|Blogtober at Montefiore
Posts from October, 2013
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|Blogtober – an Exploration of Medicine, Research Innovation and Compassion
One month…filled with nearly 30 posts, lots of laughs, some tears and even more examples of why our associates love caring for our patients. Blogtober at Montefiore was our first foray into blogging and we loved it. Doctors, nurses, physician's assistants, nurse practitioners and many other members of our Montefiore family spoke from their heart and gave an inside look into their work, their passions and their favorite stories.
Having worked at Montefiore more than 30 years, I have my share of stories about special patients I've known. One such patient has remained part of not only my memory, but the memory of my entire family. This special patient, Sophie, was an 88-year-old widow who was hospitalized throughout the holiday season. There were few visitors, in fact, I don't recall ever seeing anyone at her bedside. To pass the time, she would crochet little items and give them to the nurses who cared for her. Certainly nothing fancy, but each stitch was perfect and thoughtfully made.
As a young nurse working Christmas Eve, I can assure you I could think of nothing more important that getting home to enjoy a Christmas Eve dinner with my then boyfriend's family. As I signed out for the day, I went into Sophie's room to check on her and wish her a "Merry Christmas."
She called me to her bedside and asked me to hold her hand for a moment. When I opened my hand, I saw she had placed a small package wrapped in tissue paper. She insisted I unwrap it on Christmas morning. I gave her a hug, thanked her and for some unknown reason, I promised her I would never forget her. The next day, I carefully unwrapped her gift to find a crocheted Christmas ornament of white ice skates, laced with red and green yarn and paper clips for the blades.
That was in 1981. The boyfriend became my husband. We had three wonderful children, all of whom were youth ice hockey players. And every year since 1981, I carefully unwrap the tissue paper that protects one of my most favorite ornaments and I talk about Sophie. She's part of our holiday tradition but most of all, her memory lives on through me and my family.
We each have so many opportunities to make a difference in patients' lives. I take great pride in nursing excellence and all the wonderful ways we impact patients. What I have come to realize is that nursing is a gift that goes both ways. As much as we give of ourselves to our patients, they often give us so much more.
Everyday special stories like mine are written at Montefiore. Through Blogtober we were able to offer a glimpse into the good work taking place at Montefiore. We joined this national movement to encourage the sharing of experiences and we consider it a success because we reached thousands of you looking to know more about us. As this month comes to a close, we hope you'll continue to visit our website to learn more about the inspiring, powerful and personal stories of our patients and staff. And our blog will be back in 2014, so get ready for more great stories!
Susan Green-Lorenzen, RN, is senior vice president of Operations at Montefiore Medical Center.
Posted by blogmoderator on 11/01/2013 at 2:32 PM
|Making a Difference by Saying Yes
He was her husband of 42 years. His letter was passionate and pleading. His wife was slowly dying of end stage heart failure and needed a transplant. But there was an issue – they are Jehovah's Witnesses and she would not accept blood transfusions based on her religious beliefs.
While many operations, including surgeries on the heart, can be performed safely without the need for blood transfusions, a heart transplant can be a rather complicated procedure. Recipient patients are usually quite ill, often anemic and the risk of bleeding during and immediately after the surgery is significant. Most transplant centers, therefore, will not perform these surgeries on Jehovah's Witness patients who refuse transfusions – which had been the case for this man and his wife.
She had been denied life saving therapy at several institutions, and her husband was reaching out on her behalf. I called him the day I read his letter and his relief and gratitude were palpable. While I did not promise him we could accept her as a transplant candidate, I did offer to see her as a patient. And it gave them hope.
But things would not be so easy. She lived several states away and need to overcome issues with her insurance. No matter what, her husband continued to champion her cause and eventually they were granted permission to see us in consultation. They found a local host family and traveled to our hospital in the Bronx.
Over the next few days the patient met with several members of our transplant team, including a heart failure cardiologist, a psychiatrist, a social worker, a transplant coordinator and me. After meeting her, our team was faced with an unanticipated and crucial decision.
As there are far fewer organs available than patients in need, we are obliged to make responsible decisions regarding their use. We looked at our results and discovered that blood transfusions were rarely necessary in patients that had not had prior surgery on the heart, so we decided would consider those Jehovah's Witness patients.
That said, it turned that more than thirty years ago this patient had undergone heart surgery to close a small hole, which connected two of her heart chambers. Had we known this, we would not have agreed to an evaluation. But now we had met her, we had offered her hope and she had traveled several hundred miles for a chance to live.
In the end we developed a plan that gave us confidence to list her for transplantation. She spent many months in our hospital waiting for her lifesaving gift. When at last it came, I was on call and accepted the heart.
I knew the stakes were high for her and for us. We were performing a complex procedure without a safety net. The operation proved difficult, but her blood count at the end of the operation was near normal despite some initial blood loss.
The patient recovered well from the surgery and is enjoying her health and her new heart. She and her family have expressed their gratitude to our entire team and for the family that gave her that most precious gift.
I am especially proud of my team of dedicated practitioners who do not shy away from challenges and who work with the singular purpose of improving the lives of our patients. Especially for this couple, who after 42 years of marriage will now have more time to spend together.
David D'Alessandro is surgical director of Cardiac Transplantation, Department of Cardiovascular & Thoracic Surgery at Montefiore. He also is associate professor of Clinical Cardiovascular & Thoracic Surgery at Albert Einstein College of Medicine of Yeshiva University.
Posted by blogmoderator on 11/01/2013 at 8:50 AM
|Balancing Emotions and Reason at the End of Life
Before you can even form a thought, emotions are influencing your judgments.
—Zimmerman and Lerner (2010)
It's 9 AM on a Monday, and our palliative care team circles a table to prepare for the workday. Before us is a list of names, each representing a patient and his or her needs, support system and care team. Many are referred to us because they are suffering – be it pain, agitation, emotional distress, existential crisis or decisional ambivalence. The suffering is directed to our team with two common requests for help: symptom support or goals of care.
A request to address goals of care implies uncertainty about the benefits "routine" medical care can offer. Someone in the circle of care, be it a doctor, a nurse, mid-level provider, a social worker, patient or the patient's family member, questions: "Is this path the right direction? Is this care helping or creating more suffering?"
This reflective moment often spurs a palliative care consult. We seek to understand each patient and their support system, identify needs and discover options to share with the patient, family and the medical team. Our contribution to routine hospital care can be eye-opening – new or atypical paths are revealed, like flying a patient to see loved ones in another country or performing a wedding ceremony in a hospital room. These experiences can revive a humanity that serious illness robs from patients and families.
Other times our work is less dramatic. Instead of revealing paths, we bear witness to incomprehensible events and a myriad of difficult decisions faced by patients and families, especially related to end-of-life care. Years of this work helped me recognize the interplay of the emotional and rational intellect inherent in all decision-making.
When patients or families receive a poor prognosis, some quickly reconcile their rational and emotional intellect and seek a path to maximize the quality of time left. Others challenge the facts presented and are proven correct, but more often soon realize that the facts are accurate and it's time to focus on end-of-life care.
However, there also exists a small cohort of patients or families that can't resolve the tension between their rational and emotional intellects. They logically understand a patient's illnesses should lead to a dying process, but their emotional intellect won't let them believe it. Their minds race with thoughts of miracles, hope, just a little more time, just a little more fight, it just can't be—and with feelings of fear, sadness and hopelessness.
This conflict between the emotional and rational intellect can lead to patient care decisions that fail to "make sense" to an outside observer. However, it surprises me to think that our health systems present patients, or more often their families, with very complex decisions – should we try CPR, or life support, or stop these medical therapies – at a time when their emotions are in overdrive and their rational intellect is just trying to catch up. As providers we struggle when the responses to these questions fail to recognize a patient is dying, fail to allow for peaceful dying and moreover, force our hand to perform interventions that may actually prolong dying.
I believe care providers perform at their best when they recognize these decisions require reconciliation of emotional and rational thought. If either component is missing, patients and families are unlikely to be able to make the decision to accept end-of-life care.
In our best moments, our health system, often aided by the palliative care team, truly supports patients and families when they are facing the most difficult decisions they will ever have to make.
James Fausto, MD, is Medical Director of the Palliative Care Program and Assistant Professor, Department of Family and Social Medicine at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/31/2013 at 10:39 AM
|Young Eyes, Devastated by Diabetes
Children who live with diabetes, like all children with chronic diseases, learn to grow up rather quickly. In order to survive, they must learn how to manage a disease with which most adults struggle. In particular, not only must children completely change their diet, but they also have to deal with checking blood sugars daily, time and dose insulin shots, all while trying to fit into a world where they are different from other children.
