EMC2

No, I have not forgotten the = sign in my EMC2

• is an emerging syndrome that will soon reach epidemic proportions, 
• will be the AIDS of the 2010-30 decades,
• may consume massive health care dollars.

I suspect many of the physicians out there have encountered this syndrome but may not have fully recognized what they were seeing.  further, this new medical challenge may prove even more daunting on every level than treating early AIDS patients.  Medical school education is completely unprepared and have little ability to make the rapid adaptations that would be required to meet this new public health need.

EMC2= Elderly (with) Multiple Chronic Conditions

I can give you many examples from just the last few weeks and I suspect my medicine colleagues could rattle off dozens.   Recently, I was asked to consult on an 85 year old who slipped on some concrete stairs and suffered a skull fracture and small subdural hematoma (blood clot between the skull and brain).  He was lucky and had no real brain injury but he remained in the hospital for over a week because:

1. He developed an arrhythmia that led to extensive medical testing
2. He experienced extreme difficulty urinating and as a result, suffered a bladder infection
3. His degenerative lower back problems greatly inhibited his early mobilization and led to high concerns about the risk of acquiring a blood clot in his leg.

Part of this frustrating syndrome is the social component that almost always accompanies the medical condition.  In this patient, he was the caregiver for his wife who suffered with advanced Alzheimer's dementia.  Not a visit went by when our conversation didn't stray to his concerns about his wife-was his neighbor caring for her properly?  Did she understand why he wasn't there to prepare her meals, help her wash and dress?  Would he be able to return to providing her care when he was released from the hospital?

One of my colleagues estimated that within 2 years, one of every three patient would meet the criteria for EMC2.  Coordinating their care, balancing their social and medical needs, making decisions about complex multi-pharmacy interactions and conflicting health needs (what is good for the heart may be bad for the brain, what is good for arthritis may be toxic to the aging liver/kidney).  Sure, geriatrics has emerged as a specialty but there is remarkably little known about how to best manage these patients, few hospitals have geriatric hospitalists (there are precious few geriatric specialists and even fewer that serve as more than nursing home guardians), and many specialists refuse to defer to a geriatric doctor in managing the many medical concerns of a given patient.

I never like to raise an issue without presenting some constructive suggestions.  The first step is clearly acknowledging the problem and bringing together innovative thinkers across the spectrum of medicine and medical education to develop a rapid response to this raging epidemic.  I promise a future posting to outline some more specific areas that will need to be addressed and some initial steps I hope the medical community will consider.

I think Einstein would approve.

There are only two ways to live your life.  One is as though nothing is a miracle.  The other is though everything is a miracle.

The Economy and Healthcare

Much is said about the economy these days-is it rebounding?  Is unemployment down? Who is responsible for the massive debt? How can we save Medicare?  Into this setting, a little reality slips in to my office on a frequent basis.  Today I saw a middle aged man who has a significant lumbar (lower) spine problem.  He has a ruptured (herniated) disc with nerve compression causing severe pain, numbness and weakness.  Together we have tried many treatments to heal this problem which have given him temporary relief but the symptoms soon return, usually worse than before.  The time has come when he should seriously consider surgical intervention BUT he can't.  Here is his story.
This hard working man has spent the last 18 months out of work, made redundant in the heat of the recession.  Just two months ago he finally landed a great, competitive job which he loves (and his evaluations have been outstanding to date) and is finally beginning to right his personal economic boat.  Taking the necessary time off of work, he feels, would jeopardize his job-there are 30 or more talented individuals who would gladly snap his position up.  Bad timing all around.
I find it really difficult at times like these to remain a dispassionate neurosurgeon.  This man is suffering great pain and disability.  He has taken no time off of work and even refuses most medicines because he wants to perform well every minute at work.  Firing him because of having surgery would be wrong and probably illegal but as a large company, I suspect they could find some way to handle that.  Being ill is hard enough, having those issues compounded by fear and financial insecurity has to aggravate the problem considerably.  Of course, I understand that the company needs him at work-that is why they hired him-and what good alternative do they have?
No one plans to have a medical problem and this many has done all the right "health" things (not overweight, exercises, goes to the doctor regularly, etc.) but nature can get in the way.  I am glad that I help many patients in my practice because when faced with this patient, I felt largely helpless.  I just hope the time I took to talk with him, reassure him, adjust his medications to try and get some relief will help in some small way.

Call From ER

Sunday morning the call came from the service-the Emergency Room is looking for you. OK, so I was on my way out to walk the dogs along the Hudson River on a glorious late spring morning but...I was hoping it would be quick and painless.
"Emergency Room," she answered.
"Hi.  This is Dr. Benzil, I am returning the call to Dr. W."  I replied.
"Is HE available?" she volleyed back.
PAUSE-I wasn't sure what she meant so...
"This is Dr. Benzil, Is Dr. W. available?"  I tried a different tactic.
Still she seemed confused, "I will get her to the phone when HE picks up."
Finally I understood. "I am Dr. Benzil, a she not a he."
I imagined some light bulb turning on, "Oh, I will get Dr. W."

It is June 2011.  I have worked at this hospital and this ER for more than 7 years and do more cases there than any other neurosurgeon and yet, the deep seated notion of doctors (particularly neurosurgeons) as male clearly lives on.  Sigh, perhaps in the next decade...

The Passing

Gill Scott Heron

I learned early Saturday morning

And I wept

His music and words

Had touched my soul

Had lifted me up

Many late nights and

Early mornings

When much younger

I had a first date

And he sang to the room

But it seemed like he sang

Just to us

And we stayed on

For a second show

That date soon became

My lifelong mate

And still you would 

Croon and remind us

Of what was right

And how to live,

Think, and challenge

I am so thankful

You made such music

That I saw you

Not once or twice

But many times

And that I will always have

Your songs in my life

Your revolution is over

The world's will never be

But I hope you have

Found a little slice of

Peace and happiness

You so deserve

For all you have done for others.

Gil Scott Heron Dies May 27, 2911
(For more information see-Washington Post, NPR, CBS News, Chicago Tribune)