Wednesday, February 25, 2009

Electronic Health Care: Engineers != Doctors

For those of you who aren't programming nerds, in the C++ programming language "!=" means "not equal to".

I was in the ER last week and noticed a significant problem with the software the hospital was using to triage, order tests, and discharge patients. The doctors and nurses, regardless of age, were having difficulty using the software. The user interfaces were not intuitive to them and they couldn't navigate their way around the program. They would try to look at test results and they couldn't figure out how to display lists of x-rays. They couldn't look at notes from a patient's previous discharges. The program they were using was new, supposedly better than their old program. However, after the staff had finally learned how to use the old program, they were struggling to find their way around this new interface.

I took a look and the program seemed incredibly easy to navigate and I ended up showing the physicians how to use the application. Think about that, a first year stduent was showing these full-fledged doctors how to use the application that they use to care for their patients.

The problem was that the software was very intuitive to me because I've spent 6 years as an engineer and only 6 months as a physician (the student version). Engineers, or computer people in general, have a different set of needs for their program. We want our applications to be streamlined so that we can use the fewest number of mouse clicks possible to get the results we need. We like keyboard shortcuts to access menus quickly. We care less about a pretty interface (not always true), as long as we can maximize our efficiency. The average user doesn't think about this and they are generally willing to replace efficiency with ease of use. The hospital staff don't want to learn shortcuts, they want everything they need displayed in front of them. They don't want to click through a set of options to make sure their layout is optimized, they just want an application that does what they need 90% of the time without being told. If they have a need that falls in the 10%, they are generally willing to wait for the IT guy to come out and show them how to do it.

If software companies want widespread adoption of their applications for use in health care settings, they really need to make sure a health care professional is involved in their interface design and user experience development. Otherwise, you get a hospital with a frustrated staff who are less efficient and the already high patient wait times increase.

Monday, February 23, 2009

Why your nose runs when you cry...

If you've ever seen someone crying, I mean really crying, you'll notice that often they have a runny nose too. Normally you don't see this when your girlfriend is shedding a couple tears when the guy in He's Not That Into You is proposing. Nor do you see a runny nose when you're shedding a couple tears because you realize you were dragged out to see the most convoluted, soap opera-esque movie...ever. You do however, see the runny nose if you see someone really bawling. Just find me if they ever make a sequel to He's Not That Into You.

You see the runny nose because our eyes are connected to our nose through a nasolacrimal duct. Tears flow from the lacrimal gland, which is in the upper outside corner of our eye, and flow downwards. Some flow out of our eyes and down our face, but a large majority flow into the lacrimal sac, which is that red, ball shaped sac at the inside corner of our eyes. That lacrimal sac is connected through lacrimal cannaliculi (canals) to the nasolacrimal duct, which is connected to our nose through paranasal sinuses. And that's the path tears take to run through your nose.

This anatomy is a two way street and explains how some people can snort milk up their nose and squirt it out their eye (seriously!).

I really hope they don't make a sequel...

Saturday, February 21, 2009

ER Etiquette

The media has no shortage of stories describing the extended waits patients face when they arrive to the emergency room. However, following simple ER etiquette will help your visit be as short as possible.

Upon arrival, explain your symptoms to the nurse as accurately as you can. This will help them triage you and decide how quickly you need to see the doctor. Unfortunately, patients are often motivated to exaggerate their symptoms because making their illness appear worse will result in them skipping ahead in the line. We then see an instance of game theory where every patient is motivated to exaggerate their symptoms to prevent any other patient from skipping ahead of them in the ER queue.

I don't really have any advice on how to deal with this dilemma. However, I will tell you that exaggerating your symptoms too extremely can result in a barrage of unnecessary tests. This testing can be dangerous because every test has some associated risks, whether they be exposure to bugs or radiation. The testing will also extend your stay because waiting for equipment to become available can take a long time, especially if everyone is exaggerating their symptoms.

Once you get admitted into the ER, be polite but be heard.

