Tuesday, December 28, 2010

Doctor: I Have My Laptop, Do I Need To Talk To The Patient, Too?

Electronic Health Information - EMR or EHR

There’s a revolution going on. Slowly, medicine is shifting from paper based medical records to a computer-based system that’s likely going to impact you. Currently about 15% of hospitals and physicians have made the switch to electronic record keeping. The rest still use paper as has been the standard for decades. However, despite their familiarity, there can be drawbacks to using paper. Handwriting comes to mind immediately as I’m sure you know the old saw about doctors and legibility. Also, think about a chart that’s 3” thick from a patient who’s had the same doctor for many years or a couple significant illnesses. And, if you want this information transferred to your new physician when you move, but the original chart stays put, it can prove problematic. Culling specific test results from a chart like that can also be challenging.

In 1999 it was estimated that there were as many as 98,000 medical error related deaths annually in the U.S. A measurable percentage of those were caused by errors in medical record keeping or retrieving previously obtained information be it from physicians, pharmacists, nurses, lab personnel, etc. That said, as you’d expect the electronic record has its drawbacks as well, some of them quite significant. Anything that can happen to computer based files, good... and bad as we see frequently in the media, could potentially occur to your private medical information. This risk is present despite encryption, passwords, etc. (Think Julian Assange – WikiLeaks. Think about the big information loss that the VA system had a few years ago.)

As you might imagine, the change over is anything but free. I’ve read that it can be as much as $40 - 50,000 per physician. Then there’s a pretty steep learning curve where the doc has to cut his/her schedule in half at least short term limiting access. The top of the medical diagnostic team becomes the transcriber as well , oftentimes never really regaining the current level of efficiency.

And the personal nature of paper, little notes you leave for yourself, specific to each particular patient, like to say thanks again for the brownies they brought you at the last visit, seems to be lost with computerization. On the plus side, overall staff needs will decrease over time. The American Recovery and Reinvestment Act of 2009 provides an incentive to make this change and eventually those physicians who’ve chosen not to adopt EMR may be penalized up to 3% of their Medicare reimbursement as early as 2015.

As I write this, my wife’s practice is in the middle of this change. They enter the exam room, computer in hand, and some patients note that, “The doctor spends more time looking at the computer than me.” And they’re right. But to even get to that point, the doctors are spending endless hours, working well into the night, and sometimes into the very early morning, to get that patients labs, medicines, x-rays, notes, etc. into the electronic document for that days visit. Yep, there’s stress on both sides of the white coat.

So, we’re a system in transition. And change, any change, is often uncomfortable. But as doctor and patient both get used to “the new way’” advantages will become apparent, errors will hopefully continue to decrease and the quality of care, your care, improves steadily. And, anything you can do to help is most appreciated!

Old Kona Surf Hotel, T-2 and Carbo Dinner site.  Now the Sheraton. 

Tuesday, December 21, 2010

Ever Seen Blood In Your Urine? It's Could Be Runner's Bladder

Hematuria, blood in the urine

"Oh yeah, life goes on, long after the thrill of livin' is gone."  John Cougar Mellencamp

But Lew Hollander, yellow cap, would say you're way wrong.  At age 80, he finished his 21st  Ironman in Kona this year.  He says it's how he "tests" himself.  Hard to have higher personal standards than Lew, a role model to us all.  He also makes many older triathletes jealous as he's basically able to do this with only a modicum of injuries, often the rate limiting step to continued performance, particularly as we age.

Ever stood astride the commode after your long run, and instead of the usual concentrated deep yellow urine, you see blood?  Yep, it can be quite a shock.  But, like most things, if you take the time to do a little research you can narrow the list of possibilities...and cancel the call to the funeral home.

In medical jargon bloody urine is known as hematuria.  It can range from very slightly blood tinged all the way to frankly bloody.  It's not a diagnosis, it's a symptom.  But a symptom of what?  Let's follow a local Charlottesville runner, aged 22, runs 60 - 100 miles per week, is professionally coached and works in the local running shoe store.  He obviously has a handle on correct foot wear.  He started with a very slight pinkish tinge to his urine after his longest runs but over time has developed frank hematuria.

