He doesn't make mistakes: Cadaver grafts for ACL knee surgery

An orthopedic study, released yesterday, found a 24% failure rate in operations on young athletes who get a cadaver graft [from a dead person] in knee surgery to repair an ACL ("anterior cruciate ligament"). Many have discussed whether Tiger Woods should have this surgery. Here's the story of Keith, an avid amateur soccer player in California:

Having played an awesome game of soccer on Saturday the 15th, on Sunday July 16, 2006 I decided to help out a teammate and play for his team since they were short. The league that I play in have artificial turf fields. The league my teammate played in used various grass fields. On this particular day, it was an awful field of a junior high school. I had just recovered from a mild Achilles tendon strain to my right heel, so jokingly I stated "there's a hole out there w/my name on it, watch." 

Unfortunately, I was right, but had no clue what was in store for me. With maybe 10 minutes left in the game, the other guy playing forward w/me was on a breakaway. I was running with him, wide open, so he crossed the ball to me leaving me 1v1 with the keeper (who sucked btw). It was a simple setup that I've played through many times before: a quick cut to the side and pass the ball in. That's all I had to do. So, I did just that. 

Or attempted.

What happened, to my recollection, was that I tried to cut to the left w/the outside of my left foot. Somehow in my footing my left leg got stuck as if I couldn't lift it up quick enough. Maybe I stuttered in my steps while trying to quickly change my direction or something, but my leg was firmly planted as the rest of my body moved over it. Before I knew it, I was on the ground, my knee having bend backward and to the inside a bit and having heard a pop. I was in the most excruciating pain I've ever felt in my life, and as I was literally digging out clods of dirt and grass from the field I could only say two things, "f***" and "oh s***!" I didn't even move for a few minutes (from the ground that is). When a teammate shouted to the sideline "get some water" I blew up. "I DON'T NEED ANY F***ING WATER, WATER ISN'T GONNA HELP ME!" 

And it figures, because with my Achilles tendon strain, I bought and brought a bag of ice from Ralph's every game. The one day I don't do that is the day I tear my ACL, and some ice would have been nice initially. Anyway, when my teammates helped me up, I tried to walk and immediately my knee buckled. It was as if it were jelly, just no stability at all. The fact that somebody else said they heard a pop was a bad sign, but for the time being I had hoped that it was just a severe hyperextension. In high school I hyperextended my knee a few times and may have had Osgood Schlatter's disease (it was a debate, I had a lot of the symptoms but currently show no sign of ever having it).

My 1hr+ drive home was nervewracking because I started analyzing what could be wrong and what it could mean for the rest of MY season (screw my teammate's season!), and where the heck should I drive to. The urgent care I had intended on going to was apparently closed even though they have "24hrs 7 days a week" posted on their window. In tears from the pain, I made it to the hospital (having never been there before) and apparently parked the furthest distance from the urgent center as possible. In time I got a wheelchair and X-rayed, and 4 hours later (it was a long wait) was told to see an orthopedic surgeon. My leg/knee was in an immobilizer brace and a friend picked me up and took me home.




THE SURGEON

The next day, Monday July 17th, 2006, I went to Blue Cross' website and found the closest orthopedic surgeon to me and called. They had an opening if I could get there in 1/2hr, so I lucked out. The surgeon asked me a series of questions and prodded around my knee for a bit, injecting a giant needle into my knee and pushed out a TON of blood. The needle felt like it was going so deep so as to hit the bone, but it wasn't. Definitely painful while it lasted. I wish I could say the amount, because it was a lot even for an ACL tear, but must have been 4-6 CC's worth. He sent me off to get an MRI as it was the only way to tell for sure what was wrong. I had my fingers crossed for a "best of" situation, meaning I didn't want it to be an unhappy triad (torn ACL, MCL, and torn meniscus), but I wasn't gonna be happy with an ACL tear either. During this time, I had not only the immobilizer brace but was on crutches too. Anyway, a few days later I got the MRI results and sure enough...ACL complete tear. Unfortunately, my stupid surgeon was going on vacation to the Caribbean for THREE weeks! I wanted the surgery right away and this wasn't going to help. So, I painfully had to wait nearly a month in order to have it. At some point I got a hinged immobilizer brace which was a lot better than what the hospital gave me. This new brace had hinges which you could lock into various degrees of flexion and would be key mostly for after the surgery. So anyway, let's get to that already shall we?



