Medicine/Science

The latest cool stuff out of some of the nation's best labs; news on medical research and what it may mean for patients.

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Judge Rejects Injunction To Stop Construction On Children’s Hospital Healing Garden

Visitors relax in the Prouty Garden in this file photo. (Robin Lubbock/WBUR)

Visitors relax in the Prouty Garden in this file photo. (Robin Lubbock/WBUR)

A Suffolk Superior Court judge has denied a request for a preliminary injunction that would have stopped Boston Children’s Hospital from continuing any construction-related work on the site of its planned new clinical building. The plans call for the demolition of Prouty Garden, a healing garden that was bestowed to the hospital 60 years ago.

A group of people opposed to the development project — plaintiffs include family members of patients who’ve used Prouty Garden and physicians — had asked the judge to issue the injunction, saying the hospital has illegally started work on the site before the state Department of Public Health issues its approval.

The judge ruled the plaintiffs didn’t meet the burden of proving they’re likely to succeed in a lawsuit, but can still press forward with a suit challenging the project. Continue reading

Earlier:

Policies For Transgender High School Athletes Vary From State To State

Justin Bonoyer stands in the athletic fields at Ponaganset High School in North Scituate, Rhode Island. Justin was Elise to his coaches until a few weeks ago. (Jesse Costa/WBUR)

Justin Bonoyer stands in the athletic fields at Ponaganset High School in North Scituate, Rhode Island. Justin was Elise to his coaches until a few weeks ago. (Jesse Costa/WBUR)

Crack. A bright pink aluminum bat connects with a fluorescent yellow softball, sending it toward woods that border Ponaganset High School in northwest Rhode Island. The left fielder runs in and makes the catch.

“Two down ladies, two down,” a player calls.

This is home field for Ponaganset’s Lady Chieftains, except, it seems, the team is not all ladies.

Justin Bonoyer, a stocky 5-foot-5-inch player with a shock of blonde hair, plays right field. Justin was Elise to his coaches until a few weeks ago, although he’d already come out as transgender to most of his teammates.

“I’m a guy,” Justin says. “It’s the same as if a guy who’s not trans went and played on a girl’s softball team.”

Well, sort of. There are separate rules for transgender athletes. Rules so different from state to state that some high school athletes like Justin can try out for any team they choose while others need sex reassignment surgery before they can sign up.

There’s a lot of attention on bathrooms in the debate about transgender rights. The next battleground may be locker rooms, basketball courts and soccer fields. For high school students, the debate centers on Title IX, the federal law that bans discrimination based on gender. Does it also ban discrimination based on gender identity?

We’ll lay out the arguments in a minute. First, a little more about Justin. Continue reading

Opinion: In Simulation Era, Your Doc’s First Try At A Procedure Should Not Be On You

A mannequin for practicing open heart surgery at the Boston Children’s Hospital’s recently unveiled simulation center. Called “Surgical Sam,” it has a life-sized “heart” that accurately mimics the beating motions of a healthy or abnormal human heart. (Jesse Costa/WBUR)

A mannequin for practicing open-heart surgery at the Boston Children’s Hospital’s recently unveiled simulation center. Called “Surgical Sam,” it has a life-sized “heart” that accurately mimics the beating motions of a healthy or abnormal human heart. (Jesse Costa/WBUR)

Most doctors never forget the paralyzing terror of their first invasive procedure.

Dr. Charles Pozner, of Boston’s Brigham and Women’s Hospital, recalls the first time he placed a central line, which involves sticking an eight-inch-long needle into a patient’s jugular vein to place an intravenous line. He had never even seen it done before, but a chief resident offered him the opportunity after a long day working together.

“When I was a medical student, the last thing you wanted to say when someone offered a procedure to you was ‘no.’ You wanted to learn, to be part of the team,” Pozner told me. The chief resident walked him through it without mishap, but “it was an unsafe thing for the patient, and an unsafe thing for me, because I was potentially harming the patient,” he said.

Twenty years later, in 2013, I went through a similar process. I watched a colleague place a central line during my first week as an intern. A couple of days later, I placed my first one, as my senior resident supervised. Thankfully, everything went fine. But that doesn’t mean I’m comfortable with the idea of wielding eight-inch-long needles after only watching someone do a procedure once.

