The Medical Guide to Avoiding Ignorance

I believe there is no better place to see teamwork in action than the inpatient setting. As a medical student, the teams in question can often be ill-defined. Yet the whole hospital is, in theory, built on that contract between healthcare providers and their patients. Patients bring their their health to the table, and we bring our expertise and commitment to their service. From that foundation arises every other collaborative effort in medicine. 


After a year and a half of clinical rotations in medical school, I’ve grown familiar with the interactions between physicians: how different specialties operate and interact with each other, the valuable role of consults, and how different practitioners act given their rung on the teaching hierarchy.  Yet I still only have the faintest idea of how our nursing staff operates. Or what the day-to-day role of a clinical pharmacist is. Or how physical therapist perform their jobs. I know that collaborations between these different medical professions is essential – unfortunately my main interaction with any other field is limited to the electronic chart. Following nursing notes, PT/OT evaluations, respiratory therapists comments, etc.  I do think that for all the efficiencies brought on by the electronic chart, I’m missing out on the valuable interpersonal  interactions that physicians used to have with each and every essential personnel.

 Photo by EVG photos from Pexels

Photo by EVG photos from Pexels


In medical school the focus is on a successful evaluation of a patient and the knowledge needed to establish a differential and plan. But in learning all the theory behind our practice, we often overlook the reality of what we’re learning. I frequently catch myself not knowing what actually physically happens. SPEP? NAAT? I know when to order these labs, but have never seen the process actually performed. I’m ashamed to say that it had never crossed my mind how values like “moderate  blood” on a urinalysis are measured. When I saw it actually performed in a lab, I immediately remembered the term dipstick, and it made a lot more sense. I felt foolish in that moment, but even that quick interaction with lab technicians had a huge impact on my thought processes when working up a patient.


As far as medications are concerned, I admit I am still unfamiliar with the nuances. I was floored when I experienced how helpful having a pharmacist on rounds was. I distinctly remember a tough case involving a patient with HIV on antiretrovirals who was suffering from an adverse drug interaction. The pharmacist began talking and everyone from the attending to the medical students stopped to absorb his expertise and navigating the situation. The financial cost of these medications is another essential area in which pharmacists bring invaluable insight. No matter how theoretically sound my ideas might be when presenting a patient plan, real world factors such as cost and availability dictate what kind of management can be pursued. Even something as simple as the fact that certain pills are just too big to comfortably swallowed – or too small to be split. 


Nurses are the backbone of patient care. Whereas their roles may differ, the nurse is often the one actually carrying out the majority of medical interventions planned for the patient.  Though nurses also spend lengths of time charting their activities, they are still the ones that understand the patient best. One of the single best strategies I developed in my 3rd year rotations was talking to nurses about my patients. They always had insights to share that would leave me more prepared than spending that time recycling through the chart again. So why is it exceptional to have a physician that includes nurses on rounds? Perhaps it is time to change the standard.


My interprofessional experiences across two hospitals have been eye-opening, but I know that they are not always the norm. Hospitals around the nation still suffer from the ideal of “doctor knows best”. In the end, a collaborative patient-centered effort will always lead to better outcomes. I hope that medical training will push more toward exposing each field to one another. To those reading this article, I’d like to know more about my colleagues. The nurses, physical therapists, and pharmacists I’ll be working with to achieve the same goal. I’d especially love to hear feedback on the interactions you have had with physicians, the good and the bad! I am sure that we can collectively strive towards improving our team. 

 

 Neel Bhan, MS-4, University of Texas Southwestern Medical Center

Neel Bhan, MS-4, University of Texas Southwestern Medical Center

 

Bringing Diet to the Table in a Medication Driven World

Much like in primary care medicine, treating patients as a Registered Dietitian hinges upon creating a rapport with patients in an attempt enable them to make the necessary health modifying changes. Treating a person with obesity is much like treating a person with a substance use disorder. The patient is the sole individual in the driver’s seat and makes all of the choices that determine their success or failure. Getting a patient to “buy in” to a healthy eating pattern, just like eliminating drug use, takes significant time considering barriers to compliance. For treating obesity, barriers include long-standing untreated psychological coping mechanisms, time, financial barriers to eating healthy, social climate, and affordable access to qualified healthcare professionals. Physicians and many other practitioners simply do not have the time to elicit the necessary changes in their patients without appropriate support staff.

