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    August 5, 2012

    Doll’s Eyes

    Doll’s Eyes

    Unfortunately, the case of Sabrina Seelig at a Brooklyn hospital is not an anomaly. Medical errors that result in death are common in American hospitals. Only a few of these – the signature cases – have changed the fundamental ways hospitals do business. A few of these cases of “adverse events” or “failure to rescue” are iconic in the medical patient safety movement throughout the United States.

    Dana Farber Cancer Center had the Betsy Lehman case. A health columnist for the Boston Globe died from a chemotherapy overdose for breast cancer in 1994. Josie King died of dehydration at Johns Hopkins in 2001. The 1984 Libby Zion case at New York Hospital led to a twenty-five year effort to change the national work hour rules for doctors in training. These cases all involved young women who died while under the protective care of their physicians. These are the “Ur” teaching cases in the patient safety movement in this country, the ultimate “opportunities” for improvement. They changed the way business is done in their hospitals and galvanized a movement beyond Boston, Baltimore and New York City.

    From Libby Zion we learned that fatigue affects the judgment of physicians. We are not cyborgs with boundless energy who unstintingly deliver high quality care regardless of the hours we put in. From Betsy Lehman medication errors can be lethal from dozens of different pathways even in the most resourced hospitals with unlimited talent. Josie King taught us to listen deeply to our patients and their families. Their distress signals are not vacuous and without important medical meaning.

    Ms. Seelig’s case brought us back to the fundamental’s of medical care. As we are more seduced by technology and dependent on specialists and computer printouts from imaging and laboratories, we sometimes fail to examine and re-examine the patient. It’s that basic.

    We learned this way back. As residents in training at the Kings County Hospital Emergency Room, we faced a sprawling complex that was always packed to overflowing. We senior residents managed to establish a veneer of control by the art and rules of triage. Working closely with a couple of nurses and medical students we were the one eyed in the kingdom of the blind. Gun shot wounds and stabbings went to the trauma slot. Minor sprains and upper respiratory complaints got an automatic blood test or x-ray to minimize delays and create some space in the boxlike “Male” room.

    The cases that caused the most distress and anxiety from the lore of previous residents were handed down to the next generation of trainees. Mental status changes were high on the list of tricky and dangerous among the banal and innocuous garden of symptoms.

    Mental status changes, as in the Seelig case, were the black boxes to be deciphered and quickly. The clock was ticking. What was causing cerebral injury? A stroke, a bleed, an embolism? Liver disease, renal failure, electrolyte imbalance, alcohol, drugs, prescription interactions? Sometimes a person’s cognitive decline is not noticed until she takes an innocuous over the counter medication.

    During my training, the physician’s bible was a slim black hard cover book, Stupor and Coma by neurologists Plum and Posner from Cornell Medical School. They had looked at several hundred patients exhibiting changes in consciousness in their emergency room and established simple rules to determine if the cause was a structural intra-cerebral lesion (like a blood clot) or a metabolic derangement (intoxication, elevated blood sugar, skewed mineral levels etc.) Focal neurologic abnormalities, such as strokes, tumors or bleeds, which frequently cause weakness and reflex changes indicates a structural lesion. Except, of course, for hypoglycemia, a major exception, which mimics anything. The brain is unforgiving without blood or its mandatory glucose energy supply.

    The effluvia of drug use that washes into our emergency rooms changes constantly. The Barbiturate generation became the Valium generation and then mutated into the Xanax/Ativan/Clonopin/Ritalin generation. Heroin and Cocaine have become Oxycontin and Mephamphetamines. Now prescription drug poly-overdoses taken with alcohol is number one on coroner’s lists around the country.

    No matter what the cause, medical practitioners must perform a careful physical examination. We use a flashlight to check a patient’s pupil size and symmetry. Pinpoint pupils can indicate a narcotic overdose while fixed and dilated pupils are harbingers of brain death. We cradle a patient’s head in our hands, rapidly turning the head first to one side and then to the other. We look for “Doll’s eyes” – both turn symmetrically when we turn the head—if we turn the head left, the eyes go right. This indicates that the neuro-pathways are intact.

    Important too are any changes in the patient’s level of consciousness that are Sherlock Holmesian in their subtlety. One patient, a fluent English speaker from China, with recurrent headaches reverted to Cantonese. He had a positive CAT scan for a brain lesion but was considered stable. An astute nurse, however, interpreted the sudden language shift as a sign that his brain pressure had changed. The subtle behavioral variance triggered her suspicion. The leaking lesion was putting pressure on his brainstem and he was wheeled to the operating room.

