Commentary

It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.

However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.

There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.

While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.

In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.

Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler."

It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.

However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.

There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.

While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.

In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.

Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler."

It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.

However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.

There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.

While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.

In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.

Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler."

Obesity poses challenges to all modes of gynecologic surgery from open to minimally invasive to vaginal procedures. Operating on obese women results in more intraoperative and postoperative complications, particularly with regard to blood loss, wound infections, and venous thromboembolic disease, and contributes to increased length of hospital stay (J. Minim. Invasive Gynecol. 2014;21:259-65). Obesity has also been associated with longer operative and nonoperative times in laparoscopy, compared with those for normal-weight patients (J. Minim. Invasive Gynecol. 2012;19:701-7;Gynecol. Oncol. 2006;103:938-41; J. Minim. Invasive Gynecol. 2014;21:259-65).

While it was initially felt that obese patients were poor candidates for laparoscopic surgery, it is now widely supported that minimally invasive surgery is both feasible and may be the optimal approach in this population (Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2010;17:576-82). When obese patients are able to undergo minimally invasive procedures, the result is shorter hospitalizations, less postoperative pain, a faster return to activity, and fewer postoperative wound infections (10.5% vs. 1.3%) (Ann. Surg. 2006;243:181-8). These improved surgical outcomes are seen with both laparoscopic and robotic surgeries, compared with laparotomy in obese patients (Int. J. Gynecol. Cancer 2012;22:76-81; Ann. Surg. Oncol. 2007;14:2384-91; J. Clin. Oncol. 2009;27:5331-6).

Obesity affects most organ systems, resulting in several challenges for our anesthesiology colleagues. In addition to difficult airway management, hemodynamic concerns and metabolic changes must be considered (J. Anesth. 2012;26:758-65). Physiologically, obesity results in an increased oxygen requirement, which leads to increased cardiac output, increased stroke volume, decreased vascular resistance, and increased cardiac work. These physiologic changes result in a higher incidence of hypertension and cardiomegaly in obese patients. Both oxygen consumption and carbon dioxide production are more marked in obese patients. This requires increased ventilation. Because of the excess chest wall weight with subsequent reduced chest wall compliance, ventilation is even more difficult in obese patients.

In addition to the baseline physiology of obesity, minimally invasive surgery adds the additional obstacle of abdominal insufflation. Insufflation increases the intra-abdominal pressure, leading to venous stasis as well as a further lowering in chest wall compliance and increased airway pressure (Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). Finally, the need for Trendelenburg positioning for pelvic surgery further complicates an already difficult to ventilate patient.

In addition to the anesthetic challenges, obesity poses multiple challenges for the surgeon. With regard to laparoscopic surgery, key challenges for surgeons include safe and effective patient positioning on the operating room table, access to the abdominal cavity, and difficulty with surgical field visualization. Optimal positioning of the patient remains crucial to avoid nerve injuries.

The depth of the abdominal wall makes safely accessing the abdominal cavity more challenging. The thickness of the abdominal wall can place more torque on laparoscopic ports and instruments, which can require contorted positioning on the part of the surgeon. The surgeon risks significant personal ergonomic strain operating on patients, particularly obese patients (Gynecol. Oncol. 2012;126:437-42). Lastly, visualization in obese patients is impaired regardless of mode of surgery. All of these challenges often can be overcome or at least optimized, particularly in the hands of skilled surgical teams.

In addition to making the surgery more challenging for the surgical team, obesity increases the cost of providing surgical care. In fact, hospital-associated surgical costs totaled an additional $160 million spent annually on the care of obese patients, compared with their nonobese counterparts receiving the same services (Ann. Surg. 2013;258:541-53). Given the continued rise in the number of obese patients, particularly those with a BMI greater than 40 kg/m², the surgical concerns addressed in this column will continue to pose challenges to surgeons.

Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology, at the university. Dr. Clark and Dr. Clarke-Pearson said they had no relevant financial disclosures.

Obesity poses challenges to all modes of gynecologic surgery from open to minimally invasive to vaginal procedures. Operating on obese women results in more intraoperative and postoperative complications, particularly with regard to blood loss, wound infections, and venous thromboembolic disease, and contributes to increased length of hospital stay (J. Minim. Invasive Gynecol. 2014;21:259-65). Obesity has also been associated with longer operative and nonoperative times in laparoscopy, compared with those for normal-weight patients (J. Minim. Invasive Gynecol. 2012;19:701-7;Gynecol. Oncol. 2006;103:938-41; J. Minim. Invasive Gynecol. 2014;21:259-65).

