Compassionomics

  Toward the end of his night shift, the attending physician was catching up on completing his charts for all the patients he treated overnight. He reviewed the resident physician’s note for John’s care: it looked okay; nothing unusual. But when he reviewed Jackie’s nursing notes, he noted something peculiar. She jotted down: “+BM”.

  “+BM”? What did that mean? He went and found Jackie and asked her.

  She explained: in her time talking to John, and showing him extra care, she learned that the patient was annoyed about being there because he was actually completely embarrassed to be there.

  “Embarrassed?” the physician asked. “What do you mean?”

  She went on, “He’s a really stoic and private guy, you know. Well, there was something he hadn’t said…and he was really embarrassed about it. I could tell that he didn’t want to talk about it at first, but over the night he warmed up to me.

  So here’s the real story: Over the past couple of days, he had been really constipated. He tried fiber, prune juice, you name it. It was not providing relief. He went to the bathroom right before bed and decided: ‘This was it.’ He was going to have a bowel movement, no matter what. He strained and strained and strained. And finally, he had a huge bowel movement (actually a ‘blowout,’ is what he said) and he instantly felt better in his stomach. But that was when his headache came on.”

  “When I was talking with him, he admitted that he was so embarrassed to be there. I remember him saying, ‘I feel so stupid—here as a patient in a trauma center in the middle of the night, surrounded by people who have real problems like car crashes and heart attacks—only because I overdid it in the bathroom. I’m an idiot.’”

  So when Jackie made the note “+BM,” that meant that the headache started when the patient was straining to have a bowel movement. As Jackie was speaking, she noted that the face of the attending physician was becoming more and more pale.

  “What’s the matter?” Jackie asked.

  “Oh my God…I missed it,” said the doc.

  “Does it matter?” asked Jackie.

  Before Jackie could even get an answer, the physician was off like a shot. This attending physician, who was a veteran of more than ten years in the emergency department and was known for being exceptionally calm—even in the most dire, life-and-death situations—was right now on fire. His body language made it clear: this was a red alert, all hands on deck moment.

  The attending physician grabbed the resident physician by the arm (which no one had ever seen him do before) and commanded, “Find that patient right now and get him back here immediately. Call the police to go to his house if you have to.” Just in case there was any grey area, he added, “This is no joke.”

  But the resident demurred. “It’s 5 a.m.,” he said. “This guy had to wait three hours, only to be told nothing was wrong and be discharged. He probably just fell asleep. He’s going to kill me if I wake him up and tell him to come back!” (By the way, this is the same resident physician who saw the “+BM” in the nursing notes and did not think to ask Jackie what it meant.) The resident thought his attending physician was crazy. The CT scan was fine; it was time to move on.

  The attending physician had enough of the eye rolling from his junior colleague. He was going to call the patient himself. He needed to make sure the patient would come back and could not entrust the communication to anyone else.

  Here’s the deal: There are many warning signs in patients with headache that can signal a potential catastrophic diagnosis, even if a CT scan of the brain is normal. A headache that starts when someone is straining—like having a bowel movement or lifting an exceptionally heavy weight—can signal that it is a brain aneurysm that has popped (i.e., ruptured, bleeding).

  An aneurysm is an abnormality—actually, an enlargement—of a blood vessel caused by a weakening of the blood vessel wall. A brain aneurysm can be difficult to diagnose in the emergency department, and it doesn’t get any more high stakes than this.

  A bleeding brain aneurysm, if not diagnosed and treated promptly, can result in devastating brain damage and is often fatal. In the earliest stages of a bleeding brain aneurysm, a conventional CT scan of the brain can appear normal. In that case, other imaging is needed, or the physicians need to insert a needle into the spinal canal to sample some of the spinal fluid (also called a spinal tap) to look for evidence of bleeding.

  It’s important to point out that it wasn’t Jackie’s job to know the significance of “+BM.” It was the emergency physician’s job. But it was Jackie’s expertise and extra care that got the patient to open up. It was her extra care that got him to disclose it.

  Imagine how that phone call went: calling John and requesting that he return immediately. If the patient was a 9 out of 10 on the annoyance scale when he was in the emergency department, he was an 11 when the attending physician woke him out of a deep sleep with a phone call and asked him to come back.

  Keep in mind, the physician was also saying that they might need to stick a long needle into his spine! But the physician was insisting. Actually, he was begging John to come back. Of course, the physician had to acknowledge to the patient that there was also a very high likelihood that a bleeding aneurysm was not present, but with something potentially devastating you just can’t take any chances.

  Still groggy from being awakened, John muttered “okay,” and then hung up. But the physician, who was about to turn the emergency department over to the oncoming day shift attending physician was not convinced he would actually come back. He felt sick to his stomach. He told the day shift physician the whole story and prepared to go home. In the back of his mind, he was thinking he might do something he had never done before…drive to a patient’s house on the way home from the hospital!