    A tiny woman received a dose of medication for a man four times her size in a medication mix-up. She looked fine, but the staff recognized the mistake immediately and moved her to the intensive care unit. In a few more minutes, she would have stopped breathing far from trained staff in airway emergencies.

    Changes in mental status, stupor and progression into loss of consciousness or coma do not follow a predictable trajectory. It can be sudden or follow a slow fluctuating pathway. If patients cannot be roused, even with a painful stimulus like a pinch, then they need intensive care monitoring. When people slip into a stupor or coma, they lose their gag reflex, making them susceptible to aspiration pneumonia. Respiratory depression results in lowered oxygen levels and damage to vital organs. Constant monitoring under controlled circumstances can be life saving.

    Changes in consciousness challenge every emergency room every day. People are admitted for every conceivable issue and a large number of them, from every part of society, come in because of accidental overdoses. Our society is awash in drugs both licit and illicit. Every patient requires non-judgmental evaluation and monitoring. Let’s get back to basics. Careful ongoing neurological evaluations and targeted imaging and lab testing are good medicine. Carefully watching patients with a change in mental status in monitored settings is the standard of care. The Dolls Eye’s have stories to tell.

    July 16, 2012

    Canary Patients

    As a longtime medical director of one of the country’s largest and oldest public hospitals my colleagues at Bellevue and I frequently encountered what we called “canary patients,” patients who, like canaries in a coal mine, signal larger and less visible problems ahead. Annual influenza epidemics and the possibility of highly lethal mutations from birds to pigs to people have mobilized an international coalition of scientists and public health officials. Other diseases both contagious and non-contagious circulate globally with devastating effects, markers of political, social and economic instability and reverberations of history that is very much alive.

     

    Tibetan, Russian, and Chinese patients are routinely admitted with weight loss and fever. Their x-rays have the telltale signs of tuberculosis in its infinite variations. The crowded petri dish like prison systems of the ex-Soviet Union or the overflowing refugee camps in Katmandu, Nepal for the waves of refugees fleeing a Chinese gunpoint takeover of their society are the laboratories for breeding and spreading TB. Both inadequate and incomplete drug treatment regimens create the Darwinian storm for hyper-resistence to emerge. TB is alive and flourishing throughout the world a bell weather of social and political unrest and/or public health failure.

     

    A young man from Africa, Asia or the US with fever and chills and swollen lymph glands sits in a chair in the Urgent Care Center. His almost forgettable viral symptoms will resolve spontaneously. However his follow-up HIV test two weeks later turns positive. Fueled by crystal meth an active anonymous sex scene drives a continuing conversion rate. An HIV “morning after pill” combined with a normal life expectancy on suppressive medications plus persistent intravenous drug abuse keep HIV in the differential diagnosis for physicians everywhere under any circumstance for a variety of patient’s complaints both exotic and mundane.

     

    A jaundiced taxi driver from Egypt is wheeled in by his son. A US citizen for over twenty years he has cirrhosis and will need a liver transplant urgently. This year hepatitis C has passed HIV in its death toll. Ironically colonial public health officials introduced and spread hepatitis C and HIV in widespread vaccination campaigns with unsterilized syringes generations ago in Africa and the Middle East. The race for widespread testing, “know your Hep C status” and improved drug treatment regimens and the promise of a vaccine are reminiscent of HIV disease twenty plus years ago.

     

    A few doors down on a stretcher lies a young Guatemalan woman with a football sized heart from Chagas disease acquired decades earlier and endemic in poor areas of Latin America. She barely survived the hazardous journey through Mexico to Texas after her missing husband’s right hand was left on her doorstep. The Evangelical dictator/general, Efrain Ríos Montt, now awaiting trial, waged a genocidal war against the country’s indigenous populations; the violence destabilized the entire area that has become home to drug traffickers.  The trypanosome, the Chagas vector is now entering our blood supply.

     

    In Bellevue’s Survivors of Torture program the earliest victims of the latest terror waves throughout the world from the Lords Resistance Army before Kony went viral on YouTube to the seemingly eternal Sudanese conflict over oil and desertification  overflow the waiting room before news makes the headlines.

    The canary’s message here is about post-colonialism, climate change and energy wars.

