What About This?
2022; Lippincott Williams & Wilkins; Volume: 44; Issue: 3 Linguagem: Inglês
10.1097/01.eem.0000824160.71964.d6
ISSN1552-3624
Autores ResumoFigure: humor in medicine, diagnostics, ICDFigureThe chief complaint was “struck by car.” Luckily, the patient only had bruises and scrapes. She was in uniform delivering packages when she was knocked down in a crosswalk, so this was work-related, and I wanted a formally correct diagnosis. I typed “struck by car” into the discharge diagnosis window. Nothing. Maybe “car” was wrong. Automobile? I typed “struck by a ∗” and got: Struck by alligator Struck by alligator, initial encounter Struck by alligator, sequela Struck by alligator, subsequent encounter And down the rabbit hole I went. “Struck” by an alligator? I could accept bitten, mauled, drowned, or frightened, but struck? Was this alligator thrown? Once upon a time, a doctor would see a person hit by a car and type “hit by car” or “pedestrian struck,” whatever seemed logical as a diagnosis. Importantly, the computer was lazy and would allow this. The billing goblins over at Gringotts would then figure out which ICD code to choose from the list of International Statistical Classifications of Diseases and Related Health Problems. Then came improvements. The doctor might still want to diagnose a finger fracture, but the ICD-10-driven electronic medical record now preferred “fracture, 4th proximal phalanx, closed, initial encounter.” (As of January, we have another upgrade, to ICD-11! The World Health Organization says ICD-11 [https://bit.ly/33OUIlA] will improve tracking of everything from the use of folk remedies to COVID-19 vaccination uptake.) Back to my pedestrian struck. I broadened the search parameters, typing “struck by,” which returned alligator, baseball, baseball bat, basketball, and continued on into the Cs and Ds: Struck by chicken Struck by cow Struck by crocodile Struck by crowd with subsequent fall Struck by dog Struck by dolphin Struck by duck Of course, I get more than this. There are usually four choices for each category: Decline to specify further details about the incident with the duck. Be generous to the epidemiology nerds, and specify that this is an “initial encounter” with the duck. Clarify that this visit is for sequela. So it's post-duck-struck chronic pain. Or perhaps PTSD: “Every night I see that mallard rocketing toward me, and I wake up screaming!” Clarify that this is a subsequent encounter. It's a struck-by-duck bounce-back: “Doc, this duck is still jammed headfirst in my ear! You said, ‘Give it time, it'll fall out,’ but it's been three days!” The list includes every “struck by” option. Alligator to duck, this is the list (per the Epic EMR in 2022) of things patients get struck by. Struck by dolphin? Welcome to our universe! Struck by door? Never happens. It gets worse. Brace yourself for the “struck by” alphabet, from alligator to ... volleyball. (That's right. There's no zebra. Is that an oversight or ICD-10 discrimination against land-based fauna? Read on to decide.) Under F, “struck by” starts logically with “falling object,” but it's almost impossible to move on, mentally or emotionally, from the first subcategory: “Struck by falling object due to accident to nonpowered inflatable craft.” Your patient is on an inflatable raft. It's not powered, so it moves as fast as she can paddle. Then there's an accident! An object falls! From where does this object fall? Quit making sense! Don't look at the grammar either! Onward! Think of falling objects. You might think of a ladder or a roof, a construction site or a warehouse, overhead shelves or trees or the sky itself. The Epic universe recognizes none of that. Instead, the computer is obsessed with water-based struck by falling object scenarios, in which an “accident” happens “to” a: fishing boat merchant ship passenger ship sailboat water skis watercraft Imagine a chicken, on water skis. Nope, we don't have time for that. Onward! To finish out F, one can be struck by a field hockey puck, a field hockey stick, a football, or furniture. G: golf ball, golf club, or goose. That's it. H: hit or thrown ball, or horse. That's all. I: ice hockey puck or ice hockey stick. That's it. L: Struck by lightning. No llama. No lady. Neither lizard nor lizards (see below). Not a lacrosse ball and not a lacrosse stick. M: Macaw! N: Nonvenomous lizard. Nonvenomous lizards (plural). Nonvenomous snake. That's it. O is up next. There is some redundancy with object (no longer falling), and then there is orca. I can't have struck by car, but I can have struck by orca? What the flipper is going on? Next there is an entire “struck by other” category. Struck by other birds comes up first. Note the plural: You can't be struck by one bird, only many. Unless it's a chicken, duck, goose, or macaw. To round out the struck by other options, in order and in their entirety, we have fish, hit or thrown ball, hoof stock, mammals, marine mammals, nonvenomous marine animals—I'm not making this up!—nonvenomous reptiles, psittacines, and sports footwear. Let's bring it home, the last 11 letters of the alphabet, in order and in their entirety: parrot, pig, raccoon, sea lion, shark, sharp object, shoe cleats, skate blade, soccer ball, softball, tennis racket, turkey, turtle, and volleyball. It was a struggle to find a computer-approved diagnosis for my patient struck by a car. But I took comfort knowing that all this ICD-driven drudgery would, many years from now, help illuminate our world. Think of the things future researchers will discover: an epidemic of blunt trauma involving sea lions, orcas, and other nonvenomous marine animals, evidence that lacrosse is exponentially safer than field hockey, a shocking rise in macaw-based assaults. Trust the science! Dr. Bivensworks at emergency departments in Massachusetts, including St. Luke's in New Bedford and Beth Israel Deaconess Medical Center in Boston.
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