While it was initially felt that obese patients were poor candidates for laparoscopic surgery, it is now widely supported that minimally invasive surgery is both feasible and may be the optimal approach in this population (Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2010;17:576-82). When obese patients are able to undergo minimally invasive procedures, the result is shorter hospitalizations, less postoperative pain, a faster return to activity, and fewer postoperative wound infections (10.5% vs. 1.3%) (Ann. Surg. 2006;243:181-8). These improved surgical outcomes are seen with both laparoscopic and robotic surgeries, compared with laparotomy in obese patients (Int. J. Gynecol. Cancer 2012;22:76-81; Ann. Surg. Oncol. 2007;14:2384-91; J. Clin. Oncol. 2009;27:5331-6).

Obesity affects most organ systems, resulting in several challenges for our anesthesiology colleagues. In addition to difficult airway management, hemodynamic concerns and metabolic changes must be considered (J. Anesth. 2012;26:758-65). Physiologically, obesity results in an increased oxygen requirement, which leads to increased cardiac output, increased stroke volume, decreased vascular resistance, and increased cardiac work. These physiologic changes result in a higher incidence of hypertension and cardiomegaly in obese patients. Both oxygen consumption and carbon dioxide production are more marked in obese patients. This requires increased ventilation. Because of the excess chest wall weight with subsequent reduced chest wall compliance, ventilation is even more difficult in obese patients.

In addition to the baseline physiology of obesity, minimally invasive surgery adds the additional obstacle of abdominal insufflation. Insufflation increases the intra-abdominal pressure, leading to venous stasis as well as a further lowering in chest wall compliance and increased airway pressure (Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). Finally, the need for Trendelenburg positioning for pelvic surgery further complicates an already difficult to ventilate patient.

In addition to the anesthetic challenges, obesity poses multiple challenges for the surgeon. With regard to laparoscopic surgery, key challenges for surgeons include safe and effective patient positioning on the operating room table, access to the abdominal cavity, and difficulty with surgical field visualization. Optimal positioning of the patient remains crucial to avoid nerve injuries.

The depth of the abdominal wall makes safely accessing the abdominal cavity more challenging. The thickness of the abdominal wall can place more torque on laparoscopic ports and instruments, which can require contorted positioning on the part of the surgeon. The surgeon risks significant personal ergonomic strain operating on patients, particularly obese patients (Gynecol. Oncol. 2012;126:437-42). Lastly, visualization in obese patients is impaired regardless of mode of surgery. All of these challenges often can be overcome or at least optimized, particularly in the hands of skilled surgical teams.

In addition to making the surgery more challenging for the surgical team, obesity increases the cost of providing surgical care. In fact, hospital-associated surgical costs totaled an additional $160 million spent annually on the care of obese patients, compared with their nonobese counterparts receiving the same services (Ann. Surg. 2013;258:541-53). Given the continued rise in the number of obese patients, particularly those with a BMI greater than 40 kg/m², the surgical concerns addressed in this column will continue to pose challenges to surgeons.

Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology, at the university. Dr. Clark and Dr. Clarke-Pearson said they had no relevant financial disclosures.

Obesity poses challenges to all modes of gynecologic surgery from open to minimally invasive to vaginal procedures. Operating on obese women results in more intraoperative and postoperative complications, particularly with regard to blood loss, wound infections, and venous thromboembolic disease, and contributes to increased length of hospital stay (J. Minim. Invasive Gynecol. 2014;21:259-65). Obesity has also been associated with longer operative and nonoperative times in laparoscopy, compared with those for normal-weight patients (J. Minim. Invasive Gynecol. 2012;19:701-7;Gynecol. Oncol. 2006;103:938-41; J. Minim. Invasive Gynecol. 2014;21:259-65).

While it was initially felt that obese patients were poor candidates for laparoscopic surgery, it is now widely supported that minimally invasive surgery is both feasible and may be the optimal approach in this population (Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2010;17:576-82). When obese patients are able to undergo minimally invasive procedures, the result is shorter hospitalizations, less postoperative pain, a faster return to activity, and fewer postoperative wound infections (10.5% vs. 1.3%) (Ann. Surg. 2006;243:181-8). These improved surgical outcomes are seen with both laparoscopic and robotic surgeries, compared with laparotomy in obese patients (Int. J. Gynecol. Cancer 2012;22:76-81; Ann. Surg. Oncol. 2007;14:2384-91; J. Clin. Oncol. 2009;27:5331-6).

Obesity affects most organ systems, resulting in several challenges for our anesthesiology colleagues. In addition to difficult airway management, hemodynamic concerns and metabolic changes must be considered (J. Anesth. 2012;26:758-65). Physiologically, obesity results in an increased oxygen requirement, which leads to increased cardiac output, increased stroke volume, decreased vascular resistance, and increased cardiac work. These physiologic changes result in a higher incidence of hypertension and cardiomegaly in obese patients. Both oxygen consumption and carbon dioxide production are more marked in obese patients. This requires increased ventilation. Because of the excess chest wall weight with subsequent reduced chest wall compliance, ventilation is even more difficult in obese patients.

