates.
ruraldoctoring
#SHM: Before I forget: morphine is downgraded to IIa recommendation for
ACS--small increase in mortality. "MONA" turns into "DONA"-Dilaudid.
ruraldoctoring
#SHM: Last talk: The Year in Hospital Medicine--whirlwind of NEJM topics not covered by other speakers. Oy vey.
ruraldoctoring
#SHM: CHF exacerbations--don't stop beta blocker! 3x greater 30d mortality if you stop during hospitalization.
ruraldoctoring
#SHM: Bread & butter COPD exacerbations: PO corticosteroids are
equal to IV in efficacy/oucomes. In pts requiring ICU, IV is better.
ruraldoctoring
#SHM: Proton pump inhibitors: a/w higher C.diff in hospital, comm-acq
pneumonia 1st month of rx & osteoportic fx after 5-7 yrs rx.
ruraldoctoring
#SHM: PPI Part 2: So prolonged PPI use should be reserved for clear
indications only (Barrett's esophagus, for example).
ruraldoctoring
#SHM: Osteop hip fx: Start Ca++ and VitD, but also early initiation of
bisphosphonates prevents future fx and decr mortality.
ruraldoctoring
#SHM: Symptomatic hypercalcemia: 1st line is IVF + bisphosphonates +
calcitonin (severe elevation only). Use of Lasix not supported by evid.
ruraldoctoring
#SHM: D/C criteria for CAP: SaO2 on RA<90% a/w need for readmission,
and ongoing fever a/w higher 30d mortality. Tell that to D/C planners.
ruraldoctoring
#SHM: Duration of abx for CAP: 7 days total antibiotic therapy equally
effective compared to longer regimens, and fewer adverse effects.
ruraldoctoring
#SHM: Pneumovax for CAP: You know that annoying quality measure? Well
there's good evidence to support it, so suck it up and vaccinate.
ruraldoctoring
#SHM: Insulin regimen in ICU: Tight control doesn't get you any better
outcomes than moderate control. Target BGs <150.
ruraldoctoring
#SHM: pRBC transfusion in ICU: Target Hct>30 for pt w/MI in
progress. Other dx, transfusing just to get Hct up is a/w worse
prognosis.
ruraldoctoring
#SHM: Upper extremity DVTs: common in younger pt, cancer, cath/port pt.
Treat as for LE DVT no matter what the etiology.
ruraldoctoring
#SHM: Poor prognosis: Pt families want to be told about pt's prognosis
but will probably not believe physician's estimates.
ruraldoctoring
#SHM: Empathy: @kevinmd linked to the NEJM empathy study. Doctors missing opportunities to connect w/families. I have more to say re: this.
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