By Steve Adelman, MD

Earlier this month, the CDC’s Morbidity and Mortality Weekly Report (MMWR) presented alarming data comparing age-adjusted suicide rates between 1999 and 2010.

Historically, the two major causes of death of younger people have been motor vehicle accidents and suicide. As motor vehicle accident deaths have gone down, suicides have gone up: 2009 was the first year in which the number of people who put an end to their lives themselves was greater than the number who lost their lives in car accidents.

Overall, the suicide rate jumped by 28.4% among persons aged 35-64. The rate of increase was even greater for whites, American Indian/Alaska Natives, older women (60-64), and people living in the West. As usual, in most successful suicides the cause of death is firearms.

To put the numbers in perspective, let’s think about a busy, multispecialty ambulatory adult primary care practice that employs a group of 4 internists, 2 nurse practitioners and a physician assistant. In the course of a year, perhaps 12,000 unique patients are seen in the office. A practice of this sort in Massachusetts, New York or New Jersey is likely to see one patient die by suicide per year. In Midwestern practices of this size, a second patient suicide would be predicted.

Suicide, not murder, is the most prevalent form of firearm death in this country. What is the role of primary care physicians in addressing this worrisome, growing public health problem?

Provide an opening: Give patients in the office enough time and space to talk about the things that worry them and weigh on them. A question like, “Is there anything else going on that you’d like to share with me? “ may give permission for a suicidal person to open up. A comment like, “Sometimes the most important stuff is the hardest to talk about….I’m all ears,” followed by enough time for the patient to think and open up, can make a difference.

Know your patient’s psychiatric history: Many elements in a patient’s history elevate the risk of suicide: a history of previous suicide attempts, a known mood disorder, a history of a substance use disorder, recent losses, and family history of suicide. Take the time to know your patients, and get help from mental professionals, as appropriate.

Clarify access to firearms: As firearms are the commonest proximate cause of violent deaths, physicians should understand whether or not their patients have access to firearms. It is appropriate to be worrying about high-risk patients with access to firearms, and to address this risk factor with the help of the patient’s family, mental health professionals, and, in some cases, the police.

Let patients know that the channels of communication are always open: People who know that they can always call and reach a health care professional have a place to turn when all else fails. Make sure that your practice has accessible 24/7 coverage, and that those covering know what to do when somebody suicidal calls for help.

In my next  post, I plan to discuss an important related topic: physician suicide. We have always been a high risk group, and this is especially worrisome in view of the recent overall increase in suicide.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org. Opinions expressed here are his own, and do not necessarily reflect those of the Massachusetts Medical Society or Physician Health Services.

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Event registration, online CME courses and members-only content on the MMS website will be unavailable for several hours starting at 5 p.m. on Thursday, May 23, so that we may apply important updates to the site.

Regular website content and member email services will not be affected by this brief outage.

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By Steve Adelman, MD

Nobody has asked me to write these words; they are mine, and mine alone.

I should have realized, before the fact, that my speculative blog post on a possible marijuana-marathon connection had the potential to offend many good people. In retrospect, I regret the fact that I linked a painful and horrific public tragedy to the alleged perpetrator’s reported use of marijuana. I didn’t intend to upset, provoke and irritate, but that is exactly what my blog posting has done. I feel bad that my words and ideas were offensive to others, and I have asked that the post be removed.

I see little point in attempting to explain what I was trying to accomplish with my speculative posting. Going forward, I plan to focus on topics concerning the health of physicians. With stress and burnout growing in the medical profession, there is much work to be done in this area. Physicians who take really good care of themselves are best able to help their patients. I plan to do my best to promote the health of caregivers and the public.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org. Opinions expressed here are his own, and do not necessarily reflect those of the Massachusetts Medical Society or Physician Health Services.

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Infectious diseases have plagued the globe for hundreds of years, and through those years, medicine has had its victories: the eradication of smallpox, vaccines for polio and other once-debilitating diseases, and the change from conditions originally thought to be killers, like AIDS and TB, to manageable chronic conditions.

Yet the battle against chronic infectious disease continues, and says the renowned Dr. Paul Farmer, the biggest problem we face today is one of health care delivery to treat – and possibly cure – those conditions.

