You can't win 'em all

Seems like I've been on a real run of chest pain patients lately.  Which is fine -- it's part of the gig.  I did have a very interesting pair the other night.  They were seen in sequence, right next to one another, in room 7 and room 8.  They were both totally healthy woman in their mid-fifties.  And they were both over-the-edge, crazy, crawling-out-of-the-gurney anxious.

Anxiety is an awful red herring in the work-up of chest pain.  People who are having an anxiety attack often if not always manifest some chest pain (pressure, tightness, whatever) as a prominent symptom of their anxiety.  On the other hand, someone having a heart attack who is experiencing chest pain will also be anxious -- and for good reason!  I probably see ten patients with simple anxiety for every one patient I see with "real" chest pain, so just by probabilities and pattern recognition an ER doc might easily dismiss the anxiety cases, just blow them off.  Which would be a real mistake, since when you blow off these cases you absolutely will miss things.

So you have to pick and choose what you will work up and how far you will chase the zebras.  Most of this you are going to do by Bayesian analysis: looking at the patient's age and general state of health, incorporating some basic data like ECG, blood tests, and how well the patient's history fits with classic patterns of disease.  So the 25-year old who is hyperventilating and hysterical because her boyfriend was hitting on another girl probably will get minimal work-up, whereas the septuagenarian with a history of diabetes who has an elephant standing on his chest is a slam-dunk admit.   Those are the easy cases -- the extremes of probability.  We joke that it's the cases in the middle that are why we get paid the big bucks.

These two cases were real doozies as far as figuring out what to do with them.  The first patient was, as I mentioned, about 55 and completely healthy.  She had this sharp pain that had been migrating all over her chest for several days.  It was not exertional, nor was it associated with shortness of breath, fever, cough, etc.  She sometimes felt it between her shoulder blades, and sometimes it was worse with a deep breath or movement.  it was a very fleeting pain, and clearly seemed related to some situational stresses she was having at work.  ECG, labs and chest x-ray were completely normal, as was her exam.  The pain in the back did catch my attention: that can be a historical element associated with Aortic Dissections, a vascular catastrophe in which the aorta basically tears itself apart.  So I did a CT scan on her to evaluate the aorta, which was normal.  After a standard cardiac observation was completed, she went home with some xanax.

The second patient was even stranger in her presentation.  Her complaint was listed on the triage note as "chest pain" but she started telling me about this tooth that had been bothering her, and she had bitten down on something and it had gotten much worse.  The tooth pain was radiating over the top of her head and also down her neck into her shoulder and back.  She was so anxious that she could barely get out a coherent sentence and she would hyperventilate herself into vomiting.  She complained that after vomiting she felt a burning pain in her mid-chest, which was why she was billed as "chest pain."  It sounded pretty clearly esophageal.  As I took in this history, I wondered whether I should even work this up at all as chest pain, but the ECG and troponin had already been done (from triage) so I decided to roll with it.  She also had a normal exam, and felt much better after some ativan.

She slept through most of the night shift after that.  I would rouse her from time to time, and other than a deep conviction that she had something terribly wrong, she actually seemed to feel much better.  Never complained of any more pain.  I considered scanning her, but mindful of the one "wasted" un-indicated CT I had just done on room 7, I was feeling a little gun-shy.  I hate to shotgun tests, and this one seemed even less useful than the previous.  Eventually, I figured that "you just cannot scan everybody," and I put her in for the cardiac observation and discharge protocol, like the other woman.

By now, you probably can see where this is going. The next morning, when the patient's observation period was done and she was set for discharge, she still didn't feel right.  Fortunately, an alert nurse spoke up and asked the new doctor on shift to re-evaluate the patient.  He did, and really didn't see anything much different, but out of a general sense of "I should probably do something," he ordered a CT scan.

