Safety

I had just read an article about violence in the healthcare setting the week before Dr. David Cohen was shot in the abdomen in the halls of Johns Hopkins Hospital while disclosing medical news to the son of an elderly cancer patient.  For hours, East Baltimore took on the characteristics of a war zone, with the stationing of SWAT teams and news helicopters hovering over the scene.  Friends of mine experienced the lock-down on the campus while safety measures were enacted.  In the end was the astonishing but also sad discovery of a patient shot to death in the back of the head and the suspect having committed suicide by firearm.

Raised up through medical school and residency in East Baltimore, I experienced some concerns for my safety.  I moved to Baltimore after graduating from Mount Holyoke, a small college nestled in a country town in New England.  I was far from accustomed to the sound of sirens, helicopters overhead and even gunshots at night.  When I interviewed at Hopkins, we were invited to attend a couple of medical school classes.  There was an announcement about a student who had been raped during daylight hours, after parking her car north of campus.  One of the attending faculty members was carjacked in the parking garage on campus.  I wasn't sure whether I was safe or not safe at various times and in various places between the dorm building, the main hospital and the lecture building; though, I was never the victim of violent crime.  I did have a stethoscope or a wallet stolen from the hospital here or there.  We took care of quite a few patients who have criminal records, I'm sure, but none of them nor any of their family members ever threatened to harm me.  As it were, violence in the city is mostly suffered in impoverished communities.  We hear about it on the news when a doctor is shot.

Johns Hopkins was caught by surprise; though, it may have only been a matter of time before something like this shooting was to happen.  I don't think it came from an expected direction.  The suspect was not the kind of guy one would "profile" as being prone to violence, a devoted son and a good neighbor.  Many have surmised that he must have been mentally ill.  It seems to me that he must have been very, very stressed.  Overattached?  Possibly.  He might not have slept well, staying overnight the week before to watch over his mother who was having surgery.  He may have brought her to Hopkins, hoping for a miracle cure.  It is not that friendly of an environment.  Did he feel isolated, the hospital too far for friends to visit?  There may have been deep-seated anger and frustration that had boiled up, even for entirely different reasons.  Many Americans are angry these days.  Living with the outcome of her illness may have posed an intolerable dilemma.  I think we will never know.

Certainly, as this is unpacked among nursing staff, support staff and among physicians, I am sure there will be a lot of talk about how to recognize stress among family members, how to listen, and how to address questions in ways that defuse anger.  The hospital is an unusually intense setting, and some people can be very anxious or disturbed without outward manifestation.  Care of family members is part of the role of the healthcare team, even though our prime responsibility is to the patient.  Are there warning signals we should detect?  Are there questions we should ask?  I think expectations are very high when patients are transferred to an institution like Johns Hopkins Hospital.  Does institutional pride play a role in setting expectations?  Informed consent involves the listing of potential adverse events that may result from a medical intervention, but are patients and families really prepared for when bad things happen?  The unexpected, unwelcome outcome is understandably upsetting.

Most of us have experienced the unwelcome unexpected in hospitals.  I find it hard, as a doctor, to hold back criticism when a family member of mine is ill.  They say that the best thing to do in a hospital is to get out, and I happen to agree.  I do not think hospitalized patients are highly at risk for violent death, nor are their family members or their doctors.  They are more at risk for other things happening: infections, complications of procedures, falls, blood clots, etc.  Hospitalized patients are probably endangered most by medications that are not prescribed when they should be or medications that are prescribed when they shouldn't be.  This is why patients should keep these safety measures in mind when heading to the ER, or even to routine doctors appointments:

- keep a medication list that includes the generic name and brand name of all of the pills that you take and includes dose, frequency and the reason the medication was prescribed

- make sure the medication list matches what is in pill bottles at home or what nurses are administering in the hospital.  If not, ask what medication is being administered and why

- make sure to check prescriptions picked up at the pharmacy to be sure that the details match your list

- ask for copies of notes, lab results and x-ray documents from the doctor's office or hospital that generated them, keep them in a secure personal file, and share the information with your primary care physician

- if you are over 65, avoid sedatives or tranquilizers, anti-histimines (often in cold medications), strong pain medications, and especially benziodiazepines (which are known to cause prolonged confusion in the elderly)

- be sure to include herbs, vitamins, and alternatives on your medication list as these especially may affect blood thinners and thyroid medications and may have other interactions or side effects your doctor may advise you about

- bring a copy of your last primary care progress note to visits with specialists and be sure the specialists always fax a note or copy of their recommendations to your doctor

- share your advance directive or living will with your entire family and with your doctor, to be sure that your wishes are honored at the end of life

- read up on your disease process and ask lots of questions to be sure that you understand the treatment plan, the expected outcome, and alternative options

- write a list of questions to set the agenda for the visit; however, also recognize that your provider may not be able to tackle more than a few issues in a single visit and follow-up may be needed

- work with your doctor toward your healthcare goals and share responsibility for the details of your care and treatment decisions.

- if you are caring for a family member who is hospitalized, be sure to sleep at home at least some of the time and to eat three meals a day.  Caregiver stress can be very overwhelming.

- if your loved one is confused or forgetful, be sure to attend appointments with him or her or send a caregiver who knows the details

- if things are not going well, either with patient care or communication within the hospital setting, ask to speak with a charge nurse or patient services representative.

- have a primary care doctor whom you trust, who communicates well with you, and share care

"I'm going to live until I die."  Quote from 89 year old patient I saw this week.
"You're in great shape for the shape you're in!"  Quoted my predecessor and mentor, Dr. Jerome Koeppel.