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Saturday, September 16, 2017

Documentation in Medical Records

I have documented my love of documentation elsewhere. I blog to document my life.

I'm not perfect at it. Nobody ever can be. Because perfect documentation would take more time than the original act of knowing.

Imagine. If you were documenting a visit to a nearby tourist attraction. How would you document it perfectly? You could definitely write about it in much detail. But how much detail is enough detail? Would you be writing about everything that you saw on the way? Would you be writing about your thoughts on what you saw? Would you document the planning process? Would you care about other sensations like smell, warmth, etc?

Recording a video might capture more detail. But a video can't really capture your thoughts unless you speak into it. Even then it can't capture your reflections unless you reflect loud while shooting yourself. But how much can you videograph? Where do you store these videos

Maybe it's possible to categorize and selectively review any moment from the past using a futuristic memory capture program like shown in Black Mirror. But, seriously, who has the time?

Perfect documentation is not equal to complete documentation. Documenting all the tiny details would not be relevant at times. But sometimes the tiniest detail can be very relevant.

This is especially true in medical documentation. Patient's cousin is a diabetic - relevant. Patient had a day old chicken curry in the morning - relevant. Patient was advised to take so and so medication before food two times a day for 5 days and review if his problems didn't subside - relevant. Patient is anxious - relevant. Patient reached hospital at 9 am - relevant. Patient teaches in an anganawadi - relevant.

Documenting all the relevant information is important.

But, when there is too much information, organization of this information in an accessible manner itself becomes important. Because ultimately, the purpose of documentation is to preserve information for the future so that when one looks back in time, it is possible to accurately interpret history (and avoid controversies. Did Swami Vivekananda's speech at the Parliament of World Religions get voice recorded?)

Courtesy: Some CS Professor (Reddit)
I once saw my consultant Orthopaedician write the timeline of a patient's visits to hospital and management in her case sheet. This was not really necessary for him to document because none of the information was new or not available elsewhere. Her discharge summaries and OPD case record had all those details. But what the consultant did by summarizing all that in a single page is make it easier for recalling everything at a single glance. The timeline itself added value to the documentation.

Elsewhere, A Country Doctor writes in his blog:
Family doctors had the patient’s active problems and their medical, surgical, social, family and health maintenance history on the inside left of the chart, along with medications and allergies. Our office notes, filed in reverse order to the right, were to the point and only dealt with the things we had time to talk about that day. But the background information was always in view and on our minds. We even used to scribble little side notes, like the names of pets and grandchildren, hobbies or favorite travel destinations and sports teams. The problem list helped us see our patients as individuals, not just “the chest pain in room 1”.
This was an eye-opener for me. I am used to knowing patients' name by their case record and calling them by their name. But many times than not, I would never know the name of the person accompanying the patient, let alone their children or pets.

Documentation is an art. It can be perfected only when you know the subject deeply. And when it comes to medicine this amounts to spending quality time with the patient and getting to know them rather than just their illness(es). Like artists, make your documentation picturesque. And people will enjoy it.

Tuesday, August 15, 2017

Fellowship in HIV Medicine - Interview

A day before independence day, after the long wait of more than three months, the FHM interview took place at SVYM office.

I was on duty and was checking on a newborn with tachypnea (probably transient tachypnea of newborn) when they called me upstairs for the interview. I had others fill in for me and ran to the interview room.

My friend Swathi went in first and sitting outside I could hear them talking about the challenges faced by a clinician and public health worker in managing HIV because of the stigma associated with it and how by consistent effort we can influence at least families of HIV infected people to look at it like any other disease.

I had practised multiple times the answer to why I wanted to join FHM. I look at it as a course in infectious diseases and India is a country still struggling with infections. My personal interests and career choices are probably going to take me to places where being good at managing infectious diseases would be an advantage. Also, SVYM is a great place to be at. The clinical, academic, and overall atmosphere here is wonderful. The kind of people whom I get to work closely with - no mention. Not to forget, I was never interested in a PG seat (till I started working here, that is).

The conversation then came to how I should rigorously finish my dissertation, starting early and keeping good quality because Indians can also contribute to the knowledge base that medicine is built on.

I didn't mention my unrealistic perfectionism that kills most of my research ideas. Maybe articles like this will help me look past RCTs as the only study worth doing. Wish me great productivity.

Friday, August 11, 2017

Do Cats Get HIV?

Blalock-Thomas-Taussig shunt is a surgical technique used in colouring Blue Babies pink.

Last week we had a baby who was referred for cardiac evaluation come back with a report saying she had Tetralogy of Fallot and needs a BT shunt. The parents had not gotten it done yet. Still, the baby wasn't blue. Because she was too anaemic to have enough deoxygenated haemoglobin to be cyanotic.

