Sit Down, Get Paged, Repeat

From the December 23, 2022 issue of the Transformational Times 

 

Sit Down, Get Paged, Repeat

 

By Laura Slykhouse, MD

 

At this time of year, we celebrate and thank our hard-working residents and hospital staff that work through the nights, weekends, and holidays. Dr. Slykhouse, a resident in Internal Medicine, recounts a call night that was also her birthday. She shares some moments which are specific to being in the hospital overnight… 

 

Birthdays have a way of getting less and less exciting each year. Yes, there are some milestone birthdays we celebrate as we get older; but, as the years march on, enthusiasm lacks compared to a sweet sixteenth or a twenty-first birthday. This year, I see my schedule for June and of course, I’ll be celebrating my birthday at Froedtert at the end of a twenty-eight-hour shift. 

I readjust my expectations and wish for a calm night, good cross-cover, no ICU transfers, and friends to make the time go faster. The night is off to a good start when my favorite co-resident is pulled in to cover the night portion of the shift with me. I was obviously more excited than she was, but the night was looking promising.  

We get sign-out, nothing exciting. Then we start brainstorming our evening – what kind of food are we going to order, which movies do we hope to watch in the team room and what music should we listen to. We’re not even five minutes into our planning when two pages come through – it’s the admitting medical officer (AMO) with two outside hospital transfers who are already on the floor: one with metastatic lesions to the brain and concern for increased intracranial pressure, the other one for AMS (altered mental status) in an elderly woman. This would be the last quiet moment of the evening.  

We decide to see the patient with concern for increased intracranial pressure first. He does not appear as sick as his labs and imaging have detailed. This is one of those times in residency where I feel the sense that a patient could decompensate quickly, but next steps are not clear. I feel uneasy about this patient. We call the neurosurgical team, and they also share our concerns and take over care of the patient in the Neuro ICU. The patient and his wife are very grateful for our small contribution to his care.  

Then the cross-cover begins. Two stroke calls, status epilepticus, a transfer to the Neuro ICU and Medical ICU. This is not the night I had planned when the shift started. However, time is passing quickly as we try to triage the patients and deal with one situation at a time.  

It’s now midnight, and I’m happy there are still a few options left on Door Dash, as I have been craving Mexican food the whole night. This would not be a night for a movie. The chaos continues throughout the night, page after page, almost comical with the timing – sit down, page, sit down, page. The food delivery has been there for hours, but something about a lukewarm burrito at 4:00 AM is less appetizing.  

The last crisis of the night is the elderly woman admitted for AMS. She has dementia and hypercalcemia. We give IV calcitonin and a bisphosphonate which causes diffuse body aches. She speaks both German and English intermittently. I find myself drawn to her. I’m not sure if it’s because she reminds me of my grandma or because I feel guilty that our treatment has caused her pain. I hold her hand for a while, and she seems to feel some relief from the IV pain medication. Just this small point of contact makes the night seem less frenetic. It reminds me why I enjoy what I’m doing, even during the difficult nights, the missed holidays and celebrations.  

It’s 6:00 AM and we re-group in the team room. The window for sleeping has passed, and it’s evident I’ll need a significant amount of coffee to make it through rounds. We debrief quickly, cold burritos are half-eaten and abandoned next to the computers, and I feel proud. I learned a lot, we gave the best care that we could, and another call shift is over.  

 

Laura Slykhouse, MD, is a PGY3 Internal Medicine resident at MCW who is planning to start her career in hospital medicine.   

Design Thinking in Action: Medical Students Weigh-In on the Mobile Health Clinic

From the December 23, 2022 issue of the Transformational Times

Perspective/Opinion 

Design Thinking in Action: Medical Students Weigh-In on the Mobile Health Clinic 

 

By Emmy Lambert, BS – Medical Student 

Patient-centered care calls for patient-centered spaces. Medical students were given the opportunity to dust off their creative brains and ponder the details, big and small, of an exciting new mobile clinic…  

Human-Centered Design. It’s all around us. Or at least, it should be… 

Simply put, human-centered design is a method of empathy-based problem-solving. Through a three-phase design process of inspiration, ideation, and implementation, human-centered design tailors products towards those involved in their use – so-called “stakeholders.” These stakeholders are consulted and considered in every step of the design process to ensure the output will meet their needs. Truly an ingenious approach, if you ask me.   

They’re building a WHAT? A mobile clinic! 

In an effort to address preventative health screening disparities in certain zip codes in Milwaukee, there is a joint venture between the Population Health Department and OB/GYN Clinic at Froedtert Hospital, the Kern Institute’s Human-Centered Design (HCD) Lab, and the UW-Milwaukee Lubar Entrepreneurship Center to design and implement a Women’s* Mobile Health Clinic. The working timeline aims to complete research by the end of the 2022 calendar year, build the clinic in late spring of 2023, and begin providing care next fall.   

