who's chart is it?

is it mine?  i paid for the paper (now the computer) on which the data is stored, i wrote it and compiled it, i am required by law to keep it safe and maintain it years beyond any actual contact with the patient.

is it the patient's?  it is after all a record of their personal medical history, a repository of data that they may need access to in the future. does the patient have any real control over content? does a patient have a right to ask me to omit something from  his or her chart?

is it the insurance company's?  both the patient and i signed contracts giving the insurance company unlimited access to the chart, whether it is to be sure i am charting and billing correctly, or to be sure the patient has left no diagnosis, no matter how trivial, undeclared. (my least favorite task is filling out pre-existing condition forms for insurance companies, forms that basically hunt for some reason to deny a claim.  i feel like i am doing their dirty work, and possibly causing grief for my patient to boot, but i am obligated to fill them out.  they often have ridiculous questions like 'will this patient need surgery in the next five years?' i'm not making this up.)

is it the government's?  they increasingly want and demand access to cumulative chart data that has for so long been fragmented and inaccessible, data that now, with electronic health records, seems tantalizingly close to their fingertips.

is it the free market's?  electronic health records are already being mined by companies for marketing data, much as pharmacy records have been exploited for years.

i think the answer is e)  all of the above.

if doctors named crayons

black = eschar

white = morphea

gray = gray matter

brown = stool

purple = hematoma

blue = cyanosis

green = meconium

yellow = icterus

orange = carotenodermia

red = angioma

pink = erythema

i am so young

my patient told me that today was his 57th wedding anniversary.  he then put his face in his hands and burst into soul wrenching sobs.  i didn't see it coming, this man who has generally been so reserved in our encounters.  but i did know that the past six months had been rough for him, culminating in his wife ultimately being diagnosed with an uncommon form of dementia.  i felt so young watching him cry, glimpsing just briefly before he pulled himself back together the depth of his sadness.

grief does not wait for the last word to be spoken or the last breath to be drawn.  grief rushes in well before, when you can no longer say some day i may have to face this, some day i may lose my spouse.  grief finds you the moment you learn that your some day is today, now, and is your constant companion as your spouse slips away one forgotten day at a time.

i don't think so

i got a report on a patient from her podiatrist.  it was an electronically generated note, and in the review of systems, that infamous pandora's box of the medical record in which you are supposed to ask detailed questions about symptoms pertaining to every part of the human body (leave no stone unturned! is the ROS's war cry), it noted that my patient did not have nipple discharge.  did he really ask her that?  i think i would consider getting up and walking out of the office if my podiatrist, in a clear departure from reality, asked me a question like that. lets keep it real folks. the pressure is on but i know we can.

i love medicine

can i share with you for a moment the things i love in medicine?

1)  i love knowing things about how our bodies work
2)  i love the language of medicine, the descriptiveness and preciseness of the words
3)  i love the quiet moment when i hold my stethoscope against someone's chest and listen to the sound of their beating heart
4)  i love a well constructed consult note, one that doesn't leave out the pleasantries that remind me of an era in medicine that is quickly slipping away
5)  i love the endless learning that comes with a medical career
6)  i love the trust i feel from my patients
7)  i love the giggle that follows the knee jerk when my reflex hammer hits just right (why does that make us laugh?)

is that enough?  i could go on!  and yes, there is an equally long list of the things i don't like, but we all have those things in our jobs, and for me they are mostly mundane and far surpassed by the things i love.

viva viagra

sometimes i wonder, when i am writing a script for these little blue pills, is someone out there thanking me or cursing me?

beware the morning rounds code

one of our responsibilities in residency was to carry the code pager.  whichever residents were on the cardiology service were responsible for all the non-surgical and non-pediatric codes in the hospital.  surgery and pediatrics had there own teams.  typically there would be two residents and two interns carrying code pagers.  the pager went off at about the same time as an overhead announcement, 'code 100, 6 west, code 100, 6 west, code 100, 6 west.'  the sound of that pager and overhead call was definitely something to get your adrenaline flowing and your heart pumping.  if for some reason that didn't work, there was always the long run through the hospital and up the obligatory three or four flights of stairs to get your heart going.  invariably you were as far away from the code location as physically possible without leaving the hospital and you couldn't risk getting caught in the elevator.  so you ran.

despite the gravity of each situation, there were some funny happenings.  once, in the middle of the night when the two residents and i that comprised that night's code team were getting some precious sleep, a code was called.  we were in a set of three call rooms that all opened into a little hallway.  we each came racing out of our respective rooms, disoriented from sleep and blinded by the light of the hall, and ran smack into each other.  two of us landed on the floor, then had to scramble to get everything back in our pockets before racing out the door.

