Selected Case Vignettes George D. Comerci, Jr. MD, FACP - PowerPoint Presentation

Slide1

Selected Case Vignettes

George D. Comerci, Jr. MD, FACP

Professor of Internal Medicine

Hospitalist Best Practices Meeting

10/23/2019

Slide2

Objectives

The presenter will use case vignettes to enable the participant to discuss:

The potential for loss (and regaining) of one’s humanity as a young physician.

D

epression and suicide as the ultimate in “physician un-wellness”.

The evolution of residency training “the good and the bad-but not so ugly”.

Physicians as social agents of change.

Physicians and suffering…a case of one of many triumphs.

Slide3

When Lightening Strikes!

JC was a 19 y/o man who collapsed after he experienced a lightning strike while installing anchors for a mobile home during a monsoon thunderstorm. His brother, with whom he was working, alerted 911 and began CPR. He was brought to the ER where he was noted to be in full cardiac arrest, pulseless and without a rhythm. Aggressive treatment was instituted and despite the best efforts of the team, he could not be revived and was “pronounced”.

Slide4

Monsoon over the Sonoran Desert

Slide5

Installation of Mobile Home Anchor

Slide6

Mobile Home Anchor

Slide7

Lightning Injury:

(

Ritenour

A, et al. Lightning Injury: A review.

Burns

.2008;34:585-594.)

2

nd

leading cause of weather related death

Important regional, seasonal and temporal variation in risk of injury

2 million volts and release of tremendous heat

Lightening causes injury in several ways:

Direct hit

Contact injury

Side flash

Ground current

Blast Injury

Slide8

Skin Lesions

Linear streak

Feathering

Slide9

Lightning Injury: Clinical Presentation

Cardiac/Respiratory Arrest

Muscle injury with myolysis

ENT: rupture TMs, hearing loss, lightning cataracts

Neurologic: Immediate and delayed

Odd and

Unusual

“

Sudden Musicophilia

”

(Sacks O.

Musicophilia.

Knopf. NY.2008. pp3-17.)

Slide10

Lightning Injury

Prevention

Associated with cumulonimbus rain clouds

“Bolt from the blue”

“30-30 Rule”

Seek shelter: car, building

Drop metallic objects

If in the open, crouch with feet together

Don’t use the telephone and turn off appliances

Slide11

Further Reading & Listening

Lewis, S.

Arrowsmith

. Signet Classic. Penguin Books. NY. 1924

Wolfgang Amadeus Mozart: Requiem in D minor (K.626)

Slide12

Two cases gone terribly wrong…

TR was a medical intern who experienced a serious complication while caring for a teenaged girl in the ER. The complication resulted in permanent, serious disability for this teenager. The medical intern was harshly criticized at M&M for what may have been a crucial error in management. A month later, a fellow intern found him in the call room sobbing, with a .38 revolver in his lap. A catastrophe was averted.

Slide13

Two cases gone terribly wrong…

GC a physician in early career received a call from the ER. A patient of his was being evaluated for severe GERD and both he and his wife demanded that GC come in to the ER to see him as he did not trust the ER physician. GC, having just completed a very demanding week of call, indicated that he was off and would not come in as he had complete trust in the ER physician.

Slide14

Two cases gone terribly wrong…

In the morning

GC

reviewed the case and the EKG which demonstrated an acute inferior/RV infarct….which had been missed. The patient subsequently was called back and admitted to the hospital, developed cardiogenic shock, placed on a LV assist pump,

and

subsequently barely survived CABG. He was permanently disabled and went on to sue GC and the ER

physician. Subsequently, GC developed severe depression faulting himself for the disaster.

Slide15

Depression, Suicide and the Physician

Lifetime prevalence of depression is 20%

10

th

leading cause of death, major cause of disability (15-44 years)

Women attempt

suicide 2-3x vs. men

Men

successfully complete suicide at

4x women (79% of total suicides)

Male physicians: RR = 1.41 RR compared to men in overall population

W

omen physicians: RR = 2.27 compared to women overall

Approximately

300 to

400 medical

students and physicians

commit suicide yearly

Slide16

Depression, Suicide and the Physician

[

Medical students:

prevalence of depression or depressive symptoms among medical students was

27.2%

that of suicidal ideation was 11.1%.

[

JAMA

.2016;316(21

):2214-2236

.]

Resident physicians:

prevalence

of depression or depressive symptoms among resident physicians was 28.8%-ranging from 20.9%to 43.2% depending on the instrument used, and increased with calendar year”

[Mata D. , et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis

JAMA

. 2015;314(22):2373-2383

]

Slide17

The atmosphere is darkened by the murmurings and whimperings of men and women over the non-essentials, the trifles that are inevitably incident to the hurly burly of the day’s routine. Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity and consume your own smoke with an extra draught of hard work, so that those about you many not be annoyed with the dust and soot of your complaints.

Sir William Osler: Aequanimitas

Translation (gcomerci): “Suck it up and get over it”

Slide18

Back to TR and GC…

My care/lack of care seriously and permanently injured someone.

If I were a good physician, this would not have happened.

