You can write, but you can't edit

I'm thoroughly enjoying this month's edition of Annals of EM -- partly because of some challenges to current practice, with some research that's up my alley... but mostly because it arrived on my day off.

One article on lab turnaround times has a brilliant editorial accompanying it. Some background: I've been fascinated by charting since medical school, and this memorable post from MedPundit on the evolution of charting stayed with me as I tediously documented findings and thought process on my patients.

Nowhere is documentation more verbose than in the electronic ED. The late, great Cheerful Oncologist blog once hilariously remarked upon this problem:

It was the most amazing thing I had laid eyes on all summer. I sat mesmerized, scrutinizing page after page until finally I heard a voice asking if I was alright...

Later, while driving home, my thoughts drifted back to that emergency room report. It wasn't the facts in the case that captivated me; the patient's illness was serious but manageable, and he had improved since his admission.

It was the macros used by the E. R. doctors and nurses in their typewritten report that were stunning. They spilled over the pages, neatly stacked into parallel lines, all created to prove conclusively to any skeptics that at no time while physically present in the emergency room did the patient receive anything less than perfect care. The result was a repetitive - nay, interminable, tedious, irksome collection of about a hundred paragraphs that contained just under ten percent factual information.

The rest was just a pile of crap that I inferred was placed there for the sole purpose of vexing malpractice lawyers.

Don't get me wrong - I understand the importance of careful documentation of the events of the day inside a hospital or medical office. I get it when I'm told to leave good records of what I say to my patients. It's just that in this particular case the result is an unintentionally hilarious narrative. Let me illustrate by providing an example of a visit to a local hamburger joint, as chronicled by the restaurant's risk management team:

"The client, who walked into the lobby on his own power, had no signs of distress. He was promptly escorted to the nearest counter by staff member One. He completed this ambulation without injury. The client was asked how he felt before the Staff Member departed. The client said he felt fine, but did complain of a feeling of hunger in the vicinity of his abdomen. He was promptly examined by the staff member and found to not contain any foreign objects protruding from his abdomen or chest.

"The client placed his order for a hamburger, large fries and medium coffee. He did not show any signs of distress while waiting for his order, and was checked on by staff members One and Two at 1457 hours and again at 1502 hours. The client did not fall down at any time during his wait, but he did show brief signs of distress upon hearing the score of the Cardinals-Cubs baseball game, which was being broadcast from a nearby radio...

It goes on and on. Some ED information systems are better than others in shielding practitioners from the malpractice malarkey that creeps into charts (by highlighting freetext material, key findings, assessments and plans -- while pushing the checkbox stuff off to the periphery, at least while the patient is still in the ED).

But while we bemoan this excess verbiage, it's not often we wonder what else is at risk. That's why I enjoyed Dr. Peter Viccellio's editorial piece on hidden costs of computer systems, excerpted below:

The electronic medical record has become a tidal wave in emergency medicine. Templates. Checklists. Computerized physician order entry. Time stamps. All entries ending with "side rails up." When one walks into such an ED, it is rather typical to see most of the staff with their nose in a computer. With many hospital systems, there’s a wonderful opportunity to take a minute to chat with your colleagues as you await completion of your sign-on, to check to see if labs are back yet, knowing that you’ll be back to your seat to check again in a little while. (At my institution, the simple act of logging on consumes about 30 to 45 minutes per physician per shift.) Of course, much of this is improved by a robust tracking system (which, uniquely, is a system that works for the physician, rather than vice versa). Many places have implemented computerized physician order entry, or some tortured version of it, and would do well to adopt suggestions such as the ones outlined in the Guss et al article.

The human transaction costs of all these interactions with the computer have, oddly, been largely ignored.
Large groups of health care practitioners typically spend countless hours devoted to the design and maintenance of the system. Time spent at the computer writing notes, entering orders, and looking up lab results is time away from the bedside. The burden of clerical activity has shifted to the nurse and physician. We enter the orders. We seek out the results, often buried in multiple systems. We type our notes. We print out our discharge instructions and prescriptions.

From personal review of a number of templated charts, several things are readily evident. First, there is a struggle between free texting (which is very time consuming) or simply fitting the patient to the template and ignoring the variances. Second, a lot of sprained ankles are curiously getting their pupils checked and their bellies examined by both the physician and the nurse. Some evidently believe that any box left unchecked is an invitation to a supervisory reprimand. The third, and most important, has to do with the ultimate content of the chart. It no longer tells a story (yet, at the same time, takes pages and pages to do so).

