Early in the 20th century, a physician named Bleuler described a group of mental disorders that he labelled dementia praecox. The DSM uses the more modern term, schizophrenia. The literal translation of the word is "split mind". Schizophrenia is an abnormal perception or expression of reality. The forms of schizophrenia are characterized by delusions, hallucinations (auditory and visual), disorganized speech and often grossly disorganized behavior. Speech, emotional response and motivation are diminished or absent.
The DSM IV lists paranoid, disorganized, catatonic, undifferentiated and other forms of schizophrenia. We are all familiar with the "Law and Order" episodes of paranoid schizophrenics who commit murder because of their delusions. This is a gross exaggeration of the actual danger to the public posed by paranoid schizophrenics. Their paranoid delusions are far more likely to lead to their own suffering. Catatonics are recognized by the absence of speech and behavior. They are so disconnected from reality, that they can be "posed" and maintain a rigid posture to exhaustion.
The biological basis of schizophrenia is increased dopamine activity in the mesolimbic pathways of the brain. The only reason I mention this is that all antipsychotic medication act primarily by supressing dopamine activity. The two classes of medication used to treat schizophrenia are typical and atypical. Being a physician for more than thirty years, I think of the meds as old and new. Stelazine, thorazine, mellaril, and haldol were the med available to me early in my career. They varied in their side effect profile. Movements disorders, dystonic and dyskinetic, are disturbing and may become permanent with prolonged use. Alterations in autonomic functions such as blood pressure may cause unexpected loss of consciousness.
Dystonic reactions are prolonged and often painful contractions of muscles. The muscles of the face, tongue, and neck are especially vulnerable. Antihistamines such as Benadryl and Cogentin can be administered as an antidote or given simultaneously to try and prevent the dystonic reaction. Dyskinesias are repetitive movements such as lip smacking, tongue motions, "pill rolling" of the hands and generalized twitching. Dyskinesias are similar to the symptoms of Parkinson's disease because the dopamine suppressing effect of antipsychotics mimic the loss of dopamine producing neurons seen in Parkinson's disease.
The atypical antipsychotics have additional and dangerous side effects. They can lead to significant weight gain with the onset of diabetes and elevated cholesterol levels. Clozapine has an addition side effect, it can cause loss of bone marrow function. Agranulocytosis is the loss of formation of red and white blood cells and platelets. Anemia, infections, and bleeding problems then occur.
All antipsychotics can cause neuroleptic malignant syndrome. Life threatening fevers, muscle rigidity with break down of muscle tissue and ultimately kidney failure and shock can be fatal if not recognized and treated promptly.
Be afraid, be very afraid. The behavioral issues of schizophrenic patients may be disruptive in the ER, but are realtively easy to manage with medications and occasionally physical restraints. A calm demeanor, a soft and consistent voice and adequate "space" go far in the ER management of psychotic patients. A paranoid schizophrenic patient whom I have known since his initial "breakdown" is illustrative of this approach. He is notorious for not being medication compliant and therefore is a frequent visitor to the ER. When caught smoking in the bathroom, the ER security staff gathered to get control of the situation. I intervened. I offered a nictine patch, food, a beverage, and medication. He gave me his cigarettes and his lighter without any physical confrontation.
My primary concern is for the safety of the patients and the staff. I will use physical and chemical restraints to accomplish these goals. It is often difficult to examine and treat medical and surgical problems that arise in psychotic patients. Their delusions, and altered perceptions make them poor historians and resistant to interventions. An added burden is that lifetime occurence of drug abuse in schizophrenics is 40%. The central nervous system effects of nicotine are beneficial to the schizophrenic. This makes the ban on smoking in hospitals another problem to be addressed.
I freely admit that I like caring for schizophrenics. Treating a patient who is suffering is the reason I became a physician. Although the options in the ER are limited, compassion, empathy and kindness are always appropriate. Chronic schizophrenics often present as a homeless "crazy" accompanied by the police. They smell, may be home to "critters", and resistant to any intervention. The family may have been exhausted in the effort to care for this disabling disease. Society would rather not acknowledge the pscyhotics in their communities. The ER is the one place that is obligated legally, morally and ethically to care.