So, the first place we look is to a phenomenon called "Runner's Bladder" as it's both the most common as well as the most benign.  It's described  as bladder wall trauma, bruising, which leads to a small amount of blood in the urine.  When the runner decreases running volume or takes a couple of days off, it goes away.  For a while that is, until long runs resume.  It's said that running with a partially full bladder can eliminate this problem but it's a level of discomfort many can't stand.  Every heel strike reminds one of the urine's presence.

A visit to the Urologist by our runner reveals that although the mostly likely diagnosis is Runner's Bladder, the list of possibilities including kidney stones, tumor, infection, various kidney problems, etc., is pretty long.  So, to solidify the diagnosis, the Urologist plans to perform a cystoscopy - an in office procedure in which he will insert a small fiber optic scope through this runners penis up into the bladder. ("You're going to put a what into my where?"the runner was heard to exclaim!)  In the past, predominantly because of the larger size of the scope and the pain it would cause, this type of procedure was done in the Operating Room under anesthesia.

Good news.  During cystoscopy, our athlete's bladder wall revealed generous bruising and no other obvious source of bleeding.  So for now, he'll continue his running career, and his hematuria knowing that he's not causing irreversible long term damage.  Maybe he'll try again to learn to run with his bladder half full.  But he's 22 with a head full of steam.


Monday, December 13, 2010

Tachycardia, A Rapid Heart Rate

"She knew from the start, deep down in her heart that she and Tommy were worlds apart.  But her mother said never mind, your part is to be what you'll be."     Tommy, The Who

Heart beats. Too many of them.  This is a question I see on occasion.  Jill Athlete is serious about triathlon and uses a heart rate monitor.  She's used a resource like Joe Friel's, Triathlete's Training Bible to determine her training zones and even writes them on a piece of tape on her sleeve to make sure she doesn't get them confused when she works out.

Then, all of a sudden, one day on a routine run over familiar territory she sees a reading of 230!  What to do?

A)  Start self CPR
B)  Flag down a passing motor vehicle for a ride to the hospital
C) Panic, wonder about her will and if her "affairs are in order"
D) call 911
E) Rush home, post the symptoms on an Internet forum and wait for guidance from an anonymous source
F) stop, think reasonably and evaluate the situation

If Jill is symptomless, there's no rush to do anything.  If she's not dizzy, in pain, feeling weak - especially on only one side of the body, confused, etc., she has the ability to rationally evaluate what's going on and exercise common sense.

It's not uncommon that what may seem like bogus information is indeed bogus.  Was this erratic reading due to nearby electrical interference, overhead power lines, nearby welding, lead placement or slippage, etc?  It's unlikely that even if Jill were running with Matthew Mcconaughey, that she could generate a HR of 230!  Although many of us were taught the old 220 minus your age calculation, it would be pretty hard for one to get to the 220-230 range.

What quickly comes to the triathlete's mind is Greg Welch, winner of the 1994 Hawaii Ironman.  A few years after his victory over Dave Scott, Greg was forced to the side during the IMH swim course unable to continue.  He felt it was asthma, but was still able to get a 54 swim time.  (Pretty good, huh?)  What to do?  Stop and figure this out? Keep going?  He chose the latter and continued despite additional "attacks" during the bike segment.  He described these as feeling "...lightheaded, it's hard to see, I was short of breath, it's a horrible feeling."  Despite all this, and even more "attacks" on the run, he still finished in the top 15 with a 2:46 marathon.  What an athlete!

It took a pretty extensive work up that lasted quite some time until the diagnosis of ventricular tachycardia or V tach was made.  This rhythm is abnormal and can be very fast as well as irregular.  There are a variety of causes, some of which are managed surgically.  We don't think that our Jill, with no symptoms at all, has V tach.

Two other common arrhythmia's (abnormal heart beats) are atrial fibrillation and supra ventricular tachycardia. A different part of the heart is responsible for these two.  If they occur fairly frequently in a patient, they can be diagnosed with an office EKG at ones family physician.  Some require wearing an all day EKG known as a Holter monitor.  This records your heart beat during the day and when the abnormality occurs it can be interpreted.  Other arrhythmia's that produce symptoms even less frequently may require the triathlete to wear an event monitor to figure them out.  They wear EKG pads 24/7 for a month or two hooked up to a small monitor.  Yep, it's a pain.  But, like an enhanced TSA screen, it may yield valuable information.  When the user feels the symptoms, she triggers the monitor which records the heart tracing at that particular time.  This can then be used later to determine the abnormality.