I had to watch Something the Lord Made that night. It is the heart-touching story of how B(T)T shunt was developed. If you don't cry with Vivian Thomas at the end, you should probably check your cardiac functioning.

In the backdrop, there are dogs. Blalock and Thomas would perform their surgical experiments on dogs. Countless dogs who have lost lives for (human and animal) science. Thank you dogs!

Talking about dogs, there are cats too. I found this post on reddit.

The Litterbox Hero
Cats don't get HIV - it's Human Immunodeficiency Virus, for viral Lords' sake. Or maybe there is a Feline Immunodeficiency Virus! And when you read more about it you can find that FIV and even HIV is used in gene therapy.

Fucking science.

On the other hand scientists are marching to protect science. And being rational is increasingly being viewed as treacherous and anti-nationalistic.

People just can't understand.

I had just figured out a name for the problem one of our patients who got his tissues necrosed after an IM diclo injection had. It was Nicolau Syndrome (or livedoid dermatitis or embolia cutis medicamentosa - remember the name that can make you sound really good).

And there walked in a patient who had worked too much and was having pain in the forearms and knees. He had to get an injection. It didn't matter to him whether I gave him 3 mL normal saline or 20 mg morphine. They just have to get injected. Good luck talking them out with Nicolau Syndrome or even anaphylaxis.

When the pleasures and shortcuts are so tempting, why would people prefer the rigour of science or protocols.

Tuesday, August 1, 2017

CPR - To Terminate Or Not To - That is the Question

Unlike with many other resolutions I figured out that today is the first day of the month only after resolving to be productive today. As a part of that I woke up about an hour early and started seeing my babies in ground floor general ward. (Oh, did I forget to mention, I'm in charge of Paediatric patients since more than a couple of weeks now).

But I hadn't even figured out why Atenolol was prescribed to the child with hepatorenal syndrome and not so high BP when I was informed that I had to cover general OPD in Kenchanahalli hospital today. As I had the experience of missing the van going there for being a minute late last time, I didn't take risk and ran away after instructing the nurse to withhold Atenolol.

It was only when I was halfway over the bridge that connects our hospital to the other side of Saragur that I realized that the Atenolol was not for BP, but to control the heart rate - tachycardia and gallop rhythm. I told the consultant paediatrician about how dumb I had been and he said it also helps in relieving portal hypertension which our child had.

Anyhow, Kenchanahalli is a nice break from the hectic Saragur hospital. Serene, silent, and sleepy. I could spend up to half an hour talking with each patient and understanding their problems.

It takes only half an hour of talking and a spot capillary glucose reading of 352 to make a grandmother who has been visiting our hospital for as long as I have been alive to confess that she has not been taking the teneligliptin 20 mg tablet for the past one month (along with the glipizide + metformin combination, pioglitazone, enalapril, hydrochlorthiazide, metoprolol, and ecospirin) because our hospital didn't have it in stock the last time she came (one month ago).

It takes only half an hour of talking about various reasons to quit smoking, instant and late benefits of quitting smoking, complications of continuing smoking, showing images from Google images of healthy lungs and smoker's lungs and talking to his daughter and her husband about how they can help to convince a 60 year old who had come with a bidi (which was momentarily destroyed and thrown into dust bin in line with the practice inherited from our consultant physician), a match box in his shirt pocket (which was involuntarily donated to the canteen) and amoxycillin tablets in trouser pockets to quit smoking.

It takes only half an hour of history taking, examination, and consultation over phone (and whatsapp) with consultant to convince a family (and myself) that their newborn who was vomiting milk through mouth and nostrils and not opening her eyes like she was in shock half an hour before, but opened her eyes and mouth and started crying the moment the ambulance reached hospital, is stable and okay and to learn that Epstein Pearls are nothing to worry about. Another 15 minutes ought to be spent to check on the mother who had Tetrology of Fallot and CCF, to listen to her heart murmurs and the wonderful story of how she had to undergo emergency LSCS because she was a short primi, the adventure they experienced in going to Jayadeva hospital to be declared fit for surgery, and how much money they had to pay to the workers who pushed the trolleys or handed over the just born child to the family waiting outside. All that and I was about to send them home with just a home remedy of preparing saline water and pouring a couple of drops into each nostril as many times as possible to relieve the nasal blockage (because we had ran out of saline nasal drops) and luckily I remembered I could prescribe Vitamin D3 drops for babies or I would have sent them back empty handed.