  But then, on his way out the door, the physician passed John walking back in to the emergency department. He was so happy to see John, the physician nearly hugged him. The doc went home and went to sleep. And then, when he woke up that afternoon, he called his colleague in the emergency department to see what happened with John.

  “Are you sitting down?” she asked. “He’s in the operating room right now.” Further testing showed a brain aneurysm that had just started leaking, a very early stage of rupture. But when the neurovascular surgeon tried to stop the bleeding by threading a catheter up into the blood vessels in the brain, he could not stop the bleeding.

  The shape of the aneurysm was such that they could not get control of the bleeding with a catheter. They had to rush him to the operating room for brain surgery—a craniotomy (surgical opening in the skull)—to clip the aneurysm, in order to get the bleeding to stop. Thankfully, the surgery went exactly as planned, and John made a rapid and complete recovery. He is 100 percent back to normal today.

  So what does this story have to do with compassionomics? Yes, the physician was tenacious in following up once he realized the warning sign but, let’s be honest, he was also one of the people who missed it. In reality, it was Jackie that saved John’s life.

  Earlier, we reviewed the scientific data showing that a compassionate human connection is what makes people confide their secrets in others. Specifically, in health care, we saw that compassion leads to greater disclosure by patients.

  In John’s case, he was totally embarrassed about the details of how his headache started. He thought his headache was nothing serious—just a byproduct of his constipation—and he did not really need to be in the emergency department among people with obvious life or death conditions. His wife made him come. He felt stupid.

  He did not tell the triage nurse the “+BM” part. He did not tell the resident physician. He did not tell the attending physician. He did not even tell his wife. But he told Jackie.

  Jackie could tell there was more to the story, and that he was embarrassed about something. She cared enough to ask. Like we said earlier, that’s what Jackie was known for: exceptional caring and compassion. And because the patient could tell that she truly cared, he c
onfided in her the critical piece of information that no one else could get…the only piece of information that actually mattered.

  Jackie knows that compassion matters. Although she helped to save victims of car crashes and heart attacks on that same busy night in the emergency department, nothing was more heroic than the way she cared enough to inspire this man to open up and confide in her. And this is an important reminder of how compassion can actually save a life.

  Going the Extra Mile

  If you are a resident physician on duty at Cooper University Hospital, these words from the unit secretary might make you cringe: “Dr. Viner is on the phone and he wants to speak to you.”

  “Oh no,” you might mutter under your breath. “Not another Dr. Viner patient.”

  You see, Dr. Viner’s patients are special. At the end of Chapter 3, you were introduced to Dr. Viner. He was the chair of the Department of Medicine at Cooper for two decades, and he was also the patient in the story of the “angel” nurses who helped him get off the ventilator in the ICU.

  As a young man, Dr. Viner experienced the power of compassion firsthand, as a patient himself. From then on, he dedicated his life to showing the same level of care for others. That’s also why he founded the Center for Humanism at Cooper Medical School of Rowan University.

  If you are a resident physician and one of Dr. Viner’s patients is admitted to your service in the hospital, it’s a special experience. Most of Dr. Viner’s patients have been his patients for years, and often for decades.

  Dr. Viner will first make sure you know the whole story, every detail about the patient, all the way back to the beginning. Even if the patient is only being admitted to the hospital for a very discrete issue, you will get to hear his or her life story. You might also get the life story for everyone in the patient’s family. (Dr. Viner takes knowing the patient as a person to a whole new level.)

  You will also get Dr. Viner’s mobile phone number. And you will get the opportunity to use it…frequently. You will get to call Dr. Viner to update him about every little detail in the patient’s care. If you don’t call him at the expected time interval to give him the update, you can expect to be paged in the hospital. It’s Dr. Viner calling to check in with you.

  If something important and unexpected happens to one of his patients, good luck to you, if Dr. Viner hears it first from anyone other than you. Also, he “cyber stalks” the electronic medical record from home, so he likely knows the test results before you do. He knows every detail.

  One summer night while Dr. Viner was on vacation at the Jersey Shore, he got a phone call from the wife of a man who had been his patient for nearly forty years. The man had been admitted to the hospital and needed a consultation from a specialist.

  After spending much of the night on the phone discussing his care with the various caregivers involved, Dr. Viner decided that it was taking too long for the specialist to come and see his patient. He got in his car late at night (leaving his vacation, mind you) and drove all the way from Ocean City, New Jersey to Cooper in Camden, New Jersey which is more than sixty miles away, arriving close to midnight, just to stand by his patient’s bedside and make sure that he got everything he needed as quickly as possible.

  That’s Dr. Viner. So, if you are a resident physician on duty when one of Dr. Viner’s patients is admitted, you can expect he will be all over you to make sure that you provide the best care to his patient that you possibly can. Not acceptable care, but exceptional care.

  Why? Compassionomics. Research shows that compassion for others makes people more likely to exhibit altruistic behavior and “go the extra mile.”234, 235 Dr. Viner cares deeply about his patients. He doesn’t just know them as patients, he knows each patient as a whole person. He has celebrated with them life’s wonderful blessings—when their kids got married and their grandchildren were born—and he has stood by them through unspeakable pain, such as suffering and loss.

