slightlymoving

a lot to learn

I’m doing a rotation in the Emergency Department at the moment. And mostly I’m really enjoying it.

Like every rotation there’s a mixture of senior clinicians, some who are excellent mentors and colleagues and others who really don’t seem to care much at all. But that’s another post.

I’ve had some great clinical learning moments, but also some important learning about systems.

The other week I had a patient who had attended ED with a letter from a specialist outside of the hospital. It was short and addressed to a senior clinician in the hospital and referred to a senior registrar stating that he had said to send the patient into ED for further management as the patient had been under that team only 1 week previously. The patient was not acutely unwell - stable, not in pain, but also clearly not improving since recent admissions.

So, I took a history, did an examination and ordered some bloods. Then I called the registrar. He knew all about the patient and went on to explain that the senior consultant mentioned wasn’t the correct one due to some confusion about teams on call a few weeks ago. He said to call another registrar who knew about the situation and would see the patient.

The second registrar asked me about my findings and results and then promptly declined to come and see the patient. I was honest and direct with him, as I didn’t feel the patient was acutely unwell - certainly they needed follow-up but it didn’t have to happen immediately (as a side note, the external consultant could have done all of this but appeared to be handballing the patient). It didn’t seem like an appropriate referral but I had felt the pressure to do the bidding of an external consultant who had been in touch with a team within the hospital. The external consultant had also given the patient and family a certain expectation about admission and further investigations in hospital.

It may read like all of this happened very quickly, but this is over the course of 3 hours or so while I was also seeing other patients and doing a handover at the end of my shift.

So, what have I learnt?

Even if there are letters from consultants and plans made for a patient outside of the ED, workup the patient and refer them on as necessary. Certainly contact the teams involved, but focus on what the patient needs. Try and find a solution for their problems.

I’ve also learnt that when I’m on a receiving team I certainly won’t be telling a patient to come to ED and then not seeing them.

amongst the few

I had been working for 12 and a half hours straight.

With only half an hour to go the scrap of paper with patient names and numbers was wearing thin along the fold lines. But, to my relief, each task that had been assigned had been dutifully scratched through.

Bar one.

A simple procedure to assess the levels of oxygen and carbon dioxide in the blood was all that was left. I had minimal details; the ward, a bed number, a name. But no rationale for the test had been provided.

I headed out to the most distant ward, greeted the nurse with a tired hello and asked to see the patient’s notes. Far too much to read, but at least a confirmation of the plan to do the test. I asked the nurse where to get the equipment I needed. A needle and syringe, an antiseptic wipe, a bandaid, some gauze, a pathology bag.

At the door to the patient’s room I paused, the lights were out and it was quiet. It wasn’t that late, but clearly everyone in the room was asleep.

She was in the bed closest to the door, and startled when I woke her despite being as gentle as I could. We chatted for a moment as I explained what I’d been asked to do, and to find out if she knew the reason for the test. She did.

She was anxious about the needle, so I kept talking to her, asking about where she lived and about her family while I prepared.

She was old. But the youngest of all her family. Her children had died years ago and her husband long before them. She was an only child herself.

She averted her eyes and turned her head as I pushed the needle into the loose skin over her wrist, my other hand anchoring her strong pulsating artery as a guide. She took a short sharp breath then continued telling me about how things had changed. How she had started to become softer as she got older, that she used to be so strong and now was weak.

She cried. Not from the pain.

Her blood gushed in tiny waves into the syringe as her tears wet her cheeks. She made no attempt to wipe them away. I sat with her, keeping pressure on the place where the needle had pierced through. Held her hand. My pager bleeped, a loud cricket. And then it bleeped again. And still I sat.

She told me she’d be ok. She told me things weren’t that bad. She thanked me.

I smiled and hoped she wouldn’t be in hospital for long.

She smiled back and said she didn’t think so. But that, in the end, it didn’t really matter either way. She was ok.

I left the room, finished the paperwork, pulled out the scrap of paper and scratched off her name. Now I had only 10 minutes to go.

more on monitoring

so a quick, and non-exhaustive, search didn’t find much in the area of monitoring social media status feeds for changes in mood/behavior. there has been quite a lot published on social media and health though.

further to my initial idea i’ve mused a bit more. read on.

It seems there’s not much research out there in terms of mental state and correlations with social media updates (content and/or tone). 

A possible system for monitoring status updates would need to be ‘trained’ to each individual. It would require time to build a personalised mood dictionary that could then be used to monitor status updates in real time to provide feedback to the person (and/or their authorized mental health professional). This feedback could be graded information based on frequency of updates, mood parameters (as defined in the dictionary), durational information, and perhaps risk signals (for prioritizing interventional management). An analogous analogue system is the asthma action plans, where, based on peak flow readings and subjective symptoms there is a graded response for the person to follow with each intervention escalating in terms of medication and health professional involvement.

It would, of course, require the person to setup in consultation with a health professional and would need to have a discussion about confidentiality. For example, if there was a program that could monitor tweets in this way, what would stop someone else from monitoring a third-party? Being an official app you could limit input through oauth - but given unprotected tweets are public it would be possible to grab them an analyze them anyway. But to what end? I guess employers could monitor an employees mental state, which is ethically problematic.  In terms of mental health, this could be extensible to people on Community Treatment Orders, monitoring their digital stream (including text messages, twitter, fb) for signs of deteriorating mental state and allowing early intervention. This is also an ethically difficult area, but I think there is some potential for this idea in improving the mental health of many people.