And it showed:

and

Yes, she had a Type A aortic dissection.  Quite lethal when not treated.  My partner reported that when he got the call from the radiologist, he got all sweaty and weak in the knees, it was so unexpected.  Fortunately, the diagnosis was made and she went to the operating room for repair.

I've reviewed this case with our medical director, and his words were, "If I had taken care of this patient, she would be dead, because I doubt I would have even kept her for observation."  I don't feel that it was a "miss" so much as a "Damn!  Who'd've thunk it!"  But still, the irony is maddening that I had two weird, anxious ladies and I picked the wrong one to scan.  Crap.

There are a number of good learning points to take from this "near miss," however.

1.  Listen to the nurses.  In my opinion, the hero of this story is Kathy, whose gut told her something was wrong and she brought it back to the doc.  Woe unto the physician who blows off a nurse in this context.  Whether or not you miss this case, if you disregard their advice, it's all the less likely that he or she will be willing to stick their neck out and ask for a re-evaluation in the future.  Nurses are so much closer to the patients that their input will save your ass if you're smart enough to listen.

2.  Beware sign-outs.  Most ER docs are reluctant to get involved with a patient dispositioned by a previous doc.  I get it -- who wants to re-open Pandora's box? But like it or not, they are your responsibility, and sometimes a fresh pair of eyes/ears are all that is needed to unlock the puzzle. 

3.  Keep an open mind.  In this case, I admit that I was a little annoyed at this patient for her strange behavior, and just for the injustice of the universe at subjecting me to this sort of thing, and that bias would have made it difficult to really re-evaluate her with an open mind.  I hope I could have, but I'll never know in this case.  My partner was able to do so, and that made the difference between getting the diagnosis and missing it.

4.  Dissections are strange beasts.  I've seen several now, and none of them had the classic presentation.  I've learned to respect the isolated neck/back pain, and, on reflection, the incredible anxiety tone of almost every dissection I have seen is a remarkably consistent feature.  Having a high index of suspicion is essential.

5.  D-dimers are useful to screen for dissections.  I did not originally order a d-dimer on this patient, but it was positive in retrospect.  It appears that the majority of cases of dissections do have a positive d-dimer, which makes sense when you think about the physiology of the study.  While the correlation does not seem to be strong enough to use d-dimer solely as a test to exclude dissection, it does appear to be useful as part of a rational strategy to determine which patients you might choose for further investigation.

Our National Holiday

The best Super Bowl commercial you will see this year:

I will be rooting for the Saints in return for the national service they have done by ending Brett Favre's season.

However, I am predicting a 10+ point for the Colts.  Prove me wrong, guys!

Listen to your Gut (literally)

"Doctor, we need you in Room 15, right now!"

The call came from an experienced ER nurse and I knew better than to hesitate. It was near the end of my shift, but I put down the matter I was handling and hurried over to see the new patient. As I walked in the room, I could see that it was Something Bad [tm]. The patient was supine and rather grey-looking. The red numbers on the automatic blood pressure monitor read 54/30.

That's low. Really low. Low enough that you shouldn't be conscious, but as long as she laid flat, she said she felt OK.

It was an odd presentation. She really had no complaints -- just felt faint when she sat up. She had felt perfectly fine till a couple of hours ago -- no chest pain or fevers or trouble breathing or anything. Except maybe, she conceded, some mild abdominal pain, and maybe had diarrhea once. The list of Bad Things [tm] in the abdomen started subliminally cycling through my head as I pushed on her belly -- ruptured Aorta, dead gut, perforated bowel, etc -- but her belly was soft and essentially non-tender, which would *not* be the case with a perforation. A quick look at her Aorta with the ultrasound was normal. I felt like there was something I was missing, but I was side-tracked by the *huge* peaked T-Waves on the ECG the nurse handed me.

Peaked T-Waves are a sign of a very high blood potassium level, an imminently life-threatening condition. So at this point I stopped thinking and leaped into full-on ER doc mode. Two IVs. Lots of IV fluids. Insulin and calcium to lower the potassium. Antibiotics . . . just on general principles. Full lab panels -- she's in renal failure, which explains the potassium, though not the low blood pressure. Dopamine for the blood pressure. Get a ICU bed for her and call the ICU doc. 