Why did this happen to me….if I could only turn back the clock.

I should not be practicing medicine. I’m dangerous.

I am so terribly ashamed of myself

I will be publically humiliated.

My colleagues will never respect me again

I can’t be trusted by my colleagues. I can’t trust myself.

I can’t trust my colleagues. It is better for me to take care of things.

Slide19

Further Reading & Listening

Hilfiker D.

Healing the Wounds

. Penguin Books. NY.1986

Redfield Jamison, K.

An Unquiet Mind

. Alfred A. Knopf. NY.1995

Kalanithi P.

When Breath Becomes Air

. Random House Books. NY.2016

Bruce

Springsteen - This

Depression – YouTube

Slide20

When Giants Walked the Earth?

“ Nothing is like internship and residency. I flew Phantoms in Viet Nam. My missions were pretty routine until we crossed into Viet Cong airspace. Then I experienced continuous terror of a SAM downing me until returning to “friendly” airspace. As a house officer, I had

‘incomings’ (SAMs)

from the moment I got to the hospital until I left. It was relentless.”

First

Year Cardiology

fellow:

UC

(

ca. 1985)

Slide21

History of Internship and Residency

[Starr P.

The Social Transformation of American Medicine

. Basic Books. NY. 1982.pp,

Howell J. A History of Medical Residency. Reviews in American History.2016;44.126-131]

Before the 20

th

century there was no

formal post graduate training

Many went to Europe, especially Germany to further

training

Establishment of Medical Residencies (ca. 1900)

Sir William Osler and William Stewart Halsted at Johns

Hopkins

Slide22

History of Internship and Residency

Early residencies associate with newly created research institutions

Mid 20

th

century, most graduates completed residencies

Before WWII having a housestaff at a hospital was a luxury

Enactment of Medicaid and Medicare residency slots increased by a tenfold

Having housestaff was a

necessity and the houseofficer evolved into an essential part of inpatient care

Slide23

When Giants Walked the Earth?

Call every third

Negotiated day off

Take

Hits from ER

Cross-Cover

Start all IVs

Fever Workups

Blood cultures, CBC etc.

Gram Stain, UA

Review chest x-ray

Chest Pain Workups:

EKG

,

Shortness of Breath Workups:

ABG

Chest

X-ray

Endure the

abuse from the

occasional

“Nurse Ratchet”

Slide24

What about the wife and babies, if you have them? Leave them. Heavy as are your responsibilities to those nearest and dearest, they are outweighed by the responsibilities to yourself, to the profession and to the public…Your wife will be glad to bear her share in the sacrifice you make”. Marry the right woman!”

Sir William Osler.

Slide25

The Legacy of Libby Zion

(Patel N. The Libby Zion Case Revisited.

J

A C

C. 2014;64: 2804-2804)

In 1984 a 18 y/o college student was admitted to a NY ER with fever and an ear ache. While in the ER, she received sedatives, opioids and was restrained. She coded and died 6 hours after ER admit. Her death was attributed to the mistakes of an exhausted, overworked and poorly supervised housestaff.

Slide26

The Bell Commission issued its recommendations, including the following proposal: “Individual residents who have direct patient care responsibilities in areas other than the ED shall have a scheduled work week which will not exceed an average of 80 h per week over a 4-week period, and should not be scheduled to work as a matter of course more than 24 consecutive hours with one 24-h period of non-working time per week”

Slide27

Duty Hour Restriction

Silber J, et al. Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules. NEJM. 2019

Mendelsohn D. et al. Impact of Work hours and sleep on well-being and burnout for physicians-in-training: Med Educ.2019

Philber

I. What is known: Examining the Empirical Literature in Resident Work Hours Using 30 Influential Articles. J Grad Med Educ. 2016

Work-hour

restrictions and increased amount

of sleep

alone may not prevent

burnout

or

improve resident wellness

F

ocusing

on duty hours alone has not resulted in improvements in patient care or resident well-being.

Unclear whether improved safety is due to increased focus on supervision and emphasis on the environment of safety

More work packed into shorter time with loss of resident socialization bedside teaching and decreased satisfaction

Slide28

“Era of High

Throughput

”

[Howell J. A history of Medical Residency.

Rev in

Amer

History.

2016;44:126-131]

Change of core educational mission….(Ludmerer.2015)

“Bedside evaluation, thoughtful observation and discussion regarding . diagnosis and treatment [has] evolved into a focus of trying to discharge the patient as fast as possible”

Incomplete histories

Incomplete physical exams

Inability to observe the evolution of the disease process

The creation of the “I-Patient” (Abraham

Verghese

)

Slide29

A gun is fired

MG was a 35 y/o mother of 3 children shot by her jealous husband during a domestic incident. She arrived at the ER hypotensive and unable to move lower extremities. She exsanguinated within one hour of admission to the ER.

TP was a 44 y/o police officer who made a routine traffic stop. Smelling cannabis smoke he demanded that the driver exit the vehicle. While TP was handcuffing him, the driver extracted a semi-automatic handgun and shot him in the abdomen and chest. He was admitted to the ER, a chest tube was inserted, and he was subsequently brought to the OR to explore his abdomen. He was stabilized, air evaced. and subsequently died in the OR at a trauma center.