Their lives as care-free children or teenagers will be forever entwined with having a chronic, life-threatening disorder. Simply being able to manage sugars takes a huge psychological toll on these children, who have much higher rates of depression than non-diabetic children. Thankfully, with aggressive integrated medical and social care, many of these children do very well at dealing with this disease.
Last year I performed surgery to remove cataracts from both eyes of a teenaged patient. This was a young man who played multiple sports, excelled at school and wanted to be an executive chef, all while managing the juvenile form of diabetes. He was sent to me because he noticed his vision had become blurry and he thought he only needed a pair of glasses. Instead he was told he had cataracts, which is the formation of a cloudy lens in the eye that is typically an age-related change in the eye. But in this case, it was an effect of childhood diabetes.
The only solution to improving his vision was to have surgery, which is certainly not without risk. Although cataract surgery is commonly performed in the adult population, in the pediatric population there are additional hurdles to a successful outcome, mostly due to the fact that the eye is still growing. Even after a successful surgery, like an adult, he would need to wear reading glasses to complete his homework.
Anyone who has cataract surgery needs extensive pre-operative counseling to prepare for rigorous post-operative care. This includes frequent visits to the doctor, laborious eye drop schedules to prevent infection, restriction in all physical activities, then returning to the operating room to do it all over again for the second eye. As you can imagine, most of my patients are quite relieved to only have two eyes at this point!
Unfortunately, the formation of cataracts is not the most feared vision-related complication of diabetes, since it can be surgically corrected. That would be diabetic retinopathy, which can cause permanent blindness due to abnormal blood vessels growing in the eye. While diabetic retinopathy rates are lower in children, if it starts early enough it can be tremendously difficult to manage.
As an ophthalmologist, it is my job to be a part of the medical team that helps children with diabetes and their families understand the gravity of managing all aspects of this disease. There are many challenges, but I love what I do because of the success we have on a regular basis. The teenaged boy who I operated on last year? He is indeed attending culinary school and pursuing his dream to become an executive chef!
Erin K. Walsh, MD, is a pediatric ophthalmologist in the Department of Ophthalmology and Visual Sciences, and Assistant Professor of Ophthalmology & Visual Sciences and of Pediatrics at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/31/2013 at 10:31 AM
|The Diabetes Epidemic is Creating a Tsunami
I have been taking care of patients with diabetes for many years and have been able to see how this disease has intensified, especially here in the Bronx. Type 2 diabetes is now much more common; it is affecting younger people and causing damage to important organs such as the liver and the heart. It can cause much harm without people feeling sick, but when diagnosed, it can be treated.
When it isn't diagnosed or treated, it causes complications such as blindness, strokes, kidney failure, heart disease and amputations –often a loss of a foot or leg. Patients with complications aren't able to maintain a good quality of life, they become disabled and they become a burden for their entire family and the community.
I see many patients who are in this situation. One example is Dulce, a 40-year-old, single mother with poorly treated type 2 diabetes and high blood pressure. She was diagnosed at age 18, but never took her disease seriously and did not follow her doctors' recommendations. She was on welfare and had Medicaid , so she was able to see doctors and get her medications at a low cost.
She ultimately developed complications, starting with an infection in her foot that caused her to lose her left leg, and then her kidneys began to fail to the point that she needed dialysis. During the past two years, she had a stroke, lost vision of her right eye and was then hospitalized with chest pains. She had a heart attack and had to have heart surgery.
Diabetes and hypertension can be treated – why didn't she follow the medical recommendations? Unfortunately, this young patient is not a rare example. If cases like this continue, we will have a disaster in our society – what I call a tsunami effect on our health care system, society and our country.
Fortunately, the majority of patients with diabetes do well – they are diagnosed and treated early to prevent complications. These patients are "in charge of their disease," they know how the medications work, and make sure that their blood sugars, cholesterol and blood pressure are normal. They live a happy and productive life, and it is patients like these who encourage me and many other healthcare professionals to care for them every day!
Joel Zonszein, MD, is director of the Clinical Diabetes Center – Weiler. He also is professor of clinical medicine, Department of Medicine and Division of Endocrinology at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/31/2013 at 10:23 AM
|Helping Children with Rare Conditions Beat the Odds
Having been at Montefiore for almost 30 years, I have seen my share of complex, intriguing and heartbreaking patient cases. As a pediatric neurosurgeon, I have treated children from around the world with conditions so rare that their own families have rejected them. Thankfully, this isn't often the case, but it does make our job that much more rewarding when we can help the child and the family overcome the medical problem and the associated cultural stigma that can come along with it.
Over the years, our craniofacial team has had to learn a great deal about various cultures and religions to be able to deal with the unique cases. Since our successful separation of twins joined at the head was carried out by our team nearly ten years ago, we have consulted on 14 more cases and been involved in the separation of three more sets of twins around the world; two in the United Kingdom and one in Australia.
We are currently involved with another set of twins in the Middle East who come from a tribe that lives in the desert collecting nuts, dates and wood. Because of the conjoining at the heads, these children are, sadly, viewed unsympathetically by their extended families and can't be taken back to their home unless successfully separated.
My passion for helping children with rare and complicated medical conditions has remained steadfast since I first came to Montefiore in the late 1980s. Not only am I proud of our surgical outcomes (less than five percent of our patients need to come back to us for reoperations), but I'm also extremely proud of the successes our patients make in their owns lives, despite the adversities.
One of my patients, who has been under my care for all of her 22 years, had such a unique and multifaceted illness that the hospital where she was born had no idea what advice to give her parents. By chance, her mother learned that I was working on a very complicated case and got in touch to see if I could help them. We have been through 15 surgeries in just over two decades and not only is this patient a bright, bubbly and happy person, she also is highly accomplished, having recently completed her master's degree in accounting.
Helping children beat the odds is a rewarding and fulfilling experience. Our team has earned an international reputation for our work and we are regularly asked to consult on cases, present lectures and host workshops. Our goal is to improve the medical outcomes for the children with complex needs so that they can go on to have successful, happy lives.
We're proud of what we've accomplished so far and we have a lot more work still to do.
James T. Goodrich, MD, PhD, DSc (Hon) is Director, Division of Pediatric Neurosurgery Leo Davidoff Department of Neurological Surgery at The Children's Hospital at Montefiore and Professor of Clinical Neurosurgery, Pediatrics, Plastic and Reconstructive Surgery at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/30/2013 at 1:59 PM
|The Role of Rehab – Uncertainty to Regained Strength
Maria is an active woman with a history of diabetes and high blood pressure who has a heart attack and, unfortunately, suffers a mild stroke during her hospitalization. She is determined to get back to her home, work and family, but is unsure if she can. Maria is unsteady on her feet and is afraid she may have another heart attack. As part of her care, she is seen by the rehabilitation physician – a physiatrist – who reassures her that she can get her life back and spends time with her to explain her path to recovery.
When Maria is admitted for inpatient rehabilitation, she is introduced to a team of dedicated therapists, nurses and other specialists who work closely with her to help her regain her strength and to walk steadily. With the help of her physical and occupational therapists, Maria learns how to walk, dress herself and make her own meals. Her regained independence allows her to return home, where she can continue the recovery process with exercises.
Once she is home, Maria starts her cardiac rehabilitation program that teaches her about her heart and how she can manage her diabetes and blood pressure. The program encourages Maria to have a healthier lifestyle, and she begins choosing a healthier breakfast of yogurt with a fresh piece of fruit – instead of the egg, bacon and cheese sandwich she used to eat. She continues her exercises, and soon she has enough confidence and strength to walk a mile every day.
This story defines some of what rehabilitation medicine does and why I decided to become a rehabilitation specialist. Growing up, my family lived next door to one of the founding fathers of rehabilitation medicine, Howard Rusk. His stories of patients' triumphs over their disabilities inspired me to pursue a career in medicine and specifically rehabilitation.
Rehabilitation medicine is made up of passionate physicians, therapists and nurses who are dedicated to restoring function for our patients, improving their quality of life, alleviating discomfort and pain. It is this shared work in restoring people to their lives and function within their community that is the goal of every member of our team.
We gain our satisfaction from being able to help our patients get back to their normal function, so they can live their lives to the fullest. That feeling of satisfaction and happiness was exactly how I felt when Maria came back for a follow-up appointment. Six months after her heart attack, she is back to work, feeling better than ever and fully involved in her care. She has her life back and continues to make healthy choices every day to help her avoid another heart attack or stroke.
This is why I love my job!
Matthew N. Bartels, MD, MPH, is the Chair of the Department of Rehabilitation and Physical Medicine Department. He also is Professor and Chair of Physical Medicine and Rehabilitation at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/30/2013 at 1:56 PM
|A Vision of Total Care for Adults with Sickle Cell Disease
This was not a very good week. Three of my patients, whom I have followed for more than 20 years, were in the hospital.
