Digitalization of medical records: pearls and perils

Digitalization of medical records

 

Nitin K Sethi, MD

 

            No one would argue that digitalization of medical records represents a step in the right direction. The benefits are indeed many to reap. Digital medical records shall ensure rapid communication among caregivers and the current restriction of geography shall be overcome. A resident of Manhattan, who happens to fall ill in San Diego while on a business meeting, can rest assured that the doctor who is taking care of him in the ER shall have access to his medical history and medication list. He would know which drug to avoid based on previous history of drug allergies. Medical errors shall be avoided and costly investigations needed not be repeated. Would it potentially save a life? Yes it would. A comatosed patient brought to the ER after a motor vehicle accident cannot speak and give a history. Doctors waste precious moments trying to ascertain history from family and there are many times when we cannot track any family member to get relevant medical and surgical history. At times this lack of history and delay leads to potentially life saving treatments been denied to the patient. A case in point is the administration of a clot bursting drug to a patient who presents to the ER with an acute stroke. Unless we can document that the patient is not on any blood thinners, this therapy cannot be administered.

            Digital medical records shall also improve physician to physician communication and this shall be of tremendous benefit to patients with chronic disorders such as multiple sclerosis whose care involves multidisciplinary specialties. Care would be more coordinated and I think a win-win situation for all involved and I mean all. Patients would be treated as a whole and not in parts where the right hand does not know what the left hand does. Medical errors shall be avoided; cost of care would decrease benefiting doctors as well as insurance carriers.

            But just like a rose comes with thorns so does the good idea of digital medical records. It cannot succeed unless it is implemented in whole. Every hospital whether state or private run and every doctor clinic would have to be mandated to implement it otherwise like other bright ideas gone sour, we risk having a fractured system with some institutions having digital medical records and others paper records. Digitalization of medical records is not going to be cheap and we rather not add to our already inflated medical budget with a half hearted effort.

 

Behavioral problems in dementia, how common are they and is there any help for it?

Behavioral problems in dementia, how common are they and is there any help for it?

Nitin K Sethi, MD

 

I recently saw a 75-year-old patient in my office which has prompted me to write this post. His wife brought him in  for memory problems. As I took the history, I realised that it was not memory problems per se that was bothering her, it was his change in behavior. Recently he had become aggressive, at times verbally and physically abusive to her. True he had some memory difficulties which were apparent in the history. He had lost his way once and got confused when he could not recall the names of his grandchildren at a family get together. But as I took his history and asked him questions, I found him to have a good fund of general knowledge. He was aware of recent events like the election of President Obama and the war between Israel and Hamas. He was physically active and liked to cycle around the neighbourhood. But it was his change in behavior which was causing a strain in his relationship with his wife and she was having a difficult time taking care of him and administering all his medications.

The patient above obviously has dementia settling in. One can argue about the type of dementia (is it Alzheimer’s or some other type of dementia such as fronto-temporal dementia? You can read more about the same on my website http://braindiseases.info). But what I wanted to stress in this post was the prevalence of behavioral problems in dementia. Behavioral problems are common in all forms of dementia and are a frequent cause of caregiver stress and burnout.  Patients with dementia may present witha multitude of behavioral issues. They may either become too aggressive and hard to control (verbally and physically abusive they may lash out at loved ones when they attempt to nurse them) or they may become aphathic with loss of motivation and drive. Caregivers may complain that they are listless, just sit in one place thoughout the day and do not attempt any new task on their own.

I want to stress that caregivers need to understand that these behavioral problems are a part and parcel of the dementia complex. Lot of people just associate dementia with memory problems, little realising that the disorder is more pervasive. Thankfully now there are many drugs which can control some of these behavioral issues, thus making life easier for caregivers. These range from antidepressants to antipsychotic drugs apart from cognitive and behavioral therapy.

My advise to my readers is this.  If any of you has a loved one with dementia, learn to recognize behavioral problems early on. Bring them to the attention of the doctor since many of them can be effectively treated.

 

An interview about Multiple Sclerosis

“Merely me” is a mother, a writer and a staunch MS patient advocate. I have had the good fortune of getting to know her recently. She has an amazing drive and feels strongly about issues related to multiple sclerosis. She recently interviewed me.

