August 17th, 2007 by Dr. Val Jones in True Stories
Tags: Hospitals, Pediatrics, Surgery
3 Comments »
I was pleased to receive an email invitation from Dr. Jon Mikel from Unbounded Medicine to blog about surgery. He writes,
“Please feel free to post anything related to surgery,
like surgical procedures, mistakes during surgery or during your training,
lessons learned, tips, first operation done solo, memorable operations,
memorable patients, jokes, your point of view about surgery, or even why you dislike surgery or surgeons (if that is the case).”
As my mind wandered through all the possible posts I could prepare, I settled on a touching story that highlights the life of a wonderful surgeon named John Schullinger. Dr. Schullinger was the surprised recipient of one advanced case of intussusception in a 10 month old baby girl. The baby was shipped to him from a distant general hospital where they didn’t have any pediatric surgeons to take the case. On arrival the baby was moribund – septic and seizing, with an abdomen distended with gangrene.
Dr. Schullinger explained the gravity of the baby’s condition to her mom, promised not to give up on the baby, and took her to the O.R. for a bowel resection. Against all odds – and having to resect everything from the terminal ileum to the sigmoid colon – the baby made it through. A jubilant mother thanked the surgeon, and promised to keep in touch, though the family would be moving out of the country.
Every Christmas, the baby’s mom sent Dr. Schullinger a card from Canada – detailing her daughter’s growth and accomplishments and thanking him again for saving her life. Each Christmas he responded with a hand written note, expressing his pleasure with the child’s progress.
This ritual continued each year for 25 years until one day the young woman went to visit the surgeon and thank him in person. She was interviewing for medical school at Columbia, the same institution where Dr. Schullinger had saved her life nearly a quarter century earlier. It was a tearful reunion and touching for both surgeon and patient – because they could see how operations can change lives, and how babies that you operate on can grow up to be physicians who help other babies.
Dr. Schullinger saved my life – but his influence reached far beyond his technical skills in the O.R. His compassion and faithful follow up responses to my mom showed me what being a doctor is all about. My fondest hope is that I’ll live up to his example.
So for all you surgeons out there… you work longer hours than most others on this planet, you sacrifice your lifestyle to serve others, and yet you rarely see how your work impacts families long term. I am here to thank you on behalf of all those who can’t or don’t – please take courage from this story. You never know if the patient you operate on will come back and take over the scalpel for you one day…
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 12th, 2007 by Dr. Val Jones in True Stories
Tags: Disabilities, Grand Rounds, Hospitals, Medicare, News, Pediatrics, Physical Medicine And Rehabilitation, Plastic Surgery, Surgery
5 Comments »
This week’s host of medical grand rounds invited individuals to submit blog posts that feature stories about “sudden change.” As I meditated on this theme – I realized that one of my patients played a key role in my sudden career change from academic medicine to joining a healthcare revolution.
As chief resident in PM&R, I spent a few days a month at an inner city clinic in the Bronx, helping to treat children with disabilities. The clinic was dingy, overcrowded, largely windowless, and had waiting lines out the door starting at 8am. Home health attendants generally accompanied the wheelchair-bound children to the clinic as many of them were orphans living in group home environments. The kids had conditions ranging from cerebral palsy, to spinal cord injury from gun shot wounds, to severe spina bifida. They sat together in a tangled waiting room cluttered with wheelchairs, walkers, crutches, and various prosthetics and orthotics. There were no toys or even a TV for their amusement. The air conditioning didn’t work well, and a lone clock ticked its way through the day with a bold black and white face.
The home health aides were eager to be called back to the examination rooms so that they could escape the oppressive conditions of the waiting room. I opened the door to the room and called the name of one young man (we’ll call him Sam) and an aide leapt to her feet, knocking over another patient’s ankle-foot orthosis in the process. She pushed Sam’s electric wheelchair through a series of obstacles to the exit door and back towards the examining room.
Sam was a teenager with cerebral palsy and moderate cognitive deficits. His spine was curved into an S shape from the years of being unable to control his muscles, and he displayed the usual prominent teeth with thick gums of a patient who’d been on long-term anti-seizure medications. He looked up at me with trepidation, perhaps fearing that he’d receive botox injections for his spastic leg muscles during the visit. His wheelchair was battered and worn, with old food crumbs adhering to the nooks and crannies.
“What brings Sam here today?” I asked the home health aide, knowing that Sam was non-verbal. She told me that the joystick of his electric wheelchair had been broken for 10 months (the chair only moved to the left – and would spin in circles if the joystick were engaged), and Sam was unable to get around without someone pushing him. Previous petitions for a joystick part were denied by Medicare because the wheelchair was “too new” to qualify for spare parts according to their rules. They had come back to the clinic once a month for 10 months to ask a physician to fill out more paperwork to demonstrate the medical necessity of the spare part. That paperwork had been mailed each month as per instructions (there was no electronic submission process), but there had been no response to the request. Phone calls resulted in long waits on automated loops, without the ability to speak to a real person. The missing part was valued at ~$40.