"Whatcha got?" she asked as she strolls in.
"I'm not sure, but it's bad. A 77 year old female with unexplained shock, I presume septic, acidotic with pH 7.05, new onset acute renal failure. She looks better on pressors but I still don't understand the primary cause. She had some abdominal pain but it's pretty mild. Otherwise, she has no symptoms at all."
"Righty-ho," says she, "Send her up when the bed is ready and we'll sort her out. If you can, call nephrology and get her set up for urgent dialysis, will you?"
"No troubles."

So I start back to work on my other patients, pleased that I have stabilized and dispositioned an incredibly sick person in such a short time. It took maybe an hour, probably less. I look at my list of patients for the day - 21 in 8 hours. Damn, I'm really hitting my stride. Given that almost half of them were admits, and three to the unit, I feel pretty good about the efficiency there. I may even get to go home within an hour of the end of my shift.

But I'm bothered. I still don't really have a diagnosis on this last lady. Ordinarily, that wouldn't bother me. I like to say: "The goal of the ER doctor is to keep the patient alive long enough for them to become someone else's problem." And that is just what I have done. Mission accomplished, and I can go home, right? But there's something I'm missing here. I can't put my finger on it, and it's bugging me. 

Then the nurse comes to me and tells me that the patient just passed some stool, and it was bloody. Eureka! I literally smacked my forehead with my hand. She has dead gut, which is to say that a segment of her small bowel has lost its blood supply (most likely a blood clot) and has died. That would completely explain the sepsis, acidosis, and renal failure. A quick call to the surgeon -- patient to CT scan, and off to the OR for exploratory laparotomy. Her odds are poor -- dead bowel is a Very Bad Thing Indeed. But had I let a couple of hours go by till the busy ICU doc got to see her and figure it out, the odds of survival would have been fast approaching zero. 

I now realize the thing that was bothering me was that I *knew* all along that it was dead gut -- it was the second thing I thought of -- but I had gotten so distracted by the other stuff that I had just lost track of it. All it took was one random piece of data from the nurse to trigger that connection and it came up from my subconscious to the front of the brain. I'm glad it did. And I walked out of the ER exactly one hour after the end of the shift.

Originally posted 26 August 2006

The Mountain's Out

After weeks of steady rain/drizzle and rare if any glimpses of blue sky, it's always a shocking thing to drop the kids off at school on a clear morning and see Mt Rainier towering over the southern horizon.  It gives me a visceral jolt, like, "Hey where the heck did that massive thing come from?  Has it always been there and did I never notice it?  Or did it just sprout up like a spring flower?"

By the summer, which is quite clear in this state, I've gotten used to its presence again.  But the incessant grey of winter makes me forget that it exists.

Listen to the patient

Sometimes in this job you just get lucky.  You have an elusive and/or dangerous diagnosis just dropped in your lap.  Something devastating that you would never have been able to tease out otherwise just gets handed to you by the patient.  There's a catch, though: you have to be smart enough to know when to listen to the patient, when not to blow off their crazy talk as just crazy.

So it was recently when I saw a guy with back pain.  From the chart, it didn't sound like anything complex: a middle-aged to older guy, maybe 60 or so, with a history of chronic back pain and multiple surgeries for the same.  He was on Oxycontin 80 mg three times daily (a very high dose, and a red flag for an ER doc naturally suspicious of drug-seeking behavior).  I went to see him, and it was clear in seconds that this dude was JPN: Just Plain Nuts.

