“Jaded Julie, how would you feel if you were diagnosed with a serious illness?”
“I’d feel very much alone, Curmudge. Your family and friends can give you food, shelter and care, and they can even assume your debts. But no matter how much people love you, no one can be sick for you.”
“So what would you do?”
“I would have a choice. If I chose to be a totally passive patient, I could take the prescribed medicine, suffer its side effects, and hope and pray for the best. The other option—and that’s what I would select—is to become an expert on my disease and an active participant in my health care team. That way I could take full advantage of personalized care and maybe even help to cure my illness. Hey, the game of life vs. death is one that you can only lose once.”
“Sounds like a plan, Julie. How would you proceed?”
“Well, if I lived near a hospital with a library, like St. E’s or Mercy Medical Center, I’d seek the librarian’s help in learning all I could about my situation. But tell me, Curmudge, what should I do if a city is not nearby or if I were reluctant to share the details of my health with a librarian?”
”In the privacy of your home office, you or a relative or friend should use your computer to google your disease. That will open up a world of medical knowledge.”
“But I don’t want the world. I just want some stuff that I can comprehend.”
“There’s something for everyone out there, Julie, including a lot of sources that one can understand without an MD degree. Your Google search will provide a list of titles followed by a couple of lines describing the contents followed by the URL. Note, however, that the pages of your Google search results will show so-called Sponsored Links; some of these may contain testimonials and ads for non-FDA-approved treatments. Below are a few URLs that should be helpful; they will usually provide an overview of symptoms, diagnosis, and treatment in everyday language.
Mayo Clinic (www.mayoclinic.com)
MedLine Plus (www.nlm.nih.gov/medlineplus)
Merck Manuals (www.merck.com)
Wikipedia (en.wikipedia.org).”
“This sounds pretty useful, Curmudge, but where does evidence-based medicine enter the picture? It’s in our title, but you haven’t mentioned it once.”
“The sites mentioned above contain review articles written, for the most part, in everyday language. Procedures for diagnosis and treatment are evidence based as understood at the time of writing. To learn about new knowledge developed since then we’ll have to look into other—and often more technical—resources. We’ll also have to come back for more discussion next week.”
“So that I don’t go away empty-handed, can you give me a definition of evidence-based medicine?"
“Of course, Julie. Evidence-based medicine is the generally accepted best procedure for the diagnosis or treatment of a specific illness or condition. ‘It requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report (1).’”
“Thanks bunches, Curmudge. It will take me all week to figure out what you just said. But I do understand that I would want to receive the best care available. Presumably that will be evidence based unless my physician and I agree on a good reason to do otherwise.”
Affinity’s Kaizen Curmudgeon
(1) Agrawal, P. and Brown, C. A. An evidence-based approach to acetaminophen overdose. EBMedicine.net, September 2010.
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
Thursday, September 23, 2010
Thursday, September 9, 2010
Amazing Devices 4
“I’ve seen it, Curmudge. I’ve seen how your reading and writing about amazing devices has awakened the long-dormant scientist in you.”
"You’re right, Jaded Julie. As they say, ‘If you don’t use it, you lose it,’ and I’ve lost it. A whole new world of communication technology has passed me by. Those devices in Dr. Topol’s video that we saw last week went by pretty fast, so I decided to mosey through the literature and learn more about them. Before our readers have these things strapped onto their chest or put in their shoe, they are likely to encounter them in their doctor’s office; so let’s focus on that venue.“
“Can we begin with the humble stethoscope that we mentioned on August 5? I’ve continued to be amazed that it has remained virtually unchanged for almost 200 years.”
“Most of those you see around necks or in pockets are the old kind, but with the advent of the electronic stethoscope (Littmann 3200), the changes are dramatic. It looks similar to the classic design, except on the back of the chestpiece there is a handle and LCD display through which the features of the device are controlled. Variable sound amplification can adjust for the clinician’s hearing acuity or the patient’s obesity. Onboard recording can be played back through the eartubes.”
“Even with your hearing problem, Curmudge, you could use one of these.”
“Sure, although it would require medical education for me to understand what I was listening to. But Julie, there’s a lot more to these things than amplification. Bluetooth technology can be used to wirelessly transfer sounds to your computer for further analysis. This requires a USB wireless adapter inserted into the PC on which proprietary software has been installed. The software allows one to visualize what has been heard in a wave file format, save it in the patient’s record, or send it via the Internet across the world for further consultation.”
