June 2017 – The Undiscovered Country

Sprinting draft

Pneumothorax, Dawn Patrol, and re-introducing the story of the patient

2016-01ctlinclinicsm — NOT the patient of this story.

Our EHR’s are often way too antiseptic, full of words, graphs, numbers, and not enough about the person of the patient. We’re working on fixing this in a number of ways, but one way we can ALL do something immediately is to re-introduce the Social History, not just as a tool to detect genetic pre-dispositions, behavioral risk factors and social determinants of health, but also as a simple tool to connect us with our patients.

In my sordid past, I was the subject of some ridicule from my Chief of Service, as well as my fellow residents. You see, in 1990, I was on-call during my internship year at UC Davis medical center. The Department Chair routinely rounded each morning at 6am with the post-call team, and the intern would gamely present a patient he/she had “worked up” from being on call overnight. “Dawn Patrol” with the Chief was a uniformly feared, but nevertheless educational experience with the Chief, and it was to be my turn.

So, I was excited to find that one of my newly admitted patients in the Emergency Room that night had a pneumothorax, from injecting a needle into his neck! In my interview, I asked how this happened, and he explained to me: “So, you know how, when you bite your own thumb and blow, you can look in the mirror and see that one of your neck veins pops up, right? It’s a great place to put your needle if you have run out of spots in your elbows and such.”

What could I say? “Yeah, I know how that is.”

So, he showed me how he did it. It worked pretty well most of the time. But, this time, it seemed, his needle went a bit too far and … he developed shortness of breath. Seemed like his needle poked into the top of his lung and he “dropped his lung.” While driving. He was pulled over by some astute cops, and brought to the ER to be treated, handcuffed to his ER gurney.

Great case, I thought to myself. I got to put in a chest tube, and learned lots of interesting pathophysiology. Perfect for Dawn Patrol. My resident encouraged me to go back and take a very thorough history and detailed exam for the inevitable grilling from the Chief. I did so, and I was ready.

6 AM, and Dr. Silva walks up. “Good morning! Who’s got a case this morning?” I smiled brightly and launched into my polished presentation:

“This is a 39 year old prisoner and IV drug user, brought from jail for a chief complaint of shortness of breath, and admitted for pneumothorax. He was previously healthy until the morning of admission when he …”

“Stop there. What’s his educational level?” said the Chief.

“What?” I was taken aback. I had memorized my presentation and was on a roll, but…

“Education level?”

“He’s a prisoner.”

“I see. So he could be a medical student and you wouldn’t know. Perhaps that’s how he has access to needles.”

“No, sir. But…”

“So, has he recently purchased a truck from the Forest Service?

“Um, he’s a prisoner.”

“Because, those trucks commonly carry loads of dirt and scraps from the Central Valley, and he could have Coccidiomycosis, Valley Fever, that sometimes results in spontaneous pneumothorax.”

“Um…”

“Any travel to the Ohio river valley? Histoplasmosis? Exposure to Tuberculosis in an immigration center?”

“…”

“Is he a rose gardener?”

“Um. I don’t know”

“Because sporotrichosis is a disease commonly acquired by rose gardeners, and THAT is associated with spontaneous pneumothorax. Okay, what DO you know about his social history?”

“He’s a prisoner, sir.”

“I see. Okay, C.J., lets do this. I’m tired of interns presenting cases and not obtaining an adequate social history, either for diagnosis or for communicating and connecting with patients. From now on, Dawn Patrol will begin with a presentation of the patient BEGINNING with a detailed social history. Are we clear?”

“…. Yes, sir.” I was too flustered even to correct my own name “No, not C.J., I’m C.T.”

Over the following months, every single other intern at UC Davis personally THANKED me for my performance that morning. “Thanks C.J. Really appreciate it. Social History starts EVERY Dawn Patrol. Great.”

Just to pile-on, turns out the New York Times recently wrote about a medical mystery, wherein the SOCIAL HISTORY is the hero.

CMIO’s take? CJ sez: It is time to re-emphasize Social History in our record-keeping. It has the potential to generate helpful clues about patient illness, transform patients in to PEOPLE in front of our eyes, and improve our connection, our communication, and our own joy in the practice of medicine.

As of last week, I created a one page handout for my Medical Assistant to hand out to every patient she rooms for me:

Where did you grow up? Are you married? have kids? What do you do? What are your hobbies?

And, it is quite astounding what kind of responses I get. I’ve heard:

Well, back in the day, I used to box with Joe Louis!

I flew with the Flying Tigers over China.

I’m a reporter for National Public Radio.

I played with the jazz great Cannonball Adderley.

Now, I will use my Speech Rec tool and place this into the Social Documentation section of the chart, and using a smart-link, ALWAYS display this prominently in my progress note, to humanize the patient, to avoid the risk of my thinking of “the gallbladder in room 3.” These random and often amazing connections are some of my favorite moments in medicine.

Perhaps this has some impact on resilience, burnout, the joy of medicine, the human connection, the ability to distinguish patients on their human stories.

Have you done this? Let me know.