    I look at the abdominal x-ray of a heavily tattooed young man in leg irons and handcuffs in an orange jump suit escorted by a phalanx of uniformed officers who is lead to our psychiatric emergency room after swallowing silverware at New York City’s Rikers Island prison complex. MS-13 is visible in black ink on his neck. The Central American gang Maras Salvatrucha has made it to New York City.  Originally, these gang members grew up in L.A., children of refugees from the Central American wars of the 1970s sponsored by the US backed Contras. Deported as teenagers to ‘home’ countries they never knew, they formed the most brutal gangs imaginable and have made it back to the U.S., and to Bellevue.  The “Mexican problem” has crossed the border, the New York State border.

    These canary patients, and many others with resistant malaria, gonococcus, E. Coli along with PTSD and gender based violence as weapons of war are early warning signs of problems that are headed to our shores. Our public health systems and emergency rooms are ground zero for the detection and first response to outbreaks anywhere. The patients seeking medical care and assistance in our midst are the earliest signals. We need to listen and be prepared.

     


     

     

     

    July 10, 2012

    Broken Windows, Shattered Lives

     

    I saw Juan G. across the room. Thin almost gaunt, closely cropped salt and pepper hair, he wore faded institutional pajamas and paper slippers. He saw me, smiled and sidled over.

     

    I was making Rounds on the Prison Medical Unit at Bellevue Hospital. We met months earlier after his surgery for a cancerous growth. During his lengthy recuperation I listened as he talked about his family’s fleeing the insanity of the Trujillo dictatorship in the Dominican Republic, his career as a helicopter pilot during the Vietnam War as a nineteen year old, an intractable heroin addiction that dogged him over the next thirty five years in spite of dozens of attempts to “get straight” resulting in innumerable arrests for possession and his wife and kids.

     

    “What’s up? How come you are back on this Unit Juan?” Though I suspected.

     

    “Walking my grandson’s dog Tiger, off a leash. End of the month and a rookie cop picked me up, checked my record on the computer and dropped me in the precinct house and then I took the next bus to Rikers Island. He needed to make his arrest quota. So here I am. The system is doing what the system does.”

     

    The confluence of a failing war, a severe economic recession and a “War on Drugs” that within two generations resulted in a prison system from 500,000 prisoners to currently 2.3 million, with another 800.000 on parole and 4.2 million on probation, 10 plus million in local jails and 600 hundred thousand prisoners released annually into a no man’s land of disenfranchisement from basic citizen’s rights like voting and housing opportunities and 65 million Americans fingerprinted and in a vast security database.

     

    The majority of prisoners were in for drug related non-violent crimes. The political opportunities connected with a steady growth in commercial prison ventures, guard unions empowerment, employment opportunities in rural communities, massive federal investment in the criminal justice system, prohibitionist laws limiting judicial flexibility and Three Strike Laws forcing maximum sentencing regardless of the crimes created a perfect storm.

     

    Thirty years ago an article Broken Windows appeared in the Atlantic by George Kelling and James Q. Wilson. It offered an appealing story about the negative effects of minor disorders within communities that had the potential to lead to criminal activity and community disintegration. The broken window was the perfect metaphor for the problem of how insignificant problems lead to social decay and criminal activity and if unchecked could spread like a cancer through communities. The dots were connected from hunches gleaned from observations of community policing in New Jersey and extrapolated from studies of black Chicago housing estates.

     

    The issue of the potential for abuse of what was criminal activity was felt to be difficult and complex. Racial profiling and abuse were to be dealt with by effective training of police officers. Decriminalization of “disruptive” behavior was a “mistake”. Disruptive behavior was vague, you knew it when you saw it. The uneven application of the medical treatment opportunities of the deinstitutionalized mentally ill was begged.

     

    The article’s impact was significant and led to the escalation of “stop and frisk” policies targeting racial minority groups. Last year in New York City over 600.000 individuals were stopped. “Driving while black” became the outcome. Post 9/11 “flying while muslim” is targeting Muslim communities with increasing impunity.

     

    The results of the drop in crime nationwide and internationally has been monumental over twenty years and most particularly in New York City. The drop has been twice the rate of the rest of the country. How do we separate the facts from the fictions that fueled policies that have had devastating effects on particular segments of our society.