The explosion of information in the record, much of which is drivel, succeeds in defeating the primary purpose of an electronic medical record, ie, to tell the story in a meaningful way. It is ultimately a record designed for coding and compliance, not to portray the battle of the patient. When an ED visit for a cough, with diagnosis of pneumonia, consumes 17 pages of print, something has gone awry. (Or perhaps things went awry when pulmonary edema was no longer considered an emergency unless there was a documented family history, social history, and 10 reviews of systems.) Unstudied is the impact a template may have on critical thinking. Being led through a series of checkboxes is very different than the unrestrained and loosely structured improvisation between the physician and the patient. Will the physician have more or less "Aha!" diagnostic breakthroughs when guided and constrained by a template? Will it alter content, the exchange, the clues of body language, the personal interaction, and the diagnostic considerations for better or for worse? Where will we find the time? Whatever its impact, we can at least be sure that more boxes will be checked.

What do these comments have to do with the Guss et al work? Improving flow is centerpiece of their efforts. Although these interventions decreased lab turnaround time for specific labs, were the patients any better off? Did they get out any faster? The article is unfortunately silent on these matters. The context of the study is one in which all efforts are channeled through a computer, and most of this effort depends on those on whose time the patient would consider most valuable. After a pound of flesh for the coder and a pound for the compliance officer, what’s left for the patient? It’s great for the clerk that we now log on, enter orders, type notes, get results, print discharge instructions, and even carry our own telephones. Some of us are doing our own billing as we work.

We need to critically measure the true value of systems that potentially double or triple the amount of work required away from the bedside. Like the electronic medical record, computerized physician order entry itself has not quite been the Grand Panacea as originally envisioned, with production of its own set of errors and time-consuming processes. We don’t really have it "right" yet.

Agreed. But while ED information systems have so far been geared toward maximizing documentation (with an eye toward limiting liability and maximizing billing) new efforts are underway to make computer charting more efficient, and at the same time support decision-making. It will take effort and much trial-and-error, but fortunately, computerized charting is a platform that, by its very nature, lends itself well to research.

How Do You Sleep at Night?

Getting emergency department signout on a Monday evening is as close as I've come to drinking from a firehose. Whatever late afternoon activities I've been engaged in, they seem impossibly placid when I walk into the ED at its most crowded and chaotic.

The patients peer at the gaggle of white coats at signout, trying to size up the night team. The outgoing team has already welcomed us as liberators. And they tell us about the ongoing workups, the lab results and consults still pending, and the patients already dispositioned but still waiting for a bed.

In signout, the essentials are all there, but some nuance is inevitably glossed over. And so it was on one particularly busy Monday, when I received at least a half-dozen patients, including a hypotensive febrile encephalopathic young man who had been rejected by the MICU. My mind was still preoccupied with him when an outgoing intern started telling me about the simple, straightforward elderly woman with back flank pain and hematuria who was "probably in the CT scanner even as we speak." Just get the read, confirm the stones, give her some 'scripts and she'll be on her way.

Not surprisingly, it only took a few minutes for that neatly-bundled package to unravel (though enough minutes passed for the intern to be on well the way home). I got a call from radiology that my new patient was requesting pain meds (the scanning table was too stiff) and something for her nerves (she didn't like moving through that heavy donut of a machine).

I checked the record, and was amazed to see the patient had already received three generous rounds of opioids and benzodiazepines before signout. Combined, it was enough for procedural sedation in a young adult -- and my patient was well past retirement age. Her outpatient summary mentioned a xanax prescription, but none of this had been covered in signout.

A nurse, grappling with her own monstrous signout, graciously provided me with round four of this patient's morphine-and-ativan regimen. I scurried down to radiology, myself pretty anxious to meet this new patient, and to return to the encephalopathy case in the resuscitation bay.

When I got to radiology, which seemed so serene in comparison to the ED, I was greeted by a tech who directed me down a near-deserted hallway, to a distraught woman in a stretcher. By her side was an affable husband, holding their coats, bags, and various papers. He smiled broadly and asked, "are those her medications?"

His wife was hyperventilating and clutching her side. After introducing myself and confirming the story, I pushed the meds and reconnected her IV fluids. I apologized and hurried back to the busy ED.

The code was called overhead, about ten minutes later. Every doc's ears perked up in the ED -- we're responsible for the coding patients in some part of the hospital, but not others, so we waited to hear if we'd need to gather our gear and run.

As it turned out, the code was in radiology. We were covering. And I started to run, worried -- really panicked -- that I had just killed a patient.

I was the first from the ED to arrive, but there were already some long white coats surrounding a stretcher. And, to my eternal relief, it was not the stretcher of my patient.

Even better, this was not even a real code -- the long white coats belonged to neurosurgeons, who were concerned their head-bleed patient from upstairs was breathing funny, and wanted anesthesiology to tube him. I volunteered, but they held out for the anesthesia team, who arrived a minute later. My services were not needed, so I slung some gear over my shoulder and trudged back, stopping along the way to talk to the woman with flank pain, and her husband.

