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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

Mass. General: ‘No Heroes!’ And Other Workplace Flu Protocol

Massachusetts General Hospital (Wikimedia Commons)

Massachusetts General Hospital (Wikimedia Commons)

No, we are not panicking, but yes, there’s a lot of flu about. Boston has just declared a flu-related health emergency, citing 700 confirmed cases thus far compared to 70 all last year.

In an alert to its staff, Massachusetts General Hospital reports that it’s seeing a flu season of “impressive intensity,” with an additional 40 to 80 patients with flu-like illness per day at the hospital’s health centers, outpatient clinics and emergency department.

“This has strained capacity to its limits. Likewise, many inpatient beds have been closed to isolate influenza patients, and hospital and practice staffing has been stressed by illness within their own ranks,” says the alert from Jeanette Ives Erickson, Mass. General’s senior vice president for patient care and chief nurse.

The memo lays out “best practices” for infection control that many a workplace may want to post and disseminate. To wit: (Slightly modified to remove some specifics, and still somewhat hospital-oriented)

• No Heroes! Staff with flu-like [illness] should leave the office and STAY HOME per the protocols of Occupational Health:
Do not come to work if you have a fever of 100.5°F or more and one or more of the following symptoms:
§ Runny nose or nasal congestion
§ Sore throat
§ Cough
§ Body aches
Continue reading

Steroid Debacle Prompts Hospital Pharmacies To Ramp Up In-House Compounding

The “clean room” at Massachusetts General Hospital’s central pharmacy. (Fred Bever/WBUR)

It would be going a little far to call this a silver lining of the national outbreak of meningitis from tainted steroids that has now killed 36 people and sickened over 500. But it is perhaps heartening that the drug shortage that has arisen because the steroids’ makers closed down may lead to some long-term improvements in how hospital pharmacies operate.

In case you missed it, WBUR ran an extremely excellent story by reporter Fred Bever this morning that featured the scene at Massachusetts General Hospital’s central pharmacy:

Patients at Massachusetts General Hospital take some 400,000 doses of medication every month — 4.8 million a year. And until two months ago, close to a million of them were compounded by third-party vendors, such as NECC and, even more, Ameridose. Now, most of that work has been brought in house to MGH’s central pharmacy.

That means a far heavier in-house workload:

“We’ve increased our hours. We have three hoods that are full on all three shifts, that we didn’t have before,” [lead technician Meghan] Federico said. “We were Monday through Friday 7:30 to 4:00 operation, and now we’re 24/7.”

Check out the full story on WBUR.org here. It concludes that Partners Healthcare, the state’s biggest health care provider, “is mulling the idea of creating its own compounding pharmacy that would serve all the hospitals in its system.”

You want something done right, do it yourself…

 

‘Ethically, Is This Right For Doctors To Do?’ Help A Terminal Patient Die?

(Photo illustration by Alex Kingsbury/WBUR)

Ravi Parikh, a fourth-year student at Harvard Medical School, faced conflicting messages.

The American Medical Association, which he belongs to, and the Massachusetts Medical Society oppose Question 2, the measure on next month’s state ballot that would allow terminally ill patients to ask a doctor to prescribe them life-ending drugs.

Harvard Medical School student Ravi Parikh

In contrast, The American Medical Student Association, which he also belongs to, supports it.

Ravi faced conflict within as well. He’d applied to medical school for the usual reason — to heal patients, as spelled out in the Hippocratic oath — not to help them die.

But his medical education introduced him to the complexities of modern American dying.

It stressed patient autonomy as a “central guidepost.” Yet he saw patients losing control as they neared death. “No patient that I have spoken to wishes to die in pain, alone, or hooked to a ventilator,” Ravi said, “and yet that is the way in which many patients pass away in the ICU.”

Seeing similar confusion about the ballot measure among his peers, Ravi and fellow fourth-year Grant Smith helped organize a panel discussion for all local medical students earlier this month at Harvard.

It let the audience pepper panelists on each side of the issue with questions, and also use the teaching tool of a case study: A hypothetical elderly man with metastatic cancer who comes to his doctor asking for a lethal prescription.

That case discussion, Ravi said, brought out a valuable consensus among the opposing panelists: All agreed on the need for more and better end-of-life discussions with patients.

But on the “toughest question” — “Ethically, is this right for doctors to do?” — there was no clear answer, he said. Rather, each side argued that its position represented the true embodiment of “Do no harm.”

‘This conversation involves an irresolvable dilemma.’

If Ravi and his fellow students remain conflicted, they can at least be comforted that they are in plenty of good company.

By all indications, the ballot measure presents an extraordinarily difficult problem of medical ethics — a problem wrestled with nationally as states consider physician-assisted suicide laws. Thus far, only Oregon and Washington have passed them; polls suggest that Massachusetts may be next.

