Bedside diagnosis

Tom Benzoni benzonit at GMAIL.COM
Mon Feb 18 22:25:01 UTC 2019


You will note the over-arching concept of distraction.
Until we can infuse the idea of "sterile cockpit" into the chaos of
medicine, we will have distracted reasoning.

When I most need to think in quiet I am most inundated by interruptions,
most unnecessary.

Speaking as a current EM practitioner, this is a crucial safety issue.
Addressing it will require social scientists and anthropologists.

tom benzoni

On Mon, Feb 18, 2019 at 3:46 PM David L Meyers <dm0015 at comcast.net> wrote:

> A very interesting article on some realities of beside medicine, raised by
> Rob Bell and others on the listserv in the past.
>
> David
> David L Meyers, MD FACEP
> Society to Improve Diagnosis in Medicine
> Listserv Moderator/Board member
> www.improvediagnosis.org
> Save the Dates: Diagnostic Error in Medicine Conference (DEM2019),
> November 10-13, 2019 at Hyatt Regency Washington, DC (Capitol Hill)
> AusDEM2019, April 28-30, 2019; Melbourne, Aus
>
>
> https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2724394?guestAccessKey=a76c424d-dd3d-4d63-8ed8-70af67b2ca89&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=021819
> <
> https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2724394?guestAccessKey=a76c424d-dd3d-4d63-8ed8-70af67b2ca89&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=021819
> >
>
> The “Hemolyzed” Physical Examination—Situational Challenges to Accurate
> Bedside Diagnosis
>
> A page comes in from downstairs—another admission. A 41-year-old postal
> worker in bed 22, presented with severe back pain and needs pain control
> and a physical therapy evaluation. Three weeks ago, he was lifting a box
> when he felt a sharp pain in the middle of his lower back. The pain has not
> decreased, despite his taking naproxen around the clock. I look at the
> vital signs: temperature, 99°; pulse, 92 bpm; pressure, 140/90 mm Hg;
> respirations and oxygen saturation, normal. Nothing stands out as I click
> through the laboratory results.
>
> I look for this patient among the closely spaced cots in the emergency
> department. Before I can find him, I see another man in bed 18 whimpering
> in pain. I look at the cluster of computers where the nurses are charting;
> his nurse gives me a nod—“I know. I’m coming.” In bed 21, I recognize a
> woman behind a bilevel positive airway pressure (BiPAP) mask. She smiles
> weakly. In bed 22, the patient shivers under a blanket.
>
> Another page comes in for another admission. I will call back as soon as I
> finish here.
>
> The patient tells me that he has been shivering like this on and off for
> several weeks. However, what bothers him most is his back, and he worries
> he might lose his job if he does not get better. I gather some more history
> and move on to the examination. He looks tired, but his eyes, hands, nails,
> and teeth look healthy. His neck veins are normal. His lungs are quiet but
> clear—I think. I move on to listen to his heart, fighting through 2 gowns
> and an undershirt. I settle, trying to at least flatten any folds out of
> the way. I do not hear much, and I close my eyes to try to focus. I am
> struck by how much noise surrounds me. The cacophony of alarms, the BiPAP
> machine for the other patient, a patient with delirium yelling out to no
> one in particular. I open my eyes. He is shivering again—my cue to move on.
> His belly is soft, and his back is tender over the mid lumbar spine and
> surrounding muscles.
>
> Another page, another admission. I quickly put in orders for the patient
> and go to see the other patients—I am now 2 behind.
>
> Three hours later, I write my admission notes for this patient. Physical
> findings: “Lungs—diminished breath sounds, otherwise clear. Heart…” I
> pause, trying to remember what I had heard. Nothing echoes in my mind. I
> rub my eyes and look at the corner of the screen. It is almost 3:00 am. “JV
> [jugular veins] flat. RRR [regular rate and rhythm], no MRG [murmurs, rubs,
> or gallops].”
>
> I finish my notes in time for the next admission, a woman with black
> stools and lightheadedness. Her vital signs are stable after receiving some
> fluids. I click through her laboratory results. Hemoglobin is a bit lower
> than her baseline. Chemistry results are normal except that her potassium
