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Baking cookies, part 1

When the president of a country dies suddenly, they say that
the citizens forever remember where they were, and what they were doing, when
they first heard the news. I’ve heard people
discuss their personal circumstances when they received word that President
Kennedy was shot. For some reason, that sort
of news is a memory fixative, preserving individual experience along with
national tragedy.

For me, 9/11 was one of those events. I was getting off a night shift rotation at a
hospital in lower Manhattan, sitting in morning report, dozing off as usual –
my eye lids sticking to dry corneas, my head feeling vaguely gummy, thoughts
cluttered with worries about whether or not the incoming shift of residents
would remember to perform all the tasks I’d listed for them at sign out.

And as I dozed off, suddenly our chief resident marched up
to the front of the room, brushing aside the trembling intern who was
presenting a case at the podium at the front of the dingy room. “How rude of him” I thought hazily, as I
shifted in my seat to hear what he had to say.

“Guys, there’s been a big accident. An airplane just crashed into the World Trade Center.”

Of all the things he could have said, that was the last
thing I was expecting. I shook my head,
wondering if I was awake or asleep.

“We don’t know how many casualties to expect, but it could
be hundreds. You need to get ready, and
ALL of you report back to the ER in 30 minutes.”

I thought to myself, “surely some Cessna-flying fool fell
asleep at the controls, and this is just an exaggeration.” But worried and exhausted, I went back to my
hospital-subsidized studio apartment and turned on the TV as I searched for a
fresh pair of scrubs. All the channels
were showing the north tower on fire, and as I was listening to the news
commentary and watching the flames, whammo, the second plane hit the south
tower. I stared in disbelief as the “accident”
turned into something intentional. I
remembered having dinner at Windows on the World the week before. I knew what it must have looked like inside
the buildings.

I was in shock as I hurried back to the hospital, trying to
think of where we kept all our supplies, what sort of injuries I’d be seeing,
if there was anything I could stuff in my pockets that could help…

I joined a gathering crowd of white coats at the hospital
entrance. There was a nervous energy,
without a particular plan. We thought
maybe that ambulances filled with casualties were going to show up any second.

The chief told me, “Get everybody you can out of the
hospital – anyone who’s well enough for discharge home needs to leave. Go
prepare beds for the incoming.”

So I went back to my floor, recalling the patients who were
lingering mostly because of social dispo issues, and I quickly explained the
situation – that we needed their beds and that I was sorry but they had to
leave. They were actually very
understanding, made calls to friends and family, and packed their bags to
go.

And hours passed without a single ambulance turning up with
injuries. I could smell burning plastic
in the air, and a cloud of soot was hanging over the buildings to the south of
us. We eventually left the ER and sat
down in the chairs surrounding a TV in the room where we had gathered for
morning report. We watched the plane hit
the Pentagon, the crash in Pennsylvania…
I thought it was the beginning of World War 3.

The silence on the streets of New York was deafening. Huddling inside buildings, people were
calling one another via cell phone to see if they were ok. My friend Cindy called me to say that she had
received a call from her close friend who was working as a manager at Windows on
the World. There was a big executive
brunch scheduled that morning. Cindy
used to be a manager there too… the woman’s last words were, “the ceiling has
just collapsed, what’s the emergency evacuation route? I can’t see in here…
please help…”

That night as I reported for my shift in the cardiac ICU, I
was informed by the nursing staff that there were no patients to care for, the
few that were there yesterday were either discharged or moved to the MICU. They were shutting down the CICU for the
night. I wasn’t sure what to do… so I
went back to my apartment and baked chocolate chip cookies and brought in a warm,
gooey plate of them for the nurses. We
ate them together quietly considering the craziness of our circumstance.

“Dr. Jones, you look like crap” one of them said to me
affectionately. “Why don’t you go home
and get some rest. We’ll page you if
there’s an admission.”

So I went home, crawled into my bed with scrubs on, and
slept through the entire night without a page.
The
disaster had only 2 outcomes – people were either dead, or alive and unharmed –
with almost nothing in between. All we
docs could do was mourn… or bake cookies.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The scream

An elderly woman had had a
cardiac arrest and was resuscitated long
after a lack of oxygen had permanently damaged her brain. Her daughter remained at her side day in and
day out in the Medical ICU, keeping watch on a hopeless situation.
Many staff had encouraged her to go out and get some fresh air, to take
care of herself… but she was compelled to stay with her mom 24-7 for reasons I will
never know.

I spent some time gazing at the patient’s face – it was delicate
and quite beautiful, with flowing white hair framing fair, soft skin. I wondered what she was like when she was
herself, if she had a gentle disposition, or a fiery wit. I wondered if she had loved her husband, and
if she had had a happy life… I wondered why her daughter was clinging to her,
barely able to leave her for bathroom breaks.

The situation continued for a few weeks – I was a medical
student, and wrote some very bland and unenlightening notes about the patient
each day, describing her unchanging condition.
I felt sad as I watched the daughter slowly come to realize that her mom
was already gone.

One day the daughter looked at me and said, “I think I’ll go
out for a bite.” I smiled, knowing that
this was a turning point for her, and gave her a hug. “I’ll watch her for you,” I said.