Dr. Farmer, Kolokotrones University Professor at Harvard University and Chair of the Department of Global Health and Social Medicine at Harvard Medical School, provided a glimpse of the pitfalls and progress in combating infectious disease around the world in delivering the 123^rd Shattuck Lecture presented by the MMS Committee on Publications as part of the MMS Annual Meeting on Friday, May 10.

Well known as the founding director of the nonprofit international agency Partners in Health that works in poor environments around the globe, Dr. Farmer suggested that medicine’s view of fatalism from infectious diseases has being undermined with dramatic improvements in life expectancy and new therapies to treat disease.

While he noted that global life expectancy depends on a variety of factors, among them nutrition, sanitation, delivery of medical services, preventions, and cures, he pinpointed health care delivery as key to sustained improvement. “Health care delivery is the “least well studied,” he said, “and the bias against serious scrutiny of delivery needs to be overcome.”

Recounting his experience in fighting chronic infectious disease in countries around the world such as Haiti and Rwanda – and noting the successes in those nations – he said that the best delivery in poor areas includes community-based health workers who compliment doctors and nurses and hospitals and clinics.

From his vast experience, Dr. Farmer offered five lessons learned in fighting chronic disease:

• Drug resistance is here to stay, but its rate of emergence and spread can be slowed.
• Even the tardy introduction of robust delivery platforms leads, in settings of poverty, to improved outcomes as long as what is delivered is clinically effective.
• A shift from hospital- and clinic-based to community-based care should occur for tuberculosis patients who do not need inpatient or laboratory services.
• Therapeutic innovations need to be linked more rapidly to equitable delivery mechanisms (the “equity plan”).
• It’s not clear that any disease is helpfully termed “untreatable.”

Dr. Farmer concluded his address on a positive note, saying “we have every reason to be optimistic, with new agents being developed, and the growing activity to build integrated health systems.”

Dr. Farmer’s presentation, and biographical information, may be viewed here.

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From electronic health records to medical devices to the latest in research, technology is continuing to push into new frontiers in medicine, and that bodes well for patient care.

In introducing the 2013 Annual Education Program, Navigating the Currents of Change: Integrating Innovative Technologies Into Your Clinical Practice, MMS President Richard Aghababian, M.D. said “Incorporating technology into our approaches to patient care is one of the biggest challenges we face as physicians today. The tools and data we now have at our disposal are truly amazing. But we must balance the machines with the humans side of medicine.”

The educational program on Friday, May 10 included four distinguished clinicians and scientists who addressed concrete examples of how the latest technologies have made advances in the surveillance, diagnosis and management of disease, and how those technologies are being incorporated into patient care.

Dr. Robert L. Jesse, Principal Under Secretary of Health at the Department of Veterans Administration, discussed health information technology and how it affects patient care.

Dr. Marc Semigran, Medical Director of the Massachusetts General Hospital Heart Failure and Cardiac Transplant Program, talked about how technology and the latest medical devices are improving and extending the lives of patients with heart disease.

Dr. Suzanne  Topalian, Professor of Surgery and Oncology at Johns Hopkins School of Medicine, examined how nanotechnology and targeted immunotherapy are making progress in the battle against various forms of cancer.

Dr. John Moore, of MIT’s Media Lab, discussed the application of technology for patient empowerment within the medical home model.

The participants’ presentations, along with their biographical information, are available for viewing here.

Filed under: Electronic health records, Health IT, medical homes | No Comments »

The Commonwealth of Massachusetts has established a single web portal to access resources for post-Marathon recovery.

These resources include:

• Crisis counseling and support
• Federal disaster distress helpline
• In-person counseling support
• Assistance to businesses or organizations
• Home modification assistance
• Assistance for veterans
• Assistance for tax filers

Visit the Commonwealth’s website here.

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In the wake of the Boston Marathon bombing, the Israel Trauma Coalition (ITC) is arriving in Boston and offering two free workshops (on May 7, 9 and 10, as described below).  The number of available slots is limited, so Massachusetts physicians with an interest in participating should sign up right away.