In my experience as a dietitian, even if time is taken by typical physicians to steer patients toward healthier eating habits, minimal nutritional advice is given. What little guidance is provided usually only includes following certain caloric restrictions or my personal favorite, “don’t eat anything white.” Much more is necessary to make changes in the arena of weight management.

Another challenge that compounds the time issue is that there is so much diet information accessible to the public that may or may not be true, accurate, or safe. There are so many pop culture fads that it is impossible to keep up. Physicians and other outpatient health providers already have to manage the changes in their respective fields, but adding in the world of nutrition makes an already time-pressed existence even more hectic and inefficient. With such challenges and barriers, how can the healthcare team begin to impact the billion dollar problem of our country’s obesity epidemic? It starts with using appropriate resources, every day, and with every medically appropriate patient. 

 Photo by Trang Doan from Pexels

Photo by Trang Doan from Pexels

Working as a dietitian for 10 years in various health care settings has provided me with opportunity to experience the power of a team-based approach. I have seen where the synergy of physicians, dietitians, nurses, physician assistants, health coaches, physical therapists, personal trainers, pharmacists, and licensed clinical social workers working together can yield much success when treating obesity, diabetes, and other nutritionally-focused chronic diseases. Obesity and diabetes lead as one of the most costly issues in our healthcare landscape and 75 percent of the United States population is categorized as overweight or obese. Addressing this issue head on should be a priority in any primary care practice. 

Regularly making referrals to dietitians for overweight or obese patients is only the first step toward addressing the problem of obesity. The need for multidisciplinary metabolic centers is much needed. While these centers exist in some parts of our country, comprehensive obesity care centers are lacking in the areas of the country that need it the most such as Louisiana and Mississippi.

As I experience what it is like to be a medical student, I see how little nutrition education is given in preclinical years to future physicians. While there are progressive schools that offer more nutritional education for their medical students, the vast majority of healthcare schools just do not have enough room in the curriculum to train their students as dietitians as well. They should not need to. The resources are out there and we just have to know how to use them. 

The first step is to reach out to the state and local dietetic associations to see what resources are available for dietitians interested in working in obesity. Visiting local chapter meetings to network with dietitians is also a way to build resources. Speaking from experience, physicians do not often reach out to find dietitians are not receptive or available to have the much needed discussions. These lines of communication must be initiated by healthcare leaders, because it is the leaders who are shaping the healthcare landscape. 

After seeking out qualified dietitians who are willing to design customized weight loss programs for patients, there should be support staff and health coaches to handle the weekly follow ups. After working with bariatric patients for 4 years and owning my own weight loss clinic, I have seen the best success in treating obesity comes with establishing non-judgmental rapport with patients and offering frequent follow ups to help patients stay on track. This does not have to be with a dietitian or a physician; a certified health coach is often all that is needed to remind patients of their goals for success.

For any healthcare professional, learning advanced motivational interviewing techniques and using them daily is the best approach to helping noncompliant patients. Simply referring out is not enough. The healthcare system must have open communication with all parties involved in the treatment of obese patients to ensure accountability and progress. These simple strategies are just the beginning of what needs to be done to effectively treat obesity, and are strategies that can begin to be implemented today. 

 Rebecca Markway Lee, RDN, CSOWM, LDN

Rebecca Markway Lee, RDN, CSOWM, LDN

 

Rebecca Markway Lee, RDN, CSOWM, LDN completed her dietetic internship at North Oaks Health System in Hammond, LA, and obtained her registration and license as a RDN, LDN in 2008. She became a Board Certified Specialist in Obesity and Weight Management by the Commission on Dietetic Registration (CDR) and received a Certificate of Training in Adult Weight Management in 2010, as well a Certificate of Training in Childhood and Adolescent Weight Management in 2017. Rebecca worked for East Jefferson General Hospital in the inpatient clinical and outpatient settings, including the EJGH Wellness Center and Corporate Wellness Department. In 2012, she began working with the bariatric population and Ideal Protein Weight Loss Method at Northlake Surgical Associates. She opened her private practice, True Body Nutrition LLC in 2016. With her business partner, Katherine Bridges, she then opened a business geared toward providing childhood obesity prevention programs to preschools, True Body Kids LLC. Rebecca is current a second year medical student at William Carey University College of Osteopathic Medicine, where she is currently enrolled as a second year medical student. Just this year, Rebecca received approval to undergo a longitudinal research study aimed at discovering interventions to prevent the rise of obesity.