As it happened, the patient was on the “house service” –
assigned to the teaching attending of the month. She didn’t have her own doctor, so she was
followed by a team of rotating residents and attendings. The new team started this day, and were
somewhat unfamiliar with her case. I
dutifully updated them on the history and events over the past few weeks.

As I stood there with the team, rounding on the patient –
they noted that her lungs were becoming harder and harder to ventilate. ARDS,” they said. “She’s going to code any time now.”

And then the unthinkable happened. The new attending, who was a bit of a cowboy,
said “let’s just end this madness. Turn
off the ventilator, it’s done.” The
residents looked at one another – one protested, “I don’t think we should do
that.”

“She’s already gone – look at her! Her oxygen is dropping, she has no pupillary reflexes,
she’s on maximum pressors…”

“But wait,” I said, “Her daughter would want to be here.”

“It’s better for her not to have to go through this,” he
said. And he turned off the machine.

I gasped. “What will
we tell her daughter when she comes back from lunch?”

Annoyed by my persistence he snapped, “Tell her she coded
when she was out.”

Thirty minutes later the daughter came back to the ICU. As she walked towards her mom’s bed, the
residents scattered. Frightened, I
approached her. She could see from the
look on my face that something bad had happened.

“She’s gone,” I stumbled… “it just happened after you left.”

She looked at me as if I had convicted her of the crime of
abandonment. At that moment, her
greatest fear of leaving her mom’s side had come true – she wasn’t with her
when she died. She ran into the room,
saw that the machines were off and all was quiet. She fell to the floor and screamed.

That scream still haunts me to this day.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The healing art of listening

“Be quick to listen, slow to speak.” That’s the old wisdom I was taught growing
up, though it sure is difficult to apply regularly and consistently, isn’t it? Nonetheless I can’t think of a better
principle for practicing good medicine.

I was reading Dr. Smith’s blog and was touched by his
observations:

Patients don’t know
how to put words on their pain, and there is no disease named for the pain that
the patient wants to tell you about.  It’s about the inner anguish of this
particular person’s quest for life, their disappointment, the abuse they have
experienced, their feelings of failure and lack of significance, their rage at
the injustices they endure and they don’t have anyone else but you to talk
to.  And, by having a relationship with a safe professional, some of their
pain is relieved and, in many cases, they get well or better!  In some
cases, they don’t, but that begins to matter less than the fact that you begin
to understand that “getting better” is not the goal here.  And,
if you keep trying to make the patient better with a prescription pad, they
will just keep bringing you new problems to chew on until you figure out what
they really need.

The truth is that at the root of many medical
misunderstandings is a listening problem. Sure we hear
lots of things, but in our rush to package complaints into a convenient
diagnosis we often miss the elephant in the room. An excellent example of a doctor practicing
good listening skills was described in Signout’s blog this week.

Some parents appeared a bit overly concerned
about their young child’s cold symptoms. The resident taking care of them
wisely recalled that the mom had mentioned that her aunt died of leukemia
as a child. The doctor made the
connection between that bit of history and their angst – and reassured the
parents that the child’s blood tests were normal, and did not suggest
leukemia (without them directly asking the question). The emotional relief that
ensued was the most therapeutic effect of the physician encounter that day.

The moral of the story is that listening really can be
a healing art. And it’s not just
reserved for psychologists and psychiatrists.

*another case of good listening here*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

What is a "medical home" and why do you need one?

Ask any American if they think
their current healthcare system is operating smoothly and efficiently, and
you’ll hear a resounding “NO!”  Adjectives such as
“confusing, complicated, and disorganized” are often used to describe
our current state, and for good reason.  The science of medicine has
advanced enormously over the past 50 years, but somehow this rapid growth in
knowledge has been plagued by chaos.  With every new therapy, there’s a
new therapist – and the result is a fragmented assortment of tests, providers,
procedures, and administrative headaches.  So what does a patient in this
system really need?  She needs a coordinator of care – a compassionate
team leader who can help her navigate her way through the system.
She needs a central location for all her health information, and an easy way to
interact with her care coordinator so she can follow the path she has chosen
for optimum health.  She needs a medical home.

Primary care physicians (especially family physicians, pediatricians, and
internal medicine specialists), are ideally suited for the role of medical team
leader in the lives of their patients.  It is their job to follow the
health of their patients over time, and this enables them to make intelligent,
fully informed recommendations that are relevant to the individual.  Their
aim is to provide compassionate guidance based on a full understanding of the
individual’s life context.  The best patient care occurs when
evidence-based medicine is applied in a personalized, contextually relevant,
and sensitive manner by a physician who knows the patient well.

Revolution Health believes that establishing a medical home with a primary care
physician is the best way to reduce the difficulty of navigating the health
care system.  We believe that our role is to empower both physician and
patient with the tools, information, and technology to strengthen and
facilitate their relationship.  Revolution Health, in essence, provides
the virtual landscape for the real medical home that revolves around the
physician-patient relationship.