“Gosh Curmudge, with that perhaps I could be a cardiologist in my spare time.”
“That would indeed be a stretch, Julie. Let’s start our next topic with a trivia quiz. What is an ER doc’s first question to himself when he sees a patient with no visible trauma?”
“I’ve got it, Curmudge. He looks at the patient and asks, ‘What’s going on in there?’ Then he attempts to find out with history and physical, lab tests, and an armamentarium (see, I remember the word) of increasingly complex tests and procedures.”
“Great answer! However, one powerful procedure is noninvasive and fairly easy to perform, but it requires a trained eye to interpret. It is ultrasound, and it’s what we’re going to talk about next.”
“Hey, Curmudge, one of those tests was done on me several years ago in the ultrasound lab. I looked at the readout, and I appeared to be a confusing mass of angry storm clouds inside.”
“As I said, Julie, a trained eye is needed. A notable innovation is that now we have handheld ultrasound units that can be carried in one’s pocket (1). When not being used on a patient, the scanner (viewer) and probe sit on a docking station connected with a USB cable to a PC. Handheld ultrasound is being promoted for use by cardiologists, obstetricians, primary care physicians, in the ER, and probably everywhere a physician is asking himself, ’What’s going on in there?’ They might become as ubiquitous as the stethoscope.”
“(Ubiquitous? I’ll know what he means when I see them everywhere.) Okay, Wizened Wizard, give me an idea of some of the things that can be diagnosed by ultrasound.”
“With the handheld ultrasound and electronic stethoscope, a cardiologist might be able to avoid ordering a traditional and expensive echocardiogram. In a primary care physician’s office or an Emergency Department, an abdominal ultrasound might reveal an abdominal aortic aneurysm, gallstones, hydronephrosis, kidney stones… An ultrasound of the leg should be the easiest way to detect a blood clot (deep vein thrombosis). These ailments are not uncommon. Each has afflicted one or another of my acquaintances.”
“That, Curmudge, is because your contemporaries are so old. Aside from that, however, the beauty of these in-the-office diagnostic tools is that they can enhance the physician’s communication with the patient. The hand-held ultrasound can provide visual reinforcement of exam findings in real time. The patient can leave the office or the ED with a diagnosis and plan of care—not a schedule of additional tests. So, senior savant, although it should be obvious, what do you see as the lesson for today?”
“Lesson #1 is obvious, Jaded Julie. Advances in technology continue to make the practice of medicine more efficient and effective. However, unless these devices are used in an efficient environment, their effectiveness will not be fully realized. That’s Lesson #2. Here are some examples: an MRI machine that is used only five days per week, a Da Vinci robot on which few surgeons are trained, the report of a CT scan that is misplaced on its way back to the ordering physician.”
“I think what you are saying is that a hospital or clinic needs to have a Lean culture in order to get the most out of its technology.”
“You’ve got that right, Julie.”
Affinity’s Kaizen Curmudgeon
(1) Another handheld ultrasound system is the ACUSON P10.
"You’re right, Jaded Julie. As they say, ‘If you don’t use it, you lose it,’ and I’ve lost it. A whole new world of communication technology has passed me by. Those devices in Dr. Topol’s video that we saw last week went by pretty fast, so I decided to mosey through the literature and learn more about them. Before our readers have these things strapped onto their chest or put in their shoe, they are likely to encounter them in their doctor’s office; so let’s focus on that venue.“
“Can we begin with the humble stethoscope that we mentioned on August 5? I’ve continued to be amazed that it has remained virtually unchanged for almost 200 years.”
“Most of those you see around necks or in pockets are the old kind, but with the advent of the electronic stethoscope (Littmann 3200), the changes are dramatic. It looks similar to the classic design, except on the back of the chestpiece there is a handle and LCD display through which the features of the device are controlled. Variable sound amplification can adjust for the clinician’s hearing acuity or the patient’s obesity. Onboard recording can be played back through the eartubes.”
“Even with your hearing problem, Curmudge, you could use one of these.”