THE SURGERY

Finally, the big day came: Friday August 25th, 2006. The process I was told would take about 1hr 15 minutes, which I found surprising, but I guess it's not that long for a non life-threatening surgery, heh. The method of surgery was an allograft: a cadaver graft, meaning some dead guy's Achilles tendon was used as opposed to a hamstring (or patellar tendon) autograft. My surgeon explained he preferred this method because it doesn't require cutting into your own body. Why heal from 2 places when you can do it from 1? Fortunately, despite his jackassery of leaving for 3 weeks, he's a very good surgeon in LA. I got extremely lucky by finding him at random!

 The morning of the surgery, I wrote a giant "NO" on my right knee as it is my healthy knee. The docs later laughed at me for doing that, because "he doesn't make mistakes." But hell, why take the chance? Anyway, I was told that after the surgery I would be sent home: an outpatient. I found that cool because who wants to be in a crappy old hospital? BUT, the surgery didn't go quite as planned. Apparently my surgeon's assistant was also assisting another surgery, so rather than 1hr 15 min, it was 4 friggin hours! But, it was a success. I woke up and they wheeled me out of the recovery room and into a room in the hospital...so, rather than being an outpatient, I was an inpatient and had to spend a night in the hospital. 

That night was the longest friggin' night of my life. I knew that surgery would be painful, but I figured that knee surgery was small in comparison to hip replacement, shoulder surgery, etc...WRONG! Sorry to say but you're gonna have pain and it's gonna be extreme. I was asking for morphine every 4 hours on the hour and didn't sleep for s***...kinda sucked. I didn't eat nor drink much while there either. The next morning was quite a task as it was time to go home. Time to go home after going through traumatic surgery and having no food in my stomach. It also meant moving with a recently-operated knee. A therapist-type guy came in and helped me out of bed (painful) and showed me how to go up and down stairs w/crutches. After a long process of getting me into a wheelchair, into and out of my mom's car, and into my bed...I was home. Aside from moving, there really wasn't much pain...from surgery and on I only took 3 Vicodin pills and honestly didn't really need them. This is to say that while laying on my back all day I wasn't experiencing pain. Getting in and out of bed (basically, when my leg wasn't laying in bed) hurt, but that's to be expected. Maybe 3 inches below my knee was, and still is to this day, numb because apparently they have to cut through a nerve, but the area is only 4x3 inches? Its not bad, but it's one of those things that I'd like to have back just because I'm supposed to. 

There are some other side effects of the surgery such as lightheadedness. Considering you're stuck on your back for such a period of time AND a loss of blood/traumatic surgery AND your usual eating habits have been changed temporarily, it's entirely natural, but I tried to sit up when possible to read, etc. 

So, my surgery was Friday Aug 25th, right? Well, Wednesday August 30th I was back at my surgeon's office for a followup, and my first day of physical therapy. I guess this leads us to our the next point...



THE RECOVERY

The goal of therapy is to achieve full flexion (bending) and extension. When I saw the therapist the first time, he just did some electro-pulse type stuff on my knee. I've done it before back in high school so it was nothing new. Because a little more than a month passed between injury and surgery, my leg muscles atrophied pretty bad. If there's one thing I've always had pride over, it was my muscular soccer legs, heh. My right leg hadn't changed, but my left was kinda chicken-legged. Most notably, my quads. 8 months later, my quads are still diminished...better than post-op, but still not to where they need to be. I'd like to say that my therapist didn't have me work on them in the early stages of therapy. He stressed that the hamstrings are really important because they're the muscles that aid flexion. But, I still feel like he neglected them when it was key because I'm only doing 15 lbs on my left leg...it's not that my muscles can't handle the weight, it's that the ACL is still weak at this point. Which is normal.

Advice: Look into other patients' stories thoroughly before choosing elective surgery.

Read a more grim story of a young athlete's knee surgery.

