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Years ago, I was working as a nurse in a cardiothoracic ICU taking care of post open heart surgical patients. I was in charge one day and one of my colleagues called me over. She was worried about her patient. He had been with us for three days and something was going on with him.Nancy* asked me for a second opinion. She suspected that the patient might be having a cardiac tamponade (a slow bleed into the pericardial sac surrounding the heart) which would be potentially fatal, but very rare three days after surgery, normally it occurred within a few hours of surgery. The patient, meanwhile, a 60-year-old man, was breathing on his own and loudly demanding something to drink.“Water! I need water! I´m dying of thirst!” He kept saying over and over.I looked at Nancy and she nodded knowingly. “See why I´m worried?”Both of us had many years of experience and we knew that when patients suddenly have an uncontrollable desire for water or a sudden need to poop when they hadn´t eaten in days, that usually meant they were going to die – and soon.His signs and symptoms of tamponade were very borderline, nothing clearly pointed to her diagnosis.“Water! Water!” He started screaming, becoming very agitated.“Like I told you,” Nancy said patiently. “I believe you may be going back to surgery soon, so you can´t have anything to drink if they are going to give you anesthesia. It is too dangerous.” She spooned two tiny ice chips into his mouth.He glared at her with hatred. “Those slivers of ice are not enough. Why are you being so mean to me? Do you really think a glass of water is going to kill me?”“It could.” She said firmly. She turned to me. “What do you think?”I knew she wasn´t asking me about the water. “I don´t know. You know three days out would be really unusual for him to have that. Have you talked to the surgeon?”“Yes. He doesn´t agree with me. But I did get him to order a chest x-ray. I´m waiting for them now.”“Please, please, I´m begging you.” The patient interrupted, alternating sobbing with yelling. “I am going to die if I don´t get something to drink right now.”He grabbed my hand. “Please, you look like a nice lady. Can you get me a glass of water?” He looked at Nancy. “She´s trying to let me die of thirst.”Nancy looked at him. “You are getting plenty of IV fluids, trust me, you are not going to die of thirst. Here, have a couple more ice chips.” She spooned some more ice into his mouth as he greedily tried to pry the full cup of ice from her hands.“No, no. Just a little at a time.” She chastised him, pulling the cup out of his grasp.“Give me a glass of water!” He screamed again at the top of his lungs.The x-ray tech came in then and shot a film of his chest. After they left, I assessed him again, listening to his heart. “You could be right, Nancy. His heart sounds are pretty muffled.”“I know, right?”“Water, water, water, water…” He began to chant a manic mantra, his voice getting louder with each repetition of the word.I walked up to the front of the ICU and began to refresh the X-ray screen, waiting for the image to come through. A few minutes later, it began to download.Normal heartCrazy big heart (and not in a good way)She was right. The pericardial sac was filled to the brim with blood and clots, making it about three times its normal size.I turned to the secretary. “Page the surgeon and ask him to come.” I called over my shoulder to Nancy. “Hey, you were right, he has a huge tampo….”“OH SHIT!” I hear her yell.Upon hearing the universal ICU code sign for I need help right now, I spun and sprinted down the unit to her bedside. Both of us stood on either side of the patient´s bed, staring at his chest. There was blood seeping out from under his bandage where his fresh incision was. Lots of blood.At that moment, his chest exploded.There is no better word to describe what happened. Nancy and I jumped back simultaneously, but it was too late. A fountain of blood and clots erupted from his chest like a volcano, hitting both of us square in the face, spraying almost to the ceiling, the walls, the floor.“HOLY SHIT!” We said together. For anyone who has seen the movie Alien with Sigourney Weaver, when the alien bursts out of Kane´s chest, this was a template for that scene.We both stood there, frozen in shock. With all of our years of experience, we had NEVER seen such a thing. Clearly, the patient had to be dead. No one could have survived that explosion. Anxiously we looked at him. He looked like he had been in a head-on collision with a semi-truck. Blood and clots covered his face, hair, chest and turned the crisp white sheets red. We stepped forward at the same time, prepared to start CPR to try to save him.He blinked and looked at us calmly from behind the mask of blood. We glanced at the monitor; all of his vital signs had returned to normal.In a dead flat voice, he said, “I guess I´m never getting that glass of water now, huh?”Nancy and I burst out laughing. We stood there, dripping blood, and laughing hysterically. Even the patient started to laugh. The surgeon ran in with the anesthesiologist by his side. The secretary had been on the phone with him when the patient´s chest had exploded, and she told him what was happening.They skidded to a stop, taking in the horror scene, and stared at the three of us laughing.“Hey doc,” Nancy said. “I was right. He was tamponading. He seems to have fixed that, but I think you need to go fix his ruptured pericardium.”The surgeon left to scrub in for surgery and the anesthesiologist was left to prepare the patient.He asked him a few questions, then he said. “Sir, have you had anything to drink in the last two hours?”The patient looked at us accusingly and all of us burst out laughing again.“Ask them.” He said between gales of laughter.The next day, after he had recovered nicely from his second surgery, Nancy made sure to bring him an ice-cold glass of water and let him drink all he wanted.

So many things are getting lost.But, I would have to say, right now, that the skill I grieve for most is the art of storytelling.Many people don't realize this, but a big part of a doctor’s onus is to convey the essence of the patient, their history, the story of their illness, including what they think is the problem, and what they have done to treat it.These narratives are called ‘History and Physicals’ or H&Ps. They are the backbone of the patient’s care. Every single physician, nurse, and other practitioner would consult this document to acquaint themselves with the patient’s history and baseline physical exam. They would run something like:“Mrs. Smith is 45 year old married woman who presents today with a complaint of a headache for three days. She denies any nausea, vomiting or trauma to the head. She states she has a history of migraine headaches, which started in her early teens.”It would then proceed to address the patient’s past medical history, family history and then the physical exam. They would always be set up in SOAP format, and would end with the assessment and plan.These would be transcribed from a doctor who would dictate this information typically, right after seeing the patient. The transcription would generally take less than an hour, and voila, it appears in their medical record.Now, thanks to the bumbled efforts with EHR and the oncoming generation’s dislike of speaking into a phone, the records look like:Male ( ) Female (X ) presents with chest pain ( ) nausea ( )vomiting ( ) headache ( X). And so on.Doctors are now set up with their own templates in which they click boxes. Not just H&Ps, but operative notes and progress notes. They also pull in every lab, vital sign, radiology result, medication orders etc. from the last 36 hours so they have become very much like spam notes.Reading them is the visual equivalent of army crawling through barbed wire.An attending that I work with and I recently had this discussion about these templates and he had this to say:“The residents don't even use the phone to dictate anymore. I suggested to a first year that she just dictate the H&P while they were getting a patient ready for surgery. She was flabbergasted, she had never dictated and said that if she couldn't just text something it threw her off.”Electronic health records-welcome to the new boss.