These workshops are co-sponsored by the Massachusetts Department of Mental Health (DMH) and Department of Public Health (DPH) in collaboration with the Executive Office of Health and Human Services (EOHHS).

Psychological First Aid & Resilience in the Aftermath of Terrorism (Workshop #1)

Workshop Summary: This workshop will discuss the impacts of disaster on individuals and communities, techniques for working with impacted populations, and when to triage individuals to additional support.  Attendees will also learn the importance of self care and the importance of resilience both individually and for a community.  The Israel Trauma Coalition will incorporate their own response experience into the training.

Target Group: Licensed mental health clinicians or individuals who have served as crisis counselors in emergencies

Dates: May 7th or 10th (9am – 3pm)

May 7 – Location & Registration

• Talbot Conference Room, Hadley Building, 167 Lyman Street, Westborough Mass.
• Register for May 7th at: http://psychologicalresilience1.eventbrite.com

May 10 – Location & Registration

•  Boston Medical Intelligence Center.  This is located within Boston EMS Headquarters, Miranda-Creamer Building, 35 Northampton Street, Boston MA.  As you enter the garage there will be a large blue sign that reads Miranda-Creamer Elevators and a blue door on your far right. Exit the garage through that door and take elevator to the 6th floor. Once off the elevators, go through the double doors to your right. The Lawlor Regional Medical Intelligence Center is the fourth door on the right.
• Register for May 10th at: http://psychologicalresilience2.eventbrite.com

Introduction to Disaster Behavioral Health & the Impact Of Disaster On Communities (Workshop #2)

Workshop Summary: This workshop will provide an introduction to the psychological impacts of disaster on the community and how community members can assist individuals who have been impacted. A particular focus of the workshop will be the impact of terrorist events on immigrant communities.

Target Group: Social service employees, healthcare professionals, clergy and other natural helpers and community leaders

Date: May 9th (1 – 4pm)

• Location: Boston Room, Eric Lindeman Mental Health Center, 25 Staniford Street, Boston MA
• Register for May 9th at: http://impactofdisasteroncommunities.eventbrite.com

Please Note:

• Though registration is required, trainings are free and open.
• Lunch will not be provided at these events.
• CME credit will not be offered.
• Free on site parking is available at the Westborough workshop.  $5 garage parking is available at the Boston Medical Intelligence Center.  Attendees to the Lindeman Center trainings are strongly encouraged to take public transportation.  Paid parking and limited on street metered parking is available.

For further information contact Liam Seward (Director of Program Implementation and Emergency Management, DMH): Liam.Seward@State.MA.US (617) 626-8170

About ITC

The Israel Trauma Coalition (ITC) was created in 2001, on the initiative of the UJA-Federation of New York. Expanding from Direct Care to encompass Professional Training, Community-wide Interventions and emergency preparedness, ITC has consistently evolved its scope to address broader issues and needs.

The mission of the Israel Trauma Coalition (ITC) is to create a continuum of care in the trauma field, response and preparedness, by leveraging diverse resources to initiate, prioritize, and optimize services. The ITC provides a comprehensive view of the trauma field, whilst working towards strengthening community resilience and ensuring national emergency preparedness. The ITC harnesses the collective knowledge, expertise and experience of Israel’s leading NGO’s and government organizations- as no organization can do this work alone.

Filed under: Boston Marathon, Disaster Preparedness, violence | No Comments »

Exercising regularly, a good diet, and maintaining a proper weight are key steps medical experts consistently recommend for good health.  They’re also a good prescription for healthy joints and healthy aging. But apparently not enough people are taking the advice to heart.

Joint replacement is booming in health care, with more than a million people getting new joints every year, usually hips or knees.  And the numbers are expected
to increase as baby boomers approach their mid-sixties. Among the causes are normal wear and tear over decades of use, injuries, genetics, conditions such as arthritis, and high rates of obesity.

The May edition of Physician Focus provides an introduction into joint replacements with R. Scott Oliver, M.D., (photo, right) a board-certified orthopedic surgeon at Plymouth Bay Orthopedic Associates in Duxbury and Chief of Orthopedic Surgery at Jordan Hospital in Plymouth.  Hosting this edition is Bruce Karlin, M.D., (left) a primary care physician in Worcester.

