Sunday, May 20, 2012

You Are Not Paying Us to Steer!

As you may recall from past 'Medical Madness' posts, in academic medicine we spend most of the morning going from patient room to patient room on "rounds". This is when we talk about each patient and make decisions about the plan going forward. As you can imagine, there is a lot of information we'd like at our fingertips as we discuss the more complicated cases. Labs, imaging, pathology, medical history in the case of the "bad historian"(**see below)...we really need a computer with us at all times.

Enter COWs. Computers On Wheels.

Since we are constantly on our feet we must push our computers (i.e. peripheral brains) around with us. Some places such as my alma mater, University of Chicago, are giving physicians their own iPads and I'm sure this will be the wave of the future, but for now, enter the COW:

Much like their bovine counterparts, these cows are far from perfect. They occasionally make loud incessant beeps, similar to, but more ear-piercing than, a more traditional 'moo'. Their tails (i.e. cords) can get in the way and drag behind them in a disorganized fashion. If they aren't given enough food (i.e. electric charge) they will die. And, like our farmyard friends, they can be very stubborn and difficult to move. They always seem to have a bum wheel- kinda like that grocery cart you don't want w/ the wheel that spins in circles. It can require the full attention of a highly trained medical professional to not crash these guys into the wall, our patients and each other.

Lately, our main COW has had a mean veer to the left. We take turns pushing it. We call her the Core Workout. And like most things in life, it's all fun and games until someone gets their foot rolled over...which happens...frequently.

A few weeks ago as my friend and esteemed colleague Dr Shah was pushing ole Core Workout, she had to make a right turn which is next to impossible with this particular COW. Just as she tries to make the corner a lovely elderly patient comes barreling around the corner with her IV pole getting in her daily laps for exercise. Rather than risk hitting said patient Dr. Shah aborts mission and lets the COW veer left....directly into the wall. As the patient walks by, she apologizes for the near collision. The nice lady with her IV pole with her chemo, smiles sweetly and forgivingly to Dr Shah and says "It's okay dear. We all have our problems."

Dr Shah's problem:

(Disclaimer- no physicians, patients, or computers were harmed in this re-enactment.)

(**More medical madness style details the "bad historian". The "bad historian" is the patient who has no idea what their medical problems are or often whey they are even in the hospital. This doesn't happen as often in Oncology as it does in General Medicine, but from time to time you will come across a patient who has no idea if/what chemo they've had in the past, when they were diagnosed, etc. And there are plenty of patients who will insist, absolutely insist, that they do not have high blood pressure, only to find that they take 3 or 4 anti-hypertensive (blood pressure controlling) meds. Hmmm....For the laypeople in my audience, I implore you to make a list of your medical problems and medications to carry with you at all times. It makes us that much harder to help you if you don't!

The "bad historian" is different, but often related to, the "pan-positive review of systems" patient. The "review of systems" is the part of history taking when we ask various relevant questions that may pertain to the patient's chief complaint. For example, if someone presents with shortness of breath (which we abbreviate SOB....don't be offended, we are not calling our patients bad names.....unless we say "that sob is SOB",  just kidding of course), we will ask questions like

"have you had fevers" - might point to infection
"have you had a cough"- might point to infection or chronic lung disease
"have you had chest pain"- might point to blood clot in the lungs or heart disease
"have you had leg swelling"- again, blood clot or heart disease

We also ask about every other body system just to be sure we don't miss anything. We ask about vision, hearing, headaches, abdominal pain, constipation, diarrhea, urinary symptoms, rashes, joint pain etc, etc, etc. This line of questioning is of various utility depending on the patient. The "pan-positive review of systems" patient says yes to EVERY SINGLE QUESTION thus making the entire evaluation completely useless. Like the "bad historian" this patient has a lack of insight into what is going on in their bodies (or too much insight) which makes it a bit more difficult to hone in on the primary problem. It's important for the team to be aware that a patient is either a "bad historian" or has a "pan-positive review of systems" otherwise things they say may be given too much weight to the detriment of good clinical decision making. And when you run into these problems it is even more important to have a COW to look up the facts!

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