First came the SOAP notes. Nothing to do with cleanliness - SOAP stands for: Subjective, Objective, Assessment, and Plan.
S: “Patient states that pain is 16/10, sharp, unremitting. Feeling like a crocodile is eating insides every 10 minutes, after sprinkling them with Frank’s hot sauce.”
O: On entering the room, patient is eating Cheetos and drinking Mountain Dew while texting. Abdomen is soft, non-tender, ticklish.
A: Abdominal pain, probably gastritis.
P: Remove Cheetos, offer Maalox, follow up with PCP.
T sheets came next. Things changed a bit: Instead of my deciding what to write, the form prompted me through questions. Some were relevant. Some were not.
“Tell me about your shortness of breath,” I’d ask.
“I’m not short of breath. I’m here for a penile discharge, but I didn’t want to tell them in triage.”
Unrelenting progress brought us Electronic Health Records (EHR). Now my computer harasses me into documenting everything, relevant or not. That allows the hospital to charge for it. Now, that’s always relevant.
The EHR system rules my life, eats my lunch, and inhabits my nightmares. It’s a match made in hell, like a nagging partner, it incessantly spits nasty little comments to stop me in my tracks.
“Temperature.”
“103.”
EHR turns light pink and ignores my efforts to save the chart.
I may notice it. I may not.
If I don’t, I’m screwed. I get to start over.
If I do, I go back. I find the pink box.
"103. C/F."
C is Celsius. I know Celsius. I love Celsius. I lived in Celsius. It’s a wonderful system with crystal clear limits. Water freezes at zero. Water boils at 100. Easy, no?
I don’t know about you, but I have a short supply of boiled patients. Mine come raw. At 103, they’d be seriously overcooked. I know that. My nurses know that. My stethoscope knows that.
My computer doesn’t. It forces me back through documenting senseless boxes.
Patients wait. Patients leave. Patients die.
Without me. I’m busy, spending quality time with EHR.
"103. C/F."
"F."
Moving on. Next: Pain.
Continuous? Intermittent? Fluctuant? Radiating? Waxing? Waning?
Occasional? Sharp? Dull? Achy? Burning? Crampy? Like, really?
If they can speak, and if they have their hearing aids on, and if they are neither drunk, nor obtunded, or on the phone with somebody more important than me, our conversation goes something like this:
“When you got dizzy, how did that feel?”
Suspicion ensues. For full disclosure: I have an accent. I sound like Dracula. Some call it a Beekmantown accent.
“Like, dizzy. “
“Say I never heard the word ‘dizzy’ before. How would you explain it to me?”
Getting worse. They look at their spouse. They consider bolting.
“I was like, dizzy.”
“Dizzy like passing out, or dizzy like the room is spinning?”
“Dizzy like dizzy. “
Take that, EHR. Pain, like, pain. Hurts.
Moving on. Physical exam.
“The abdomen is: Soft? Hard? Tympanitic? Obese? Scaphoid? Distended? The discharge is: Clear? Serosanguinolent? Bloody? Purulent? Scant? Abundant?"
I spend three quarters of my shift on the computer. Another 10% communicating with the staff. Another 10% on the phone, advertising my patients to consultants as if I’m trying to sell them a used car. Everything else is direct patient care. How’s your math?
To be fair, I do type like a Neanderthal. My younger colleagues have nimble fingers. They dance on the keyboard like ballerinas performing Swan Lake. Mine are like two old stiff drunks trying to waltz.
Time for orders. EHR is there, standing right between my patients and my care.
“Aspirin, 325,” I order.
EHR turns deep pink and balks. “Allergy to Aspirin.”
I click on it. “Stomach upset.”
I click the next button looking for: ”That’s not a fucking allergy.” Not there.
I click “medically necessary.”
Next: “Ciprofloxacin.”
EHR gets really upset. “Not indicated in pregnancy.”
Pregnancy?! She’s 55! Really? Who knows?
I log out. I go back to my patient.
“Any chance you may be pregnant?”
She looks at me like I’ve lost it.
“I’m 55. I had a hysterectomy 12 years ago.”
I nod. I go back to EHR. I scan in my ID, then type in my username, my password, my PIN.
No good.
I start over.
I get it right this time. I log in. I look for: “not pregnant.”
Not there. I shrug and move on.
“Medically indicated.”
Same with lactation. EHR must think that humans, since they are mammals (unlike factory-built computers), once pregnant, stay pregnant. Indefinitely. Unless they start lactating. Then they lactate forever like goats.
I disagree. EHR doesn’t care.
“Medically indicated.”
Done with the orders.
I finally get to medical decision making, the most important part of the chart. The part that really matters. That I can input as I choose.
I skip it.
I’ve been fighting EHR for an hour now for this one patient and others are waiting.
So here's to the VOMIT, Victims of Modern Information Technology, in the ER.
Rada Jones MD MBA FACEP is an Emergency Physician in Upstate New York, where winters are long, people are sturdy, and geese speak French. She lives with her husband, Steve, and Paxil, his deaf, black cat. Her ER novel OVERDOSE, a psychological thriller in which many people die in exciting ways and the good guys drink like fishes is now on preorder on Amazon Kindle.