We all have these patients. Patients who have essentially grown older with us. We know their families well. We talk to their wives, husbands, siblings and children. We worry when their jobs fall apart. But mine are special patients – they have sickle cell disease, an inherited blood disorder that affects approximately 1,400 Bronx residents, most of them of African-American and Hispanic descent. Many of them I have been seeing since I first came to Montefiore and Einstein as junior faculty in 1985.
Sickle cell care has a unique historic connection to the Bronx. A clinic set up at Einstein in the 1960s was the first in the U.S. to focus on the condition. It was called the "Heredity Clinic" and was designed to take care of patients while exploring the interaction of genes and medicine –at that time a revolutionary goal. And the patients came. They came because they knew their doctors were people who cared about all aspects of sickle cell disease.
Some 20 years later, this idea of total care became the Bronx Comprehensive Sickle Cell Center at Montefiore. It was one of only 10 NIH-funded centers in the country and its directive was to be all things to all people with sickle cell disease. Patients came with their complications such as leg ulcers, stroke, renal failure and sickle cell crises, severe painful episodes that occur when irregularly shaped red blood cells become lodged in small blood vessels and block the flow of blood and oxygen to the body. But in 2009, the NIH stopped funding the centers. Devoid of this vital financial support, adult sickle cell care at Montefiore had to be scaled back.
Montefiore, with its long history of caring for these patients, realized something had to be done for adults with sickle cell disease. Forty years ago we might not have had to worry, since sickle cell patients didn't live very long into adulthood. But today, we have patients in their 70s and a few in their 80s. What's more, they're now getting the diseases that other middle-aged and elderly people get – heart disease, diabetes and obesity. They need hip replacements, eye doctors, dentists and vascular surgeons. We help deliver their babies. I expect now to help deliver their grandchildren.
Very soon we will be able to look after all adult sickle cell patients in a much more complete way, from young adults who are "aging out" of pediatric care to the elderly. We are recruiting clinicians to treat adults of all ages with sickle cell disease -- nurse practitioners and physicians who will follow our patients in the clinic, in the ED, on inpatient units and even to the OR. The team for this updated service will manage the medical and social service needs of sickle cell patients, running clinical trials in order to get state-of-the-art therapy for patients and engaging subspecialists to handle sickle cell complications.
When my three patients returned to the hospital this week, I was reminded of how difficult life can be for many people with this disease. But change is underway, and I feel hopeful that better days are ahead for the hundreds of adult sickle cell patients my colleagues and I follow. Our vision to provide them with the total care they need is within our reach.
Henny Billett, MD, MSc is Chief of the Division of Hematology at Montefiore Medical Center, and Professor of Clinical Medicine and Clinical Pathology at Albert Einstein College of Medicine of Yeshiva University.
Posted by blogmoderator on 10/30/2013 at 8:52 AM
|Remembering Hurricane Sandy – One Year Later
For most of us, Hurricane Sandy is just a memory. But for the families that remain in shelters and the many others still displaced, the storm is an ever-present fact of life. Any reflection on Sandy must start by acknowledging that some of our colleagues are still living through the devastation left in its wake. In our neonatal intensive care unit (NICU) alone, two nurses are still putting their homes back together and a third hasn't returned to work after getting hurt cleaning up her home. Most of us, though, have recovered from the storm.
October 29 is meaningful for me because it's also my birthday, though it's hard to celebrate when we're left shaking our heads in anguish because of what happened. The trauma of Hurricane Sandy tempers my day with sadness, but also gratitude.
Disastrous as it was, Hurricane Sandy also provided our Weiler NICU staff an opportunity to show the world something I already knew – their strength and heart. The challenges of that Monday night were beyond any we expected. A year later, I still marvel at the staff's ability to care for those patients and families – no matter the obstacles.
Due to the storm, we were low on staff that night. When NYU Langone Medical Center called urgently requesting our assistance, Dr. Orna Rosen kept us on track with her absolute belief in the team and our ability to manage what seemed like an impossible task. She leaned on her army experience to help us mobilize forces.
The phone call came around 1 a.m. from the NICU clinical director at NYU. Our medical team immediately accepted the babies over the phone and executed an admission plan. We were prepared for four babies, however six arrived. While providing care, our team worked to locate the families of the two additional babies so they knew to come to Montefiore – another transfer wasn't a good idea.
Eileen Cunnigham's leadership as the nurse in charge was indispensable. Her repeated reassurances – "We got this," "Ok, this is what we will do," and "It's gonna be ok" – were a balm to the team working that night.
I salute the three E's – Emily, Emily and Eileen – who came in early and stayed forever, as well as the nurses who slept over so they could be there in the morning. Awakened at 3 a.m. to help, they leapt into action - especially one nurse (who will remain nameless) who was so eager that she ran to support the team and had to be reminded to get dressed first!
I was touched by the sentiment of the mother-daughter team, labor and delivery nurse Ilana Bennet and NICU nurse Sharone Halperin, who could have gone home but chose to stay. When awakened, Ilana simply said, "I knew there was a reason we didn't go home last night. We needed to be here to help."
From the moment we got the call that patients from NYU were coming, every nurse, respiratory therapist, nurse practitioner, neonatologist, physician assistant and nurse's aide gave everything they had.
The families also arrived exhausted, worried and confused. Our NICU team provided food, drink and comfort while arranging for the safe care of six babies. In those hectic hours, we took care of the babies, their parents and the doctors and nurses who brought them.
So on my birthday this year, I reflect more than celebrate. Our NICU staff is often described as angels on earth, but for me it's so much more than that. They are caretakers of the highest caliber – they care for the infants, their parents and each other, unconditionally.
It was hard to live through the storm, but an honor to watch this team in action. I thank the nurses and doctors, NPs, PAs and nurse's aides who show their courage and commitment every day, and especially on October 29, 2012.
Zahava Cohen, RN, MSN, RNC-NIC is Administrative Nurse Manager in the NICU at Montefiore's Weiler Campus.
Posted by blogmoderator on 10/28/2013 at 5:02 PM
|Life is what happens when you're making other plans…
If life is what happens while you're busy making other plans, then stroke is what happens while you're living that life.
The morning sun streams through the stroke unit windows and across my resident's rumpled scrubs as he presents the overnight admissions.
"The first patient is a 68 year-old retired construction worker who was eating dinner with his wife last night when his speech became slurred and his left arm fell to his side…" As the resident shuffles though papers and presents the pertinent parts of his medical history and neurological exam, my eyes gaze over his shoulder and at the patient, who fumbles with opening the contents of his breakfast tray.
As we enter the room, Mr. W's face brightens as he recognizes me from the emergency department last night.
"Hey doc," he says with a slightly crooked smile. "Look what I can do now." He lifts up his left arm and we both stare, amazed, as he slowly opens and closes his hand. I think back to last night, when we pushed his stretcher through the doors of the Emergency Department, rushing back from the CAT scan to start the infusion of a powerful blood thinner, which would restore blood flow to a blocked artery in his brain and bring his left arm back to life. In two weeks he'll return to my office, with a barely perceptible limp. He'll proudly tell me that he quit smoking since the stroke, and we'll joke about how he can take his wife to Atlantic City with all the money he's saved.
Our next patient is an 86-year-old retired librarian whose daughter found her on the living room floor, confused and unable to move her right side. Her daughter produces a meticulous list of her medications, but I know it's of little use – she won't be able to swallow them anyway. She asks me if she should look into hiring someone to help when her mother goes home, but she can tell by my downcast eyes, even before I answer, that she won't be coming home. "Mom? Mom! Who am I? What's my name?" Her mother's eyes narrow slightly as she studies her daughter's face. "I…I don't know" she says softly. "Just talk to her," I try to comfort her. "She will recognize your voice."
Sometimes my residents ask me why I decided to become a stroke doctor and I try to remember back to five years ago when I took this path. Perhaps it was the fascinating anatomy and physiology of the blood vessels in the brain and the many ways in which a stroke can affect one's ability to speak, move and reason. It amazes me to this day. Maybe it was the assuredness of data from large clinical trials in a disease which is so common that it is the 4th leading cause of death in the U.S.
But with time, I have come to realize that the greatest thing about being a stroke doctor is my patients. They are struck with a life-altering event while going about their business. The determination, the strength, the dignity and the grace with which they recover from that stroke, or unfortunately sometimes succumb to it, is truly extraordinary.
It's late afternoon and it's the last patient of the day in the stroke clinic. A young mother is here with her newborn – two months after a brain hemorrhage during her pregnancy nearly took her and her baby's life. She shows me all the skills she has regained in rehabilitation, while her baby sleeps contentedly in her blanket. I know they will have a good life. I nod excitedly and then slip out of the room to blot my teary eyes.