I examined Sam and found that he had a large ulcer on his sacrum. The home health aid explained that Sam had been spending most of his awake time in a loaner wheelchair without the customized cushioning that his body needs to keep the pressure off his thin skin. She said that she had tried to put the electric wheelchair cushion on the manual chair, but it kept slipping off and was unsafe. Sam’s skin had been in perfect condition until the joystick malfunction. I asked if he’d been having fevers. The aide responded that he had, but she just figured it was because of the summer heat.
Sam was transferred from the clinic to the hospital for IV antibiotics, wound debridement, and a plastic surgery flap to cover the gaping ulcer hole. His ulcer was infected and had given him blood poisoning (sepsis). While in the hospital he contracted pneumonia since he had difficulty clearing his secretions. He had to go to the ICU for a period of time due to respiratory failure. Sam’s home health aide didn’t visit him in the hospital, and since he was an orphan who was unable to speak, the hospital staff had to rely on his paper medical chart from the group home for his medical history. Unfortunately, his paper record was difficult to read (due to poor handwriting) and the hospital clerk never transferred his allergy profile into the hospital EMR. Sam was violently allergic to a certain antibiotic (which he was given for his pneumonia), and he developed Stevens-Johnson Syndrome and eventually died of a combination of anaphylaxis, sepsis, and respiratory failure.
When I heard about Sam’s tragic fate, it occurred to me that the entire system had let him down. Bureaucratic red tape had prevented him from getting his wheelchair part, poor care at his group home had resulted in a severe ulcer, unreliable transfer of information at the hospital resulted in a life-threatening allergic reaction, and a lack of continuity of care ensured his fate. Sam had no voice and no advocate. He died frightened and alone, a life valued at <$40 in a downward spiral of SNAFUs beginning with denial of a wheelchair part that would give him mobility and freedom in a world where he had little to look forward to.
Sam’s story was the last straw in my long list of frustrations with the healthcare system. I began looking for a way to contribute to some large scale improvements – and felt that IT and enhanced information sharing would be the foundation of any true revolution in healthcare. And so when I learned about Revolution Health’s mission and vision, I eagerly joined the team. This is a 20 year project – creating the online medical home for America, with complete and secure interoperability between hospitals, health plans, healthcare professionals, and patients. But we’re committed to it, we’re building the foundation for it now, and we know that if successful – people like Sam will have a new chance at life. I can only hope that my “sudden change” will have long lasting effects on those who desperately need a change in healthcare.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 14th, 2007 by Dr. Val Jones in True Stories
Tags: Addictions, Hospitals, Illicit Drugs, Medical Training, Neurology, Personal
No Comments »
This story is from my intern year diary. It’s a quick snapshot of a patient who had overdosed on heroine, coded, and was resuscitated. I think about him sometimes… especially when I read about the rampant drug abuse problem in the US.
—————
I poked my head into the 4-bed communal room on the sixth
floor. The nurse had called to say that
one of the patients was agitated and required restraints. I was asked to assess the situation.
It was immediately clear to me which of the four patients required
my attention. In the far, right corner
was a pale young man, stark naked and thrashing about in his bed. He was babbling something about Ireland and how
he needed to get home. I had gathered
from a quick review of his chart that he had overdosed on heroine, was
resuscitated after coding in the E.R. and transferred to the floor for
observation as he detoxed from the overdose.
I approached the flailing body tentatively. “Hello.
I’m Dr. Jones. You appear to
be quite distressed. What seems to be
the matter?” I said as I pulled a sheet up from the bottom of his bed and
placed it over his genitals.
The young man, barely in his twenties, lay very still as I
spoke to him. He stared at my face with
bulging eyes, speechless for a full 10 seconds.
“Are you alright?” I asked.
“Where am I?” asked the man in a quiet voice.
“Where do you think you are?” I asked, using the opportunity
to assess his mental status.
“I’m somewhere in Ireland,” he said, head turned
towards the window with a view of the Chrysler building.
Seeing that his reasoning was not intact, I replied kindly,
“Well, actually you’re in a hospital in New
York City. You
took an overdose of heroine and your heart stopped…”
“Wow, that sucks,” said the man, sincerely surprised by the
news.
“We were able to resuscitate you in the emergency room,” I
added.
“Cool,” he said, as if the event had transpired in another
person’s life.
“So right now you still have a lot of drugs in your system
which is why you feel confused,” I said, “I think it will take several days
until you return to your normal state of health.”
