Another EMR, and a Parkinson’s patient improved.


A tremor after the Great Flu
Is Parkinson’s, we already knew.
There’s more! Please just wait,
There’s a shuffling gait,
And the facial movements are few.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Towards the end of his life, my father developed Parkinson’s disease, which eventually killed him. Ever since I’ve been alert to the diagnostic clues.

When I started in training, 80% of the Parkinson’s that we saw came in the wake of the Great Influenza of 1918. By the 90’s I could tell you from across the street who had escaped that flu (the spry) and who hadn’t (the slow movers). That generation has passed.

When most people think of Parkinson’s, they think of the characteristic “pill-rolling” tremor that goes away when the person moves with intent. But I don’t often see that tremor. I look for facial expression that doesn’t change much, a stiff, shuffling gait, and very small handwriting (micrographia). I listen for monotonous, quiet speech. I inquire about loss of sense of smell (anosmia). I feel the muscles between the thumb and forefinger while I talk tot he patient, which will show the beginnings of a resting tremor long before it becomes visible.

Today a patient made my day with Parkinson’s visibly improved. I had made the diagnosis relatively early. The voice had more music, and the small, involuntary facial and hand movements had returned. Much work remains to fine-tune the medication.

I now have access to the current EMR, NextGen, the 7th EMR I’ve learned since January. I have left off dictating my records like I did in the first two weeks. The computer gets in the way of patient care, but complaining about it does no more good than honking one’s horn in a traffic jam. Nonetheless I worked three unscheduled patients in, and for each one I spent a good deal more time entering data into the computer than I did with the patient. I’ve had lots worse EMRs here in this country (New Zealand’s, MedTech32, stands as a shining ray of hope that we could have a good system), but I have had better, too. It doesn’t stick very much. When I run into a click-and-wait, it doesn’t last more than 20 seconds. Sign on takes less than 3 minutes. But it has design flaws. The button to sign off sits in the top left corner right next to the button used to clear one patient’s chart and move to another. Every drug for every patient comes with a warning, mostly frivolous, but a lot like the boy who cried wolf.

The clinic won’t have it much longer, Cerner will replace it in February.

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