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Education, Patient Care, Stanford Medicine Unplugged

As long as I have these hands

As long as I have these hands

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

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In neurology clinic, I was asked to see a young man with epilepsy — a seizure disorder — due to cerebral palsy from birth. It was one of my first clinical encounters of my first rotation of medical school, the tenuous transition from knowledge-absorber to translator and caretaker. I walked in to find a patient who was wheelchair-bound and largely non-verbal, and who interacted with the world by tracking gaze and moving his arms. He held a toy in one hand that he rotated constantly; the other lay limp on the side of the chair.

I read in the medical record that he attended a day program where he enjoyed watching other children play ball and liked giving high-fives. So instead of launching immediately into an interview of his parents for recent medical symptoms, I asked my patient for a high-five.

At first he didn’t respond, his body like stone. The father patted him on the chest several times, hard, signaling to his son to make the movement while asking him in Spanish to do so. I winced at the vigor of each tap. But soon the young man responded. He put out his hand towards mine, his eyes locked on me, and we high-fived, softly and repeatedly. When I move my hand higher, or to the side, he followed excitedly, and he did not want to stop high-fiving me until the visit ended. “He likes you,” the father said, his fiercely protective expression softening a bit.

When my portion of the interview was over, the supervising neurologist entered the room. After ensuring that the patient’s seizures were under good control, the doctor asked if the family wanted to consider an injection that would help reduce the young man’s oral secretions.

“Won’t that give him a dry mouth?” asked the father. “I don’t want him to suffer. I don’t want his mouth to be dry.” There was so much history to his mistrust; when the doctors had previously offered a surgery to help improve his son’s ability to walk, the son had ended up in this wheelchair. The mother shook her head before the words even left the doctor’s mouth, her red lips pursed. She looked at me imploringly, as if I would understand.  “No, no, no,” she said, holding up her arms to me. “As long as I have these hands, I can clean his drool.” Then, to the doctor, “I don’t mind.”

The doctor inquired again, suggesting that the oral secretions might be minimized by this injection and that it wouldn’t be permanent. “As long as I have these hands,” the mother said again, and I could read the depths of her care by the way she held her hands in the air, emphatically, hands that had mothered a son for many more years than she could have ever anticipated, but hands that had done so patiently, willingly, with no hesitation. Her hands will wipe his drool, no matter how much drips out of the corner of his mouth. She does not mind.

Now that I have completed most of my medical school rotations, I find myself returning to the phrase as long as I have these hands.

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Big data, Dermatology, Palliative Care, Patient Care, Precision health, Stanford News

Wounds too deep to heal: Study sheds light on which wounds may need special care

Wounds too deep to heal: Study sheds light on which wounds may need special care

WoundKids heal fast; old folks a lot more slowly. We all know that. But what happens when wounds take far longer to heal than is normal? Is it possible to predict which wounds need extra care?

Nigam Shah, MBBS, PhD, a Stanford associate professor of medicine, took another one of his deep dives into patient medical records to find out. The result is a creative proof-of-concept model that can predict which wounds need special care.

Earlier work has shown that even very simple models of wound healing can help caregivers pay attention to the wounds most likely to take 15 weeks or longer to heal, the definition of delayed healing.

For this work, Shah, an expert in biomedical informatics; first author Kenneth Jung, a research scientist at Stanford; and a national team of researchers turned to a dataset consisting of more than 150,000 wounds from more than 53,000 people. The team looked at hundreds of variables from patient records, including, for example the length, breadth, area, and depth of wounds, and how old patients were. The wounds in the study ranged from bed sores or diabetic ulcers to surgical or trauma wounds.

The researchers randomly assigned patients to one of two groups. One group constituted the raw data on which computers could learn which factors predicted slow wound healing in order to create a predictive model. The other group was the test that showed that the model worked on a new, and previously unseen, separate set of data.

They found that the best 100 predictors accounted for 95 percent of the influence on whether wounds were slow to heal. The single most important predictor of poor wound healing was whether a patient was receiving palliative care. Other good predictors of poor wound healing were the patient’s age, the size of the wound and how quickly it began healing in the first week.

