There are some things that Electronic Medical Records do well and there are some things that Electronic Medical Records do poorly. To say that I need Electronic Medical Records to help me type is nothing short of ridiculous. Unfortunately, when engineers meet computer programmers and try to help health care professionals type in the health care record in the name of “safety,” the results can torment those they’re trying to help.
Take auto-spelling, for instance. I have the nasty habit of typing “Lungs: Claer to A&P” and marvel at the auto-correction feature automatically correcting my typing to “Lungs: Clear to A&P.” This is an example of the wonders of electronics.
But when I type “DC Cardioversion” and the computer won’t left me type “DC” because it wants to know if I mean “discharge” or “discontinue,” the computer becomes intrusive, obstructive, and performs a service that should be right up there with water-boarding. I mean, is someone really going to mistaken that I mean “Discontinue cardioversion” or “Discharge cardioversion” when I’m typing my operative report? I could see this being a problem in the order-entry portion of the software, but when I’m typing by progress note or operative note?
Please.
Even better are the wonderfully useful letters “MS.” These might mean “magnesium sulfate,” “mental status,” mitral stenosis, “MS Contin,” “multiple sclerosis,” “musculoskeletal,” “Ms.,” or maybe even “Mississipi.” So, instead of being able to type a logical sentence without interruption, the doctor finds that that a drop-down pick list prevents those magic letters from being typed. It seems the chance that a nurse will wonder if you’re prescribing a drug in a southern state trumps the ability to enter a simple sentence on the computer. This is, after all, how we’re preventing medical errors.
But I wonder if these computer engineering road blocks are doing something much more insidious and detrimental to our health care delivery of tomorrow: like devaluing independent thought, reason, permitting the subtleties of context, and common sense.
Urinary incontinence affects millions of women – 38% of women over the age of 60 – yet only 45% ever seek help for it. Men suffer from the problem too but at about half the rate. Only 22% of men seek help.
Why is this a taboo subject? One reason is that it’s an embarrassing – even infantilizing – problem. But patients’ shame is, well, a shame. Because urinary incontinence – the involuntary leakage of urine – can often be treated quite successfully. The first step is to make a proper diagnosis. One common type is “urge incontinence” – the bladder contracting when a person isn’t ready to urinate and can’t get to the toilet fast enough. Another common type, especially after childbirth or in athletes, is “stress incontinence.” It happens when there is a weakness in the pelvic muscles supporting the bladder and urethra (the structure through which urine exits the bladder), causing the urethra to lose its seal and allowing urine to escape when there is increased pressure on the bladder (e.g. coughing, sneezing, laughing, lifting, or exercise). As women get older, it’s more likely they will develop urge rather than stress incontinence. A very simple three question test has been created to help with the diagnosis.
It’s important to get a complete, head to toe medical evaluation because urinary incontinence may be a symptom of an underlying condition (e.g., neurological problem, diabetes, urinary tract infection, chronic bladder inflammation, or even a tumor) or may be a result of medication. Talk to your primary health provider and/or gynecologist. If needed, a specialist (e.g., urologist or urogynecologist) can be consulted.
Treatments for urge incontinence include bladder retraining and pelvic muscle exercises, medications to relax the bladder, and decreasing fluid intake. Approaches to stress incontinence include weight loss if obesity is present, a vaginal pessary, and surgery.
In today’s segment of CBS Doc Dot Com, Dr. Lori Warren and Dr. Jody Blanco, gynecologists with expertise in urinary incontinence, discuss the problem. You’ll meet a woman who overcame her embarrassment, sought help from Dr. Blanco, and is now symptom free after surgery.
There are several online resources on the subject, listed at the end of an excellent discussion in the online medical database, UpToDate.com.
Outdoor enthusiasts are often stricken with infections for which they might be prescribed antibiotics in the class known as fluoroquinolones, one common member of which is ciprofloxacin (Cipro). They should be aware that a fairly well accepted complication of taking a fluoroquinolone for more than a few days is development of tendinitis leading to tendon rupture, notably of the Achilles tendon. The risk is such that the Food and Drug Administration (FDA) requires the makers of such drugs as ciprofloxacin and levofloxacin (Levaquin) to publish a black box warning on the packages alerting users to potentially serious side effects. The full list of drugs affected by the warning include ciprofloxacin (marketed as Cipro and generic ciprofloxacin); ciprofloxacin extended release (marketed as Cipro XR and Proquin XR); gemifloxacin (marketed as Factive); levofloxacin (marketed as Levaquin); moxifloxacin (marketed as Avelox); norfloxacin (marketed as Noroxin); and ofloxacin (marketed as Floxin and generic ofloxacin). As new fluoroquinolones appear on the market, they will undoubtedly be included in the warning program. The warning does not apply to eye and ear drops – only to medications taken orally or by injection.
Many patients and health care professionals are not aware of this risk, which is very real, having been officially reported in literally hundreds of patients. Although the drugs are phenomenal in terms of their ability to fight certain bacterial infections, users should be aware of this possible side effect, so that they can discontinue taking the culprit medication and switch to an alternative antibiotic(s) if need be. If tendon pain develops (typically about a week after initiation of therapy) when a person is taking a fluoroquinolone antibiotic, that is the time to make the switch. Simultaneously, anyone affected should diminish or avoid exercise and cease stressing the affected area until such time as the situation is resolved, as would be determined by decreased pain and other signs of inflammation. Most patients can be expected to recover within 10 weeks after discontinuing the antibiotic, but it may take longer.
