May 12th, 2007 by Dr. Val Jones in True Stories
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Panda Bear, MD (a feisty young blogger) gives some advice to
new medical interns in his recent post.
Internship, for those of you who may not know, is the first year of
residency training. It is the first time
that a doctor, fresh out of medical school, has responsibility for patient
care. The intern prescribes medications,
performs procedures, writes notes that are part of the medical record, and
generally learns the art of medicine under the careful watch of more senior
physicians.
Internship is a frightening time for all of us. We’ve studied medicine for 4 years, memorized
ungodly amounts of largely irrelevant material, played “doctor” in third and
fourth year clerkships, but never before have lives actually been put in our hands. We know the expression, “never get sick in
July” because that’s when all the well-intentioned, but generally incompetent
new interns start caring for patients. And so, as Panda describes the experience,
we tremble as we begin the new stage in our careers – applying our medical knowledge
to real life situations, and praying that we don’t kill anybody.
I’ll never forget my first day of internship. I must have drawn the short straw, because
not only was I assigned to the busiest, sickest ward in my hospital (the HIV
and infectious disease unit), but I was on call that day (so I’d be working for
24 hours straight) with the most hated resident in the program (he had a
reputation for treating interns poorly and being arrogant to the nurses). As I reviewed my patient list, I noticed that
the sign out sheet (the paper “baton” of information handed to you by the last
intern who cared for the patients – meant to give you a synopsis of what they
needed) was supremely unhelpful. Chicken
scratch with diagnoses and little check boxes of “to do’s” for me. I was really nervous.
So I began to round on my patients – introducing myself to
each of them, letting them know that I was their new doctor. I figured that even if I couldn’t completely
understand the sign out notes, at least by eye-balling them I’d have an idea of
whether or not they were in imminent danger of coding or some other awful thing
that I figured they’d be trying to do.
My third patient (of 15) was a thin, elderly Hispanic man,
Mr. Santos. He smiled at me when I came
in the door – the kind of lecherous smile that a certain type of man gives to
all women of child bearing age. I
ignored it and introduced myself in a professional manner and began to check
his vital signs. I was listening to his
heart, and I honestly couldn’t hear much of anything. There was a weird very distant beat –
something I wouldn’t expect for such a thin chest. The man himself looked awful, but I really
wasn’t sure why – he just seemed really, really ill.
My pager was going off mercilessly all night. I wondered if this was how the nurses got to
know the characters of their new interns – to test them by paging them for
anything under the sun, tempting us to tip our hand if we had tendencies to be
impatient or disrespectful. But in the
midst of all the “we need you to sign this Tylenol order” pages, there came a
concerning one: “Hey, Mr. Santos doesn’t look good. Better get up here.”
My heart raced as I rushed to his bedside. Yup, he sure didn’t look too good. He was breathing heavily, and had some kind
of fearful expression on his face. I
didn’t really know what to do, so I decided to call the resident in charge
(much as I was loathe to do so, since I knew he would humiliate me for bothering
him).
The resident appeared in a froth – “why are you paging
me? What’s wrong with the patient? Why do you need me here? This better be good!”
“Um… Mr. Santos doesn’t look too good.” I said, frightened
to death.
“What do you mean ‘he doesn’t look too good?’ Can you be a little bit more specific” he
said, sarcasm dripping from his tongue.
“Well, I can’t hear his heart and he’s breathing hard.”
“I see,” said the resident, rolling his eyes. He marched off towards the patient’s room,
certain to make an example of me and this case.
I trotted along behind him, hoping I hadn’t been wrong in
paging him – trying to remember the ACLS
protocol from 2 weeks prior.
The resident drew back the curtain around the man’s bed with
one grand sweep of the arm. “Mr. Santos,
how are you doing?” he shouted, as if the man were deaf.
The man was staring at the wall, taking in deep, labored
breaths of air. I saw that the resident
immediately realized that this was serious, and he placed his stethoscope on
the man’s chest.
I approached on the other side of the bed and held his
hand. “Mr. Santos, I’m back, remember
me?” He smiled and looked me straight in
the eye.
He replied, “Angel.” (in Spanish) Then he let out a deep breath and all was
silent.
The resident shook the man, “Mr. Santos? Mr. Santos?!”
There was no response.
“Should I call a code?” I asked sheepishly.
“Nope, he’s DNR,” said the resident.
I was flabbergasted.
“Yep, you just killed your first patient. Welcome to intern year.”
As I thought about his cruel accusation, I was comforted by
the fact that at least, as Mr. Santos released his final breath, he thought he
had seen an angel. Maybe my presence
with him that night did something good… even though I was only a lowly intern.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
May 4th, 2007 by Dr. Val Jones in True Stories
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A few weeks ago I tripped and fell on the sidewalk. I went down on hands and knees and scraped my left knee pretty badly. The onlookers pretended not to notice, I suppose sparing me the embarrassment of asking if I was ok. I dusted myself off and bled down my leg en route to work.
Since then I kept the wound moist with neosporin and band aids, allowing the skin to heal with minimal scarring. But as I marveled at how painful this little patch of road burn is, I remembered a young girl I met about a decade ago who had a much more serious burn.
