Tuesday, June 17, 2014
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.
One 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 Massachusetts General Hospital 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?
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
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