Chandra's corner - August 2019

Dr PH Chandrasekar

"Cure sometimes, treat often, comfort always." Hippocrates has been credited with this glorious reminder. I keep recalling this aphorism particularly walking through the cancer/transplant floors, attempting to care for young and old with desperately complicated and unpredictable futures and, very often leaving me at a loss for words. Invaluable life lessons are learned on the bedside.

Warm summer is here – this means schools are closed and many Indian families make their annual trips to their home towns and not infrequently return with infection-related medical issues. Emergency Department physicians are well trained to consider malaria and typhoid in the list of their top diagnoses. A few weeks ago, a woman pathologist returned from South India with fever and chills; multiple malarial smears were negative. With left flank plain, urinary tract infection was suspected, and the urine culture grew ESBL E. coli. It turned out she had cared for her bedridden, ailing dad (with dementia) in Kerala when he developed ESBL E. coli pneumonia. Following two weeks of IV ertapenem at home in Detroit, her condition slowly improved. However, somewhat surprisingly, the fever relapsed. After many more negative malarial smears and blood cultures, CT abdomen revealed a perinephric abscess that had developed during appropriate therapy; drainage yielded the same pathogen requiring additional therapy. Lesson for me – advise long distance travelers to stay well hydrated. No amount of infection control measures could have prevented transmission of E. coli from the bedridden father to the loving daughter.

Summertime, we have visiting residents/fellows as Observers from India. One of them (Dr Venkat Ramesh, Fellow, Apollo Hospital in Hyderdad ) encountered an interesting patient during rounds. A 38-year-old man with chronic graft vs host disease of the gastrointestinal tract presented with sudden onset of fever and neck pain. Within minutes in the Emergency Department, he became restless and obtunded requiring intubation and ICU care. He had undergone a peripheral blood stem cell transplant about 7 months ago for lymphoma and was receiving tacrolimus and methylprednisolone, in addition to his antimicrobial prophylaxis with cotrimoxazole, acyclovir and posaconazole. On the day before admission, the patient had nicked his scalp at the edge of his Ommaya reservoir while shaving his head, and this led to some purulent drainage at the reservoir site. Based on the CSF exam and MRI brain, a diagnosis of methicillin-susceptible Staphylococcus aureus ventriculitis with hydrocephalus secondary to Ommaya infection was established; therapy for this critically ill man necessitated reservoir removal, placement of an external ventricular drainage device combined with intraventricular vancomycin and intravenous nafcillin. Miraculously, the patient made a complete recovery with no residual deficit. The Ommaya reservoir had been placed years ago for intraventricular therapy for his Burkitt lymphoma. Lessons for me – keep bugging the onco-hematologist to remove every device (Ommaya, intravenous and others) once its purpose has been accomplished; often the physicians forget about such devices or more often leave them for ‘just in case’. Not infrequently, some devices are left in place for years, long after their use. Removal of such devices may not always be easy. Importantly, remind patients to be extra careful about their Ommaya and perhaps avoid head shaving as consequences, though rare, can be devastating. Our fellow is writing up this case for the oncologists to remember these pearls.

New York Times, my “favorite medical journal” - on June 9th paper, I came across an article on electronic medical records (EMR) system. I am not a fan of the EMR system as it has deliberately led to a lower standard of care, in my opinion. EMR charting takes an enormous amount of time, snatching the clinician away from the bedside. EMR has many salutary effects no doubt, however unfortunately, most EMR is performed not for good medical practice but to ensure maximum billing from insurance companies. “Cut and paste” has become routine in every chart, every day. At a time when the number of complex patients is increasing, demanding increased time on the clinician’s part, the EMR has added an extra heavy layer of workload. The article says, “the biggest culprit of the relentless workload is the EMR – burrowing its tentacles into every aspect of healthcare system”. For each hour of direct patient care, roughly two hours are spent typing into the EMR. Most of our trainees work late, long after hours, charting the data into the EMR and the attending physicians then read/correct/sign these notes, frequently well past midnight. This means, the work day has been extended into late evening for every clinician for mind numbing data entry. Hospitals have “conveniently” arranged for EMR access from home. Attending physicians, aware of the demands on the trainees’ time, frequently shorten the bedside rounds, resulting in loss of precious time at the temple (bedside). In fact, many programs encourage shorter rounds so that the trainees can finish their EMR responsibilities and head home at a respectable hour. At a recent medical school graduation ceremony, the Chief Guest lamented about the EMR - “if Hippocrates had to deal with EMR, he probably would have picked a different profession or changed the oath to ‘first do no harm unless if breaking the damn computer!’ Watch out, EMR has great reach - it’s fast coming your way.