Don't Leave Depression To The Psychiatrists

The depression epidemic is a pervasive health crisis that has yet to receive the full attention it deserves. Healthcare professionals can take measures during the patients’ earlier stages of depression that can help provide a more effective form of diagnosis and care. Patient treatment of depression is usually only initiated after a particularly troublesome episode such as an instance of self-harm or attempted suicide. This is also the very worst stage of depression, and we can do better to start treatment earlier. By the time the patient has attempted self-harm, it might already be too late. Therefore, effective treatment of depression relies on a consistent method of early detection in patients who are prone to depression.


Traditional screening for depression involves the use of two standardized questionnaires: PHQ-2 and PHQ-9. It might seem that questionnaires are a convenient and timely way to screen for depression; after all, a questionnaire can be filled out with a pen and paper and doesn't require a physician to administer. However, here is where a breakdown between healthcare provider and patient occurs. From a diagnostic standpoint, many signs which might indicate a patient in need of help are taken away when the questionnaire is the main method of screening. For one, the physician does not see the patient face-to-face when the patient is answering these questions. This could lead to the physician missing many non-verbal cues or mannerisms exhibited by the patient that might be indicative of an imminent depressive crisis. Furthermore, patients might be more inclined to open up to a physician if he/she knows that the doctor is actively listening and paying attention to the patient’s answers. In other words, including depression screening in the medical interview would lead to more successful and effective screenings of mental health inadequacies.

sasha-freemind-780719-unsplash (1).jpg

“… own ignorance and the negative stigma I had associated with depression delayed my diagnosis for years…”


Many students in high school, college, undergraduate education, post-baccalaureate studies, professional school, and residents experience a common onset of depression. My personal experience with depression is not representative of every patient’s struggle; each patient deals with depression in his or her own way, hopefully with the aid of a healthcare professional who is trained to handle such cases. However, I do think that my case could have been managed better on multiple fronts.


My experience with depression started long before my diagnosis, which seems to be the case more often than not in patients today. After all, one of the screening criteria is a formal suicide plan or attempt. This poses a problem in that many patients between the area of mental wellness and depression are missed, just because they haven’t experienced or are afraid to admit that they have suicidal ideations.


As for me, every doctor visit consisted staring at the floor, waiting for the history and physical exam to be finished. When asked questions designed to screen for positive depression, I would generally mumble the answers I thought were unremarkable without much thought to the questions. Furthermore, it was always either a paper questionnaire I ended up filling out or a tech conducting the interview without an upwards glance towards the patient as he or she filled in the answers for the doctor to glance at. I am quite confident that any competent health care professional, if told to specifically look for signs of depression, would have noticed something off in my wellness during any number of doctor visits I had during my college education. During that time, I remember being morose, stressed, lethargic, unmotivated, and complaining of sleeplessness. However, my own ignorance and the negative stigma I had associated with depression delayed my diagnosis for years. These years could have been spent as time taken for understanding my illness as well as possible therapy. I wish a single healthcare worker I interacted with would speak up. 


Depression is a huge problem in that it is more common than the average practitioners believes. Screening procedures are designed for time-based efficiency rather than efficacy. As a healthcare worker, we all know this, but we push off our responsibility to others. 


“Maybe a psychiatrist could deal with this better.” 
“Maybe the attending physician will say something.”
“Maybe they are just having a bad day.”
Maybe it is time to listen to our patients. 

 Anthony Silvestre, MS-2, Ross University School of Medicine

Anthony Silvestre, MS-2, Ross University School of Medicine

 

Bridging Gender Inequities: Do We Care in Healthcare?

