Friday, March 27, 2015

By Any Other Name

It's probably no surprise that great ideas are often nipped in the bud by the actions of others, and in today's society that Great Inhibitor in the Sky is often political bodies, bureaucracies, and courts that promulgate the flotsam we affectionately call "the law."  (I liked how in the sixties these groups were known as "The Man," but even given the  an increasing number of females in these bodies with no observable progress, "The Persons" just doesn't have the same ring to it.)  So it was that a law called HIPAA ruined my great idea for a blog post. 

For those of you unfamiliar with it (and I hope you are, because unlike Buddhism, in this instance mindfulness does not bring peace), HIPAA stands for the Health Insurance Portability and Accountability Act.  The intent was good, as it often is.  The idea was that if your employer provides health insurance, you should be able to keep your coverage between employers, with a "carry-over" period so if you lose one job, you get some breathing space to continue your current plan before it gets cut off or before coverage at your new job kicks in.  And it does this pretty well.

The other piece of it is the privacy component.  Health information is considered "protected data," and can only be released to those who "need to know," and only then with the consent of the patient.  I can readily understand the impetus for this, especially now that privacy has been enshrined by culture and the courts as an inherent right (often properly, sometimes not).  And none of us would particularly want our neighbors who happened to work at the local hospital looking up our medical records.  But HIPPA also means that it's hard to share information between hospitals and health care professionals without a host of written agreements; and the flow of data is essentially controlled by the patient, who determines what information can be seen or not.  While the difficulties in information sharing probably outweigh deliberate withholding by patients, both can lead to inefficient, duplicative, and more costly care at best. 

Clinically, however, HIPAA turns out to be a mess.  There are so many hoops to jump through, especially when electronic systems are involved or after business hours (which is, in the case
of the former at least, ALL the time), that time-critical information sharing is often non-existent.  In the ER, though, I'm most troubled trying to figure out what you can talk about in the room with the patient who is accompanied by family and friends.  I think most of us ER docs operate under the assumption that if others are in the room and the patient hasn't excused them, the patient's given implied consent for them to hear whatever discussions you're going to have.  That being said, we use a lot of discretion; for example, we'll find an excuse ("Registration need to check your address again") to pull family and friends out of the exam room when telling someone they're pregnant or they have a sexually transmitted disease, or when we want to get some history otherwise unavailable to us that might be embarrassing or (such as in victims of domestic violence or other abuse) frankly dangerous for others to hear.  But the whole area is still gray, if not quite in 50 shades. For example, there was a patient with a history of HIV disease in the records who came in with a fever.  The two are clinically connected, as the presence of HIV disease greatly expands the potential causes of the fever, and as a result your diagnostic net gets tossed farther out to sea.  But when asking him about his past medical history, he omitted the HIV, so I asked about the medical record entry. He became quite upset because he had not disclosed that to the friend who brought him to the ER and now sat in a chair in the corner of the exam room.  While clinically it was the right thing to do, I don't know what HIPAA would say.  Maybe we just need to tell patients up front that we're going to ask about everything and anything, and if they're not okay with that they should just ask their visitors to head to the waiting room.  (But of course, that would damage our customer service ratings...)

Of course, there was health care information available before HIPAA.  It was called medical records, reams of paper bounded by clips and filed away in the hospital basement in bulging manilla folders.  In the ER, when a patient hit the door you would routinely placed a request for medical records.  When it arrived, the first thing you did was listen.  If the records slid onto the desk with a slight "whoosh," there was a pretty good chance the patient was gong to be able to go home.  If they landed with a thud, you may as well prepare the admission paperwork, because anyone with records that loud had too many issues to go home.  If you actually had to read anything, you generally just looked at the last discharge summary because that was your best insight into the current issue. You could leaf through the pages trying to find the tabs that would lead you to a surgery three years ago, but why?  Plus if it was three years ago, chances are the records were somewhere in off-site storage, most commonly known as "the garage."  And records from a physician's office?  Please.