“See one, do one, teach one” is the ancient medical adage for this: that after doctors in training have seen one procedure or operation, they’re qualified to do the next one. It has been the model for teaching physicians for generations.

But in the age of robotic surgery and simulation medicine, is this concept really acceptable anymore?

The short answer is no. Clearly, doctors in training should practice on computers and simulated patients, not real ones. Particularly when, according to a study out this week, medical errors are the No. 3 cause of death nationwide.

The longer answer is more complicated. No one openly defends the concept in medical journals — in fact, experts talk about “see one, practice many, do one.” But the “see one, do one, teach one” culture still persists in hospitals around the country, and it remains routine for physicians in training to practice their first procedure on real patients. (As a patient, what can you do about it? See the tips below.)

“Would you fly on an airplane if they say, ‘We’ll drop the price of our tickets but our pilots will opt out of flight simulation?'”

– Dr. Antonio Gargiulo

But that is changing, as more hospitals and medical schools invest in high-tech simulation centers like the $12 million center unveiled by Boston Children’s Hospital this week.

Dr. Pozner, who is medical director of the Brigham’s STRATUS Center for Medical Simulation, says that in time, medical simulation will mean the death of “see one, do one, teach one.”

The Pilot Analogy

Consider pilots. Chesley “Sully” Sullenberger, the pilot who remarkably landed his plane on the Hudson River, is often mentioned in the medical literature on simulation, as are his hundreds of hours practicing simulated emergencies. If Dr. Atul Gawande famously brought the pilot’s checklist to surgery, simulation proponents think more pilot-style simulation should be brought to medicine.

“It’s called procedural memory,” Dr. Pozner said.

And studies show that simulation works in medicine. One small study trained doctors in robotic surgery, showing that they could reach expert level proficiency by the time they operated on their first real patient.

“The main advantage of this tool is you can get technically perfect before you even touch a patient,” said Dr. Antonio Gargiulo, medical director of the Center for Robotic Surgery at Brigham and Women’s Hospital. Continue reading

Narrating Medicine: Let’s Talk Bedpans, And Why Doctors Should Get Good With Them

As a doctor myself, writes Dr. Anna Reisman, I was embarrassed that I didn’t know how to help a patient with a bedpan. (Michaelwalk/Wikimedia Commons)

As a doctor myself, writes Dr. Anna Reisman, I was embarrassed that I didn’t know how to help a patient with a bedpan. (Michaelwalk/Wikimedia Commons)

I was visiting my friend in the hospital and she had to pee. Walking to the bathroom was not an option: She’d been told not to get out of bed, she felt weak and lightheaded, and she was attached to an IV and a monitor.

She pressed the call button and stated her problem. A voice: They’d let her nurse know. A few minutes later, I stuck my head outside the curtain and scanned the empty hallway, feeling guilty that all I could do was share her frustration.

Then someone pulled open the curtain and smiled in at us. “I need the bedpan, we’ve already called twice,” my friend said. The woman in scrubs, who turned out to be one of the doctors, said she’d take care of it. My friend and I sighed with relief.

But the doctor slipped back out. Taking care of it meant finding someone who knew how to do it. When she returned a couple of minutes later and saw that still nobody had showed up, the good doctor offered to do it herself. She fetched a bedpan and awkwardly slid the pink plastic container under my friend, the whole time apologizing that she didn’t know which end was up.

The current U.S. nursing shortage includes licensed practical nurses and certified nursing assistants, the people who usually manage bedpans. And so hospitalized patients feeling the urge to urinate may have to wait longer than is possible.

If you’re thinking this is a minor issue, think again: Holding one’s urine can set a patient up for a urinary tract infection; the physical discomfort can be a stress on an already sick body, driving up blood pressure and pulse; and waiting with a bursting bladder is a mental stress, too.

As a doctor myself, I was embarrassed that I didn’t know how to help. I didn’t learn bedpan basics in medical school.

