Chapter 67: Note Cards

December 28, 1988, McKinley, Ohio

"Mike, there's a call for you," Nurse Kelly said just before 9:00am. "Line 2."

I got up and went over to the multi-line phone hanging on the wall. I lifted the handset and pushed the second button.

"Mike Loucks."

"Mike, it's Kris! The car was just delivered. Thank you!"

"You're welcome! You should put the car seat in the back right away so you don't have to mess with it later."

"Neil from the dealership helped me put it in. It's all set."

"Great! I'll see you tomorrow morning at the house for breakfast."

"What time?" Kris asked.

"I'll be awake, showered, and dressed by 8:00am."

"Then Rachel and I will see you then!"

We said 'goodbye', I hung up, and went back to reading Cardiology, as I'd finished JAMA and The Lancet. With no procedures scheduled, and two of the three discharges completed, there were only three patients on our service, one of whom would be discharged after lunch. I read until 10:00am when I went to check on Mr. Jacoby, the warfarin patient, and his blood test results were in line, and he was not showing any A-fib on the monitor.

"How's it look?" he asked.

"Everything is good, Mr. Jacoby. I need to speak to Doctor Javadi, but as she said this morning, if your next set of blood test show similar results, and your EKG shows no fibrillation, you'll be discharged after lunch. I'm going to draw blood now to check your PT, PR, and INR levels and your vitamin K level. Those results will be back around lunchtime.

"Thanks, Mike."

"You're welcome."

I drew the blood, then hand carried the vial to the lab.

"1:00pm discharge," I said to the tech, Jim.

"Have it for you by 12:30pm," he replied.

"Thanks."

I went back upstairs and found Felicity in the lounge.

"Indigestion," she said.

"They actually called you down on a consult for indigestion?"

"A PGY1 claimed to have seen a blip on the monitor and decided to call for a consult."

"Who was the PGY1?"

"Doctor Billings."

"You saw nothing on the monitor?"

"Nothing. And Doctor Billings didn't have a strip. Fast pulse, slightly elevated BP, sweating, and claims of chest and arm pain,"

"This is a teaching moment," I said. "Repeat that to me properly, please."

"Properly?"

"Using medical terms."

"Tachy, slightly hypertensive, diaphoretic, and I know there's a name for clenching his fist over his sternum, but I don't remember."

"Levine's sign," I replied. "Anything else?"

"No. Cardiac enzymes were normal and the EKG shows sinus rhythm. Doctor Javadi advised discharge and referral to his personal physician. I thought about suggesting Alka-Seltzer or Pepto-Bismol."

"Given a patient we have in the ward, I'll ask if you know the contraindication for those two drugs."

"No."

"Both have salicylates, so they cannot be taken by anyone on warfarin, because of the risk of bleeding. In addition, they shouldn't be given to anyone under eighteen recovering from influenza or chickenpox because of the risk of Reye Syndrome. They should not be taken by nursing mothers for the same reason."

"How do you remember those things?"

"In this case, I know both compounds contain salicylates, which we most often encounter as ASA. You know what that is, right?"

"Aspirin, basically."

"And the contraindications for aspirin are..."

"The ones you just mentioned. OK. That makes sense."

"All of those things are on my flashcards. I think I have eight on ASA alone. It's a wonder drug, but also can be dangerous, or even fatal, for patients with certain conditions. While we're on the subject, do you know about the interactions for warfarin?"

"No."

"They'll be on the discharge papers that we'll go over with Mr. Jacoby. Most importantly, use of NSAIDs can lead to gastrointestinal bleeding, so they should only be taken under direction of a physician. The same with alcohol. Many antibiotics increase warfarin metabolism, and given it's difficult to titrate to the correct blood levels in the first place, they make it more difficult and require close monitoring. And there are interactions with common herbs and spices such as garlic, Saint John's wort, and ginger. And, finally, you have to watch your intake of foods that affect Vitamin K, such as broccoli or dark green leafy vegetables."

