July 24th, 2009 by Bongi in True Stories
Tags: Death, Head Trauma, Murder, Neurosurgery, Pretoria, South Africa, Taxi, Triage
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I noticed my use of the phrase ‘call it’ a few times recently. It is something I saw on American TV and not at all something that is common in my neck of the woods. The sort of scene that you would get in gray’s when the junior doctor is pumping the chest shouting ‘I will not let you die, dammit!’ while the senior doctors stand one side and instruct him to ‘call it!’ is pretty foreign to our way of doing things. I even got ragged a bit for using the phrase at all. I thought I’d relate a story from days gone by that illustrates this point.
It was the time of the taxi wars. Now taxis in our country are nothing like you might be thinking. They are fleets of mini-buses, quite often owned by people of questionable legal character. Occasionally rival groups try to take each other out (I mentioned this before here). But roughly at the turn of the millennium there was outright war. When the war came to Pretoria we saw quite a few of the victims, but neurosurgery got the most. A friend of mine was rotating through neurosurgery and this story came from him.
There had been a contact between two different taxi organisations. The casualties were streaming in. The neurosurgeon and my friend, his trusty lackey, were overworked and I think it had affected their sense of humour. So while they were getting another gunshot head ready for surgery and heard another four were en route, they were not amused. When the ambulances arrived the neurosurgeon said he wanted to go out and triage them in the ambulances before they were unloaded. And this is what they did.
The neurosurgeon looked at each patient in turn. The first three he told them to send into casualties for his attention. But the fourth…he took one look at the fourth and exclaimed;
“Vat hom weg! hierdie een is gefok!*”
My colleague laughed the next day when the newspapers reported: “On arrival at the hospital, one taxi driver was declared dead by the neurosurgeon on duty.” Fortunately they did not quote him verbatim.
*take him away! this one is f#@ked!
*This blog post was originally published at other things amanzi*
July 23rd, 2009 by Olajide Williams, M.D. in Health Policy, True Stories
Tags: African Americans, Disparities, Harlem, Health, Healthcare Disparities, Neurology, New York City, Stroke
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Stroke is the leading cause of adult disability in the United States and the third leading cause of death. Worldwide, stroke is the second leading cause of death. Like heart disease and cancer, serious stroke disparities persist in America. African Americans have a relative risk of stroke death that is 4 times higher that whites at ages 35-54, 3 times higher at ages 55-64, and 2 times higher at ages 65-74.
The reasons for this are the focus of my two blog posts.
Over the last decade, most of the research dollars spent on stroke has focused on treatment and recovery. Researchers have spent millions trying to come up with new blockbuster treatments that reduce stroke burden or reverse it’s disabling impact. Therapeutic clot-busters have emerged with narrow time-windows within which they must be administered. Relaxing these time constraints have been the subject of even more research, and stroke recovery laboratories explore brain re-learning, neuronal plasticity, and cellular regeneration.
While I believe that we must continue to remain leaders of new and innovative treatments of disease, there is no doubt in my mind that the best return for our healthcare dollars is prevention. It is the only thing that can reign in the runaway disparities in healthcare and reduce the physical and economic burden of disease among all Americans.
But prevention is complex. It is much more challenging than administering a clot-buster or taking a cholesterol-lowering drug. Prevention involves the entire community – the whole ecosystem. It involves the child or individual, his parents and grandparents, his schoolteachers, his neighborhood stores and local parks, his local government policies, his primary care physician, his local community clinic or hospital, his employment status, his wallet, and lastly, his genes. Compare this to treatment, which involves having access to particular medical interventions such as a drug or surgical procedure.
Stroke prevention can be subdivided into primordial prevention (preventing stroke risk factors like high blood pressure, diabetes, and obesity, from developing in the first place through healthy living), primary prevention (preventing a first stroke by treating identified modifiable risk factors like high blood pressure etc), and secondary prevention (preventing a second stroke from occurring by controlling risk factors and administering specific treatments like taking a daily aspirin or having surgery to open up clogged arteries in the neck).
For the purposes of this post, I will focus on primordial prevention. To begin, I will re-introduce the root causes of disparities outlined previously:
- Educational status
- Employment status
- Insurance status
- Income level
How do these factors influence primordial prevention? How do they interact to define ecological conditions within a specific community? How did they contribute to the young boy’s adolescent stroke? To begin, I will list factors endemic to the young boy’s environment:
1] Low Health Literacy – the “hidden dragon” of all treatable risk factors; so often underestimated and so dangerous to the beholder.
2] Unacceptable numbers of uninsured – the “crouching tiger” threatening to tear down the entire health system
3] Poor access to care – an unforgiving predicament.
4] Limited access to healthy and inexpensive food
5] Ubiquitous access to unhealthy and cheap food
6] Low levels of non-occupational physical activity or leisure-related exercise
7] High tobacco and alcohol consumption.
8] Chronic persistent stress levels that overwhelm coping mechanisms.