Saturday, February 27, 2010
Thursday, February 25, 2010
manic-depressive
The DSM (Diagnostic and Statistical Manual) is the ultimate guide to psychiatric diagnoses. This tome has been amended and updated for more than 40 years. The DSM V is soon to be published. Unlike all other fields of medical diagnosis, psychiatric diagnosis is subjective. The diagnosis of a patient is based on symptoms not specific laboratory or radiographic or genetic testing. A reading of the DSM would have you believe that any practitioner could apply the algorithms and come up with an accurate diagnosis.
If the hodge-podge of diagnoses that my patients carry on their problem list is any indication, psychiatric diagnoses are less than ironclad. A recent patient had depression, bipolar, schizophrenia and drug abuse as current diagnoses. The other inconvient and inconsistent problem with the DSM is its mutability. Manic-depressive disease is now refered to as bipolar disorder. The critieria for diagnosis is quite similar, so why the name change.
Bipolar disorder is characterized but alternating periods of depression and mania. Depression is a profound sense of sadness, anhedonia (inability to feel pleasure), and often thoughts of suicide. Sleep disturbances, anorexia, even hallucinations may accompany the depression. Mania is the "polar" opposite. Bursts of activity, sexual, creative and destructive occur. Insomnia is common. Drug use exacerbates the mania. The manic is a danger to himself or herself and to others. These bipolar extremes can last for weeks or months. Medications are prescribed to try and keep the patient on a more level emotional plain. People with bipolar disorder have been prominent in history. Vincent Van Gogh has been retroactively diagnosed woth bipolar disorder by many psychiatric specialists.
An older neurotic condition was labeled cyclothymic personality disorder. This could be applied to anyone who was moody. We all know family and friends who blow hot and cold. The spectrum of bipolar patients can run the gamut from moody to suicidal and self destructive.
Health insurers rarely pay for prolonged psychotherapy, medications are the cheaper solution. Psychiatric medications are very problematic. They are relatively blunt instruments. The mechanism of action is to change the levels of neurotrasmitters in the brain. How these mediations effect an individual patient is very variable. Psychiatrists and primary care doctors try a ever changing combination of meds in an attempt to ameliorate the symptoms of bipolar disorder. Other medications are prescribed to counter the disturbing side effects of the psychotropic medications.
Some combination of antidepressants and antipsychotic are used. Mood stabilizers such as lithium salts and anticonvulsants may also be prescribed. Patients infrequently take their medications as prescribed. The number, cost and scheduling of medications is inversely related to compliance. The more medications prescribed, the less likely that the patient will take the meds correctly.
With strong support from family, friends and both couselors and physicians, bipolar disease can be managed effectively. The tragedy is that very few patients have this level of support. The psychotic and destructive behavior of a manic episode and the frequent "self-medication" with alcohol, cocaine, methamphetamine and other drugs drives people away. The profound depression that is a part of bipolar disorder may make the patient incapable of seeking the help they need.
As I mentioned in my posting "Psi", the ER is the failsafe setting for bipolar patients. Suicidal thoughts or actions, and manic behavior or outright psychosis leads to an involuntary commitment to the local ER. The familiar cycle of assuring the patients safety and health needs, and the search for an in-patient psychitric placements begins.
There are no simple solutions to the inadequacies of psychiatric treatment. The ever-changing diagnostic criteria of the DSM is but one symptom of the illness. Homosexual behavior was considered a treatable psychiatric condition back in the 1960's. An overly strong mother and weak father led to this aberration. Psychiatry is now much more enlightened. When the diagnosis of a "disease" is based on subjective criteria, there is room for disagreement between clinicians. Watch court TV shows to observe the experts for the defense and prosecution give opposing diagnoses of the defendant.
The greatest dilemma in my dealing with bipolar disorder is the diagnosis and treatment of children. Preschoolers are now being diagnosed with bipolar disease. They are being given the same medications as adults. These drugs have never been tested for long term safety in children. I am an unwilling witness to this travesty. A recent criminal trial took place in the death of a four year girl. She died from an overdosing of her meds for bipolar disease.
A community hospital ER is not the ideal setting for quality psychitric care. Counseling and medication supervision would be an effective first step. Insurance coverage at least equal to any other chronic medical condition and treatment for comorbid factors, such as drug abuse would add greatly to good management. I would also ask that we all educate ourselves about bipolar disorder. Be informed, be compassionate, be involved.