Here is the link to her site and the interview. I hope you find the information presented there helpful.

http://www.healthcentral.com/multiple-sclerosis/c/73302/54272/doctor

Personal Regards,

Nitin Sethi, MD

Sudden Unexpected Death In Epilepsy

Sudden Unexpected Death In Epilepsy

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10021

I recently read about the tragic death of John Travolta’s son from a reported seizure while on a family vacation. The news got extensive coverage on prime time television networks but unfortunately none of the news segments provided any credible information about death from a seizure or epilepsy in general.  While I respect medical journalists and the work they do, I feel they owe a bigger moral obligation not just in getting news across to the public but also going a step forward in researching the topic and utilizing the news story  to spread awareness about a disease. The tragic death of Mr. Travolta’s son limelights epilepsy and its at times unexpected tragic consequences.

When people think of a seizure or epilepsy, death as a possible consequence does not come to mind as conjured by other illnesses like cancer. Seizures usually are discreet episodes, guaranteed they are frightening to witness (if you happen to be a family member or a bystander). The patient falls down (if standing at the time of seizure onset), shakes and jerks violently, eyes roll up, drools and may bite his or her tongue. After a minute or two (which for the caregiver or bystander may seem like an eternity), the person stops shaking and may infact appear to fall asleep and breathe loudly. Emergency medical staff are there by then and take the person to the hospital.

ALL’S WELL THAT ENDS WELL YOU MAY SAY!!!

Well yes and no. As I tell most of my patients and their concerned family members, most seizures end on their own and do not need any “active intervention” (meaning giving them some drug to stop the seizure). By the time EMS arrive, the seizure is already over and the patient is confused and disoriented (we call this the post-ictal stage meaning the stage after the ictus/seizure is over). There are a few patients in whom the seizure may not stop or in whom one seizure is followed in rapid succession by another seizure without regaining consciousness in between. These patients are said to be in “status epilepticus” and need urgent medical attention to abort the onoing seizures. These are the patients who the EMS give intravenous medications to stop the seizure (you can read about this more on my website http://braindiseases.info), once these patients reach the ER, intravenous medications to abort the seizure are administered.

But coming back to where I started most seizures do abort on their own. That is what I tell my patients and their caregivers. As a physician the seizure itself does not worry me so much, it is the circumstances surrounding the seizure which can prove to be fatal. When a person is having a seizure, his or her brain is malfunctioning (think of it as a massive short circuit in the neural pathways), he is thus unable to fend for himself.  Seizures are usually associated with a loss of body tone, a standing patient thus may fall and injure himself. A hard fall on the head may result in a fatal head injury due to intracranial hemorrhage. A person standing next to a subway line in New York City may fall onto the tracks after a seizure episode and get hit by an oncoming train, he or she may suffer a fatal car crash if the seizure happens to occur while they are driving (this of course poses a risk to other motorists and pedestrians who share the road. There are rules with respect to driving with epilepsy and these vary from state to state). Deaths have occurred due to submersion and drowning if the patient has a seizure while swimming or while taking a bath in a tub.

So what I tell my patients is this

“YOU DO NOT WANT TO GET CAUGHT WITH A SEIZURE AT THE WRONG PLACE AND AT THE WRONG TIME”.

There is a further entity called “Sudden Unexplained Death in Epilepsy” also called SUDEP. SUDEP refers to patients with epilepsy/ seizure disorder who are found dead due to no “apparent reason”.  These usually are epilepsy patients who on the surface seem to be fine and one day are found dead. At times they may go to bed okay but are found in bed dead the next morning. A lot of research and studies have looked into SUDEP to try to determine its etiology and thus help in better identification of those epilepsy patients who are more prone to SUDEP. While we still do not know what causes SUDEP, we now do know certain facts.

There is neural control of heart rate (meaning parts in the brain control our heart rate). Hence seizures which arise from certain areas in the brain such as the insular cortex may at times be accompanied with bradycardia (that is the heart slows down and in extreme cases may even stop for a few seconds to minutes). Thus ictal bradycardia or ictal asystole may be one of the mechanism underlying SUDEP.  In other documented cases of SUDEP, patient was found to have severe laryngeal muscle spasm  thus impairing respiratory effort.

So who are the patients who are at high risk for SUDEP? These are usually patients who have poorly controlled epilepsy (seizure control is inadequate on current therapy). Patients who have seizures associated with ictal bradycardia and/or laryngeal spasm remain at exceptionally high risk.

Epilepsy is a relatively common neurological disorder. It imposes a high price in terms of socio-economic costs and quality of life issues. Every attempt should be made to attain good seizure control (thankfully we now have many options both medical therapy ( anti-seizure medications) as well as surgical, you can read about them on my website http://braindiseases.info).

The battle is still to be won but together we can!!!