As part of the ongoing research process, the HCD lab hosted a design workshop for second-year medical students in the Health Systems Management & Policy Pathway. As a student member of the HCD lab for nearly a year, I had the privilege of facilitating this session with Dr. Ilya Avdeev and Dr. Lana Minshew. As a team, we guided students through a series of activities to stimulate creativity and prime their listening skills before conducting design research for the clinic.   

We asked the HSMP students to brainstorm the needs of a women’s mobile health clinic, identify stakeholders, and generate solutions to a few stakeholder concerns. Students collaborated in teams, writing furiously on sticky notes, whiteboards, and scrap paper. The room was abuzz with solution-oriented energy. Their knowledge of health systems and roles as medical students added a unique perspective to the ongoing project. Some of Dr. Avdeev’s graduate-level engineering students attended the session as well, lending a different angle of design understanding to the process.    

The students said they loved it! 

The session was well received by the students. Clayton Vesperman, M2, commented, “I thought that the Mobile Clinic Design session was one of the most unique and engaging sessions I have had as part of the Health Systems Management and Policy pathway. The opportunity to collaborate with Engineering students who had a background that was outside of the medical field was a great opportunity to learn how other fields approach problems as well as the types of issues they prioritize. As medical students, we have abundant opportunities to learn from other health professions, but learning to work alongside entirely different fields can be very beneficial as they can play a large impact in the patient experience even without directly influencing the patients’ healthcare.”  

Victoria Le, an M2 also in the HSMP Pathway, commented, “I thought it was interesting to see the process of working through nitty-gritty details of making an idea come to life. I liked how thorough it was, including the way we tried to anticipate different issues that would be roadblocks to the mobile clinic. I also thought it was a good way to balance the creative process with a more rigorous evaluation of ideas.”  

My takeaway? 

I was so impressed with the creativity and collaboration demonstrated by my peers! Their willingness to engage across disciplines, work together to problem solve, and experience medicine from the patient perspective is promising for the future of medicine. A few of the ideas presented at this workshop have been considered for the ultimate implementation of the mobile health clinic, which is set to hit the streets in the fall of 2023.   

Design with us! 

The Human-Centered Design lab is currently collaborating with the Lubar Entrepreneurship Center at the University of Wisconsin – Milwaukee and Froedtert hospital on a community-centered design project focused on designing two mobile health clinics to serve the greater Milwaukee area. To create the most effective community-centered design as possible, we invite community members to join the design team by sharing your experience with mobile healthcare or offering your ideas using a full-scale clinic design model. The model is in the first-floor cafeteria lobby of the MCW – Medical Education Building and will be open to everyone through January 31, 2023.   

Note: 

*The term “women” encompasses those who identify as female, possess female reproductive anatomy, or face female-related health issues. 

Emmy Lambert is currently an M2 at MCW Milwaukee. She is a student member of the Human-Centered Design Lab pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. She passionately co-runs the MCW Chapter of Medical Students for Choice, manages operations of MCW DOSE, and teaches Hatha and yin yoga classes at Collective Flow MKE.  

“Is There a Doctor Onboard?” Doctoring and Prayers at 35,000 Feet

From the December 16, 2022 Spiritually in Medicine issue of the Transformational Times

“Is There a Doctor Onboard?” Doctoring and Prayers at 35,000 Feet

By Adina Kalet, MD, MPH

Given the theme of Spirituality in Medicine in this week’s Transformational Times, Dr. Kalet shares the most recent of many experiences she has had answering the overhead call on airplanes. In this case, the faith traditions of both the doctor and of the patient led to series of surprises and unique styles of gratitude for caring and kindness expressed in prayer …

Given that I was listening to a movie through my headphones while my hands were busy knitting, the announcement just barely registered. We were three hours away from our destination, and a long, uncomfortable eight hours into our flight. After a few seconds delay, I untangled myself and headed toward the uniformed purser standing in the aisle. 

“I am a doctor. How can I help?” She looked me over and nodded discretely toward the young, pale, diaphoretic, and mildly distressed bearded man slumped in his seat. 

The flight attendant whispered, “He is asking for medication, but I can’t administer anything without a physicians order.” She gestured to her handheld device. “This is what we have available.” She looked back-and-forth from the man in the seat to me. “We are over land now, so if you decide…” Her voice trailed off, suggesting that, on my say-so, they were prepared to land the plane.

“Give me a minute to assess the situation,” I said. She offered to retrieve a blood pressure cuff and oxygen tank.  

My new patient’s religious garb, facial hair, and head covering told me that he was part of an Ultra-Orthodox Jewish family. I grabbed my sweater and covered my bare shoulders since, in his culture—one I know intimately—modesty is paramount. In his community’s view of the world, a secular appearing, barefooted and bareheaded woman might be dismissed or treated with suspicion. I assumed he would avoid eye contact and refuse to let me touch him. To be trusted enough to make an accurate medical assessment, I needed to minimize the barriers.  

