Top Doctors 2007
The Crossroads of Medicine At any moment of any day, someone who is ill or injured can come through the doors of an emergency room in New Hampshire. The physician on duty has to know how to handle whatever it is — quickly and calmly. We talked to two emergency physicians, both chosen by their peers as Top Doctors, about the stresses and the rewards of their work. By Barbara Coles / Photos by John Hession The emergency room is quiet right now,just a few patients with minor problems being treated. But that will soon change — there are three ambulances headed there from a bad accident on I-93. It is a typical scenario for the state’s emergency departments — where the only constant is change. “You always know things will change,” says emergency physician Michael Lynch of Concord Hospital. “It can very quickly go from quiet to busy and fast, and you always have to be prepared mentally and logically.” And with 24 ambulance services using Concord Hospital, every day brings new challenges. Across the state, at Dartmouth-Hitchcock Medical Center, some 30,000 people a year use the emergency department, many of them arriving by helicopter. “We are the only level 1 trauma center in the state,” says Dr. Norman Yanofsky, the emergency department medical director, “so patients from all over New Hampshire, Vermont and, occasionally, New York are transferred here, usually with severe injuries.” The emergency physician's first job is to stabilize the patient and then make the diagnosis — and it frequently has to be done quickly. “That is one of the biggest parts of our training,” says Lynch. “You see many different cases under stressful conditions in training, so that the necessary procedures and treatments become automatic. Frequently there are only a few possible diagnoses, given a set of symptoms and physical findings.” Lynch adds that, because emergency medicine is a gateway to the hospital, it touches nearly all parts of medicine and all parts of the hospital. “We have to know a little bit about everything, but we also have to be comfortable not being the expert on most things.” The most common reasons for going to the emergency department are chest pain, abdominal pain and trauma. If someone arrives at 2 a.m. needing a lab or a CAT scan, they can get it, with results coming back quickly. At DHMC, if specialists are needed they are available 24 hours a day. That’s required for certification as a level 1 trauma center.
Other hospitals in the state are not as fortunate when it comes to always having specialists available, especially if the specialist is a neurosurgeon, because there is a serious shortage of them. “There are three on-call neurosurgeons covering the whole southern half of the state, and they can’t be in three places at once,” says Lynch. “If we can’t get a neurosurgeon, we stabilize the patient and send them to Dartmouth-Hitchcock or Boston. There’s no other way.” The shortage, in large part, is the result of the difficulties of on-call work and the higher liability risk with emergency patients. Another shortage that impacts emergency medicine — hospital beds. The national movement to reduce health care costs has significantly reduced the number of hospital beds available. Both Concord Hospital and Dartmouth-Hitchcock are working to address that, but in the meantime emergency departments sometimes have to deal with “boarding.” That’s when sick or injured patients who have been admitted to the hospital have to spend the night in the emergency room because there are no beds available. The situation is much more critical in other parts of the country, where patients are boarded more often and for longer periods of time. The issue is starting to get the attention of Congress. Rep. Bart Gordon of (D-Tenn.) says, “Too many of our nation’s emergency departments are overcrowded, underfunded and stretched to the breaking point.” He and others have sponsored legislation that would: require hospitals to report to HHS the amount of time admitted patients are being boarded, with action to be taken if the data justifies it; authorize additional payment through Medicare to on-call specialists; and create a commission to examine factors that impede delivery of emergency medical services, including high medical liability insurance premiums. One issue that is not addressed by the legislation — caring for the uninsured. “Patients tell me they can’t afford a doctor’s office appointment,” Dr. Yanofsky says, “but they pay five times as much for the emergency department. It doesn’t make sense.” Often, though, the care is never paid for, and hospitals and the insured — with higher premiums — pick up the tab, essentially making it an unfunded federal mandate. Both Yanofsky and Lynch say that, whether someone is insured or not, the care they give is the same. Ask Dr. Lynch about a case that stands out for him and he talks about the little girl who sustained a head injury