“Sure, although it would require medical education for me to understand what I was listening to. But Julie, there’s a lot more to these things than amplification. Bluetooth technology can be used to wirelessly transfer sounds to your computer for further analysis. This requires a USB wireless adapter inserted into the PC on which proprietary software has been installed. The software allows one to visualize what has been heard in a wave file format, save it in the patient’s record, or send it via the Internet across the world for further consultation.”
“Gosh Curmudge, with that perhaps I could be a cardiologist in my spare time.”
“That would indeed be a stretch, Julie. Let’s start our next topic with a trivia quiz. What is an ER doc’s first question to himself when he sees a patient with no visible trauma?”
“I’ve got it, Curmudge. He looks at the patient and asks, ‘What’s going on in there?’ Then he attempts to find out with history and physical, lab tests, and an armamentarium (see, I remember the word) of increasingly complex tests and procedures.”
“Great answer! However, one powerful procedure is noninvasive and fairly easy to perform, but it requires a trained eye to interpret. It is ultrasound, and it’s what we’re going to talk about next.”
“Hey, Curmudge, one of those tests was done on me several years ago in the ultrasound lab. I looked at the readout, and I appeared to be a confusing mass of angry storm clouds inside.”
“As I said, Julie, a trained eye is needed. A notable innovation is that now we have handheld ultrasound units that can be carried in one’s pocket (1). When not being used on a patient, the scanner (viewer) and probe sit on a docking station connected with a USB cable to a PC. Handheld ultrasound is being promoted for use by cardiologists, obstetricians, primary care physicians, in the ER, and probably everywhere a physician is asking himself, ’What’s going on in there?’ They might become as ubiquitous as the stethoscope.”
“(Ubiquitous? I’ll know what he means when I see them everywhere.) Okay, Wizened Wizard, give me an idea of some of the things that can be diagnosed by ultrasound.”
“With the handheld ultrasound and electronic stethoscope, a cardiologist might be able to avoid ordering a traditional and expensive echocardiogram. In a primary care physician’s office or an Emergency Department, an abdominal ultrasound might reveal an abdominal aortic aneurysm, gallstones, hydronephrosis, kidney stones… An ultrasound of the leg should be the easiest way to detect a blood clot (deep vein thrombosis). These ailments are not uncommon. Each has afflicted one or another of my acquaintances.”
“That, Curmudge, is because your contemporaries are so old. Aside from that, however, the beauty of these in-the-office diagnostic tools is that they can enhance the physician’s communication with the patient. The hand-held ultrasound can provide visual reinforcement of exam findings in real time. The patient can leave the office or the ED with a diagnosis and plan of care—not a schedule of additional tests. So, senior savant, although it should be obvious, what do you see as the lesson for today?”
“Lesson #1 is obvious, Jaded Julie. Advances in technology continue to make the practice of medicine more efficient and effective. However, unless these devices are used in an efficient environment, their effectiveness will not be fully realized. That’s Lesson #2. Here are some examples: an MRI machine that is used only five days per week, a Da Vinci robot on which few surgeons are trained, the report of a CT scan that is misplaced on its way back to the ordering physician.”
“I think what you are saying is that a hospital or clinic needs to have a Lean culture in order to get the most out of its technology.”
“You’ve got that right, Julie.”
Affinity’s Kaizen Curmudgeon
(1) Another handheld ultrasound system is the ACUSON P10.
Thursday, September 2, 2010
Amazing Devices 3
“You know, Curmudge, the curious thing about you old guys is that you are so easily amazed. I think the reason is that nearly all of today’s wonderful devices were invented after you had completed your education.”
“Au contraire, Sleeping Beauty. In our years together haven’t you perceived that my education has never been completed? I suspect that at least 90% of the knowledge I used in my professional life was gained either in kindergarten or after graduate school. Even now, every day is an eye-opening educational experience.”
“Okay, mind-boggled blogger, what was yesterday’s gem of new knowledge?”
“Jaded Julie, it’s right here in this video, The Wireless Future of Medicine by Eric J. Topol (1). Although it runs for 17 minutes, it is well worth the viewing time.”
(17 minutes later) “The video was truly impressive, Curmudge. Will you have some comments about it?”
“Perhaps, but not today. If a busy person has spent the past 17 minutes watching Dr. Topol, he will undoubtedly feel that he has learned enough about amazing devices for the moment.”