  When his patients are sick, he walks with them. He meets them in their pain and suffering with an authentic desire to help. You will remember from Chapter 2, that’s actually the definition of compassion. And the manifestation of Dr. Viner’s compassion for patients? Going the extra mile.

  Going the extra mile for his patients ensures that the care they receive has a characteristic kind of meticulousness, the highest standard. On a Dr. Viner patient, nothing falls through the cracks. He makes certain of it. Every little detail goes under the microscope and is attended to diligently. And quality of care is all about the details.

  His compassion elevates the quality of care by elevating the expectations for everyone’s care of his patients, the whole team. He is legendary for this, and it has left an indelible mark on trainees at Cooper for decades. Essentially, Dr. Viner has taught physicians-in-training a whole new level of what it means to care.

  But, you do not have to know a patient for decades in order to care enough to go the extra mile and make a difference. Sometimes, those bonds can be built in just a matter of minutes, and in the back of an ambulance of all places.

  Consider this story:

  A previously healthy young man in his mid-thirties, Joe, was brought to the emergency department by ambulance because he passed out cold while at work. He just collapsed with no warning. When paramedics arrived, Joe’s vital signs were okay, but he was out of it. They put him on a stretcher, slapped an oxygen mask on his face, and loaded him in the ambulance.

  When the ambulance began to pull away from the scene, Joe was now fully awake with normal mental status. He sat up and asked, “What happened?” He recalled having a dull headache during his shift, but that was all he remembered. Then he woke up in the back of an ambulance.

  But then Joe went into panic mode. He wanted out of the ambulance immediately, saying that he had to get back to work. But Layla, the paramedic in the back of the ambulance, was able to calm him down and recognize that he needed medical attention. That’s when a much unexpected compassion connection happened.

  Joe explained the reason for his panic to Layla: He had been out of work for a number of months, almost a year, until this current job came around just two weeks ago. Through a very fortunate set of circumstances—a friend of a friend—he landed a job as a forklift operator, and (thankfully) it was the best paying job he ever had.

  He needed the money desperately. He and his wife had a two-year-old at home and, unexpectedly, they had just learned she was pregnant again. They were almost evicted from their apartment the prior month, until a family member floated them a last-minute loan to pay the rent.

  His wife was in school full-time, so Joe had to find work. He said he had been so stressed out. And then he got the call about this job—it was a godsend and just in the nick of time. He broke down in tears in the back of that ambulance, terrified that his boss who barely knew him yet would think he was flaky if he missed work so soon after starting the job and would want to let him go.

  Layla knew exactly how he felt. She had been there before—living paycheck to paycheck, barely making ends meet. Before landing this steady (not to mention rewarding) paramedic job two years ago, she was unemployed herself…a single mom with two kids to care for. She had felt his stress and fear.

  But healthy people in their mid-thirties don’t just pass out for no reason, so she tried to convince Joe that he had to let her take him to the hospital. What finally convinced him was when she said, “You won’t be of any use to your family if you end up dead.” Layla smiled at him warmly and held his hand so he would not be afraid as she said, “C’mon, let’s get you checked out.” He agreed, so off to the hospital they went.

  On arrival to the emergency department, Layla said her goodbyes, took his hand once more, and let him know that she wished the best for him. Then she left on another ambulance call. The emergency department team put him in an exam room and the evaluation began:

  Vital signs: Normal

  Chief complaint: None (He was asymptomatic now…“I feel fine.”)
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  History: “I think I blacked out.” (That’s what Layla told him.)

  Past medical history: None

  Physical exam: Normal

  Electrocardiogram (heart tracing): Normal

  Chest x-ray: Normal

  CT scan of the brain: Normal

  The emergency physician was perplexed. Totally stumped. What would make this young man suddenly collapse and go unconscious? Everything in his history was unrevealing and all of his tests were coming back normal so far.

  That’s when Joe started back with the panic. He had to get released, to get back to work. “Please tell my boss everything is totally fine if he calls,” Joe urged. That’s when Layla showed up…again. She was out on another ambulance call and could not get Joe out of her head. She knew the fear and anxiety he was going through, and even though she just met him, she was very worried about him.

  Why did she come back? One thing was bugging her. In thinking about his case some more, she thought it was sort of striking that Joe started to recover his mental status as soon as they put him in the back of the ambulance…like immediately. It was as if getting him out of the warehouse where they found him had made a huge difference. He had been operating a forklift in there.

  Layla said to the emergency physician, “I think you should check the carbon monoxide level in his blood.”

  The nurses gasped and almost started laughing; did the paramedic really just say that to our doc? Now, there are a few things you should know about the emergency department in this story: It’s a very busy urban academic trauma center that has an impressive reputation. Their emergency team knows exactly what they are doing, and they don’t like being told their business…by anyone.