Thanks to Keith, and to Drs. Kurre Luber and Gene Barrett for their presentation at the 2008 American Orthopaedic Society for Sports Medicine's Annual Meeting.

With hormone pills, radiation, surgery and grit: Skin lotion for cancer patients

Kairol Rosenthal, 35, is a choreographer and writer in Chicago. For the last seven years she has battled thyroid cancer with hormone pills, radiation, surgery and grit. She has had to contend with 101-degree fevers, heart palpitations, and a severe lack of appetite.

The hormone therapy to slow the growth of the tumor, leaves red blotches on her face and bone-dry patches along her jaw line.

"I have not yet made my peace with skin that doesn't look good," she said. She spends much of her free time in hunting for news about thyroid cancer. She is writing a book about living with the disease.

Radiation can cause what looks and feels like a sunburn on the area that the beam passes through to get to cancerous cells. Chemotherapy can make the skin and lips feel dry and itchy because it indiscriminately tries to damage all fast-growing cells, including skin cells.

Kairol heard a radio ad for Lindi Skin, a skincare line of products designed for cancer patients. Several companies now make skincare products for cancer patients.

Depending on who you ask, such products give patients one more tool to ease side effects, or a false hope that a costly lotion will be more effective than a mild drugstore lotion.

Oncologists and dermatologists are now looking into these products because cancer-fighting drugs called targeted therapies can cause rashes so severe that some patients threaten to drop out if they are left untreated. As of now, there is no scientific study that shows these products are any better than less expensive and less glamorous products like Cetaphil or CeraVe.

Yet some patients prefer them. Dianne Dassa, a breast cancer patient in New York, said the Lindi body wash and serum helped heal her radiation burn and her psyche. And "they were so beautifully packaged, I felt like I was getting a gift."

Advice: As a gift, you can give the fancy lotions to the cancer patient you care for. Cancer patients themselves can buy the less expensive drugstore products that have been shown to be effective.

Read a story of an entrepreneurial cancer survivor.

Thanks to Kayleen Schaefer for the source article in today's NY Times.

They said it was a new policy, just out: Denial of care for an insured undocumented immigrant

Over the Memorial Day weekend, a 9-year-old girl in the Bronx, New York went grocery shopping with her mother. A man banged into Lauren's left arm with his cart, tearing away part of a big mole. Her mother brought her to the local hospital's Emergency Room, where a biopsy of the mole revealed that Lauren had a serious skin cancer - melanoma.

At a cancer hospital, she was scheduled to have the mole, surrounding tissue lymph nodes in her arm removed, and to have scans of her lungs and liver. Yet no treatment has started: Lauren was born in Ireland, and is not a legal resident of the US. Since age 4, she has had regular checkups and immunizations through a managed care company that was set up by the Roman Catholic bishops of New York under contract with the state to provide Child Health Plus insurance – which had been created precisely for children who did not qualify for ordinary government insurance.

Her mother said, "Around the 14th of June I got the call that since she did not have any [legal] status, her request was being denied. I never heard anything about this until she got sick. They said it was a new policy, just out."

Though several employees of the insurer have said the matter has been resolved, Lauren still has not received treatment. Most recently, the surgery, which had been rescheduled for Wednesday, was further postponed because the hospital is not a member of the insurer's network of providers.

Advice to undocumented immigrants needing health care: Your local newspaper and your congressman may be strong champions. The Irish Times and the office of U.S. Senator Charles Schumer are now helping Lauren.

Read another child’s healthcare access story.

Thanks to Jim Dwyer for the source story in today's NY Times.

It's an inconvenience, but the alternative is death: Paying for cancer drugs

William Dexter, a 67-year-old retired Air Force sergeant and mail carrier, had been coming to his doctor's office for monthly intravenous immune globulin infusions to bolster his immune system after a bone-marrow transplant, radiation and chemotherapy and other drugs for non-Hodgkin's lymphoma, a cancer of the lymph system.

The infusions can leave patients drained and shivering, with low blood pressure. William liked getting them in his doctor's office, where nurses comforted him with coffee, blankets, and chats about his dogs and military history.