Affinity’s Kaizen Curmudgeon
(1) Topol, E.J. The wireless future of medicine (video). http://www.ted.com/talks/eric_topol_the_wireless_future_of_medicine.html
“Au contraire, Sleeping Beauty. In our years together haven’t you perceived that my education has never been completed? I suspect that at least 90% of the knowledge I used in my professional life was gained either in kindergarten or after graduate school. Even now, every day is an eye-opening educational experience.”
“Okay, mind-boggled blogger, what was yesterday’s gem of new knowledge?”
“Jaded Julie, it’s right here in this video, The Wireless Future of Medicine by Eric J. Topol (1). Although it runs for 17 minutes, it is well worth the viewing time.”
(17 minutes later) “The video was truly impressive, Curmudge. Will you have some comments about it?”
“Perhaps, but not today. If a busy person has spent the past 17 minutes watching Dr. Topol, he will undoubtedly feel that he has learned enough about amazing devices for the moment.”
Affinity’s Kaizen Curmudgeon
(1) Topol, E.J. The wireless future of medicine (video). http://www.ted.com/talks/eric_topol_the_wireless_future_of_medicine.html
Thursday, August 26, 2010
Medical Home Workflows
“Jaded Julie, in a symphony orchestra, how does one make sure that all of the bass fiddles play the same notes?”
“I don’t know much about orchestras, Curmudge, but I suspect that each bass player reads from an identical musical score.”
“Closer to home, Julie, if a sample is sent to the hospital’s lab for a multi-step analysis, should the result depend on who the analyst was?”
“Absolutely not! The lab has a standard process and procedure for every step in the analysis that each analyst must follow. Even a non-clinical old geezer like you should know that.”
“And finally, in a medical home with several patient service representatives, should a patient’s phone call to renew a prescription be handled differently depending on the PSR that she speaks with?”
“Of course not. I get it, Curmudge. In the medical home we have workflows just like an orchestra has scores and the lab has standard methods. It’s like you taught me, ‘You can’t improve a process until you can control it; you can’t control it until you understand it; and you can’t prove you understand it until you document it.’ The workflows get everyone on the same page. You can’t have people running around willy-nilly ‘doing their own thing.’”
“You are mighty quick on the uptake, Julie. Can you think of ways in which Lean is used in developing workflows?”
“You know I can. Where do you think I’ve been for the past three years? To begin with, you assemble a team from gemba who know best the processes and procedures in present use. They use sticky notes that are color-coded to differentiate patient service reps, health care associates, and providers. Then they make a process diagram on the conference room wall for each of the clinic’s main processes. Sometimes ‘just do it’ improvements are introduced as the workflow is being constructed.”
“That’s the idea, Julie. What happens next?”
“Then the workflow is copied from the wall with Visio software for printing, discussion, and further improvements. Later the team looks into the individual sticky-note boxes to identify procedures that need to be documented. It looks to me, Curmudge, as if workflows are standard work for clinic-wide processes and individual procedures.”
“The drivers for this effort are the forthcoming implementation of the electronic health record (EHR) and ultimate recognition by the National Committee for Quality Assurance (NCQA). As we said last week, one must not try to overlay a good technology on a bad process. Workflows represent the medical homes’ development of effective paper-based process and procedure descriptions for incorporation into the EHR.”
“It’s pretty obvious, Curmudge, that one must know where she is ‘at’ before finding her way to someplace better. By the way, do you realize that the next generation might not even know what a paper-based process description is?”
“That’s likely, Julie, but if there still are bass fiddles, I’ll bet that bass players will still be reading Beethoven from paper scores.”
Affinity’s Kaizen Curmudgeon
“I don’t know much about orchestras, Curmudge, but I suspect that each bass player reads from an identical musical score.”
“Closer to home, Julie, if a sample is sent to the hospital’s lab for a multi-step analysis, should the result depend on who the analyst was?”
“Absolutely not! The lab has a standard process and procedure for every step in the analysis that each analyst must follow. Even a non-clinical old geezer like you should know that.”
“And finally, in a medical home with several patient service representatives, should a patient’s phone call to renew a prescription be handled differently depending on the PSR that she speaks with?”