"You remember all that?" Felicity asked.

"I read up on it last night after Clarissa told me we had a warfarin patient who might be discharged today. I remembered the NSAID interaction, but the rest I had to refresh. I created four new flashcards from what I read. The other thing he'll need to do is have regular blood work for at least the next three months while they work out the correct oral dosage, given his diet and lifestyle."

"Do you think there's a chance I could copy your flashcards?"

"I have well over two thousand," I replied. "I carry about a hundred with me pretty much all the time, cycling through them. And I can't really allow them out of my sight because it would be nearly impossible to recreate them. I could bring them here, in sets, and you could copy them. You also might ask Clarissa, because she has different cards, in the same style, though hers are focused more on internal medicine than emergency medicine. Not that either of us ignores the other disciplines, but what she needs to know and what I need to know is different, as is what you would need to know in oncology."

"Would you bring some cards on Friday? I suspect it'll be just as quiet, with no scheduled procedures."

"Sure. Get yourself packs of colored 3x5 note cards. I use different colors for procedures, anatomy, drugs and tests, and diagnoses, but you can use whatever scheme you think will work best for you. Some cards are created in what Fran called Jeopardy style, so you can look at either side and answer for the other. Anatomy cards have the term on one side, and then definitions and location on the other. The diagnoses cards are split into two groups — one where there are specific symptoms on one side, and a diagnosis on the other, and one where there is a list of symptoms and the differential diagnosis on the other. And so on."

"That's a cool idea."

"It was totally Fran's doing, and it works great."

"She's going OB/GYN, right?"

"Yes. Also, before I forget, I want to give you the same advice I gave John — practice your suturing before you start your rotation in the ED. It'll be the one thing you can do besides chase labs, insert IVs and catheters, and triage. And if you show you are able to suture, you might get a chance to do other things as well. It's all about building trust with the Residents."

"Not the Attendings?"

"Except for rounds, how often do you see an Attending?"

"Not very."

"Residents," I said firmly. "They will make or break you. You want the box next to 'recommend for Match' to have an x in it, even if you don't intend to Match here. Think about what it says if that box is not checked by the Residents who train, mentor, and evaluate you."

"I assume you've received that every time?"

"It's part of the Sub-Internship evaluations, not the Clerkships evaluations, but yes, so far, I have. You can do it, too, if you stop worrying about what other people are doing and focus on what you're doing."

"I am sorry about that."

"And I accept your apology. I'll bring some cards on Friday and you can start there. You'll obviously need to make your own for oncology, and I strongly suggest you start reading before you start your oncology Sub-I in June. The more you know, the more they'll trust you, and the more you'll get to do. And if they give you a positive evaluation, that will help with the Sub-Is that follow."

Felicity nodded, and we both went to sit in the lounge, reading journals, and we took our lunch at 11:30am so I'd be back in time to complete Mr. Jacoby's discharge. On the way back from lunch, I stopped at the lab and found they had the results of Mr. Jacoby's blood work, and everything looked good. When we returned to Cardiology, I went to find Doctor Javadi.

"PT, PR, INR, and K₁ are all in the acceptable range. No reported incidence of A-fib since yesterday at 2:33pm. All other labs this morning were in range, as reported."

"Prepare the discharge papers; he'll need the warfarin instructions."

"Right away, Doctor."

I left and went to the nurses' station, retrieved Mr. Jacoby's chart, a discharge form, and a copy of the warfarin instructions, then returned to the lounge to fill out the triplicate paperwork. I was happy that the hospital used 'carbonless' forms which had replaced carbon paper in most instances, though a few credit card flimsies still had carbon paper. I filled in all the blanks, wrote the discharge notes on the chart, then took everything to Doctor Javadi to review and sign, with Felicity following just behind.

"Everything looks good," Doctor Javadi said, making her own discharge notes on the chart, then signing both it and the discharge form. "I'll come with you to do the discharge, but you handle it."