“Sounds good,” nodded the man.
“Do you know where you are right now?” I asked, suspecting
that his short-term memory had been completely lost.
“I’m in Amsterdam,”
he said, undisturbed by his delirium.
I sighed as I realized that nothing I said to him would
register for longer than a second or two.
“Such a young person, what a waste,” I thought.
The man started to thrash about in his bed again.
“What are you doing?” I asked.
“The back stroke,” he said, surprised that I didn’t know.
I glanced at the man in the bed nearby. He was watching our interaction with some
amusement. He had been reading the New
York Times with a book light. He was a
private patient on a heparin drip for a deep venous thrombosis behind his right
knee. I nodded at him and shook my
head.
Weeks later I heard that the young man’s thoughts were no clearer than they were that night, and that he was transferred to a nursing home for long term care. The brain damage that he suffered from his drug use (and lack of oxygen during his cardiac arrest) had caused permanent, irreparable damage. Another tragic victim of a brain on drugs.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 24th, 2007 by Dr. Val Jones in True Stories
Tags: Cancer, Medical Training, Palliative Care, Surgery
1 Comment »
During my residency I kept a diary as a way to relieve some of the sadness related to the death and dying that I witnessed. I recorded various encounters in a series of vignettes. Although these are a bit long for a blog, I thought I’d share a few now and then in the hope that they’d preserve the memory of those who are gone. All personal data have been removed so that the identity of the patients is protected.
***
It’s 3:00am and I was paged to examine yet another patient who had fallen out of bed – to rule out a hip fracture.
Too tired to read the chart prior to examining the patient,
I thought I’d leap right into the physical exam. I assumed that the patient would be the usual
elderly woman who, in her sickened delirium, thought she was at home and tried
to walk by herself to the bathroom and fell en route.
I marched into the room and stopped at bed 23. All my pre-conceived notions evaporated as I
looked at the young man before me.
Emaciated and stiff, with all four limbs contracted, he lay on the bed,
clinging to a thin white sheet. The
whites of his eyes flashed in the darkness.
“Hi there.” I said, trying to seem casual at the sight of
the living corpse before me. “I’m Dr. Jones. I heard that you fell. Are you in any pain?”
His eyes suddenly fixed themselves on me and he spoke, not
with a thin raspy voice, but with the robust youthful voice appropriate to his
age rather than the decrepitude of his body.
“I’m in no pain,” he said.
“I was trying to sit down on the chair.
I thought it was against the wall, but it was actually a couple of feet
away. So when I leaned on it, it slid
and I fell on the floor.”
“Do you think you broke anything?” I asked, trusting in his
judgment as his mental status was clearly in tact.
“No, I just scraped my butt,” he said, pointing a frail
finger towards his sacrum.
“Did you hit the floor hard?” I asked as I used my pen-light
to examine his back side.
“Not really,” he said.
“Would you like me to order an X-ray of your pelvis to see
if you broke anything?”
“I don’t think I need it,” he said.
“Well let me see if it hurts when I rotate your leg in your
hip socket, ok?” I pulled down the sheet
and asked the young man to allow his right leg to fall to the side. As I looked down at his hip I gasped slightly
as his inner thigh came into view. A
gaping ulcer lay before me, deep to the bone, exposing tendons and ligaments
with pus, and red knobs of flesh surrounding a football sized hole in the man’s
groin. His paper-thin scrotum lay stuck
to his left thigh. The smell overcame
me, it was at once wet and fetid, with a hint of chemical odor from the
antibiotic ointment that was clinging ineffectively to the fringes of the wound.
“Oh my God. Does that
hurt?” I stammered.
“No, not at all.”
“And does it hurt when I rotate your leg in your hip
socket?” I asked, trying desperately to remain focused on the task at hand.
“No, it doesn’t.”
“Well, then,” I said, gathering my faculties. “I don’t think you broke your hip. And if you don’t want an X-ray, I don’t think
we need one. Perhaps you’d like to go
back to sleep and get some rest?”
“Yes, that sounds good,” he said, drifting off into a
morphine induced altered state of awareness.
I wandered out towards the nursing station, looking around
vaguely for the patient’s chart to make note of my “fall assessment.”
One of the nurses anticipated my need and handed me the
thick plastic folder.
“What does this patient have?” I asked.
“Oh, he has AIDS and metastatic anal cancer” she said as she collected some sputum in a clear plastic cup. “He’s 38 years old.”
“The same age as my boyfriend,” I thought to myself. “And why exactly did he fall?” I asked the
nurse.
“I was trying to help him to get to the commode,” she said printing something on a label. “He fell because I wasn’t strong enough to
hold him up. My right arm is a little
bit weak.”