“Of course not. I get it, Curmudge. In the medical home we have workflows just like an orchestra has scores and the lab has standard methods. It’s like you taught me, ‘You can’t improve a process until you can control it; you can’t control it until you understand it; and you can’t prove you understand it until you document it.’ The workflows get everyone on the same page. You can’t have people running around willy-nilly ‘doing their own thing.’”
“You are mighty quick on the uptake, Julie. Can you think of ways in which Lean is used in developing workflows?”
“You know I can. Where do you think I’ve been for the past three years? To begin with, you assemble a team from gemba who know best the processes and procedures in present use. They use sticky notes that are color-coded to differentiate patient service reps, health care associates, and providers. Then they make a process diagram on the conference room wall for each of the clinic’s main processes. Sometimes ‘just do it’ improvements are introduced as the workflow is being constructed.”
“That’s the idea, Julie. What happens next?”
“Then the workflow is copied from the wall with Visio software for printing, discussion, and further improvements. Later the team looks into the individual sticky-note boxes to identify procedures that need to be documented. It looks to me, Curmudge, as if workflows are standard work for clinic-wide processes and individual procedures.”
“The drivers for this effort are the forthcoming implementation of the electronic health record (EHR) and ultimate recognition by the National Committee for Quality Assurance (NCQA). As we said last week, one must not try to overlay a good technology on a bad process. Workflows represent the medical homes’ development of effective paper-based process and procedure descriptions for incorporation into the EHR.”
“It’s pretty obvious, Curmudge, that one must know where she is ‘at’ before finding her way to someplace better. By the way, do you realize that the next generation might not even know what a paper-based process description is?”
“That’s likely, Julie, but if there still are bass fiddles, I’ll bet that bass players will still be reading Beethoven from paper scores.”
Affinity’s Kaizen Curmudgeon
Thursday, August 19, 2010
The World Health Congress
“I’ll bet, Curmudge, that during your professional career you attended a lot of meetings and conferences.”
“I sure did, Jaded Julie. Although I found the short courses associated with the conferences to be most valuable, I also tried to observe some of the local culture when the meeting was held in an exotic location. Let me tell you about what I saw as I walked down Bourbon St. in New Orleans one Halloween night.”
“You may, but not in Kaizen Curmudgeon. I understand that several of our newer colleagues recently attended the World Congress on Excellence in Health Care.”
“They did, and after their return they reported on the high points of the conference. My perception is that they brought home a strengthened conviction that Lean is the right culture for Affinity and that we are progressing well on our Lean journey. In fact, we are among the leaders in Lean health care. When a speaker asked—regarding the focus of his presentation—‘Who is doing this?’, our people could proudly raise their hands to signify, ‘We are.’”
“How about some examples, Old Guy. I presume since this meeting was held in Chicago, their examples will be free of New Orleans-style rowdiness and debauchery.”
“Not a problem, Julie. I believe that the essence of the presentations may be discerned by the following statements and quotations:
‘Philosophy—Patients and families first. Then support our people.’
‘Waste comes cleverly disguised as a lot of work.’
‘Lean is lead from the top down; change from the ground up.’
‘The first day of a kaizen event is usually a food fight, i,e., lots of blaming and finger-pointing.’
‘There is an affinity between Lean and Green.’
‘In their personal behavior, employees must distinguish between being on-stage (in view of patients and visitors) and off-stage (out of view).’
‘Lean is a part of the strategic plan (sounds like hoshin-kanri).’
‘Report-outs must be attended by everyone.’
‘The Joint Commission (TJC) is working to improve their consistency of standards interpretation (anyone who has been audited by anyone should appreciate that).’
‘The middle manager is no longer a problem solver but a facilitator of problem solving.’
‘Overlaying a new technology on a bad process is like shrink-wrapping a cactus.’”
“I think I understand, Curmudge. These statements are all familiar or obvious to us. They represent problems that we have solved, or are working on, or that we are aware of and need to work on. To someone totally new to Lean, they might be confusing. To an experienced ‘Leaner,’ they are an inspiration. Come to think of it, that’s what a conference is supposed to be—an inspiration.”
Affinity’s Kaizen Curmudgeon
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
“I sure did, Jaded Julie. Although I found the short courses associated with the conferences to be most valuable, I also tried to observe some of the local culture when the meeting was held in an exotic location. Let me tell you about what I saw as I walked down Bourbon St. in New Orleans one Halloween night.”