    We are taught in nursing school that all patients are individuals and that no assumptions should be made based off of disease, age, gender, etc. We must approach our patients with compassion and a longing to understand them and their circumstances. But is this emphasis on individuality also applied to us? Each person is an individual with a story. Take myself for instance. Had you told me three years ago that I would be halfway through nursing school, I would have called you crazy. I spent my whole life wanting to be an officer in the military. After a four-day hospital stay, my doctors discovered that I had suffered a transient ischemic attack (TIA), or ‘mini stroke’. I was left with my dreams crushed and curiosity about how this occurred. It was this curiosity that led me to where I am now. 

 Photo by  rawpixel  on  Unsplash

Photo by rawpixel on Unsplash

    My path took me from Army ROTC, a male dominated world, to nursing school. In nursing school, I am one of only three men. In today’s age, a lot of emphasis is rightfully placed on female equality in the workplace. It is interesting to consider how men are treated in the opposite setting. I have had nurses warn me to stay away from certain patients because they refuse to be cared for by a male nurse. The first time it happened, I felt surprised and awkward. Thankfully, the nurses on the floor were all supportive, and I was able to move past it quickly. Yet why am I limited in my practice when male physicians are almost never barred from their patients? This is why respecting everyone’s individuality is essential. The real world isn’t fair, and I’m not going to be upset at my patients for discomfort around male nurses. The nurses and my professors were are supportive and understanding. I think that is the key to ensuring a positive workplace environment and culture. If all we did was focus on each other’s weaknesses, the workplace would become hostile. This is evident in the hospitals where you see certain employees exclude others, whether due to profession, gender, or simple dislike. I believe incorporating and respecting everyone’s individuality is the only way that we can ensure that healthcare is focused on working together as a team to serve patients. 

    As a student, I thankfully have not had any major issues when it comes to being treated differently for being a male student. Yet people often mention how easy it is for males to get into nursing school. Since I am a student and not an admissions director, I cannot comment to whether or not this is a true statement. I do know however, that I was on the higher side of GPAs when compared to the rest of the cohort. Despite not knowing my qualifications or experiences, the assumption with almost everyone I talk to is that it was easier for me to gain admission. I do not take these comments personally, but it is intriguing when thinking about a male who failed our first semester, and it makes me question whether the rumors could be true. 

The other gender issue I see from time to time from afar, is when discussing whether there is a pay gap. I have read articles from several organizations that mention a pay gap between male and female nurses. Since I do not yet work as a nurse, I can not speak to personal experiences of any kind of pay gap. What I do notice in every one of these article is the arguing and lateral violence that occurs in all of the comment sections. It is surprising that even in a women dominated profession, men may still be paid more. Yet despite these imbalances, I hope that my peers won’t make generalizations about me when I enter the workforce. This again speaks to the pursuit of treating everyone as an individual so that we can better focus on the care of our patients. 
 

 Logan Paul was born in New Orleans, LA, but has have lived all over the country. He is now in his third semester of nursing school at Jefferson College of Health Sciences

Logan Paul was born in New Orleans, LA, but has have lived all over the country. He is now in his third semester of nursing school at Jefferson College of Health Sciences

 

Comic #1: A Somnolent Proposal

 
Sleep Deprivation
 
 
 Dennis Kulp, OMS-2, Texas College of Osteopathic Medicine

Dennis Kulp, OMS-2, Texas College of Osteopathic Medicine

 Also Dennis Kulp, but drawn.

Also Dennis Kulp, but drawn.

The National Sleep Foundation recommends seven to nine hours of sleep a night for adults under the age of 65.[1] Unfortunately, for many of us, didactic obligations somehow seem to take up the rest of the 15-17 hours in any given day. Now I’m no Pythagoras, but that math doesn’t seem to add up to a healthy amount of “me time” or as some people like to call it “eating and surviving.” In fact, even among typical undergraduate college students, 70% do not attain an acceptable amount of sleep each night.[2]  One can only imagine what it might be like for a healthcare student who is even partially interested in expanding his or her curriculum vitae. Especially when you consider that disruptions in circadian rhythm and sleep-wake homeostasis can have devastating effects on memory, learning and concentration, we should be doing everything in our power to reach those precious hours of unconscious bliss.[2]

Luckily for the sleepy ones among us, there is hope. There are some students who have no problem getting adequate sleep. Maybe it’s the guy who sits in the front and answers literally every question out loud no matter how many times he is told to raise his hand. It could be the girl who has a tattoo of an eagle on her leg and listens exclusively to experimental jazz when she studies in the anatomy lab every morning. Jeez, it could even be the kid who hides in the back of the lecture hall and thinks that no one can see him watching videos.  One thing is for certain though, these people are always well rested.