> is 6.3 mmol/L, with a comment that the blood specimen is “grossly
> hemolyzed.” I order a repeat metabolic panel.
>
> On my way to see her, I notice a room on the floor labeled with the
> patient’s name. I stop in to check on his pain. The medicine has improved
> his pain, and he is hoping to finally rest, because “it’s so nice and quiet
> up here.” I look back at the closed door hiding the hallway. It is quiet. I
> ask the patient if I can listen to him again. He is able to move better and
> sits up on the edge of the bed. I untie his gowns and apologize for my cold
> stethoscope on his skin. I hear a systolic murmur over his apex and axilla.
> It is not subtle. I listen to his lungs again, hearing faint crackles at
> the left base and right mid lung. I look again in his mouth, at his palate,
> and see some petechiae.
>
> The patient’s echocardiogram the next day shows a large mitral valve
> vegetation. A magnetic resonance image of his lumbar spine shows
> osteomyelitis and diskitis as the cause of his pain. He began to improve
> with antibiotics and supportive care and eventually required a valve
> replacement.
>
> Several recent reviews and commentaries reflect a renewed interest in
> bedside medicine, including physical diagnosis.1-5 Some reviews remind us
> that certain aspects of the physical examination are irreplaceable in terms
> of the information they confer and the human connection they foster with
> the patient.4 Other reviews are more technical, providing data about test
> characteristics of specific maneuvers and outlining concepts such as
> likelihood ratios of examination findings.5
>
> An important aspect of physical diagnosis requires more attention—context
> specificity. When referencing sensitivities, specificities, and likelihood
> ratios of various examination findings, we should recognize that they are
> not universal or static. The percentages reported in the literature are
> averages across hundreds of patients, clinicians, and techniques. Even when
> the clinician and patient are the same, circumstance can change everything.
> When the blood sample of my other patient was hemolyzed, I was quick to
> regard the test as spoiled and repeat it. But the other set of tests—my
> physical examination of the patient—was also spoiled by noise, distraction,
> poor positioning, and haste. Only serendipity led me to repeat the physical
> examination that had been “hemolyzed.” Instead, we should be attentive to
> situational impediments to accurate bedside test results. Sometimes we can
> optimize the situation in the moment. Other times we may need to repeat the
> test under improved circumstances, or we may simply acknowledge that a
> particular test did not influence the diagnostic process. “JV flat. RRR.
> Exam for any abnormal sounds limited.”
>
> The notion that physical examination test characteristics are variable and
> dynamic adds to the uncertainty that already challenges clinicians every
> day. Yet this variability can also motivate us to improve our personal
> examination skills. The reported sensitivity of a new murmur in the
> diagnosis of endocarditis may be as high as 85%.6 But what is the
> sensitivity of murmur for endocarditis through your stethoscope, in this
> patient, in that moment, under those conditions? And can you improve it
> instead of settling for a hemolyzed examination?
>
>
>
> Article Information
>
> Corresponding Author: Zaven Sargsyan, MD, Department of Medicine, Baylor
> College of Medicine, 1504 Taub Loop, 2RM81-001A-F, MS: BCM285, Houston, TX
> 77030 (zavens at bcm.edu <mailto:zavens at bcm.edu <zavens at bcm.edu>>).
>
> Published Online: February 18, 2019. doi:10.1001/jamainternmed.2018.8753 <
> http://jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2018.8753>
> Conflict of Interest Disclosures: None reported.
>
> Additional Contributions: I thank Chana Sacks, MD, Massachusetts General
> Hospital, Boston, Massachusetts, and Ricardo Nuila, MD, Baylor College of
> Medicine, Houston, Texas for reviewing earlier drafts of this article. They
> received no compensation for their contributions. I thank this patient for
> the lessons he taught me.
>
> Additional Contributions: We thank the patient for granting permission to
> publish this information.