“You may, but not in Kaizen Curmudgeon. I understand that several of our newer colleagues recently attended the World Congress on Excellence in Health Care.”
“They did, and after their return they reported on the high points of the conference. My perception is that they brought home a strengthened conviction that Lean is the right culture for Affinity and that we are progressing well on our Lean journey. In fact, we are among the leaders in Lean health care. When a speaker asked—regarding the focus of his presentation—‘Who is doing this?’, our people could proudly raise their hands to signify, ‘We are.’”
“How about some examples, Old Guy. I presume since this meeting was held in Chicago, their examples will be free of New Orleans-style rowdiness and debauchery.”
“Not a problem, Julie. I believe that the essence of the presentations may be discerned by the following statements and quotations:
‘Philosophy—Patients and families first. Then support our people.’
‘Waste comes cleverly disguised as a lot of work.’
‘Lean is lead from the top down; change from the ground up.’
‘The first day of a kaizen event is usually a food fight, i,e., lots of blaming and finger-pointing.’
‘There is an affinity between Lean and Green.’
‘In their personal behavior, employees must distinguish between being on-stage (in view of patients and visitors) and off-stage (out of view).’
‘Lean is a part of the strategic plan (sounds like hoshin-kanri).’
‘Report-outs must be attended by everyone.’
‘The Joint Commission (TJC) is working to improve their consistency of standards interpretation (anyone who has been audited by anyone should appreciate that).’
‘The middle manager is no longer a problem solver but a facilitator of problem solving.’
‘Overlaying a new technology on a bad process is like shrink-wrapping a cactus.’”
“I think I understand, Curmudge. These statements are all familiar or obvious to us. They represent problems that we have solved, or are working on, or that we are aware of and need to work on. To someone totally new to Lean, they might be confusing. To an experienced ‘Leaner,’ they are an inspiration. Come to think of it, that’s what a conference is supposed to be—an inspiration.”
Affinity’s Kaizen Curmudgeon
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
Thursday, August 12, 2010
Amazing Devices 2
“Curmudge, I trust that you read Affinity’s electronic newspaper, The Weekly, every week.”
“I do, Jaded Julie, and there was recently an interesting Library Services’ note on Mobile Devices: Health Care Resources in the June 7 Weekly.”
“I guess you are saying that the note demands a careful reading, which you did. My second guess is that your ancient but orderly mind wants to put the info from the Library note into some sort of historical context. Okay, Curmudge, have at it.”
“In our posting on August 6, 2009, Information at Your Fingertips, I envisioned a provider turning to his/her exam room desktop computer to access information via the Affinity intranet. During the past year, laptop computers have become more common throughout our hospitals and clinics. With these, the provider can use the computer while facing the patient and create a more personalized experience.”
“That’s an interesting observation, Curmudge. With the provider facing the patient I’m sure patients would feel like they are in a much more collaborative conversation.”
“Fortunately, now many providers use handheld devices, and those are what Library Services’ note in the Weekly tells us about. It references their PDA Road Map: its title is Mobile Computing for Healthcare: Smart Phones, PDAs, Pocket PCs, etc. Main headings include: Resources for Affinity Library Users, Free Starter Apps, Calculators (free), Clinical POC, Internet Gateways, and PubMed & Evidence-based Practice. In addition, here’s another resource for handheld users: How the iPad Can Change Emergency Medicine.”
“Very impressive! Perhaps this should be called Information at the Fingertips of Only One Hand.”
Affinity’s Kaizen Curmudgeon
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
“I do, Jaded Julie, and there was recently an interesting Library Services’ note on Mobile Devices: Health Care Resources in the June 7 Weekly.”
“I guess you are saying that the note demands a careful reading, which you did. My second guess is that your ancient but orderly mind wants to put the info from the Library note into some sort of historical context. Okay, Curmudge, have at it.”
“In our posting on August 6, 2009, Information at Your Fingertips, I envisioned a provider turning to his/her exam room desktop computer to access information via the Affinity intranet. During the past year, laptop computers have become more common throughout our hospitals and clinics. With these, the provider can use the computer while facing the patient and create a more personalized experience.”