Kathryn Kirchoff-Torres, MD, is a stroke expert in the Department of Neurology at Montefiore. She also is assistant professor of Neurology at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/28/2013 at 10:27 AM
|Addressing the Needs of Patients – as a Parent and a Provider
For 28 years, I've worked as a clinical research coordinator and physician assistant in Montefiore's Division of Pediatric Endocrinology. I have seen and cared for patients with a range of medical conditions - from thyroid disorders to early puberty. As a mother of four children I understand that parents tend to blame themselves for the health problems that afflict their kids. I also know all things can't be perfect, but we all want what's best for our children.
In our division, we pride ourselves on providing the best care for kids with a wide range of conditions, those that are well known and those that people are largely unaware of. Our team strives to address all aspects of a child's needs - physical, social and emotional. One specific group of patients that requires this kind of specialized care is girls with Turner Syndrome.
Turner Syndrome is a condition that affects 1 in 2,000 live births and occurs when there is an absence of all or part of the second X chromosome in the female body. This abnormality affects many parts of the body - potentially leaving girls with infertility issues, kidney abnormalities, hearing loss, cardiac problems, scoliosis, dental problems, webbed necks, social issues and anxiety.
Most girls with this genetic abnormality don't get diagnosed until they're in their early teens, when the first symptom that appears is usually poor growth. I can remember a cute "tween" girl, who came to me years ago because of poor growth. Her standard workup included doing a test to check for chromosomal abnormalities. When the diagnosis came back as Turner Syndrome, both the patient and the mom were distraught, since there were no other physical abnormalities that were evident. Mom blamed herself and would cry. However, after enrolling the patient in a novel research protocol which treated her short stature with synthetic growth hormone, she began to grow and felt more "normal." All of a sudden she wasn't the smallest in class anymore and both mom and patient felt happy and relieved that one obvious problem was corrected.
With this often late diagnosis, it is essential that these girls have access to a range of pediatric specialists including endocrine, cardiac, ENT, gastrointestinal and ophthalmology. Guidelines for the care of Turner girls do exist, yet many patients fail to get the care they desperately need because public awareness is low and many doctors have limited experience with this condition.
To rectify this, I, along with the Turner Syndrome Foundation, coordinated a workshop for girls with the condition. This was a first for Montefiore and it offered a host of difficult-to-find resources to families from around the Tri-state area.
The workshop featured lectures from clinicians on how to treat the various conditions associated with Turner Syndrome and also addressed issues such as bullying, self-esteem and identity. Child Life Therapists, including art therapists and music therapists, worked with the girls during break-out sessions, encouraging them to discuss common experiences and learn how to cope with various aspects of the syndrome. The families asked important questions, found connections to vital resources and, most importantly, formed bonds and friendships with other girls and family members that will last a lifetime. It was truly a wonderful event.
Working with girls with Turner Syndrome over the years, seeing their potential and possibilities for the future, I know that despite all the obstacles they face, with proper care, these girls can truly develop their full potential and lead a healthy, productive life.
Susan Wesoly, RPA-C, is a senior physician assistant and clinical coordinator in the Division of Pediatric Endocrinology at The Children's Hospital at Montefiore.
Posted by blogmoderator on 10/25/2013 at 2:25 PM
|Helping a New Nurse Have a Successful Transition into the Clinical Setting
More than 28 years ago, I began my nursing journey in Jamaica, West Indies. During my career, I completed a B.S. and M.S. in Nursing and finally a Ph.D. in Education Leadership. In my role on the clinical faculty at Montefiore, I interact with a large number of new graduate registered nurses, which has increased my awareness of some of the issues they face as they move from the classroom into the clinical setting.
While conducting research for my dissertation,I learned that new registered nurses continue to face challenges, such as communicating with the members of the health team, handling the workload and time management and prioritizing as they transition into the clinical setting.
The new nurses leave the comfort of the classroom, where they are supported by their instructors, into a clinical setting where they experience fear, anxiety and feeling unprepared for the role. Clinical leaders and senior nurses should provide an environment which is nurturing and supportive for the young inexperienced nurses. These nurses are going to be our replacements someday – it is our responsibility to provide them with the tools for success.
Some ways we can assist the new nurses is to acknowledge their limitations and develop plans to help them master essential skills. Secondly, we must recognize that the new nurses are in the novice phase and require timely, well-planned orientation and a supportive post-orientation plan. Experienced nurses should mentor the new nurses and arrange for added time and activities to address their learning needs.
I can recall my first experience as a new nurse and how scared I was as I walked into a patient care area. Luckily, I had been an intern for a year, where experienced nurses mentored me and I learned the role and responsibilities of the registered nurse. This internship helped me learn essential skills – time management, prioritization and how to communicate with the health care team. All of this so important for the new nurse to have a smooth transition into the clinical setting.
I was provided a special experience in the early years of my career and I'm committed to ensuring that same level of mentorship and care is provided here at Montefiore! We're all one big team and these nurses are the future caretakers of this community – we owe to them to make the transition as smooth as possible.
Veronica Thompson, EdD, RN-BC, MS, FNP-BC is on the clinical faculty in the Montefiore Learning Center at Montefiore Medical Center.
Posted by blogmoderator on 10/24/2013 at 3:37 PM
|It's the Little Things That Make Nursing So Rewarding
Over the past five years, my experiences in the medical surgical unit have molded me into becoming a better and more knowledgeable nurse. Being a nurse is a special experience – one that allows you to build bonds with patients. However, since we only know our patients in the hospital setting, we sometimes forget that they also have lives outside of these walls.
I will never forget one elderly patient I cared for recently. His wife was also admitted to the hospital, but she was transferred to a different unit. As I rounded in the patient room, the only complaint the man had was that his wife was on a different unit. It was evident to see that this made him anxious and unhappy. He told me that they had been married for 60 years and have never been apart from each other.
Despite the medical challenges on the unit, I began to put myself in his shoes. Although he was sick and in the hospital, his sense of comfort and healing was in knowing that his wife was safe and would be by his side. I managed to gain approval to make some changes to accommodate this couple.
Throughout the day, we would see this man walking with his cane and looking out of his room to see if his wife was coming down the hall. Even though the staff reminded him that the room had to be cleaned and paperwork had to be processed, he was eager to see his wife's arrival on the unit.
I cannot even put into words the excitement and joy on this man's face when she came down the hallway. He must have said "thank you" at least 10 times and came running to greet his wife. This sweet moment brought tears to our eyes. Helping this man reunite with his wife was the best thing I did that day.
We take for granted the simplicity of life. It truly is the small things that make most people happy. It's knowing that our loved ones are safe and within our arms reach. It's easy to be task oriented and go about our daily routines. We all need to take a step back and focus on the most important things in life; for this couple, it was their true love and comfort in knowing they were close to one another.
Days later, the husband became very ill and his prognosis became poor. He eventually passed away. Everyone who knew this couple was heart-broken. The only peace and comfort I had was knowing that I was able to be a part of making his last wish become reality. The small things you do for people go a long way and are never in vain.
Renzy Mathew, RN, is a patient care coordinator at Montefiore Medical Center.
Posted by blogmoderator on 10/24/2013 at 8:49 AM
|Cancer: An Experience of Feeling Alone in a Crowd
For something that affects one in two men and one in three women in this country, living with a diagnosis of cancer makes many people feel very alone. This may seem striking in a country where millions of people are cancer survivors, and cancer advocacy groups, fundraising events, and celebrity survivor role models abound, but it's true!
As a psychologist who runs the Montefiore Einstein Center for Cancer Care's Psychosocial Oncology Program, I have worked with both newly diagnosed patients and long-term survivors who have shared these ubiquitous feelings of isolation, loneliness and even shame. To understand this, one need only start with history. Cancer's legacy has been one of trepidation and fear from the days when it was referred to as the "C" word and considered the dread disease. Despite medical advances, most people know someone or of someone who has died or suffered from cancer. Many are aware of common side effects of treatment including losing one's hair, one's breast, or an organ, and the fact that cancer can recur – even after years of remission.
Further compounding the fear is the fact that a clear cause for many cancers is not known. As human beings like to find meaning in the world, many patients come up with their own attributions for their cancers that can further feed the loneliness and shame. "I'm being punished by God" and "I did it to myself for how I lived my life" are two such examples often heard. Moreover, cultural and social perceptions can contribute to feelings of isolation, with views of cancer as a contagious affliction or signifying a death sentence not uncommon. In fact, one Jamaican woman I spoke with said she wouldn't even tell her friend, a fellow cancer survivor, about her new diagnosis of cancer because she believed she would be shunned by her community and spouse. Others from many cultures have witnessed family members and friends withdrawing, minimizing, or catastrophizing their disease, and, as a result, have chosen to keep mum about their own diagnosis.
