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.

Author: CT Lin

CMIO, UCHealth (Colorado); Professor, University of Colorado School of Medicine

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