If the hodge-podge of diagnoses that my patients carry on their problem list is any indication, psychiatric diagnoses are less than ironclad. A recent patient had depression, bipolar, schizophrenia and drug abuse as current diagnoses. The other inconvient and inconsistent problem with the DSM is its mutability. Manic-depressive disease is now refered to as bipolar disorder. The critieria for diagnosis is quite similar, so why the name change.
Bipolar disorder is characterized but alternating periods of depression and mania. Depression is a profound sense of sadness, anhedonia (inability to feel pleasure), and often thoughts of suicide. Sleep disturbances, anorexia, even hallucinations may accompany the depression. Mania is the "polar" opposite. Bursts of activity, sexual, creative and destructive occur. Insomnia is common. Drug use exacerbates the mania. The manic is a danger to himself or herself and to others. These bipolar extremes can last for weeks or months. Medications are prescribed to try and keep the patient on a more level emotional plain. People with bipolar disorder have been prominent in history. Vincent Van Gogh has been retroactively diagnosed woth bipolar disorder by many psychiatric specialists.
An older neurotic condition was labeled cyclothymic personality disorder. This could be applied to anyone who was moody. We all know family and friends who blow hot and cold. The spectrum of bipolar patients can run the gamut from moody to suicidal and self destructive.
Health insurers rarely pay for prolonged psychotherapy, medications are the cheaper solution. Psychiatric medications are very problematic. They are relatively blunt instruments. The mechanism of action is to change the levels of neurotrasmitters in the brain. How these mediations effect an individual patient is very variable. Psychiatrists and primary care doctors try a ever changing combination of meds in an attempt to ameliorate the symptoms of bipolar disorder. Other medications are prescribed to counter the disturbing side effects of the psychotropic medications.
Some combination of antidepressants and antipsychotic are used. Mood stabilizers such as lithium salts and anticonvulsants may also be prescribed. Patients infrequently take their medications as prescribed. The number, cost and scheduling of medications is inversely related to compliance. The more medications prescribed, the less likely that the patient will take the meds correctly.
With strong support from family, friends and both couselors and physicians, bipolar disease can be managed effectively. The tragedy is that very few patients have this level of support. The psychotic and destructive behavior of a manic episode and the frequent "self-medication" with alcohol, cocaine, methamphetamine and other drugs drives people away. The profound depression that is a part of bipolar disorder may make the patient incapable of seeking the help they need.
As I mentioned in my posting "Psi", the ER is the failsafe setting for bipolar patients. Suicidal thoughts or actions, and manic behavior or outright psychosis leads to an involuntary commitment to the local ER. The familiar cycle of assuring the patients safety and health needs, and the search for an in-patient psychitric placements begins.
There are no simple solutions to the inadequacies of psychiatric treatment. The ever-changing diagnostic criteria of the DSM is but one symptom of the illness. Homosexual behavior was considered a treatable psychiatric condition back in the 1960's. An overly strong mother and weak father led to this aberration. Psychiatry is now much more enlightened. When the diagnosis of a "disease" is based on subjective criteria, there is room for disagreement between clinicians. Watch court TV shows to observe the experts for the defense and prosecution give opposing diagnoses of the defendant.
The greatest dilemma in my dealing with bipolar disorder is the diagnosis and treatment of children. Preschoolers are now being diagnosed with bipolar disease. They are being given the same medications as adults. These drugs have never been tested for long term safety in children. I am an unwilling witness to this travesty. A recent criminal trial took place in the death of a four year girl. She died from an overdosing of her meds for bipolar disease.
A community hospital ER is not the ideal setting for quality psychitric care. Counseling and medication supervision would be an effective first step. Insurance coverage at least equal to any other chronic medical condition and treatment for comorbid factors, such as drug abuse would add greatly to good management. I would also ask that we all educate ourselves about bipolar disorder. Be informed, be compassionate, be involved.