What’s the advantage of having a medical home?  Jeff Gruen, MD, Chief
Medical Officer of Revolution Health:

1.  Care is less
fragmented: how many times have you heard of friends with multiple medical
problems who are visiting several physicians, each of whom has little idea
of what the other is doing or prescribing, and none of which are focusing
on the big picture?    When a single physician is also
helping to “quarterback” the care, there is less chance that
issues will fall between the cracks, and less chance that consumers will be
put through unnecessary and costly tests or procedures

2.  Care is better:
studies have shown that excellent primary care can reduce unnecessary
hospitalizations and assure that preventive tests are performed on
time.   One study for example showed that the more likely
it is that a person has a primary care family physician, the less likely
it is that they will have an avoidable trip to the hospital.  This
makes intuitive sense: a physician who knows you is critical to have if
you were to get very sick and need alot of medical
attention.

3. Care is more holistic:
medical care is part art and part science and good care requires the
clinician to understand something about the whole person they are caring
for.  Many complaints that are seen in primary care practices are
physical manifestations of underlying emotional, family or adjustment
issues.  A good primary care clinician who knows the individual and
family is more likely to strike the right balance between appropriately investigating
physical causes for complaints, and addressing more subtle underlying
causes

So to physicians and patients alike, we say, “Welcome home to Revolution Health.”

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The case of a predator in the hospital

Several years ago I was taking care of a pleasant elderly woman with a heart condition on an inpatient unit. One morning I went into her room to check on her and I found her sitting up in bed, clutching her purse and crying.

“What’s wrong, Mrs. Johnson?” I asked, perplexed.

She blew her nose in a Kleenex and replied, “Someone stole my insurance cards, my money, and my credit cards! They were in my wallet just yesterday evening – and this morning they’re gone.”

I paused for a moment, considering the order of priority in which she reported the missing items, glanced at her telemetry monitor (her rhythm was regular though her heart rate was elevated from crying), and asked if she knew how this might have happened.

She told me that she suspected that a certain patient had sneaked into her room in the middle of the night and removed the items from her wallet.

“How do you know it was that patient?” I asked, growing suspicious.

“I’ve seen her sneaking around at night in other people’s rooms – a couple of nights ago she was in here digging through my roommate’s dresser drawers.”

The suspect was a 38 year old woman with a known history of heroine abuse, who was admitted to the General Surgery service (conveniently boarded on our Internal Medicine floor) from the Emergency Department to complete an acute abdominal pain work up. This woman had already terrorized the surgical intern assigned to her case (as I had heard on rounds the day before) by chasing her around the hospital room with a hypodermic needle. Security had come to restore order and had found a stash of heroine and some needles in her bathroom that had been brought in by her visitors the night before. The team decided not to discharge her because they had discovered a large abscess on her ovary (from an advanced and untreated sexually transmitted disease) that they felt obligated to drain and treat her with antibiotics. Of course, on the morning of her scheduled surgery she ate breakfast, making it unsafe to put her under general anesthesia. These games continued (sneaking food before surgery, refusing surgery or medications, then changing her mind, then claiming to be homeless with no safe discharge plan, etc.) so that her length of stay grew from days to weeks.

“And now,” I thought to myself, “she’s using our hospital as a flop house, victimizing MY patients on the same floor – stealing their belongings in the middle of the night?!” This was the last straw. I told Mrs. Johnson that I would get to the bottom of the matter.

And so I waited for the victimizer to leave her hospital room for a scheduled test – I sneaked into her room and went through her bedside table drawers. Lo and behold, my patient’s ID and credit cards were stashed in a box with a bunch of other IDs that clearly didn’t belong to the woman.

I called hospital security, and we reviewed all the items that she had stolen. As it turned out, she was admitted to the hospital under a stolen Medicare card (the woman had claimed to be on disability). Her name matched with our records of a 67 year old woman, so we knew that she had been admitted under another’s name – and the admitting clerk had not noticed the age discrepancy. A careful record search turned up the drug user’s previous admissions under this alias. This predator had been gaming the system for years, eluding detection!

I asked the security guards to help me interview other patients on the inpatient unit to see if they had experienced anything out of the ordinary over the past few weeks. What we found was astounding. Several frail elderly patients described similar night terrors (being unable to stop the woman from going through their personal items at night) and one gentleman with advanced AIDS, who was admitted for treatment of severe pneumonia, reported that the woman had attempted to molest him in the middle of the night when she was high and in a hypersexual state.

Thanks to our investigation, many patients had their belongings returned to them (though some of their jewelry was not recovered – the woman probably sold it for heroine to her visiting dealer), and I heard that the predator was caught by the city police after choosing to leave the hospital against medical advice.

I don’t know what happened to this woman after that, and I doubt that the police were able to detain her for very long. I felt horrible for the patients who had been victimized in their ill and vulnerable states, and I wondered what kind of lasting psychological damage that this woman had inflicted upon them, especially poor Mrs. Johnson. I also felt frustrated and vulnerable – unable to really protect my hospital from future assaults. What could I do, stand in the Emergency Department each night to identify her if she chose to return? I can only imagine that this woman is still up to her old tricks at a neighboring inner city hospital near you…

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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