Case of Caring

I have long been a fan of the “Case Records of the Massachusetts General Hospital,” which is published weekly in the New England Journal of Medicine. For many years, I made a point of recommending them to medical students and internal medicine residents as a model of concise yet comprehensive case presentations.No wasted words, no missing information, and none of the filler that trainees often added when they presented cases, such as “on heart exam….” or “the sodium was high at….”  As I always reminded them (often not as gently as I should have), if they were reporting a heart murmur, I knew it part of their examination of the heart, and if the sodium was 149, I knew that was high. Over the years, the Case Records have evolved from the old “stump the chump” format, where some oddball “zebra” was presented, “the medical students” always got it right, and the discussant often made an idiot out of himself. Those were admittedly fun to read, but probably not all that helpful to practicing physicians. An atypical presentation of tsutsugamushi fever? Really? I also had a warm place in my heart for the old CPC format, since I was once long ago one of those medical students (we were given a few hints by the chief resident that really helped) and, later, a discussant (NEJM 1994;330:126-34) who, luckily, did not make an idiot of himself, but was convinced for weeks that he was about to.

The medical students stopped offering their diagnoses a long time ago, and the mystery cases were dropped more recently. The current format is less detective story and more narrative – an explanation of the presentation and treatment of an interesting case.

Last week’s case was obviously chosen to coincide with the first anniversary of the Boston Marathon bombing. It detailed the care of a young man grievously wounded in the blast, from the time he arrived in the MGH emergency department 31 minutes after the bomb went off (“covered in ash and smell[ing] of smoke”) until his discharge weeks later to a rehabilitation facility.

A few things really struck me about the case discussion. First, the methodical accounting of the patient’s various wounds, including a traumatic amputation of his right leg and the presence of intracardiac shrapnel, was a vivid reminder of just how evil the attack was. Second, the imaging modalities used to assess his injuries and guide his treatment were almost eerie in their clarity. Third, the teamwork evident in his care was really impressive. From the first responders who probably saved his life by applying a tourniquet at the scene, to the physicians, nurses, therapists, psychologists and others who directly cared for him in the hospital, it clearly “took a village” to restore him. Finally, I was really impressed by what the patient himself had to say about his care. It really is worth reading, but he cites three things in particular that stood out: “just being personable makes a huge difference in  a person’s recovery… my family and I always felt included in every discussion with the doctors” and the control of his pain was critical to his recovery.

This Case Record retaught old, but important lessons. Being personable, being generous with information, and being attentive to physical comfort are things we can and should do for every patient.

What do you think?

5 thoughts on “Case of Caring

  1. I can’t imagine care being any other way. I’m famous for saying, “I’m not the only one with cancer. My whole family has cancer too.” Sadly, you can imagine why I’ve been compelled to say this to medical, nursing and counseling staff.

    How can the family be supportive, if the medical staff didn’t support the family?

    It’s more than being a personable doctor, nurse, etc. I had a personable oncologist until I asked him how the surgery wound would be cared for? Please give me a guestimate about how long it would take to get prosthetics? What should I and my family expect for care and where? I have another doctor that isn’t personable, but he treats me with skill and respect. I really trust him.

    I first contacted administration that I didn’t want a burnt out oncologist and Nurse navigator caring for me. I deal directly with my new oncologist-no social worker/counselors, no one to coordinate my care, as I do that myself.

    I immediately prayed that the victims and their families were treated better than mine.
    I think this is the most important article about long-term medical care that has been written in ages.

    I really want to salute the caretakers of this young man. Boston rules

  2. I believe that listening to the patients is the foundation of establishing patient-doctor relationship.Just this simple gesture makes the patient feel included in ongoing care. Very often a keen ear and observation give important clues to the diagnosis .These “cost efficient” techniques go a long way in helping the patient heal as well as being fulfilling for the health care provider.

    1. If a patient shows up for the 2nd appointment, there is a relationship. Doctor-patient relationships are like a marriage—someone pretends to listen-smile-and come up with what they think is an appropriate answer-question-solution-and they aren’t even on the same planet-they are so busy reading the paper or electronic chart. To get a strep test, I had to scream look and spit in my hand to prove that I didn’t have dry mouth causing a sore throat. I did indeed have strep throat.

      You are prescribing a good relationship-not a negative relationship. I’d like a better relationship, but the PCPs that I had before were really bad, and this one seems to be coming around to respecting me.

      We sort of had ‘counseling’. I complained to my oncologists that he wanted to have me loose weight, was blasee-blasee about initial care and follow up for sinusitis that inflamed-swelled my radiation and surgery site. I can go to urgent care or get into my PCP quicker than my ENT and oncologists. Also-it is ridiculous to run into oncology for an antibiotic.

      Anyway, he’s had 2 oncologists counsel him about the possibility of me losing 40 lbs in 6 weeks-that my labs are perfect for them-that my nose could be inflamed from the cancer coming back-and I quickly need initial nose care and a good follow up. I had an appt. for thyroid, when my nose went south.

      Now, I’m hoping that I can go directly to UC-then my PCP for follow up-and there isn’t a need to contact my oncologists and ENT for anything except routine care. I also reminded him that he’d get brownie points from the HMO for keeping my costs down..

      1. My PCP decided to follow the weight loss plan. He referred me to a specialist that cared for non-compliant patients. They found out what non-compliant meant. I’m in endocrinology now. They went over my labs and records, and decided that the internal medicine specialist that was my PCP was trying to treat me for things I didn’t have, and my thyroid still wasn’t under control. My oncologists and the oncology social workers got me a new PCP. She seems to understand that I need to maintain this weight, because I’m so small-and cancer seems to burn the weight off of a person. I don’t have much to lose, and she’s concerned about my IBS. It’s nice to not have to be fighting and feel safe.

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