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Boston Marathon Medical Director: Getting Back To What The Race Is About

 

Medical personnel work outside the medical tent after the Boston Marathon bombing on April 15, 2013. (Elise Amendola/AP)

Medical personnel work outside the medical tent after the Boston Marathon bombing on April 15, 2013. (Elise Amendola/AP)

Last April 15 at about 2:45, Dr. Aaron Baggish was enjoying the sunny spring day and, in his role as medical director of the Boston Marathon, marveling at the low volume of runners who needed his care. Then the first bomb exploded, about 15 feet away from him. It blew out his right eardrum but the crowd blocked much of the force of the blast, and within seconds he was over the barrier and starting to work on the injured.

After the bombing, Dr. Baggish, who heads the Cardiovascular Performance Program at Massachusetts General Hospital, declined requests for interviews, feeling unable to speak publicly about what happened. But as Boston gears up for its next marathon on April 21 and he prepares to help oversee the race’s medical staff once again, he agreed to share some of his thoughts.

As you reflect back on what happened at last year’s marathon, what are you thinking, what lessons do you see?

Basically, I gave up very early on trying to make sense of any of this. There’s no way to make sense of a senseless, horrible act. We’ll never be able to put it into a neat compartment and say, ‘Oh, yes, that’s why this happened.’ No sense can be made of it. So the next step is, what was the impact on me personally? How do I go about some form of healing process? And how do you reconcile the personal trauma with ‘I have a job I have to do’? And we have a job now that we have to do this year, which is as important if not more important than ever: To run the safest, most medically comprehensive race we possibly can.

Are you medical director again?

Of course. You’d better believe it. Nowhere I’d rather be.

Dr. Aaron Baggish (Courtesy MGH)

Dr. Aaron Baggish at work (MGH)

To ask you your own questions, what was the impact on you personally? How do you go about some form of healing process?

It’s been a series of phases, if you will. There was an immediate, necessary phase of blocking everything out and dealing with the professional aftermath: the meetings and debriefings and making sure the volunteers were okay. That lasted for about a month and was more of a business-as-usual sort of feel than anyone could imagine.

But once the media coverage slowed down and Boylston Street was cleared, that’s when the real, hard personal work started. That’s when the concept of PTSD became a reality.

For example?

For example, I was participating in a Triathlon on Lake Winnepesaukee in August. It’s a race I do every year, a half Iron Man, it’s a special day for me, and I was standing on the beach and watching the professional athletes get going, and they fired a cannon for the men’s start. I knew it was coming. What I didn’t realize was that they would fire a second cannon for the women. So three minutes later, they fired a second cannon and I just disintegrated. I had an unbelievable physiological response. I became nauseous, shaking, and it was then I realized that this was a real, deep scar that would be left for a long time. That was a turning point for me; it made me aware I needed to talk about things more, not publicly but with family and friends and colleagues. That was a good step, and over the fall I very actively engaged with people I trust and feel emotionally safe with, to make certain I could start processing some of this. That took some time, and there were some dark moments there. Continue reading

Must-Read: Dr. Arnold Relman On Lessons From Breaking His Neck

Dr. Arnold Relman on YouTube in 2009.

Dr. Arnold Relman on YouTube in 2009.

Dr. Arnold Relman, former editor of the New England Journal of Medicine, has long played a rare role in the health care sphere: He’s an exceedingly senior and authoritative Harvard figure willing to speak out about what’s wrong in American medicine, from financial conflicts to the need for health care reform.

Now, unfortunately, Dr. Relman has new, first-person lessons to share. In a powerful and compelling piece in The New York Review of Books — On Breaking One’s Neck – he describes the stairway fall that nearly killed him at age 90, and offers his assessment of the care he received at Massachusetts General Hospital and Spaulding Rehabilitation Hospital in Cambridge during his time as a desperately ill patient.  Among the lessons he shares:

What did this experience teach me about the current state of medical care in the US? Quite a lot, as it turns out. I always knew that the treatment of the critically ill in our best teaching hospitals was excellent. That was certainly confirmed by the life-saving treatment I received in the Massachusetts General emergency room. Physicians there simply refused to let me die (try as hard as I might). But what I hadn’t appreciated was the extent to which, when there is no emergency, new technologies and electronic record-keeping affect how doctors do their work. Attention to the masses of data generated by laboratory and imaging studies has shifted their focus away from the patient. Doctors now spend more time with their computers than at the bedside. That seemed true at both the ICU and Spaulding. Reading the physicians’ notes in the MGH and Spaulding records, I found only a few brief descriptions of how I felt or looked, but there were copious reports of the data from tests and monitoring devices. Conversations with my physicians were infrequent, brief, and hardly ever reported.