Medicine is exceedingly fun (and sometimes horribly sad) when you can spend more time with the patient (and family) than what is required to just figure out the diagnosis. Realizations like these are easy to come by when you walk through the now empty corridors of Kenchanahalli hospital where the soul of people behind SVYM always remains.

But I did not have time to revel in such thoughts. As a part of being not resolute, I had been postponing the task of drafting a CPR protocol for our hospital. I had to finish it somehow. But wherever I search, I couldn't find a definite answer to the question of when to terminate resuscitation (or efforts at resuscitation). AHA who is the authority on CPR leaves it at that multiple variables should be taken into account. An Indian CPR guideline didn't even acknowledge this question exists. Someone in Japan had done an analysis based on survival rates and figured out the factors that coincided with prolonged survival or vice versa and set an algorithm for termination. With no definite answer, I resorted to the diplomacy that everyone seems to be following. My protocol draft says that the team leader should make a decision based on a list of variables and that they should continue CPR if they can't make a decision (in the hope that something changes to make the decision easier, or help comes in the form of a senior doctor who can then take the decision).

While returning to Saragur in the Maruti Omni ambulance (this car model is so versatile I want to buy one and set up a mobile clinic in the Himalayas later in my life) I was looking at all the clouds with golden lining because the Orange sun was setting behind them and thinking that I should definitely resume the habit of journaling.

And my children were all fine except one of them is at the lowest point of Dengue thrombocytopenia and looks so sick he could fall down and disappear if someone didn't hold him up. And the guy whom I withheld Atenolol for? Seems like there is no way to figure out his exact BP. He is too long for a child so we might be tempted to not use the Paediatric BP cuff, but his arms are so thin that an adult cuff would go twice or thrice around his arm. Not to mention that there are two kinds of machines - the adult one with mercury and the Paediatric one with aneroid technology. Mix them up and you get 4 combinations. And we were getting different values for each of these configurations. Finally, I decided to assume that his BP was not too low because he could sit up without giddiness and I could feel the dorsalis pedis artery inside his grossly swollen foot.

The decision to terminate CPR or not might not make a huge difference in many cases, the patient would die anyhow with the sorry state of our health facilities and infrastructure. But a doctor is forced to be iron minded and make tough decisions every day. Wish them great luck.

Thursday, June 15, 2017

The Sour Grape

I have been told by at least one person (and I think many more might have the same idea) that "I have disregard for postgraduate entrance examinations and am working where I am currently working like it is something heroic because I find entrance examinations difficult to crack, because I'm incapable of getting a good rank, and I am just finding excuses that I can't figure out what postgraduation to do, that I don't want to lock myself in a garage to learn".

To them I would say, maybe you are right.

Maybe I am an idiot.
Maybe I barely passed MBBS.
Maybe I should not have been a doctor on the first hand.
Maybe I do not have the aptitude to crack entrance exams.
Maybe I am not even smart enough to do the "right" things in life.
Maybe I am stupid.

But, guess what?

I don't care.

My choices are entirely mine. My outlook is formed by my thought processes and I can live with the same. Maybe I don't fit your definition of success. Maybe I don't fit your definition of smart. I don't care.

It is my life. And I will choose how to tread it.

If your idea of successful and smart is to eternally run behind happiness in a pattern that is set by the expectations of the community. Pity you. I am happy where I am. And I am confident of being able to find happy places throughout my life. I don't need your free advice on what is the smartest thing to do.

Do I sound arrogant? Well, that's your problem to solve. Because if you feel like you have been smitten, it's exactly you whom I intended to smite.

You think I will learn myself? Yeah I will. I might some day come back and write entrance exams. But I won't be writing it for you. I will be writing it for myself.

I am in control of my life.
Don't try to wrestle that control away from me.

You can try to unsettle me and shake my confidence.
Well, thank you. But it doesn't work on me.

You know why?
Because my strength lies in knowing what I am doing.

My future is uncertain. But I'm comfortable with uncertainty.
My ideas are abstract. But I can think in abstract.
My philosophy is impractical. But I can make it work.
You may be right. But dare you say I am wrong.

Monday, June 5, 2017

My Idea of a Perfect Electronic Medical Record System

The COWs are coming to our hospital.

No, not these. They're getting more attention than they deserve.

Our hospital might soon switch to an Electronic Medical Record system. And this will bring in Computer on Wheels, COW as they're affectionately called in other hospitals.
More like this
While that makes me more happy about where I'm working, it also brings back a lot of ideas I've had during medical school. I have seen hard problems for humans that are pretty easy for computers to solve. I have seen processes that could be hastened by leaps and bounds if computers were involved even partially.