The alternative isn’t any better: Consider the shame and discomfort of lying in cold, wet sheets until someone can change them, plus the serious health risks that include skin breakdown and infection. For patients who already have pressure sores, these complications can be life-threatening.

As a doctor myself, I was embarrassed that I didn’t know how to help. I didn’t learn bedpan basics in medical school, or at any other time during my training. I would guess that most doctors, like me, would rather volunteer to hunt for someone else to do this than just getting the job done.

No, it isn’t rocket science to place a bedpan, but it’s easy to bumble by making a mess, leaving the patient in an uncomfortable position, exposing and embarrassing, and so on. Continue reading

Harvard Study: Shopping For Health Care Fails To Lower Costs

A new study is bad news for the push for health care shopping. (Caden Crawford/Flickr)

A new study is bad news for the push for health care shopping. (Caden Crawford/Flickr)

I hate it when there’s more bad news about the health care costs that are devouring our family, municipal and national budgets. (Latest number: $3 trillion, or 17.5 percent of America’s GDP.)

But here it is: A Harvard study just out in JAMA finds that when health care consumers use price-comparison tools, they don’t end up spending less. In fact, they may even spend a bit more, perhaps because they think higher prices mean better quality.

So much for the idea that if you just let people shop for cheaper care, prices will surely go down.

The study’s senior author, Dr. Ateev Mehrotra of Harvard Medical School, says the findings do not mean that health care price transparency mandates — which have passed here in Massachusetts and more than half of states overall — are a bad idea. Rather, he says, the message is that “It isn’t that easy just to fix this problem.”

About the study: It looks at nearly 150,000 employees at two big companies that gave their workers access to an online health care shopping tool, and compares them to nearly 300,000 status-quo employees. It found that among the employees who got the tool, outpatient spending on average went up a couple of hundred dollars, from $2,021 to $2,233.

The control group’s spending also went up slightly, but among the workers with the shopping tool, spending went up a bit more: by an average of $59 for outpatient care, including $18 out of pocket.

“Some of it is benefits design. …[And] we should also recognize that not everything in health care is shoppable.”

– Dr. Ateev Mehrotra

“Not A Panacea For High Health Care Costs,” says the headline of an accompanying editorial in JAMA. No kidding. Surely no one expected price transparency to solve our $3 trillion problem, but still, these results are also surely disappointing to anyone who hoped health care shopping might at least make a dent.

Or perhaps it will, someday. I spoke with Dr. Mehrotra, an expert on consumerism in health care, about what the results mean. Our conversation, lightly edited:

How would you sum up what you found?

There’s a lot of enthusiasm in the health care system about increasing price transparency, to both help patients become better consumers and to decrease health care spending. And unfortunately, in our results, we do not find that providing price transparency decreases health care spending.

I think there’s been this general idea that, ‘Oh, all we need to do is give people high deductibles, give them prices, and magic will happen, and people will start switching their providers to lower-cost providers.’ And one main message from this is that this should temper that enthusiasm, and it’s more complicated than that.

I don’t think it’s that patients think shopping for care is a bad idea. People generally realize that prices in health care are high and they should switch. But there are other factors that are playing a role.

Dr. Ateev Mehrotra (Courtesy)

Dr. Ateev Mehrotra (Courtesy)

Some of it is benefits design. We have these really complicated health care benefits designs that people really struggle to master, and under our current benefit design you might go to such a website and say, ‘Oh, I’m thinking of having my knee operated on and I’ll pay the same amount at every hospital, so it doesn’t matter.’ And a lot of the surgeries were for things that were relatively higher cost and therefore it didn’t matter. So that’s an issue.

And also, a lot of health care is emergent: When you’re having a heart attack and you’re in an ambulance, you’re not going to say, ‘Oh, let me see where it’s cheaper for me to go for care.’ So we should also recognize that not everything in health care is shoppable. Continue reading

Buffets One Day, Vomiting The Next — Life With A Rare GI Disease

Melissa Adams Van Houten was diagnosed with a rare GI disorder in 2014. (Courtesy)

Melissa Adams Van Houten was diagnosed with a rare GI disorder in 2014. (Courtesy)

I am going to share some pretty personal information. Not a big deal to some of you, I am sure, but to me, it is huge. I am not the kind of person who does this — or at least I did not used to be. But things have changed.