Cancer can truly and heartbreakingly be an experience of feeling alone in a crowd. But it doesn't have to be that way! There are many resources available, including support groups, individual counseling, peer support and telephone/online support where cancer patients can know they are not alone. In an effort to bring community and support to isolated cancer patients, we launched the Bronx Oncology Living Daily (BOLD) Buddy Program in 2011. Cancer patients can connect with trained volunteers known as BOLD Buddies, many of whom are cancer survivors themselves and eager to provide support, acceptance and understanding. Our BOLD Buddies have offered companionship during treatment and medical appointments when anxiety is often highest, and phone support when patients may feel down or alone.
While changing deep-seated cultural views about cancer may take time, no one has to feel alone when living with cancer. I lost my mother to cancer when I was a teenager, and understand and shared the loneliness my mother felt. Cancer may be an enigma, but it is not a punishment, or anything to be ashamed of. I write this blog hoping that it will help reduce the loneliness and increase the community that exists for anyone touched by cancer.
To learn more about the BOLD Buddy Program, contact: firstname.lastname@example.org, 718-430-4044, or www.einstein.yu.edu/cancercenter/support
Alyson Moadel-Robblee, PhD, is director of the Psychosocial Oncology Program, Montefiore Einstein Center for Cancer Care and Associate Professor of Clinical Epidemiology & Population Health and of Clinical Medicine at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/23/2013 at 1:42 PM
|Leaving a Lasting Impression
"He's just a baby. He won't remember this." How many times have we heard some version of those words, spoken during a traumatic time in hopes that the toddler will emerge unscathed? Not so long ago, even doctors subscribed to thinking along these lines, and, as a result, failed to appropriately manage pain medication for infants. Even today, many people believe that young children are somehow impervious to stress.
We now know that, contrary to previous scientific thinking, the young child's brain is actually disproportionately receptive to stimuli – both positive and negative. On the positive end, this helps to explain why a preschool-aged child can learn a second language after just a few months, when it might take her mother years and years. On the negative side, however, it explains why young children exposed to toxic stress (repeated exposure to very difficult situations in their surroundings), trauma, abuse and neglect are at particular risk for problems later in life. The early childhood brain is like a sponge, and it soaks it all up, the good and the bad.
At Montefiore, we pay particular attention to early childhood development and well-being, in acknowledgment of the critical importance of these early years, via our Healthy Steps program, established in 2006.
Over the last seven years, we have screened nearly 10,000 young children regarding their social emotional development, and provided follow-up whenever indicated. Some families enroll in Healthy Steps even before the baby is born, and enjoy three to five years of co-managed well child care – every visit to the pediatrician also includes a Healthy Steps Specialist, who may be a social worker or a child psychologist with special expertise in early childhood development and parent-child relationships.
The well-being of parents also is of particular importance when we think about ensuring young children live lives free of toxic stress, trauma, neglect and abuse. As such, we also screen parents of young children for current depression and for their own adverse childhood experiences, or ACES. If parents request their own help to manage any of these issues, we offer onsite psychotherapy and psychiatry, as needed.
We also spend a lot of time teaching medical students, pediatric residents, nursing staff and attending physicians about early childhood brain development, attachment theory, and ways to prevent and recognize toxic stress in the life of a young child.
All of this is with the express goal of ensuring that Montefiore's infants, toddlers and preschool aged children grow up in environments where everyone acknowledges how "spongey" their brains are, soaking it all up at all hours. We are working to create communities of awareness within our pediatric practices to ensure we are doing everything we can to prevent early childhood exposure to toxic stress and trauma. And in those unfortunate events when these things do happen, that we offer a family all the supports we have, within their medical home, at the earliest possible moment. The future looks bright for our Healthy Steps kids.
Rahil D. Briggs, PsyD. is director of Pediatric Behavioral Health Services at Montefiore and assistant professor of Pediatrics at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/22/2013 at 2:18 PM
|Healthy Babies…Loving, Capable Mothers
"Birth is not only about making babies. Birth is about making mothers--strong, competent, capable mothers who trust themselves and know their inner strength." - Barbara Katz Rothman
Indeed, it is a privilege and a pleasure to participate in the birth of a baby. The days, and nights, in the life of an obstetrician are mostly filled with witnessing the miracle and joy of childbirth.
Labor and delivery is also a team sport composed of many dedicated and talented people. The nurses, OB technicians, unit business and service associates, physician assistants, midwives, residents, anesthesiologists, obstetricians and numerous specialists work together like a well-oiled engine!
Our team takes the health of the mother before, during and after pregnancy very seriously as it can be helpful in the future health and well-being of both mother and child. We offer care and counseling before pregnancy and if a woman has a preexisting medical condition, we focus on treating and stabilizing her health before conception. It's the truth -- women who get regular care during pregnancy (prenatal care) have healthier babies.
We work with women in the Bronx to share simple steps to help protect their health:
- Eat a healthy diet
- Exercise most days of the week
- Don't smoke
- Limit alcohol
- Early and regular visits to the doctor
We find pregnant women are often confused about information they read online, hear in the press and from their friends and family. For example, there are many myths about diet and weight gain.
During pregnancy – as in the rest of our lives – a healthy diet full of fresh fruits, vegetables, whole grains, lean meats and fish is essential. We recommend women with a normal weight entering into pregnancy should gain about 25 pounds and if she is overweight to start, the limit is 15 to 20 pounds. Whatever their number, we work with them to manage their nutrition and support healthy weight gain during pregnancy.
Fortunately, most pregnancies, labors and deliveries are uneventful and come off without a hitch. However, some health issues can lead to health problems for moms and babies during and after pregnancy. Finding these problems early can lead to early treatment, prevention and may save a woman's life down the road.
There are two glaring health problems we often deal with and that are red flag alerts for our team:
- High Blood Pressure – may occur during pregnancy as chronic hypertension, gestational hypertension, preeclampsia or eclampsia.
When one of these occurs – the patient's lifetime risk of heart disease is increased up to four times and heart disease is the number one killer of women in the United States.
- Gestational Diabetes – is diabetes that occurs during pregnancy and is a problem with high glucose (sugar) in the blood. Gestational diabetes increases the risk of diabetes in the older adult. Diabetes also increases the risk of heart disease and premature death.
I am dedicated to caring for these patients because health and overall wellness contribute to the strength of all mothers – not just during pregnancy, but also throughout their lifetime. Healthy moms breed healthy kids – and so it's the cycle of life!
Mary Rosser, MD, PhD, is an Obstetrician/Gynecologist (OBGYN) in the Department of OBGYN and Women’s Health at Montefiore Medical Center. She also is assistant professor, Department of OBGYN and Women's Health at the Albert Einstein College of Medicine.
Posted by blogmoderator on 10/22/2013 at 8:52 AM
|The History, Vision and Leadership of The Montefiore School Health Program
"I don't want to go to school today, my tummy hurts," whined Kiara at 7 am. She doesn't want to get up and Crystal, her mom, has to get to work. Is she sick? Is she having a bad experience at school? At some point every parent has faced this dilemma. Crystal has an ally at her daughter's school-based health center.
Montefiore School Health Program's 21st health center opens today. We serve more than 30,000 children and parents in 65 schools in the Bronx. It all started thirty years ago, in 1983, when Montefiore joined a group to open a part-time school health program at PS 85. The center had a nurse practitioner (NP) and a medical assistant who split their time between Montefiore and the school. Healthcare institutions, including Jacobi, Morrisania, Martin Luther King Jr. Health Center and Bronx Lebanon were among the early sponsors and providers of school health services. The centers provided well-child care, acute care and monitoring of chronic illness.
Supplies were carried from the sponsoring site to the school. School health NPs had prescribing privileges, well before their hospital and health center counterparts, thanks to a special provision by the state. The services were well utilized and well received in these early years, but inadequate.
Our director, Dr. David Appel, was a social pediatric resident during these years. He saw the great need in this community and designed a comprehensive school health center as his social medicine project. It was a great plan, but seen as almost impossible by the folks that oversaw the budget.
Ten years later, a door opened and new regulations allowed school visits to be reimbursed at the same rate as their sponsoring organizations. This change allowed the chairman of the Department of Family Medicine to track Dr. Appel down and offer him the challenge of his lifetime - to create a sustainable school health program at Montefiore.
And he accepted that challenge!
In 1993 the program had three part-time sites. Then he was able to add in dentistry and mental health services. By 1996 we had seven full-time health centers. Through great vision and leadership, along with creative partnerships, institutional support, statewide advocacy and the hard work of everyone involved in the program, we have made a great impact to the children and families in the Bronx. But our work isn't even close to done.