"I've got to confess," I remarked, tapping on the airway equipment, "I thought we were called to use this on you."

"She's alright," the husband responded.

"No I'm not!" the woman exclaimed. "All this activity has made me very anxious..."

Everywhere you sing your smile

Seeing this funny video reminded me of the time the Google StreetView van stopped outside my apartment. I asked the driver what was wrong, but he was not very forthcoming -- despite the fact he was photographing absolutely everything and everyone around him (on second thought, this might explain his evasiveness).

Next to these excellent photos of the Google Van and hardware (including some self-portraits and a glimpse of the Google Beetle) I add my own blurry cameraphone pic, on the right.

More Google Van pics and coverage at, you guessed it,

Program Note

I'll be calling in tonight to the Dr. Anonymous Show on BlogTalkRadio. We'll be talking about medical blogs, and blog awards, and the blogging of blogs. If this interests you (and honestly, why wouldn't it?) you should tune in, or even call into the show. Hopefully some of my colleagues from Medgadget will join us.

If Political Pundits Covered an Emergency Department Shift

This long, rambling dialog took shape while I walked home from the ED just now, to yet another night of surprising election results. To follow the analogy, just substitute "doctors" with "voters," "patients" with "primaries" ... and the causes of abdominal pain... as major US presidential candidates:
Jeff Greenfield: If you’re joining us from home, this is a very special night in the ER. After hearing about diseases for so long, a group of doctors is finally going to step up and decide what's ailing a waiting room full of patients.

Wolf Blitzer: It’s a big night, no doubt, and let’s see how doctors are evaluating their first patient.

Dan Rather: She’s a young woman with several hours of periumbilical pain. Now it seems to hurt a little more on the right. She’s vomited. That's all we've been able to uncover.

Chris Matthews: I was talking with some of the doctors tonight. While they've obviously given this a lot of thought, many seemed ready to back appendicitis.

Anderson Cooper: Appendicitis has received major endorsements from several surgeons, and it clearly has the name-recognition among the general public. It’s a heavy hitter.

Jeff Greenfield: The ER docs are conferring. I wonder what they’re discussing?

Keith Olbermann: Maybe they want to know if the patient pregnant? Afebrile? I think they’re ordering labs of some kind.

Doris Kearns Goodwin: Well, it hardly seems to matter at this time, Keith. Appendicitis has a well-honed message of fear. These doctors, facing uncertain times, can’t afford to back a dark horse diagnosis now.

Larry King: I think I heard one doc mention torsion. What do you think of that?

Jeff Greenfield: Torsion is very popular among this demographic.

George Stephanopoulos: You know, torsion has surprised me a lot recently. Women *and* men seem pretty impressed by the pain and damage from gonads twisting on a stalk. This is one diagnosis they don’t want to overlook.

Larry King: Well, here we go. The patient’s getting a CT scan. And there’s the wet read! We are calling it appendicitis!

Wolf Blitzer: Amazing. You know, grassroots organization really carried appendicitis in this first key patient of the night. Everybody knows somebody who's lost their appendix -- and that kind of familiarity with the disease really figured into the doctor’s decision-making.

George Will: And, you know, as I look across the waiting room at all the patients clutching their bellies, I really think appendicitis is going to run the table tonight.

Jeff Greenfield: You think everyone with abdominal pain has appendicitis?

Anderson Cooper: Appendicitis has the momentum, Jeff. Its brand is strong.

Chris Matthews: Appendicitis has reached the top of the differential by borrowing from so many other diseases. It's like a chameleon. And these doctors are just blown away by its broad appeal across so many key demographic groups. They're true believers.

Jeff Greenfield: Here’s another patient. The doctors are evaluating him. How do you think this one’s going to turn out?

Ted Koppel: A wise man once said, if you want to know what’s ailing the patient, you ought to ask the patient. And measure vitals, do a physical exam, and consider some imaging and labs – and also, spend some time building an appreciation of pathology.

Chris Matthews: I don’t know, I’m ready to just call this one for appendicitis.

Sean Hannity: Appendicitis is a *juggernaut*. The other diagnoses should just *give up*.

Dan Rather: You know, the other day I was talking with an agent of Yersinia... From a certain point of view, Yersinia and appendicitis have a lot in common.

Chris Matthews: Yersinia’s time has passed. It’s embarrassing that Yersinia is still on the differential diagnosis.

Larry King: The doctors are looking up something... prior visits, it would seem. And now, orders are going in.

Dan Rather: I don’t see any calls to surgery, nor is there a CT scan ordered. We may be looking at a major upset.

Larry King: They’ve given their fluids, pepcid... and some reglan! And they’re moving on!

Tim Russert: Gastroenteritis! The doctors have spoken.

Jeff Greenfield: Unbelievable. This is a huge setback for appendicitis.

