A moment of reflection…

I sit here today, in this small, windowless call room with its low twin bed that is covered in untouched hospital blankets and sheets. Tonight is one of my last nights on a 30-hour call shift in the medical intensive care unit. Yet another mile-marker on this long journey of residency. My day began at the break of dawn, when I and another resident passed each other in the parking lot at 7AM – the only souls trudging to our cars at such an ungodly hour on a Sunday morning. But this is the life we chose.

The day passed as many days have passed in the intensive care unit – extubating one patient, intubating another, placing one or two central lines, and being present with families in a time of crisis and even in the face of death. It is a charged atmosphere. At one point, our hospital raised the Donate Life flag in honor of a young gentleman who had died and donated his organs to patients in need across the country. At another point, we gathered round in a patient’s room with family and chaplain to offer the only piece of caring we still could offer her – empathy, compassion, and prayers.

The families and patients in this unit have reminded me, over the past few weeks, of the primary reason I chose to become a doctor: to care for my patients. Patients roll into this unit on stretchers, many with breathing tubes in place, many so confused or sedated that their memories of this visit will merely be a vague sense – blurred brush strokes across canvas, lacking definition or purpose. But perhaps it is better that they do not remember – it serves as a survival mechanism, if they ever make it out of here.

All too soon, however, reality will hit. Some of these patients will be paralyzed for the rest of their lives. Others will never be able to eat or lie flat again, because they are at such a high risk for aspiration . Still others may never speak again because of malignant masses occluding their vocal cords. Hard to imagine, really, but it happens here every day.

Even with these tragedies, though, some patients will make it out of the ICU in good health, at least in a medical sense. But even they must struggle to overcome the effects of their prolonged hospital stay – weakness, anxiety, fear. Many of them will need rehabilitation, both mental and physical, for extended periods of time.

ICU patient walking in Johns Hopkins Hospital Critical Care Unit

In an attempt to prevent this, there is a new movement in critical care units to sedate patients less, to exercise them more, and to allow them to return functioning, mobilizing human beings as quickly as possible and even in the setting of the grave illnesses which brought them here. An article in the New York Times published in 2009, Get Patients Up, introduces some of the new and relatively radical approaches that physicians are using at Johns Hopkins, including mobilizing patients on ventilators. The idea is to allow patients to maintain their strength, to minimize muscle wasting, and to prevent long-term neuromuscular weakness that ultimately requires patients to participate in months of physical therapy to return to their baseline.

An article from Vanderbilt University in Chest 2010, Vasilevskis et al., describes an “ABCDE bundle” which is a strategy to minimize delirium and weakness in critically ill patients. It includes awakening patients daily, allowing them to breathe on their own without ventilator assistance for brief periods every day, coordinating their breathing and awakening, closely monitoring their delirium using consistent guidelines, mobilizing them early, and initiating physical and cognitive therapy. The goal of this bundle approach is to reduce the devastating effects of delirium and weakness which patients commonly struggle with after their ICU stays.
Although these ideas push the bounds of conventional ICU medicine, which include deep sedation and bed rest, they mark the beginning of a new and perhaps even more humane approach to care for the critically ill. Even more interestingly, these new techniques recall the age-old wisdom of Hippocrates. Primum non nocere. First, do no harm. By sedating patients with high doses of medications to treat their pain and agitation, by paralyzing patients to minimize the use of their respiratory muscles, and by restraining them to strict bed rest, we are in some cases harming them more than we are helping them. So let us take a fresh look at critical care medicine and remind ourselves that, at least for some of our patients, less is more.

The Downsides of the Emergency Room

An article published in Smart Money on January 24, 10 Things the Emergency Room Won’t Tell You, discussed some of the downsides to emergency room care. I will tackle these claims one by one.