Our community still has great needs for complete and integrated medical and mental healthcare services. We also are committed to impacting the obesity epidemic - providing nutrition and fitness programming.
The vital services offered through the Montefiore School Health Program help families like Crystal and Kiara all the time. When Crystal stopped by the school health center on her way to work, Kiara was examined by the medical provider who found that her stomach aches were related to being bullied at school. They were able to meet with the school health mental health provider the same day and Kiara now feels safer at school – and no more tummy aches!
We are making a difference and history is happening now!
Margaret E. Rogers DNP, RN, FNP-BC, is Director of Primary Health Care at The Montefiore School Health Program
Posted by blogmoderator on 10/21/2013 at 8:40 AM
|Struggling to keep up with shift work? Ask for help!
In the eight years I've been at Montefiore, I've seen a very busy community that thrives because of the dedicated workers who take care of patients 24/7. Running a quality medical institution requires its workers to be on their game, regardless of whether it is 4pm or 4am. And in our society of being on-call at all hours of the day and night, we often feel that it is considered "weak" to admit that we can't cope with being "on" all the time.
In my practice at the Sleep-Wake Disorders Center, I've started to see more and more Montefiore associates as patients over the years who are recognizing that they aren't adjusting to their shifts. They refuse to see it as a weakness and instead ask for help.
I recently saw a nurse who started working the night shift after many years working in a different 9-5 career. She was struggling with staying alert and awake at night, while also having trouble staying asleep during the day. She feared that she would make mistakes at work and she also was concerned about missing out on time with her family. All of this was beginning to affect her mood as well as attention and concentration.
To help, she and I worked on protecting her time during the day for sleep and discussing with her family how things can get done while she sleeps. We also created a personalized bed/wake time, napping, caffeine, and bright light exposure program that was practical for her to implement daily. After a few months of following the program, she had more energy and alertness while working and was able to sleep soundly at home.
Our bodies have circadian rhythms that biologically program us to be awake during the day and asleep at night. When we are asked to work shifts outside of the traditional 9-5 day, we go against what our body is naturally meant to do. Although some people have no issue working shifts, many find it extremely difficult and can develop shift work sleep disorder (SWSD). Symptoms of SWSD include weight gain, gastrointestinal problems, insomnia, headaches, work absenteeism, irritability, sleepiness at work, insomnia at home and issues with attention and concentration. Many shift workers miss out on social events and are at an increased risk for workplace accidents, errors and depression.
A cure does not exist for SWSD, but effective treatments are available. Although not always practical, the best treatment option is to work the same shift every day and keep the same sleep schedule, seven days a week. And they should try to limit any interruptions such as housework, appointments and phone calls during the times they are supposed to be asleep.
I see too many patients with SWSD who suffer in silence, fearful that they'll lose their jobs – working off hours despite feeling miserable at times. The more we take SWSD seriously, the more people will hear about it and seek treatment without feeling stigmatized. There is no shame in asking for help if you are struggling with adjusting to your shift – proper treatment will help not only you but those you work with as well. That nurse I told you about, and many of my other patients, would agree!
Shelby Harris, PsyD, is director of the Behavioral Sleep Medicine Program, Sleep-Wake Disorders Center at Montefiore Medical Center. She also is assistant professor, The Saul R. Korey Department of Neurology, and assistant professor, Department of Psychiatry and Behavioral Sciencesat Albert Einstein College of Medicine.
Posted by blogmoderator on 10/18/2013 at 9:55 AM
|Strangers No More
She arrived at the Caregiver Support Center early in the morning. When I arrived for work, she was behind a screened door, in one of the private rooms. I was told that she and a relative were brought down from the surgical waiting room. Her relative was in one room, she in another. I didn't know her name or her relationship to the patient in surgery. It was going to be a long operation. Cardiac.
Throughout the course of the day, she would come out of the room every now and then – to use the ladies' room outside of the center. The lights remained off in the room she occupied. I could see that she had been given some blankets to keep her warm, covered.
I'd say hello and ask her if there was anything we could get for her, or do for her. Politely she'd say, "No thank you, I'm o.k." She appeared to be about 45 years old. A seemingly friendly person – someone who wanted her privacy, her space. She would accept a bottle of water and that was all.
At some point later in the afternoon, her relative briefly joined her. There was an exchange of joyful tears. Perhaps they had received good news?
The woman's relative left the center, thanking us. The woman remained in her darkened space, alone.
After two more hours, we got word that the operation was almost over and the woman could meet with the surgeon on the 4th floor, where the O.R. is located. I knocked on the door and entered to deliver this information to her.
I found her standing up, a blanket covering her shoulders, tissues in her hands and wiping her nose. Tears fell from her weary eyes. She look disheveled, exhausted. She started to offer apologies for her state – I told her no apologies were necessary. I let her know that the operation would soon be over. She started to shake and sob, her body didn't seem to know what to do with itself.
She stood there, this solitary person, whom I did not know, nor she me. I asked her who was in surgery. "My husband. I'm so sorry, it's just that I've been keeping so much in for so long...we have five children. My youngest is taking this all very hard."
Now I knew. I was struck by her trembling hands, which seemed to be reaching out for something, and her quivering body. We stood less than two feet apart. The interior room was barely lit. Tissues were everywhere. Blankets, pillow. Her and me.
"You look like you could use a hug, would it be alright if you got a hug from a stranger," I gently asked. It seemed like she fell into my arms. I held her trembling body until it calmed down. She held me tight.
"My husband had an LVAD removed. He wasn't supposed to live. It's a miracle. A complete miracle. His heart pinked up!"
I accompanied her upstairs to the recovery area where she hugged me. Strangers no more.
Randi Kaplan, LMSW, is director of the Caregiver Support Center at Montefiore Medical Center.
Posted by blogmoderator on 10/17/2013 at 11:21 AM
|What Every Woman with Breast Cancer Needs to Know
Pink is everywhere. Corporations go pink. 320-pound linemen in the NFL go pink. Flight attendants on airlines go pink. Entire television networks go pink. It may be impossible to travel through the month of October without seeing pink. Breast Cancer Awareness Month is in high gear. The awareness campaign waged on behalf of breast cancer over the last quarter century has been remarkably successful.
It is, after all, a relatively common disease that takes the lives of too many of our wives, mothers, sisters and friends. Research and screening programs are humming. Exciting new developments in genetics and treatment are here. There are more than a dozen different ways of reconstructing part of the breast or the entire breast after lumpectomy or mastectomy.
Last week, a woman named Penelope walked into my office to discuss breast reconstruction. She is 51 years old, a mother of two and had a right mastectomy last year. She is African-American, unemployed and on Medicaid. Her cancer surgery was performed at a different hospital than where I work by a breast surgeon I know to be technically good and careful and compassionate. Her lymph nodes were negative and, from everything we can tell, she has an excellent prognosis.
During her appointment, we had a long chat about different ways to reconstruct her breast. It is one of my favorite parts of my job. There are lots of ways to reconstruct a breast. There are implants. There are ways to use a woman's own tissues – from her belly or abdomen, from her buttocks, from her thighs or from her back. There are ways that require just one operation and those that require multiple operations. There are simple ways and more complex ways. All have pros and cons.
I like having this conversation because after lots of consultations that involve the "have tos" of chemotherapy, radiation, and mastectomy, this is about the "want tos." "Do you want to use your own tissue?" "Do you want to change the other breast to match your reconstructed one?" "Do you want to have the shortest possible recovery time?" We agreed upon implant-based reconstruction with a small enlargement of her left breast at the same time.
All of that is good. So, where's the problem? The problem is that Penelope wasn't offered reconstruction at the time of her mastectomy, at the same hospital, by the same group of doctors that were treating her cancer. This is not so good.
In New York City, like many places in America, the likelihood that a woman undergoing surgery for breast cancer will receive reconstruction is influenced by her race, her socioeconomic status and her level of education. To put is simply, but accurately, if you are wealthy, White and college educated, your chances of receiving reconstruction are a lot higher than if you are poor, Black and not college educated.
Laws have been passed on the federal and state levels that eliminate financial barriers for women receiving care for breast cancer. Reconstruction is covered for all women, everywhere. In New York State, we, at Montefiore, helped write legislation that mandates that all women be informed of reconstructive options. It has helped but we're not there yet.
There are still far too many women in America, like Penelope, who weren't offered and didn't receive reconstruction after mastectomy surgery. This is a problem. We need to solve it. Talk about reconstruction with your friends and family. Demand information from your doctors. And realize that rich or poor, Black or White, every woman is entitled to a certain level of breast cancer care – including reconstruction.
That is breast cancer awareness, too!
