"House" Rules
Cesar M Limjoco MD
Chief Medical Officer | Board Advisor | Keynote Speaker | 26k+ Linkedin followers/connections
I posted a Linkedin poll asking about a true situation that I personally experienced. Here is the link to the Postop Respiratory Failure? poll.
“But it met the definition criteriaâ€
The greatest lesson in the highly-rated TV series, House, is that patients may initially seem to meet criteria for a certain condition but later negated by the true clinical picture at the end of the 30 min show. Diagnosis is the core of Medicine. Like Dr House, one needs to be a good detective and investigate all the clues to arrive at the Clinical Truth?!
Definitions, criteria, parameters, protocols and ICD codes/guidelines are devised to capture the true nature of the patient's condition. They are valuable means to an end. In all these, it is essential to find the etiology, the pathophysiology, in order to exact as close to a bona fide depiction of the true clinical picture.
Postop respiratory failure is a dire condition that carries high mortality. It is a major concern for all healthcare providers with any surgery. This is a serious complication. Common causes are pre-existing diseases, substantial Pulmonary Atelectasis, Aspiration Bronchitis/Pneumonia, Pulmonary Embolism and ARDS.
Narcotics are respiratory depressants. The respiratory depression adverse effects span the gamut of hypercapnea and/or hypoxia to full-on acute respiratory failure to respiratory arrest. Even appropriate doses can end up with respiratory depression (throughout the spectrum) in sensitive patients. Doses in excess of standard treatment can cause toxicity. Toxic doses rarely happen in the hospital setting, although therapeutic misadventures do occur.
As you can see, these conditions have subtle nuances with different considerations and impact on patient management and outcomes. It is crucial to call them out appropriately. It’s not just semantics. Words do matter. This is not a competition or game with no untoward consequences.
Everything we do should have the patient as the priority. All other agenda is secondary. So tell me -- when all the chips are in, what does the patient truly have? This should be the underlying theme in every quest. Like in the defunct TV series House, the definitive diagnosis is not always clear at the outset. Time is needed for all the chips to come in. In the beginning, there is the initial impression and differential diagnoses. As patient monitoring and tests come in, diagnoses are ruled out. And finally when all the chips are in, the most definitive or at the least, the most probable diagnosis becomes clear. It may take half an hour of monitoring a postop patient to several outpatient encounters or a full inpatient encounter to get there.
It goes beyond coding and coding rules. Fulfilling criteria is the minimum requirement (Was criteria really met?). We have to go over and beyond the lower thresholds and aim for the highest imperative. It is about transparency and ascertaining the...
#Clinical Truth?
No more, no less.
This is what we try to convince the provider, but their colleagues and mentors try to hide their misunderstanding by poo-pooing us as just annoying. Therefore slowing the Learning Curve