"Yes, Doctor."

"Any questions about what to say?"

"No. I reviewed the warfarin material last night as soon as Clarissa handed the patient over."

"Then let's go."

The three of us went to Mr. Jacoby's room and found his adult son visiting.

"Good news, Mr. Jacoby," I said. "Your test results confirmed that you're ready to be discharged, and Doctor Javadi signed the necessary forms. I'd like to go over the discharge information with you, if that's OK."

"Fire away!" he declared. "The sooner I can get out of here, the better!"

I nodded, "You've been diagnosed with atrial fibrillation, sometimes called A-fib. That means that the upper chambers of your heart occasionally beat rapidly and erratically. You recognized the problem when you became lightheaded and felt what you called a 'flutter' which is a good description of atrial fibrillation in layman's terms.

"Doctor Javadi prescribed warfarin, an anticoagulant or blood thinner, which is sold under the prescription name Coumadin, to reduce the risk of blood clots, and recommended you follow up with your personal physician. She's also written out a referral to a cardiologist. You may see him, or another one of your choice. It's vital that you speak to your personal physician, as your blood chemistry needs to be monitored closely to ensure you're taking the correct dose.

"Many things can affect how your body metabolizes, or uses, warfarin. First, you should not take any nonsteroidal anti-inflammatory drug, including, but not limited to, aspirin and ibuprofen, which is the active ingredient in Advil. You may take acetaminophen, the active ingredient in Tylenol, but you should only do so after consultation with your physician. Any questions so far?"

"No."

"In addition, there are interactions between warfarin and antibiotics as well as common herbs and spices, including ginger, garlic, and Saint John's wort. You should also be careful with any food which is rich in Vitamin K, including broccoli, cabbage, and green leafy vegetables, as they can interfere with warfarin. There's a complete list on the paperwork I'm going to give you. Any questions about that?"

"What happens if I eat those things? Not that I like broccoli, but out of curiosity."

"It can impact the effectiveness of warfarin. Until you speak to your personal physician and a cardiologist, please avoid the listed foods. The other thing to avoid is alcohol, as it can cause gastrointestinal bleeding — that's bleeding in your stomach, intestines, or rectum. We strongly encourage you to abstain completely and discuss it with your doctor. Any questions?"

"New Year's?"

"Doctor?" I asked, turning to her.

"One glass of champagne would be OK," she said. "But no more."

"Thanks, Doc."

"That's it, Mr. Jacoby," I said. "Any further questions?"

"No."

"If you think of anything, or have any concerns, call the hospital and ask for Cardiology. Now, I'll have the nurse come in and unhook everything, and she'll call an orderly with a wheelchair to take you to the door. You can also stop by Patient Services, if you wish, or they'll follow up with you after the 1st. Good luck!"

"Thanks! And thanks to you, too, Doc."

"You're welcome, Mr. Jacoby," Doctor Javadi said. "Don't hesitate to call if you have any concerns before you see your physician."

I handed him the warfarin information sheet and the patient copy of the discharge form. Doctor Javadi, Felicity, and I left the room, and I took the chart and paperwork to the nurses' station.

"Mr. Jacoby has been discharged," I said to Nurse Julie. "His son is here to take him home."

"Great! I'll send Trish in to help him, and I'll call an orderly!"

"Thanks."

We left the nurses' station and Doctor Javadi followed us into the lounge.

"Good job, Mike. Felicity, that's how you do a discharge. Mike, one point, and it's really minor, but you should have asked for questions after you described the diagnosis."

"Yes, Doctor," I replied. "I'll remember for next time."

"It's really minor, you did a good job of explaining it, and Mr. Jacoby obviously understood, but you want to ask, even if you've discussed the diagnosis before."

"Understood."

She left, and Felicity and I sat down.

"You don't feel that was a bit nit-picky?" Felicity asked.