JG was a ? y/o Mexican police officer shot in the chest and shoulder by a cartel member with a AK 47. He was stabilized, air evaced. to Tucson where his left arm was amputated but survived after a prolonged hospital course.

Slide30

Popular Firearms

AR 15 Assault Rifle

Glock 9 mm Semi-Automatic Pistol

Slide31

Bullets

Popular Bullet Sizes

Hollow Point (“defensive”)

Bullets

Slide32

Bullet Cartridge

Anatomy of a Bullet Cartridge

Ballistics

Slide33

Gun Violence in the United States

[Fowler K, et al. Gun Violence in the US.

Preventive

Medicine. 2015; 79:5–14]

Age: 25-34 y/o

Gender: male

Race/Ethnicity: Non-Hispanic Black

Black vs Hispanic: 5x

Black vs. Non-Hispanic White: 19x

Trends: Decreasing since 1993 and currently stable

Where:

South

> West > NE US

Slide34

Gunshot injuries have plateaued

[Fowler K, et al. Gun Violence in the US.

Preventive Medicine. 2015; 79:5–14]

Slide35

Gun Violence in the United States

[Fowler K, et al. Gun Violence in the US.

Preventive Medicine. 2015; 79:5–14]

Unlike most causes of

injury where

deaths comprise a fraction of

the total

burden of injury, the average annual distribution of

firearm-related, to hospitalizations to ER visits forms a tower rather than a pyramid

Slide36

Mass Shootings

[

Meindl

J, Ivy J, Mass Shootings: The Role of the Media in Promoting Generalized Imitation.

J

Public Health

.

2017;107:368–370]

31% of mass shootings worldwide occur in the US

One every 12.5 days

Generalized Imitation Model

:

a learned ability

to perform behaviors

that are

similar to behaviors

observed or

described, even when

performance is delayed.

Research has

demonstrated that media

can influence imitation.

1

“

Don’t

Name Them

”

Present the shooters actions in negative light

Avoid describing shooters rationale for the crime

Limit the duration of news coverage

Avoid live coverage

Slide37

Further thoughts on Firearms…

Thorough Background checks: dealers AND Gun shows

Waiting period between purchase and acquisition

Selective

vetting of those with mental illness who seek to purchase firearms

Ban on all assault-type weapons AND paraphernalia for making firearms more deadly

Responsible gun-ownership and training

Physicians MUST talk to patients objectively about firearm safety

Slide38

Should we repeal the Second Amendment?

“

A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.”

Slide39

Governments vs. Their Citizens

Armenian Genocide

(Turkey)

The Holocaust

(Europe)

Khmer Rouge (Cambodia)

Years of Terror

: Josef Stalin (Soviet Union)

Rwanda Genocide

(Hutus vs. Tutsis)

Slide40

Suggested Viewing, Reading and Listening

Boyz

n the Hood

: 1991 John Singleton. (Starring Ice Cube, Cuba Gooding Jr.)

The Fall of the Ottomans

. Eugene Rogan. Basic Books.2015.NY.pp172-184

St Petersburg. Three Centuries of Murderous Desire

. Jonathan Miles. 2017.Penguin. London. pp386-436.

Movie and Music Soundtrack from

The Killing Fields

. 1984. Michael Oldfield.

Ninth Symphony

Victory Symphony.

Shostakovich, Dmitri

Slide41

God’s Own Medicine (1910)

And then abruptly

, of working out of the steady pain, come

the paroxysm

, like a twisting tearing hurricane, with

its well-known

radiation, followed by the vaso-vagal

features, the

pallor, cold extremities, feeble pulse,

nausea, vomiting

, and in two attacks, a final, not

altogether unpleasant

period, when unconsciousness

and the

pain seemed wrestling for a victory reached

only with

the help of God’s own medicine—

morphia

.

Sir William Osler, Lumleian Lectures: The

Royal College of

Physicians. London. March 1910

Slide42

God’s Own Medicine (

ca

1990)

JC was a 72 y/o man with DM and HTN. He presented to the ER with crushing chest pain which began 30 minutes prior. On exam he was pale and diaphoretic with a soft S3 and fine bibasilar crackles. He received morphine, SL NTG and O2.

Slide43

God’s Own Medicine (

ca

1990)

Tissue Plasminogen Activator (TPA) !

Slide44

History of PCI

[Canfield J,

Totary

-Jain H.

40 Years of Percutaneous Coronary Intervention: History and Future

Directions.2018. J

Pers

Med. 2018;8: 4]

Slide45

The Doctor

: Luke

Fildes

: 1891

Slide46

The Doctor

Patient is at the center of our world

Physician treats not only patients but their families

Physician honors and respects the cultural and spiritual belief systems of their patients

Physician is an observer of disease

The old scourges will reappear and new scourges will

appear

Physician is at the bedside

Slide47

Slide48

To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.

Sir William Osler:

Aequanimitas

The duty of every physician is to go to sea and to sail where

There be Monsters (human suffering).