He was a real character, in a good way.  He was one of those old Vietnam vets with the leather vests and long graying hair.  His wizened face bespoke many years of cigarette smoke, and his crazy eyes hinted at a long history of illegal substances.  Of course, he had no veins left from years of IV drug use, but he told me he was "too old for that shit any more," and I believed him.  He was a dedicated biker, and had not let the loss of his right leg in a motorcycle accident dampen his enthusiasm for the hobby.  He had a method, he told me, of using his prosthetic to operate the rear brake, while relying primarily on the front brake, since the poor sensitivity in the right led to overbraking and rear-wheel skids. 

It was such a mishap which had led him to lay down his Harley a couple of months before, and the road rash on his hip had developed a MRSA abscess before eventually responding to antibiotics.

This is all stuff I got from him after the fact, though.  Initially, he was in so much pain that he could barely give me any history at all.  Writhing on the gurney as much as possible without jostling his back, he was all-but-nonverbal.  He gasped, in a gravelly but intense voice, "Doc, I just know, I just know that I've got an infection in my back.  I can feel it!  It's there!"  With great effort, he sat up and stared at me with an insane expression that I remember from Hulk Hogan's glory days, lids fully retracted and teeth bared in a rictus of pain, "I can feel the infection in my eyes!  Behind my eyes!  It's fire and pressure and it's pure poison!  I just know it!"  And with that he collapsed back onto the gurney, mute, into his own private and rather unpleasant little world.

I couldn't examine him for anything.  His whole back hurt -- heck, he hurt everywhere.  Forget a neuro exam.  After about five minutes I gave up the whole effort as futile.

I mused on the "infection" thing, though.  What the hell.  Osteo?  Diskitis?  Epidural?  How would he know if he had an infection there?  No fever.  Abscess -- risk factor -- so not exactly implausible.  Did I have any evidence for it?  Not a shred.  Anything to suggest that this was just chronic pain?  Nothing but his two dozen ER visits for chronic back pain.  For some reason, I decided, "Fuck it.  I'm just going to get an MRI on his back."

This is highly unusual for me.  In our group of 40+ docs, I am the lowest utilizer of diagnostic imaging services.  Generally, I have to have a high level of concern to get an MRI from the ER (though they are far more common than they used to be).  Yeah, I also ordered the other stuff -- you know, the stuff Vijay wants before he'll authorize the MRI -- a white count, CRP, Sed rate, etc.  But it was 8AM and the radiologist must have been undercaffeinated, because he just said OK without asking any questions.

He was over at radiology as the labs started to come back: sed rate>100, CRP>200, WBC 24,000.  Wow. That all looks bad.  Glad I decided to scan him.  The MRI?  You guessed it:

Well fuck me sideways and call me a donkey, but there's the epidural abscess, just like he said it would be.  How the hell did he know?  I mean, really, how did he know?!?  Because he told me the diagnosis from the moment I saw him. 

My Irish mom used to always say that God looks after children, fools and drunks.  I don't know that this was divine intercession per se, but I consider the unlikely sequence of events: an unreliable patient asserts he has an unlikely disease, I, without supporting evidence, order the difficult-to-obtain test, the radiologist fails to erect a roadblock to the test, and against all probability, the patient has exactly what he said he did. With early surgical intervention he avoids permanent paralysis. If I hadn't listened to him...

There for the grace of God go I.

Not dead yet

Been pretty quiet here lately.  I've been working clinically quite a lot, and have some cool things going on in my professional life that I just can't blog about -- more's the pity.  It's funny, with several years of blogging under my belt, when something interesting happens, my automatic instinct is to post about it.  I've just gotten used to living my life in a very public fashion.  But it's not a great way to run a business -- there are lots of things that simply have to be kept confidential.  So I compartmentalize it, but I still can't stop writing the hypothetical blog post in my mind and thinking how cool it would be.

Yeah, I'm a terrible tease.  Sorry.