In February of 2014, I spent a week in the hospital and was eventually diagnosed with gastroparesis, a disorder that slows or stops food from moving from the stomach to the small intestine.

I am guessing most people have never heard of this; I know I had not, prior to being diagnosed.

A Life-Altering Day

My life changed in ways I could not have imagined — overnight.

One day, I was able to eat at buffets, and the next day, I was unable to tolerate all foods and liquids. I was hospitalized with severe pain and vomiting, put through a battery of tests (including one particularly terrible one where they forced a tube down my nose and pumped my stomach). Eventually, I was diagnosed, but was given only a brief explanation of my illness and its treatment before I was sent home.

For the next few weeks, I was on a liquids-only diet, and was told that I had to gradually work my way up to soft foods and (eventually) solids. I am able to eat some soft foods, these days, in tiny amounts, but it is becoming clear to me that I will likely never again be able to eat “normal” foods in “normal” amounts.

Thinking About Food — Always

At first, I told myself that I would not let this stupid disease define or control me — it simply would not be the center of my life. But as time passed, I began to see how foolish this was. Every single day, every second of every day, I think about food. I see it; I smell it; I cook it and feed it to the other members of my household; but I cannot have it myself. Continue reading

A Death, And A ‘Changed Life’: Traumatic Births Take Toll On Health Workers Too

Sarah Jagger and midwife Stephanie Avila were together when Jagger's son suffered a brain injury during labor that led to his death. Here, about a year later, in 2013, Jagger and Avila share a moment of gratitude after the safe arrival of a healthy baby girl. (Courtesy of Orchard Cove Photography)

Sarah Jagger and midwife Stephanie Avila were together when Jagger’s son suffered a brain injury during labor that led to his death. Here, about a year later, in 2013, Jagger and Avila share a moment of gratitude after the safe arrival of a healthy baby girl. (Courtesy of Orchard Cove Photography)

Everything seemed fine until the little boy was born.

He wasn’t breathing, but his heart was strong, recalled Stephanie Avila, the midwife attending the baby’s birth at a Rhode Island hospital back in 2012. But it soon became clear that the boy had suffered a brain injury during labor.

Eleven days later, after an MRI confirmed the severity of the injury and the family withdrew life-support, the child died. His official diagnosis: hypoxic ischemic encephalopathy, a brain injury caused by oxygen deprivation.

“I was prepared to stand by the family through this trauma,” Avila said in an interview. “But I fully expected I’d get sued — and it was going to get ugly, or uglier.”

Of course, the little boy’s family was devastated. “I just went into my own world,” said his mother, Sarah Jagger, speaking about the loss of her son.

But Avila suffered too. “I was a wreck,” she said.

Immediately after the birth, Avila said, she remained on call overnight at the hospital, Women & Infants, in Providence. “I retreated to the call room and curled up in the fetal position and prayed that no other people in labor would show up. I cried, had the worst headache I’ve ever had in my life, and felt like I’d vomit. For days I felt emotionally and physically terrible. I’d be walking down the street and suddenly could no longer move.”

At the time, Avila had two small children of her own. “And whenever my 2-year-old would do this cute thing, I’d think, their baby will never walk around in his mother’s high-heeled shoes. I’d get these terrible thoughts and I’d never know when it would strike.”

The Psychological Toll

After a traumatic birth — or any traumatic medical event — attention, rightly, turns to the grieving family. But research has been mounting in recent years that health care providers, sometimes called “the second victims,” also sustain long-lasting emotional damage following such a trauma.

A new study published by Danish researchers underscores the phenomena: Midwives and obstetricians who experienced a traumatic birth — one involving severe injuries or death — report that the psychological toll of such an event is deep and long-lasting.

More than one third of those surveyed said that they always would feel some sort of guilt when reflecting on the event, researchers report. Nearly 50 percent agreed that the traumatic birth had made them think more about the meaning of life. “This tells us that health care professionals are affected, not only professionally, but also at a personal and even existential level,” said Katja Schrøder, the study’s first author and a Ph.D. fellow at the University of Southern Denmark.