First, be polite. Do not talk to the staff rudely, especially the nurses. If you are frustrated with their work or attitude, you can let them know if you really want to, but talk to them like they are colleagues, not the hired help. For example, if you were promised breakfast at 8 and it's already 8:30 and you haven't got your oatmeal. When you see the nurse, you can say "Hey, I know you're really busy, but I was told I'd have breakfast at 8 and it's already 8:30, can I get you to help me out, I'm starving." This is the preferred response over, "Hey, you told me I'd get my breakfast at 8, it's 8:30, can't you do your job right?"

Seriously, be polite, I'm not trying to teach you manners, this advice will help you if you're ever in the ER. I have seen quality of care deteriorate because patients have been disrespectful. At best, the health care staff will try to admit you to a different department and your stay at the hospital will be extended longer than it needs to be. At worst, you may be discharged quicker than you should be because you are an ass. The ER staff will obviously not intentionally harm you, but it is human nature to not be as eager to help someone who is treating you like dirt.

Secondly, be heard. The ER gets VERY busy and if you are too quiet the staff may forget about you. Or worse yet, mistakenly assume that your illness isn't as serious. Though I have yet to see the latter, I have seen a girl who was forgotten because she was too quiet. She came to the ER because she had a severe bout of diarrhea, but after the doctor saw her he decided that she had passed through the worst of it and that she should be discharged. Unfortunately, he was sidetracked because there were 20 other cases that all came in at once and the girl, who was sitting quietly in her bed, spent an extra 4 hours in the emergency room before the doctor got around to ordering the discharge.

Friday, February 20, 2009

The White Whale of Endocrinology

Some time last term an endocrinologist was lecturing to us about the autonomic nervous system. He brought up a hypothetical scenario where a patient had overdosed on a sympathetic stimulant, which would cause tachycardia (fast heart rate), bronchodilation, pallor (paleness), diaphoresis (sweating), etc. Turns out this situation rarely occurs from an overdose of drugs because we don't give people many sympathetic stimulants. However, patients can have a pheochromocytoma, a tumour on their adrenal gland, which causes excess adrenaline to be secreted throughout the body. These episodes of excess adrenaline are often on and off, not constant. Adrenaline is a sympathetic hormone which causes the aforementioned symptoms. This illness is VERY rare, yet doctors, especially endocrinologists, cannot stop talking about it. I have heard 6 different doctors tell me about pheochromocytomas, but none, not a SINGLE one, had ever seen one before. They all ended the discussion with some variation of "remember, if you ever see one while you're on the wards, give me a shout if I'm at the hospital".

The pheochromocytoma is the white whale of endocrinology. Endocrinologists keep chasing after this rare disease and, it seems, they will not be fulfilled with their careers until they see it. I'm sure that through the years I will go on to learn about the white whales of other specialties.

Oddly enough, last week, a patient came to talk to my class about his pheochromocytoma. Turns out he had been having regular bouts of panic attacks when he was stressed and went to his family doctor to see what was happening. A cyst was found above one of the patient's kidney in the past, but he had been told that many people have them and that these cysts are entirely normal. The family doctor ran a blood test and measured his blood pressure and saw that everything was normal, so he thought the problem was entirely emotional. Then a few months later, things got worse. The patient would be climbing a set of stairs and have the same "panic attacks". He would also be having these panic attacks more often.

Finally, his doctor sent him to an endocrinologist who began piecing the puzzle together. The patient had panic attacks. Panic attacks are a "fight or flight" response. When you have a panic attack, your heart rate rises, your skin becomes pale, and you are having a sympathetic response. The blood test ordered by the patient's family doctor did not alarm the doctor because the pheochromocytoma had episodic bouts of adrenaline secretion and the patient was not having an episode when his blood was tested. Finally, guess what is sitting right on top of the kidneys, where these "cysts" were...the adrenal glands. Those cysts were actually adrenal medullary tumours.

