Mile 8246: To Tell the Truth

Above: A depiction of the electronic medical records system from Upstream.

WHO CAN I TRUST MORE:
THE PATIENT OR THE CHART?

Infectious Diseases has been a great rotation thus far. Although I'm still at the same hospital as my previous rotation, the days feel a lot different as a consultant than as someone who's working the floors. Maybe its that the subject matter is much more specialized, or its probably also not having to deal with as many folks left and right when managing patients (on the floors for the last twelve weeks, everything from nurses to consultants and even writing notes would slow down a day's efficiency dramatically). However, I'll be honest that after 12 weeks of intensely working the floors, 4 weeks of consulting is a breath of fresh air.

Don't get me wrong, I've learned a lot about management of infectious disease simply from my first week on the post. I've at least had some slight refining with my knowledge of antibiotic spectra, common sense on when to appropriately check for blood cultures, and even evaluating if a "fever" is truly a fever. For some odd reason the "card-playing" game with empiric and more targeted antibiotics is something that intrigued me. I'm looking forward to learning more about that in the near future.

1:30 PM Friday. My attending and I are in the room of a patient along with their family. However, when my attending was further questioning a part of the patient's family history, we basically got a irate response of, "Go look in the chart!" from the family (I'm guessing that getting asked the same questions multiple times by multiple people finally go to them). My attending handled the situation calmly and well and explained to them that it is better to get the information from the patient rather than from the chart, because the chart has the higher chance for errors. Only when the patient couldn't recall the information would my attending refer to the chart. My attending further mentioned that the patient was someone that could be trusted more. With that, the patient, along with the family, had smiles of confidence and breaths of relief.

The point makes much sense though. If you've ever seen people try to spread news from one person to another, it never comes out straight after being handed down several people. The chart is like that, especially exaggerated when trying to interpret someone else's words when someone is not there to clarify or answer any of the doctor's questions. The bottom line from this lesson is that the purpose of the chart is to document what was done, but not to be used to substitute for a proper history taking or physical examination.

A simple, but very useful lesson.

Green Binder

Above: Jeeps at the off-road exhibit at the Chicago Auto Show. Now look at the Jeep on the incline, and paint yourself a picture, putting the car on a small concrete road, surrounded by tropical flora. Now, that describes some of those roads around Ross.

IN THE UNITED STATES,
A RAINBOW EXISTS TOO.

I love the nurses at the Jackson Park neonatal ward. They have been very helpful to me and my medical education. I feel very comfortable asking them questions about the patients, and they're always willing to help when my attending doctor is elsewhere. A few days ago, I was heading out the door, and I said "Have a good one!" to both of the nurses at the nurses' desk.

"Hey, Wait!" one of them then shouted.

We then had one of those exchanges solely in body language. I looked at the nurses with one of those What did I do? facial expressions. They both then pointed at my chest... I looked down, and instead of my clipboard, they caught a green binder that was a patient chart, instead of my clipboard. Whoops... that gave me another reason to be appreciative to have the nursing staff around. After a nervous laugh and apology, I walked to return the binder where it belonged.

That, my friends, is my embarrassing medical student mistake #1.

---

A few months ago, I wrote an article about how primitive record keeping in Dominica was. In each record, a multitude of colors for different types of documentation could be found, pink, yellow, and green. But now I face a new dilemma, as colors aren't exactly as helpful in the states as it was in Dominica. I've noticed two issues with paper record systems in America, to my current experience.

1. Forms, Forms, Forms - The one advantage to Dominica's record system was that at least I just needed to keep track of a couple of colors, and I knew what the colors and sheets were going to present to me (although, the standard as to what information needed to be put on the page wasn't exactly the same from doctor/staffer to doctor/staffer). In the American hospitals, there's loads and loads of forms, making it easy for someone who knows what's where to find the info they need, but to a medical student like me, a pain in the butt, when finding out that different hospitals have different standards.

2. Reading the Doctor's handwriting - This is a problem anywhere, but at least in Dominica, only a few doctors and staffers wrote information in each record, so I got to know their handwriting patterns well. However, in America I've noticed that several doctors can contribute to a patient's record, making me feel I'm in a game show where in order to win (the prize: getting the diagnosis), I have to be able to skillfully read paragraphs of information. Well, I guess I'm slowly getting the hang of it - I figured that if I can't read the word, its like trying to figure out the definition to the word I've never heard of before: try to guess out of context. But whenever it's possible, it's always better to ask when the doctor or staffer's available.