But with the gap between his Medicare policy and his doctor's expenses, the doctor's medical practice was losing about $500 on each infusion. Now, instead of one monthly doctor visit, William makes two 90-minute round trips: one to the doctor for a checkup and to open the IV port in his chest, and another to the hospital, where the four-hour infusion involves more delays and less comfort. "It's an inconvenience, but the alternative is death," William says.
"I knew the doctor had to do it to stay in business."

Advice to cancer patients who need to take costly drugs: Ask about the drug company's financial aid programs.

Read another chemotherapy story.

Thanks to Marilyn Chase for the source article in today's Wall St. Journal.

For an audience of one: A hospice musician

As Judith Jackson recalls, last October "my mother was in her final week of life when Marcia [Feldman] came to play for her. It was a wonderful gift not only to my mother but to me. I was spending hour after hour sitting at her bedside, and then Marcia would come in and play this very soothing music. The nurses told me the last thing to go is the hearing. And my mother always loved that type of music."

Marcia, a classical guitarist, is a hospice musician. She has educated herself in the musical traditions of a variety of cultures, so that she can best match the music she plays to the heritage and preferences of the patient she is playing for. "Even when patients are too sick for verbal expression, the nurses can tell me when they are responding well to my music – their breathing may become less labored, for example," she said.

Marcia first began thinking about the connection between death and music when she lost her father 20 years ago. "His situation did not involve hospice care; he died suddenly. But something about the process of grieving for him made me think increasingly about the role music plays at our most troubling times," she said.

She has recently released a new CD, "Between the Worlds."

Advice: Consider bringing some music for your loved one in hospice care.

Read another hospice story.

Thanks to Nancy Shohet West for the source story in today's Boston Globe Sidekick magazine.

You can order her CD at CDBaby.com. I haven't heard the CD. I don't get any money for recommending this.

My military psychiatrist advocated for me: Treatment of mental illness

Ann Breitengross' story:
The military needs to arrive at a consensus concerning proper mental health care for troops. When I received a diagnosis of a mental illness in 2003 prior to an impending deployment, my military psychiatrist advocated for me. Despite my suggesting an alternative assignment to honor the terms of my contract, he recommended a medical discharge, giving me the opportunity to recover and develop the coping skills necessary to live a successful life. Not all military officers are so empathic. Had I been forced to deploy at that time, I know the stresses of being in a war zone would have exacerbated my symptoms, compromising the mission or, worse yet, my own life.

Advice to soldiers: Most people now know that tough soldiers can get mental illness without being crazy.


Read a story of a tough soldier who has overcome tough psychological issues.

Thanks to Ann for her letter to the editor of Time Magazine, published on June 30.

Too busy to take in what I have to tell her: Physicians' work-flow with an electronic medical record

Joyce Adams' wry observations:
A doctor I see is one of the 4% of doctors who make full use of electronic records to assist their practices. It seems obvious to me that having lab results, previous clinical observations and recommendations at her fingertips enhances the care she provides.

On the other hand, visits to this doctor involve minutes spent while she locates my health records on the computer, and minutes spent as she enters new data, all the while with her gaze and attention fixed on the computer rather than on me. The tap-tap of her fingers indicates that she is too busy to be taking in whatever I have to tell her, and that the electronic task has been elevated over the old-fashioned hands-on approach to clinical care.

Once records are enshrined in my doctor's computer, they are available for her use and the use of other doctors in her clinic. However, they fail to travel beyond the clinic to the office of my primary care doctor because apparently the task of faxing them over is too onerous in this high-tech age.

Getting electronic records to my primary care doctor, who oversees all aspects of my health, requires a more basic effort: a hand-carry by the patient.

So much, and so little, progress!

Advice: Choose a physician who has both an electronic medical record and high patient satisfaction ratings.

Read another story on the work-flow of physicians with an electronic medical record.

Thanks to Joyce Adams for her letter to the editor, published in today's NY Times.

Stronger than I've ever been: A heart transplant athlete

The heart transplant survivor Kelly Perkins has added another first to her long string of mountaineering feats since getting a new heart 13 years ago – a dangerous climb up a sheer, 2,000-foot face of Half Dome in Yosemite National Park.

