“Please Choose One”

A short story by Phillip Allen Green. 


Please choose one:

The three words blink in front of me on the computer screen.

Please choose one:
Patient is-

Male     Female 

I click FEMALE.

I watch as the auto-template feature fills in the paragraph for me based on my choices.

Patient #879302045

Patient is: 38-year-old female status post motor vehicle accident. Please acknowledge you have reviewed her allergiesmedications, and past medical history.

I click YES.

Have you counseled her about smoking cessation?

I click NO.

A little animated icon of a doctor pops up on the screen. His mouth begins to move as if speaking. A speech bubble from a comic strip appears next to it.

“Tip of the day: smoking cessation is important for both the patient’s health and part of a complete billing record.” 

The animated doctor smiles and swings his stethoscope like a lasso.


A new screen appears.

Please choose one:
The patient’s current emotional state is best described as-
☐ Distraught     Calm      Agitated

I turn away from the computer to look at the patient. She lies curled in a ball on her side. Her bare feet stick out below the sheets halfway off the gurney. I notice she has a turquoise blue toe ring. She stares straight ahead. She plays with her patient ID band, twisting it round and round with her other hand. Makeup is smeared around small brown eyes. She stares blankly at the wall behind me. I clear my throat. She doesn’t blink. I clear it louder. Still nothing.

I look back to the computer. The same screen is still there.

Please choose one:
The patient’s current emotional state is best described as- 
☐ Distraught     Calm      Agitated

I turn back around.

Blonde hair is matted to the right side of her face where tears have dried it to her skin. A thick strand of it hangs across her eyes and I wonder if it annoys her. I watch as tears reform in her eyes and run sideways across her face. A teardrop starts to grow on the side of her cheek. More tears are added until finally it falls from her face onto her tear soaked pillow.

Her chest rises and falls at a rapid pace. She is breathing fast, almost panting. It is a raspy sound. I bet if she spoke right now her voice would sound raw, the kind of scratchy raw that comes after too much screaming. But she doesn’t speak. She just lies there breathing with a thousand yard stare fixed to her face.

The computer dings.

Please choose one.


The computer takes me to a new screen.

Please choose one:
Patient’s primary reason for being distraught-
Emotional     Physical     Other

The patient starts moaning. I look over. A guttural sound that is part wail, part cry spills out of her just loud enough for me to hear.


That selection triggers a new screen for me with new choices:

Please choose one:
What is the reason for patient’s emotional problem?
Intoxication   ☐Psychiatric   ☐Neurologic

Hmm, I look at her trying to decide which to choose. She is in a hospital gown. Her clothes were cut off with the trauma shears when she came in. She still smells like gasoline and blood and burnt plastic smoke. It burns my nose sitting this close to her and makes my eyes water.

There’s dried blood mixed with car oil and dirt on her chest. There is a lot of it. It covers her shoulders and the top of her breasts like a red patchy shawl, yet she is not injured. She has been examined and x-rayed and CAT scanned from head to toe. Her body is fine.

The computer dings again impatiently, prompting me to choose one.

Please choose one:
What is the reason for patient’s emotional problem?
Intoxication   ☐Psychiatric   ☐Neurologic

I click the Next arrow at the bottom of the screen to try and advance the page without choosing one.


My mouse circles the screen hesitantly. I guess I will click… PSYCHIATRIC. In a way emotions are psychiatric, I tell myself.

Choosing psychiatric has opened a new screen.

The patient shifts on the bed. A glimmer on her head, reflecting the fluorescent lights above, attracts my attention. I lean in closer. There are shards of broken up windshield glass scattered throughout her hair. Some are brown from dirt from where she lay on the ground, some are stuck to her head from blood, and some are scattered on the sheet below her. The shards twinkle on the bed like little stars.

I frown, the nurse was supposed to clean her up. I wheel backwards on my doctor stool across the trauma room to the door. I lean my head out through the curtain.

I look around. I spot the patient’s nurse. She is sitting on the other side of the ER, working at a computer. I know she is trying to enter data from the patient’s visit to get her charting done. Well, I think, maybe someone else can help us.

I scan the ER. There are doctors and nurses everywhere down here, yet every single one that I see sits at a computer with their eyes chained to the screens and a scowl on their faces while they click and type, click and type. I bet the hospital could burn down around them and they wouldn’t notice.

“Hey!” I yell.

No one even looks up. The clicking and typing continue.