In a study by Mauricio Avendano and Maria Glymour, wealth and income levels were shown to be independent risk factors for stroke. Another study by Glymour, Avendano, Haas, and Berkman showed that childhood social conditions (southern state of birth, parental Socio-Economic Status or SES, self-reported fair/poor childhood health, and attained height) predicted stroke risk in black and white adults. Moreover, adjustment for adult SES, in particular wealth, nearly eliminated all the disparity in stroke risk between black and white subjects
The ecological conditions that shaped the young boy’s physical and limbic traits are examples of an uneven playing field. He was born into it – just like I was born into my little world. The sporadic binging on cheap ubiquitous fast food whenever his mom had a little money and the absence of playtime ultimately led to his childhood obesity. The complex conditioning of his limbic needs led to a psychological fragility that was encased by a shell of defensive behavior that in-turn caused truancy. Substance abuse was around the corner waiting patiently for him. By age 15, the young boy was already a user; with open arms he was welcomed into “the hustle”. Mom was broken. One could see it in her eyes. She no longer worked. She no longer cared. That is, until her son had a stroke when he was just 17-years-old – the day the drought ended, and she cried.
It was a hemorrhagic stroke. The high blood pressure in his brain arteries caused by accelerated atherosclerosis – the consequence of his substance abuse (tobacco, alcohol, cocaine), type-two diabetes, and undiagnosed hypertension – was what caused the stroke. The stroke was so large that it shifted half of his brain across the midline of his skull, crushing it against the inner-table on the other side. Fortunately (some would say), the kid survived. Unfortunately, he wanted to die – 17-years-old and nursing home bound, unable to speak or swallow or move his right side.
The stroke was the final blow dealt by a cascade of disparities all too common in America.
July 22nd, 2009 by Olajide Williams, M.D. in Health Policy, True Stories
Tags: African American, Disparities, Harlem, Harlem Hospital, Health, healthcare, Neurology, New York City, Pediatrics
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Disparities in healthcare are composed of several interconnected layers – multiple layers joined together like the bricks of a divisive wall, separating better health from poor health. And while we must acknowledge the pre-eminence of personal responsibility, we must also address the uneven distribution of mountains and valleys on the American playing field.
Disparity sometimes begins before one is born; before one is conceived – it may begin in-utero, with the absence of adequate prenatal care, with maternal co-morbidities and high-risk behavior, long before one is old enough to assume personal responsibility within an “inherited” landscape or community that is filled with steep climbs and dark valleys. Many of us are familiar with root causes of healthcare disparities – the four components or foundational bricks that sustain physical and economic health in capitalist societies.
- Educational status
- Employment status
- Insurance status
- Income level
Individual or combined deficits in these components typically lead to accumulating disadvantages within which good health is considered an outlier. It is often these environmental factors, and not genetic ones or racial ones that are largely responsible for the disproportionate morbidity and mortality we witness all over America – especially in Harlem – the site of my neurological practice.
A young child is born on Malcolm X Boulevard in central Harlem. He is the most beautiful baby I have ever seen. And yet, his passage into the world is not without hardship. His single mom, a sixth grade dropout, did not have health insurance even though she worked two minimal wage jobs. She did not receive adequate prenatal care. Indeed, the only time she visited the hospital was to fix the broken bones in her face she sustained from domestic violence. Fortunately, she escaped from that life by fighting back with everything she had. Even her child was born through conflict – amidst the peril of eclampsia. It was a stormy delivery in a safety net hospital. Luckily, she survived and the beautiful baby boy thrived.
The early years of the child’s life were spent with grandma, until she died when her grandson was only 9-years-old. Mom had nobody else to help her, and there were no breaks in Harlem. She could not afford the childcare she needed to keep her second job, which she fought so hard in vain to keep. She became homeless. After squatting with her son in an old boyfriends house for a period of time, they finally moved into a housing shelter and were placed on a waiting list for section 8.
Mom was born poor; she had no successful role models; no good yardsticks with which she could measure herself against. Everyone around her seemed resigned to the status quo, which they would refer to as “the hustle”. She did not make it to high school; she fought for her minimum wage; she had no health insurance; and yet she worked hard to provide basic needs for her and her son. Each brick of disparity – educational status, employment status, insurance status, and income level – formed a wall so tall that it was hard to imagine how she would get to the other side.
Depression crept in – an irrepressible feeling of worthlessness and hopelessness. A feeling that no matter how hard she tried she would always fail. Most of her girlfriends were already on the streets or in jail. Their children had dropped out of school to join gangs or resort to petty crimes. She promised her own mother long before she died that she would never resort to crime. She would fight a good fight for her son and herself. But depression dug deeper, breaking her will, piece by piece until she finally succumbed to the twin pressures of emotional and economic desperation.
We all have limbic needs. For some, these needs are nurtured by loving hands that paint lasting portraits of hope inside our souls. Expressions of hope hanging on the walls of our heart chambers: a mother’s attention; a father’s approval, a caregiver’s warmth, a schoolteacher’s encouragement. For other’s, there is insufficient nurturing – these limbic needs are not met; rather, they are torn down – left out in the cold, often on impoverished streets – unanchored, undermined, forced to adapt alone in a Darwinian society.
In my next post, I will finish this story. I will describe the boy’s life and his ultimate stroke in an attempt to show the interconnectivity of health and the four components of healthcare disparities.