The other written records we had were much less formal, and ones that we would deny ever existed if asked at the time.  Every ER had their own version of the Recipe Box.  This was an index card file of chronic patients, repeat offenders, drug seekers, or others who were likely to be a problem.  When the patient was triaged, the nurse would clip the card from the box to the front of the chart so you new exactly what you were getting into.  The card is where we wrote down what was actually going on with the patient, as opposed to those benign phrases you put in the medical record.  Even I, as flinty as I can be, will fudge on that a little.  I usually use a phrase such as "While the patient may have an underlying issue, there seems to be a significant concern about the patient's medication use," to mean those folks who are looking for meds.    Similarly, I use these phrase "There may be a supratentorial component to tonight's presentation" to mean bat shit crazy.  And the polite way to refer to the neurotic patient in Room 4 is to softly whistle the first few bars of Patsy Cline's biggest hit. 

(In a related note, they've recently updated our electronic medical record and, in a nod to Recipe Boxes of Ages Past, have put a little marker shaped like a red airplane by the names of patients the system designates as an excessive user of ER services, or a "frequent flyer."  Rumor has it that the original idea was to put a small image of a turkey by the name instead to represent their universal sandwich request.) 

Once we get over the hurdles of HIPAA, today it's often much easier to get the information you need.  Good electronic medical records systems (EMR's) make it easy to select and view the most relevant portions of medical records, and where hospitals that use similar EMR's but are under different ownership put differences aside in the interest of patient care, that shared information is incredibly helpful.  (Disclaimer:  I'm fortunate to be working at a place that shares systems with the other hospital in town as well as a regional academic referral center, so I'm biased in that regard.)  And as hospitals and health care systems are increasingly owning physician practices and outpatient lab and x-ray facilities, that information is often now available for review as well.  While HIPAA does require patient consent to access this information, such consent if often buried within a more general document consenting to ER care, so fortunately that's usually not an issue.  When a patient does raise an objection to your asking other providers or hospitals for information, you already know that something's up. 

The best way to get information, of course, remains talking to people.  Most of the time, the patient is happy I can talk to another provider, especially if it's tog et more insight into the current problem to avoid spinning wheels or repeat tests, or if I can arrange follow-up for a problem beyond our scope of care in the ED.  There are a small minority of patients who don't want you to know anything, but they most often won't come out an say it.  They'll obfuscate, bringing up the out-of-town doctor who prescribes their medications, but not remembering how to spell his or name or what hospital they practice at.  Maybe they only know they were last in the hospital "somewhere in Texas."  Maybe they'll know the name of a nurse practitioner but not the physician they work with.  Maybe they'll know their doctor is on vacation or retired and can't be reached.  Any of these are red flags and, to be honest, a chance to play amateur detective in a break from the routine.  The game's afoot, and it's pretty easy nowadays to use the phone and the internet.  When you're able to reach someone, you get the real story and, to be fair, sometimes it's legitimate. When you can't, or that person doesn't exist, well, that's another tale.  One of my favorites was when a patient told me they get methadone from their doctor at a hospital in Pennsylvania.  Unfortunately, his prescription had just run out as he hit to city limits of our fair village.  He knew the doctor's name started with a P and was "not American," but he didn't know how to spell it or a phone number where I could reach either the doctor or someone on call.  So I printed out the medical staff list from the hospital's public website and asked him who I should call.  He departed the ER on his own accord a few moments later.  Elementary, Watson. 

(Pro tip:  Don't try this in my ER. Proving your story wrong is something I take extra time with because it's such a break from what I usually do.  It's really fun to call you out.  And I always ask others to come into the room with me to share in the experience.) 

So anyway, I had this great idea for a blog post about names.  I've noticed that I'm having increasing difficulty pronouncing then names of people under thirty.  I realize, of course, that names of choice change over time; it's been a while since we've seen any Cottons, Increases, Temperances, Goodwifes, or even the occasional Gouvernor.  But it did seem that for the first twenty years of my career, most names were related to the old classics, things that were self-explanatory to spell and pronounce.  Even nicknames, like Bob for Robert or Liz for Elizabeth, had a sense about them.  And foreign or otherwise unfamiliar names were most often reflections of local cultures and traditions.  No problem there. 