As much as during my lifetime, I'll probably get to see electronic record keeping, I can say that I still need to get used to the plethora of forms and handwriting styles known to man. Record keeping is really important in medicine: the ability to communicate and understand communication is important to appropriately manage our patients. This is just another one of those "unwritten skills" that I need to learn during my clerkships.

Green Yarn

AT PMH, ALL YOU

NEED TO KNOW

IS THE

RAINBOW.

My very good friend Neal, from Champaign, IL asks:

"I'd love to hear about the medical gadgets and technology you're using [in Dominica]. Which do you think are cool? Are there old fashioned devices/new ones?"

On Friday of this week, President Obama named a Harvard professor (Dr. David Blumenthal) to take over the modernization of information technology (IT) record keeping (from the days of paper-domination) in the United States (with a price of about $20 billion dollars). For everyone, I'm sure you've seen those tabular sheets that your doctor probably carries around in a light manila folder whenever you're in the office. When you're talking to him or her, it won't seem like he's trying to actually fill it in properly: He's not circling all the items, using handwriting that's not much better than the output of a seismograph during an earthquake, and not following his mother's advice by writing outside of the lines. That's the issue with record keeping: it's hard to keep it uniform so that when another doctor that gets a hold of the records, he or she can understand your situation.

Well, Neal, you probably are still wondering if I'm ever am going to answer your question, but I mentioned the above to create a dramatic contrast of the level of technology simply based on organizing critical patient information.

Like I said above, it's all about the rainbow. At PMH, record keeping is definitely old-fashioned. When handed a patient's records, I don't get a manila folder here. I end up with a pink (or sometimes blue, or sometimes tan-ish) colored folder that's seemingly constructed out of (go figure) construction paper. Holding together the massive amounts of colored paper that are inside are pieces of green yarn. Inside, the paper forms are definitely consolidated to a small set: Green is usually for doctor's notes, Yellow is for blood tests, Manila is for admission information, and Red (I think) seems to be more admission information. The best part is that there's no standardized chart on the Doctor's / Nurse's Notes. So, aggravated by the seismograph-like handwriting, it makes it more tough figuring out abbreviations or organization of critical information when trying to report back on the patient. As you can tell, Neal, to me, record keeping is one of my biggest concerns with technology for the Dominican Hospital (and to me, probably the easiest to set up: get together and IT department and wire up the hospital).

With that out of the way (and knowing you're an engineer), I think one of the best pieces of technology actually is something I carry everyday. You've probably noted your doctor ask you for permission to look into your eyes during a general check up and he'll flash a light into your eye and look through an instrument right into your eyes. This baby is called an ophthalmoscope. Looking into your eye and visualizing the rear wall of your inner eye (the retina) can be very diagnostic of signs of conditions that plague many of us (i.e. Diabetes or Hypertension). However, the ophthalmoscope I carry around (the WelchAllyn PanOptic, with a more detailed link below), is about 3 times as large as a standard ophthalmoscope you see in a typical Doctor's office. Using refractory technology, it actually gives a Doctor 5 times the viewing field of the rear of your retina than the standard opthalmoscope, allowing someone like myself to catch abnormal changes in your retina more easily.

Otherwise, PMH isn't really fully featured with technology, to be honest to ya. You'll find good, up-to date standards in the operating room (i.e. finger-placed optical detectors for vital signs such as blood pressure and oxygen saturation), also there's standard tech such as X-Rays and (I think a CT machine), but its hard to find even computers to organize patient data or records of who has been admitted in some of the wards. Another stark contrast occurs when noticing that there's no TVs to keep patients occupied as they lay in the wards.

It sounds like technology acts as a detractor to the whole experience, but I totally believe that technology can only be as good as the doctor that uses it him/herself, and the hands-on experience with patients (the people who truly matter) is something I can take with me in the future. Trust me, when I say that the doctors at PMH are absolutely amazing as clinicians and also as teachers, because it's amazing what they can do even without the big-bucks technology we find in U.S. hospitals today. With T-19 days left until I return home, I'll say it before I forget: Thanks for Everything, Princess Margaret.

Hope this answers your question. I'm looking forward to another good prompt (it keeps me occupied). :D

Sources: RedOrbit, WelchAllyn