Kelly, age 46, and her husband, led by guide Scott Stowe, began the climb on Thursday and reached the top of the 8,842 foot high dome early on Saturday afternoon.

"I feel great," she said by phone from the top of Half Dome. "Physically, I feel I'm stronger than I've ever been."

Advice to transplant patients: Live your life as fully as Kelly.

Read another superstar athlete’s story.

Thanks to the NY Times for publishing the source article today.

The furthest you could be from courageous: Attitudes toward one's own cancer

Although public figures like Teddy Kennedy promote enduring impressions of the stalwart, pumped-up spirit, Dr. Joseph Finns says patients themselves often describe a more nuanced, evolving journey.

When Robert Kosinski was told he had a tumor on top of his brain stem, entwined with his optic nerve, "Everything went dark, went blank," he recalled. "I was overwhelmed by the idea that I had a brain tumor stuck inside me. The train ride home lasted so long and I just kept wondering, 'How long do I have to live?'"

Faced with potentially harrowing repercussions from a biopsy, Robert, a husband and father in Jersey City, said he felt depressed and ultimately alone with his decisions.

He chose not to have the biopsy, and went through chemotherapy. He would endure a dozen blood transfusions. Optimism, or even stoicism, were not part of his emotional makeup during those grueling months. "I never felt brave or courageous," he said. "I don't know what that means. I was scared. I was the furthest you could be from courageous."

That was 15 years ago. Now 61, he paints and attends a monthly support group, where he ascribes his odds-defying survival to luck and medical expertise, rather than personal will. "Some people in my group don't want to hear the upbeat scenario," he said. "The way they're coping is completely the opposite because they feel they may not make it."

Dr. Finns' advice to patients: There's no scripted way to handle this. Write your own script based on your own narrative.

Read a story about Teddy Kennedy’s brain cancer.

Thanks to Jan Hoffman for her source article in the June 1 issue of the NY Times.

I'll do anything to save money: Patient testimonials for face-lifts

For Dave Gibson, 53, a New York actor, who had his Lasek surgery in May, posting a video on Facebook and YouTube was a no-brainer. He even added his own blow-by-blow narration. ("The first thing the doctor does is place a round apparatus in the center of my eye…") At the doctor's request, he also sent an email message to 100 of his closest friends, racking up a $1 credit for each one. As soon as the doctor had mentioned the rebate, Dave thought to himself, "I'll do anything to save money."

Another patient asked to remain anonymous because he is still undergoing treatment for an operation he had done about six months ago. Never mind that the video went up almost immediately, before he had time to heal. "Regardless of whether I'm happy – that's not going to stop me from posting," he said. "It's money in my pocket." As it turns out, he isn't satisfied with his results, but he hasn't taken down his glowing endorsement.

Advice: Take patients' testimonials with a grain of salt.

Read another plastic surgery story.

Thanks to Abby Ellin for the source article in the NY Times of June 26.

I got my mother back: Overuse of antipsychotic drugs in nursing homes

Last fall, Theresa Lamascola of the Bronx, suffering from anxiety and confusion, was put on the antipsychotic drug Risperdal. When she had trouble walking, her daughter took her to another doctor, who found that she had unrecognized hypothyroidism, a disorder that can contribute to dementia.

She was moved to a nursing home to get the problems under control. But things only got worse. She "was screaming and out of it, drooling on herself and twitching," said her daughter, a nurse. The psychiatrist in the nursing home stopped the Risperdal, which can cause twitching and vocal tics, and prescribed a sedative and two other antipsychotics.

"I knew the drugs were doing this to her," said her daughter. "I told him to stop the medications and stay away from Mom."

Not until another doctor took her off the drugs did she begin to improve. He prescribed Aricept. "It's not clear whether it was getting her hypothyroid and other medical issues finally under control or getting rid of the offending medications. But she had a miraculous turnaround," said the new doctor.

She still has dementia but she went from confinement in a wheelchair – unable to sit still and screaming out in fear – to being able to walk with help, sit peacefully, have some memory and ability to communicate, understand subtleties of conversation and even make jokes.

Or, as her daughter put it, "I got my mother back."

