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How the Changing Role of Doctors Will Revolutionize Health Care
By William Hanson
Palgrave Macmillan Copyright © 2011 William Hanson, M.D.
All rights reserved.
BED NINE DID DIE
Like many of today's doctors, I no longer carry a pager. I use my smartphone for all personal and professional communications. This has the benefit of consolidating a variety of functions onto a single device and means that I have less weight to carry on my hip. I spend parts of many days wearing scrubs, and the scrub-pant drawstring is less sturdy than a belt as a platform for waist-based devices. Interns and residents who may have to carry a hospital phone, their own phone and a code-red beeper often develop an unsightly sag in the scrubs where the pants pull down. During a my residency, when I needed to carry both a pager and one of the original, heavy cell phones, I briefly considered wearing a fanny pack or one of those utility belts worn by police or army officers but quickly decided that it just wouldn't look right on me. Of course, the downside to using my cell phone as the single point of contact is that, as a physician, I can't afford to screen calls because a lot of people I don't know need to be able to contact me for medical emergencies. So I get a lot of chaff along with the wheat when I answer unfamiliar numbers.
My smartphone displays a high-tech white analog clock face on a black background when I plug it in to recharge. This virtual timepiece can be configured to act as an alarm clock, too. One night it dawned on me that I could actually do away with my old electric alarm, which I'd laboriously reset after every power outage, and instead use the phone's clock for that function. After some fiddling, I selected a ringtone labeled "Inspired Asian Morning" as my wake-up reveille. It features some double-reeded instrument, like an Eastern variant of the oboe, playing a rising, quavering note against a backdrop of drums. I like this because it wakes me more gently than the old alarm clock did and doesn't bother my wife if I need to wake up earlier than she does.
After some use, I've found that this wedding of smartphone with alarm clock is convenient and saves bedside space; but, as with many marriages, it comes with pros and cons. Once I dismiss the alarm, the "You've got mail" prompt automatically pops up. And I can't always resist the urge to see what rolled in during the night. Occasionally I find a message from a friend in a different time zone; sometimes there's nothing but a few stray spams. In reality, there's almost never anything important enough to warrant postponing a good toothbrushing, but it's become an almost Pavlovian response: the alarm sounds and, like a well-trained dog, I open my email.
One recent morning I awakened to find a message that had arrived earlier, at 3:02 AM, entitled "Attending Mortality Form Notification." The sending party was someone, or perhaps some thing, called "Death Forms Application." Neither the subject nor the sender fell into any category I recognized immediately, and both sounded vaguely ominous. So I further postponed the dental hygiene and after some investigation found that I had also gotten a text message at 2:50 AM, about 15 minutes earlier, one that hadn't awakened me. After checking my phone log (and further waking from my groggy condition), I remembered that I had gotten and answered a couple of calls from the hospital shortly before midnight.
This probably warrants a quick bit of personal disclosure. Like some of you, I have my own individual, multi-tiered response to cell-phone-based communications. As it happens, not through any particular design, my alerts all have an Eastern flavor. The "Inspired Asian Morning" alarm clock harmonizes nicely with my phone's "Chi Gong" ringtone, which sounds like one of those giant hanging gongs used in Asian temples. I prefer my alerts to some of the alternatives I hear around the hospital: the opening bars of "A Hard Day's Night" or the howling of a submarine "Dive!" I've come to believe that you can tell a lot about a person by the alerts they choose, and it's no surprise that an entire industry has grown up around ringtones.
I have chosen not to get any notification about new emails. A colleague set his phone set to vibrate with every new mail message—checking his email became a visible, twitchy habit. His wife thought he had developed a tic and forced him to buy a phone that couldn't be configured to notify him about new emails. I prefer to check mine every now and then to see if anything new has arrived. Recent neurological research has actually shown that these random email alerts trigger little surges of neurotransmitters in the brain, simultaneously signaling stress and pleasure ... like little dominatrices.
My incoming text messages are configured to sound a single "Light Chime," also Asian in flavor. And both my phone and text message alerts are set to vibrate simultaneously with the audio alert so I don't miss a medical emergency when, for example, as is often the case, two or more of my children are in a heated discussion about some piece of disputed property, like the shotgun position in the car, or food. This seemingly redundant pairing of vibrate and sound is actually designed to act as a "belt and suspenders": vibration notifies me when it's too loud to hear, and sound does so when I'm already vibrating as I when drive in my bouncy Jeep.
On the morning at issue, I had actually gotten three different types of electronic messages during the night. One of them, the phone call, had awakened me, and two of them, the email and text messages, hadn't. I actually smiled to myself because this alerting configuration that I'd carefully customized had worked exactly as I intended: I did want to be awakened by phone calls but not by texts or emails.