some codes were not funny, but maybe ridiculous, like this code at 5 am.  the alarms went off and we ran to the room.  a thin muscular man lay on the bed, no rise and fall of his chest, no heartbeat.   my senior resident immediately had me start chest compressions, as the second year started to work inserting a central venous catheter.  the nurses were busy with the crash cart.  the senior resident, observing my chest compressions, repeatedly asked me to press harder.  i was kneeling over this guy, two hands on his chest, pressing as hard as i could.  despite the board we'd put under his back, i was barely moving his chest.  at this point the anesthesiology resident sauntered in (they never ran, knowing the nurses would use the ambu bag until they arrived to establish the airway),  walked to the head of the bed, pried the patient's lips apart, noted the firmly clamped jaw, and walked out of the room shaking his head.

rigor mortis.  this man had been dead for hours.  the nurse had come in to get morning vitals, noticed the patient had none, and called a code.  that certainly explained my inadequate chest compressions, and also the congealed blood the second year resident was pulling out of his central line...

i'll pass on that, thank you.

did you ever walk by someone on the street or in the mall and they hold something out to you and you automatically take it - a flyer or a sample or something?  you take it reflexively, partly because you are being polite and partly because it's easier to just take it and throw it away then to refuse.  this happens in the exam room too.

sometimes when i hold the ophthalmoscope up to shine the light in my patients' eyes, they will reach for it like i am offfering them a microphone, and it always makes me laugh.  i ask them if they are going to sing some karaoke for me.

but sometimes in the exam room, someone holds something out to me that i refuse to accept.  now i'm not squeamish about too many things, but this just really grosses me out.  the patient will reach into his or her pocket or purse and hold out to me a greasy looking used up tube of some unidentified ointment and say something like  'my other doctor used to prescribe this for my hemorrhoids, can you refill it?'  i'll gladly refill it, but i'm not touching it!

nutella delivery system

your specialist said what?

many a patient encounter begins with an ear full for me about the specialist my patient just saw.  i usually give them a minute or two to vent, during which time i listen sympathetically, but i've learned to keep my mouth shut and then quickly redirect the conversation toward safer ground. who knows what the specialist really said?  certainly not me.  secretly though i can't believe some of the things people tell me.  one of my patients said she went to a podiatrist and he never touched her feet.  another patient said the specialist walked into the room, laughed at her, walked out, then billed her for the visit.  another patient told me he saw a neurologist for a gait disturbance and the only question the neurologist asked him was are you having any difficulty swallowing.  huh?

i am sure some of it is a lost in translation sort of thing.  it has even happened to me, where a patient will come back and say, well you told me... and it's something i couldn't possibly imagine myself saying, like try putting salami on it or call me back if your cold isn't gone tomorrow.

regarding the specialists though, a week or so later, after hearing these wild reports, i always get a very nice consult letter that is thorough and appropriate to the purpose of the visit.  i scratch my head.  life goes on.

another chink in the foundation of my self image emerges

it is not just my fashion sense coming under attack.  my son brought home a paper today that he wrote about our family.  here it is, unedited:

My dad stays at home and does work for my mom.  My mom goes to work all day and comes home to watch TV.  My sister likes to watch TV and play with me.  I like to play with my sister and go on the computer.

fortunately my mental mythology is robust enough to overcome this clear misconception about my role in the family.

fashion emergency?

i may have proof that you really don't look the way you think you look.  i wore a blouse to work today that i thought was really cute.  two patients asked me if i was pregnant.  (good lord, no!)

one woman then dug herself further into her hole (as we so often do) by saying, 'well, it's just that you usually wear such tight clothes.'  really?  i am choosing to believe that when she said tight she really meant tailored.  i won't accept defeat until stacy and clinton come knocking on my door.

doctors are like shoes

i'm sure some of my patients don't like me all that much. maybe our personalities don't mesh, maybe my approach to things doesn't suit them, or maybe there is a  more specific reason, but one i can't do much about, who knows.  for whatever reason, the relationship is like a shoe that doesn't quite fit, that always rubs in that one place. uncomfortable, annoying.  sometimes you can brake it in, sometimes you can't.   i always hope those patients will eventually find another doctor, a shoe that fits more comfortably.  until then, i do my best to make it work.

and, yes, plenty of times i am the shoe, but sometimes i am the foot and the patient is the shoe!

top five things you probably shouldn't worry about

1.  gas
2.  snapping, creaking, popping or any other noise your joints make that is not associated with pain
3.  gradually thinning hair
4.  toenail fungus
5.  GAS (i felt this needed special emphasis as people seem inclined to tell me in detail about their troublesome gas problems.)

the following reasons not to worry apply to all of the above:

1.  it won't kill you
2.  you can't really do anything about it

i don't think that's what you mean to say

we doctors have our very own language just so we can laugh when others misspeak.  my patient pointed to his nose today and told me he thought he had a deviated scrotum.

mental mythology

a woman told me today that her husband's claim (apparently unfounded) that he had improved his eating habits was just a bit of mental mythology.  how funny!  don't we all have a bit of mental mythology working for us?  i hear plenty of it everyday.

'why can't i lose weight?  all i eat is _____ .'
fill in the blank with any two tasteless, calorieless food choices such as skinless chicken or cucumbers.

