Sources of fiber in your diet: case

This one comes up so often there is no particular case I can describe.

Here are the resources I recommend to patients at the clinic:

Family Doctor: Fiber: How to increase the amount in your diet
Family Doctor: Irritable Bowel Syndrome: Tips on controlling your symptoms
Mayo Clinic: Dietary fiber: Essential for a healthy diet
WebMD Fibor-o-meter
HealthLink BC: Fibre and your health
BC cancer Agency: Dietary fibre content of common foods

Tetanus vaccine: case

I haven't posted a case in while so I thought I would put my discussion of shared-decision-making and decision aids on hold, and spend the next couple of posts writing up cases instead.

Scenario

A man sends me an email. He would like some information about tetanus shots. He is scheduled for one the following week and would like to know what to expect in terms of normal reactions because a friend of his told him her arm swelled up a week after getting her shot.

Resolution

Judging from the man's email he has relatively high literacy and so I an able to give him information at a fairly complex level.

MedlinePlus - Medical encyclopedia entry on tetanus vaccines.

Immunization Action Coalition - vaccine information for the public and health professionals: Questions & answers about the tetanus vaccine.

The Immunization Action Coalition works to increase immunization rates and prevent disease by creating and distributing educational materials for health professionals and the public that enhance the delivery of safe and effective immunization services. The Coalition also facilitates communication about the safety, efficacy, and use of vaccines within the broad immunization community of patients, parents, health care organizations, and government health agencies.

UpToDate - Adult immunization (there is a nice section that covers possible side-effects from mild to severe, and a brief description of tetanus the disease).

Discussion

Immunization is THE top subject of interest to patients at the Herzl. Aside from a few questions I've received on the topic, my website statistics show that so far 832 people have visited the Vaccinations page 501 times since April (when the page was created). In second place is the page providing links to online Resources in French with 627 visits by 224 people (since January); and Heart disease and stroke in third place with 402 visits by 202 people (since March).

Depression: case

Scenario

A young man visits me at the clinic. He believes he is suffering from depression and would like to have some information on the topic, as well as about various medications, and alternative therapies. He admits that he is hesitant to go on medication, but also realizes that this may be his best option. He would like to be better informed before discussing his situation with his doctor. He has already looked online, but admits that most of what he's read is not particularly trustworthy and would like some advice on better resources.

Resolution

The first thing I do is show him MedlinePlus. I run a sample search and show him how he can also search the encyclopedia, and the drugs and supplements. It occurs to me that a decision aid might be useful to him, since he is in the process of trying to make a decision. I search the Ottawa health research Institute A-Z Inventory of Patient decision aids and find the Mayo Clinic's Depression guide which includes information on antidepressant meds, complementary and alternative therapies, personal stories and things to consider.

While we are talking it becomes apparent that he is a voracious reader, and quite prepared to actively participate in managing his own health, so I decide to also recommend a couple of books that he might find useful:

The Noonday demon: An atlas of depression, by Andrew Solomon, provides an astute and in depth look at depression through the ages and the controversy. The book is an engrossing read, is well researched, and provides a balanced look at the pros and cons of medication as treatment.

Full catastrophy living: Using the wisdom of your body and mind to face stress, pain and illness, by Jon Kabat-Zin. This book is a companion to the Stress Reduction Clinic at the University of Massachusetts Medical Centre, founded by the author. Yoga and mindfulness meditation are taken out of the realm of spirituality and religion, and used as practical and effective stress, pain and illness management tools. The program can be followed independently using guided yoga and medication tapes.

Discussion

It feels good to recommend books as well as online resources for a change. I don't often get the chance to do so since most of the questions I get are better answered in a relatively quick and dirty way. Usually people who come to me are looking for immediate and timely answers: information about clinical trials, medications, back exercises, dietary recommendations related to various conditions etc.

Total time: 1 hr

Staff requests: 2 cases and Ethics: challenge

It has recently been brought to my attention that there may be ethical problems with posting cases the way I have been, even though I have been very careful to remove any personally identifying information. Hopefully I will be able to continue once I have spoken to the ethics consultant at the hospital in order to confirm that all is indeed okay.

In the meantime I have taken the cases offline (hopefully temporarily), and today I will write about a couple of requests I've gotten from staff.

Case#1

Scenario

One of the health professionals (HP) at the clinic asks me to find some information regarding which vaccines that do not contain thimerosal (a mercury-based preservative used in multi-dose vials to prevent contamination) are available in Canada, as one of his patients has expressed concerns over the additive. He gives me a list of possible vaccines.