So what advice do we give Jill?  I'd tell her to first look for some external cause for the errant number.  However, if it happens again, or she becomes symptomatic, she ought to give her family doc a call.

Greg Welch now "wears" an implanted defibrillator (sort of like the pacemakers you've seen implanted subcutaneously) which, if needed, can hopefully reverse a future episode of V tach...a potentially life saving maneuver.

Go Jill!



Monday, December 6, 2010

Raynauds Syndrome, Cold Hands and Feet in Winter Training

And I love to live so pleasantly,
Live this life of luxury,
Lazing on a summer afternoon.
In the summer time,....

                                                    The Kinks

Ah summertime, for many of us it's only a memory.  The arrival of winter has brought with it a host of training challenges. The cold, shorter days, more competition for pool access, the kids back in school, did I mention the cold?  And how we meet these challenges tells us a lot about our seriousness in the sport.  (In last weeks blog, Arthritis part 3, I talked about the committment and life changes made by Farrokh Bulsara who transformed himself into Freddie Mercury . " I guess the question is...are you willing to make the types of sacrifices Freddie made to achieve your goals?") 

The past few weeks have seen below freezing temperatures for those wishing to stay outside for the morning run/bike ride, particularly the long ride on the week end.  A simple solution would be to put your bike on a training stand and "ride" indoors watching CDs of last years TdF to see if Alberto wins again.  Funny, that same question is being asked elsewhere... the name clenbuterol ring any bells?  Also, I'm sure that a number of readers own Computrainers that can reproduce a variety of race courses.  I enjoy outdoor biking and if the road surface is safe, no snow or ice, I'll probably ride regardless of the temperature as will many of you.

But some have significant complaints about very cold fingers and toes despite several trials with gloves, mittens, chemical hand warmers or battery powered shoe inserts.  They report a variety of color changes in their digits when exposed to the cold. These occur secondary to spasms of the local finger arteries as seen below.

First, the fingers turns white and get a bit of a numb feel because of the lack of blood flow.  This loss of blood can make the fingers turn a purple blue color, almost black on some occasions.  When the spasms resolve the digits turn red for a short period and then slowly back to their normal color.  This is known as Raynaud's Disease or Raynaud's Phenomenon when it occurs without other disease processes.   Frequently, when it's a part of other diseases, it's called secondary RP.  A large study from Massachusettes found that 5% of men and 8% of women suffer from RP.

 The actual cause of RP is unknown.  What is known is that the blood vessels narrow because of spasming of tiny muscles in the walls of the arteries, eventually followed by sudden relaxation of these muscles opening the vessel back up.  The symptoms can be quite variable.  Some will complain of only a small amount of skin discoloration/numbness/tingling if they have mild disease.  Others get these same symptoms in their ears and nose.  An unlucky few will have such prolonged spasm that the tips of the fingers actually develop ulcers, get infected, and then become subject to amputations.  Fortunately it's a very small population.  RP can be exacerbated by certain drugs like beta-blockers or in occupations that have a great deal of vibration. Those who have secondary RP can also have a skin and joint disease called scleroderma or have it associated with with an arthritis-like disease such as Lupus or rheumatoid arthritis.

So, what's recommended for those who have this?  If possible, try to avoid the stresses that bring on the symptoms.  Try to keep your hands and feet warm, regardless of the outside conditions.  Companies like Assos carefully divide their catalogs by riding temperatures and recomend specific clothing, including gloves/mittens and foot wear for each temperature range.  If you smoke, this can exacerbate RP and it would be recommended that you try to quit. Diabetics need to take the best care of their disease possible.  They say that caffeine can bring this on. 

If the symptoms occur, warming the affected area is recommended.  Put your hands in your pockets, pants or arm pits.  If it's only a finger or two, put them in your mouth!  Some will even put their hands in warm water to more quickly reverse the symptoms.

A very small number of folks will need drug therapy or even surgery to keep the symptoms at bay.

So, if you can do your best to keep warm, those winter rides can be just as enjoyable as the summertime. Well, almost, till you get to the end at the local coffee shop.