I've got a few posts ready to come out over the next few days if I have time to put them in decent shape, but till then I'll content myself with linking to an interesting commentary via GruntDoc:

GruntDoc  We’re Failing Our Residents: Training ED Docs for the Real World

Residents training in large urban centers typically see more than 200 patients a day. They have access to all subspecialty care, typically available 24 hours a day. Residents have around-the-clock access to angioplasty, interventional radiology, hand surgeons, neurosurgeons, and plastic surgeons. Most practice emergency medicine with cardiologists and neurologists in the building or a short phone call away. Decision-making is shared, and occurs with a relative surplus of information and opinions and in a milieu of shared risk.

In reality, though, these very large and highly-specialized EDs with Level I trauma comprise less than five percent of U.S. EDs, according to the American College of Surgeons. The average ED is in a community hospital, and sees fewer than 100 patients a day.

Right on.  I used to joke, after doing a residency at Hopkins where there were no fewer than three separate ENT services on call every day, that it was a huge culture shock coming to a community hospital, even a relatively busy one.  When I was frustrated I would loudly exclaim "Whaddya mean there's no oculoplastics in-house on-call?" in a joking tone, or I would muse "So how long have you people had electricity anyways?"

But I think this article slightly misses the point.  After three years of critical care training and trauma care, after working with specialists shoulder-to-shoulder every day, that stuff is actually not too hard.  You do a few peritonsillar abscesses with the ENT resident, you do a million trauma resuscitations with the surgeons, and you can replicate their thinking and decision-making with reasonable quality.  When I got out of training I was pretty comfortable calling up a surgical consultant and telling them what needed to be done (or at least giving them enough information to formulate a plan). 

It was the little stuff, the low-acuity stuff that was the real head-scratcher.  I still remember the first time I saw hand-foot-mouth disease.  Kinda embarrassing, now, the work-up and effort I put into what is today a doorway diagnosis.  The mandibular dislocation.  The lacerations in odd places.  Foley catheter trouble-shooting.  The rashes.  The weepy umbilicus stump.  A lot of primary care-type issues.  All of this was stuff that I just had to figure out on my own, jury-rig it with duct tape and baling wire and hope to hell that I had gotten it right.  And now that I'm one of the more senior docs, I see my new graduate colleagues struggling with the same things.  Fortunately, I can be a resource to them and show them the tips and tricks that I discovered, just as my senior partners were for me.

I don't think I'd say we're failing our residents, though.  This stuff is not too hard to figure out, and the breadth of the problems that you will see in an ER is so huge that it's just not possible to see everything in a three-year residency, much of which is spent on off-service rotations.  It's certainly more important that our grads be able to do the critical care and procedures to a very high standard of quality from day one after graduation, and this in fact has been my experience.  The folks we have hired universally have been comfortable managing the really sick patients, and I think that's the important thing given the limitations of training and the need to prioritize topics.

The source article does make another criticism of ER residency training that I have been harping on for years:
 We're Failing Our Residents...

Residency programs train physicians in some of the most inefficient EDs in the land. Relative value units of emergency medicine work per hour in the teaching hospital setting is typically half that seen in private practice. And residents train in a culture where customer service is an unaffordable luxury amid the chaos of the typical academic ED. ... These safety net patients have nowhere else to go and so will tolerate greater waits and delays without leaving. On the other hand, community hospital patients are more likely to be adequately insured, and have higher service quality expectations. [...]

We continue to graduate physicians with no proper training in health care management and few of the leadership skills necessary for working in a health system that is increasingly organized around team care and team management. ... [T]he academic emergency medicine anti-business bias should be replaced with the realization that no emergency medicine practice can survive or prosper without sound business leadership and management skills. These abilities are not typically necessary in the world of academic emergency medicine, but they are imperative in the rest of the practice world.