1. Patience will get you nowhere.

The emergency room is a busy place, and it is generally true that being clear about your symptoms is important. However, patients are generally triaged by experienced nurses and physicians who are particularly attuned to the dangers mentioned in the article – shoulder pain, for example, should not simply be disregarded because it is not chest pain. The initial workup, including an ekg to analyze the rhythm of the heart, will be performed immediately for patients who are in high-risk groups based on age, gender, and other predictive factors. This ekg will be interpreted by an experienced physician. The moral of the story? Be clear about your symptoms and alert the triage staff if there are any changes in your symptoms.

Patience will get you somewhere – it will get you, even if it takes time,  to the emergency room. Although waiting can be frustrating, if your condition was serious enough to bring you to the ER in the first place, then it is probably serious enough to warrant waiting for a complete examination by a physician. Although some conditions will not cause death or serious consequences in the first few hours, many of these conditions can progress to cause serious problems in the next 24 to 48 hours. Thus, the wait may very well be worth it. It is your health, after all, and it is better to err on the side of caution.

2. There’s a cheaper option down the street.

Urgent care centers, if they are open and are conveniently located, are certainly an alternative worth considering. They are especially good for straightforward medical problems, such as lacerations or sprains. It is true that the ER does not offer extensive information on cheaper options, other locations, or alternatives to ER care – we are there to take every sick patient who walks through our doors and to treat them as best we can. That is our primary focus. And we certainly do not want any patient to feel that we are turning them away just because their condition can be treated elsewhere. Furthermore, many ERs now have urgent care centers as part of the facility, where patients can be seen and treated by physician assistants.

3. Bring a book.

Excellent idea. I could not agree more. Waiting – to be seen, to be treated, to receive test results, or to be admitted to the hospital – are all part of the normal course of things in the hospital. Bring a book, a magazine, music, or anything else that will keep you occupied during this time.

4. Come back in the morning.

Be careful on this one. We have many patients who decide to wait until morning to come to the emergency room – and by this time they may have already been trying to “ride out” a heart attack, aortic aneurysm, or other life-threatening condition for several hours. Although the wait may be shorter in the morning hours, if there is a possibility that you have a life-threatening medical condition, you will be seen quickly at almost any hour of the day – this is the main purpose of the ER. And ultimately, experienced nurses and physicians are better equipped than you to decide how serious your condition might be – patients often underestimate the gravity of their symptoms.

5. We might make you sicker.

This is not any more true of the ER than it is of the hospital. In fact, the case used as an example in the article was of a patient who was admitted to the hospital and underwent surgery – her complications are likely not associated with her ER visit. However, it is true that hospitals are places where infections can spread. As a result, hospitals have been proactive about placing Purell dispensers outside almost every patient room in the hospital. They have also been proactive about instituting hand-washing measures with rewards and punitive measures for physicians, nurses, or other hospital staff based on overall performance. In the ER, we are especially attuned to the potential spread of infections. During the 2010 H1N1 outbreak, many ERs were so cautious that they required patients, visitors, and physicians to wear masks if there were signs or symptoms of flu (fever, chills, cough, and the list goes on).

6. To us, you’re like a lab rat…

I don’t think ER physicians would bother to do such extensive medical workup on a lab rat. And most of these tests are not invasive. The “workup” for chest pain involves blood tests, an ekg, a chest x-ray, and possibly the scheduling of an outpatient stress test if everything checks out – not an unreasonable test, I would argue, for any middle-aged person who has chest pain. Many people have chest pain, but chest pain that is serious enough to bring you to our doorstep – the ER – is taken just as seriously by us as by you. As for unnecessary testing, refer to Defensive Medicine Supersedes Quality Medicine. This is one of the problems at the heart of medicine in this country, and it is a problem that we must fight to overcome.

7. …but don’t expect us to figure out what’s wrong.