'the reason my blood pressure is high today is because _____ .'
 fill in the blank with any number of unlikely reasons for your blood pressure to be high today or any day.

'i always need an antibiotic for my viral respiratory illness because _____ .'
 fill in the blank with just about any random reason you can think of.

it goes on and on. oh, what limitless deceptions and misconceptions our clever minds are capable of!  of course, i'm sure i have absolutely no mental mythology of my own...

i make a big mistake

it is a great relief to me that i did not kill anyone in my residency, but that is not to say that i did not make mistakes, even big ones.  this one, although it ends as well as it could, still makes me feel pretty lousy to think about.

i have spoken before about the 3 west hallway of our training hospital, a long corridor of patient rooms tucked out of site of the not so central nursing station, the perfect setting for this unfortunate tale.  3 west was usually the 'GI' wing, home to all things gastrointestinal, but it was also the repository for any overflow from other floors.  you sort of cringed when you learned that your non-GI admission was going to 3 west, if only for the smells they would have to endure.

one afternoon, my attending and i were checking in on our liver failure patient.  she was jaundiced and ascitic, but stable.  as we were leaving her room, an elderly woman ran out of the adjacent room and grabbed us.  she had been sitting peacefully at her husband's bedside when he suddenly embarked on the deadly journey of anaphylaxis.  fifteen minutes prior, he had been given an intravenous dose of a new drug in a last attempt to quell his raging lymphoma.  despite a reported risk of serious allergic reactions being greater than 30%, there was no protocol for administration or observation of this new drug.

we rushed to his bedside.  he was sitting up in bed, leaning forward, clearly struggling to breath.  his mouth and tongue were visibly swollen and dusky against his otherwise too pale skin.  he looked at us with such a startling mix of terror and pleading, his wife saying the words his swollen airway could not, 'please help!'  but then, in almost the same sentence, telling us that he is 'DNR'.  do not resuscitate.  the dilemma could not have been more clear.  call a code and intubate this man against his prior stated wishes, or watch him die.  because he couldn't speak, and because his distress was so great that he couldn't even nod his head in consent, we had to decide for him.  his wife, equally distraught, just wanted us to do whatever we could.  there was no time to revisit the nuances of a hospital DNR order, no meeting of the ethics committee.

we quickly decided we would give him epinephrine subcutaneously.  by that time the nurse was in the room with the crash cart, but the only epinephrine she could find was the kind used intravenously in cardiac arrest, the difference being its much greater potency.  we, or rather i, because my attending was sort of hanging back and allowing me to take the lead, said give it anyway.  so this poor man was given a dose of epinephrine ten times stronger than what he should have had.  at this point he collapses, he's not breathing and his heart is pounding at what sounds like 300 beats a minute.  his wife is sobbing, my attending is silent.  i call a code.

i later learned that although he survived the code, his lymphoma had not responded to the new drug.  he was discharged home with hospice, and died soon after.  i also learned that a protocol for the giving of that drug had been made and included 30 minutes of post administration observation and epinephrine at the bedside.

i felt so guilty about that whole event, guilty about going against some one's end of life wishes, a man that i did not know at all, guilty for giving him the wrong dose of epinephrine and sending him in to ventricular tachycardia, guilty for not later finding that couple and telling them how sorry i was.  i felt angry at the team to which the patient belonged for having essentially no plan in place for the administration of that drug, angry at my attending for not stepping in and helping me (maybe she was as unsure that day as i was, who knows), angry at my residency program for always seeming to give me more responsibility than i felt prepared to handle.  but mostly i felt ashamed for panicking, for not behaving like the doctor i was supposed to be.  i took an action that i knew was wrong because i was caught up in the panic of the moment.  lesson learned.

doctor roboto

did i mention we are transitioning to an electronic health record?

(thank you to my daughter for teaching me how to use brushes on our ipad.)

rotating tourniquets

my dad likes to remind me that when he trained in internal medicine in the late 1960's and early 70's, they were still applying rotating tourniquets to patient's extremities in an effort to manage the volume overload of decompensated congestive heart failure, the idea being that, by temporarily pooling venous blood in the extremities, the failing heart would be better able to handle its load.  once the potent diuretic lasix made its debute, the tourniquets fell by the wayside.

sometimes i wonder, what will be my rotating tourniquets?  what am i doing right now that i'll eventually look back and say, wow, can you believe that's the best we could do to manage that problem?  i think about the mask and machinery of CPAP (continuous positive airway pressure used to treat obstructive sleep apnea).  the patient is tethered each night by a tube to a machine that blows air into his or her mouth to prevent airway collapse. the effect is akin to a slumbering darth vader.  it is a far cry from the tracheostomy that used to be employed (only in the most extreme cases) to prevent this problem of arrested nocturnal respiration and its ultimate strain on the heart, but still a far cry, too, from ideal.  what better interventions will come?  i wait for them eagerly.

we are april fools

we have chosen this most auspicious day to launch our new electronic health record...  wish us luck!