Inga was camping with her parents in a synthetic tent. They had spent the day fishing and canoing near a campground somewhere in Eastern Europe. They were huddled together inside the tent in the cool of the evening, speaking animatedly about the day’s events and the beauty of nature when Inga accidentally knocked over the kerosene lamp situated near the exit flap. The kerosene spilled out onto the tent and the fire ignited immediately. The tent began to melt in the fire and the zipper got stuck in the hot plastic material. The unimaginable screams of her dying parents as they burned alive, trapped in this tent, brought help just in time to save Inga’s life.
But Inga was horribly disfigured by the fire. She spent nearly a year in the hospital, receiving skin grafts and fighting off infections. She was eventually able to return to school, but was treated like an outcast. Her former friends were too horrified by her appearance to welcome her back and she spent most of her days sitting alone in the corner, covering her face with a scarf, blaming herself for the death of her own parents.
Her story reached the compassionate ears of a plastic surgeon friend of mine. He traveled to Eastern Europe to meet Inga and see if he could help her. As it turns out, she had no living relatives and was dirt poor. He could see that the medical team taking care of her had carefully covered the defects in her skin, but had not attempted to restore a normal appearance with modern plastic surgery techniques.
The surgeon knew that it would take many surgeries over many years to give her the best result possible. After some debate and soul searching, he decided to sponsor Inga to come to America where he committed to taking care of her financial needs and to giving her a new life.
I first met Inga after she had been in the states for several years. She looked like a burn victim, with tight facial skin and abnormal contours – but compared to how she appeared in the photos of when she first arrived (with no nose or cheek flesh at all) this was a huge improvement. She was meeting with the surgeon to have a seroma evacuated from under her left cheek. He had to remove the extra fluid with a large syringe.
As I watched him numb the area and sink a deep, large bore needle into this young girl’s face, I cringed internally but tried to appear unphased for her sake. She didn’t flinch, but sat staring forward bravely, her grey eyes fixed on the wall in front of her. I saw a tear well up and trickle down her disfigured cheek during the procedure and I instinctively reached for her hand. The tears continued in silence. This burn had penetrated so much deeper than the skin.
I haven’t seen Inga since, though I’ve heard that she’s doing well in school, has made some good friends, and is planning to become a nurse one day. Her decision to devote her life to caring for others is a beautiful example of “paying it forward.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 21st, 2007 by Dr. Val Jones in True Stories
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One day I was consulted on a patient in the surgical
ICU. It is uncommon for rehab physicians
to be called to the SICU, and so en route, I pondered what I might find. Maybe a multiple trauma patient who needs a
walker or chest PT?
As it happened, the patient was a 21 year old male who had
gotten into a fight in the West Village. He was hit on the head with a blunt object, resulting
in a subdural hematoma and severe brain injury.
He was intubated, sedated, and expressing decerebrate posturing (a
really bad sign).
The surgeons had called me because they were concerned about
pressure ulcers and contractures. They
wanted to initiate physical therapy and stretching exercises to make sure that
his Achilles tendons didn’t shorten irreparably as his feet were pointing
downward in the bed. Although I thought
it was great that the surgeons were planning ahead like that, truthfully I didn’t
think the patient would ever walk again, or perhaps even survive the SICU. The level of brain injury was just too
severe.
I wrote orders for daily physical therapy, got him some Multi Podus Boots, and recommended frequent turns in bed.
I figured I’d never see him again as I was scheduled to change rotations
and transfer follow up of this consult to another resident. It was a tragic case.
About 2 months later I began an inpatient rotation and was
listening to the story of several patients whose care was being transferred to
me. As the resident presented the final
one, I thought the story sounded familiar.
A young man out partying with his friends, got into a fight, sustained a
severe brain injury after being hit in the head…
“This isn’t the guy I saw in the SICU 2 months ago, is it?” I asked the resident.
“Yeah, that’s the one!
I remember seeing your note in the chart. The PTs did a great job with his ankles – he could
stand on them just fine when he got up.”
“Dude, no way! When I
saw him he was posturing in the SICU… this guy actually recovered?!”
“Yeah, I know… he’s the first one I’ve ever seen like this. Do you wanna see him?”
“Heck yeah,” I said, “I’ve got to see this with my own eyes.”
My colleague led me down the hallway to the occupational
therapy kitchen. As we got closer, a
wonderful chocolatey smell filled the air.
“What smells so good?” I asked.
“Oh, the patient is making cookies with the occupational
therapists. He’s learning how to cook
and take care of himself.”
I rounded the corner into the kitchen and there was a young
man, handsome and healthy, pulling a tray of cookies from an oven – I could barely believe it was the same
person.
“Hey doc,” he said to me – not recognizing me of course, but
friendly nonetheless. “You want a
cookie?”
“I’d love a cookie,” I said, remembering the last time I had baked them.
“I believe that this is the best cookie I’ve ever tasted,” I
said, looking at the man with tears in my eyes.
He grinned from ear to ear.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 21st, 2007 by Dr. Val Jones in True Stories
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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.
April 18th, 2007 by Dr. Val Jones in Opinion
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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.