This is generally true. In the emergency room, we determine if your condition is life-threatening or if it needs urgent intervention. We decide if you need to stay in the hospital or not. We elicit certain important characteristics about what is wrong, but we cannot necessarily give you a diagnosis in the brief time period that we care for you. In the end, however – and this goes back to the title of my blog – much remains a mystery in the world of medicine and human health. Many conditions will take months or years to diagnose, and other conditions will never be given a formal diagnosis. Many conditions necessitate extensive testing or knowledge of symptoms over long periods of time – information which, for purposes of time and money, the ER is simply not equipped to obtain. But even after all the testing has been done in the outpatient setting, physicians cannot always come up with a diagnosis. This is one of the great frustrations of medicine.

8. Good luck seeing a specialist.

This is completely dependent on where you go. Furthermore, many conditions necessitate being seen by a specialist in the next few days (especially orthopedic injuries, hand injuries, and urologic issues, which are all mentioned in the article), and in these cases you will be referred to the appropriate specialist in a specific time range. Ultimately, these referrals may delay but should not compromise the quality of  your care.

9. Your doctor can get you priority access.

If you have time, alerting your physician that you are going to the ER is a good thing. However, there has been a trend since the 1960s that private physician like to rely on ER physicians more and more, and many private physicians no longer come to the ER themselves. If they are willing to, they serve as an invaluable resource – after all, they know you far better than the emergency physician who will be treating you.

10. You can choose your doctor.

There are two different points made here – one is that you can choose to see your own specialist in the ER. This is generally true if he or she is affiliated with the hospital in some way – otherwise, as in the previous point, it is difficult to get a specialist to see you in the ER if he or she does not have an established relationship with you. In fact, ER physicians often view these people as a valuable resource – even if they do not come in to see you, we make a point of calling them to obtain important medical information.

The second point is about ER certification. The article cites statistics by the Institute of Medicine that 40% of ER physicians are not board certified in emergency medicine. It is almost ironic – and a good thing – that being board-certified in EM is now the gold standard. As recently as the 1990s, it was commonplace that physicians trained in medicine and surgery ran the ER without any emergency medicine training. With the rise of ER residency programs, which began in the 1980s, we are finally catching up with the nation’s demands for board-certified ER physicians. EM residency programs continue to expand, and the requirements for full-time ER positions are becoming increasingly stringent. This is a positive trend, and I hope it continues well into the 21st century.

Emergency medicine is an invaluable part of medical care in this country, and it is important that we fill our emergency rooms with physicians who have the diagnostic skills and the proper training to recognize sick patients, to stabilize sick patients, to save lives, and to devise for all patients who walk through our doors the appropriate disposition plans that will optimize their care. Thus, in spite of some of the flaws of the ER and of the hospital in general, it comes down to risks and benefits. Do not let some of the downsides of the ER turn you away – the consequences of avoiding the health system, however unpleasant it may be, can be devastating.

And so it goes…

I have avoided this blog as much as I have avoided the hospital in the last few weeks. In short, it has been wonderful. As I enter the doors of the emergency room again tomorrow morning, I will be facing the world as a resident yet again. This next stretch, two months of intensive care back to back, will mark the finale of my most difficult months of residency. I will finish out most of my 30-hour nights in the hospital and will be more than halfway done with second year by the time  it ends. By this time, the last of the leaves will have fallen from the trees and we will have gotten our first frost and likely our first snow. The holidays will have come and gone in the midst of far too many call nights, and it will be a new year, 2011. This new year marks the end of one long trek and the beginning of a new one – hopefully not as strenuous.

A controversial article appeared in The New York Times and The Wall Street Journal today, CT Scans Can Reduce Lung Cancer Deaths, Study Finds. There have been several recent discussions among health professionals, both in and out of the emergency department, about the risks and benefits of CT scan. Refer to a prior post, To Scan or Not to Scan: The Use of CT, for more information. The study to which it refers, National Lung Screening Trial, is currently being performed by the National Cancer Institute. The preliminary results, which were just released, indicate that there are some potential benefits to CT scan for detecting lung cancer in a high-risk population of current or former heavy smokers. These benefits are not without risks. Until a more comprehensive analysis of study design, participants, and results is released, the information is interesting at best but does not provide sufficient evidence to establish any guidelines for clinical practice.

