osmano807

Probably liability... on the amputations I indicated and contraindicated, it's increasingly difficult to navigate trough patient perceptions while not disclosing so much as to give them rope to hang us. Some decisions are a game of probability that often we don't have clear numbers. In trauma, I have both cases where I recommended an amputation and at last minute decided to see that happened and the patient is walking with their leg today; and cases where I didn't recommend and later had to amputate as the lesion evolved. With cancer it's more straightforward, the cancer is what dictates the surgery... some cancers have poor response to other treatments, so we amputate. Some cancers had invaded the neurovascular bundle, so curative options involve necessarily amputation to get good margins. In cancer there's less doubt in the prognosis, so less chance of legal ramifications.

In my hospital we have ample experience with another technique using polypropylene sheets for defect coverage, popularized in Brazil orthopedics as "Figueiredo's technique", which is in practice an extension of common techinques for temporary closure of abdominal wall ("Bogota's bag").

We put a transparent polypropylene sheet as skin replacement, suture it directly to the skin. We can monitor the wound and its secretions, can cover exposed tendons and bones without immediate doing microsurgical flaps. For example, we can monitor the second intention skin closure with reduced infection and analgesics use, sometimes without needing a graft at all.

Through the years I've worked with several EHR, be helping their development be using it in my practice, and each had it's idiosyncrasies. In my country there was proposals by the government of integration, but as all things that need coordination, we're nowhere close to sharing information between care centers.

On a city we have several places controlled by the same entity, and they use an integrated EHR, so that a doctor who sees a patient at the emergency department has access to it's full history from the tertiary center, but at the same time the major tertiary/quaternary hospital isn't managed by that same entity and doesn't use the same EHR system, so we can't share information digitally. To make things worse, one system is made in Flash and all computers need to have an outdated Chrome version with the Flash plugin to run it. The other system is made in Java and some form of custom frontend framework, which works ok until it doesn't.

Expanding on this other system made in Java, it's a federal hospital, and we have other internal systems which doesn't communicate with this main EHR, so for example emitting radiology requests need us to copy paste information from two systems (like address, contact numbers), and on top of that those systems aren't connected to the national patient registry, and daily I have residents redoing requests to merge the information, otherwise the requests are made invalid.

I haven't touched on payments, imagine that each health insurance plan have different billings and we need to adapt the reality of what we did to what code better pays and input that in the system, so in practice the records are tailor fitted for each payment system, the actual procedure descriptions change, and we need to remember all that when billing and when treating the patient.

Add on top of that system outage and unreliability, and I haven't even touched much on the UI, which sometimes loses input text data or sometimes we have to input in certain fields order or else the system crashes, or the fact that the tabindex isn't set on all fields and we need to click with the mouse to go to a field.

Personally I've made a simple system for my private practice, while it doesn't have all the functionality, at least I'm the one to blame for it's particularities. I'm still exploring how to better input the clinical data, and I'm starting to think that general systems doesn't work. Each specialty has specific routines which need to be accommodated in the system, be it structured forms, be it clinical image input with annotations and commentary. The field is huge, and we're looking at how to design UX for immediate input and for later review, which sometimes are at odds (for example, a single textarea is easy to input, but how do we parse that data and present a timeline of clinical signs for example?).

I guess we need a Linux of the EHR, something which we can iterate on. I've looked into open source projects, but I don't know if the field is entrenched in inherent complexity or we're all trying to model too generic abstractions on top so that a small team of developers can't comprehend the system.

I should publish some code instead of rambling, but as the field is covered in regulations, I fear not even a code license can disclaim legal obligations.

I really like this, as from an outsider it seems that CL doesn't have a community and the few packages it has are more like building blocks for customizing and implementing you required functionality rather than packaged black boxes. With all those new languages, it appears that the value proposition of CL is dwindling, static checking feels primitive, macros are easily attainable now, and live runtime image manipulation misses the point on the world of short lived containers.

Unless we have a clear indication, plates are not meant to be removed. For example, plating children we usually remove the plate as to not interfere with growth, or in some cases a fibula plate can irritate the tendons and should be removed, or in cases of infection.

Functional outcomes seem similar, trough we have a increased rate of malunion, delayed or non-union with nonoperative treatment. We usually indicate surgery if it's an active patient.

I downloaded and opened an CDS for osteoporosis from the link (as a disease in my specialty), I need an API key to view what a "valueset" entails, so in practice I couldn't assert if the recommendation aligns with clinical practice, nor in the CQL provided have any scientific references (even a textbook or a weak recommendation from a guideline would be sufficient, I don't think the algorithm should be the primary source of the knowledge)

I tried to see if HL7 was approachable for small teams, I personally became exhausted from reading it and trying to think how to implement a subset of it, I know it's "standard" but all this is kinda unapproachable.

I know it's not the same, but in many areas we have this "follow the arrows" system in many guidelines. For some examples, see the EULAR guidelines with it's fluxograms for treatments and also AO Surgery Reference with a graphical approach to select treatments based on fracture pattern, avaliable materials and skill set.

I think that's a logical and necessary step to join medical reasoning and computer helpers, we need easier access to new information and more importantly to present clinical relevant facts from the literature in a way that helps actual patient care decision making.

I'm just not too sure we can have generic approaches to all specialties, but it’s nice seeing efforts in this area.

Those sites have something like Phoenix LiveView or it's something ad hoc like a simple SSR template engine? Would be nice to have something to handle migrations in the client side code to match the server side API.

Unrelated, all my devices freeze when accessing this page, desktop Firefox and Chrome, mobile Firefox and Brave. Is this the best alternative to access code ai helpers besides the GitHub Copilot and Google Gemini on VSCode?

Isn't there any UI framework alternative for the web that doesn't use JavaScript or Typescript?

Something like DaisyUI but using other languages when needing interactivity.

Also, tested the DatePicker and it's examples with time is unusable on mobile, renders outside of the viewport without option of scrolling.

HN really strange, page jumped from front to page 3...

I'm still searching for the holy grail of web development without Javascript or TypeScript, still not found.

Leptos still ahead but still imature, recently with panic! with signal usage. Dioxus today commited improvements to suspension such as placeholders...

egui unusable in mobile, as Android keyboard overlaps the window.

Don't know other alternatives in other languages, but for those who don't want JS it's difficult.

Thanks for your experience, that's important to remind us (me) of the other side.

Sometimes I feel really sad that the bus factor of some treatment is 1, and double sad when that one is me. No one should have delayed care just because I need my vacation, or my day off.

Kudos to the surgeon who trusted his instincts and suggested a surgical biopsy, sometimes patients get so happy with dubious results that we feel like we're removing their happiness, or that we're secretly hoping for the worst.

I hope that you're going through this with peace of mind.

Brazil too have notification with the numbers published weekly by each State of the country, all cases are notified even without laboratory confirmation. They too have zoonosis agents which inspect locations, but they're not allowed to enter without warrant.

Why's lithium a 'folk remedy? We have scientific evidence of the efficacy of lithium as adjunct in depression treatment and anti-suicidal.