Resolution

I run several searches in Google which verify the correct spelling and allow me to narrow my results to those pertinent to Canada. Unfortunately, as I write this, I do not remember my exact searches, except that I did not include the vaccines from the list in my searches. I do remember running several relatively convoluted ones before I was able to find the information I was looking for. I have tried to reproduce my search for the purposes of this post and for some reason I am only able to find an older 1 March 2003 version of the 2007 document I am ultimately able to find for the HP:

Canada Communicable Disease Report
Volume 33 • ACS-6
1 July 2007 An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI)
Thimerosal: Updated Statement

Discussion

I find the older version by typing in thimerosal canada which is a search I know I would have run the last time, so I am doubly confused at to why I did not find the older version last time but have now found it so easily. Having found it there would have been no reason to keep looking as there is no indication that there is a more recent version available. This is yet another example of why searching for information using Google can be hit and miss. I have tried to reproduce searches before and have had similar problems, something I demonstrate in the Google course I developed for the Health Sciences Library: Google-eyed? Don't despair! How often do we take screen captures of our search results? It is way too easy for us to doubt ourselves and not the tool we have become so dependent on.

Total time: 30 mins

Case#2

Scenario

One of the GPs at the clinic asks me where he can find decision aids to use with his patients and their families.

Resolution

I happen to have a very useful site already bookmarked in MyHq so I show it to him: Ottawa health research Institute A-Z Inventory of Patient decision aids.

I also show him a really neat one I have found recently during an encounter with a family member in the Gynecologic Oncology department: Ovarian Cancer Treatment Guidelines for Patients– Version III, April 2007. The reason I like this one so much is that is not just a list you can print out and tick off, but rather a fully interactive tool that works something like a choose you own adventure.

Total time: 5 mins

Low back pain week: 2 cases

I am glad to report that this week I was presented with not one, but two cases, both having to do with low back pain.

Case #1

Scenario

A French-speaking middle-aged man has been referred to me by his physician at the clinic. He suffers from chronic low back pain and would like to know which exercises might help.

Resolution

First I go to Passeportsanté, hoping to find something in French similar to the MedlinePlus interactive tutorials, or at least with illustrated exercises.

Passportsanté > A-Z > D > Dos (mal de). This takes you to the same page as Douleurs lombaires.

Unfortunately there are no illustrations and certainly nothing interactive. I print it out anyway and then try CiSMeF (sites médicaux francophones à destination des patients et de leurs familles) to see what they have there.

CiSMeF > keywords: "exercises dos." I get two results, neither of which include illustrations, or even examples of exercises. Somewhat interesting though, so I print them out too.

Mal de dos: guide pratique
Mal de dos: pour faire le point

At this point I decide it's time to go to MedlinePlus. Since the information is illustrated, and the patient does speak some English, he will still be able to benefit from it.

MedlinePlus > keywords: "back exercises." I print out the list of results so he can access it again at home, and also print out the text summary of the interactive tutorial (which includes illustrations), and the second hit on the list which is a Low back pain exercise guide from the American Academy of Orthopaedic Surgeons.


Case #2

Scenario

One of the health professionals (HP) at the clinic comes into my room and asks if there is a pamphlet on back exercises. I know which one he is thinking of but we have run out.

Resolution

Since the patient speaks English and I have already fielded a similar question earlier in the week, I go directly to MyHq where I have bookmarked some useful links under the Pain management section.

I show the HP the aforementioned MedlinePlus interactive tutorial which he thinks is great (it really is), and Low back pain exercise guide from the American Academy of orthopaedic Surgeons, and this time I also include Low back pain: tips on pain relief and prevention from familydoctor.org.

I ask the HP to fill out an Rx so I can document the consultation and he is happy to do so even though it means returning to the exam room to get the patient's information (name, chart no.). I run into him later in the hall and he tells me he was impressed by how quickly I was able to find the information and that he is going to go back and explore MedlinePlus for himself.

Discussion

I often find that the French language information I am able to find is rich in theory and somewhat lacking in terms of image/illustration and maintaining an appropriate reading level. Fortunately most of the patients I see at the clinic are able to read enough English to still benefit from those resources. It is interesting to note that CiSMeF links directly from each topic to the corresponding section in MedlinePlus. All roads lead...

It is also interesting to note that this resource that we (librarians/information professionals) take for granted, is still not well known to all health professionals. I think this is true of many of the resources we use on a regular basis. I have noticed that health professionals at the clinic often request information in pamphlet form, even though they are all too aware that their patients are going online for information. The clinic used to have a "pamphlet room" and a pamphlet database, so I suspect that this is partly due to habit rather than ignorance.

Picky eaters: case

Case/challenge

Scenario

A young man follows his child into the room and sees a pamphlet he's interested in but we only have the French version displayed. He asks if we have it in English and I pull it out from one of the many boxes I am keeping under the extra desk until we can find someplace to store them. Eventually the plan is to have an extra computer at that desk that patients and their families can use while they wait. The pamphlet is called Feeding your child ages 2-5. The man tells me his daughter is 2 years and 7 months old and a very finicky eater. I offer to see if I can find some other resources. He's nervous about staying in the room with me as he might not hear his name being called. The waiting room is quite animated this morning and a vacuum is being used nearby. I offer to find some information for him and tell him she can pick it up after his appointment.