The Perfect Electronic Medical Record System

The perfect EMR does not just record what the physician or nurse puts in. It is an intelligent assistant that does some thinking of its own and comes back with suggestions and autofills for the physician or assistant.

For example, when a child comes to you and her mother says she has fever, you start entering "fe..." and the EMR autofills fever. Next you can enter the duration from a dropdown menu. Also associated symptoms can be ticked "yes/no". As you're done and move to the next row, the computer automatically populates an entry - "Cough? Yes/No". If you choose yes, it asks you for characterization.
If at any point you're in doubt or do not want to characterize a symptom, you can just delete the autosuggestion and move on to the next line.

Once you are done with the symptoms and exhausted the negative history that the smart EMR suggested for you, you can enter the examination findings. Again the EMR will suggest for you the most important findings you should not forget to look for based on existing data on what the most common findings are for that particular set of complaints.

Later, the computer will show you a list of provisional diagnoses based on the data you've entered about the patient, and the past set of data the computer has, and even the compendium of knowledge that it potentially has access to. You can reorder the diagnoses if you like.

Accordingly the computer will suggest investigations and management plans with dosages calculated according to weight or dosage adjustments that are required for special conditions.

The computer will always suggest and ask you for guidance when in doubt. You can always override the computer, but you can also take computers help in not missing important things.

Such a system might not be useful for an expert clinician, but it will definitely help a new doctor in emergency rooms late night. Most importantly, the system makes sure that an exhaustive history taking and examination has been done. It also helps in making clinical decisions based on data and evidence.

Impossible?

Certainly not. I just discovered that Dr Lawrence Weed, MD has been saying this exact thing since years. He might even have developed such a system already. But EMR systems do not seem to have this kind of intelligence integrated yet.

The accuracy of simple software powered by big data like Akinator is testimonial to the power of computers when it comes to problems like this.

Clinical decision making is no holy grail and it will soon be heavily relying on, if not replaced by, artificial intelligence.

Pictures courtesy pixabay.com

Wednesday, May 31, 2017

Joining Swami Vivekananda Youth Movement

Till yesterday, I had thought that I had joined Vivekananda Memorial Hospital.  But, yesterday there was an orientation session for new employees at this organization. And the events made me realize that I have indeed joined, or want to join, Swami Vivekananda Youth Movement, the parent organization of VMH.

SVYM's story is very heart-touchingly written in the blog of Dr R Balu (RB).

I am not aware of any other organization which has the story of its inception so beautifully and lucidly laid out. RB's experiences that led him to start SVYM are relatable. And he has made it possible to connect dots from those strokes of inspiration to the concrete structure that exists today.

But Dr M A Balasubramanya nevertheless described the same in a couple of hours yesterday. Some of his words dug deeper than I expected them to go inside my mind. I was expecting him to speak about how they had to undergo a lot of hardships and struggle to reach where we are. He did. But I wasn't expecting to shake my mind and say that SVYM now has presence throughout Karnataka and caters to lakhs of people under education, health, community empowerment, research, training, and ultimately development and achieved this growth over 32 years by not faltering even once from its core values of "Satya, Ahimsa, Seva, Tyaga". It sent depolarizations through some of my old neurons.

We had a brief on organization policies, accounting practices, etc.

After lunch, we went on a long trip to Kenchanahalli and Hosahalli campuses where other activities of SVYM happens.

Kenchanahalli is on the verge of being converted to a centre for socio-economic empowerment program.

And Hosahalli! Hosahalli is a beautiful campus in 24 acres. There is Vivekananda Teacher Training and Research Centre here. And befittingly, the tribal school right next to it. Dr Ramkumar who works there rightly puts it. After years of working in Bengaluru and other places,.  they come here with lots of experience and every day they face a new challenge. The tribal kids have their own culture. Their language is different. Their aptitudes and attitudes are different. There is sometimes more to learn from them than to teach them.

Challenges like these, and the motivation to work with principles to overcome these challenges on a regular basis is what makes SVYM truly special

Take this example from Vivekananda Memorial Hospital.

VK is an 11 year old boy who got admitted with Diabetic Keto Acidosis. We were counselling him and his mother regarding the importance of strictly taking insulin, even while in school. And we were concerned about them being not able to recognize and treat hypoglycemia. The mother was in fact very much aware of hypoglycemia and apparently she used to manage it at home using sugar water.

"But who will make sugar water for him at school, ma?" we asked her. She gave a blank smile.

We gave our usual advice. "So, keep a sweet something in his pocket so that even at school when he feels symptoms of hypoglycemia he can eat it".

She smiled and said "My boy is just a kid. He will eat the sweet whenever he likes."