The model’s strengths are that it works regardless of the kind of wound and it can be customized for different situations. However, as noted in the paper, the model was developed within the confines of a single company — a chain of specialty wound-care clinics called Healogics — so the model may not necessarily apply to wound healing at other institutions or for patients at home.

The paper, which made the front cover of the journal Wound Repair and Regeneration yesterday, is accessible for an academic paper — so if you’re interested in learning more about using patient records to create predictive health-care models, check it out.

Previously: Stanford researchers investigate source of scarring and To boldly go into a scar-free future: Stanford researchers tackle wound healing
Art — The Incredulity of Saint Thomas by Caravaggio — from Wikimedia

Neuroscience, Patient Care, Stanford News, Videos

Stanford Neuroscience Health Center opens to patients today

Stanford Neuroscience Health Center opens to patients today

Today, the Stanford Neuroscience Health Center officially opened its doors. Every part of the five-story, 92,000-square-feet building was designed with patients in mind.

As neurologist Jeffrey Dunn, MD, explains in the video above: “The medical architecture of the last generation placed the physician at the center of things. This building flips that. It puts the patient at the center of all things we do.”

Enjoy the tour.

Previously: Celebrating the new Stanford Neuroscience Health Center and Building for collaboration spurs innovative science

Mental Health, Patient Care, Rural Health

Horse therapy could help people cope with early-onset dementia

Duell and Paula HertelAs a kid growing up in rural Minnesota, I spent many of my waking hours searching for a reason to be near the five horses that roamed the 40 acres behind our house. Their methodical munching and tail-swishing put me at ease and learning how to ride a 1,200-pound animal that could easily wipe me off on a fence post taught me much of what I know about courage and persistence.

A similar sense of calm, accomplishment and fortitude are among the potential benefits of a new pilot study at Stanford University’s Red Barn called the Connected Horse Project. This project aims to help people learn how to manage the symptoms of early-stage dementia through a series of workshops where they participate in supervised activities with horses.

The project is the brainchild of Paula Hertel, Nancy Schier Anzelmo and Elke Tekin, three senior care practitioners and equestrians who work at the Senior Living Consult. For this study they worked with Stanford’s Dolores Gallagher Thompson, PhD, and Nusha Askari, PhD, and Jacqueline Hartman at the Stanford Red Barn Leadership Program.

In the pilot study, five individuals and their care partners participated in a three-week workshop. The study measures the workshop’s effect on the participants’ stress levels, their quality of sleep and their ability to relate to and communicate with others. The results will be presented at Stanford’s Annual Community Health Symposium on Jan. 14 and will be used to develop programs that can be implemented throughout the country, including in rural areas where support services are often lacking.

Hertel and Schier Anzelmo told me more about the program and its potential applications in an email interview:

What prompted you to start the Connected Horse Project?

A shared passion is the simple answer. We are practitioners in senior care and know firsthand that traditional models of care are not adequate. We have also experienced the power of the human/horse connection on a personal level.

Why horses? Do you think a program that pairs humans with dogs or cats could work as well or in the same way? 

Many of us smile when we think about our favorite dog or cat, or in my [Paula’s] case, my first pony. Interactions with animals spark emotional memories that stay intact. Horses can be particularly therapeutic for people because they have an innate ability to sense what others around them feel; they depend on the herd for survival.

In the workshop, the equine facilitators guide the participants through activities that showcase the horses’ characteristics and abilities. This helps the participants recognize their own strengths and the power of their relationships with others.

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Education, Health Costs, In the News, Patient Care, Research, Stanford News, Technology

Medical errors caused by doctors not examining their patients

Medical errors caused by doctors not examining their patients

800px-Child_examined_by_doctorStories of shocking medical errors that occur because doctors miss something during a physical exam — or forget to examine a patient at all — are common. Every physician knows them, says Stanford physician Abraham Verghese.

A missed breast mass in a patient that presents with chest pain. A missed gunshot wound in a patient wheeled into the emergency room. A missed pregnancy in a patient with a large belly.

But little has been done to quantify this type of medical error. In a first step toward creating data-based measurements of medical errors due to inadequacies in the physical exam, a study published recently in the American Journal of Medicine reports on a collection of 208 such occurrences, and their consequences.

I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition.