What personal care hospitalized patients now get is mostly from nurses. In the MGH ICU the nursing care was superb; at Spaulding it was inconsistent. I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.

Read Dr. Relman’s full piece here. One personal reaction: I felt a bit defensive for Spaulding; my late mother received excellent care at their Boston facility. But then I thought: If every patient — particularly patients with as much authority as Dr. Relman — routinely reported publicly on where the nursing care was great and where it was inconsistent, that could help lead to constructive change at the places where it’s needed. We often talk about care that falls short in personal chats, but hospitals need that feedback — and perhaps some of it should be public — to help them improve.

Readers, thoughts, reactions?

Brain Cancer: Gene Test May Do Work Of Biopsy, Help Track Tumors

Performing a brain biopsy (Wikimedia Commons)

Performing a brain biopsy (Wikimedia Commons)

If you remember the progression of bad medical news about the late Sen. Ted Kennedy, you know that a diagnosis of brain cancer tends to go like this: Something prompts suspicion — in Kennedy’s case, a seizure. A brain scan adds more information. Then the surgeons drill through the skull for a biopsy, taking a sample of the tumor for an analysis of its make-up that then guides the medical team’s treatment strategy.

New research just out of Massachusetts General Hospital suggests a possible improvement on that routine: Instead of the brain biopsy, the researchers found, it may be possible to analyze a patient’s brain tumor just by taking a sample of cerebrospinal fluid and checking the genetic material in tiny sacs that the tumor sheds into the fluid. And that method could also enable doctors to track a tumor over time — it’s far easier to take repeated spinal fluid samples than to repeatedly drill into the skull — and thus follow how the tumor evolves and fight it as it does.

Xandra Breakefield of Mass. General’s Molecular Neurogenetics Unit explains that these latest brain-tumor findings fit into the relatively new field — from perhaps the last five years or so — of analyzing DNA and RNA in body fluids to track cancer patients’ tumors.

“Each tumor is a bit of an individual in the sense that different kinds of changes in the DNA of the cells turn it into a tumor and define the kind of tumor it is,” she said. “So in this age of personalized medicine and making drugs for cancer that target specific changes that are driving specific tumors, when a person starts having symptoms, the physician wants to know, is this a tumor and if so, what kind of a tumor is it? Is it going to be slow-growing or fast-growing? That’s going to determine how aggressively, or how, to go after it.”

Dr. Breakefield and her team found genetic evidence  in spinal fluid that a tumor was very slow-growing — good news for a patient and very important for the medical team to know. When it’s known that a tumor is less aggressive, surgery may be able to spare more of a patient’s brain, she said. Continue reading

The Man Behind The Mass. General Mummy

Padi, the Masschusetts General Hospital mummy (Photo: Sascha Garrey)

Padi, the Masschusetts General Hospital mummy (Photo: Sascha Garrey)

Over the weekend, Padihershef, the most famous mummy in Boston, was treated to a facelift.

Since 1823, when the city of Boston donated him to the hospital as a medical oddity, Padihershef — nicknamed Padi — has kept a silent vigil in his ornate but fading coffin in the Ether Dome, the amphitheater of Massachusetts General Hospital.

He has been privy to pedagogical surgeries performed in front of generations of medical students. But this weekend, it was Padi’s turn to take the stage.

Mimi Leveque, a seasoned mummy conservator and restorer of ancient artifacts, performed what she called a “mummy spa-treatment,” in which she removed salt deposits from Padi’s face using swabs dipped in saliva, while a team of medical experts examined MRI scans of the hospital’s ancient resident.

The effort aimed in part to answer the question that has haunted the Ether Dome for nearly two centuries: Who is the man behind the mummy?

A few things are known about the mysterious Padi. About 2,500 years ago, 40-year-old Padihershef was unmarried and working as a stone-cutter in the Necropolis in Thebes.

Bone X-rays from 1931 and 1976 revealed stunted bone growth in Padi’s skeleton, suggesting he suffered from a grim illness in his childhood.