An old man standing in the doorway of another patient room makes eye contact with me. He scowls as he surveys our ER. He shakes his head in disgust. I blush and duck back into the room behind the curtain.

The computer dings twice now, prompting me to hurry up. I remember my patient throughput time is monitored and reported and compared to the national average. A timer has appeared on the bottom of the screen, letting me know that I am four minutes twenty-eight seconds past the average ER doctor throughput time.

The numbers keep climbing. If I spend too much time on one patient, I will get a letter from administration for not meeting my throughput quota. I wheel back up to the computer.

Please choose one:
Because you chose Psychiatric, patient was offered-
Counseling     ☐Medications     ☐Inpatient Care

A sob wracks my patient’s body interrupting me again. She shifts in the bed, leaving clumps of brown dirt crumbling on white sheets. She is absolutely filthy. I wonder how long she lay in that field before someone found her. She still stares at the wall, unresponsive.

I look back at the computer. I didn’t offer her any of these things. Maybe I should lie and click counseling so that I can finish her chart.

I click Next.

YOU MUST CHOOSE ONE pops up again.

Please choose one:
Because you chose Psychiatric, patient was offered-
Counseling    ☐Medications   ☐Inpatient Services

I try alt tab. No luck.


I give up and click COUNSELING.

Another screen.

Please choose one:
Patient responded to counseling with:
Excellent Improvement Some Improvement No Improvement 


The little doctor figure reappears on the screen. He’s holding up his index finger and a light bulb appears over his head as if he’s just had a fantastic idea he can’t wait to share with me.

“Dr. Tom Tip reminds you: Did you try offering a drink of water or a tissue? Surveys show that sometimes it’s the little things that make patients feel better.”

I look over at her. I can’t bring myself to offer her water. Her knuckles are blanched white from the death grip she has on the side rail. She’s mouthing the word NO over and over to herself and shaking her head back and forth. Her eyes are wide with terror and do not see me. The skin of her face is pulled taut with fear.

I know that look. She is seeing the moment. I know she is going to see it again and again for the rest of her life. It will come in nightmares, it will come in dreams, it will come at the worst possible moment of what should be happy occasions, more likely than not it will even come at the moment just before her own death no matter how long she lives. She will never escape it. Sixty-eight minutes ago her brain burned an image into the inside of her skull that she will never be able to unsee.

I click SKIP.

The doctor icon disappears, replaced by text.

Please choose one:
Did you offer the patient water?
Yes     No

I click NO.

The little figure pops up again this time with a stern look on his face and his arms crossed.

“Surveys show patients like it when their doctors offer them water or a tissue. Patient satisfaction scores go up. Try it, you might be surprised.” He uncrosses his arms and holds out a little of glass of water.

For a brief second I imagine punching my fist through the computer screen. It would feel so good to climb the stairs to the top floor of the hospital with the computer stuck on my arm. I imagine spinning in a circle and launching it as hard as I can off the roof of the hospital towards the pavement below. I would give anything to see it smashed and destroyed and ruined, just as it has done to this profession I once loved.

But I know they would just replace it with another computer and just as quickly with another doctor.

I sigh and look around the room.

There is a cup on the counter.

I frown, it is awfully dirty.

I pick it up and turn it over.

A child’s tiny, bloody shoe falls out onto the counter.

The woman cries out, Oh God Oh God Oh God and grabs the child’s shoe before I can pick it up.

She holds it next to her face. She’s sobbing now and starting to scream. Oh God Oh God Oh God Oh God Oh God. She clenches the shoe to her chest. The blood on the shoe matches the blood on her chest.

The computer dings.

“Did you give the patient a cup of water?”

I lie and click YES.

“Good job!” The computer trumpets out a happy horn sound. It’s hard to hear over the patient’s screaming. The little doctor gives me a thumbs up and high fives a hand that appears on the screen next to him.

“Sometimes it’s the little things that make people feel better.” The doctor says.

I click NEXT.

The Patient Disposition Screen loads.

Please choose one:
Where is the patient going after the ER?
Home     ☐Admitted     ☐Transferred

I hover the mouse on the screen for a second, trying to decide.

I click HOME.

Please choose one:
How is the patient doing after your care for her?
Improved      ☐Not Improved     ☐Other

I look at her again.



This time the whole screen flashes. The little doctor is back, hands on his hips. His face is stern as the speech bubble appears next to his head. The letters are in red this time.