"It was," I replied. "But that's her job as a teacher. She's right, too. In this case, I'd spoken to Mr. Jacoby several times, and so had Clarissa, but with only four or five patients in the ward, he had extra attention. Normally, with anywhere from a dozen to as many as twenty, we'd have had a lot less time to speak to him. Asking if the patient understands each piece of information is key, even if you think they know. Basically, never assume, because you know what happens when you assume."

"You make an 'ass' out of 'u' and 'me'."

"Yes. Though in our situation, people die. One thing was made clear to me and that is you don't assume. I've seen in two different M & M review situations where a physician assumed something to be true, which wasn't, that led to what are euphemistically called 'adverse outcomes'."

"What happened to the doctors?"

"Nothing, officially, as what they did followed medical protocol. Both were taken to task by the M & M, but that was the end of it both times as it was judged to be sub-optimal decision making, and didn't rise even close to the level of negligence."

"And you're OK with that?"

"It's an interesting challenge. The point of the M & M is to learn from those 'adverse outcomes' and improve overall patient care. That requires frank, open discussion, and if every 'adverse outcome' led to discipline or malpractice claims, few doctors would risk participating and the hospital might even forbid doctors from participating. That would be detrimental to medicine. One way to answer is to borrow a quote from Mr. Spock from The Wrath of Khan."

"I'm not a fan of Star Trek."

"Spock said, after sacrificing himself for the good of the rest of the crew, that 'The needs of the many outweigh the needs of the few, or the one'. If you think about the purpose of the M & M, the quote fits."

"Do you agree with that?"

"The sentiment, yes, at least with regard to the M & M process, because we have to concern ourselves with both individual outcomes and overall outcomes. I don't see how punishing a doctor or the hospital for adverse outcomes that are not the result of negligence serves the public good. I don't see how we could reasonably do anything different. Well, reform how malpractice works, but I don't see that happening."

"What would you do?"

"I haven't given it serious thought, really. I've thought more about how we can improve and avoid errors, and that mostly goes right back to the quote Doctor Getty has on the wall of his office. I think you learned the hard way that book learning does not make you a good physician, nor does it qualify you to be a physician. It's the price of entry to the actual training, which started last June for you and will continue for another five or six years."

"You don't think two years of classroom learning is necessary? Well, and anatomy lab?"

"I don't think six years of classroom learning is necessary. You have to have an undergraduate degree to get into medical school. Why not compress those six years into four, or even two? Two might be pushing it because I do believe the non-science courses I took at Taft were valuable. So maybe three years, where your first year is all humanities and electives, your second year is all chemistry and biology, and your third year is anatomy lab, practice of medicine, and compressed versions of the other courses from first and second year. Then you begin your clinical work."

"That's similar to Europe, right?"

"They compress eight years into six, but I'd go further. Or at least I think I would. Ask me again when I'm an Attending in about nine years, because I need more experience before I could actually propose that kind of change. But that's a windmill to tilt at much later."

"You don't think things will change?"

"The problem is that changes such as that can't be made unilaterally, and I think the chances of obtaining a consensus to make that kind of radical change would be impossible to create. That said, it's possible to chip away at the edges, which Taft has done with Preceptorships which get students into the wards and medical practices during their first two years of medical school. That's an innovative idea, and I've seen pushback from other hospitals."

"Why?"

"On the theory that everyone should do it exactly the same way until there is complete consensus that something should change. That's an impossible standard, so people who want to improve things do what I said — chip away at the edges. Preceptorships are very likely to become standard. The key is to find the next change that can be made without completely upsetting the apple cart."

"I take it that it wasn't a doctor here who objected?"

"It was the OB chief at Good Samaritan who was basically forced out by the Attendings and Residents because he had a 1950s view of obstetrics. The Attending with whom I stayed in Cincinnati is the new Chief, and she's the new broom that sweeps clean."

"Do you think older doctors are a problem in general?"