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...