Evan Garfein, MD, is a plastic and reconstructive surgeon in the Department of Surgery at Montefiore Medical Center and Assistant Professor of Surgery and Otorhinolaryngology – Head & Neck Surgery at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/16/2013 at 9:20 AM
|This is a Story of a Little Girl with a Rare Neurological Disease
This is a story of a little girl. She came into this world like any other happy and healthy little girl. Her parents, who already had two older sons, called her their princess. The princess soon started to smile, reach and giggle. Family bonds flourished. She played with her doll, took her first steps and spoke several words by the time she was one. But then, something strange started to happen to the princess: her hands could not hold the doll anymore, she lost her words and by the time she was three, epileptic fits started to strike. The world of giggles, toys and parental ambitions was replaced by feeding tubes, plans for special education and worries about her future. Her life of joy became a life of isolation. From the moment she was conceived she was destined to develop Rett Syndrome, but nobody knew.
Rett Syndrome is a genetic disease that affects brain development. The girls are born with the normal number of typical looking brain cells and the initial stages of brain development proceed in an undisturbed way, but by age one, when the brain cells are supposed to branch and brain activity and development literally "explode," the presence of a mutation on the X-chromosome blocks this branching process.
The Rett Center at The Children's Hospital at Montefiore was born out of the optimism brought by scientific discovery that even in the most severe stages of this disease, animals with Rett Syndrome can be completely cured. Because we believe the day will come when girls with Rett Syndrome will be cured at the Rett Center, we are focused on providing medical care that is the absolute best available. At the moment, we are enrolling patients into our first trial with the hope of improving the girls' symptoms, including motor problems, seizures, disordered breathing, poor attention and memory. We are working closely with a multidisciplinary team of specialists and scientists across the country to develop the most efficient, novel strategies for these girls.
You know, there was one thing that the princess from our story did not lose - the clarity and the warmth of her eye gaze. Our research has, for the first time, provided objective evidence that girls with Rett Syndrome see the world in the same way other children see it: they remember, they feel emotions and have thoughts. But these princesses are locked in their bodies and cannot move. To end their isolation we have developed special communication tools and strategies, we teach them how to "talk without words" in the way deaf children and their families do through sign language.
I met this little princess when she was two years old. Her parents carried her into my office and did not believe that she even knew her name anymore. Quickly we worked together and showed them how to communicate. Before long their princess was able to tell them when her tooth was hurting, when she did not like dinner and she started to make jokes! All of this transformed the atmosphere in their home and her parents never forget to thank me for showing them that their little princess was inside.
When these girls come for their appointment and look at me I know they are asking me to please unlock them. I go to sleep every night and wake up every morning with the same conviction. The question of being able to unlock them is not a question of if, but a question when.
Aleksandra Djukic, MD, PhD is director of the Tri-State Rett Syndrome Center at The Children's Hospital at Montefiore and associate professor of Neurology and Pediatrics, The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine.
Posted by blogmoderator on 10/15/2013 at 10:39 AM
|Women over 45: You are not alone!
We keep hearing 40 is the new 30, 50 is the new 40 and that we are in the prime of our lives. However, why don't we always feel this way? Because hot flushes are interfering with our sleep and we experience changes in our mood and memory.
Questions like "Where did I put my keys, did I lock the door, what is my neighbor's name" are not uncommon. We may have less patience and tolerance with loved ones because we are tired from having interrupted sleep. Our relationship with our partner may be stressed because of feelings of neglect, when in truth we just want to relax and at times prefer a pint of Ben and Jerry's in our bed rather than Ben or Jerry.
As a menopausal woman myself, I am appreciative of these common complaints. When my patients come to see me, it's often the first time they express their symptoms and find out that not only can they get help, they are not alone.
It is my privilege to give them advice about what they can do to make their lives better. Medications aren't always needed; treatment may instead involve identifying what causes their symptoms. For example, I had a patient who experienced hot flushes, and by keeping a symptom diary, realized that they occurred before she went into church because of a childhood fear of the confessional. Once she identified the trigger, she was better able to control her flushes.
As a gynecologist specializing in care of the maturing woman, I know first-hand how education can greatly improve patient symptoms. I encourage my patients to ask me anything – from what can they do when sex hurts to how they can prevent hip fractures. We work together to identify the causes and develop a management plan best for them. No two women are identical and neither should their plan.
More and more women are living longer, and it is my joy to help them improve their quality of life. One thing is certain: all women seem relieved to learn they are not alone and they can be helped, which I consider an honor to do every day as their doctor.
Judi L. Chervenak, MD, is an Obstetrician/Gynecologist (OB/GYN) in the Division of Reproductive Endocrinology, Department of Obstetrics & Gynecology and Women's Health at Montefiore Medical Center. She also is associate professor, Department of Obstetrics & Gynecology and Women's Health (Reproductive Endocrinology and Infertility) at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/14/2013 at 12:21 PM
|Are E-Cigarettes Safe for Our Teens?
Many smokers believe that electronic cigarettes are safer than regular cigarettes - but as a pediatrician, I'm concerned about the health effects these devices could have on teens, a population that's increasingly using them.
A recent survey from the U.S. Centers of Disease Control and Prevention (CDC) found that the percentage of high school students who had smoked electronic cigarettes more than doubled from 4.7 percent in 2011 to 10 percent in 2012. For middle-schoolers, this rose from 1.4 percent to 2.7 percent. More than three-quarters of students who used these devices in the last 30 days reported smoking regular cigarettes at the same time.
Electronic cigarettes ("e-cigarettes" or "e-cigs"), formally called "electronic nicotine delivery systems," have the same shape, size and general appearance as real cigarettes. E-cigs use a battery to vaporize a nicotine-containing solution, creating mist that's inhaled. The tips of e-cigs often have a light that looks like the burning ash of a regular cigarette. Using e-cigs is called "vaping."
Like regular cigarettes, e-cigs contain nicotine. They don't contain the thousands of other toxic chemicals – many of them cancer-causing – found in regular cigarettes. It's the nicotine in cigarettes and e-cigs that's highly addictive.
Nicotine addiction usually starts early in life – about 90 percent of people who smoke started before age 19. Research suggests that when nicotine addiction starts in adolescence (rather than older ages), it's harder to kick the habit. Unless a smoker can stop, this addiction creates a lifetime of tobacco dependence. Smokers face higher risks of developing lung cancer and other cancers, heart disease and other miserable diseases. In the U.S., 440,000 people die from smoking each year – about 1,200 deaths per day – an astounding number.
So it's really worrisome when I hear that teens are using e-cigs because this could be another road to nicotine addiction and using regular cigarettes. Some studies show that there are cancer-causing and other chemicals in the vapor, and there may be adverse effects on lung functioning. E-cig use in public may expose others involuntarily to harmful substances in the vapor – including nicotine!
Experts are concerned that e-cigs are heavily promoted to teens, who may find the products especially appealing because they are available in vanilla, menthol and fruit flavors. Companies employ young attractive celebrities to market e-cigs, making them appear glamorous and cool. They are touted as being better smelling, cheaper and a guilt-free way to smoke.
Unlike regular cigarettes (and nicotine replacement products used to help smokers stop), e-cigs are not regulated by the FDA. However, the FDA has expressed "great concern" over the dramatic rise in e-cig use among youth and is discussing regulating these products. Some states, including New York and New Jersey, have prohibited the sale of e-cigs to minors.
As a pediatrician, I routinely discuss tobacco use with teens and parents. Fortunately, most teens aren't using tobacco – that's great! It's so important for teens never to start smoking cigarettes or using other tobacco products. If teens smoke, we discuss how to stop. Based on the CDC report, I'm going to ask my teen patients about e-cigarettes and will strongly advise teens not to use them – their lifelong health may depend on it.
Sophie J. Balk, MD, is an Attending Pediatrician at The Children's Hospital at Montefiore and Professor of Clinical Pediatrics at the Albert Einstein College of Medicine.
Posted by blogmoderator on 10/11/2013 at 8:48 AM
|My Time at Camp
When I was a child growing up in Brooklyn, I looked forward to every summer when I could escape the city, be with friends in the country, play sports, have counselors as heroes and come of age as a teenager. After a long lapse, this opportunity returned in a unique manner — I was asked to represent The Children's Hospital at Montefiore at its summer kidney camp program at the Frost Valley YMCA, which is run in partnership with the Ruth Gottshco Foundation.
This pioneer initiative began in 1974 with the desire of Ruth's mother, Eva, to have a summer camp experience for children stricken with kidney disease requiring dialysis. Although Ruth, unfortunately, was not alive at the start of this program during the summer of 1974, history was made when 60 children and teenagers from around the United States ventured to Claryville, New York, and the Frost Valley YMCA to experience the beauty of being a mainstreamed camper while receiving hemodialysis in a small renovated facility in the middle of the Catskill mountains. Indeed, this was the first-of-its-kind program that became a model for others to simulate worldwide.