Researchers collected the incidents from responses to surveys sent to 5,000 physicians asking for first-hand stories of such medical errors. The cause of the oversights in the 208 responses was most often a failure to perform the physical examination at all — in 63 percent of the cases, the study states. Other times, errors were caused by misinterpretating or overlooking physical signs.

“I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition,” says Verghese, who is known as a champion of bedside medicine. “I call it the ‘low hanging fruit,'” he says, referring to the simple yet essential process of conducting the physical exam — and its low cost.

The consequences of these mostly preventable mistakes varied from missed or delayed diagnoses in 65 percent of the patients, to incorrect diagnosis in 27 percent or unnecessary treatment in 18 percent, the study says.

“We are talking about missing things that are very common, a mass, or a sore or a heart murmur or something in the lungs, that leads you down the wrong path,” says John Ioannidis, MD, senior author of the study. “This is something that happens everyday, and it’s something that could be corrected to a good extent.”

A well-known report conducted by the Institute of Medicine titled, “To Err is Human,” found that medical errors cause nearly 100,000 deaths per year, according to the study. The extent to which physical examination errors contribute to this figure remains uncertain and, as a result, little has been done to prevent them, it says.

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Aging, Chronic Disease, Neuroscience, Patient Care, Research, Stanford News, Stroke

Stanford study: Commonly used sleeping pill may boost stroke recovery

Stanford study: Commonly used sleeping pill may boost stroke recovery

sleeping pillIf what works in mice works in people, a widely popular sleeping pill could someday start seeing action as an aid to stroke recovery, according to a study carried out by Stanford neuroscientists Gary Steinberg, MD, PhD, and Tonya Bliss, PhD, and published in Brain.

Count to 40. Chances are that sometime between when you start and when you finish, someone in the United States will experience a stroke. That’s how common they are: about 800,000 strokes every year in the U.S., and – far from being confined to rich countries – around 35 million worldwide.

But that’s just the number of new strokes annually. Unfortunately, a stroke isn’t something you just get and then get over. Few people fully recover, leaving some 5.4 million Americans currently saddled with stroke-caused disabilities.

The main way for anyone incurring a stroke to minimize its damage is to get to a treatment center right away. As I wrote in a news release summarizing the study’s findings:

A stroke’s initial damage, which arises when the blood supply to part of the brain is blocked, occurs within the first several hours. Drugs and mechanical devices for clearing the blockage are available, but to be effective they must be initiated within several hours of the stroke’s onset. As a result, fewer than 10 percent of stroke patients benefit from them.

I repeat: Get to a treatment center right away. Don’t wait “to see if it blows over.” But since even in the best-case scenario many stroke sufferers will sustain some brain damage, the next best thing is a treatment that could help undo that damage – if only there were one.

Sad to say, no effective treatments during the recovery phase exist other than physical therapy, which has been shown to be only marginally successful. So anything that could enhance patients’ recovery during the  three- to six-month post-stroke period when 90 percent of whatever recovery a patient’s going to experience occurs, as a rule, would be a home run.

In their study, Steinberg, Bliss and their colleagues swung for the fences. They induced strokes in animal models, then waited for a few days to make sure that what they planned to do next, if it helped, was working during the recovery phase rather than the rush-rush damage-control phase.

Then they gave some of the mice the FDA-approved insomnia drug zolpidem (better known by the trade name Ambien) and others a control solution that did not contain the drug. Over the next month, they compared the mice’s performance on various tests of sensory and motor-coordination ability. By several measures, the zolpidem-treated mice were back at their pre-stroke levels within a few days of treatment; the control mice took the entire month. (Unlike humans, mice do eventually recover from strokes even when untreated.)

Mice are mice, and humans are humans. But Zolpidem’s already-on-the-market status greatly improves the prospects for clinical trials of the drug. And wouldn’t it be ironic if faculties slumbering under a stroke’s spell could be awakened by a pill designed to put us asleep?