‘Changed My Life Forever’

This was indeed the case for Avila. “I feel as though that day — even to this day — changed my life forever in many ways,” she said. And while the “acute” nature of the trauma has passed, she said, the enormity of it continued to grip her, sometimes unexpectedly and at random times.

In the Danish study, published in Acta Obstetricia et Gynecologica Scandinavica, a journal of the Nordic Federation of Societies of Obstetrics and Gynecology, more than 1,200 Danish obstetricians and midwives responded to a survey on the aftermath of a traumatic birth. Of those respondents, 14 were selected for a followup interview.

Many of the providers spoke of not being able to shake the trauma, whether they were blamed for the bad outcome or not. “Although blame from patients, peers or official authorities was feared (and sometimes experienced), the inner struggles with guilt and existential considerations were dominant,” researchers report.

From the paper:

One mid-wife explained that even now, 12 years after the event, she would still think about that particular mother and child when passing through their town…

Most participants described having spent many hours agonizing and wondering whether they could have prevented the adverse outcome. One midwife said that her sense of guilt would never disappear because she knew that the parents would have to live with the consequences of her handling of the delivery.

Still, the researchers found that for many providers, “the traumatic childbirth had given rise to personal development opportunities of an emotional and/or spiritual character …for instance by achieving a more humble and profound understanding of both professional roles and of life as a whole.”

A Meaningful Meal

About a month after her infant son’s death, Jagger did something unusual: She asked Avila to meet for lunch. Up until then, the two women had been in touch — Avila had called to check in often, offering to help out and attend followup medical appointments with Jagger.

But the lunch date marked a turning point, the women agreed. First, it became clear that Jagger didn’t blame Avila for the boy’s death, and did not want to focus on the tragedy going forward.

“We had this little boy who had a such a short life,” Jagger said. “I didn’t want his life to be clouded in anger. I wanted his life to be about love…and not focus on the horrible part.”

But the meeting also underscored the growing bond between the women. When it was over, they walked outside and Jagger posed a question: “I said to her, ‘If I have another baby, would you deliver it?’ And I think she was horrified. But I think because I trusted her so completely, through the birth, and his death, and her calls and the followup, I felt like she was there with me, like this was our loss, it wasn’t just my loss.”

The Danish research paper quotes Donald Berwick, a pediatrician who served in the Obama administration and is also a patient safety guru of sorts. In a 2009 interview published in the Journal of Patient Safety, Berwick speaks about those “second victims”:

Health care workers’ egos can be big. But believe me, their superegos are a lot bigger. You carry into work — as a nurse, or doctor, or a technician or pharmacist– the intent to do well. And when something goes wrong, almost always you feel guilty, terribly guilty. The very thing you didn’t want to happen is exactly what happened. And if you don’t understand how things work, you feel like you caused it. That creates a victim. My heart goes out to the injured patient and family, of course. That’s the first and most important victim. But health care workers who get wrapped up in error and injury, as almost all someday will, get seriously hurt too. And if we’re really healers, then we have a job of healing them too. That’s part of the job. It’s not an elective issue, it’s an ethical issue.

In the past decade or so, various institutions and nonprofits have emerged with tools and systems to better support medical professionals who have endured a traumatic event.

One of those groups, MITSS, or Medically Induced Trauma Support Services, based in Massachusetts, provides trauma tool kits used around the country.

Linda Kenney, the founder of MITSS, was herself the victim of an anesthesia error that nearly killed her. She said that for her, connecting with the anesthesiologist who caused her injury (he called her afterwards to express his regrets) and creating the nonprofit to help others, helped her heal.

But for health care providers, sometimes talking to peers at a hospital, or others in the institution, isn’t enough and can actually feel isolating, Avila, the Rhode Island midwife, said. Because of the omnipresent fear of lawsuits, and also due to patient privacy laws, she said, “there are very few environments where we can freely discuss what happened.”

A Second Chance

In 2013, a few days shy of what would have been her son’s first birthday, Jagger went into labor with her second child, and she called on Avila to attend the birth. By that time, Avila was no longer working for the same midwifery group, but the practice arranged for her to have insurance during the birth, and Avila left a family gathering on Block Island to get to Providence on time.