Saturday, February 20, 2010
Psi
It is time to address a large and often difficult aspect of emergency medicine, psychiatry. A little history may be helpful to understand the problem of psychiatric patients in the ER. Back in the 1960's, the first effective medications for schizophrenia became available. The dehumanizing treatments that had been applied prior to these medications is reminiscent of the Spanish inquisition. Patients were shocked with electricity, immersed in tubs of freezing cold water, given large doses of insulin to induce shock from low blood sugar, and subjected to psychosurgery. Prefrontal lobotomy was a well accepted treatment. Watch "One flew over the cuckoo's nest" for a taste of the "treatment" of schizophrenics.
The most common treatment involved storing these patients in large state psychiatric hospitals. Out of sight, out of mind. Having medications that could ameliorate the symptoms of psychosis made these human warehouses unnecessary. Plans were for community based out-patient treatment centers. Patients would get their medications, and counseling near to home. The drugs were prescribed but few of these psychiatric clinics were built.
The medictions had severe and disabling side effects. Long term use led to movement disorders such as tardive dyskinesia, a medication induced form of Parkinson's disease. Newer and supposedly better pharmaceuticals have been developed but they also have severe acute and chronic side effects. Weight gain, diabetes, elevated cholesterol are all known consequences of today's "atypical" anti-psychotics. One drug can even cause bone marrow damage that may be permanent.
A very eloquent paranoid schizophrenic, who I have known for 20 years, described his reaction to his medications most poetically. When asked why he continued to resist treatment by stopping his meds, he told me that they made him feel dead inside. He added that he would rather be crazy than be anesthetized.
Today the warehousing of psychiatric patients occurs in the ER. There is a revolving door from in-patient psychiatric hospitals to the community and this portal is the ER. When a psychiatric patient becomes a danger to the public or to themselves the police, EMS or their therapist sends them to the ER. The ER doc is supposed to "medically clear" the patient and then find an in-patient facility that will accept the patient.
Medical clearance is a mine field. The ER staff is responsible to diagnose and treat any and all medical conditions that the patient may have. The psychotic patient is often agitated, and even violent. Physical and chemical restraints are often necessary. Both the patient and the ER staff are at risk. This evaluation is frequently made more difficult because of a lack of medical records and the patient's inability to assist the ER staff.
The ER doc and nurses have examined, x-rayed, lab tested and sedated the psychotic patient. Only one task remains, disposition. Insurance or lack thereof, prexisting medical condtions, pregnancy, advanced age, and drug use all make this search difficult and long. Patients cannot be discharged back to the general community. The psychiatric hospitals hold all the cards. Patients have been stuck in the ER for days while a "bed search" continues. The patient gets fed, and has a bed but little actual treatment is given.
Finally a bed is found and the patient is sent to the psychiatric hospital by ambulance. I breath a sigh of relief as I sign the paper work for the transfer. The next week, or even just a few days later, the same patient is back in the ER. His meds were adjusted and he was discharged from the psyche hospital. He or she is still schizophrenic, bipolar, etc. One call to 911 and the cycle begins anew.
This is only the first of several postings concerning psychitric care in the ER. The vagaries of psychiatric diagnoses and specific conditions will be addressed in future blogs.
The most common treatment involved storing these patients in large state psychiatric hospitals. Out of sight, out of mind. Having medications that could ameliorate the symptoms of psychosis made these human warehouses unnecessary. Plans were for community based out-patient treatment centers. Patients would get their medications, and counseling near to home. The drugs were prescribed but few of these psychiatric clinics were built.
The medictions had severe and disabling side effects. Long term use led to movement disorders such as tardive dyskinesia, a medication induced form of Parkinson's disease. Newer and supposedly better pharmaceuticals have been developed but they also have severe acute and chronic side effects. Weight gain, diabetes, elevated cholesterol are all known consequences of today's "atypical" anti-psychotics. One drug can even cause bone marrow damage that may be permanent.
A very eloquent paranoid schizophrenic, who I have known for 20 years, described his reaction to his medications most poetically. When asked why he continued to resist treatment by stopping his meds, he told me that they made him feel dead inside. He added that he would rather be crazy than be anesthetized.
Today the warehousing of psychiatric patients occurs in the ER. There is a revolving door from in-patient psychiatric hospitals to the community and this portal is the ER. When a psychiatric patient becomes a danger to the public or to themselves the police, EMS or their therapist sends them to the ER. The ER doc is supposed to "medically clear" the patient and then find an in-patient facility that will accept the patient.