Fluoroquinolones are widely used to treat infections in adults. They are not commonly prescribed for children because of a risk for eroding cartilage; however, if the medical necessity is important, they can be used in young individuals. The tendon rupture problem is therefore largely a problem of adults, and typically affects the Achilles tendon, with onset of symptoms within the first few weeks after the initiation of antibiotic therapy. Other tendons, including those of the upper extremity, may be involved. It is perhaps the large forces placed upon the Achilles tendon that makes it so prominent in this particular medical situation. Furthermore, the risk of fluoroquinolone-associated tendinitis and tendon rupture appears to be greater in persons older than 60 years of age, in those taking corticosteroid drugs (“steroids”), and in kidney, heart, and lung transplant recipients.
Nurses are experts at navigating through rough waters. We are always there for our patients in their time of need. Check this nurse out. She is using her critical thinking skills while she sails her boat through a stormy ocean. It’s true. Nurses can do just about anything, just so long as they have a good mentor to show them the way.
From time to time, I get letters from new psych nurses asking me for advice.
I was very lucky when I first started out as a psych nurse. Nurses and doctors who gave me valuable tips when I was new in the field surrounded me on the unit, and made sure that I didn’t get myself into trouble. Here are some pearls of wisdom that my mentors passed onto me when I was the new kid on the block. I hope they help you, too.
Pearl of wisdom #1: The first rule that I learned was that I never was to accept abuse from a patient. Patients may be angry about how things are going in their life, but they must learn to vent their anger appropriately. That means no hitting, swearing, or throwing stuff at other people. Period! Just because someone has “problems” doesn’t give them a license to act inappropriately on the unit. Seriously. Nurses are not punching bags. We have rights. Nurses must teach their patients to function in the real world, and we do them a disservice if we allow our patients to act out on a psych unit.
Pearl of wisdom #2: The second pearl of wisdom has to do with the myth that nurses can say something wrong to a psych patient. Many nurses are afraid that a patient will crumble if they say the wrong thing to the wrong person. I’ve never seen this happen during my nursing career. Just listen to your patients with your ears and with your heart. Everything else will fall into place.
Pearl of wisdom #3: Never turn your back on a patient. This is self explanatory. Psych units are unpredictable.
Pearl of wisdom #4: Don’t get offended if a patient hates you. That probably means that you are doing your job. Many patients come to the hospital because they have boundary issues, and issues involving the need for immediate gratification.
Pearl of wisdom #5: Never forget that you are a REAL nurse. You may not be caring for a wounded body, however you are caring for a wounded soul.
The patient sits across the exam room and looks at me with a combination of surprise and hurt. He had answered all of my questions to the best of his abilities, hoping that I would figure out what was causing the symptoms and fix his problem. A bit of doubt shows on his brow as he goes over what he feels and what happened in the past. Did he say things wrong? Did he mistake the way it felt? Is he just bad at explaining things?
“I am not accusing you of being untruthful. Your symptoms are your symptoms, and you felt what you felt. Unfortunately they don’t always read the medical textbooks and so make me earn my keep. I believe your symptoms are real; I just don’t understand how they fit together. It’s confusing.” I say this as reassuringly as possible. He relaxes visibly as I speak.
But that doesn’t change the fact that the symptoms defy logic. It’s my job to figure things out and fix things, right? Isn’t this an admission of defeat? Isn’t it a confession of my inadequacy? Won’t this undermine the thing that I have said is the cornerstone of a doctor/patient relationship: trust?
Some people seem impatient for an answer, but most are OK with me not knowing for a while. The thing that makes it acceptable for me to be confused is the longstanding nature of the relationship of a patient with their PCP. This is one page in the book, not the whole story. This concept – of the patient’s “story” – is one I actually use in this situation. I say:
You know when you see a movie that is really confusing in the start? You don’t know who is who, or why one person was mad at the other, etc. It is just hard to figure out what is going on. But later on in the movie things become clear. You say “Oh, so that’s who that guy was! That’s why she was so mad at him.” It all clears up over time. With your illness, we may just be at that confusion part of the movie. It may just take time for us to be able to make sense of what is going on.
I have to say that I actually am glad for those cases where things are confusing at the start. No, I am not happy for the patients, but the hard stuff is what separates the good docs from the bad ones. If I can sort through things and come up with an answer when one wasn’t apparent, I am showing the merit of all of my hard work. I justify my salary. I go home feeling like I am more than just a bunch of algorythms.
I don’t want everyone to be confusing, but just because things seem to not add up it doesn’t mean we won’t come to a good answer eventually.
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“That doesn’t make any sense.”
I have to say that I actually am glad for those cases where things are confusing at the start. No, I am not happy for the patients, but the hard stuff is what separates the good docs from the bad ones. If I can sort through things and come up with an answer when one wasn’t apparent, I am showing the merit of all of my hard work. I justify my salary. I go home feeling like I am more than just a bunch of algorythms.