My proposal is that we speak to these wonderful characters and learn from them. Somehow, these classmates find a balance between sleep, school, and general life. They may not be people we would normally talk to, but should we find out how they manage time and emulate their processes, it may just save our careers.  Who knows, we might even make some friends along the way.

 

 Peter Harvey, OMS-2, William Carey University College of Osteopathic Medicine

Peter Harvey, OMS-2,
William Carey University College of Osteopathic
Medicine

 

[1] Hershner, S. D., & Chervin, R. D. (2014). Causes and consequences of sleepiness among college students. Nature and Science of Sleep6, 73–84. http://doi.org/10.2147/NSS.S62907

[2] Lichtenstein, G. R. (2015). The Importance of Sleep. Gastroenterology & Hepatology11(12), 790.

 

From Lab to Liver: Understanding the Complexities of the Pharmaceutical Industry

Physicians are the sole decision makers in selecting appropriate medications for patients. This is a common misconception. In actuality, choice of therapy is determined by a collaboration between many sources, including pharmacists, physician assistants, nurses, and even patients.

 

What goes on behind the scenes before a patient gets a medication?

The process of how a new medication gets to a patient is complex because it integrates many players. Below is an example of this journey.

  1. A pharmaceutical manufacturer (eg. Pfizer) develops a new medication (Lyrica).

  2. The medication is sold to a wholesaler (McKesson), that distributes it to several pharmacies (CVS, Walgreens).

  3. The pharmacy is paid for the product by receiving money from 1) the patient, and/or 2) the Pharmacy Benefit Manager (PBM). A PBM (Express Scripts) is a middleman that negotiates pricing and develops formularies for a Third-Party Payer/Health Insurance Company (Cigna).

  4. The PBM pays the pharmacy for the product, but also receives money, called rebates, directly from the manufacturer. These rebates help lower costs, and get medications onto a formulary.

  5. If a prescriber writes a prescription for a medication that is not approved by the Payer, the prescriber may be required to communicate with a pharmacist before moving forward.

In the end, a managed care pharmacist employed by a PBM/Payer can utilize a formulary to act as a stop-gate and ensure that a patient is prescribed the most appropriate medication based on cost and therapeutic outcome. 

 

Why does it matter which medication a physician prescribes?

Formularies restrict prescribers by reducing the number of choices when selecting a medication for a patient. Though it may seem like an inconvenience, these restrictions are put in place to ensure that patients receive optimal therapy using evidence-based medicine.

Even if a medication is approved for an indication, managed care pharmacists aim to identify the niche population within the indication that would see the most benefit from the medication. It is inappropriate to use a new medication in a patient for which the benefits have not been shown to outweigh the risks when compared to an older, more studied, less expensive alternative.

 Photo by  rawpixel  on  Unsplash

Photo by rawpixel on Unsplash

Managed care pharmacists are in charge of assessing the information provided by a manufacturer and establishing prescribing standards. It takes upwards of six months after a new medication approval to conduct the necessary cost/benefit analyses and prospective budgeting to accommodate new medications into the healthcare system. As new specialty medications are becoming more expensive, this process will become more difficult and time-consuming.

 

Why are medications so expensive?

On average, it takes $2.5 billion and 15 years to bring a new medication to market, and the success rate for a medication to get through the development process is approximately 6.2%. Once a medication is discovered, the manufacturer files for a 20-year patent. Certain factors can increase this number, but the medication spends a majority of its patent life in development. After the patent life expires, generic alternatives enter the market, and the manufacturer finds it more difficult to earn back the money that was invested to develop the product.

There are many reasons that manufacturers need a return on their investment. It is a driving force for innovation. Also, many companies have a portfolio of medications that are in development, and the ability to bring new life-saving medications to market in the near future is dependent upon how the company is performing in the present.