Anyone interested in looking into this further?

monitoring

while riding to work i was musing on twitter and mental health.

i’ll have to go and search to see if it already exists, but i was thinking about the possibilities for people with bipolar or mood/affective diagnoses in terms of monitoring twitter streams. i was thinking that moving into a more manic phase may show more frequent tweets with any of the various elements of being in such a state appearing in content - as a monitoring tool this could be used to trigger earlier interventions to help people manage their condition. could probably even be an automated process to some degree.

will have a search and see what comes up.

seesaw

last year i had an interview in Panacea, the Australian Medical Students’ Association magazine, it was for being awarded the inaugural National Student Award.

they emailed me a set of questions and i wrote answers then they sent me an edit for final corrections. very nice really. but some of it didn’t get in - probably because i waffle too much.

i thought i’d post some of the questions and answers here. then people (the 3 people who actually read this - hi mum) can accuse me of blowing my own trumpet. which i do, given i’m a trumpet player. or was, during my first degree.

anyway, after that rambling intro, here’s what i had about the whole work life balance issue which people harp on about a lot.

AMSA: As a person with very diverse interests what advice would you offer to junior medical students to help them maintain a good work life balance?

David: The phrase “work life balance” gets used a lot, but I feel like the focus should actually be on “life balance”. I think balance in our lives is predicated on finding sustenance in what we do. Work and study can be sustaining, as can family, sport, art and many other hobbies. Each aspect of our lives can feed into and support the others, and giving our many interests, including work, some attention or space can recharge us and help to maintain our energy levels.

I strongly believe that getting involved – in student groups, in sports groups, in research, in tutoring, in medical forums - and contributing to something that interests you provides sustenance in the long run. I think a quote from Sir William Osler sums things up nicely, “We are here to add what we can to life, not to get what we can from life.”

i sound serious don’t i.

keep on learning

I’m not sure I’ve written here before about Life in the Fast Lane.

But I should have.

Such a great resource for junior doctors. And not so junior doctors as well.

Tonight, while on night shift, I’ve been reading a post about the 6 true emergencies, which is gold for new docs. Of course we get taught about approaches to MET calls and following the ACLS guidelines in an arrest - and i’m sure everyone has a way of remembering the Hs and Ts to find reversible causes of arrest - but this post makes it even more straightforward for determining emergency treatment.

1. Is the airway obstructed?
2. Is there a tension pneumothorax?
3. Do they have a ventricular dysrhythmia?
4. Are they bleeding out?
5. Do they have a pericardial tamponade?
6. Are they hypoglycaemic?

These 6 things all require immediate treatment/management - everything else can be a little more leisurely. What is great about the post though is that for each condition they’ve given a guide to prevalence (how likely is it going to be this), the basic problem and solution, how long it takes to address, and the difficulty. Like I said, gold for the new doctor.

The one thing it doesn’t mention, and I think it’d always worth remembering, is that in any emergency situation you’re never alone. Always ask for help, and always work with the other healthcare professionals who are there. Particularly as a junior doctor.

options for documentation

like a lot of people (currently 6 million users), i’ve been using Evernote regularly for the last year or so. and it has improved in leaps and bounds over that time by introducing support for more platforms, creating shareable and editable notebooks, and plenty more.

so far though, it’s been useful for my study purposes. but now i’m working in the hospital setting i can see more uses for it - and the potential for both making my work easier and patient care safer.

i’ve previously mentioned the importance and role of documentation, and this aspect of clinical practice becomes even more vital in handover and referral situations.

here’s an example of how Evernote could be used for clinical documentation, in a way that would fit in with the existing workflow at hospitals (which is generally inefficient and cumbersome).

with the notebook sharing feature of Evernote you could have, for example, a Surgical Ward notebook. within that notebook individual notes could be created for patients using their UR numbers/surnames/whatever. it would be possible to create further subnotes for each patient as well if needed.

each surgical team could then share the notebook (need to use a premium version of Evernote to allow all members to edit the notes) for documentation for the patients. with the checkbox function of Evernote it is possible to build ‘todo’ lists for each note or patient - this would be particularly useful for handover. any tasks still to be done would already appear on the new rotations synced notebooks - no chance of losing that information or not having it available. particularly with Evernote available on mobile and desktop platforms.

what would be even better would be to utilise the features of Livescribe, a digital and ink pen that captures writing and is integrated with Evernote. the only downside that it currently needs specially printed paper to work. but, what this would mean is that the usual written notes could be taken while on ward rounds and seeing patients, and these notes would automatically be syncronised to the medical team devices Evernote notebooks.

of course, there will be issues with internet access for syncing. hospitals are notorious for lack of wireless and 3G reception. but having Evernote on hardwired network computers in possible as well. in terms of security all transactions are SSL - which should meet most organisational security requirements.

if anyone has been using a similar system, i’d love to know. i hope to trial this out sometime in the coming months. any comments welcome.