Sunday, February 18, 2018

First Responder


Image result for first responderMy first real post.  By way of introduction, I am an endocrinologist, class of  '77, on medicine's exit ramp, or at least planning to retire from office care.  We can debate whether my hospital's EMR killed the golden goose or Father Time just caught up with me, but I have a genuine Medicare card in my wallet that has started to fray.  The final vestiges of my engagement are a real fondness for hospital consults, the more extreme the lab work, the more enthused I become, and expressing my opinion, which accounts for my not being on any important committees ever in forty years.

This weekend the beeper went off Saturday morning with at least one consult that should not wait until Monday.  It could have waited until Sunday, but having declared Sunday a Me Day, right after Shabbos Services, I schlepped to the hospital.  While there, I may as well round on everyone or at least look at all the glucoses.  I started from the top floor, planning to work downward. Player #1, just an insulin adjustment.  Player #2 I greeted as the physical therapist put him through his paces with a walker.  His sugars had gotten high and the therapist informed me of chills and a swollen arm.  Sure enough, he had been febrile for two days, seen by the ID consultant, judged not real sick, and wait and see advice seemed reasonable at the time.  But with chills and a temperature just under 39C, he got a real exam.  Ordinarily I would call the resident but he was assigned a non-resident service so I'm on my own.  Having been a hospitalist before there were hospitalists everywhere, I knew how to address a fever.  Some abdominal tenderness, probably a hot right wrist or cellulitis of the forearm.  However, I do not know much about antibiotics.  I called the attending physician to convey the findings, the ID consultant in a mournful plea for help, and ordered blood cultures x 2, urine culture, an xray of the wrist and forearm, and a single dose of vancomycin at the recommendation of the attending physician.  And he needed more insulin.  That I know how to do.   A resident stopped by and showed me how to enter an IV order on the computer.  And before I left, the cavalry in the form of the ID consultant made a trip in to save the day.

Then downstairs to newly identified rip-roaring primary hyperthyroidism, something I know how to address without help.

While I have become something of a mullet at sorting out fevers, diarrhea, headaches and insomnia, the things nurses call residents about, I am still from an era where we were taught to read charts and examine people.  A fever could come from anywhere.  That hot wrist could only be found if you went and looked at the patient without any preconceptions of where the fever might be originating.  It was a challenge, totally unexpected, but pretty gratifying to still be able to do this.


Tuesday, January 23, 2018

The Singing Pen of Doctor Jen: In defense of SOAP notes

The Singing Pen of Doctor Jen: In defense of SOAP notes: Our hospital system's IT department has recently encouraged us all to change our default encounter note template from the traditional &q...



Hi Jen:



Never been a fan of SOAP notes but our templates both in and out patient follow that format, however the A/P are lumped together.  The S is also problematic, as patients are often here for nothing that really has an S like an incedentaloma on an imaging study, though they do have pertinent negaitives. 



Interestingly, now that we have PDOCS for consults and Dragon Dictation, I find myself doing consults with Stephen Covey's sage advice "Begin with the end in mind."  I will list the problems, dictate the analysis and solutions, the go back to page 1 and dictate the HPI, copy and paste the pertinent lab in the lab section, then click what's needed for past history, ROS and exam, with a few phrase dictations where needed.  What's different between my note and our residents' output is that mine has no fake news.  If I didn't ask about dyspareunia, which I don't, it is left blank.  My patients with prostheses never have pulses in them, and if a thyroid is palpable there is a description of that.  Where we lose out in the EMR seems to be in the copy/paste which saves time but propagates falsehood.