     

    In Frank Zimring’s The City That Became Safe, the Berkeley Professor looked hard at the data. The answer was not in stop and frisk. It was not in higher incarceration rates (they dropped in NYC). It was not in jailing squeejee men and jaywalkers. The major impact appeared to be in targeting street drug markets, the “hot spots” at the same time that drug consumption has not changed one iota.

     

    The unintended consequences of an idea without a basis in fact had a career of its own. Mayors and Police Commissioners built computer databases and vigorously supported mass incarceration, minor drug offenses such as the possession of small amounts of marijuana for personal use brought felony offenses and fostered criminal careers. Communities of color were further devastated and compelling arguments have been make that Jim Crow is alive and well.

     

    Tiger was a Chihuahua.

     

     

     

     

     

     

     

     

     

     

     

    July 4, 2012

    Neighborhoods and Health: Geo-medicine

    It is decades since the famous Whitehall studies in Britain documented the relationship between mortality and social class. The study used British civil servants (thus Whitehall study) and the fact that in Great Britain there is coding at the time of death that puts its citizens into categories. Civil servants in different levels of the official hierarchy were coded and it was found that independent of smoking and traditional risk factors civil servants who were at the high end of the social spectrum lived significantly longer than those at every level below. Remember this is GB and everyone has access to medical care through their National Health Service, so access was not an issue.

    The studies have been replicated countless times in many countries and repeatedly demonstrates a strong relative relationship between class and mortality independent of other risk factors for disease.

    The monumental amount of work on the different databases both demonstrates and suggests that it is the stressors of life, the lack of control over your daily activities plus your neighborhood and what it provides and doesn’t in terms of schools, security, food quality, parks and recreation that makes the difference. So enters public health directly into the lives and longevity of citizens.

    A new concept is developing of mapping neighborhoods ie Geo + Medicine to do a forensic evaluation of a city, a town or a neighborhood to assess the risks to its citizens. It allows for a methodology to be applied to “fix” the social determinants of health. Imagine a Rand McNally of health in your neighborhood?

    http://www.alternet.org/story/156139/what_gis_mapping_technology_can_tell_you_about_the_health_of_your_neighborhood_and_your_risk_for_illness?page=entire

    June 26, 2012

    The War on Drugs and Mexican Drug Policy

    UNAM, the National University in Mexico City was host at their Faculty of Medicine a few blocks from the Zocalo in late April 2012 to an international group of activists, lawyers, physicians, epidemiologists, criminal justice specialists and academic scholars from a variety of other disciplines to sit together for a week and address drug policy for the Mexican Government. …read more

    June 18, 2012

    Stop, Frisk and Privatize

    The front page of the New York Times this week  has a series of articles on the privatization of half-way houses for prisoners released from the New Jersey penal system. As the stories leak out about prisoner abuse, faulty triage of high risk prisoners, the sexual abuse of women by janitors on the night shift and the inevitable dots leading back to the political leaders of the the state whose motto is “Liberty and Prosperity” one might begin to ask liberty for whom? and prosperity for which interest group?

    At the same time this Father’s Day weekend there was the silent (mostly) march from upper Manhattan to the Mayor’s residence by a group of citizens of New York who are putting their feet to the streets in defiance of the Stop and Frisk policies of the New York City Police Department and the signature method of securing the “peace” by the Commissioner.

    What is clear through a huge body of literature, research and data from sociologists to activists in the Criminal Justice system is that the system of justice in the US is broken and has been for over forty years. The system of prisons that includes local jails, state and federal prisons has swollen in the forty years since Richard Nixon declared a War on Drugs from a few hundred thousand prisoners to 2.5 million incarcerated human beings approximately half in the “house” for drug possession charges. In addition, millions more are under state supervision through the various probation systems for previous contact with the criminal justice system. This marks them indelibly and through a variety of restrictive legalisms limits their prospects for re-entering society after having paid their debt. The collateral damage to children and families has been well articulated in too numerous to count articles, books and documentaries. Probably the most salient accounts  recently have been Michelle Alexander’s The New Jim Crow and Ernie Drucker’s A Plague of Prisons.

    I was reminded of one of my patients Juan Guerra (pseudonym) who ended up at Bellevue Hospital transferred from Rikers Island for some health issues. I asked him why he was back again? “I was walking my dog off a leash. It was the end of the month and the cops had to make their numbers. The rookie picked me up, checked my record in the computer and arrrested me.” The dog in question was a Chihuahua.

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