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Saturday, February 22, 2014

Requiem for ABC David.

When I first learned to take care of patients in the hospital, as a third year medical student, we used a mnemonic to help us remember what to order when a patient was first admitted. Patients would come in to the hospital from a doctor's office or from the emergency room and the nurses needed a set of orders to know what to do for the patient. The mnemonic we used was "ABC DAVID." This is how it worked:

  1. Admit: to medical surgical unit
  2. Because: diagnosis--Congestive heart failure
  3. Condition: guarded
  4. Diet: sodium restricted
  5. Allergies: no known drug allergies
  6. Activity (sorry, 2 A's): bedrest with bathroom privileges
  7. Vital signs: every 4 hours while awake
  8. Investigations: chest x-ray, morning labs - chemistry panel and blood count
  9. Drugs: digoxin, a diuretic, potassium, a beta blocker, maybe insulin or blood pressure medications, acetaminophen for pain, something mild for sleep, if needed.
It worked pretty well. It did allow me to forget certain things that I really didn't want to forget, like having the nurses measure accurate intake and output (food, water, IV fluids, poop, pee and vomit), care of catheters or nasogastric tubes, but it made sure that I didn't forget the main things.

Today I admitted a patient with congestive heart failure and used our hospital's brand new computerized order entry system with its brand new congestive heart failure admission order protocol. It's huge compared to ABC DAVID, who seemed like a strapping lad a mere quarter of a century ago. It includes the medications that experts have determined from large studies to be necessary for optimal treatment of congestive heart failure, the tests that must be done to adequately diagnose congestive heart failure, plus the other things that we think should be done on everyone who is admitted to the hospital including vaccination for flu and pneumonia, smoking cessation, prevention of blood clots in the legs, plus numerous medications that patients are felt to need even if they don't take them at home, including laxatives, sedatives and nicotine replacement. I must use my rudimentary knowledge of hospital billing to characterize the patient as being an inpatient or on observation. End of life wishes must be documented. Also, of course, ABC DAVID is buried inside the order set.

Even though the computer has various habits that I find irritating, like wanting medication orders to be written in a specific way and notifying me of medication interactions that I am already aware of or which are of no clinical significance, I was grateful to have a way to remember all of this stuff that is, apparently, important and necessary. My brain is too small to hold all of these orders and even too small to hold a mnemonic large enough to remind me of all of these things. Orders are different, of course, for congestive heart failure and community acquired pneumonia, for hip fractures and bowel obstructions and for exacerbations of chronic obstructive lung disease. If I made room in my mind for all of this stuff, I'm sure I would have to jettison something that is far more precious.

It is concerning, at least a bit, to be so dependent on either a computer or a printed cheat sheet to initiate treatment for patients. Physicians being trained now don't even have a mnemonic to fall back on, and I imagine that their brains are perhaps like giant card catalogs without any of the books in the library. This, of course, completely labels me as being nearly senile, since card catalogs only exist in primitive societies and old peoples' memories. (I can still evoke that particular wood and paper smell as I type the words "card catalog.") But unless physicians become familiar with techniques of advanced memory training like the ancient Greeks used for reciting epic poems, there is just too much to know in medicine. We must walk around with some of the vast amount of information that makes up our field of knowledge in order to deduce things, make connections, create solutions to complex problems, but we need to be selective. It is possible to design orders for each patient based upon disease principles and knowledge of hospital processes, recent research and individual patient characteristics. This might be better for patients, but only if we are in top form as we write them. Patient safety advocates favor order forms, for good reason, since I and my fellow physicians can certainly not guarantee that at any given moment we will be in top form.

As I remember ABC DAVID and the days of simpler medicine, it is with the bittersweet regret that makes the past look preferable to the present regardless of whether that is in any way accurate. I would like medicine to be less complicated, and perhaps it will be if we rein in our excesses. But while patients continue to be on too many powerful medications and too many expensive and potentially hazardous tests and procedures are part of everyday practice I am grateful for preprinted order sheets and even computerized order entry when it's not too bug infested. I have found ways to be creative and innovative and to personalize my care for patients without excessive hindrance by protocolized treatment for high profile diseases. If the powers that be want me to remember to vaccinate and provide smoking cessation information to my patients as I am submerged in their acute, pressing and life threatening immediate needs, I thank whatever inanimate order generator that will relieve me of that burden.




1 comment:

Chris Porter MD said...

"giant card catalogs without any of the books in the library" - excellent.

Great writing!