A Country Doctor Writes:

I have this irresistible urge to write, in case nobody noticed. I have a fledging Swedish blog under a pseudonym I won’t tell you about, but I finally decided to use Facebook, not just to keep in touch with my family in Sweden and my children, but for people who want to know what’s up in my life. So, under my own name, I do write things about my life, my pets and reflections that don’t fit on A Country Doctor Writes. But, as I wrote in one early post, I don’t want to be friends with a gazillion people because I really don’t have the space to read lots of updates. If somebody wants to know what is going on in the private ruminations of this country doctor, it’s there.

The timeline of a patient’s symptoms is often crucial in making a correct diagnosis. Similarly, the timeline of our own clinical decisions is necessary to document and review when following a patient through their treatment.

In the old paper charts, particularly when they were handwritten, office notes, phone calls, refills and many other things were displayed in the order they happened (usually reverse chronological order). This made following the treatment of a case effortless, for example:

3/1 OFFICE VISIT: ?UTI (where ciprofloxacin was prescribed and culture sent off)

3/3 Clinical note that the culture came back, bacteria resistant and treatment changed to sulfonamide.

3/5 Phone call: Patient developed a rash, quick handwritten addition on left side of chart folder, sulfa allergy. New prescription for nitrofurantoin.

3/8 Phone call: Now has yeast infection, prescribed fluconazole.

Each of these notes took virtually no time to create and you could see them all in one glance.

In one of the EMRs I work with (hi, Greenway, it’s me again), when the culture comes back and I need to change the antibiotic, I open the patient’s chart, go to the medication section and hit the + sign. The system then asks me which existing “encounter” I want to use for my new prescription. Excuse me, I am sending in a new prescription right now, doesn’t the system know what day it is? How could I today send in a new prescription dated yesterday?? So I have to create a new encounter, choosing “medication encounter” as the type and then I’m good to go. Sort of. That type of encounter doesn’t display when I later look at my office notes, because it isn’t classified as an office note.

When the patient later calls to report the rash, that telephone call comes to me as a “task” (oh, how I despise that demeaning word…), which will also not enter the timeline of office notes. I can create a medication encounter when I change the antibiotic again, just like with the first medication change. I can then use the same encounter to document the allergy. But if I want my actions to display in any kind of timeline, I have to use the encounter type “chart update”, which will enter the encounter list.

This is all very fussy and, frankly, reminds me of working with the earliest versions of DOS, which many of my readers are too young to even have encountered.

The time it takes to document the simple clinical scenario I described above in my current EMR – and to review the next time I see my patient – compared to when we did it on paper is 5-10 times longer.

Some progress, huh.

I wish the EMR would know that when I add a medication, I am doing it today and not yesterday.

I wish that it would know that it is a medication encounter when I am adding a medication.

I wish the EMR would display the story as simply as the old paper chart. I’m sure it’s possible. Computers can do amazing things. But of course, it’s a question of whom the holy grail actually serves.

I sometimes explain to patients that shortness of breath is usually one of three things: Bad lungs, bad heart or bad blood. We need the lungs to oxygenate our blood, the heart to pump the blood around and enough hemoglobin in our blood to carry the oxygen. I have sometimes been a little slow in thinking that anemia can be a cause of shortness of breath.

The other day I saw a patient who seemed not fit into either category and he reminded me of Wayne Brown, who died from another condition that can make you short of breath.

I thought of Wayne as I heard the story of Carl, a heavy smoker with severe COPD. He had been to the emergency room half a dozen times since Thanksgiving and had received prednisone with or without antibiotics every time. He had his last chest X-ray in December and it didn’t show anything different from the ones before.

Carl, the man in front of me, made a slight noise with each breath, but it wasn’t quite a wheeze. It was an ever so slight stridor, a sound from higher up in his windpipe.

“I keep telling them it’s not my lungs”, he said, “it’s here”, and pointed to his neck.

Years ago, I remember hearing that same noise as I was leaving the hospital after a meeting one night. My patient, Wayne, was sitting on a bench outside the emergency room. He was waiting for his ride back home after a visit to the ER for breathing problems, diagnosed as another COPD exacerbation. It was a damp, cold evening when you could almost see your breath. He was making this little stridorous noise. He wasn’t hoarse when he talked, but once we got him to see an ear nose and throat doctor, he turned out to have cancer of his larynx. He lived for a while with his tracheostomy, which I helped him manage, and he whispered when we talked for the remaining few months of his life.

