Translating clinical knowledge into wisdom

I would like to share another quote from Osler (also contextualized in another paper in the same issue of the Journal with Carmel and Achim as co authors):

http://www.ingentaconnect.com/content/bsc/jecp/2008/00000014/00000005/art00021

"Carry a small note-book, and never ask a new patient a question without note-book and pencil in hand...Begin early to make a three-fold category - clear cases, doubtful cases and mistakes. And learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch. It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way you gain wisdom with experience."(Osler 1904, 1928)

Another definition of Knowledge and wisdom comes from Information theory:

Knowledge is information that can be easily recalled ( Imagine a very knowledgeable person who expounds volumes on a particular topic that may be vaguely related to the query you have posed but hardly goes anywhere near answering it). Even google is quite knowledgeable that way and can even often answer our queries after giving us a lot of information options to choose from.

Wisdom is in being able to apply knowledge in a manner that answers our queries with minimum noise or redundancy in the information conveyed. This off course just remains a human trait for now, I am not sure how long though.

I am very interested in clinical problem solving exercises (which you mentioned about your student) that would apply a patient centered stance rather than the disease based stance that we are compelled to publish as case reports.

I wonder when we shall get a case reports journal which would include patient's perspectives as well and not just talk on the disease. This may have come out in isolated snippets as the patient's journey in BMJ but its time we had a complete journal devoted to it.

Or better still an open access online data base that keeps getting regularly updated...Or why not conate/collate already accumulated patient health professional experiences available on the net to help solve our clinical problems in a patient centered manner on a regular basis? ( this is probably the bottom line in the other paper with Carmel and Achim in the same issue of the journal)

A patient's journey: finding keys to a locked in state

December 7
He fell down from his bed today. Was it that his power was returning?

He had developed a slowly progressive weakness beginning from his left arm and spreading to involve his right arm and subsequently right leg and left leg. They also noticed tremors that were coarse and static but fast and also involved his head that went side to side in a 'no' fashion.

That was two years back, much before he fell from his bed today, much before the day two weeks back when he suddenly developed a complete paralysis of all his muscles to the extent that he could not lift a finger or utter a word although he could see and hear the world (which they/we didn't realize initially).

He could however move his eyelids and this was what brought his diagnosis to our notice.

He had locked in syndrome a recognized entity that has been much discussed before.
See:
a) http://www.bmj.com/cgi/content/full/330/7488/406

b) http://www.bmj.com/cgi/content/full/331/7508/94

If we think of our nerves that travel from the pyramidal cells of our brain as long threads dangling from a cortical rooftop then one can comprehend that these threads are bundled through various stations as they descend down to the spinal cord and finally relay to the peripheral nerves that conduct the current that moves our muscles.

So there is a particular station in the brain called pons where this man's threads were suddenly affected two weeks back. What started as a slow dying of the neuronal cells that conduct current through the threads in their downward journey suddenly became an acute shut down (presumably as the myelin sheath covering those neurons and threads were affected). So was this a superaddded acute demyelination on top of a slowly progressive demyelination? Well at this point of time it looks like a secondary demyelination and the pattern seems extremely unlikely for primary demyelination (multiple sclerosis that is).

I had started him on a shot of steroids just in case it was primary inflammatory demyelination and responded like magic. His wife talked a lot today in his presence and I could notice his eye movements become uncomfortable at times particularly when she mentioned how he used to denigrate his brother in law for limping due to polio etc and added that perhaps he was just being punished short term for that and she was confident he would recover completely. I merely nodded in agreement although wished she had more evidence to support her confidence in the future.

December 8

I found him sleeping alone and unguarded (I had forgotten to mention that he had fallen off his bed yesterday). The resident informed me that he was doing well and also able to talk a little.

Wow! Sure enough he managed a 'doctor saab' rather well. His wife has been ecstatic and talks to him more often now and he seems to be happy from whatever I can make out through his expressive eyes.

I have continued the steroids for another two days just in case it is reducing some inflammation that may help to increase a bit more of his power

Case based reasoning through care pathways: a patient of toxic epidermal necrolysis

Have been busy with some interesting patients these few days.

Although I am a unit incharge I prefer having complete charge of a few patients and tend to sometimes also work like a resident for them. Right now have this interesting patient with Toxic epidermal necrolysis who developed severe sepsis with acute tubular necrosis and non oliguric renal failure soon after admission to our ICU. Other than a posible cutaneous source of infection I found that a few attempts had been made to catheterize him with a foley's as per our ICU protocol (which I discovered to my horror advocates foley's in all patients which the residents tried to follow blindly).

His urine cultures also showed muti drug resistant E coli as a result and I had to start him on imipenem for the UTI along with linezolid for his presumed cutaneous infection.

This is one danger I believe of going by average information in protocols that is necessary for learning in the initial phases but again more subtle layers of information are needed to guide the execution of protocol based information. At the moment we need to develop this layer. One way would be: if health professionals share their experiences a form of experiential learning could be promoted. It is taking place but needs to be promoted on a wider basis. Most of the times our case based reasoning and subsequent sharing is very limited to our local friends and colleagues (but again can be remarkably augmented with the power of the net).

Again coming back to the same patient yesterday I noticed that his potassium had suddenly gone up to 8.9 mmol/L. I got an ECG done and found it normal and relaxed thinking it (his high potassium) couldn't be true especially since one report the day before was 3.4 mmol/L. However on closer look at the report of 3.4 mmol/L I realized it was someone else's report wrongly stuck on to this patient's file (doesn't speak well of our ICU staff including myself I know).

The patient's relative had obtained this wrong report from the lab without noticing the name, handed it over to the ICU sister who stuck it to the file without noticing and I had glanced through the day before without noticing the wrong name either. When we collected the correct report that was also raised (which proved that it was steadily rising and we rushed him for a hemodialysis for severe hyperkalemia).

Yesterday night I reflected on the appearance of severe hyperkalemia in this patient and that too without ECG changes and sure enough found some reliable literature in the net describing severe hyperkalemia without ECG changes and also realized that this person had been started on an enteral protein supplementation and it was possible that he was gaining a lot of potassium through that. I have changed his protein supplement powder to one that contains low potassium along with continued other drug management for his hyperkalemia.

The point of all this case discussion is to a) illustrate the simple, complex to chaotic evolution of care pathways (this was off course acute care) and b) reiterate the inadequacy of average text book information which may not cater to real time point of care requirements and c) emphasize the urgency of creating online experiential patient centered learning networks to facilitate better health care outcomes (and improve medical education in general which still hangs on to gleaning average information in intermittent boluses of lectures/discussions in weekly/monthly conferences etc). d) Obviously all of us need not go through all the experiences of others but only that which may be relevant to our point of care case based needs. There is a very interesting article on case based medical informatics that is being developed and needs our support in its further development at this link:http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=544898