Wednesday, July 2, 2014

Wednesday special

So usually I keep my posts to scion meetings and Sherlockian gatherings, because this is a gossip blog, after all. However, I felt encouraged to post this after some discussion and it's something I plan to present to the real-life (as opposed to virtual) public sometime this fall.

It's sort of an essay/script I wrote about Sherlock Holmes and medicine, or more specifically, Holmesian methods as applied to pharmacy.

Read under the cut!

First off, let me tell you a bit about myself. I am currently a candidate for the doctorate of Pharmacy for 2015, from the St., Louis College of Pharmacy in the Central West End.

At least from what I have been taught, pharmacists don’t necessarily go into anatomy and physiology as much as physicians do, but I’ll do my best to explain

The practice of medicine relies heavily on the “Holmesian method” for diagnosis of a problem. Clearly, Sir ACD thought so too, since Holmes was based on the real life physician, Joesph Bell who stressed the importance of observation on a patient.

 A patient will present to the emergency room or clinic, may not know what is happening, so the Physician attempts to figure out the problem. .

So the patient comes into the ER. Maybe he comes in, short of breath, squeezing pain in the chest, looking sweaty. What could it be? Holmes would say that the first step would be to gather the facts.
 What happened when the thing went wrong? What is the patient’s history? Diseases? Medications? Unfortunately, the problem can be so acutely life threatening or bad, that a treatment decision has to be made very quickly- or at least something to alleviate symptoms so that the team can examine the patient.

Next, an examination takes place. The team will whisk away a patient’s clothing and personal items on expectation of admission, but clothes would be helpful. Someone who comes in with street clothes is more likely to have had an acute problem rather than someone who comes dressed in pajamas, or even someone who comes with a suitcase (probably been before, expecting to stay for a while). The state of their clothing might even tell what they were doing at the time of what happened. Like, were there any stains? Trauma?
 One of the patients who I talked with came in with sweaty clothes, and grass clippings stuck to his neck and shoes. So, he was probably cutting the grass right before he came. He probably didn’t  bother to change into more comfortable garments, so it was probably an acute problem where he needed attention right away, so maybe muscle cramps? Heart attack? Blood clot?

So blood is sent to the laboratory, cultures, etc. MRIs- you know the picture. If you’ve ever needed to go to the ER, you’ve had all these procedures done because the MD was trying to figure out what’s wrong.
The facts are gathered, sorted. And then we generate ideas. Of the most likely problems, which of these could it be? Remember to fit the explanation to the facts, rather than vice versa. Throw out theories that contradict evidence and do not discard facts.

Pharmacy is a bit different. The detective work comes in from a retrospective point of view. At least from a hospital setting, the detective work is figuring out what the MD have done and what patients have done.
For example, I monitored all the patients who were on blood thinners. There are different doses given to patients who are on blood thinners to prevent getting one, and those who actually got a blood clot and need treatment doses for it. So to boil down my method of thinking in a systematic way, I look at which patients have a dose that sticks out to me.

Then I think to myself about all the reasons why someone would receive that specific dose. Then I look through their chart for evidence of that diagnosis to receive the dose. Luckily for me, most of the time the doctors will record the diagnosis, so I can be okay with it. However, if they don’t record the diagnosis, I have to look for evidence of something that would prompt them to use the blood thinner for that reason.
So I start looking for what time they started that medicine. If they got it during their hospital stay, I look at the documents around that time period- a little before and a little after. If they got it right of the bat, I look at the initial diagnosis- why they came in- leg pain? Short of breath? Chest pain? Okay, all those could be suspect for a blood clot.

Then I look at what medicines they gave. So, antibiotics- for short of breath- okay, probably going to get diagnosed with pneumonia or something. Next.
I look at diagnostic tests- what do they have to say about the patient? Did they record any occlusions in a blood vessel? What medications are they currently getting?
And then, sometimes I conclude that they really don’t need that dose. The error could be in failure to record the diagnosis + evidence or they could really just not need it.

Sometimes not all of the evidence is available. However, it’s been brought up in the presentation that as the detective, one decides which facts to include and exclude as the evidence.

So all these things I talked about appear in the Holmesian method of deduction- decide on the problem, look for evidence, include/exclude facts, formulate theory, and make a plan.