Medical clearance is a mine field. The ER staff is responsible to diagnose and treat any and all medical conditions that the patient may have. The psychotic patient is often agitated, and even violent. Physical and chemical restraints are often necessary. Both the patient and the ER staff are at risk. This evaluation is frequently made more difficult because of a lack of medical records and the patient's inability to assist the ER staff.
The ER doc and nurses have examined, x-rayed, lab tested and sedated the psychotic patient. Only one task remains, disposition. Insurance or lack thereof, prexisting medical condtions, pregnancy, advanced age, and drug use all make this search difficult and long. Patients cannot be discharged back to the general community. The psychiatric hospitals hold all the cards. Patients have been stuck in the ER for days while a "bed search" continues. The patient gets fed, and has a bed but little actual treatment is given.
Finally a bed is found and the patient is sent to the psychiatric hospital by ambulance. I breath a sigh of relief as I sign the paper work for the transfer. The next week, or even just a few days later, the same patient is back in the ER. His meds were adjusted and he was discharged from the psyche hospital. He or she is still schizophrenic, bipolar, etc. One call to 911 and the cycle begins anew.
This is only the first of several postings concerning psychitric care in the ER. The vagaries of psychiatric diagnoses and specific conditions will be addressed in future blogs.
Friday, February 12, 2010
a career in emergency medicine
So you want to be an ER doc. Four years of premed, four years of medical school and four years on EM residency don't intimidate you. Upwards of a 1/4 million dollars of debt, no problem. The glamour of body fluids extruding from every orifice, working 24/7/365, bring it on.
Back in the mid 70's, I suggested to my faculty adviser, an endocrinologist trained at the world's best medical school, that I wished to become an EM doctor. He laughed and explained that a doctor worked in ER's for extra cash while training in medicine, surgery, pediatrics or OB/GYN. I had performed well in my clerkships, especially surgery, and he encouraged me to apply for surgical residencies. When I insisted that EM was a new but real specialty he told me that I was wasting my career.
When I graduated from medical school, there were only 18 residencies in EM in the 50 states. New England had zero EM programs. I visited at least half of all the programs and was fortunate to train in NYC. Each year of the program had only three residents. We worked long hours with little "adult" supervision. The experience was humbling but exciting. Gun shots, stabbings, MVC's gave ample chances to cut, suture, drill and get up to one's elbows in gore.
The first board certification exams in EM became a reality in the late 70's. I completed my residency in 1980 and became board certified in 1981. Unique at the time, the EM boards were in two parts, written and an oral examination. EM also pioneered the concept of having to recertify in the specialty every ten years.
Thirty years later there are more than 120 EM residencies. The attraction to the field is still the hands-on nature of the work. The adrenaline rush appeals to some, while others like the idea of working 36 hours a week for a decent remuneration and no beepers or on-call schedule. Nights, weekends and holidays must be covered but when you are off, you are truly free.
As mentioned in prior posts, the reality of working different shifts and the grinding nature of the sheer volume of patients, makes for a high degree of career burnout. It is imperative that the EM physician take care of him or her self. Proper diet, exercise, and a supportive home life all help to relieve the stress. Sharing with your fellow ER docs and mentoring of the young grads by the more experienced docs also contribute to career longevity.
The specialty of EM has expanded to include a number of subspecialties. Pediatrics, toxicology, diving, travel and cruise ship branches allow for greater flexibility in one's career. EM has become a very popular choice for medical students. EM has cool toys to play with. Ultrasound, and fiberoptics have become standard in most ER's.
You are a good student. You want to do something meaningful in life. You wish to make a difference in the lives of others. Medicine may be the best path for you. If you also like extreme sports, live for the rush of stress hormones coursing through your veins and can multitask without breaking a sweat, EM may be for you.
Back in the mid 70's, I suggested to my faculty adviser, an endocrinologist trained at the world's best medical school, that I wished to become an EM doctor. He laughed and explained that a doctor worked in ER's for extra cash while training in medicine, surgery, pediatrics or OB/GYN. I had performed well in my clerkships, especially surgery, and he encouraged me to apply for surgical residencies. When I insisted that EM was a new but real specialty he told me that I was wasting my career.