What I remember vividly and experience every time I go there (and this year will be the thirty-fifth year) is the wonderfully rewarding feeling of seeing children, that we often encounter in the hospital setting while on dialysis or after receiving a transplant, engaging in the wonders of camping with its attendant challenges and milestones. Almost equally important is the mutual appreciation by their fellow campers and counselors who are fortunate enough to have shared their camp experiences with them.
It is difficult to quantitate this mutual growth and understanding but I can recall many examples where it has changed lives. I remember the kidney campers who were amazed that they could ride a horse, backpack into the woods for overnight stays, and sing to their hearts content in the dining hall along with hundreds of other campers. More importantly, I remember those who used their newfound confidence to move forward with their lives; finish high school, go to college and still return every summer to Frost Valley, not as a camper, but instead as a counselor either on dialysis or with a kidney transplant, now with tremendous responsibilities for others.
I also remember the young visiting international counselor who at age 17 first saw children on dialysis at camp. He returned year after year while in college and is now a leading transplant surgeon at a major medical center. His children also started at Frost Valley as soon as they were old enough and became counselors in the true "Lifer Spirit" of this unique camp.
So why do I love to go to camp? Because I get fueled by the energy and belief that anyone — if given the opportunity — can overcome even the most difficult obstacles and strive to grow and reach their potential. Around this time of the year I again begin thinking about camp, but these days it's more often thoughts of our Children's Kidney Center at Frost Valley, rather than memories of my own childhood camp experiences. Come join us sometime and see why thousands of campers and staff also have these memories in their minds and hearts.
Frederick J. Kaskel, MD, PhD, is chief of the Division of Pediatric Nephrology at The Children's Hospital at Montefiore and Professor and Vice Chair of Pediatrics at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/10/2013 at 9:07 AM
|The Road to Wound Healing
In recognition of National Physician Assistants Week (Oct. 6-12), which is sponsored by the American Academy of Physician Assistants, I want to acknowledge all the PAs who work side by side with our physicians to provide outstanding patient care throughout the medical center!
Having been a physician's assistant for more than 30 years, working as a member of the Wound Healing Program at Montefiore is a humbling experience. Patients often acquire their wounds under sad circumstances -- the most common include:
- lying on the floor for days after a fall
- gun-shot wounds that cause paralysis and lead to bedsores
- diabetes causing ulcers and amputations
- painful leg ulcers from sickle cell disease
An open wound often causes the patient to feel ashamed because it is such a visible and disturbing result of disease. Some ulcers have been present for months, years and even decades. The odors and sights can be difficult to witness but when I can help heal it, or at least ease some of the suffering, it is very rewarding.
When we initially see patients, we tell them we will work with them as a team to heal their ulcer and we'll get them to the point of being able to "ring the bell". When an ulcer is healed, there are hugs all around and we ring a special bell to celebrate!
I remember one patient who had suffered with leg ulcers for 15 years, trying many different treatments. She is nearly healed now. She brings us flowers and says "thank you from the bottom of my heart." Her life had been so limited before because of the ulcers, the drainage and the pain — and now she goes to the theater regularly!
The Wound Healing Program began in response to the need to deal with pressure ulcers, which is an underserved area in medicine. We work closely with a patient's medical team to provide follow-up care — even after they've left the hospital. We utilize advanced treatments, like tissue grafts and compression therapy, and we even provide advice on nutrition. We help provide a continuum of care and reduced readmissions.
My work and this program at Montefiore are all about hope, it's about caring and it's about healing. Next time you hear a bell ringing, you'll know that one more ulcer is healed!
Cary Andrews, MS, CWS, is Senior PA in the Wound Healing Program DFSM/Hyperbaric Medicine at Montefiore Medical Center. She also is an associate at the Albert Einstein College of Medicine of Yeshiva University.
Posted by blogmoderator on 10/09/2013 at 9:29 AM
|Why I Love and Hate the Bronx
Women in the Bronx get sick.
Pregnant women in the Bronx get really sick.
The patients of the Bronx live in a hard place that has some of the poorest zip codes in the United States. And if there's anything I've learned from my medical training as a fellow at Montefiore — and now as an attending in Maternal-Fetal Medicine — it's that poverty can make you sick, not just theoretically, or mentally, or figuratively. I'm speaking about real, clinical, dangerous illnesses.
Theories exist about discrepancies in health outcomes: One is that underserved communities lack resources, so that small health problems are not addressed until they are large and dangerous. But the outcomes that we see cannot entirely be explained by delays. Many of us have come to believe that the everyday stresses have caused these discrepancies. The new theory is that the hundreds and thousands of tiny stressors on any one person, cumulative across a day, across a week, across a year, will damage the human body.
I don't know why this is true. I can just tell you that from my four years taking care of patients here, it's the truth.
I hate this about the Bronx. And I love this about the Bronx.
I hate this about the Bronx because I don't want to see a young woman with metastatic breast cancer in early pregnancy. I don't want to mourn after telling a teenage girl that her water has broken at 19 weeks gestation, and that we cannot save her pregnancy. I don't want to be at a "routine" visit in our clinic, listening to the lungs of a woman who had a baby one week before, and realize that she is in cardiac failure and needs to go to the hospital, and probably to the intensive care unit, while she weeps about who will take care of the baby. All of these things are too, too hard.
I've taken care of all of these women. All of these women, and more. Many get through their hard time with us and get better; some do not.
But in the face of difficulty, I also have to love this about the Bronx, even as I hate it. The truth is that taking care of these patients has given me an education that I don't think a doctor can get in many other places. Now, when I see that postpartum patient in heart failure, it's not the first --or sadly, even the second or third time that I've dealt with this rare complication. That's tragic, but it also means that now I know a lot and know, now, the right medical thing to do, and the right medicines to start thinking about. And I know, now, who are the right people to call, and how to help this woman with the other parts of her life so that she can be in the right place to heal.
And so, one by one, the women of the Bronx have taught me to be the right doctor for the women of the Bronx. And that is something that I can love.
Eve (Chavi) Karkowsky, MD, is an Ob/Gyn in the Department of Obstetrics & Gynecology and Women's Health at Montefiore Medical Center. She also is assistant professor in the Department of Obstetrics & Gynecology and Women's Health at the Albert Einstein College of Medicine of Yeshiva University.
Posted by blogmoderator on 10/08/2013 at 8:55 AM
|Welcome to Blogtober at Montefiore
Every October bloggers around the U.S. try to encourage others to share stories through online writing as part of a national movement called Blogtober. Sharing experiences through storytelling enriches our understanding of the world, broadens our perspective on life and helps us achieve mutual respect.
With 550,000 patient visits each year and more than 19,000 associates working together to care for the Bronx and surrounding areas, Montefiore is full of stories. Our participation in this effort allows us to share personal stories and life-changing experiences while also giving others an inside look into the lives of those who make up this institution.
I consider myself a storyteller. As a practicing pediatrician, telling stories allowed me to connect with the kids I cared for and their parents. As a faculty member, I use storytelling to teach medical students and residents, as well as colleagues. And as a member of the leadership team, I use stories to help the organization evolve and continue to meet the changing needs of the community.
So, I'm kicking off this month-long adventure with one of my personal stories…
As pediatricians, one of the most important things we do, particularly for families of young children, is to frame the journey of parenting in a way that will help them cope – sometimes in difficult circumstances. I remember taking care of an infant girl in the newborn nursery when I was an intern and realizing she had a series of slight physical abnormalities and behavioral limitations. Both of those suggested that her development would probably not be entirely normal. We tried to identify a specific genetic abnormality, but were unsuccessful and remained worried nonetheless.
At a meeting with her parents, who had also noticed that their brand new baby girl was less vibrant and engaging than expected, the mother asked me directly whether her baby would walk on time or begin speaking at the appropriate age. At first, I wasn't sure how to answer since it wasn't clear what the future held for her child. But after a brief pause, I replied that's not the question that needs answering. The real question was – did they think they could love this little girl?
If the answer was "yes," then whether she walked – at one year, three years, six years or never – I could guarantee them she would have the best developmental outcome possible no matter what hurdles she would face. If the answer, however, was "no," then it didn't matter whether she got up and walked out of the nursery the next day, she would never be able to fully achieve her developmental potential.
I often think about that discussion and hope that reframing the situation was helpful for that mother and father. I'm certain it was helpful for the infant girl!
We all tell stories every day, so I hope you will check back regularly to hear from our team of experts about what it takes to help our patients and community.
Andrew D. Racine, MD, PhD, is Senior Vice President and Chief Medical Officer at Montefiore Medical Center. He is also Professor of Clinical Pediatrics at Albert Einstein College of Medicine.
Posted by blogmoderator on 10/07/2013 at 11:16 AM