“That’s an interesting observation, Curmudge. With the provider facing the patient I’m sure patients would feel like they are in a much more collaborative conversation.”
“Fortunately, now many providers use handheld devices, and those are what Library Services’ note in the Weekly tells us about. It references their PDA Road Map: its title is Mobile Computing for Healthcare: Smart Phones, PDAs, Pocket PCs, etc. Main headings include: Resources for Affinity Library Users, Free Starter Apps, Calculators (free), Clinical POC, Internet Gateways, and PubMed & Evidence-based Practice. In addition, here’s another resource for handheld users: How the iPad Can Change Emergency Medicine.”
“Very impressive! Perhaps this should be called Information at the Fingertips of Only One Hand.”
Affinity’s Kaizen Curmudgeon
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
Thursday, August 5, 2010
Amazing Devices
“Curmudge, nothing documents your antiquity more convincingly than when you talk about the devices you used early in your career.”
“I recall that before the days of photocopiers I had to make 12 copies of an exam by dragging each page plus a so-called ‘master’ through some sort of magic bath. Then the copies were spread out on the counter to dry. I was grateful there weren’t more than a dozen people in the class.”
“That must have been when you had a moonlight job teaching chemistry in the early 1960’s. Since then, advances in all sorts of devices and instruments have really been dramatic. In health care even the simplest of measurement tools, like the glass rectal thermometer, have been replaced. There can’t have been many things that have remained the same. Can you think of one?”
“I sure can, Jaded Julie. What about the stethoscope? It’s not even a scope; it’s a hearing device and should be called a stethophone. It’s still used to listen to the heart and lungs and for measurements of blood pressure. There are anecdotal reports that replacing the stethoscope and manometer with electronic sphygmomanometers yields higher bp’s. However, studies reported in the literature suggest that the methods give comparable results (1, 2). When my wife was in a Czech hospital a year ago, the electronic sphygmomanometer in her room appeared to be the only modern device in the facility.”
“What about pulse oximeters, Curmudge, for measuring the oxygen saturation of blood? The devices clipped onto the end of one’s finger have been in use for a long time, but on your time scale you’d probably consider them a modern invention.”
“You’ve got that right, Julie. When I was studying the use of near-infrared spectroscopy for analysis of wood pulp in the late 1980’s, I met a woman in a short course who was studying near-infrared for clinical applications. Among her interests was pulse oximetry. It seems like only yesterday. Prior to that time, the test of O2 saturation was invasive and labor intensive.”
“I understand that you had in your lab a predecessor of today’s magnetic resonance imaging (MRI) device. That must have been at least 30 years ago.”
“It was a nuclear magnetic resonance (NMR) spectrometer. A solution of the sample was put in a small tube and spun at high speed for the measurement. Someone put a lot of work into scaling up the system to the point where the ‘sample’ is a human lying quietly (not spinning) in the magnetic field. I think they changed the name from NMR to MRI because the term ‘nuclear’ alarmed patients.”
“Speaking of laboratories, Curmudge, clinical labs have undergone great changes over time, haven’t they?”
“I never worked in clinical chemistry, Julie, but I was in a research group with people who did. Leonard Skeggs’ development of the AutoAnalyzer revolutionized clinical chemistry (he was in Cleveland; we were in Madison). He found that samples could be separated from one another by air bubbles as they were pumped sequentially through plastic tubing into as many as 12 concurrent analysis modules. By now, modern lab instruments have undoubtedly displaced the old AutoAnalyzers.”
“While Skeggs and others were automating the clinical laboratory back in the 1960’s, what were you doing?”
“As a research associate in biochemistry, I was developing an instrument for the continuous determination of cyanide in grass. And I’ll answer your question before you ask it; it was not the kind of grass that lots of people were smoking back then. Despite the student riots, Madison was a pretty stimulating place in the late 60’s.”
“Curmudge, other than ‘Gee Whiz,’ what’s the lesson from today’s discussion?”
“Lessons plural, Julie. Most importantly, one should embrace change, both technological and organizational as in Lean. Both kinds of change will make our lives more productive and enjoyable. The second lesson is that one should take a moment to look around and appreciate the astounding developments that have occurred in science and health care in a few short years. Everyone should be inspired to shout an emphatic ‘Wow!’ We’ll talk more about this in later postings.”