“Patients who are NOT improved should NOT be sent home. You clicked Psychiatric as her primary issue. Perhaps some medications would help the Healthcare Consumer. Would you like me to recommend some choices available on the hospital formulary?”

I ponder the question. Is there a drug for this? Something that will make her feel better? Something that doesn’t wear off like, ever?

I click NO.

Are you sure? The computer asks again.

I click YES.

A big red flag now pops up on screen and the computer buzzes like a half time buzzer in a sports game that I have just lost.

A note of this patient encounter has been sent to your Hospital Administrator for chart review of this patient. It is the goal of our healthcare facility to make patients feel better before they are discharged. You have acknowledged that you failed to do so. You will likely receive a lower patient satisfaction score for this.

Please acknowledge.

I click NO.

It flashes again.

Please acknowledge.

I click NO.

Please acknowledge.

I click NO.

A box pops up.

I am sorry, Valued Healthcare Provider, do you not understand the question? Would you like to fill out a service ticket?

Yes   No

Please choose one.

The words blink at me on the screen.

I look over at the patient. She is on her side again, sobbing as she cradles the tiny shoe to her chest. Her eyes are squeezed shut and she’s rocking back and forth so hard the whole gurney is shaking.

I look back at the computer.

Please choose one.

I look back at my patient.

Please choose one.

Suddenly I get it. I choose.

I reach down and unplug the computer. The screen goes black.

Without the noise of the computer fan whirring, the room is suddenly silent- save for her quiet sobs.

A strange feeling comes over me, one I almost forgot existed after so many years.

I remember who I am and why I am here.

I stand up and take a deep breath. I step towards the patient and begin the long and tedious process of gently picking out the shards of bloody glass stuck throughout her hair. As I start to work she opens her eyes and blinks.

She sees me.

The terror filling them fades just a tiny bit.

For once the computer stays quiet.

I pick through the strands of her hair. The three words blink in my mind over and over.

Please choose one…

Please choose one…

Please choose one…




©Philip Allen Green


via Blogger http://ift.tt/1DwrukN February 15, 2015 at 10:18PM

IT Laments From An ER Doc–Dalai’s 10th Anniversary Post

Fellow blogger and ER physician Edwin Leap, M.D. has apparently discovered the joys of poorly written software I’ve been bemoaning for so long.

In a December entry, Dr. Leap opens with an apology for the behavior of some less-than-tech-savvy physicians:

I know that, on many levels, physicians must be the absolute banes of your existence. We are grumpy and resistant to change. And some of us are still confused by graphing calculators, much less complex modern computer systems. We call you because we forgot our passwords, then because we forgot the new passwords. We call because the system crashes and we call because the voice recognition doesn’t work and we curse the screen and shake our collective fists at things that slow us every day. I get it.

He’s a bit more conciliatory in this than I’ve been, but he’s right. There are some docs for whom the acronym P.B.K.A.C. (Problem Between Keyboard and Chair) is 100% applicable. These unfortunate folks are the inspiration for Dalai’s XIIth Law

XII. The PACS needs to be operable by the least technically-savvy radiologist on staff.

That being established, Dr. Leap takes the gloves off, and picks up my battle-flag, starting with his disgust with his EMR.

However, there are some things that you and those who develop your systems need to understand. Allow me to elucidate.

We didn’t ask for EMR in its current incarnation. It is now a gargantuan billing and data collection industry, with precious little utility in our day to day practices. As such, your bosses love it because it squeezes the last gasping penny out of every chart. They write your checks, we don’t. Nevertheless, we have difficulty being excited about ever more fields to fill out, ever more time-stamps, ever more screening exams, and the caucophanous symphony of key-strokes and mouse clicks that echo through the modern hospital and threaten to muffle the sound of suffering and human interaction.

The vast majority of EMR’s, CPOE’s, etc., are unwieldy, unusable pieces of convoluted trash, which add to the hours of the already full day of a busy physician. More on this in a moment.

Next, passwords and security make a lot of sense to you. You dwell in a world of hackers and identity theft and you worship at the silicon altar of HIPAA. We, however, are busily seeing patients and trying to do it as quickly as possible in hospitals, clinics and especially ER’s that have no ‘off’ switch but which do track our ‘quality’ in part by tracking our speed and efficiency. Thus, we have little time to spend logging on. And when we step away to, say, intubate a dying patient, the last thing we want to do is log back on to 1) the computer 2) the hospital EMR system and 3) the particular department system and 4) the radiology viewing system. But here’s the really, really important part: nobody is busily stalking behind us trying to look at medical records or interpret xrays on strangers so that they can violate their privacy. We’re watching; trust me.