Among the topics of conversation are why more people are getting joint replacements, how they are done, and what patients need to know before, during, and after surgery.  With models of a hip and knees, Dr. Oliver also provides viewers with a visual tour of replacement surgery.

Physician Focus is available for viewing on public access television stations throughout Massachusetts and also available online at www.massmed.org/physicianfocus, www.physicianfocus.org  and on iTunes at www.massmed.org/itunes.

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By Jacqueline DePasse, MD

As an internal medicine resident at Massachusetts General Hospital, many of my colleagues and friends were on the front lines. The following story comes from two co-workers who I spoke with as they tried to process the senselessness of these tragic events.

Dr. Zachary Landman, an orthopedics resident at Massachusetts General Hospital, had just finished examining a patient’s wound and was scribbling a note at the nursing station when he overheard rumors from the nursing staff of a bomb detonation at the Boston Marathon. He ducked into a call room and flipped on one of the rarely used televisions. After only a few seconds to take in the scene of smoke and chaos, he shut off the television and briskly walked towards the emergency department.

Dr. Elias Baedorf-Kassis sat in the Acute bay of the MGH emergency department. As a third year medicine resident on his ED triage rotation, his job that day was to evaluate patients in the emergency department and decide if they needed ICU level care, admission to an inpatient ward, or simply observation.

The day was fairly typical, and patients started to move from the ED to the inpatient units as the early afternoon wore on.  Suddenly the radio speaker crackled with an incoming report. Dr. Baedorf-Kassis expected to hear reports of an incoming med-flight or a cardiac arrest coming in via ambulance. Instead, over the speaker came reports of the attack. Everyone stopped what they were doing and listened. “At first we didn’t quite believe what we had heard,” he said.  “We weren’t sure if this was just a mistake…very quickly we realized that something serious was happening.” His thoughts flashed to his pregnant wife, who was one of the many spectators that day.

Dr. Landman had gowned up and was waiting by the ambulance door where he met the first wave of patients. “They just kept coming in through the door,” He estimates around twenty patients arrived in the first wave, the most critically injured among them. “The nature of the blast was such that it was a high temperature explosion and there was a lot of shrapnel. It’s difficult to quantify how many people came in, but I would estimate at least a dozen people had serious injuries and burns from the shrapnel.”

While Dr. Landman attended to the trauma victims, Dr. Baedorf-Kassis helped to coordinate staff members to clear the emergency department of any patients who were not involved with the trauma. Doctors began pouring into the emergency room. Some came from home wearing jeans and got straight to work assessing patients, sewing up lacerations, and getting beds cleared as quickly as possible. “We weren’t sure the extent of the casualties, if the first bomb was only the beginning, so we prepared for the worst possibility,” said Baedorf-Kassis.

As the ED was being cleared out by other specialties, the trauma surgeons and nurses organized themselves. In a typical day one or two trauma operating rooms may be running at a time. Now, there were six ORs open. A mass text page was sent out to all surgery residents to immediately stop any non-urgent work and come to the ED, where teams were formed with a junior and senior resident as well as an attending surgeon and nursing staff. “When an acute injury was found they would roll patients back to the OR and another team would step into place,” Landman recalls. Many residents repeatedly commented that the healthcare staff demonstrated incredible coordination and teamwork to safely and effectively treat the influx of patients.

The scene was described by anonymous residents as a “war zone” as patients with severed limbs and shrapnel injuries and horrific burns arrived to be treated. These injuries were unfamiliar to many staff members. The x-ray techs kept the machines constantly running to identify hidden shrapnel in patients’ bodies. Dozens of young, athletic runners and spectators appeared shell shocked, traumatized by what they had seen.

At this point there were overwhelming crowds in the ED. Police and security staff were placed at the entrance to the acute bay to only allow people in who were part of active trauma management. The internal medicine program director sent an email out to his residents to stem the influx of doctors, “Thanks to the many people who have already reached out to try and help. The current status is that the ED has more than enough doctors and is focusing on taking patients to the ORs and stabilizing people.  We appreciate the outpouring of support and hope everyone’s family and loved ones are safe.”

