The Wonderful Mr. W

            When I was assigned on my first day of wards to follow Mr. W, I was skeptical. As I write this, I recall thinking about how much I already knew about pleural effusions.  I was ready to discuss the factors in determining transudative versus exudative effusions by Light’s Criteria.  I could discuss with ease the finer points of whisper pectoriloqy and tactile fremitus.  To be honest, chylothorax was a bit new to me, but the uptodate app on my phone had me cued in to the basics in a few moments after the assignment.  I supposed that the ascities secondary to cirrhosis was useful review, even if I had already hit the textbooks scouring for details on hepatic dysfunction and failure the day before my start on the wards.

            On paper, Mr. W was the poster child for the kind of person the radio talk show pundits bemoan are the reason for our healthcare system’s failures.  Mr. W had a history of polysubstance abuse, with chronic alcohol use being the primary culprit for his hepatic cirrhosis.  The medical record shows that there were early warning signs, but Mr. W failed to heed the advice of his providers along the way, or so the paperwork would have you believe.   It would be easy to dismiss this man before walking into the room.

            Perhaps it was my experience as a paramedic, or maybe it was simply my joy to finally be out of the classroom and on the wards, but I walked into the room for the first time with a smile and introduced myself.  In life, first impressions matter.  This is true, but in a different way in medicine.  Immediately, I noticed that Mr. W was sitting up in bed, mildly short of breath, had a distended abdomen, and slightly icteric sclerae.  However, it was his smile that caught my attention.  Mr. W’s smile was immediately disarming.  Over the course of two weeks, I learned to lean on that smile to guide his treatment. 

An afternoon with the H Family

           During the third year of medical school, all students are required to rotate through a variety of services.  This is partly to establish that we can apply the knowledge learned during the first two years, but mainly to learn the difference between the book and the practice of medicine.  During my family medicine rotation, I was asked to do a ‘home-visit’ to a family under the care of my preceptor.  Working a small rural family practice has it’s own challenges and benefits.  My preceptor additionally has developed his own ACO (essentially a revamped approach to healthcare management that is based on the old HMO model).  He is starting to develop and expand his practice to look more like a ‘medical home”; a concept of having one stop shopping for multiple specialties and expanded access to those seeking care.  While the full model has not been realized, the practice is on it’s way to trying to maximize the benefits of the ‘Obamacare’, or the ACA as it is more formally called.

            Home visits at this practice are not uncommon.  While the rest of medicine has given up on the idea of home visits, Dr. T. has been trying to revive them, so it was fairly straight forward when he asked one of the families to allow students into their home.

            The Hs live in a small rural area of Massachusetts.  They grew up in the same small town, raised a family, and continue to be the pillar on which the other leans.  At 96, DH still cuts an imposing figure.  When DH and HH stand together, their smiles light up a room.  I recently had the honor of spending some time with these two this past week.  And the pair were unforgettable.

A Closer Look at the Problem of Post Traumatic Stress Disorder and Emergency Medical Services. (Written circa 2010)

There is no question that Posttraumatic Stress Disorder (PTSD) has been of increasing interest of late.  With soldiers returning from combat operations overseas, the literature on the issue has expanded a great deal.  However, little work has been done on issues related to PTSD regarding Emergency Medical Services (EMS).  What little work there is on the subject is uniform in the assessment that rates in the profession are at twenty percent or more (Bennett, et al., 2005; Berger, et al., 2007; Grevin, 1996). This paper looks into the limited work on PTSD in EMS and attempts to evaluate the broader work in the context of EMS.  An overview of the disorder is offered along with who is effected, to what degree, and a glimpse into possible mechanisms of acquiring the disorder.  Additionally, common treatments are discussed including an evaluation of Critical Incident Stress Debrief (CISD), the most common treatment and identification modality for the disorder in EMS.  Ultimately, it is asserted here that, regardless of the homogeny of symptoms, the disorder is a deeply personal reaction that requires an individually tailored response.  In the context of EMS, a great deal more work must be done to identify commonalities in the development of the disorder without over generalizing to the group.