>
> <>References
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
> Medicine
>
> To unsubscribe from the IMPROVEDX list, click the following link:<br>
> <a href="
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1"
> target="_blank">
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> </a>
> </p>
>
> *From: *David L Meyers <dm0015 at comcast.net>
> *Subject: **The “Hemolyzed” Physical Examination—Situational Challenges
> to Accurate Bedside Diagnosis*
> *Date: *February 18, 2019 at 4:40:59 PM EST
> *To: *Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>
>
> A very interesting article on some realities of beside medicine raised by
> Rob bell and others on the listserv in the past.
>
> David
> David L Meyers, MD FACEP
> Society to Improve Diagnosis in Medicine
> Listserv Moderator/Board member
> www.improvediagnosis.org
> Save the Dates: Diagnostic Error in Medicine Conference (DEM2019),
> November 10-13, 2019 at Hyatt Regency Washington, DC (Capitol Hill)
> AusDEM2019, April 28-30, 2019; Melbourne, Aus
>
>
>
> https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2724394?guestAccessKey=a76c424d-dd3d-4d63-8ed8-70af67b2ca89&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=021819
>
> The “Hemolyzed” Physical Examination—Situational Challenges to Accurate
> Bedside Diagnosis
>
> A page comes in from downstairs—another admission. A 41-year-old postal
> worker in bed 22, presented with severe back pain and needs pain control
> and a physical therapy evaluation. Three weeks ago, he was lifting a box
> when he felt a sharp pain in the middle of his lower back. The pain has not
> decreased, despite his taking naproxen around the clock. I look at the
> vital signs: temperature, 99°; pulse, 92 bpm; pressure, 140/90 mm Hg;
> respirations and oxygen saturation, normal. Nothing stands out as I click
> through the laboratory results.
>
> I look for this patient among the closely spaced cots in the emergency
> department. Before I can find him, I see another man in bed 18 whimpering
> in pain. I look at the cluster of computers where the nurses are charting;
> his nurse gives me a nod—“I know. I’m coming.” In bed 21, I recognize a
> woman behind a bilevel positive airway pressure (BiPAP) mask. She smiles
> weakly. In bed 22, the patient shivers under a blanket.
>
> Another page comes in for another admission. I will call back as soon as I
> finish here.
>
> The patient tells me that he has been shivering like this on and off for
> several weeks. However, what bothers him most is his back, and he worries
> he might lose his job if he does not get better. I gather some more history
> and move on to the examination. He looks tired, but his eyes, hands, nails,
> and teeth look healthy. His neck veins are normal. His lungs are quiet but
> clear—I think. I move on to listen to his heart, fighting through 2 gowns
> and an undershirt. I settle, trying to at least flatten any folds out of
> the way. I do not hear much, and I close my eyes to try to focus. I am
> struck by how much noise surrounds me. The cacophony of alarms, the BiPAP
> machine for the other patient, a patient with delirium yelling out to no
> one in particular. I open my eyes. He is shivering again—my cue to move on.
> His belly is soft, and his back is tender over the mid lumbar spine and
> surrounding muscles.
>
> Another page, another admission. I quickly put in orders for the patient
> and go to see the other patients—I am now 2 behind.
>
> Three hours later, I write my admission notes for this patient. Physical
> findings: “Lungs—diminished breath sounds, otherwise clear. Heart…” I
> pause, trying to remember what I had heard. Nothing echoes in my mind. I
> rub my eyes and look at the corner of the screen. It is almost 3:00 am.
> “JV [jugular veins] flat. RRR [regular rate and rhythm], no MRG [murmurs,
> rubs, or gallops].”
>
> I finish my notes in time for the next admission, a woman with black
> stools and lightheadedness. Her vital signs are stable after receiving some
> fluids. I click through her laboratory results. Hemoglobin is a bit lower
> than her baseline. Chemistry results are normal except that her potassium
> is 6.3 mmol/L, with a comment that the blood specimen is “grossly
> hemolyzed.” I order a repeat metabolic panel.
>