 

How can we improve patient access to medications?

While managed care pharmacy is always focused on improving the future, proper planning in the present will help manage the volatile and exciting pipeline of expensive specialty medications. H.R. 2026, the Pharmaceutical Information Exchange (PIE) act, is a bill in Congress that aims to increase pre-approval information exchange between manufacturers and managed care pharmacists. This will ultimately reduce the time it takes for patients to gain access to medications. Managed care pharmacists who are armed with clinical and economic information can allocate funds in advance and make better decisions, allowing prescribers to select medications that maximize value.

 

References:

  1. DiMasi JA, Grabowski HG, Hansen RA. Innovation in the pharmaceutical industry: new estimates of R&D costs. Journal of Health Economics 2016;47:20-33.

  2. Biotechnology Innovation Organization. Probability of success for new drugs in the U.S. by development phase between 2006 and 2015, by drug classification. Statista. Accessed Mar 2018. Web.

  3. U.S. Food and Drug Administration. Frequently asked questions on patents and exclusivity. Updated Feb 2018. Web.

  4. Cantrell SA. New drugs, but slow access - here’s how to speed breakthroughs to patients. The Hill. Jan 2018. Web.

 

 Soham Shukla, Pharm.D. Candidate 2019, is the immediate past president of the Rutgers Academy of Managed Care Pharmacy. He also serves on the AMCP National Student Pharmacist Committee, and was an intern in the AMCP Foundation/Pfizer Managed Care Internship program in 2017.

Soham Shukla, Pharm.D. Candidate 2019, is the immediate past president of the Rutgers Academy of Managed Care Pharmacy. He also serves on the AMCP National Student Pharmacist Committee, and was an intern in the AMCP Foundation/Pfizer Managed Care Internship program in 2017.

 Sumie Kakehi, Pharm.D. Candidate 2020, serves as the Vice President of Rutgers Academy of Managed Care Pharmacy, and was an intern in the AMCP Foundation/Pfizer Managed Care Internship program in 2018 She is also a sister of Lambda Kappa Sigma, a professional pharmacy sorority.

Sumie Kakehi, Pharm.D. Candidate 2020, serves as the Vice President of Rutgers Academy of Managed Care Pharmacy, and was an intern in the AMCP Foundation/Pfizer Managed Care Internship program in 2018 She is also a sister of Lambda Kappa Sigma, a professional pharmacy sorority.

 Nihal Narsipur, Pharm.D. Candidate 2019, serves on the Rutgers Academy of Managed Care Pharmacy Board of Directors, and is interested in pursuing a career in the pharmaceutical industry upon graduation.

Nihal Narsipur, Pharm.D. Candidate 2019, serves on the Rutgers Academy of Managed Care Pharmacy Board of Directors, and is interested in pursuing a career in the pharmaceutical industry upon graduation.

 Jane Yi, Pharm.D. Candidate 2020, serves as President of Rutgers Academy of Managed Care Pharmacy.

Jane Yi, Pharm.D. Candidate 2020, serves as President of Rutgers Academy of Managed Care Pharmacy.

 

Not All is Fair in Love and Medicine

What does medical malpractice mean on a personal level?

This is hard to answer. What does it mean to lose a patient and know it was your fault? How do you begin to explain yourself? How do you prepare yourself for a legal battle that will require you to continuously deny you were negligent, but deep down you know you are lying?

These are questions I someday hope to know the answer to.

My name is Daniel Gonzalez and when I was three years old, my mother was killed by a physician. My mother was always self-conscious about her weight and after decades of failed yoyo dieting, she elected to undergo bariatric surgery. With some research and help from her primary care physician she was connected with a high volume bariatric surgeon known as Dr. J. After her initial consult and meeting the superstar doctor, she had nothing but high hopes for the procedure and an optimistic outlook for the years ahead with a new weapon to help her fight to reclaim her own body.

In the weeks leading up to the surgery, my father continuously asked, “honey are you sure you want to go through with this? You look wonderful to me and I love you just the way you are.” She was firm: “I need this, and your support. This is for me, not you. Enough is enough and I need you.”