It was a nice idea but now it’s a poison. It is the law of unintended consequences on steroids. It’s all redundant, irrelevant, obnoxious busy work that stands between us and efficiency. If you really insist on it, then make it all biometric with thumb prints. Because tracking usernames and passwords is starting to take up more of our fragile brains than drug doses and diagnoses. And that, my friends, is not good.

Yes, security. We all understand the importance of keeping hackers and other slime out of patient data. I wonder how many passwords Anthem had that didn’t prevent 80 MILLION records from being compromised. Screw passwords. Let’s try biometrics, wrist-worn RFID’s, implanted chips, retina scans, anything that will get the job done painlessly (well, after the chip implant, anyway). We simply don’t have the time to re-log in 35 times per day.

You might recall my tale of IT tyranny from the same Laws of PACS lecture wherein I used AutoHotKey to create a little macro script that pushed the button that kept my RIS active. IT at first banned the macro because “someone might use the program to bypass a password screen.” Yeah, right. They knew quite well that I was the only radiologist in my group capable of even understanding how that might be done, and they knew me well enough to know that I wasn’t going to do it. I did win out in the end, but as usual, it was a battle that really didn’t need to be fought.

Dr. Leap continues his velvet-gloved attack, documenting another pet peeve of mine, the inability of IT to grasp the mission-criticality of what we physicians do, day in and day out.

Now, about tech support and system back-ups. We have to use these systems. There is no option. And we have to use them 24/7/365. Because that’s when people get sick and die. Therefore, every system needs to have a parallel back up system that kicks in whenever a data transfer or update or repair or anything else is happening. ‘We’ll be shutting down for four hours’ isn’t an option anymore. Since ‘we won’t see heart attacks for four hours’ isn’t an option either. Furthermore, when things are going badly, when we need a reset password or when the computers are locked up in some loop that looks like an alien language, we need help immediately. We don’t need ‘a ticket’ submitted. A round-the-clock job that requires EMR necessitates round-the-clock IT. No questions asked.

And finally, my new friend the ER doc rediscovers the travesties I’ve been bellowing about for just over 10 years on this very blog:

Finally, to those who design these monstrosities and those who buy them to the protests of clinicians, what are you thinking? Medicine is about caring for patients. And anything you create that makes it more difficult is an insult. Shame on you. You should do better, for your staff and for the patients who ultimately pay your salaries and fees.

Dr. Leap ends with a leap of niceness toward IT that I wish I could manifest as well…

And for you IT folks, I’m sorry. I’ll keep trying to do better. I generally know where to find ‘start’ when I’m talking to you and I can actually navigate the directions you give in a fairly efficient manner. I know that the disc drive isn’t a cup-holder and that I have PC, not a Mac. I’ve even been storing my passwords on my smart phone! I realize you have a tough job; made tougher for dealing with physicians and nurses.

All I’m saying is this: I understand your frustrations. Try to understand ours!

Yes, IT departments, and particularly software vendors…TRY to understand our frustrations. I have been blogging for TEN YEARS, saying basically the same thing. A significant plurality, if not the vast majority, of medical software is utter, complete, unmitigated GARBAGE. It is designed by engineers with no experience in healthcare and tuned to the specs of bean-counters, with no experience in healthcare. It is pitifully clear that absolutely NO thought has been given to the usability in the hands of those who need to make these abominations work in the process of treating patients and hopefully saving lives. It is nothing short of criminal, but it is no surprise. These Rube-Goldberg contraptions are NOT selected and purchased by the people that use them, but rather by those beholden to the bean-counters or other administrative influences, and those who wish to have the easiest time servicing the product.

Sadly, even after 10 years, I don’t know the solution to this situation. CIO’s and IT departments are not about to give up their influence over these huge expenditures, and I’m not sure how to take it away from them. Perhaps the only thing I can do is to slap the vendors in the face repeatedly with the fact that their software sucks, and hope that the subsequent embarrassment will prompt them to clean up their acts. I’m not holding my breath, and I have grave doubts that I’ve influenced anything much at all. Perhaps once I’m fully retired, I can turn my attention more fully toward this effort.

In the meantime, the frustration continues, with potentially deadly consequences.

via Blogger http://ift.tt/1FM3kCx February 14, 2015 at 02:25PM