“And why is your arm weak?” I asked, assuming that it was
because of a small strain injury.
“I have breast cancer,” she said, finally making eye contact
with me.
“Oh my God, I’m so sorry,” I said, feeling the weight of her
diagnosis amidst a ward of terminal cancer patients.
“Well, you know the funny thing is that my husband is
particularly upset. He doesn’t want me
to have a radical mastectomy. He says
that it would hurt to see my body differently than he’s used to… he likes to
think I’m still the bouncy cheerleader I was when we first met. To see me with only one breast is upsetting
to him. And quite frankly, I’m afraid he
won’t be attracted to me anymore. That’s
what scares me the most,” she said, becoming misty-eyed.
My pager let out a familiar series of beeps.
“I’m so sorry,” I said, squeezing the nurse’s shoulder. I paused and tried to be encouraging: “Well, even if you need a mastectomy – I’ve seen some great reconstructive surgeries
where the breast can be reformed at the same time with an implant. Maybe you’ll be a good candidate for that
surgery? I’m so sorry that I have to
run… can we talk later?”
“Sure,” she said, smiling faintly.
***
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 10th, 2007 by Dr. Val Jones in Humor, True Stories
Tags: Cancer, Dermatology, Humor, Personal, Skin Cancer
5 Comments »
I’ve been thinking about skin cancer lately. A young, fair skinned friend of mine
recently had a small mole removed from her leg.
It turned out to be melanoma! It
didn’t take me too long to make the connection between her complexion and mine,
and the fact that I’d been avoiding the dermatologist for several years,
worried that I’d come out like a punch biopsy pin cushion since I have quite a
few freckles and moles (and I’ve heard that dermatologists like to err on the
side of caution and biopsy anything remotely suspicious). But the melanoma story galvanized me into
action. I made an appointment with a
dermatologist (yes, I had to wait 4 months to get an appointment!) and got a
skin check. Luckily for me, all was fine. But I started to reflect on various conversations
I’ve had about my skin recently. All you
Irish types out there will relate…
Conversation 1
Coworker A: Val, are you ok?
You look kind of sick.
Me: I’m just fine.
Coworker A: But Val, you look a little… bluish…
Me: That’s just my skin color. My veins show through my skin because it has
no melanin.
Coworker A: (Appearing sympathetic) Oh, well glad you’re
alright.
Conversation 2
Coworker B: (in the middle of a conversation with me, sitting
across from one another on chairs. I’m wearing a skirt. Suddenly she lunges forward
and touches my knee and gasps). Is that
your real skin?
Me: Um… yes. What
else would it be?
Coworker B: Well, I thought you were wearing white pantyhose.
Me: Nope. It’s too
hot for pantyhose so I just go bare legged.
Coworker B: (still in shock). But that’s your skin? Just like that?
Me: Yeah. I don’t
tan.
Coworker B: (appearing sympathetic) Oh, wow.
Conversation 3
Dermatologist: Hi, I’m Dr. XXX. (Peering at me, seated on the examining table
in a paper gown.) Are you Scandinavian?
Me: No, I’m part Welsh – you know, “Jones.”
Dermatologist: Oh, well the Vikings probably invaded Wales
at some point.
Me: (to myself) well thanks for alluding to the raping and pillaging
of my ancestors.
Dermatoligst: You’re high risk for skin cancer. People like you need to have careful skin
exams every year.
Me: Yes I know. But
please don’t take any unnecessary biopsies!
I think my moles are all fine.
Dermatologist: Well let’s see…(tearing the paper gown in two). You definitely need to wear SPF 50…
Me: Sigh. I know…
Conversation 4:
Husband: (giving me what I thought was a tender look. He leans in…) Your eye lids are kind of pinkish purple
Me: Yes, that’s the color of the capillaries that show
through my lid skin. Hard to get a tan
there you know.
Husband: You don’t need a tan – I like your color. Kind of pastel pink and blue. (He leans in even closer to inspect my eye lids.)
Me: Yeah, not exactly attractive in a bathing suit. (I pull away. He laughs.)
Husband: Well, yeah.
It’s better not to be out in the sun or on the beach, but you can still
go outside!
Me: Thanks.
Conversation 5:
Asian manicurist: (looking at my hands) Your skin is so white!
Me: Yes, I’m afraid my past efforts to alter that have failed.
Asian manicurist: How did you get your skin so white?
Me: I didn’t do anything.
It’s like that naturally.
Asian manicurist: (looking closer at my hands) I wish I had skin like yours.
Me: Why? (Hoping she’d say something flattering after all).
Asian manicurist: It looks clean.
And so I guess despite all the people I’ve worried with my vaguely cyanotic appearance, there’s one thing for sure: I look clean. I guess I can live with that.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