Resolution

I find a few good resources that will supplement the pamphlet nicely:

From Eat Right Ontario: Picky eaters and serving sizes
From Kids Health: Nutrition & Fitness section
From the BC Ministry for Children and Families: Feeding your toddler with love and good food (pdf)

I print these out and place them handily on my desk for the man to pick up when he leaves. He never returns for them.

Discussion

I'm not sure what to do with the 10 pages or so that I have printed. We have not yet established a procedure for this eventuality but I am now inspired to create one. Some things to consider: a way for patients to be located when they are with me and their name is called; a way to get printed information to a patient in case they forget it (email, fax?); a place to put abandoned printed information that may be used at a later time.

Further resolution & discussion

The following week I decide to try and track down the man and see if he still wants the information. I go to the chief administrator at Herzl to ask if she can suggest how to find the man using only a first name. Medivisit, the clinic's appointment scheduling software, only allows a search using both first and last. She randomly calls one of the team coordinators, who as it happens knows the man we are looking for. I have contact information in my hands within 2 minutes. I call the man and he does still want the information. I leave it with the team coordinator for him to pick up at his next visit. I am very impressed with how well the teams seem to know their patients.

What not to feed gout & whose pager is it anyway?: case

Case/challenge

Scenario

I am at the library helping to conduct a workshop for a small group of residents. They are reviewing how to use selected EBM resources to answer clinical questions and a couple of the cases at the end of the session are specifically related to providing health information to patients and families. This is why I have agreed to assist during a time when I would normally be on site and available to patients. It is also an opportunity to promote the service to residents, who have so far been extremely enthusiastic about using the service. A short way into the workshop a beeper goes off. After a moment's pause I realize it's mine. I excuse myself to call in and am told that a patient is waiting for me at the clinic which is in an entirely separate building. I run over to the clinic and arrive slightly out of breath to find a young woman waiting for me. Her father's physician would like him to have some information about which foods to avoid when suffering from Gout.

Resolution

I do a quick search on MedlinePlus and find a link to the Arthritis Foundation that answers the question (literally since it is a Q&A from the Arthritis Foundation's consumer health magazine Arthritis Today, in the On call section). I ask if she thinks her father would like more information and shen answers that for now she thinks it will be enough and will contact me if she or her father have more questions. I run back to the library in time to cover the 2 cases that deal with the information needs of patients and families.

Discussion

In this case what is interesting is not so much the information need or how it was met, but rather the challenge that was presented by the fact that I was engaged in other aspects of my position which required that I be off-site during a time when I would normally be available to patients. In the end my having a pager helped to resolve the issue to everyone's satisfaction and the timing worked out just right. Had the person been unable or unwilling to wait the ten minutes it took for me to arrive on site, an opportunity to provide the service would have been lost. This has already happened once so far. The fact that a librarian was paged in a room full of physicians was an added bonus! I could not have found a better way to promote the service than that.

Pediatric MS: case

Case

Scenario

One of the Herzl health professionals (HP) comes to see me while I am working in the library. She has a young patient, a nine year child, who has been diagnosed with pediatric MS. She would like some information for the family.

Resolution

This diagnosis is relatively rare and we are both thinking it may be difficult to find information. As she will be visiting the Montreal Children's Hospital that Friday I suggest they go to the Family Resource Library there, which is excellent, in case they have any special resources on the topic. I tell the HP I will follow up when I am at the Herzl and ask her to write up an InfoRx and leave it for me so that I can fill out a consult.

The next day I call the Family Resource Library at the Children's to see if they do in fact have any special resources on the topic, which it turns out they do not. I decide to do a quick Google search first thing Monday to see what might be out there. I don't normally turn to Google first unless I looking for the US name of a drug before looking it up in a US resource, but this time it seems like the thing to do. I am surprised to see how many excellent resources come up right off the bat:

Search: pediatric multiple sclerosis

Results:

For the health professional:

MS Society of Canada
Hospital for Sick Children Paedetric Multiple Sclerosis (MS) Clinic

National MS Society (US)
Pediatric MS

Quebec chapter of MS Society of Canada


For the patient and family:

MS Society of Canada publications on young persons with MS
Includes an activity book for children with MS, a guide for parents, and answers to FAQ

University of California Children's Hospital
Pediatric MS Center

National MS Society (US)
About MS: Pediatric (Childhood) MS

Children's Hospital of Philadelphia
Neurology: Pediatric Multiple Sclerosis Clinic

National Pediatric MS Center at Stony Brook University Hospital

I also search NOAH (New York Online Access to Health), as well as the default MedlinePlus, to see what they have on the topic. Noah has a couple of links to to the National Multiple Sclerosis Society, ones I have already found, but MedlinePlus does not have anything at all on the topic.