in a sledding accident. “Within a half hour she became comatose and had trouble breathing,” Lynch says. “We got a CAT scan, intubated her and gave her medication to decrease pressure on her brain, all in 30 or 40 minutes. She was stabilized and made it to the OR in time for the neurosurgeon to save her. She was in school four days later. That’s the kind of thing that makes it all worthwhile.” Dr. Yanofsky agrees: “When you get someone who is very sick, and you turn it around and they go home, it’s very satisfying.” NH Medical Mysteries By Rick Broussard Everyone loves a good mystery, unless the puzzle involves their own pain and suffering. At Dartmouth-Hitchcock Medical Center, each week a team of medical detectives searches for clues that can lead to new cures. Every Wednesday at Dartmouth-Hitchcock Medical Center, a group of health care specialists and Dartmouth College faculty members takes a break from rounds and classes and gathers to hear mystery stories. Ears perked for details, eyes sharply focused on a slideshow and a whiteboard, they listen as another physician spins the tale. To the untrained eye and ear, the details of the story might soon be lost in the maze of technical jargon, acronyms and symbols hastily scribbled in different color ink, but the lure is obvious. Somewhere in that thicket of diagnosis and conjecture is a treasure waiting to be found, a secret of medicine that could be worth more than gold - could be worth life itself. Dr. Jonathan Ross has overseen these sessions, known as the weekly Mortality and Morbidity session, for 18 years. He spends time before each session helping the resident who will present the week’s case figure out what elements to include and how it should unfold. The goal is to stimulate thinking by presenting the case in stages, each one eliciting a variety of possible conclusions — much the way that real cases present themselves to physicians and medical staff, who must sometimes make life or death decisions using only the facts available to them. Once the hour of M&M is done, the presenting physician receives a round of applause, but the real reward is knowing that everyone leaves a bit wiser and more prepared. But part of that wisdom is knowing that, even after all that scrutiny, questions remain. Saga of the Sick Shriners Sometimes medical mysteries play out on a larger scale and in full view of the public. Such a case in 1966 gave the DHMC, then known as the Mary Hitchcock Hospital, a chance to provide a lesson to the entire country. It was on a humid Saturday in August with the temperatures in the ’80s, but people lined the streets of Hanover to witness the Shrine Parade, a colorful prelude to the annual Maple Sugar Bowl football game between New Hampshire and Vermont high-school all stars. Even patients from nearby Mary Hitchcock Hospital had been rolled out in wheelchairs and gurneys to join the spectators as the bands, clowns and Shriners from all over the Northeast rolled by in their comical display of costumes, convertibles and noisy mini-bikes. But soon a different kind of parade began, as the Mary Hitchcock emergency room began filling up. One doctor recalls a colleague saying, "You've got to come in and help me. We have an emergency room and a lobby full of sick Shriners. They are trying to be gentlemanly, not make a mess, and some are vomiting into their fezzes as they come through the door." Doctors on staff were able to rule out most infectious diseases, since the symptoms of violent projectile vomiting and diarrhea were not accompanied by fever, but it took a while to discover the culprit in this low-grade medical mystery. The common denominator was group of men who had traveled together on a summer day in hot cars and busses. Soon the list of prospects narrowed to one: The affected Shriners’ lunch boxes had all been prepared by the same western Massachusetts caterer. A pathologist examined a sandwich and determined that staphylococcus aureus, a common organism found on the skin or in nasal cavities, had probably been transmitted by a food preparer to the ham and potato salads. A two-hour ride in the sun allowed the bacteria to propagate and generate sufficient toxins to cause the symptoms. What seems like a mundane solution, now, was pretty eye-opening at the time, and contributed to the general public awareness of the dangers of improperly storing food, particularly high-protein fare, such as cream-filled pastries or ham, chicken, potato and egg salads. Medicine has grown much more complex in the 40 years since that episode, but the basic tool of learning is essentially the same, whether handled on the fly in an emergency, or in the cool intellectual repose of an M&M session. Life and health and its enemies are always, fundamentally, mysterious. Doctors look at each medical disorder as a puzzle that must be solved, and in the plot that results, new mysteries appear and beg for solutions. This