Part of the weekend’s hubbub was to compare these older bone scans to recent MRI’s to get a better understanding of how Padi died.  Leveque speculates that his bones may have been subject to a slow crushing from a large object, one theory of the cause of Padi’s death.

Whatever it was that annihilated the stone-cutting bachelor centuries ago, the afterlife has been kind to Padihershef’s looks and reputation. Lying between the top and bottom cases of his coffin — which was also receiving some modernizing restorative re-vamps — his celebrity mummy’s skin was deeply bronzed, encasing high cheekbones and a grin of teeth so white that even the slickest game-show host would be impressed.

“The Egyptians didn’t have sugar the way we do,” Leveque said. “Teeth preserve well.”

Continue reading

MGH Braces For Millions In Research Cuts

WBUR’s Curt Nickisch reports that Massachusetts General Hospital is budgeting for a $19 million cut next year due to decreases in federal research funding: 

MGH President Peter Slavin says the projected loss of $19 million is only part of it — that’s the amount that goes to the hospital to help pay overhead. Slavin says the National Institutes of Health has also been telling researchers to lower their maximum salaries, and warning that fewer grants will get the green light.

“Some young people who might have considered careers in biomedical research are just going to see this incredibly steep hill, and decide to do other things,” Slavin said. “That is tragic.”

mgh

Mass General’s annual research budget is about $800 million.

Last week WBUR reported on further sequester-related research cuts and how they might undermine basic science — and, specifically, Boston’s biomedical edge — in the future: Continue reading

Mass. General’s Last Marathon Bombing Patient Checks Out

Here’s a nice landmark: Just over six weeks after the Boston Marathon bombings, Massachusetts General Hospital has just released its last remaining marathon patient out of the 31 initially hospitalized there. It reports that Marc Fucarile headed out to rehab care today.

In the touching May 10 video by the Boston Globe above, Marc discusses the anxiety that lingered for him and his “worrywart” son after the bombings: “You can’t trust anybody. You can’t believe this guy just did this to everybody and killed innocent people.

‘There’s more good in the world than there is bad.’

“But then, at the same time, the next day you have random people, strangers, just offering things, sending you things, giving you things, helping you, praying for you, lighting candles…what other people are doing just makes you feel like there’s more good in the world than there is bad.”

WBUR has been tracking the marathon-related patients, and finds that now just one remains hospitalized: Nicole Brannock Gross at Beth Israel Deaconess Medical Center, whose first media interview appears here on CBS today. She is expected to be released this week. At last count, Spaulding Rehabilitation Hospital still had nine marathon-related patients.

I’m just taking a moment to savor the contrast between today’s positive news and the daunting lists that the newsroom was gathering just after the attacks. Here’s an example from April 18:

Marathon Patients
TOTAL: 191 (at 14 hospitals)
Beth Israel – 24
Boston Medical Center – 23 (10 critical)
Brigham – 35 (5 critical)
Cambridge Health Alliance affiliated centers -5 (All walk-ins, treated and released)
Carney – 7 (all treated and released)
Children’s – 10 (3 still hospitalized)
Emerson – 2 (treated and released)
Faulkner – 13 (1 critical)
MGH – 29 (8 in critical, but stable)
Mount Auburn Hospital – 5 (all treated and released)
Newton Wellesley – 1
Norwood – 2 (hearing loss, treated and released)
St. E’s – 18 (all treated and released. Injuries ranged from schrapnel to hearing loss)
Tufts Medical Center – 17 (Some serious injuries but none considered life-threatening)

Note: This post was updated to include the CBS interview.

Specialist: My Prime Take-Home Points From ‘Dot Earth’ Reporter’s Stroke

 

 

This week, longtime New York Times reporter and popular “Dot Earth” blogger Andrew Revkin vividly describes his 2011 stroke in the first-person piece “My Lucky Stroke.” He includes these “prime take-home points”: “Take your body seriously. Time (wasted) is brain (lost). Question authority, but not too much. Old habits die hard.”

Dr. Lee Schwamm, chief of Massachusetts General Hospital’s stroke service and medical director of Mass General TeleHealth, would suggest that readers take away some rather different stroke lessons from Andy Revkin’s story. He shares them here.