When I graduated from medical school, there were only 18 residencies in EM in the 50 states. New England had zero EM programs. I visited at least half of all the programs and was fortunate to train in NYC. Each year of the program had only three residents. We worked long hours with little "adult" supervision. The experience was humbling but exciting. Gun shots, stabbings, MVC's gave ample chances to cut, suture, drill and get up to one's elbows in gore.
The first board certification exams in EM became a reality in the late 70's. I completed my residency in 1980 and became board certified in 1981. Unique at the time, the EM boards were in two parts, written and an oral examination. EM also pioneered the concept of having to recertify in the specialty every ten years.
Thirty years later there are more than 120 EM residencies. The attraction to the field is still the hands-on nature of the work. The adrenaline rush appeals to some, while others like the idea of working 36 hours a week for a decent remuneration and no beepers or on-call schedule. Nights, weekends and holidays must be covered but when you are off, you are truly free.
As mentioned in prior posts, the reality of working different shifts and the grinding nature of the sheer volume of patients, makes for a high degree of career burnout. It is imperative that the EM physician take care of him or her self. Proper diet, exercise, and a supportive home life all help to relieve the stress. Sharing with your fellow ER docs and mentoring of the young grads by the more experienced docs also contribute to career longevity.
The specialty of EM has expanded to include a number of subspecialties. Pediatrics, toxicology, diving, travel and cruise ship branches allow for greater flexibility in one's career. EM has become a very popular choice for medical students. EM has cool toys to play with. Ultrasound, and fiberoptics have become standard in most ER's.
You are a good student. You want to do something meaningful in life. You wish to make a difference in the lives of others. Medicine may be the best path for you. If you also like extreme sports, live for the rush of stress hormones coursing through your veins and can multitask without breaking a sweat, EM may be for you.
Thursday, February 11, 2010
EMR
The answer to all that is wrong with medicine, the EMR. The electronic medical record will eliminate all medical errors. It will allow safer and more coordinated health care. It will make the patient health care history more secure and yet be available to another physician treating the patient. Sounds too good to be true? That's because it's a pipe dream (crack pipe).
I became familiar with the EMR three years ago. I diligently went to the classes (held of course during the day). The world's oldest ER doc is not a luddite. I may not be the first one to buy the latest technology but I am far from the last. This blog is produced on a laptop using Windows 7. I have a home wifi. I use a PDA loaded with the latest and greatest medical software. My cell phone is 3G and I text with my family and friends. My typing is done with my trusty index fingers, but at 30 words a minute. Ready, willing and able; bring on the EMR.
First let's look at the benefits of the EMR to the ER staff. Having the ability to access all prior medical information on the patient you are treating does improve care. Knowledge is power. Medications, allergies, prior surgeries, radiology reports, and consultation notes give invaluable help to the diligent ER doc. Ordering tests and reviewing the results, and placing data directly into the patient ER record makes for a more complete chart.
The problems arise because there is no standard for an EMR. Each hospital and sometimes individual departments within a hospital choose there software vender and EMR format. Having to maintain the confidentiality of the patients' medical record precludes a health care provider from outside your system from accessing an EMR. Murphy's law applies to both the hardware and software of your EMR system.
Computer systems must be maintained and periodically upgraded. During this "downtime" the overworked ER doc must revert back to "paper". The ability to read the prior records of your patient is lost during downtime. Coders, the people who decipher the doctors gibberish into a form that allows for billing, sent messages to the doc seeking the misplaced paper record. These scheduled interruptions are always on the night shift. I have several theories as to why the B.O.N.E.R. docs and their coworkers are the sacrificial lambs to the computer gods but I will only share my paranoid theories with my wife.
What prompted tonight's blog was a recent unscheduled downtime. Every computer work station in the ER threw us out of the EMR system. A call to the computer help desk wasn't helpful. When one station would freeze, his advise was always the same, "reboot". Realizing that the entire system was out, he boldly proclaimed, "I'll call my supervisor". The higher ranking computer nerds arrived and told us what we had already deduced. The servers for our system are in another state and these servers had "corrupted software". My faithful PA and I softly wept as we confronted this unscheduled downtime. Three hours later the problem was fixed and a cheer and prayer of gratitude was offered to the geek god.