may sound a bit like the storyline to a popular TV drama, and it is. In the award-winning FOX TV series “House,” actor Hugh Laurie portrays Dr. Gregory House, a brilliantly twisted pathologist who leads team of diagnosticians as they attack a bizarre medical mystery each week. But even this program is based on older sources, ranging from the dialogues of Socrates to the unravelings of Sherlock Holmes to the less known but highly influential writings of a man named Berton Roueche, who wrote medical mysteries up in novel form and produced a series for the New Yorker magazine for 40 years in the latter half of the 20th century. The creator of House acknowledges Roueche as an inspiration. Baby Sings the Blues Roueche was certainly an inspiration to generations of diagnosticians, including Dartmouth toxicologist Roger Smith. After a long career at Dartmouth Medical School, Smith has retired, but he continues to teach and to write on medical mysteries. Smith notes on his Web site. "One of my favorites [of Roueche's stories] was 'Eleven Blue Men.' Perhaps it was only a coincidence that I was to spend 40 years at Dartmouth Medical School exploring related areas." “Eleven Blue Men” outlined a strange case of chemical poisoning which fascinated Smith as a toxicologist. Smith went on to conduct clinical investigations of a phenomenon known as “blue baby syndrome” in which the red iron content of the hemoglobin essentially “rusts” and turns dark, creating the blue or cyanotic appearance, first around the mouth and other membranes, then over the skin. Rural well water was thought by many to be the cause. Smith’s exhaustive report on the syndrome revealed one of its likely causes — the ability of bacteria like e coli, common in farm ponds, to convert common nitrates, used in fertilizers, to more hazardous “nitrites.” The implications of the research stretched from infant mortality to deformations in frogs living in agricultural wetlands. A Do-it-yourself Diagnosis An ABC News episode of “Primetime: Medical Mysteries” that aired in January offered millions of viewers a chance to participate in a kind of televised Morbidity and Mortality session. Diana Wyman and her husband Curtis live deep in the woods of New Hampshire and raise llamas. Diana cares for the animals, morning and night, so when she came down with an ear infection and started feeling weak, she couldn’t just pull the covers over her head. She got a prescription for antibiotics, but soon she had lost 10 pounds and was sleeping 18 hours a day. She also developed a rash. Soon she could not stand and her legs were black and blue from the knees down. Primetime posed the question to its viewers: Was Diana suffering from: A. A nutritional deficiency B. An infection, maybe caused by the llamas C. Cancer D. A circulatory disease. Dr. Osei Bonsu was on call at DHMC when the Wymans arrived. The professional diagnosticians got busy. Most suspected an animal-borne illness, but Dr. Jonathan Ross was summoned for an opinion. He began to focus instead on Diana’s diet and soon discovered she didn’t eat citrus fruits (they upset her stomach), and she also avoided milk and soy. Her husband admitted: “I can name what she eats on five fingers.” Ross’s diagnosis: A rare case of scurvy — that old sailor’s disease caused by a lack of vitamin C. So if you guessed “A,” consider yourself an amateur diagnostician, and then kick back and watch an episode of House with a smug grin on your face. But don’t get too cocky. It’s a mysterious world out there. NH Art ImitatIng Reality Ever wonder whether physicians watch the TV doctor shows like “E.R.” and “Grey’s Anatomy?” We did, so we asked Drs. Lynch and Yanofsky. Dr. Lynch says he watches “Grey’s Anatomy” with his two teenage daughters. In the episode that portrayed Meredith Grey’s near drowning, he says he was reassuring his worried daughters that Meredith wasn’t going to die. He believed that was the case, first, because the show had to go on and Meredith was the title character. Second, he says, “They said she was hypothermic from the cold water. That slows the metabolic rate to the point where you almost hibernate, which preserves the organs.” He adds, though, “It’s unlikely she would have been breathing on her own so quickly, much less waking up and talking to Derek.” Lynch is also a fan of “E.R.,” which he says is pretty accurate because the creator, Michael Crichton, is an M.D. Dr. Yanofsky used to watch E.R. and agrees “the medicine is better than on any other program like it because they have emergency medicine consultants.” The stories speed up events by “at least 10 times,” he says. “It just doesn’t happen at that pace. To get that amount of drama would take two or three months in a real emergency department.” Plus, the “social stuff you see, the drama, is well beyond the normal course of events.” His favorite doctor show — “Scrubs,” which he says is “quite funny, but beyond reality.”