Surprising how a disease that is mentioned in med school so often (6 times in 5 months!) can go unnoticed because it is so rare in the population. Fortunately, the tumours were removed and the patient has made a full recovery.

Scary that he went undiagnosed for so long because a pheochromocytoma can easily be fatal. Too much adrenaline can cause heart failure. I guess the lesson is that you should always look out for the white whale.

Wednesday, February 11, 2009

Migraines Lead To Temporary Blindness!?

Follow up on a case I discussed earlier this month. The patient went to the opthamologist and he told her that her eyes were healthy. The patient then came back to see my preceptor, who suspected that the symptoms could be prodrome for migraines.

Turns out that the patient used to have bad migraines 10 years ago and a day after she saw us she had them again.

I had no idea that migraines can induce temporary blindness! Apparently this is relatively common in migraine sufferers.


Sunday, February 8, 2009

Vision Acuity Test

In my latest post I talked about doing a vision acuity test, so I thought it might be a good idea to explain how the test actually works. Most people have seen an eye chart in either their doctor's or their optometrist's office. It's a standard white chart with black letters in rows. From the top down, each row has more letters and the letters in the row are smaller than the letters in the row above them. Beside each row you see a score, the top one is usually 20/200, the next one is 20/100, and so on. The numerator refers to how far in feet the patient is when he or she is doing the test. The denominator refers to the farthest distance, in feet, that a person with normal vision, 20/20, can be and still be able to read that row.

During the test, the patient usually stands 20 feet away from the chart and reads aloud the smallest row of letters that he or she can. The score beside the letter represents their vision acuity. The patient usually does the test once with the left eye covered, once with the right eye covered, and then with both eyes uncovered.

Warped vision -> Blindness -> Out Of My League

As I've mentioned before, at UBC we start working in a family practice clinic from day 1. In our first term, we spend the majority of our time in the clinic interviewing patients because we don't really know anything about medicine. In second term, which we are currently in, we begin learning the fundamentals of medicine and we begin to develop our diagnostic skills.

Since January, I've been seeing a variety of patients who have mostly had infections, sprained ankles, and needed vaccinations. Most of the patients have been fairly straight forward and I am already able to predict the course of action the doctor I am working with will take with these cases.

There are some cases that are a little bit tougher though. Last week, I saw a woman whose chart stated that she wanted to see the doctor because she was feeling dizzy. I was thinking I'd see her, do an interview, take her blood pressure, check her ears, and everything would move along smoothly. Instead, as soon as I start asking her about her presenting complaint, I find out she temporarily lost her vision. She was talking to a friend and all of a sudden her vision started to warp and then she went completely blind. A few minutes later her vision came back but it was cloudy. Then, she went to lie down, and the back of her head started to twitch. That may have been a coincidence, but it was interesting because your visual cortex is located in the rear portion of the brain. After the twitching, she made her way to the clinic and now she was feeling dizzy but her vision was fine. I just sat there thinking...she temporarily went blind, and she told the office assistant that she wanted to see the doctor for her dizziness?!

Her blood pressure was fine, a little low maybe, but nothing that would set off any red flags. The problems with her vision, and by "problem with her vision" I mean the disappearance of it, made me give her a vision acuity test. She said that she had glasses but only needed them for driving. I gave her the test and she had 20/20 vision in her left eye. Her right eye, however, was 20/100. That's pretty bad! Afterwards, surprise surprise, she told me that she wears her glasses to correct the vision in one of her eyes, but she wasn't sure which one. I'd put my money on it being the right eye ;)

Anyways, after all this...I had no idea what the cause of her symptoms could be. This one was completely out of my league. Apparently 5 months of medical school doesn't make you knowledgeable enough to be a doctor. All I could do was try to comfort her because she was understandably shaken up by the whole ordeal. I am fairly certain, however, that she should be wearing her glasses at all times. Relying on her left eye all the time will put excessive strain on it.

My preceptor wasn't sure what the diagnosis was either, so we decided to refer her to an opthamologist.