The EMR is a reality. Embrace the new. Drink the kool-aid. Be the nerd.
I became familiar with the EMR three years ago. I diligently went to the classes (held of course during the day). The world's oldest ER doc is not a luddite. I may not be the first one to buy the latest technology but I am far from the last. This blog is produced on a laptop using Windows 7. I have a home wifi. I use a PDA loaded with the latest and greatest medical software. My cell phone is 3G and I text with my family and friends. My typing is done with my trusty index fingers, but at 30 words a minute. Ready, willing and able; bring on the EMR.
First let's look at the benefits of the EMR to the ER staff. Having the ability to access all prior medical information on the patient you are treating does improve care. Knowledge is power. Medications, allergies, prior surgeries, radiology reports, and consultation notes give invaluable help to the diligent ER doc. Ordering tests and reviewing the results, and placing data directly into the patient ER record makes for a more complete chart.
The problems arise because there is no standard for an EMR. Each hospital and sometimes individual departments within a hospital choose there software vender and EMR format. Having to maintain the confidentiality of the patients' medical record precludes a health care provider from outside your system from accessing an EMR. Murphy's law applies to both the hardware and software of your EMR system.
Computer systems must be maintained and periodically upgraded. During this "downtime" the overworked ER doc must revert back to "paper". The ability to read the prior records of your patient is lost during downtime. Coders, the people who decipher the doctors gibberish into a form that allows for billing, sent messages to the doc seeking the misplaced paper record. These scheduled interruptions are always on the night shift. I have several theories as to why the B.O.N.E.R. docs and their coworkers are the sacrificial lambs to the computer gods but I will only share my paranoid theories with my wife.
What prompted tonight's blog was a recent unscheduled downtime. Every computer work station in the ER threw us out of the EMR system. A call to the computer help desk wasn't helpful. When one station would freeze, his advise was always the same, "reboot". Realizing that the entire system was out, he boldly proclaimed, "I'll call my supervisor". The higher ranking computer nerds arrived and told us what we had already deduced. The servers for our system are in another state and these servers had "corrupted software". My faithful PA and I softly wept as we confronted this unscheduled downtime. Three hours later the problem was fixed and a cheer and prayer of gratitude was offered to the geek god.
The EMR is a reality. Embrace the new. Drink the kool-aid. Be the nerd.
Saturday, February 6, 2010
the agony of da feet
Injuries and diseases involving the feet are considered (bad pun alert) pedestrian by most ER staff. Stubbed toes, warts, ingrown toenails, and athelete's foot are given low acuity ratings by the triage nurse. There is no smell more offensive and lingering than the funk emanating from a street person's tootsies. Feet are the Rodney Dangerfield of the human body.
Warts, corns, and callouses are usually treated by our podiatrist colleagues and more power to them. Occasionally someone will present with an infected growth on the foot, usually caused by the patient's inept and unsterile attempt at self-treatment. The diabetic's foot is a mine field for the patient and the health care professional. The loss of sensation and poor circulation associated with diabetes can lead to ulcers, gangrene, ischemia and all too often amputation of toes or parts of the foot. Good foot care includes well fitting shoes and socks, cleaning and throughly drying the foot and a regularly scheduled appointment to the podiatrist.
Arthritis can effect the joints of the foot. The foot contains lots of bones and joints (see Gray's Anatomy, the text, not the TV series). Gout, a form of arthritis has a propensity to involve the great toe. Uric acid crystals occur in the joint and lead to extreme pain, redness, and swelling. The only way to confirm the diagnosis is to stick a needle into the joint and examine the fluid under a polarizing microscope. Osteoarthritis, and rheumatoid arthritis can also cause painful and swollen joints in the feet. The poor foot has to bear the weight of the entire body. Each step can be agony when the foot joints are diseased.
Being encased in socks and shoes and having sweat glands, the feet are ripe for the growth of bacteria and fungi. The limberger cheese odor of some people's feet come from this overgrowth of microorganisms. Athelete's foot is a fungal infection that causes burning and itching. Non-prescription medication are very effective in treating this condition. Soap and water cleaning, complete drying, and frequent changing of laudered socks all help to combat these annoying infections. When the weather permits, let yours dogs breath free. Flipflops, however, should not be worn in the winter or when you are participating in sports or even prolonged walking.