The ethical issues involved are hard and deep enough to divide not just medical associations but medical staffs — a Massachusetts General Hospital panel presented arguments for and against Question 2 earlier this month — and seasoned ethicists.

Consider the Boston-based Community Ethics Committee, a group of 18 diverse volunteers who gather to craft opinions on some of the thorniest of bio-medical issues. Continue reading

Isn’t Parkinson’s Degenerative? How Can Michael J. Fox Be Better?

Actor Michael J. Fox in a 1988 photo (Wikimedia Commons)

“Great news,” I thought when I read that Michael J. Fox was returning to a comic television role, 12 years after he left to focus on treating his own Parkinson’s disease and funding research to help all patients.

“But how can this be? If there’s a big breakthrough in Parkinson’s disease treatment, wouldn’t we have heard about it? And if there isn’t one, isn’t the definition of a degenerative disease that it goes downhill? How can he have climbed back up again?”

Dr. Michael Schwarzschild, a Parkinson’s expert and director of the Molecular Neurobiology Laboratory at the MassGeneral Institute for Neurodegenerative Disease, kindly fielded my questions. First the disclaimers: He is not involved in Fox’s treatment, and has received grant support from the Michael J. Fox Foundation for Parkinson’s Research. Now the answer to my first query: What could it mean that Fox told ABC he “kind of stumbled onto a new cocktail of meds” that made him better enough to work again? Dr. Schwarzschild:

I heard his quote, too, and of course it’s wonderful that he’s making a comeback. In terms of what to make of this somewhat cryptic comment, I don’t think it relates to some new treatment that others don’t know about, or something newly approved and dramatic, because there isn’t anything like that.

‘Someone can improve without breaking the laws of physics about Parkinson’s disease being an inexorably progressive disorder.’

As a clinician who treats patients with Parkinson’s, your impression is right: It’s a progressive neurodegenerative disease. On average, in typical or even not-typical Parkinson’s disease, it’s inexorable.

That being said, it’s not a constant decline even though it goes in that direction, and medication can have a huge effect. Levodopa, when it came around in the sixties and seventies, took people out of nursing homes. Usually, with someone who’s getting reasonable care, you don’t expect, late in the disease, to discover some combination of currently available medications that make a huge difference. But sometimes you do.

I’ll give you a couple of examples even with approved medications in the United States. Continue reading

Hospital Video: What It’s Like To Be Attacked By A Great White

In case you missed the Globe story, Massachusetts General Hospital has posted this two-minute, hospital-bed video of Chris Myers, the swimmer who was bitten by a Great White Shark off Truro on July 30. This is apparently the first such attack in the state’s waters in more than 70 years, so it’s a rare chance to ask the inevitable question: What does it feel like?

Chris Myers on the video: “The first thing i felt was a huge bite on my left foot. It felt like i had my foot stuck in a refrigerator or a vise, and I knew instantly that it was a shark. And we started swimming as hard as we could toward shore.”

Chris says he had eight deep puncture wounds and it took 47 stitches to sew up his wounds. A couple of tendons in his ankle had been severed, and had to be surgically repaired. He can now walk on crutches and take a few steps on his own, he said, and is expected to make a full recovery.

“I feel very lucky to have made it back to that beach in one piece,” he says. “Very very lucky that my son did not get bitten, and very thrilled that the two of us are going to get to home today together.”

Old surfer saying: You don’t have to swim faster than the shark, just faster than your buddy. My thought: But if the buddy is your son, then do you maybe swim slower?

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Biggest Health Challenges: Flu, Polio, Wars — And Now Costs

Massachusetts General Hospital president Peter L. Slavin

Massachusetts General Hospital president Peter L. Slavin (MGH)

The Massachusetts Hospital Association just sent over word about its June 7 annual meeting, including the news that Massachusetts General Hospital president Peter L. Slavin is the association’s new chair of the board of trustees.

It included this:

In his inaugural speech that called for the hospital community to unite during the healthcare reform efforts now under way in the state, Slavin said “For more than 200 years, the hospital community in this state has tackled our society’s most significant health care challenges — influenza epidemics, polio epidemics, and world wars to name a few. I would argue that perhaps the most significant threat to the future health of the people of Massachusetts is the rising cost of healthcare itself. We must tackle this challenge head on just like the others. To do so is our greatest challenge, our solemn responsibility, and a remarkable opportunity for us to lead.”

My first reaction: Flu, polio, war — and health costs? Doesn’t that list end a little anti-climactically? (I’m reminded of the chorus “For God, For Country and For Yale,” cited as “the outstanding single anti-climax in the English language.”) On the other hand, if health costs are crowding schools and safety and more out of public budgets, then perhaps — ? If costs are keeping people from care, as today’s poll suggests? Readers, thoughts?

For Massachusetts medical insiders, here are the new MHA officers: Continue reading