This is a predictable consequence of the RRC core curriculum requirements and the incredible emphasis placed on the inservice exam scores.  The residency directors teach to the test.  Billing, management, healthcare economics, and ED operations are not on the test, so they're not in the curriculum that residents are exposed to.  It's a rational choice, if youa re a residency director. If you have an open lecture slot, you can have someone come talk about difficult toxicology cases or billing stuff, you for the tox, no question.  (Plus, many academic docs have never worked outside academics and so they have no experience in billing/management/ED operations, so they can't informally teach residents in the ER.)  The consequence is that ER docs graduate naive and vulnerable to exploitation by their employers, unprepared to succeed in their new job, and left to figure it out along the way or not.

To their credit, some residencies have recognized this deficiency and have made small steps to remedy it, but it's generally inadequate.  Still, credit where it's due.

It's also telling that this criticism of ER residency training, coauthored by several respected and accomplished leaders in the field, was published not in ACEP's Annals of Emergency Medicine, nor in Academic Emergency Medicine, but in the trade publication, Emergency Medicine News.  I have to wonder whether this was a deliberate choice on the part of the authors, or if the "respectable" journals shied away from such a topic.

Rounding at 37,000 Feet

Anyone who has flown long-distance flights has heard the call: "If there is a doctor on board, please identify yourself to a flight attendant." But it's impossible to understand how that call induces the urge to flee to the lavatory and hide unless you are one of those unfortunate few who are on the hook, which is to say that you are qualified to respond, but you really really don't want to.

"But Gee," I can hear you think, "Aren't you an ER doctor? Isn't this sort of thing second nature to you? Don't you revel in the adrenaline and glory?" Well, yes. But. First of all, there is the performance anxiety thing. I'm used to working with a very small audience. In Economy class, there may be 300 people watching me try to do my thing, and I'm just not used to that many people being in the exam room -- and I know they are very interested in what's going on. Also, being an ER doc, I am terminally paranoid, and over the Atlantic Ocean there's just no easy way to differentiate the Very Bad Things[tm] from the more common complaints which occasionally represent Very Bad Things[tm]. So that also is anxiety-provoking. And then there's the potential that things might turn bad, and then it's a flog to run a code in the limited space available.

So, on Olympic Air, somewhere over the mid-atlantic, the dreaded call goes out. I cringe and try to sink deeper into my seat, hiding my face behind my magazine. Finally, seeing that nobody else responded, I gave a deep sigh and pushed the call light. It was a 60-70ish guy in First Class with abdominal pain which radiated through to his back. Great, I thought to myself, It's an Aortic Aneurysm. (see? I told you I was paranoid.) But his belly was soft with no pulsatile mass, good femoral pulses, and clinically, I thought the pain was much more suggestive of a kidney stone. I gave him some ibuprofen and said I'd check on him later.

I tried to sleep, but maybe an hour later, the attendant approached me again . . . there's another patient for you. Sheesh. This is an older fellow with a history of heart disease who has epigastric pain and nausea. How the hell am I supposed to tell heartburn from angina over the Atlantic? I asked the attendant if there was a defibrillator on board, thinking maybe I could at least look at the ST segments, but the Greek-speaking attendant seemed to not understand the question. I mimed shocking somone with paddles, and his eyes got very big, but then said, no, they didn't have anything like that. The patient said he has had typical chest pain with his heart attacks and this felt much more like his stomach. Then he threw up and felt a little better. I rooted through the medical kit and found something which looked like Greek meclizine and gave it to him. I checked on the first guy and he said he felt a lot better.

A couple of hours later, they roused me from a deep sleep (this was an overnight flight), to apologetically tell me that there was a third passenger in need of attention. Oh. My. God. This elderly lady was having trouble breathing and they had gotten an oxygen mask on her. Well, her lungs were clear and her pulse was normal and she seemed really panicky and her traveling companion said she had been under a lot of stress and hated to fly. So probably a panic attack. I told the flight attendant to keep her on oxygen for another half an hour (purely for placebo value) and told the patient in my most authoritatively reassuring tone that she would be feeling better by then. I then checked on the kidney stone (sleeping) and the nauseated fellow (much better, thank you). I went back to the galley and hung out with the crew, drinking coffee for half an hour, then went back to the panicky lady who had in fact experienced a miraculous recovery.