Injuries to the feet can be devastating. The movements of the foot and ankle allowed us to be the bipedal hunter of the African plain. Humans can walk and run barefoot with amazing grace. A recent trend in running for exercise involves taking off the expensive shoes and going au natural.
When the bones and joints of the foot are disrupted by fracture or dislocation, the outcome can be less than ideal.
Falls from a height onto one's feet, front end MVC's where the feet are crunched against the pedals, and motorcycle or bicycle accidents often cause these crippling injuries. The ligaments and articulations of the many joints in the feet are tight and strong. This is a necessity when every foot fall can bring up to three times the body's weight onto the foot. It takes a great deal of energy to fracture or dislocate the ankle, ankle-foot and mid-foot bones and joints. X-rays and CT are needed to assess the amount of damage. Many if not most of these injuries require the skills of the orthopedic surgeon. The ER docs and PA's must have a high degree of suspicion based on the mechanism of injury.
The lowly (another bad pun) foot is not the subject of poetry or art. Bunions, veiny, discolored toenails and frequently stinky lead to jokes and neglect of proper care. Treat your feet well. Clean them, dry them, wear the appropriate foot wear for the activity (no sandals while motorcycling). The ER will be ready to treat your foot emergencies.
Warts, corns, and callouses are usually treated by our podiatrist colleagues and more power to them. Occasionally someone will present with an infected growth on the foot, usually caused by the patient's inept and unsterile attempt at self-treatment. The diabetic's foot is a mine field for the patient and the health care professional. The loss of sensation and poor circulation associated with diabetes can lead to ulcers, gangrene, ischemia and all too often amputation of toes or parts of the foot. Good foot care includes well fitting shoes and socks, cleaning and throughly drying the foot and a regularly scheduled appointment to the podiatrist.
Arthritis can effect the joints of the foot. The foot contains lots of bones and joints (see Gray's Anatomy, the text, not the TV series). Gout, a form of arthritis has a propensity to involve the great toe. Uric acid crystals occur in the joint and lead to extreme pain, redness, and swelling. The only way to confirm the diagnosis is to stick a needle into the joint and examine the fluid under a polarizing microscope. Osteoarthritis, and rheumatoid arthritis can also cause painful and swollen joints in the feet. The poor foot has to bear the weight of the entire body. Each step can be agony when the foot joints are diseased.
Being encased in socks and shoes and having sweat glands, the feet are ripe for the growth of bacteria and fungi. The limberger cheese odor of some people's feet come from this overgrowth of microorganisms. Athelete's foot is a fungal infection that causes burning and itching. Non-prescription medication are very effective in treating this condition. Soap and water cleaning, complete drying, and frequent changing of laudered socks all help to combat these annoying infections. When the weather permits, let yours dogs breath free. Flipflops, however, should not be worn in the winter or when you are participating in sports or even prolonged walking.
Injuries to the feet can be devastating. The movements of the foot and ankle allowed us to be the bipedal hunter of the African plain. Humans can walk and run barefoot with amazing grace. A recent trend in running for exercise involves taking off the expensive shoes and going au natural.
When the bones and joints of the foot are disrupted by fracture or dislocation, the outcome can be less than ideal.
Falls from a height onto one's feet, front end MVC's where the feet are crunched against the pedals, and motorcycle or bicycle accidents often cause these crippling injuries. The ligaments and articulations of the many joints in the feet are tight and strong. This is a necessity when every foot fall can bring up to three times the body's weight onto the foot. It takes a great deal of energy to fracture or dislocate the ankle, ankle-foot and mid-foot bones and joints. X-rays and CT are needed to assess the amount of damage. Many if not most of these injuries require the skills of the orthopedic surgeon. The ER docs and PA's must have a high degree of suspicion based on the mechanism of injury.
The lowly (another bad pun) foot is not the subject of poetry or art. Bunions, veiny, discolored toenails and frequently stinky lead to jokes and neglect of proper care. Treat your feet well. Clean them, dry them, wear the appropriate foot wear for the activity (no sandals while motorcycling). The ER will be ready to treat your foot emergencies.
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