Researchers found 20 percent less lung cancer deaths among trial participants who were screened with low-dose helical CT as compared to chest x-ray. First, these results only include participants who were at high risk for developing lung cancer. Secondly, the main objective of the study is to assess the number of deaths due to lung cancer – a more important question may be whether or not CT scan reduces overall deaths in this population. Thirdly, other imaging modalities including MRI and PET scan were not included in the study – these may be worth examining before developing screening guidelines.

As with much in medicine, it will take time, further analysis, and additional studies to determine what the best clinical practice should be. And, as with everything in medicine, it is important that we weigh the risks and benefits of any test or intervention. The radiation associated with CT scan poses a significant cancer risk to patients, and recent studies are beginning to estimate that these risks may be greater than we had anticipated.

 

Grand Rounds, Volume 7, Number 4: Uplifting Moments in Medicine

Good morning! Thank you for all the submissions which have flooded my inbox over the past week. They kept me going through a stretch of countless overnight shifts in the emergency department, which seemed never-ending and darker than a moonless night. In the midst of stunning fall foliage this October, the vibrant colors of this week’s Grand Rounds reach towards the sky. Take a moment out of the day to live in the present. Listen to the sounds around you, whatever they may be – leaves rustling in the wind, blaring sirens, constant monitors. Sit back, relax, take a long, deep breath and a sip of your favorite morning drink. Take in the flying kites, subtle music, and silver linings of today’s indulgence: Uplifting Moments in Medicine.

Autumn Sugar Maples, by John Eastcott and Yva Momatiuk. Vermont's outstanding array of fall foliage is highlighted by the colorful sugar maple. Broadleaf plants shed their leaves each year in preparation for winter, but variable temperatures and moisture determine how spectacular each annual show will be.

We begin with a story of redemption in Copiapó, Chile: the rescue of 33 miners who had been trapped after the collapse of a mine on August 5. The miners spent 69 days underground. In the first days after the collapse, they set off explosives and burned tires in an effort to communicate with the outside world. Shift boss Luis Urzúa rationed milk, crackers, peaches, and canned tuna for his entire crew over 17 days, before the world knew that the men remained alive 2000 feet underground. When their reserves of bottled water dwindled to only 10 liters, they began drinking water tainted with motor oil from metal drums. By the evening of October 13, all 33 men had been successfully recused and reunited with their families. The spirit which kept them alive through 69 days of darkness is awe-inspiring. The miners worked with each other and with the doctors, scientists, and support groups above ground in order to survive. Gómez, the eldest miner, served as a religious leader and worked with psychologists to support the team’s spiritual health. Yonni Barrios served as the medic for the group; he monitored their health, administered vaccinations, and provided reports for doctors on the surface. Sepúlveda organized the miners’ video journals, and Ticona worked to maintain the underground portion of the telephone and videoconferencing systems. The story highlights the best of medicine, science, and humanity. Watch all 33 rescues online at CNN. Elaine Schattner supplements this with a wonderful post, Copiapó Dreaming – The Copper Miners’ Tale, about the uplifting aspects of their story.

Luis Urzúa, the last miner to be rescued, celebrated with President Sebastián Piñera of Chile.

Along the same theme, we must remember and reflect on the brave men and women who put themselves in danger in the line of duty – fire fighters, police officers, EMTs, and medics. Some even choose this calling without the prospect of compensation. In Michelle Wood’s post, The Volunteer EMS, she recounts the story of her parents who worked as volunteer EMTs in a small town. She mentions a site with poetry dedicated to volunteer EMS personnel.

Moving on to more practical but still uplifting stories, David Harlow interviews Massachusetts State Representative Ruth Balser on the success of Massachusetts health care reform – the state has successfully achieved 97% health care coverage in just a few years. Massachusetts takes the lead again in patient-centered health care with new legislation. On October 1, 2010, it became the first state to require that all hospitals have a Patient Family Advisory Council. Read more at Bedside Manner in the post Leading the Way on Patient Centered Care. On a more personal level, in An Educator by Chance, medical librarian at Laika’s MedLibLog discusses the development and implementation of training modules for medical students and residents who are learning how to navigate the vast world of technology and medical information.