Discussion

(Also see Challenges post for today)

I recently gave a course to hospital staff on using Google wisely and well, and one of the things I made a point of stressing is that Google is just a means to an end. There is a lot of controversy surrounding the use of Google as a diagnostic tool, and especially on its use by consumers to find health information. I believe that *if* you know what you're doing, and more importantly *if* you know how to evaluate what you find, then it can be a really useful, if unreliable, tool for finding information quickly in multiple resources.

Nutrition information in Cantonese: case

Scenario

A middle aged man is referred to me. He leaves a phone message telling me he is interested in information on Type II Diabetes and diet in Cantonese for his father who is a patient at the Herzl.

Resolution

I search the following resources*:

The 24 languages project
Health Information Translations
Healthy Roads Media
HICUP
NLM Consumer Health Information in Many Languages Resources
SPIRAL

I am able to find some good information in Chinese on the SPIRAL site:

SPIRAL > Patient information by language > Chinese > select "diabetes"

Unfortunately I am not able to determine whether this information is specifically in Cantonese (health information is generally available in either traditional or simplified Chinese). I call the man back and he asks me to email the links and says he will ask his father whether he is able to read the information. I tell him I will be happy to continue looking if necessary. He then asks if I can find something that might help his father understand the different food groups and portion sizes. I do a web search using Google: canadian food guide chinese. The first hit is a copy of the guide translated into Chinese (pdf).

I email these links to the man including some information about navigating the SPIRAL site.

I place a copy of the consultation form in the attending physician's mailbox.

*All of these resources have been bookmarked in the list of public MyHq bookmarks I have created for myself and the Herzl health staff.

Total time: 20 mins

Discussion

I consider every encounter an opportunity to teach people how to find information and not just hand it over. At the very least I show the path from the resource's home page to the desired information. This also minimizes dead links.

Genetic counseling, uninsured population & birth order: 3 cases from the Patient and Family Resource Centre (PFRC)

Case #1

Scenario

A pregnant woman in her late twenties comes into the library. To my untrained eye she looks like she is in her 3rd trimester. She speaks halting French and asks if we have any information on genetic counselling. I conduct a reference interview, asking a few questions in order to narrow down her information needs. She wishes to know whether there is someone she can speak to confidentially at the hospital about the results of a DNA test done recently on her baby.

Resolution

I phone one of the GPs I provide research assistance to at the Herzl. He suggests that I contact the hospital's genetic counsellor, which I do. I am advised to inform the patient that she will be able to speak with the genetic counsellor but that she will need a referral from her GP in order to do so. I relay this infomration to the woman.

Total time: 20 mins

Case #2

Scenario

A woman phones and asks for information about admission and regarding the costs of delivery at the hospital (both vaginal and C-section). The woman's sister is 8 months pregnant, has recently immigrated and does not have Quebec insurance.

Resolution

I contact one of the nurses in Maternal-child health who I have recently assisted with the creation of patient handouts. She advises that the woman contact JGH Admissions for this information. She suspects that the sister is without status and likely has not yet seen a GP in this country, and gives me several names of GPs who are accustomed to accepting uninsured patients. I call the woman back with contact information for JGH Admissions. I also provide the names and tel. nos. of the aforementioned GPs and tell her she can contact them if her sister needs to see a GP before her due date, regardless of insurance status.

Total time: 40 mins

Discussion

Had the woman contacted JGH Admission directly it is unlikely that they would have detected her sister's underlying and more important need to see a GP.

Case #3

Scenario*

A older female Herzl patient contacts me at the library. Her husband has recently passed away and her three children, who are in their late teens and early twenties, have been arguing over their inheritances. She would like to read 1 or 2 journal articles on the subject of social dominance and sibling rivalry. She believes that reading about these dynamics might help her to cope with her situation.

Resolution*

I contact my colleague at the Institute of Community and Family Psychiatry (ICFP) Library as our collection does not include psychiatry or psychology and this is not my area of expertise. She suggests I do a search in PsychInfo, and provides a couple of key words I might find useful. (PsychInfo does not index using the MeSH vocabulary). I do a quick search in the database and find several articles that may be of interest.

I get back to the woman and conduct a more extensive reference interview, wanting to confirm that I have correctly understood her information needs. She speaks to me at length about her family history and this present situation. She tells me that she wants something that will be simple to read, and I suggest that perhaps she should consider going to Chapters or Amazon instead. She then admits that several weeks ago she found some very interesting articles in our library's Journal of Psychosocial Nursing at which point I am confident that she will be able to read the articles I have found.

Total time: 1 hour

Discussion

This is an example of an information need that requires access to a library and the assistance of a librarian in order to be filled.