Costs and Ethics: Dr. Kaldjian

Today Dr. Kaldjian, Director of the Program in Bioethics and Humanities at the University of Iowa Carver College of Medicine and professor in the Department of Internal Medicine visited UTSW today.

After joining us at Morning Report today with resident Dr. Bryan Wilner presenting a very difficult and interesting ethical case.

Dr. Kaldjian then went on to give the Ethics Lecture during UTSW’s Update in Internal Medicine (lead by Dr. Weissler) entited “Ethics, Goals, and Role when Discussing Healthcare Costs with Patients.”

He spoke about the tension between patient-centered concerns and society-centered concerns. We were encouraged to think about which concern promotes the good of person vs. promotes justice.

Promoting the Good of Persons:

  • beneficence (one patient at a time)
  • utility (maximizing beneficience)

Promoting Justice

  • commutative: giving to each what they are due as a person (in healthcare: to each according to their need)
  • distributive: justice as fairness (similar treatment for similar cases)

Dr. Kaldjian also reminded the audience that as patient advocates, he encourages us to think about “intention.”

Some additional notes and references used in his talk. Enjoy!

Choosing your words wisely: stewardship vs. rationing

 

“Hospital-acquired bankrupcy” and a recent survey by the Kaiser Family Foundation: in order to pay the bills, what do patients?

 

 

Chest xray and Chest CT: discrepancy?

Today at #MorningReport we had a case of a common diagnosis with an uncommon presentation.

A patient with recent cancer, s/p kidney transplant on immunosuppression but now with CKDIII came into the hospital for worsening shortness of breath and a dry cough. PA+lateral chest xray showed patchy RLL consolidation with very small bilateral effusions. He was started on antibiotics for community-acquired pneumonia and no JVD, rales and trace bilateral edema.

See the initial PA/lateral CXR:

Over the next 6 hours after lying in his bed, he came significantly more tachynpenic with an ABG of pH 7.42 and pCO2 24 and pO2 56. What do you think?

Repeat portable CXR at that time. Yikes!

Looks like worsening interstitial pattern! Differentials included: 

  • Bacterial: CAP, atypical, legionella, nocardia, actino, aspiration, MRSA
  • Fungal: PCP (“fluffed out”), crypto, histo, NTMB
  • Non-infectious: metastic cancer, pneumotoxicity – COP/BOOP/eos pneumonia 2/2 Tacro or Statin or pneumonitis, PF and DAD 2/2 chemo, DAD, DAH or sarcoid
  • Hypervolemia from CKD
  • Pulmonary embolism
  • ACS, heart failure

CT scan confirmed the diagnosis!

Cause of his SOB and acute worsening? Volume!

Patient recieved some diuretics and tachypnea improved dramatically.

Dr. Meredith Greer sent these notes over from our very own, Dr. Abbara, in the Radiology Department: look at the CT chest because there you can see the bilateral pleural effusions looking much bigger as the patient is laying supine and they are sort of layered out. When the pt is getting the PA/L CXR a lot of the effusion can hide in the gutters. It is possible that while the pt was laying down he developed atelectasis on top of his effusions and when he stood upright for the plain film that his effusions went down but the atelectasis didn’t have time to open back up yet.

https://radiopaedia.org/articles/pulmonary-pseudotumour

 

 

#TodayAtMorningReport

We had a fascinating case of anemia, thrombocytopenia and hemolysis – initially we had a broad differential but eventually focusing on MAHA vs transfusion reaction.

Take a look at the graphic below as well as some slides from Dr. Nagalla discussing a Clinical-Pathology-Case recently and his diagnostic reasoning around this topic.

From Wintrobe’s Clinical Hematology 13th edition:

 

 

 

 

#fridayimagechallenge(with answers)

45yo Buddhist monk with no past medical history presents to the parkland ED with 1 week mild chest pain on exertion and palpitations. Initial ECG is shown below.

 

Continue reading #fridayimagechallenge(with answers)

RESIDENT RECOGNITION!

Shout out to our stellar resident Dr. Bryan Wilner! Here’s what our ICU nurses had to say:

Dr. Wilner was of great assistance to us this evening for some critically thinking time. We were perplexed about a specific cardiac issue with a patient. Unsure if it was cause for concern, we asked Dr. Wilner who was sitting in the CCU rounding room for time to pick his brain, he obliged.  We are thankful for his collaboration while we provided our patients with the safest proactive care.

What an amazing example of great teamwork and collaboration! Your patients are benefiting from it! 🙂

#fridayimagechallenge

55yo hispanic gentleman with poorly controlled diabetes presents with substernal chest pain radiating to his jaw starting 3 days ago, in ED troponin 1.2 and initial EKG below.

UTSW Internal Medicine

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