Facilitating, brainstorming and “six thinking hats”

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Sometimes it is good to be humble and facilitate the work of smart, innovative colleagues. I recently had the opportunity to meet with some amazing nurse leaders at UCHealth and talk about improving the work life of nurses. We spent two hours white-boarding (or in this case, large post-it boarding) our ideas. They spoke too quickly for this novice doodler to add anything more than a couple of rudimentary doodles, but I very much enjoyed the interaction and capturing the free flow of ideas. In this session, I served purely as facilitator, and had little to contribute from a content perspective. It is remarkable how effective and refreshing this is: to remove oneself from the details of the discussion and purely think about categorizing, shaping, guiding a discussion to a productive conclusion.

Although I’m a fan of Edward de Bono’s books on Serious Creativity, and Six Thinking Hats, I don’t claim to be an expert practitioner of his ideas. I do, however, often use the Thinking Hat colors to easily redirect comments during meetings that threaten to derail conversations, for example:

“This will never work, because ….” (“Thanks! That’s black hat thinking, and we’ll get back to that later in this meeting, meantime, lets ….”)

“Hey, what about this other idea that I had” (“Hold on, let me jot that down on this other sheet. OK, with your permission, lets return to our current discussion on …”)

“Are we even thinking about this right? because …” (“Great point. Do we want to pivot and discuss this now? Or shall we finish our current discussion?”

At the right time, these are crucial inputs. At the wrong time, it can derail a nicely-unfolding sequence of collaborative comments. So, to guide our conversation, I set up a couple of items:

We were scheduled to meet in our fancy 10th floor Board room, a room with a large projection screen, lots of hanging art, and NO WHITE BOARD. So, I requested a tripod with large post-it notes. Although I’ve not seen it done, I asked the attendees to remove all the meeting-overflow chairs lining the windows and use the windows themselves as my massive white board (so satisfying!).
Arbitrarily, I suggested that “Low hanging fruit” would be a discussion category, written in green. “Blue Sky” thinking would be generating ideas about the ideal day for nurses. “Red hat” would indicate the things nurses hate about their working day. And so on. I very much enjoyed running back and forth and placing comments in the right spots on the wall so that threads of conversation did not cross, and to allow older threads to be resurfaced smoothly. And, it was easy to see where we needed to fill in more details as the meeting went on.
Finally, having ended up with dozens of possible projects, I asked the participants to “put your nickel down,” something I learned from a physician attending when I was a resident. Often during rounds, we would generate numerous possible diagnoses for a patient. Part of the learning process was “committing” to a specific diagnosis. So, he would ask us to “put your nickel down” on the ONE diagnosis, of all those discussed, and to see in the next couple days as test results returned, which diagnosis was correct, and see how our intuition and diagnostic skill performed. One learns SO MUCH from committing to something rather than “seeing how it turns out.” Similarly, “putting your nickel down” allowed us to choose the 1-3 ideas that we would put our collective efforts into.

One of the nurse participants let me know: (1) “Your handwriting is too nice for you to be a real doctor” and (2) “Can we do this more often? It is a good feeling to have a doctor scribing comments for a meeting of nurses.”

As Maui would say from the recent movie Moana, “You’re Welcome.”

Review: The Emerald Mile: The Epic Story of the Fastest Ride in History Through the Heart of the Grand Canyon

The Emerald Mile: The Epic Story of the Fastest Ride in History Through the Heart of the Grand Canyon by Kevin Fedarko

My rating: 5 of 5 stars

Another of those books picked up off the coffee table at home: “Hey, who’s reading this?” And the daughter has found time … to READ. For fun.

Well, it’s a parent’s prerogative to borrow the book, take it on trips out of town, and generally be a nuisance, so I devoured this book. I’m not much of a white-water enthusiast, but I have purchased a seat on a few commercial floats and have enjoyed myself. My most memorable was a 3-day raft trip on the Rogue River in Oregon.

It was my last year as a primary care internal medicine resident at UCDavis in Sacramento. I was plowing through my final rotations as a trainee, looking forward nervously to being a full-fledged physician. As such, I had sought out a month-long rotation at a small internal medicine practice in Auburn, California, a reasonably rural town where Internal Medicine’s scope of practice is much broader than that in a metropolitan area with lots of specialists. A couple dozen surgeons and internists had cohered into a tight-knit community. I enjoyed my stay, found ways to be helpful, and began to relax: turns out I had learned enough in my 12 +4 (undergrad) +4 (med school) +3 (residency for internal med) years of schooling (twenty-three!) to be seen as a physician and be treated as a colleague by such a community.

It was with great surprise, that near the end of my month rotation, that my preceptor offered me a spot on their 3-day rafting trip through white water in Oregon. One of the surgeons had to cancel and I was to be the beneficiary. I rushed to my local Sacramento dive shop to rent a wet-suit for the trip, neglecting to mention that I was headed to Oregon. It was an oversight that I would come to regret.