Affinity’s Kaizen Curmudgeon
(1) McManus, R.J. et al. Does changing from mercury to electronic blood pressure measurement influence recorded blood pressure?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314749/pdf/14960220.pdf
(2) Elliott, W. J. et al. A comparison of two sphygmomanometers that may replace the traditional mercury column…
http://www.ncbi.nlm.nih.gov/pubmed/17303984
“I recall that before the days of photocopiers I had to make 12 copies of an exam by dragging each page plus a so-called ‘master’ through some sort of magic bath. Then the copies were spread out on the counter to dry. I was grateful there weren’t more than a dozen people in the class.”
“That must have been when you had a moonlight job teaching chemistry in the early 1960’s. Since then, advances in all sorts of devices and instruments have really been dramatic. In health care even the simplest of measurement tools, like the glass rectal thermometer, have been replaced. There can’t have been many things that have remained the same. Can you think of one?”
“I sure can, Jaded Julie. What about the stethoscope? It’s not even a scope; it’s a hearing device and should be called a stethophone. It’s still used to listen to the heart and lungs and for measurements of blood pressure. There are anecdotal reports that replacing the stethoscope and manometer with electronic sphygmomanometers yields higher bp’s. However, studies reported in the literature suggest that the methods give comparable results (1, 2). When my wife was in a Czech hospital a year ago, the electronic sphygmomanometer in her room appeared to be the only modern device in the facility.”
“What about pulse oximeters, Curmudge, for measuring the oxygen saturation of blood? The devices clipped onto the end of one’s finger have been in use for a long time, but on your time scale you’d probably consider them a modern invention.”
“You’ve got that right, Julie. When I was studying the use of near-infrared spectroscopy for analysis of wood pulp in the late 1980’s, I met a woman in a short course who was studying near-infrared for clinical applications. Among her interests was pulse oximetry. It seems like only yesterday. Prior to that time, the test of O2 saturation was invasive and labor intensive.”
“I understand that you had in your lab a predecessor of today’s magnetic resonance imaging (MRI) device. That must have been at least 30 years ago.”
“It was a nuclear magnetic resonance (NMR) spectrometer. A solution of the sample was put in a small tube and spun at high speed for the measurement. Someone put a lot of work into scaling up the system to the point where the ‘sample’ is a human lying quietly (not spinning) in the magnetic field. I think they changed the name from NMR to MRI because the term ‘nuclear’ alarmed patients.”
“Speaking of laboratories, Curmudge, clinical labs have undergone great changes over time, haven’t they?”
“I never worked in clinical chemistry, Julie, but I was in a research group with people who did. Leonard Skeggs’ development of the AutoAnalyzer revolutionized clinical chemistry (he was in Cleveland; we were in Madison). He found that samples could be separated from one another by air bubbles as they were pumped sequentially through plastic tubing into as many as 12 concurrent analysis modules. By now, modern lab instruments have undoubtedly displaced the old AutoAnalyzers.”
“While Skeggs and others were automating the clinical laboratory back in the 1960’s, what were you doing?”
“As a research associate in biochemistry, I was developing an instrument for the continuous determination of cyanide in grass. And I’ll answer your question before you ask it; it was not the kind of grass that lots of people were smoking back then. Despite the student riots, Madison was a pretty stimulating place in the late 60’s.”
“Curmudge, other than ‘Gee Whiz,’ what’s the lesson from today’s discussion?”
“Lessons plural, Julie. Most importantly, one should embrace change, both technological and organizational as in Lean. Both kinds of change will make our lives more productive and enjoyable. The second lesson is that one should take a moment to look around and appreciate the astounding developments that have occurred in science and health care in a few short years. Everyone should be inspired to shout an emphatic ‘Wow!’ We’ll talk more about this in later postings.”
Affinity’s Kaizen Curmudgeon
(1) McManus, R.J. et al. Does changing from mercury to electronic blood pressure measurement influence recorded blood pressure?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314749/pdf/14960220.pdf
(2) Elliott, W. J. et al. A comparison of two sphygmomanometers that may replace the traditional mercury column…
http://www.ncbi.nlm.nih.gov/pubmed/17303984
Subscribe to:
Posts (Atom)