As I lay there that morning in the pre-dawn dark, it occurred to me that my father, who was a general internist, also had mornings like this, when he awakened bleary after a night interrupted by patient-related phone calls. But he never carried a cell phone, never got the hang of email and certainly never texted. The type of medicine I practice is definitely not my father's medicine.
I had been covering the intensive care service that week, which meant that I got a lot of calls every night. These calls were related to bed management in our crowded ICU (intensive care unit) as well as questions from the residents who were in-house, dealing with the issues that crop up with regularity during any given night. We also "round"—visiting each patient's bedside several times each day—because critically ill patients change continually in one direction or another, and their care requires lots of round-the-clock fine tuning.
Margarita Latincic was one of my patients that week. I met her on rounds after surgery for a collection of pus in her belly, although she was still sedated and on a respirator at the time.
She was 69 years old and had been admitted to the hospital several times for the same problem over the past two months. Mrs. Latincic had initially developed inflammation and infection around her colon months earlier as a result of a condition called diverticulitis, in which little pockets develop in the wall of the large bowel. Diverticular disease is usually asymptomatic but can result in bleeding into the bowel, known as diverticulosis, or in an infection. Hoping to avoid a big operation, her doctors had initially drained a large collection of pus around the bowel via a catheter inserted through the skin by radiologists, but that had only worked briefly, and she went on to be readmitted for dehydration and kidney failure. Eventually, after several admissions, it became obvious that open surgery was needed to remove the infected bowel. This was her third major surgery, and there was concern about whether her system could take the stress.
Years earlier, Mrs. Latincic had developed an unusual liver disease called primary biliary cirrhosis in which the bile ducts become inflamed, probably as some sort of autoimmune reaction. As is often the case, the problem eventually progressed to the point that she required a liver transplant. Her first replacement liver lasted for about ten years and then failed. She then underwent a second, inevitably more complicated, liver transplant along with a simultaneous kidney transplant from the same donor.
The issue of retransplantation comes up often in ethical debates. With the scarcity of available organs and long waiting lists, ethicists ask if each potential recipient should be treated equally regardless of prior transplantation history, or should patients who've already been transplanted once rank lower in priority than first-time recipients. I know of one patient, a rabbi, who has received three livers over the course of several years.
Successful transplants can result in significant improvements in the lives of recipients. A patient who had been bedbound on oxygen prior to lung transplantation can return to breathing normally. An avid tennis player I know returned to the court after his heart transplant. The same is true for liver and kidney patients like Mrs. Latincic.
But this good comes with a cost. Almost every transplanted patient spends the rest of his life on drugs that suppress the immune system, and the immune system's role is to stave off infections and cancer. Immunosuppressed patients are at significantly increased risk from bacteria, from their own cells that "go rogue" and become malignant, as well as from immune cells that come along with the transplanted organ. In graft-versus-host disease, the transplanted organ's cells essentially attack the recipient.
Mrs. Latincic came to the ICU after an operation in which the inflamed section of her bowel was removed and the colon was then sewn back together. At first, everything appeared to be fine, although she was still on a ventilator and I noted that her heart rate was higher than normal after this kind of surgery. She was also hyperventilating and her kidneys weren't putting out enough urine. I wasn't surprised by the latter because I anticipated that she would need a little more intravenous (IV) fluid to replace the blood and serum lost during the operation. Also, for 24 to 28 hours after a big operation, fluid leaks out of the blood vessels into the tissues as part of a general inflammatory reaction, like a total body bruise; these patients appear to be dehydrated even though they may end up weighing more than they did before the operation when they started getting their needed transfusions.
During morning rounds that first day, I told the team to give her a liter or two of intravenous saline to see if her heart rate would come down. I also asked them to see if she was able to breathe on her own. In order to be safely taken off the ventilator after an operation, the patient must be awake and strong, and the lungs must be working. When I came back later in the day, she had gotten several more liters of IV fluid but still wasn't urinating enough. Also, her heart rate was still well over 100, which is high. She was awake enough to wince and point at her stomach, over the area of the surgery, indicating that it hurt. While the belly pain was normal, the whole constellation of other issues suggested that all was not well, and we decided to keep her on the ventilator overnight, which turned out to be a good thing.
Medicine is usually described as both a science and an art. The decision to keep this patient on the ventilator that afternoon falls on the art side of the equation. By all objective respiratory criteria at that point, Mrs. Latincic was ready to breathe on her own, but the high heart rate and low urine output were analogous to the cracking of twigs to an army sentry. They suggested that something was looming out there and that we should be extra vigilant.
