The SOAP Note Diaries: Introduction

The SOAP Note Diaries: “ER docs in a cannabis world”

Introduction:

Dr. Khalsa and I were initially nervous to take the leap and start specializing in medical cannabis.  We knew some of our colleagues would look down on us.  However a part of us always knew we were supposed to advocate for this patient population.  People who could genuinely benefit from medical cannabis.

This blog became a way that Dr. Khalsa and I could share our stories with you from working in the emergency department.  We encounter so many different people who are battling severe diseases and we feel they deserve access to medical cannabis without stigmatization.

They deserve to be treated as patients who are seeking medications that work best for them.

They deserve to be treated not as drug addicts or uneducated people but as patients who are looking for a different approach to their treatment plans, when nothing else seems to be working.

These are their stories and we hope we can do them justice.

Our hope is for this blog to bring a new perspective to the table.  Thank you for keeping an open mind and for taking the time to read our stories.

What is a SOAP note?

A SOAP note is used by many physicians to document the patient’s encounter.  It is a shorter simplified note made up of 3 parts.

“Subjective” explains why the patient is there.  This part is told completely from the side of the patient.  Why are they here today?  What is bothering them?  What makes it better?  What makes it worse?

In our blog, this is where we tell the patient’s story.  All names are fictional and specific details about the case have been changed to protect the patient’s privacy.

“Objective” is the physician’s evaluation of the patient, including a physical exam. It states the facts of what they have observed with the patient and their clinical findings.

In our blog, this is where we review the literature on medical cannabis related to a specific disease process.  We talk about what the studies showed, any weaknesses in the literature and any future research that is pending.

“Assessment and Plan” is the part where a physician documents what he/she thinks the diagnosis may be and his/her plan for further evaluation or treatment.

In our blog, this is where we summarize our thoughts on the disease and the effectiveness of medical cannabis.  They are our “take home points.”

‘Final Impression” is where the physician documents his/her final diagnosis and thoughts.

In our blog, this is where we express our final thoughts about the patient and topic at hand.

We always cite recommended resources and additional reading materials on the subject matter at the end of each blog post.

Thanks for reading!

Drs. Khalsa and Ratnabalasuriar

Fighting Cancer: Ann’s Story

Subjective:

I remember her face as I was breaking the news. Fighting back tears in her eyes while tightly clutching her husband’s hand. He was gently sobbing into her arms with a deep love in his eyes evident to any stranger like me. Ann had come to the emergency department (ED) for a bruised shoulder that just wasn’t getting better. She left that day with her entire world changed forever.

As an emergency doctor we are trained to move from room to room with pristine efficiency. Labs ordered? Check. Pain medication? Check. Follow up on the CT scan? Check. Discharge room 9, run to the cardiac code in room 1, speak to the consultant for room 3, reduce the shoulder in room 7? Check. Check. Check. Check.

Our chaos is a world I wouldn’t wish on anyone. It’s messy at times, unforgiving, and doesn’t care if you’re tired, hungry or upset. Life in the ED continues on with or without you.

But then you meet a family like Ann’s. A loving, happy family. A simple bump on the shoulder. You figure it’s been a few weeks, why not get an X-­‐ray just to make sure the bone is ok?

When I saw Ann, I immediately knew something was wrong even though she appeared well. In our field we refer to it as “spidey sense.” Instead of the X ray, I said, “Why don’t we get a CT of your chest? My job is to think of the worse things that could be causing your pain. I’d like to make sure your heart and lungs are OK.” “Sure,” she said. “Why not? I haven’t had a decent check up in awhile.”

As I scrolled through the images, all I could see were huge white threatening masses. In her lungs. Around her ribs. In her spine. Cancer. My world stopped.

“Oh Ann. How am I going to tell you this?” I think as my phone rings endlessly and the ambulances continue to stream in. The ED keeps moving and all of a sudden I feel paralyzed.

Ann is one of many patients I have diagnosed with cancer in the emergency department. It’s a terrible part of the job and none of us truly know how we have affected someone’s life after that day.

We see cancer patients come in and out of the emergency department for infections, fatigue, low blood counts, and frequent nausea and vomiting related to the side effects of chemotherapy.

As I ordered medication after medication for cancer patients, I started to wonder if there was a better way.

Objective:

Review of the literature led us to understand how medical cannabis can be used to treat cancer related symptoms.

Some try to stretch the effects of cannabis by claiming it cures cancer. This is partially true. We have seen antitumor effects of cannabis. However, we have also seen proliferative effects (causing the cancer to grow more). There is certainly potential there, and we have read some promising preclinical studies regarding treatment in breast cancer and glioblastoma multiforme. Despite this, we do not know enough to make such strong claims that cancer can be cured solely by cannabis.

Yet, we do see strong evidence that suggests it can be a wonderful adjunct to conventional cancer therapy, especially in treatment of nausea and vomiting.

Assessment and Plan:

Medical cannabis can serve as an adjunct in traditional chemotherapy regimens. At this time, it seems most helpful to treat cancer-­‐related symptoms such as nausea and vomiting. It is sometimes helpful to treat cancer-­‐related lack of appetite, sleep, nerve and organ pain.

Involving your oncologist in your decision to use medical cannabis is of the utmost importance.

Your medical team should strive to listen to your needs and help guide you in your care.

Remember, no single isolated medication is ever likely to be the answer when it comes to cancer treatment. At this time, we do NOT recommend only using cannabis as treatment for cancer.

We do acknowledge promising preclinical studies and look forward to future research evaluating cannabis and its role in targeted chemotherapy.

Final Impression:

I still think of Ann and her family quite often. I wonder how they are living day to day. If she is doing the things she loves, spending time with the people that matter.

In a moment, you can change someone’s life forever. I hope our patients know their stories stay with us. We go home and grieve for them. We think of them as we lay next to our loved ones at night. We are pulling for all the “Anns” out there.

Signed,

Radhika Ratnabalasuriar MD & Hari Khalsa MD

Recommended Reading and Resources:

P.F Whiting, R.F. Wolff, S. Deshpande, M. Di Nisio, S. Duffy,A. V. Hernandez, J.C. Keurentjes, S. Lang, K. Misso, S. Ryder, S. Schmidlkofer, M Westwood, J. Kleijnen, “Cannabinoids for Medical Use: A Systematic Review and Meta-­‐Analysis.” JAMA 2015;313:2456-­‐73.

D.I. Abhrams, M. Guzmán, “Cannabis in Cancer Care,” Clinical Pharmacology & Therapeutics 2015;313:2456-­‐73.

F.C. Rocha, J.G. Dos Santos Junior, S.C. Stefano, D.X. da Silveira, “Systemic Review of the Literature on Clinical and Experimental Trials on the Antitumor Effects of Cannabinoids in Gliomas,” Journal of Neuro-­‐Oncology 2014; 111:11-­‐24.

M.M. Caffarel, C. Andradas, E. Perez-­‐Gómez, M. Guzmán, C. Sanchez, “Cannabinoids: A New Hope for Breast Cancer Therapy?” Cancer Treatment Reviews. 2012;38:911-­‐8.