Leaning over him, I introduced myself and asked him to tell me what was going on. I was happy to see that he was fully awake and alert, spoke fluent mildly-accented English, was willing to make eye contact, and seemed eager for my help. He described his weakness, dizziness, and nausea. After asking permission, I carefully and firmly ran my hand over the key locations (no belly, chest, or calf tenderness) landing on his wrist to feel for his radial pulse. I engaged him in conversation about his health and recent events as I monitored the cardiac rate and rhythm. He had been perfectly healthy  and described no ominous symptoms. 

The relatives surrounding him were eager to tell me that they had all spent the day before in a hospital emergency room with a beloved relative. As his uncle graphically described the details of how the old woman had fallen and had sustained a nasty, bloody gash, my patient became paler, his heart rate went up, and his pulse became “thready.” Before long, he was dry heaving into a plastic bag. Clearly, the stress of hearing the story again was taking a toll. I expressed my empathy for the upsetting situation to the group. My patient’s pulse slowed a bit. 

The flight attendant handed me the automatic blood pressure device. As I wrapped the cuff around his arm, I confirmed he had eaten little, had slept poorly, and had not had anything to drink during the flight because the options were not guaranteed to meet his religious requirements. The machine finished its reading and, although not dangerous, his blood pressure was quite low. 

We laid him as flat as the airplane seat would allow and elevated his legs. I assessed the width of the aisle just in case we needed to get him on his back. Happily, his blood pressure climbed a bit and his pulse headed toward normal. 

The flight attendant pointed out that we were seven miles above the Earth, and some supplemental oxygen might help. We put the mask on him and started the flow. He “pinked” up immediately, and his nausea resolved. Soon, he was able and eager to drink fluids. As time passed, his symptoms resolved, and he felt stronger. 

I spent a few minutes talking with his relatives, including the old woman with the fresh stitches and a bandage above her eye. I was able to fend off one of his aunts who offered several nonspecific pills she had in her carry-on bag. Everyone noticeably relaxed and soon I felt comfortable enough to return to my seat. 

The flight attendant stopped by, reporting that she had told the pilot we were not anticipating an emergency landing. She offered me a gift from the airline which I tried to refuse but, in the end, I accepted some extra miles for my frequent flyer account. 

After a while, the patient’s aunt came by, an emissary from the senior male members of the family. She thanked me profusely for my help, then said, “Your smile and gentleness are a blessing from G-d! You didn’t need to be kind, but you were.”  The family wanted to give me something in return for my kindness. 

“No!” I said. “That is very kind, but this is my work. There is no need for gifts.”

“Well, then,” she replied, “you will be in our daily prayers.” She nodded, thanked me again, and returned to her seat. I smiled, found my headphones, and went back to my knitting. 

I was relieved that things turned out so well; they don’t always. This was not my first rodeo. I have had  a few opportunities to answer “the call” on airplanes, at the theater, and on the sidewalk.  Given the settings, the medical intervention and decision-making options are severely limited. Had the situation worsened, and I had needed extra hands to help start an IV or do chest compressions, I suspect other healthcare workers might have appeared, or the trained crew members would have been there to assist. Depending on the acuity of the crisis, I might have recommended to the pilot that she land the plane.

But, on this day, that was not what was needed. In the end, what was most needed and appreciated was kindness. This experience, as well as medical student Sarah Root, in her essay in this issue of the Transformational Times, reminds me once again, through the the words of Sarah’s physician grandfather, “that medicine is not just a practice, but a privilege.”

We reached our destination and headed our separate ways. I am humbled to know that there is a family, not so very different from my own, that is prayerfully grateful for our moments together at 35,000 feet. 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.

The Kern Institute Announces Publication of the Second Collection of Transformational Times Essays

 Book Presale - Character and Caring: Medical Education Emerges From the Pandemic

The Kern Institute Announces Publication of the Second Collection of Transformational Times Essays

Medical students, residents, physicians, and caregivers have struggled during the pandemic. The times in which we live will transform medicine. These essays, drawn from the Kern Institute’s Transformational Times newsletter, offer glimpses into what we have experienced and what might yet come. 
Each essay reveals remarkable insights and reflects the interplay of the world we inhabit with the present and future of medicine and healthcare.

"Incredibly timely."
—Carol Bradford, MD FACS
“[This book] provides an unparalleled opportunity to bring one’s best self to the bedside and looks for the unexpected opportunities to impact the world.”
—Jesse Ehrenfeld, MD, MPH
“...a ready-made syllabus to embrace social, psychological, spiritual, and humanistic dimensions of medical education.”
—Louis N. Pangaro, MD, MACP
“...the art, as well as the science, of medicine are eloquently delivered, provoking the reader to reflect and see the world from new perspectives.”
—J. Larry Jameson, MD, PhD

In these pages, readers engage with unsettling realities unmasked by COVID-19, including workplace biases, inattention to wellness, residency-related stress, the loneliness of military responsibility, the inequity of the world around us, reproductive healthcare uncertainty, new educational realities, and the imperative for flourishing and practical wisdom in physicians.

To purchase a copy of Character and Caring: Medical Education Emerges From the Pandemic, click here. 

To purchase a copy of our our first book, Character and Caring: A Pandemic Year in Medical Education, click here.