July 21st, 2009 by GruntDoc in True Stories
Tags: Bad Diagnosis, Cancer, Death, Emergency Medicine, Test Results, Ultrasound
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The patient with a loving family, a job, good insurance and an abnormal test. Terrible.
When they come in, with their abnormal test (a sono in this case) from an outside place, from a doctor who sends them to your ED with ‘you need more tests’, it’s hard to keep the stiff upper lip. The family, well dressed and pleasant, just make it worse. I know what’s coming. I’d encourage them to run for the door, if I thought it’d help.
The sono usually says “…blah blah blah mass in the blah blah…further imaging is recommended…blah“.
While this usually isn’t a true emergency, let’s face it: the patient deserves an answer and their doctor has given up (or in) and has sent them to me. (And it’s not like I don’t know how to order CT’s, I do).
While waiting for the CT you imagine it’s all going to be nothing, unlike the ones before. Very very occasionally it’s good news, and relief all around.
The vast majority of the time that CT has been utterly horrible news for everyone involved. There are tears, and referrals, and ‘…I don’t know for certain, you need a biopsy, because diagnosis leads to prognosis…’ and I feel rotten for about a week. Unlike the family, for whom I’ve just unmasked Death, who get to have him as a constant companion.
I don’t know if it’s because they seem so normal, or I see myself in everyone in the room, or guilt. Dunno. But it’s horrible.
*This blog post was originally published at GruntDoc*
July 12th, 2009 by Bongi in Better Health Network, True Stories
Tags: AAA, Abdominal Aortic Aneurysm, Counseling, Death, General Surgery, South Africa, Vascular Surgery
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Sometimes before you are even called the sh!t has already hit the fan. The mopping up is not fun.
I was on call. As usual I was hanging around in the radiology suite (I spend a lot of my free time there sharpening up my CT scan reading skills. The radiologists even think I’m a frustrated radiologist, poor fools). The urologist phoned me. He had a nervous laugh. Most types of laughs of urologists I quite enjoy. But the nervous laugh I do not. He then went on to tell me about a patient he had been referred with possible kidney stone and severe pain, but on the scan they found a large abdominal aorta aneurysm. I quickly called the scan up on the monitor and sure enough there it was. The patient was mine.
There was an 8cm aneurysm. But just anterior to this there were signs of recent retroperitoneal bleeding. This was not good. The guy was just one step away from a fatal rupture. I phoned my vascular colleague in Pretoria who was unfortunately in theater but they assured me he would get back to me in about 20 minutes. Then another call came through.
“Doctor, the urologist says I must call you about his patient. He says it is now your patient. Something has happened.”
I knew I needed to run.
“I’m on my way!”
As I rushed through the ward I saw what must have been the family. They were all looking anxious and some had tears in their eyes. I rushed on. I needed to focus.
In the patient’s room it looked like well orchestrated chaos. Lying on the floor was a massive man who was as pale as a sheet. The casualty officer was intubating. A sister was doing CPR. The urologist looked up.
“Glad to see you! well then I am no longer needed. See you around.” And with that he walked out. Someone was trying to place a drip with little to no success. A large group of young student nurses were looking on with expressions ranging from shock to morbid fascination to excitement. I needed to take control. Only thing is I had seen the scan and I knew what had happened (when an 8cm aortic aneurysm ruptures into the abdomen it causes almost guaranteed instant death).
I told the nurse to stop CPR long enough for me to check for signs of life. There were none. She continued. I then did some basic tests to gauge brain stem function. There was no detectable brain stem function. I called it right there.
After a dramatic unsuccessful resus there is usually an eery silence in the room. Maybe it is a sort of respect for the departed or maybe it has to do with confronting one’s own mortality. I think it has a lot to do with thinking who is going to say what to the family.
“Are you going to speak to the family?” I asked the casualty doctor. I had to try.
“No! you are!”
“Great!” I thought. “I walk in on the closing act and I’m left with the hot potato.”
I took time to speak to the nursing staff, telling all those directly involved that they did well and just trying to somehow let the students know that it is ok to not be ok with death up close. Then I went quiet. I needed to focus.
The family had been taken into the sisters’ tea room. They then sent me in. The mopping up had begun.
I have spoken before about breaking bad news. Fact is, it is never easy and I’m not sure there is any easy way to do it. I try not to leave the family in the dark too long. Once they know I try to be as supportive as possible and to answer their questions as best as can. Usually I am struck by the human tragedy and I allow it to affect me as it should. Sometimes when I have been overcome by the relentless nature of my work I must stand back and observe. This was one of those times.
*This blog post was originally published at other things amanzi*
I noticed my use of the phrase ‘call it’ a few times recently. It is something I saw on American TV and not at all something that is common in my neck of the woods. The sort of scene that you would get in gray’s when the junior doctor is pumping the chest shouting ‘I will not let you die, dammit!’ while the senior doctors stand one side and instruct him to ‘call it!’ is pretty foreign to our way of doing things. I even got ragged a bit for using the phrase at all. I thought I’d relate a story from days gone by that illustrates this point.