 Photo by  rawpixel  on  Unsplash

Photo by rawpixel on Unsplash

I distinctly remember my grandparents coming to my house to watch over me while my parents went to the hospital. I remember my mother wearing a baggy red dress and her teacher’s necklace with little apples, rulers, letters, and book charms on it. She was a spanish and math teacher at Kirbyville High School and all the kids called her Señora Gonzalez. They would skip class and go to her room adorned with piñatas, parrots, and maracas when they were trying to get out of gym class or dodge a quiz. I remember her saying goodbye to me, and I asked to play with her necklace when she leaned over to hug me. I remember she took off her necklace and told me to keep it safe for her until she got back.

After the surgery things appeared to have gone well. Dr. J. had completed another fantastic case in record speed and was off to another hospital to perform more procedures. My mother was still groggy but my father noticed there seemed to be a lot of blood in her drains. He asked the nursing staff about it and they assured him, bleeding after a surgery is completely normal. The nurses emptied the drains, jotted down their notes in the chart and went about their rounds. Two hours later, the drains were full of dark red blood. Again, the nurses emptied the drains and assured my father all was well. Now, six hours post op and the drains were full of blood. My father sat at the bedside and watched as they slowly filled like bags full of a thick red wine.

He became worried, because he noticed my mother growing pale and her hands were becoming clammy and cool. He called the nurses in again. This time their response was different. The assured him everything was fine, changed the drains, but told him they were going to try and get ahold of Dr. J. Forty five minutes passed, no word from the doctor, and drop by drop the drains were filling up. My father called the nurses again, and they told him that Dr J was in a procedure and would call them as soon as he was out. My dad lost it at this point and demanded someone, anyone, please come and assess his wife. The nurses called an ER doc who was working that night to come and assess Dr J’s patient. When the ER doctor saw her and the amount of blood she was losing he immediately ordered a transfusion. Finally, Dr. J was able to be contacted, and he was enroute to the hospital but wouldn't be there for at least another hour. The ER doctors were trying to keep her stable but the bleeding was increasing and now her blood pressure was dropping as well. Another blood transfusion was ordered and my mother was taken to be prepared for emergency intervention.

Rapidly they opened up the sutures and started to wade through the pool of blood to look for the source of bleeding. The liver, bowels, and mesenteries were intact. The stomach was stapled and bleeding but not enough to explain the hemmorage. Finally, the surgeons found that the spleen had been lacerated and was seeping blood. Quickly they tried to repair the damage but despite closing the wound, they had failed to halt the hemorrhaging. Another transfusion was ordered, but now it was noticed that the patient’s eyes, nose, ears, and rectum were bleeding as well. The patient was deteriorating rapidly, and bleeding from every orifice. The patient’s bleeding was becoming worse and they were now going into shock. The patient’s heartrate was rapid but pulse was weak. The breathing became strained. Despite their best efforts, and subsequent transfusion, the patient went into irreversible hypovolemic shock and subsequently died June 1, 1997. Cause of death: internal bleeding due to a lacerated spleen as a complication from bariatric surgery.

My father was devastated. In less than 10 hours from saying goodbye in the pre-op room, he lost his wife of 18 years.

Dr. J never should never have left the hospital. He should have been available sooner and he should have been more cautious as to notice the laceration of the spleen.

Mom never came home. However I did keep her necklace safe for her until she could wear it again. My father decided to bury her with that necklace because she always wore it when she was in the classroom and teaching was her passion.

It’s interesting though to consider how Dr. J’s actions influenced me for a lifetime. I wonder how much the death of my mother influenced him. Dr. J is still practicing. I wonder if he has kids? I wonder if they went to medical school, and I wonder if he ever told them about my mother. I wonder if his kids ever had to ride their bikes to schools or if Dr. J ever thought about me and my dad ever again.

I’m attending law school next fall and I mean to study healthcare law and patent law. My mission is to create a new medical system that limits losses and will better serve the people.

Future healthcare professionals: your actions have consequences. Consequences far reaching and capable of dramatically altering people's lives.

Remember your oath, and do no harm.

 

 

 Daniel Gonzalez is a first year student studying Medical Law at The University of Houston Law Center

Daniel Gonzalez is a first year student studying Medical Law at The University of Houston Law Center