Rescuers applaud the rescue of a firefighter rescued at site of World Trade Center.

And that brings us to the life of the physician. The first Grand Rounds of the year, at Doctor Grumpy in the House, served as a humorous and disgruntled reflection on medicine. Today’s edition serves as a nice juxtaposition to this. Jill of All Trades, MD, writes about the positive aspects of being a physician in Practice Perks. She cites an article by Abigail Beckel in Physicians PracticeTop 10 Reasons to Be Happy You’re a Doctor. For all the physicians, residents, and medical students who are having a difficult time, enjoy these small reminders that our contribution does matter. Despite our endless complaints, grievances, and hardships, remember that the grass is always greener on the other side.

And now we move along to our patients, who are our greatest source of hope. Mattie Stepanek said it best, “While we are living in the present, we must celebrate life everyday, knowing that we are becoming history with every work, every action, every deed.” Bongi, a general surgeon in South Africa, writes about a fulfilling relationship with his patient in the gift. Spice Island Queen, who will be hosting Grand Rounds next week, writes about her experiences at “the best place on earth,” a Camp for Teens with Multiple Sclerosis.

Boy in Mid-Flight, Jodhpur, India in 2007. Photograph by Steve McCurry.

Happiness is not always straightforward. Although countless studies have examined what makes people happy, we have not yet come up with a formula that provides a clean-cut answer. But perhaps there are a few basic principles which can guide us along our path. A psychiatrist at How To Cope With Pain discusses some of these in Are Banana Split Jelly Bellies The Key To Happiness? No – But Here’s What Is (Even Despite Your Pain!). And to end with an uplifting note of laughter – the Happy Hospitalist shares with us a video about a comical interaction between a doctor and a neurologist.

I hope you all leave this morning’s Grand Rounds with a little hop in your step and flutter in your heart. Thank you for stopping by! Please be sure to check out Grand Rounds on Twitter and Facebook.

Grand Rounds: Uplifting Moments in Medicine

I am looking forward to hosting my first Grand Rounds next week! There are many things about medicine and health that are frustrating, angering, and even depressing. I have vented about some of them lately, as I complete a long string of shifts in the emergency department. But for the week of October 19, let’s take the “glass is half full” approach.

The theme: Uplifting Moments in Medicine.

The theme is broad-based, and I encourage all of you to use your imagination and think big. Uplifting moments can include anything about health, hospitals, health care providers, family, friends, dreams, life goals – anything and everything that has given you some sense of hope and enlightenment.

The words of Mattie Stepanek explain it best, in his poem below. Mattie, born with a rare form of muscular dystrophy known as dysautonomic mitcochondrial myopathy, was a writer and an optimist. Mattie began writing poetry at the age of three in order to cope with the death of his older brother. He published six collections of poetry and one collection of peace essays, all of which were New York Times bestsellers. Sadly, he passed away in 2004, three weeks before his 14th birthday. But his legacy – and his love for life – live on in his poems.

On Being a Champion

A Champion is a winner,
A hero…
Someone who never gives up
Even when the going gets rough.
A champion is a member of
A winning team…
Someone who overcomes challenges
Even when it requires creative solutions.
A champion is an optimist,
A hopeful spirit…
Someone who plays the game,
Even when the game is called life.
There can be a champion in each of us,
If we live as a winner,
If we live as a member of the team,
If we live with a hopeful spirit,
For Life.

Search for a hero, a slice of optimism, a diamond in the rough, a silver lining. Or anything else which suits your fancy. When you find it, send it along to idiopathicmedicine at gmail dot com. I look forward to reading your entries!

Abridged Version
Please submit entries for Grand Rounds by Sunday, October 17, at 6PM to idiopathicmedicine at gmail dot com.

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