Previously: Targeted brain stimulation of specific brain cells aids stroke recovery in mice, Calling all pharmacologists: Stroke-recovery mechanism found, small molecule needed and Brain sponge: Stroke treatment may extend time to prevent brain damage
Photo by Guian Bolisay

Cancer, Pain, Palliative Care, Patient Care, Public Health, Stanford News

Ernest and Isadora Rosenbaum Library: A free, comprehensive guide to living with cancer

Ernest and Isadora Rosenbaum Library: A free, comprehensive guide to living with cancer

Spiegel in office - 600“What’s it like to be told you have cancer?” I asked a friend recently. She told me she was shocked to have received the news, and that this shock quickly gave way to a seemingly endless string of questions. How did I get cancer? What’s the best treatment? What will my care be like? What will the rest of my life be like?

As we talked, I learned that getting her the best care possible, although important, wasn’t the only thing she needed to survive. An equally important need was the peace of mind she regained when her doctors, caregivers and loved-ones helped her tackle her unanswered questions.

Addressing the questions and needs of cancer patients, like my friend, is the primary aim of the web-based Ernest and Isadora Rosenbaum Library at Stanford’s Center for Integrative Medicine.

Recently, I had the opportunity to talk about the library with the center’s medical director, psychiatrist David Spiegel, MD. Spiegel first came to know the late Ernest Rosenbaum, MD, through Rosenbaum’s work at San Francisco’s Mt. Zion Hospital. Rosenbaum treated cancer by addressing the patient as a whole – considering not just patients’ physical needs, but their emotional ones as well – and, at the time, his approach was groundbreaking. He wrote Everyone’s Guide to Supportive Cancer Care, Everyone’s Guide to Cancer Therapy and The Inner Fire decades before such support was recommended by the Institute of Medicine in its report, Lost in Transition, long before the National Cancer Institute had an Office of Cancer Survivorship, and before palliative care was widely talked about.

When Spiegel opened the Stanford Center for Integrative Medicine in 1998, Rosenbaum brought his cancer supportive care program to Stanford. There, Rosenbaum and colleagues gave and recorded talks and penned articles that address the many scientific and emotional aspects of cancer care.

Ernie and IzzyRosenbaum bequeathed his writings to Stanford when he passed away in 2010. Volunteer Vahe Katros did the hard work of bringing this material to the web, donating hundreds of hours to bring the website to life. “Vahe represents the best in those who volunteer to help cancer patients, and he shows how we can all help one another,” Spiegel said.

Visitors to the online library will find information on such things as coping with cancer, sources of support, the value of forgiveness and the role of creativity – “topics [that] Rosenbaum selected due to his being personally being involved in the struggles of thousands,” Spiegel explained. The library contains excerpts from Rosenbaum’s book, The Inner Fire, and will be expanded in 2016 to include writings from his unpublished final work and additional content.

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Cancer, Patient Care

How a kidney cancer survivor became a partner in his care

How a kidney cancer survivor became a partner in his care

We’ve partnered with Inspire, a company that builds and manages online support communities for patients and caregivers, to launch a patient-focused series here on Scope. Once a month, patients affected by serious and often rare diseases share their unique stories; this month’s column comes from cancer survivor and advocate Michael Lawing.

My life changed forever on a cold rainy November afternoon in 1997 as I sat in a crowded emergency room. A surgical urologist knelt beside my chair and uttered five words, “You have cancer; it’s bad.”

A week later, the day after Thanksgiving, a huge tumor that had completely enveloped my right kidney was removed.

Prior to that diagnosis I had never heard of kidney cancer and had little experience with the medical community. I had not been to a doctor in years and viewed that profession as one filled with persons who had a good education, commanded a lot of respect, had a luxurious lifestyle, and enjoyed a life of relative ease. As it turned out, I was not only ignorant about kidney cancer, I had a lot of misconceptions about doctors and the entire medical profession.

I now view medical appointments in much the same way that a salesperson would view appointments with prospective clients.

In 2000, I was referred to a specialist in a medical center some 90 miles from my home. This oncologist was knowledgeable about the only treatment that had any degree of success in kidney cancer, a very rigorous infusion therapy with many side effects that required hospitalization.

A year later, cancer was found in lymph nodes in my abdomen, and I entered the hospital to begin treatments with interleukin-2 (IL-2). Although I had been impressed by the patience and skill of this doctor, it was during the IL-2 treatments that I began to really see his commitment and dedication to his patients.