Over the next 48 hours, Mrs. Latincic's situation gradually worsened. Her heart rate remained high and her blood pressure began to drop. Her kidneys stopped making urine altogether. She also developed a fever, and her lungs began to fill up with fluid so that she required more and more oxygen through the ventilator. She was developing the group of problems known as sepsis (a general inflammatory reaction throughout the body) and adult respiratory distress syndrome, wherein the lungs become "leaky."
At this point we engaged some help from several different specialist teams. Transplant infectious disease is a sub-sub-specialty of plain old infectious disease, which is in turn a sub-specialty of internal medicine, one of medicine's traditional core specialties. These super-specialists are typically only found at a transplant center like ours. We also contacted the renal team—the nephrologists—because it began to look like she'd need to start on dialysis as her kidneys failed.
Mrs. Latincic's core family members included her husband and two sons. They were very experienced with intensive care units, having witnessed her two prior transplants and the more recent hospitalizations for diverticulitis. Like many families, they spent a lot of time watching the monitors as they sat at her bedside. We briefed them frequently, but they were well aware that things were not proceeding in the right direction just from watching her vital signs and the expressions on the caregivers' faces.
The two sons sat vigil by the bedside. Their father had been there immediately after surgery, when things seemed straightforward, but was strangely absent as her course deteriorated. When we asked the sons whether he would be available to sign a consent form for interventions like dialysis, the older one explained that they shared power of attorney and could speak for their mother legally. Usually this role would fall to a spouse, but Mr. Latincic had, as they put it, "lost his mind" the last time she was critically ill. And the sons explained that this time he was staying at home but was extremely upset and felt we, the care team of doctors and nurses, were killing her. They also indicated that he had a gun.
In a previous era, we might have dismissed this information as interesting but not really relevant—but not anymore. On September 17, 2010, as I wrote this chapter, Paul Warren Pardus, a bus driver for disabled people, shot the orthopedic surgeon who was caring for his 84-year-old mother at Johns Hopkins Hospital. He had evidently just been told that she wasn't likely to walk again after her spinal procedure and on hearing the news, pulled a semiautomatic handgun from his waistband and shot Dr. David Cohen in the abdomen. He then ran down the hall to his mother's room and barricaded himself within with her.
Over the subsequent two hours, police secured and evacuated that portion of the hospital, and a SWAT team was summoned. As the predictable flurry of news reports ensued, a surge of related tweets on the topic pushed the story into the top ten list on Twitter. Eventually, after hearing nothing from the room, the police entered and found both Pardus and his mother dead with gunshot wounds to the head in a presumed murder-suicide. According to Pardus's brother, Alvin Gibson, "I guess [he did it] because he thought my mom was suffering because the surgery wasn't successful and she probably wouldn't be able to walk again. She was a dear, sweet lady. She just wanted to walk around like she did when she was younger."1 Cohen recovered, but the news rocketed around the medical world.
Like Pardus, Latincic's husband was upset by similarly unmet expectations of the medical system, and her sons were alarmed enough to ask the police to go over and talk to their father. Hospital security also became involved. While some hospitals screen every visitor with a metal detector, most don't. Yet violence in the health-care setting is on the rise, and some experts feel that controlling access to the hospital is a critical part of the solution. Modern hospitals have increasingly become pressure cookers where doctors, nurses, patients and families grapple with tough emotional issues, critical life-and-death decisions and, sometimes, mutually incompatible goals.
By Friday afternoon of my week on service, it was clear that Mrs. Latincic was "struggling," a term I sometimes use when talking to families wanting updates about very ill loved ones in the ICU. Her medical condition had worsened to the point that we were no longer able to get a sufficient amount of oxygen into her lungs using the respirator. Her kidneys were shutting down and she was now on dialysis. She was deeply sedated and on a complicated regimen of extreme antibiotics as well as four different drugs to support her blood pressure. We measured and analyzed her urine output, liver function, cardiac performance and lungs' ability to exchange oxygen and carbon dioxide between blood and air. All of this information was stored in an intelligent intensive care electronic medical record that could display trended graphics and automatically identify aberrant laboratory values.
Dedicated doctors and nurses watched over her night and day, with assistance from a team of doctors and nurses located off-site who augmented the vigilance of the bedside team with smart software and audiovisual feeds from the room. They used a combination of computer logic and human vigilance to pick up vital sign anomalies even when the intensive care nurse wasn't in the room. Despite all of this extreme care, Mrs. Latincic deteriorated inexorably.
Excerpted from Smart Medicine by William Hanson. Copyright © 2011 William Hanson, M.D.. Excerpted by permission of Palgrave Macmillan.
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