> On my way to see her, I notice a room on the floor labeled with the
> patient’s name. I stop in to check on his pain. The medicine has improved
> his pain, and he is hoping to finally rest, because “it’s so nice and quiet
> up here.” I look back at the closed door hiding the hallway. It *is*
> quiet. I ask the patient if I can listen to him again. He is able to move
> better and sits up on the edge of the bed. I untie his gowns and apologize
> for my cold stethoscope on his skin. I hear a systolic murmur over his apex
> and axilla. It is not subtle. I listen to his lungs again, hearing faint
> crackles at the left base and right mid lung. I look again in his mouth, at
> his palate, and see some petechiae.
>
> The patient’s echocardiogram the next day shows a large mitral valve
> vegetation. A magnetic resonance image of his lumbar spine shows
> osteomyelitis and diskitis as the cause of his pain. He began to improve
> with antibiotics and supportive care and eventually required a valve
> replacement.
>
> Several recent reviews and commentaries reflect a renewed interest in
> bedside medicine, including physical diagnosis.1-5 Some reviews remind us
> that certain aspects of the physical examination are irreplaceable in terms
> of the information they confer and the human connection they foster with
> the patient.4 Other reviews are more technical, providing data about test
> characteristics of specific maneuvers and outlining concepts such as
> likelihood ratios of examination findings.5
>
> An important aspect of physical diagnosis requires more attention—context
> specificity. When referencing sensitivities, specificities, and likelihood
> ratios of various examination findings, we should recognize that they are
> not universal or static. The percentages reported in the literature are
> averages across hundreds of patients, clinicians, and techniques. Even when
> the clinician and patient are the same, circumstance can change everything.
> When the blood sample of my other patient was hemolyzed, I was quick to
> regard the test as spoiled and repeat it. But the other set of tests—my
> physical examination of the patient—was also spoiled by noise, distraction,
> poor positioning, and haste. Only serendipity led me to repeat the physical
> examination that had been “hemolyzed.” Instead, we should be attentive to
> situational impediments to accurate bedside test results. Sometimes we can
> optimize the situation in the moment. Other times we may need to repeat the
> test under improved circumstances, or we may simply acknowledge that a
> particular test did not influence the diagnostic process. “JV flat. RRR.
> Exam for any abnormal sounds limited.”
>
> The notion that physical examination test characteristics are variable and
> dynamic adds to the uncertainty that already challenges clinicians every
> day. Yet this variability can also motivate us to improve our personal
> examination skills. The reported sensitivity of a new murmur in the
> diagnosis of endocarditis may be as high as 85%.6 But what is the
> sensitivity of murmur for endocarditis through *your* stethoscope, in
> *this* patient, in *that* moment, under *those* conditions? And can you
> improve it instead of settling for a hemolyzed examination?
> Back to top
>
> Article Information
>
> *Corresponding Author:* Zaven Sargsyan, MD, Department of Medicine,
> Baylor College of Medicine, 1504 Taub Loop, 2RM81-001A-F, MS: BCM285,
> Houston, TX 77030 (zavens at bcm.edu).
>
> *Published Online:* February 18, 2019. doi:10.1001/jamainternmed.2018.8753
> <http://jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2018.8753>
>
> *Conflict of Interest Disclosures:* None reported.
>
> *Additional Contributions:* I thank Chana Sacks, MD, Massachusetts
> General Hospital, Boston, Massachusetts, and Ricardo Nuila, MD, Baylor
> College of Medicine, Houston, Texas for reviewing earlier drafts of this
> article. They received no compensation for their contributions. I thank
> this patient for the lessons he taught me.
>
> *Additional Contributions: *We thank the patient for granting permission
> to publish this information.
>
> References
>
>
>
>
>
>
>
>
>
>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
>
>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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