Researchers estimate that one third of all nursing home patients have been given antipsychotic drugs.

Advice to people with elderly relatives in a nursing home: Ask the doctor about alternatives to antipsychotic medicines.

Read another story about drug side-effects in the elderly.

Thanks to Laurie Tarkan for the source article in today's NY Times.

Blind-sided by my reaction: The role of attitude in surviving cancer

Richard Haimowitz, 62, a lawyer in Queens, New York who was found to have pancreatic cancer in January 2007, thought of himself as a warrior, fighting with all available ammunition.

"The day of my last treatment, people congratulated me, but I felt blind-sided by my reaction," he said. "I thought, 'Oh my God, I have nothing left to fight with,' and I felt angry that there was nothing left for me to do." Statistics to the contrary, he has had two clean scans, is back at work and takes spinning classes. As he soldiered through treatment, he did not fear death, even though he did not want to die.

Many studies published in oncology and mental health journals have looked at whether attitude is a factor in survival or recurrence rates, a core belief in many cultures and faiths. Some studies say Yes; others say No. They all have their critics.

Advice to friends and families of cancer patients: Try to empathize with them regardless of their mix of feelings.

Read another story about the role of attitude in recovering from cancer.

Thanks to Jan Hoffman for the source article in the June 1 issue of the NY Times.

He has resumed athletic activities: Attitudes toward one's own cancer

Brian Wickman, a manager at a luxury hotel in Manhattan, needed to refrain his loved ones' language. Two years ago, an oncologist told him there was little published data about the aggressive tumor on his ankle because it was so rare and because "no one wants to publish when all the subjects die." A month later, Brian, then 30, a skier and a rock climber, had his left leg amputated. He was also found to have thyroid cancer. He reacted severely to chemotherapy, and spent two months in intensive care.

His awestruck friends would say, "You're so brave, I don't know how you do it; you're my inspiration." "They would put me on a pedestal," Brian said. "That doesn't allow me to be human an in pain, angry or depressed."

His email messages reveal a spirit of great equanimity and eloquence. He now wears a prosthesis and has resumed athletic activities, and will attend graduate school in the fall for a joint degree in social work and divinity.

But in his darker moments, he refused to construct a front. He would write bluntly about feeling grumpy, frustrated and afraid nobody would date him. "This is not a call for pity responses," he would add. "Just let me be where I am."

Advice to friends and families of cancer patients: Try to just let them be where they are.

Read another story about the role of hope.

Thanks to Jan Hoffman for the source article in the NY Times of June 1.

Coming from several blocks away to gawk: Privacy and neighbors

Dear Amy,
I have a sensitive issue and nosy neighbors. Three weeks ago, I was taken to the hospital because I suffered from major depression and was suicidal. I was in the hospital for eight days.

One week to the day of my release, I had four police cars, eight officers and two paramedics at my home to take me back to the hospital. Literally, every one of my neighbors was outside wondering what was happening, and they saw me being carried away on a stretcher. I was gone for three days and was diagnosed with bipolar disorder.

That weekend I had the police at my house four times because of my son running away, becoming violent and threatening suicide. The last incident ended with five police cars, 10 officers and the obligatory ambulance and paramedics. They blocked the roadway in both directions. Everyone was outside and watching, some coming from several blocks away to gawk.

What do I say to these people? Do I tell them I was suicidal, depressed and now diagnosed as bipolar? Do I tell them my son has a drug and alcohol problem along with also being bipolar?

Or do I just ask them why they're so interested in something so personal?

I need a subtle way to tell them that it's none of their business without revealing the true reasons. Any suggestions?

Amy's Advice to Wondering:
First of all, I hope your situation has stabilized. I can imagine that you feel very exposed because of the public drama brought on by these crises.

You don't have to reveal anything to your neighbors, but if you choose to, you can say, "I realize that things have been very dramatic at our house lately I've had some health issues that brought on a crisis for me and my son, but we're hoping things are better now."

Browse for related stories in the index at the very bottom of this page, or read another privacy story.

Thanks to Amy Dickinson for the source letter in her column, published in the June 16 issue of the Philadelphia Inquirer.