His daily schedule was impressive. The doctor would arrive each morning at 6 a.m. to review the treatment notes of the two or three patients receiving IL-2, pay each of us a visit and then would be off to see patients in the clinic or to perform surgeries. He would usually stop by during the day and he would always come by in the afternoon or evening before going home. That visit would often be after 6 or 7 p.m.

In addition to those visits, he had to be called by the nurse prior to giving an infusion to a patient. Since the patient could receive an infusion as often as every eight hours if everything was okay, this meant a call to his home in the night; sometimes he would receive several calls if patients were on different schedules.

In the ensuing years since those treatments, I’ve come to realize that the vast majority of doctors, nurses and other healthcare professionals have a very similar commitment and passion for their work. It is therefore only reasonable that I should honor that commitment and passion when I’m seeing them for an appointment.

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Neuroscience, Patient Care, Stanford News

Celebrating the new Stanford Neuroscience Health Center

Celebrating the new Stanford Neuroscience Health Center

neuro health center ribbon cutting - 560

The first time Chris Bjornson walked through the infusion area in the new Stanford Neuroscience Health Center, he couldn’t stop smiling. Bjornson, 45, was diagnosed with multiple sclerosis seven years ago. He’s happy with how well his doctor, neuro-immunologist Jeffrey Dunn, MD, has worked with him to control the progress of a disease that has gradually eroded Bjornson’s ability to walk.

Getting to his appointments, however, was something else. Many neurological disorders and injuries leave people with less ability to maneuver through crowded hallways, negotiate the changes in texture from one type of floor covering to another or endure going from one place to another to see different specialists. High countertops, narrow bathroom stalls and tight turns at corners become additional obstacles.

Stanford doctors agreed that asking patients to make such a difficult journey for care had to change. They also knew that that change couldn’t be done by renovating the several buildings that now house the Department of Neurology and Neurological Sciences and the Department of Neurosurgery. Only a from-scratch approach would work.

Last week, Stanford Health Care, in partnership with the Stanford School of Medicine, cut the ribbons to officially open the new Stanford Neuroscience Health Center for outpatient care. It’s a five-story, 92,000-square-foot building on the medical school campus. The exterior is, of course, brightly new and sparkling. It is the interior, however, where the center shows its best.

Hallways, floor coverings, lighting, chairs, bathrooms and the building’s floor-by-floor organization all reflect what the Center’s 12-person Patient Advisory Council told Stanford Health Care would eliminate those physical barriers to care — and, as a consequence, their stress. The infusion center that so impressed Bjornson has no dark corners or tiny treatment rooms. Instead, the area is filled with the light and views from three walls of windows.

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Health and Fitness, Patient Care, Public Health

Doctor’s visits should include exercise check, researchers urge

Doctor's visits should include exercise check, researchers urge

21189950643_4982e7769a_zEvidence on the health benefits of exercise abounds. Despite that, exercise is discussed in fewer than 40 percent of doctors’ exams in the United States, and that needs to change, a team of researchers including Stanford’s Kathy Berra, MSN, NP-BC, wrote last week in a piece in the Journal of the American Medical Association. Berra is affiliated with the Stanford Prevention Research Center.

“The lack of physical activity counseling in clinical settings represents a lost opportunity to improve the health and well-being of patients, and with minimal cost,” the team wrote.

It can be as easy as having a medical assistant ask a patient if he or she exercises while measuring blood pressure, temperature and weight, Berra told me. Physicians or nurses can then follow up and offer congratulations for a job well done or offer suggestions to incorporate or improve exercise regimes, she said.

“It shows the patient you are really interested in them doing well, interested as much in activity as in giving them another pill,” she said.

Asking the patients to keep and exercise record can also be very effective, the researchers write. Health-care providers should then ask to see it on subsequent visits. “There’s a lot of competition for time during office visits, but it doesn’t have to take a long time,” Berra said.

The key is keeping the tone motivational and expressing genuine interest, she said. Clinicians can also offer a list of helpful apps or refer patients to a community gym or exercise program, they researchers wrote.

Berra said she added her voice to a nationwide chorus calling for health-care providers to get more involved in exercise advocacy.

Previously: Examining the long-term health benefits for women of exercise in adolescence, Study clarifies link between dieting, exercise and reduced inflammation
Photo by Dragan

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