By Dr. Lee H. Schwamm
Guest contributor

I congratulate the journalist and blogger Andy Revkin for courageously sharing the story of his stroke and his subsequent recovery. I also thank him for taking the time to share his personal experience for the benefit of his readers, and for the opportunity it presents to highlight some key learning points for patients, as we dissect his journey through the health-care system.

Mr. Revkin was relatively young and healthy, out for a run with his son, when he experienced stroke symptoms. All too often, when we think of stroke, we envision an older patient clutching their chest and being unable to move or speak. This stereotype is dangerous, both for patients and health-care providers, because it lowers our sensitivity to stroke-like symptoms in patients of any age.

Mr. Revkin and his son were concerned enough about his symptoms that he went home, but they didn’t appreciate the immediate seriousness of his condition and he took a shower, hoping his symptoms would resolve. Watch the video clip above showing a young news reporter having stroke-like symptoms, and ask yourself, would you have called 911 if you’d been present? You should have.

Without treatment to restore the blocked blood flow to the brain, 2 million nerve cells are dying every minute of continued stroke.

Then Mr. Revkin did what generations of doctors have advised us to do for a heart attack; namely, take some aspirin and call your doctor’s office. Unfortunately, when it comes to stroke, there are two types: those caused by blocked arteries (ischemic) and those caused by rupture of blood vessels (hemorrhagic). It’s not possible to tell just from symptoms if a stroke is ischemic or hemorrhagic; only a CAT scan or MRI can distinguish them.

Obviously, you don’t want to take an aspirin if you’re having bleeding in your brain, as it will make the bleeding worse. But it’s also not a great idea to take aspirin if it’s an ischemic stroke, especially not six aspirin, as Mr. Revkin did, because there are powerful clot-busting drugs that can be given to reverse the disability caused by ischemic stroke. These drugs — the main one is known as tPA — are only effective if they are given within the first 4.5 hours after the start of symptoms, and aspirin might increase the risk that the drugs could convert an ischemic stroke into a giant hemorrhage that could be fatal.

It’s also really important to realize, as Mr. Revkin mentions, that “time is brain.” Continue reading

Mass. General ‘Be Nice’ Video Meant For Staff But Useful For Patients

 

“Is this begging for parody or what?” I thought. Massachusetts General Hospital paid its employees $250 each to watch a video reminding them to be nice to patients?!

That was my first reaction upon reading this scrupulously deadpan Boston Globe story headlined “Mass. General employees watch customer service video — for $250.” It carefully notes that the $250 incentive brought complaints from some competitors at a time of tight health care dollars, but also that such pay is “an approach common in other industries and that proved to be an overwhelming success for the hospital.”

(Dear Boston Globe: At times like this, I can’t help hoping that you’ll be bought by The Onion or The Daily Show. Can’t you have even a little fun with news that makes people go “Huh?”)

So how could one best bowdlerize the earnest, mission-driven video above featuring Mass. General chief Dr. Peter Slavin? One idea: You could provide translations to plainer speech. For example:

Massachusetts General Hospital president Peter L. Slavin

Massachusetts General Hospital president Peter L. Slavin (MGH)

Slavin: “It’s also important that we speak well of each other and of other departments when interacting with patients and their loved ones, to help them feel assured of our teamwork in caring for them.”

Translation: When your colleagues are jerks, do not scare patients by telling them about it.

Slavin: “There is no doubt that even long-time patients and their families can often be nervous and uncomfortable when coming to the hospital or visiting their doctor or other clinician. How we first greet them often sets the tone for a successful positive admission or visit.”

Translation: Most people walking into our halls are scared out of their wits. Have a heart.

Readers, other translations welcome. But in truth, I come away from watching the 11-minute video with the sense that though it was meant for the hospital’s 22,000 staffers, it is an excellent tutorial for every one of us as potential patients. Continue reading

Doctor’s Musings As Insurance Call Makes Him Wait And Wait

Dr. Steven Schlozman

Dr. Steven Schlozman

Dr. Steven Schlozman is an assistant professor of psychiatry at Harvard Medical School and a staff child psychiatrist at Massachusetts General Hospital. He is also the Co-Director of Medical Student Education in Psychiatry. His first novel, “The Zombie Autopsies,” was published in 2011, and his affinity for zombies might explain his mind-numbing rage at being stuck on hold all the time. Readers, have you had muzak musings of your own lately? Please share in the comments below.