The physician ordered the methotrexate as listed: A wrong dose near-miss

An 85-year-old man who'd been getting treatment for severe psoriasis was admitted to the hospital with a three-week history of confusion, forgetfulness, and weakness. Home medications listed on his medication reconcilation sheet included oral methotrexate, 25 milligrams every Saturday at breakfast and lunchtime. The hospital used patients' medication reconciliation sheets as order sheets, and a physician ordered the methotrexate as listed.

A typical dose of methotrexate for psoriasis is 2.5 milligrams at 12-hour intervals for three doses once a week. Doses may be gradually adjusted but generally should not exceed 30 milligrams/week. The pharmacist recognized that a 50 milligram weekly dose was high, so he asked the nurse to confirm it. The patient verified that he was taking 25 milligram doses.

Before dispensing any methotrexate, a second pharmacist questioned the order. The pharmacist called the patient's family and asked them to read the prescription container. It indicated that each dose was supposed to be 2.5 milligrams. The order was changed because of the pharmacy intercept, and the patient received the correct dose.

Advice: Bring your medication containers and a list of your medications when you go to the hospital.

Read another near-miss of a drug error story.

Thanks to Michael Cohen for the source story in the June issue of Nursing2008.

A buffer and enabler for the patient: VIP care

Dr. Victoria McEvoy on VIP care:
One Emergency Room doctor told me recently about a VIP patient who came to the ER complaining of chest pain. The patient's visit triggered a cascade of events at the hospital administration level. The "VIP Office" sent a delegate to smooth the way, and the patient came with his own personal physician, who was there to serve as a buffer and enabler for the patient. Not only was the "physician bodyguard" not in the right specialty for the complaint and age of the patient, but the physician gave orders: "Call the cardiologist and get an echocardiogram."

Both the resident and the responsible physician thought the patient's problem was gastro-intestinal: he had swallowed a huge antibiotic pill without water, and the esophagus was irritated enough to cause the chest pain. Instead of quickly looking at the patient's esophagus, hours were wasted getting cardiology and cardiac tests which were not needed. His VIP status delayed him getting proper care.

Advice to Very Important Persons: If you bring in your personal physician, make sure they will listen to other doctors' opinions.

Read a celebrity drug error story.

Thanks to Dr. Victoria McEvoy for the source article in yesterday's Boston Globe.

National Marrow Donor Registry

The Dana-Farber Cancer Institute is encouraging everyone to join the National Marrow Donor Registry today from 10 am – 3 p at Tufts University's Cousens Gymnasium in Medford, Massachusetts. Former Red Sox pitcher Bill Monbouquette, recently diagnosed with leukemia, is among thousands of people who are awaiting a transplant.

Advice: Look for a time and place to register with the National Marrow Donor Registry. You might save someone's life.

Read a donor story.

Thanks to the Boston Globe for the source article in today's newspaper.

A pictogram in return for another pictogram: Diabetes patient education

Consultations with Mrs. L are difficult: sometimes, she comes
without her diabetes logbook, or forgets to have the requested
HbA1c assay. Above all, she comes either alone or accompanied
by someone who, like herself, speaks nothing but Chinese. All I
can do, in order to understand her repeatedly high HbA1c
levels, is to look at her logbook and try to understand the
documented insulin doses and the blood glucose concentrations.

Recently, I admitted her to hospital. Firstly, we verified that
the technical aspects of blood glucose determination and
insulin injection were perfectly correct. I also told her that
I needed an interpreter. A Chinese neighbour who was fluent in
French came with Mrs. L on the following day. I first checked
with Mrs. L the basics of adapting insulin doses and began to
ask her questions through the interpreter. No answer. I
therefore asked the interpreter if he, himself, had understood
the meaning of the questions. He was positive. I then asked Mrs.
L to tell me what she thought of insulin. No answer. I realised
that she knew nothing about it and that the treatment made
absolutely no sense for her.

This situation reminded me of John Searle’s "Chinese room"
argument. Imagine a Westerner, speaking English but not
Chinese, in a room with a window. Through the window, a Chinese
person shows Chinese pictograms. The Westerner has a manual,
written in English, instructing him how to show a pictogram
specific for the pictogram he sees through the window. He is
not aware that the pictogram he sees is a question, and that
what he then shows is the correct answer. The Chinese person
outside cannot work out that the Westerner does not understand
Chinese.

