Getting under the skin

Br J Cardiol 2008;15:241-42 Leave a comment
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We continue our series in which Consultant Interventionist Dr Michael Norell takes a sideways look at life in the cath lab…and beyond. In this column, he considers personal health records.

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Two, completely unrelated events prompted me to put pen to paper on this occasion (just in case you were under the impression that this column was simply the result of random neuronal discharges).

The first was yet another news item about any individual’s medical details and the idea that these are best retained by the patient him/herself. Perhaps with credit card-type technology, or in the future on an implanted computer chip, stored information could be available for any doctor–patient interaction – anywhere in the world – in order to be viewed and updated as appropriate. The second was a 1969 film I recently chanced upon, based on a short story by Ray Bradbury and starring Rod Steiger as The Illustrated Man, an admittedly odd bloke covered from head to toe in all possible varieties and descriptions of … tattoos.

The synaptic collision of these two cerebral inputs resulted in the generation of what might loosely be called a thought process. Might it be possible for useful – if not vital – medical information to be displayed in a permanently visible and indelible, yet suitably confidential, manner using the age old technique of staining the dermis with pigments?

Suggested positioning

Extending this hypothesis, one might imagine that one’s date of birth, and clinical features that are permanent or genetically acquired, might be listed on the right shoulder (as traditionally the physical examination tends to be from that side). Among some forward-thinking members of the armed forces, blood group is already documented in this way. I am thinking about other important diagnoses that might result in an acute presentation to medical care in circumstances when such information might be crucial; haemophilia, acute intermittent porphyria and diabetes are some examples.

I’m sure you may be able to think of others (if there is anyone out there still reading this), but my own recollection of general medicine becomes a little sparse at this point. An allergy to penicillin or, say, contrast medium would also be indicated here.

The left shoulder would be the site for medications and other past medical history, the latter listed in the same manner as adorns the first half page of so many letters generated by hospitals in accordance with the novel idea of viewing patients as a collection of ‘problems’. Thus: ‘depression, asthma, migraine, coronary artery disease, mild renal dysfunction, hypertension, hyperlipidaemia, possession of seven or more problems’… the list goes on and on. (It is surprising that such an individual is still able to draw breath.) Anyway, just so long as there is enough room between the shoulder and the elbow to accommodate the burden of such acquired diagnoses.

I trust you are now getting the picture, and – acknowledging the need for at least some discretion – we still have the chest, back and abdomen to go.

Removals

It used to be possible to deduce what organs were – or weren’t – in situ by inspecting the belly and noting the presence and position of any surgical scars. However, given the modern tendency to adopt minimally invasive laparoscopic technology, this fallback is no longer reliable. I am now informed that one’s gall bladder can be removed, not via a Kocher’s incision and 10 days in hospital, but through a couple of small nicks in the skin and being advised to take the rest of the day off.

Nevertheless, my new approach to past medical history can circumvent this minor obstacle. Under the heading ‘The following have been removed:’ it would be an easy matter to document any items, such as ‘right kidney, appendix, spleen, etc….’ together with the date of surgery. Providing the list begins at the epigastrium, there should be enough space down to and around the umbilicus in order to account for most organs that could possibly be extracted without jeopardising continued existence.

The liver edge could also be indicated (together with the date) so that its inexorable descent as a result of ‘lifestyle malfunction’, may be plotted and displayed graphically.

Cardiology advantages

From the cardiological point of view, the advantages are clear. The femoral pulse can be easily displayed, for instance with a cross, together with a cephalic pointing arrow in order to remind the more junior trainee of which direction the catheter should be advanced in order to maximise the chances of reaching the heart. A target design, like the Royal Air Force insignia, could lie on the xiphisternum with the helpful instruction: ‘In case of cardiac arrest, press here’.

It would be an easy matter for the limbs, ribs, clavicle, etc., to show the sites of previous fractures (with some form of jagged line, perhaps) – together with the date, of course. If internal fixation had been required then the various screws or plates would be represented with suitable diagrams as well.

But back to the chest, and those pieces of information that would be of value to cardiological inspection. The vertical height of the venous pressure above the sternal angle is invariably difficult to quantify to the nearest centimetre, let alone document using a neat fluid level like a Plimsoll line on the side of the neck. However, the apical impulse is more locatable and its position on the praecordium, as it moves laterally with the progression of cardiac disease, can be easily observed.

Ideal echocardiographic window positions and the correct sites of electrocardiogram (ECG) electrode placement would be other options, the latter showing the QRS configuration for each lead. Similarly, the optimal locations for cardiac auscultation can be signed, and the graphical depiction of the sounds and murmurs that the examiner is likely to hear, appropriately notated.

Turf wars

I fully appreciate that there may be some drawbacks with this concept. Would different specialities have turf wars over cutaneous territory felt to be the rightful domain of each? Respiratory physicians and cardiologists might fall out over some parts of the chest – the lung bases particularly – as might general surgeons and gynaecologists over the lower reaches of the abdomen.

I can imagine that ophthalmologic or ear nose and throat conditions would certainly be less than straightforward to describe accurately, let alone in the relevant position and, come to think of it, there are other specialities (no need to specify here) that would be similarly hampered. And what would the dermatologists do, always assuming they can find a space somewhere?

I am beginning to realise that I have taken this novel concept about as far as it can reasonably go. I look at my left arm upon which my medications are listed in a dull blue pigment embedded under the skin and below the motto, ‘Keep taking the tablets’. Good idea.

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