However, it does seem that over the last several years there has been an explosion of new names no one has ever thought of before, and some of them seem honestly to be more hindrance than help for the poor kid with that moniker.  (I'm pretty sure that no matter how open and multicultural our society becomes, you're still not going to see a Supreme Court Justice named "Placenta" any time soon.)  It's not the kid's fault, and it may be that as an AARP cardholder, I'm too closed-minded and need to open up a bit.  But you can't help the feeling that these names will hamper the kid's success in life.  One of things I still have strong feelings about in the of the few things I still have strong feelings about at when you see active, bright-eyed kids full of promise who are already doomed by their parents.  I think names can have that effect.  A unique name with cute spelling at age four is simply that.  At age 30, it becomes a handicap to advancing in the real world. 

That being said, I'm not necessarily promoting all older names.  One name that, I think, can probably be done with is Howard.  I've never liked it.  In grade school is was "Howard Cosell" or "How-weird" or "Howard the Coward." (In reference to the latter, I admit to flinching when hit with a dodge ball or run over playing sandlot football.  However, in the one fight I was in I never flinched.  That's because I didn't even see the punch coming before it laid me out on the concrete.) I suppose it got a little better when kazillionaire E. Howard Marshall bagged Anna Nicole Smith, but by that time the damage was done.  Now I can't even get friends or family members to name their kids Howard, Howardina, or Howardette even with the promise of free college tuition.  I once asked my parents why they gave me that name.  They explained the Jewish tradition of using the first letter of a deceased relative's name for the name of a new child, which makes sense,  Then they noted that they gave me a better middle name (David), so I could just use the H as an initial like famous Watergate conspiriators G. Gordon Liddy and E. Howard Hunt.  "So why didn't you just call me David growing up?" I asked.  The deep and insightful parental reply?  A sort of grin, a sly smile, and a sheepish, "Ummmm...we never thought of that." 

And so I've complied a list of names I was hoping to share with you under the title of "Names You'll Never See on a Harvard Diploma But Will See on a Nametag That Says Serving You Since 2016."  And that's where HIPAA has ruined my blog post, because the names I was hoping to share with you are so...well, interesting...that no one else would ever have them, and given where I live there would be little doubt about who I meant.  That means you would have been able to identify the patient, and that means a HIPAA violation and relegation to those remote ER's where they're just happy you speak English as a first language, let alone got out of medical school  I can tell you that the list as it currently stands is over 110 names long.  And all compiled in just the last two months.  However, my study has given me some insights, which I would share with you as "Naming Rules for Children:  2015." 

If you're going to name your child after geography, please spell it as it lies on the map.  There is no "h" in Dakota.  There is no "ph" in California.  And there is no extra "s" in Kansas.  If you insist on adding a letter, may I suggest a directional indicator such as S or N, as in "S. Dakota Smith."  That even sounds distinguished.  While I'm sure it's a fine and upstanding member of the Community of Nations, please avoid honoring the country of Niger, especially if you're a weak speller. 

If you're going with a theme, stay consistent.  If four of your children are named after flowers, one should not be named after a cartoon rodent.  If the names of your first six children all start with the letter "J," naming the seventh one with an "E" will not help you keep them straight at the dinner table.  While I admire George Foreman for his contributions to grilling technology, he is not to be emulated here. 

If you intend for there to be punctuation in the pronounciation of your child's name (such as a hyphen, apostrophe, or comma) in your child's name, please put it in writing.  But do not make the punctuation part of the pronounciation. There's a reason "D'Artangian" is not pronounced "Dapostropheartangian." 

No child should be named after breakfast foods or cereal products. 