In the case of Mrs. L, we doctors were the Chinese. We had no
direct way of recognising that the blood glucose determinations
or the insulin injections that she performed impeccably had no
meaning for her.

I decided to start her education from scratch. What is
diabetes? What is a normal glucose concentration,
hypoglycaemia, hyperglycaemia, etc? Repeatedly, I asked the
interpreter whether he understood and whether he thought that
Mrs. L understood. He was affirmative. I arrived at a problem—
how to verify that the dose of insulin was correct. At this
point, I was unsure whether the interpreter understood the
question, and I decided to stop the session, giving him another
appointment for the next day. In fact, I doubted the
interpreter’s comprehension of the real sense of what I had
said. It seemed to me that the Chinese room was now separated
from me by two walls and windows.

The next day, a different person accompanied Mrs. L to the
appointment—her nephew, also perfectly fluent in French.
Needing to go through my explanations all over again, I decided
to use another strategy and asked the nephew to imagine that he
was diabetic, and that he had to listen to my explanations as
if they concerned him, in order to give a meaning to the
therapeutic education. Only then would he translate the
information to his aunt. I had the sensation of trying to enter
the Chinese room by climbing through the first window.

To a lesser degree, this story may be relevant to many
consultations, even when there is no obvious language barrier.
It is vital that the patient understands the message as a whole
and not just the words, or else the treatment routines may be
analogous to nothing more than showing a pictogram in response
to another pictogram.

Advice for speakers of a foreign language: Get a good interpreter.

Thanks to Dr. Gerard Reach for the source article in the Feb. 16 issue of the British Medical Journal.

Including her favorite meals and TV shows: Web-based caregiver communities

When Stephen Dworkin's father was diagnosed with pancreatic cancer in 2005, he and his two siblings began to share in his care. But Stephen was in Newton, his parent lived in Florida, and his brother and sister lived in Connecticut. "My dad passed away relatively quickly. And then we were completely unprepared to care for my mother," Stephen said.

At the time, Stephen's business partner, Jonathan Quint, saw the challenges his wife was having in caring for her mother, and the two knew they'd hit on a much-needed service: helping baby boomers care for aging parents.

They came up with Caregiver Helper, a secure online community resource that houses information about medications being taken, emergency contacts, doctors' appointments, and even the patient's favorite activities.

"Anytime a new caregiver came to my mother's house, all the information was available, including her favorite meals and television shows. And each time there was a new doctor, all of her medications could be printed out."

One in four American families are juggling similar caregiving responsibilities, according to the National Alliance for Caregiving.

Advice to Baby Boomers caring for parents who live far away: Consider a resource like this one.

Thanks to Susan Chaityn Lebovits for the source article in the Feb. 25 issue of the Boston Globe.

An hour after being discharged from the Emergency Room: Conflict of interest on a potential malpractice suit

Dr. J.R.'s question:
I am a family physician. A patient I'd not seen in months passed away about an hour after being discharged from an emergency room. Her mother, also my patient, asked me to review the records and autopsy to see if she should bring a malpractice suit against the E.R. physician and the hospital. I am friends with the physician and on the hospital's board. Ought I comply with this request?


Ethicist Randy Cohen's answer:
You should not. Indeed, you cannot – not properly, not without risking charges of bias. Your attachment to your friend and your position on the hospital's board create – or may seem to create – divided loyalties. You should recuse yourself from this task, explain to the patient's mother why you are doing so and refer her to a disinterested physician with the expertise to review the records and advise her how best to proceed.

Update: J.R. met with the family but did not offer a medical opinion, explaining that the records provided insufficient information for him to do so. He said he believed that they would not be satisfied unless the matter were investigated further and so suggested they speak to a lawyer who would have a neutral expert review the case.


Advice to family members considering a lawsuit for a medical error: Consult a doctor or nurse who was not involved.


Thanks to Randy Cohen for the source article in the Ethicist column of the New York Times Magazine of May 25.