Carl had a normal oxygen saturation, a miserable peak flow of 150, poor but clean breath sounds, no cough and no hoarseness. He will of course need a CT of his lungs, because I have seen even large cancers not show on chest X-rays, but he also will need his larynx evaluated.

I hope my hunch is wrong.

What are the odds that the Bucksport EMR that I use for my telemedicine services there should become non-functional on Friday and my local clinic’s system should have a major crash the very next day?

We live in a state of dependence on tenuous infrastructure. Not long ago, Texas was paralyzed by massive power failures and soon thereafter we learned that both government and industry e-mail systems were hacked by foreign countries.

The increased centralization of information and resources and the simultaneous increased remote access to them has created a situation where users may become helpless, unable to work, communicate, eat, stay warm or even wash their hands after using toilets they can’t flush.

My Bucksport clinic upgraded their cloud based EMR in some fashion, so now my two workhorse iPads of different generations can’t access the system. Upgrading the operating system or the app didn’t help.

My local clinic’s EMR is working, but not the prescription functionality. Greenway (hi, guys, I’m talking about you again!) experienced a major failure in their clearinghouse functionality Saturday morning. I ended up printing and faxing prescriptions during my morning clinic hours, but colleagues doing catch-up work from home couldn’t use that option. Many patients didn’t get their refills this weekend.

I finished my Saturday clinic schedule and spent the rest of the day tending to my farm routines.

So here it is, Sunday morning. Overnight, the operating system on my newer iPad Pro updated, and now I will install and try the very latest app for my telemedicine job. I will also crank up the old laptop, which has a different app and also a plugin for a browser based access to the system. My next clinic on Tuesday is at stake. I will keep my fingers crossed.

We landed on Mars with great precision but the more mundane technology closer to home isn’t as perfect.

Wish me luck today.

When we take a medical history, there is a modern tendency to concentrate on simply listing symptoms. This is evident in many EMR notes, since the number of items in a medical history or review of systems for many years has driven reimbursement.

This, and clinician compulsion to quickly get to the diagnosis in a time pressured visit, has kept us from letting the patient tell their story.

The order in which symptoms appeared is an important part of solving a diagnostic dilemma.

A simple example is the mysterious rash I read a case description of a while ago. Someone had an itch that turned into a severe rash on one leg and later developed a similar rash on the other leg. The timeline (if I remember correctly) revealed that a harmless itch was first treated with a cortisone cream to no avail and later treated with topical neosporin. This worsened the itch and caused a local allergic reaction. Rubbing one leg against the other during sleep exposed the other leg to neosporin, which the patient was by now allergic to. This case made it all the way to the medical journals. A simple question, like “tell me what happened, from beginning to end” would have solved this case very quickly.

When a patient is on multiple medications and has a new symptom that could be a side effect or interaction, the timelines of symptoms and treatments can sort things out. In my experience, patients aren’t usually able to recall which drug was started exactly when. Modern EMRs don’t display a graphic medication timeline the way our old paper charts used to. For this reason it takes more work than our patients would expect to correlate medication stops and starts with symptoms.

My 2011 post, A Deadly Interaction, illustrates how the stopping and starting of statin drugs can severely affect INRs in patients on warfarin, sometimes to the point of causing death. In the case I saw, the patient fared better, but it took the timeline to understand what had happened.

Speaking of statin drugs, I’ve lost count of the many times patients ignore their own timeline. People will say, “I think the medicine is causing my legs to hurt”. I then often get a positive answer when I ask, “did they hurt before you started the medicine?”

A dry cough from lisinopril and other ACE inhibitors is another case where I try to tease out the timeline. But if a patient with a preexisting cough still blames the medicine, I don’t argue the point; I just move on.

Twice so far this year I have seen a diabetic suddenly present with dramatically increased blood sugars. In both cases they had decided to eat healthier on the advice of helpful relatives and increased their fruit consumption. These patients had been diabetics for a long time, and somehow had forgotten that if something tastes sweet, it probably raises your blood sugar.

The detailed timeline is time-tested tool in making a correct diagnosis, just like the broad view of asking “what else is going on”.