Dr. Baedorf-Kassis commented, “The medicine part was the easy part in a way. The harder thing about this experience was the fear of the unknown and the worry that your home was so vulnerable. Being able to focus on the medicine made things easier, we felt like we were being productive.” He breathed a sigh of relief when he found out that his wife was safely home.

With the crowds under control and most of the most critically ill patients in the operating room, the staff turned to the patients with lower acuity injuries. A significant number of patients were unable to hear because of the volume of the blast.  Many of the family members accompanying patients were also victims. As these patients were evaluated and treated, the ED began to return to normal, and by six o’clock thing had calmed down.

“There was a sense of teamwork and community…no jobs were below any member of the team.” Landman comments. “MGH had a huge influx of patients and two hours later the ED was empty with patients on the floors or in the operating room.”

It is challenging to see any silver lining in this horrific event. My colleagues and all of the members of the healthcare team rallied together in a phenomenal display of collaboration and teamwork. Though many were concerned about their own loved ones, they acted quickly in a professional and focused manner. I am incredibly proud to be working with many of the men and women at MGH who truly were heroes during this catastrophe.

Jacqueline DePasse, MD, is a first-year internal medicine resident at Massachusetts General Hospital. She has a B.A. from Stanford University and went to medical school at the University of California, San Francisco. Her professional interests include global health and technology, health policy, and writing. 

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By Steve Adelman, MD

In the past two days, I have had the privilege of participating in two large support sessions for volunteers who witnessed the horrors at the Boston Marathon finish line. The sessions were organized by the Boston Athletic Association, in conjunction with the Massachusetts Department of Public Health.

The purpose of these events was to give stressed and  traumatized volunteers an opportunity to come together, share their experiences, and to commence the process of regaining a sense of emotional well-being after having served a sudden and unexpected tour of duty in an urban war zone.

Sunday’s session took place at the Boston Sheraton on Boylston Street, not far from the finish line. Monday’s session took place at the offices of the Massachusetts Medical Society and Physician Health Services, in Waltham.

Many affected volunteers at each session expressed feelings that they wish they had done more. Virtually everybody at the scene was thrust into a chaotic and unpredictable situation, one that nobody anticipated. In the minutes after the blasts, most everyone at the scene of carnage experienced serious challenges to their sense of being competent and effective.

Although the results speak for themselves – many, many lives and limbs were saved by a superlative team effort – the members of the team are all feeling pretty bad. It’s as if they were saying, “I have no idea how our team won on Monday, because I certainly could have played better.”

Many of the survivors described awkward conversations in the community and the workplace:  “People call me a hero, but I don’t feel like a hero.” It’s very difficult to feel incompetent and to be told that you are a hero.

Several survivors have learned that people out there “just don’t know what to say.” After the manhunt ended on Friday, a common comment they heard was, “You must feel better now.” But they didn’t feel better – many of them felt worse.

Question: How do we talk to people who have recently endured extreme trauma?

Answer: Very little – better to listen than to talk.

Listen very carefully, and try to put yourself in their shoes. Ask open-ended questions and respect their answers and wishes. Follow the lead of the person you are listening to. Here are a few questions and comments to consider utilizing if you undertake a conversation with a traumatized person:

• Do you feel like talking?
• What would you like to talk about?
• Tell me more.
• What was that like?

Don’t assume that you know how the other person feels, and don’t assume that their experience of the trauma is what you imagine it to be. By asking gentle, empathic questions, you can help the trauma survivor to unburden himself or herself, but only if he or she wants to.

As an empathic listener, your job is to follow the other person’s lead, never to take the lead. If the survivor you are with prefers to remain silent, that’s okay. Just let them know that you’re ready to listen if they ever feel like talking.

Gregorio Billikopf Encina of the University of California Berkeley has referred to this form of “empathic listening” as “listening first aid.”

Now that the acute trauma of the Marathon explosions is beginning to subside, let’s approach our conversations with the survivors – in our communities and throughout the health care system – in a low-key, respectful, and empathic way. By applying “Listening First Aid,” we can promote healing by helping them to feel understood, by trying, as best we can, to see the fractured world through their eyes.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org.

Filed under: Boston Marathon, mental health, Physician Health, Steve Adelman, violence | 1 Comment »