Wolf Blitzer: But what an amazing comeback for an old standby. Lately gastroenteritis didn’t really seem to have the vision, or the ability to reach doctors on a visceral level anymore. Tonight it seemed almost like an afterthought, especially with that first patient.

Dan Rather: Acute gastroenteritis has pulled itself back from the diagnostic abyss.

Tim Russert: I have to wonder what the doctors are basing their decision-making on. It’s almost as though there are factors besides momentum that play into their thought process.

George Stephanopoulos: I think doctors were trying to send appendicitis a message – appy’s got to earn its spot at the top. The doctor's aren't so enamored with it anymore, that's for sure.

Anderson Cooper: Well, it just goes to show, doctors are a fickle bunch. There’s still a long way to go in this shift, and now the ER is a battleground for disease.

Dan Rather: This is where the fun starts.

Forgive the length. And I don't mean to imply that the presidential candidates cause upset stomachs. Just that voter's decisions, like medical decisions, are a good deal more sophisticated than the talking heads give them credit for. If pundits spend time on fundamentals, like policies and platforms, instead of canditates' momentum and maneuvering, they might improve their accuracy -- and at the very least, render more of a service to their viewers.

Informed Review

I know it's January, but that somehow makes this IRB appraisal of Santa's activities more timely. Excerpts below (via Grahamazon):

1. You propose to study "children of all ages". Please provide an exact lower and upper age limit, as well as the precise number of subjects. Provide a statistically valid power calculation to justify this large of a study.

7. The database of good and bad children will be kept "on a scroll at the North Pole." Please describe the security provisions you have in place to protect the research data. Is the scroll kept in a locked cabinet in a locked room? Who has access to the scroll? Are there backup copies of the scroll and how often are they compared to the original?

10. As this study involves prospective data collection and is more than minimal risk without prospect of direct benefit to the subjects, informed consent signed by both parents will be required. Please have the consent form translated into every language spoken by children.

In googling for more IRB rants, I found this thoughtful blog post that points to a number of papers considering the ethics of IRB regulations. A 2003 report on IRB Mission Creep seems like an evenhanded approach to addressing some faults in the system.

Making Modern Music has an interesting story on the Death of High Fidelity. Of course we've known since the beginning that MP3 sampling is a poor substitute for CD quality sound, which itself pales next to vinyl on a high-end system. But what this article tells us is how the music industry is adjusting to the new milieu, mixing 'louder' songs with less detail that are designed to play well on iPods, car stereos, and bars. RS talk about 'ear fatigue' in relation to new albums (so that's why I can't tolerate Arctic Monkeys) and includes a lamentation from Steely Dan's Donald Fagen, whose music isn't translating well on my iPod.

Rolling Stone prints a damning comparison of songs waveforms -- past, present and reissued. And a link to a technical wikipedia discussion (with more examples, and some possible solutions).

But there is one marriage of technology and music I can enthusiastically endorse: Air Karaoke, available on Channel 1017 in New York City (the Oxygen network's On Demand channel). Apparently this has been available for ble years, but I was unaware until the week hours of 2008. Already, this new technology has impacted my life, and certainly, the lives of everyone within earshot.

Check it out

Much has been said about this excellent New Yorker article on checklists in medicine, by Atul Gawande, in which he talks with two checklist gurus -- intensivist Peter Pronovost from Hopkins (he wrote the Tintinalli chapter on ABG interpretation) and Markus Thalmann, an Austrian surgeon who led some truly incredible hypothermia arrest resuscitations.

The article gives a historical perspective to the concept of checklists -- from engineering to pilots -- and how it's moving into medicine. Checklists standardize complex activities like sterile line placement, leading to fewer complications, shorter ICU stays, and more lives saved. It's engagingly written and very relevant to ED practice.

Key grafs:

If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them. But, with the checklist, what we have is Peter Pronovost trying to see if maybe, in the next year or two, hospitals in Rhode Island and New Jersey will give his idea a try.

Pronovost remains, in a way, an odd bird in medical research. He does not have the multimillion-dollar grants that his colleagues in bench science have. He has no swarm of doctoral students and lab animals. He’s focussed on work that is not normally considered a significant contribution in academic medicine. As a result, few other researchers are venturing to extend his achievements. Yet his work has already saved more lives than that of any laboratory scientist in the past decade.

I emailed the residents about this a month ago, but since then, the article has taken on additional significance, as I've committed to an informatics project on decision support. Not surprisingly, Gawande has covered this territory, as well.

So, there's not much more nuance I will add to what's already been said about Gawande's piece, other than to speculate that the Dr. Markus Thalmann that Gawande interviewd is the same man Austrian doctor listed as the winner of the 2003 Spartathlon. Runners like their checklists, too.