The flight crew was very nice and gave me a free bottle of champagne as a gift. And I swore I would never again admit that I was a doctor on an airplane flight.

The time in Greece was lovely. We started off on the island of Kos, Hippocrates' birthplace, and I got a cool T-shirt with the Hippocratic Oath on it, in Greek. As it happened, that was the only clean garment I had for the flight home (this time on Delta). This time we made it most of the way across the Atlantic before the call came for a doctor. I waited and waited and nobody else responded. Finally I decided that I couldn't very well walk around with the fricking Hippocratic Oath on my chest and not help out, so I gave in and rang the bell.

As I stood up, I saw an elderly man about ten rows in front of me, standing in the aisle in the tripod position, labored breathing, gray and sweating. That must be my patient, I thought. He doesn't look good. He couldn't tell me anything (too short of breath), but his traveling companion cheerfully informed me that he had had a heart attack only two weeks ago, and just got out of the hospital with congestive heart failure and had a pacemaker put in. Oh, is that all? His pulse was about 150, way too fast, and his blood pressure was also very high. When I asked, he nodded "yes" that he was having chest pain.

I figured that most likely he had gone into an irregular heart rhythm as a consequence of his heart failure and the low oxygen pressure in the cabin. I got out the defibrillator and moved him to an empty seat in business class because I figured that if he was going to code, I wanted room to work it. He looked that bad. I rooted through his med bag (a cornucopia of heart meds) and gave him aspirin, nitro, lasix, and metoprolol. And oxygen, of course. Then I went to talk to the pilot. We were two hours out from JFK, he said, but we could get down just a bit sooner by landing at Halifax, Nova Scotia. I tried really hard not to let the knowledge that I had a connecting flight affect my decision-making. Tough decision. Finally, I said that I thought he could make JFK but we should expedite it. I heard the engines spool up as the pilot accelerated the plane.

So I sat up in first class with him to keep an eye on him (The Wife eventually joined me when I didn't return to our seats in coach), and he progressively improved. His pulse came back towards normal with a second dose of metoprolol, and by the time we landed (almost 40 minutes early) his color was much better and his breathing was a lot easier. I wrote up a little report for the paramedics/ER, and after the fastest landing and shortest taxi I have ever had, the medics bustled him off the plane.

Again, the flight crew was really nice (and almost pathetically grateful, which was appropriate, since an unscheduled landing would be just about the end of the world to them). They took my business card and promised me a "nice little something." Lord knows what that'll be -- probably a fruit basket. It was rather a pain in the butt, but at least the guy really needed me, and it was gratifying to see him get so much better.

And I have resolved that from now on, I will fly with an iPod in my ears, cranked up so loud I cannot hear a single overhead announcement ever again.

Originally posted 2 June 2006

Tablet PCs and Health Care

Looking at the iPad released by Apple today, it's a pretty natural impulse to see that sucker in the ER.  I can see viewing the EMR and the EDIS on it (if those platforms were safari-compatible, which they are not).  I'm not sure that I can see doing a lot of data entry on it with the virtual keyboard, but there is the dock option.    It's been pointed out that Apple has not generally done enterprise marketing/support very well, and most enterprise IT folks view Apple with something between aversion and contempt, so it may be an entirely moot point.

Chris over at Medical Software Advice reports that Apple reps have been spotted at Los Angeles’ Cedar-Sinai hospital, probing physicians about how a tablet (Apple’s iPad) could be used in a hospital setting.  While I like the idea, I'm pretty skeptical that we'll see the iPad much in large hospital environments.  We will see.

Chris also has an interesting survey on what features health care professionals would like/need in a tablet device.  If you are a health care provider, click the link and make your voice heard.  I'll be interested to see the results.

WANT. NOW.

(Pulling out wallet) So, when I can I have this?  Sixty days?  Sheesh. It's gonna be a long two months.