Jagger’s little girl is now a healthy 2-and-a-half-year-old who considers Avlia her “auntie.”

“It was this amazingly cathartic experience for all of us,” Jagger said.

Avila is now a family nurse practitioner and attends births less frequently as part of her work. These days, she and Jagger are extremely close: They’ve vacationed together, bake each other birthday cakes and talk almost daily.

“I never would have expected our relationship to evolve to this point,” Avila said. “But despite how close we are now, I would sacrifice it in a moment if I could change the outcome of that first birth.”

Related:

When Doctors Encounter Human Trafficking: What To Look For

(Ira Gelb/Flickr)

(Ira Gelb/Flickr)

It was 2 a.m. on a typically hectic Friday overnight shift in the emergency department.

A young woman, Kelly, checked into triage, accompanied by her older boyfriend Jim, who explained that Kelly had abdominal pain and some vaginal bleeding. Jim wanted her checked out and maybe some pain medicine to help her rest at home.

Kelly had no identification. She appeared younger than her stated age of 18. I also noticed track marks punctuating both of her arms — a sign of IV drug use. She immediately looked to Jim after answering all my questions.

If this sounds suspicious, that’s because it is. While clinicians are trained to address Kelly’s medical ailment, many of us fail to recognize the larger social cues right in front of us. It appears that Jim is in control of the situation. Kelly is young, maybe very young. As a clinician I must consider Kelly’s living situation, and her relationship with Jim.

As emergency care providers, it is standard practice for us to separate patients from their visitors long enough to at least ask about domestic violence. And for most of us, that would likely be the first concern in this case. But Kelly is actually a victim of human trafficking. Continue reading

Related:

Narrating Medicine: The Long Lasting Impact Of Child Abuse

One day when we were in first grade and sitting on a rickety wooden bench under a large oak tree in her backyard, my best friend’s mother called her to come inside.

A few minutes later, I heard wailing like an animal being gutted. Squinting my eyes and looking perplexed, I turned to my friend’s younger sister who was sitting beside me. She whispered, “She’s just getting beat.” Beat? What’s that, I wondered. She explained. Depending on the severity of their perceived wrongdoings, they were administered one of three levels of physical punishment: a stick, a belt or a big slab of wood. Their parents had moved from Ireland to our small suburb in New Jersey.

The Catholic schools the parents had attended as children in Ireland were very strict and the nuns reportedly beat them until their knuckles bled. Here, as parents in New Jersey, they told their daughters to strip naked and mercilessly receive corporal punishment. (I learned this from her sister, and over the years, from my friend.)

This was not a onetime event. These were repeated, deliberate acts. Continue reading

Study Tracks Yik Yak App To Learn More About College Drinking And Drug Use

The Yik Yak app, lower left, is seen on an iPhone on Nov. 11, 2015. (Ronald Lizik/AP)

The Yik Yak app, lower left, is seen on an iPhone on Nov. 11, 2015. (Ronald Lizik/AP)

Consider this message, most likely posted by a college student in or around Brandeis University near Boston: “I just remembered I have a 4loko in my minifridge. Guess who’s getting sloppy day drunk tomorrow!”

Good luck finding the Four Loko fanatic. The post is from Yik Yak, an anonymous, free social media platform popular on college campuses.

Even so, a recent study analyzing Yik Yak posts gathered from 120 campuses suggests that tracking these messages does have an upside: Public health experts say it may ultimately help them learn more about issues like alcohol and substance use.

Over the span of one month, researchers at Johns Hopkins University and the University of Colorado at Boulder found 2,047 health-related yaks — the term for posts on Yik Yak — dealing with themes like smoking, drinking and drug use.

“Because it’s anonymous, people disclose things about themselves that they might not publicly post, either on Twitter or even necessarily to their doctors,” said Michael Paul, an assistant professor and founder of the Information Science Department at UC Boulder,  in an interview.

While big data collected from social media has been used to study public health, such as influenza surveillance through Google search queries and Twitter, the field is relatively new and Paul’s study is the first to look at public health using Yik Yak. Continue reading