There was a story in the Boston Globe last week about “alarm fatigue.” In hospitals across the country, alarms designed to alert staff to critical changes in patients’ vital signs are often not heeded, lost among the many beeps and blares that have become background noise in emergency rooms and ICUs everywhere. In the hospital setting, warnings sound for all kinds of things from low batteries on infusion pumps to IV fluids running low. When my mother-in-law Sylvia was hospitalized last year, her bedside chair was equipped with an alarmed cushion. Whenever she stood up, an automated voice would warn, “Richard, sit down. Richard, sit down.” Apparently no one had bothered to re-program it to address Sylvia. Oh, and no one ever came to help Sylvia or Richard when the thing went off.
I’ve discovered another kind of fatigue as I search a medical record for specific information. Call it “word fatigue.” While electronic medical records with their drop-down menus and point-and-click notations make charting legible and uniform, it is that very uniformity that makes these records difficult to digest. ER notes and nursery discharge summaries arrive on my desk daily looking frighteningly monotonous.
I recently had a teenager make a trip to the emergency room for evaluation of a serious eating disorder. I scoured seven pages of notes looking for the one piece of information vital to his case: his weight. It was missing from the triage nurse’s vital signs, though there was a pain scale and a Glasgow Coma scale. It was also gone from the physician’s notes. Temperature was recorded, as well as his oxygen saturation, all well and good, but not a top priority for a boy with anorexia. On my third examination of the document, I finally found the weight. 56.6kg. It was in between “speaks English” and “safety screen: denied” (whatever that means.)
A local newborn nursery has also recently switched over to an electronic medical record. Now instead of the familiar one page “yellow sheet” where I knew right where to look for birth weight, discharge weight and Apgar scores, I have to wade through 12 pages of “mother updated at bedside” and “reacts well to exam” (whatever that means) to find the one critical piece of information I need: “jaundiced in the first 24 hours of life.” (And those 12 pages are just for a two-day stay for a vaginal delivery. A baby born by Caesarian section can haul upwards of 25 pages into his first visit with me.)
WBUR aired a very interesting story recently about a new technology that replaces the sounds of a patient’s heart beat, blood pressure and oxygen saturation with music. When the patient’s heart rate starts to rise dangerously or the O2 sat drops out of the normal range, the music becomes discordant, easily alerting attending medical staff to the trouble.
Maybe I just need someone to sing me my patients’ ER notes.