Unless you are of Eastern European extraction, or have an inordinate fondness for the people and culture of Krygygzstan, there should be no more than three consonants in a row in a child's name, and then only in extreme conditions, such as nuclear holocaust or a nationwide lack of Hostess cakes.  Similarly, unless you can document ancestry from the islands of the South Seas, no more than two vowels in a row, please.  And "y' counts as a vowel. 

No child should be named after current pop music or hip-hop chart-toppers, especially those whose hits use the terms "anaconda."  Unless it's Katy Perry or Paul McCartney.  There should be more of those. 

More children should be named "Leland Melvin."  He's very cool. 

I would also welcome more children named "Neil Armstrong" and "Ann-Margaret."  Oh, and I would be okay with a few more Gouvenors. 

No one should ever be named "Honey Boo-Boo."  Ever. 

If you want your child to make his or her flights and not get held up by the TSA, do not put a "Kh" or an "Al-" at the start of their name. 

Heaven backwards is not Neveah.  It's Hell. 

And above all, as goes the Internet meme, "Don't get pissed off at me for mispronouncing your child's made-up name."

(Here's a happy afterthought, probably only of interest to sadly underemployed English majors or writer wannabes like me. In everyday conversation, we actually call the law by the wrong name.  Everyone thinks the abbreviation is HIPPA, and it means the Health Insurance Portability and Privacy Act.  In either case, the title contains a nice bit of alliteration with either two A word or two the P words in a row.  We had a similar alliterative episode in the ER a few months back.  A patient...WHO SHALL REMAIN NAMELESS ACCORDING TO HIPAA...presented after passing out in the bathroom in the performance of a "Numero Due."  When someone shows up with a complaint that might be even vaguely cardiac-related such as syncope (a clinical term we use for no other reason I can think of other that it sounds better than "passing out"), there is a knee-jerk reaction to get an electrocardiogram just in case this might be a heart attack.  This tracing is supposed to be evaluated by a physician within moments of being done, no matter what else the physician happens to be doing at the time.  In a busy ER such as ours with multiple doctors on duty at any one time, the acquisition of the EKG sets off a mad scramble to find a physician to lay eyes on it (even though the nurses themselves are pretty good at telling what's what.) It always feels like I wind up looking at the lion's share of them, probably because I either lack the work ethic or are not fast enough to get up from my desk and hide in a patient room.  Once the EKG is read...basically to make sure there's no obvious signs of a heart attack or a life-threatening problem with the heart write on the EKG something like "No STEMI" (which stands for "no ST-segment elevation myocardial infarction, if you're keeping score") or, in my case, "NGD" ("not gonna die") and occasionally a happy face to brighten up the process.  The EKG then vanishes within the Unit Clerk's Forest of Papers, to be sought again by the actual treating physician another hour down the road. 

So anyway, this middle-aged woman passes out while pooping.  Her initials...well, I can't tell you that, because someone reading randomly during the four hours they have power each day in Baghdad might be reading and happen to have been in Northeast Kansas visiting this lady just last week, and heard the whole story, including probably bathroom details I did not care to know or ask about, and now can IDENTIFY THE PATIENT.  But I think I can safely say we found an opportunity for alliteration. So what started out as (patient first and last name) became Plump perky puffy (patient's first and last name) prematurely pooped, paled, and passed out with precipitously plunging pressures as a potential presenting problem.  This would be a lot funnier if I could put in her real name or even her initials, but HIPAA, and Baghdad, would prohibitively proscribe that pun.  By the way, the same Nurse Practitioner who helped with the alliteration project also came up with Little Blind Warren and the Heaving Pannus as a good name for a rock band.  She also has shooting medals and can kill from 200 yards. I'm glad she's my friend.  You are my friend, right?)

(In the Great Minds Think Alike Department, please see this related post from GomerBlog:


  1. Are you a ghost writer for Gomerblog? Because there are eerie parallels between these "medical literature journals"....

  2. I wish I was. Some of those Gomerblog things are brilliant. My favorites are the ones where they take on JACHO.