So, 23 physicians set off on a sunny Wednesday, drove all day to our hotel, met our outfitters, and headed out to dinner to carbo-load. In the middle of the night, to our dismay, one of our number awoke with severe right lower quadrant abdominal pain. With a plethora of surgeons and internists, the differential diagnosis of his pain was a hotly debated topic. Nearly everyone palpated his abdomen, and eventually, his brother was elected to drive him an hour into town to be seen in the small ER there for a possible appendicitis diagnosis.

We suited up at our launch site, still talking about his misfortune, when the brothers showed up with huge grins. Turns out as they arrived in the ER, someone had a massive BM, which completely relieved the pain. Seems that excessive carbo-loading isn’t always the best idea.

We launched in 3 large rubber rafts and a couple of inflatable kayaks and proceeded to have a blast of a time. No pagers, no one on-call, great story telling, great meals, fantastic scenery, great friendships. And bailing. lots of bailing. And I volunteered for it all. You see, my wetsuit was the 1/4 inch-thick variety, intended for relatively warm water, not the much thicker version that Oregon weather and whitewater called for. Consequently I spent a large portion of that trip in teeth-chattering, drenching cold, looking for SOMETHING to do to get warm. I became Bailing-boy.

Near the end of the trip, our final overnight had an actual functioning sauna, and I spent enough time in that tiny shack to finally unclench the jaws, loosen the knots of muscle and return to the land of the living. Even 25 years later, I think fondly of that trip AND that warming hut.

But, I digress! The Emerald Mile is a fantastic read, and an instant throw-back for me to those days on the river. It is a dramatized documentary of the personalities among the renegade dory-drivers, the law-abiding dam-builders and the adventurers along the Grand Canyon. The ‘Emerald Mile’ was the prototype and the most famous among the wooden dories that the best river pilots would take down the Colorado River. It tells the story of the quasi-illegal speed run that 3 men in a wooden boat took down the 240 miles of Colorado river within the Grand Canyon, a legendary trip that took less than 2 days at flood stage, when the average guided tour for that distance could take 3-5 weeks.

The people you meet in these pages become your friends, your co-conspirators, your co-defenders of one of the greatest engineering feats in the world. This would be enough, but the lyricism of the writing elevates this to a book that embodies the spirit of the southwest.

Favorite Quotes from the book:

“We are three quarters of a mile in the depths of the earth, and the great river shrinks into insignificance, as it dashes its angry waves against the walls and cliffs, that rise to the world above; they are but puny ripples, and we but pygmies, running up and down the sands, or lost among the boulders. We have an unknown distance yet to run; an unknown river yet to explore. What falls there are, we know not; what rocks beset the channel, we know not; what walls rise over the river, we know not.”

–John Wesley Powell, 1869, about the first exploration of the Grand Canyon.

Page 50. “On May 24, 1869, 10 men in 4 wooden boats plunged down an unknown river through the heart of the last blank spot on the map of the United States. 99 days later, and just shy of 1000 miles down river, six men and 2 boats emerged. They had run through 414 rapids and portaged or lined another hundred. In the process, they enabled America to take full position of this last, hidden landscape feature, while simultaneously laying the foundation by which that same landscape would eventually turn the tables and take possession of Americans who would fall under it’s spell.”

Page 81. “…the color of the river when it was rinsed in the morning light, the little tendrils of perfume that ascended from the brittlebrush flower just before the rain arrives, the quiet music the boat hull made when moored inside an eddy at night.”

“The place seemed to transmit a shattering reminder of the insignificance and irrelevancy of human affairs when set against the twin pools of deep time and geologic indifference.”

Page 110. “For a minute or two, you would find yourself drifting on a flat and glassy cushion of serenity as the current slowly gathered its speed and heft beneath the bottom of your boat and you drifted towards this thing that waited, invisible, just beyond the horizon. It was silent during those minutes, the only sound being the creak of your oars in their locks and the dipping of the blades as you made a few micro adjustments in the hope of putting your hull squarely on the one tiny patch of current that would insert you through the keyhole in the cosmos. Then in the final seconds, you would start to hear the dull, thunderous roar, and you would see the little fistfuls of spray being flung high into the air.”

“This, perhaps, was the most riveting moment of all, because by now all of your decisions had been made-you had done your homework and saw the point of balance between instinct and analysis, listening to the data flowing from both your brain and your gut, and know you were well and truly committed. This thing you were running down had no brakes, no rewind, no possibility of a do-over. You would ride the surge of your adrenaline and surf the watery crescendo that was about to explode before you, and you would accept the consequences, good or bad, along with whatever gifts or punishments the river was prepared dish out…And if you were lucky, you might navigate to a place that would enable you to glimpse, however obliquely, a bit of who you truly were.”

Page 299. “What Wren was doing, in effect, was performing an act of supplication, a plea for hydraulic clemency, hoping the river might condescend to allow the Emerald Mile to surf through the chaos on the shining fortitude of her own righteousness.

No dice.”
CMIO’s take?

Carbo-loading: not always a good idea.
A float trip and unplugging from the world? Great.
Reading about the deep history of places near and far? Priceless.
Having seen the Grand Canyon merely from the south rim, I must return. Armchair travel can be good, but make sure that real-time travel is in your plans as well.