By Dr. Steven Schlozman
Guest contributor

I am a physician practicing in Boston. I do my best to get my work done as carefully and efficiently as possible.

I am writing to you right now, in real time, as I enter my…wait for it…38th minute on hold with Blue Cross/Blue Shield in my attempt to gain approval for a treatment that my patient absolutely needs. No one who knew the details of this case would argue otherwise; not politicians, or business specialists, or cost efficiency specialists, or medical school professors, or anyone really. Neither would anyone deny that the treatment that I am trying to procure for my patient is costly. Finally, no one would deny that it is legions more costly to not treat my patient with the treatment for which I am now sitting on hold and trying to procure.

Help. I love being a doctor. But this isn’t doctoring.

Still, here I sit. I sat initially for 26 minutes, at which point the very pleasant muzak stopped and a recorded and maddeningly soothing female voice told me that I would “have to call back later.” Then the line went dead.

So I called back later.

I called back exactly 12 seconds later, and that was now 42 minutes ago. I mean, 42 minutes, in real time, as I write this letter. I have patients in the waiting room who will understandably expect me to get to them soon. I also know that there are those who will tell me that this is what I signed up to do for a living.

But they’re wrong. I did not sign up to do this for a living. There are no courses in medical school about how to spend one’s time on hold while patients need your help.

Minute 58 just passed, by the way. Continue reading

When Doctors Don’t Listen (And Hangover Leads To Spinal Tap)

Dr. Leana Wen consults with co-author Dr. Joshua Kosowsky (Associated Press)

Dr. Leana Wen consults with co-author Dr. Joshua Kosowsky (Associated Press)

Consider these cautionary tales:

• The college student who came to the emergency room for an intense hangover, only to be told she would need a spinal tap to rule out possible brain hemorrhage. (True story. Spinal tap as in puncturing the back to draw fluid. For a hangover. She slipped away instead.)

• The drowsy obese woman hospitalized for days for a possible clot when all she really had was sleep apnea.

•The strapping middle-aged man whose chest felt sore after a day of moving heavy furniture, condemned to a battery of tests for possible heart attack.

These are the kinds of alarming cases that populate a provocative new book to be published next week: “When Doctors Don’t Listen: How To Avoid Misdiagnoses And Unnecessary Tests,”

Dr. Leana Wen (courtesy Darren Pellegrino)

Dr. Leana Wen (courtesy Darren Pellegrino)

Dr. Joshua Kosowsky

Dr. Joshua Kosowsky

Dr. Leana Wen, a senior resident in emergency medicine at Brigham and Women’s Hospital and Massachusetts General Hospital, co-authored the book with Dr. Joshua Kosowsky, clinical director of the Brigham and Women’s emergency department — a new-minted doctor joining forces with a senior colleague, both seeking to warn patients about prevalent flaws in medical thinking that could cause them harm — and how to counteract them.

Our conversation, lightly edited, is below, and beneath it, an abridged excerpt recounting the tale of the hung-over college student in more detail.

Here’s how I think I’d distill the message of your book: Patients, beware of “cookbook medicine” and of getting stuck on a “diagnostic pathway,” of doctors who get hung up on trying to “rule out” a “worst-case scenario,” and so bombard you with yes-and-no questions that you cannot tell your story, the story that may actually point to your diagnosis.’

But how would you distill it, and translate those phrases I just used? 

I like what you said. The way I think about it, too, is that our health care system, and our individual parterships with our doctors, have become so out of control, and patients have the ability to — and have to empower themselves to — take control of their health care. And they should start by understanding what the doctor’s thought process is, understanding the ‘cookbook medicine’ that many doctors practice, and what they can do to focus care on their individual symptoms and story.

How would you explain what you mean by cookbook medicine?

Doctors are under a lot of pressure to be faster and faster and see patients in shorter and shorter periods of time. And so instead of listening for 10 minutes without interruption, they begin to ask yes/no questions –

Yes, I was amazed by the statistic in the book that the patient on average only gets 12 seconds to start telling the doctor what’s wrong before they get interrupted —

Another study recently showed that it’s more like eight seconds. And so that’s how cookbook medicine comes about. Anyone can relate to being asked, ‘Do you have chest pain? Do you have shortness of breath? Do you have headache?’ That’s not individualized care, that’s putting you in a pre-set mold and trying to say that whatever applies for everyone else, also applies to you.

For example? Continue reading