In addition to the baseline physiology of obesity, minimally invasive surgery adds the additional obstacle of abdominal insufflation. Insufflation increases the intra-abdominal pressure, leading to venous stasis as well as a further lowering in chest wall compliance and increased airway pressure (Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). Finally, the need for Trendelenburg positioning for pelvic surgery further complicates an already difficult to ventilate patient.

In addition to the anesthetic challenges, obesity poses multiple challenges for the surgeon. With regard to laparoscopic surgery, key challenges for surgeons include safe and effective patient positioning on the operating room table, access to the abdominal cavity, and difficulty with surgical field visualization. Optimal positioning of the patient remains crucial to avoid nerve injuries.

The depth of the abdominal wall makes safely accessing the abdominal cavity more challenging. The thickness of the abdominal wall can place more torque on laparoscopic ports and instruments, which can require contorted positioning on the part of the surgeon. The surgeon risks significant personal ergonomic strain operating on patients, particularly obese patients (Gynecol. Oncol. 2012;126:437-42). Lastly, visualization in obese patients is impaired regardless of mode of surgery. All of these challenges often can be overcome or at least optimized, particularly in the hands of skilled surgical teams.

In addition to making the surgery more challenging for the surgical team, obesity increases the cost of providing surgical care. In fact, hospital-associated surgical costs totaled an additional $160 million spent annually on the care of obese patients, compared with their nonobese counterparts receiving the same services (Ann. Surg. 2013;258:541-53). Given the continued rise in the number of obese patients, particularly those with a BMI greater than 40 kg/m², the surgical concerns addressed in this column will continue to pose challenges to surgeons.

Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology, at the university. Dr. Clark and Dr. Clarke-Pearson said they had no relevant financial disclosures.

DB was a 22-year-old man who was brought to the hospital after he was found down in the street by police. Witnesses confirmed that DB was a pedestrian involved in a hit-and-run accident with a motor vehicle.

Upon initial assessment at the hospital, DB was awake and alert. Imaging confirmed several rib fractures, a broken right humerus, and two burst fractures of the thoracic spine. In addition, DB had evidence of a pulmonary contusion and a pneumothorax. DB went to the operating room for his spinal injuries and was subsequently admitted by Dr. Hospitalist 1 to the trauma intensive care unit. DB remained intubated and sedated. Dr. Hospitalist 1 documented that DB was at high risk for venous thromboembolism (VTE) and DB received bilateral intermittent pneumatic compression (IPC) of his legs and subcutaneous unfractionated heparin (UFH), 5,000 units every 8 hours, for VTE prophylaxis.

©LeeAnnWhite/thinkstockphotos.com

Over the next week, DB underwent open reduction and internal fixation of his right humerus fracture, along with an additional neurosurgical procedure to further stabilize his spine. DB made progress with respect to his pneumothorax and his chest tubes were eventually discontinued. DB was extubated on hospital day 5. On hospital day 7, DB was transferred out of the trauma ICU. For unclear reasons, DB’s prophylactic UFH was discontinued at the time of transfer. DB continued to wear bilateral IPC devices on his legs while he was in bed.

DB began physical therapy, but he had significant pain control issues. On hospital day 11, Dr. Hospitalist 2 restarted UFH, 5,000 units every 8 hours, for VTE prophylaxis. Two days later, DB was noted to have asymmetric edema of his right lower extremity and Dr. Hospitalist 3 obtained a vascular ultrasound. DB was diagnosed with an acute right femoral deep vein thrombosis. Dr. Hospitalist 3 ordered intravenous UFH 80 units/kg bolus followed by an intravenous infusion at 18 units/kg per hour.

The following morning (hospital day 14), the activated partial thromboplastin time was noted to be 82 seconds (1.5-2.5 thromboplastin time control). At approximately 10 a.m. that same day, DB collapsed while he was up to the commode. A code blue was called, but DB did not respond to resuscitation and was pronounced dead at 10:45 a.m. Autopsy confirmed the cause of death as a large saddle pulmonary embolism.

Complaint

DB’s mother was a flight attendant and very familiar with the concept of VTE and VTE prevention. According to her research on the internet, pulmonary embolism (PE) was a "never event" for hospitals and she immediately sought DB’s medical records to ascertain whether appropriate VTE prophylaxis had occurred. Once she discovered that DB had his prophylactic UFH discontinued for 4 days (12 doses of heparin missed), she contacted an attorney and a complaint was filed.

The complaint alleged that the physicians caring for DB failed to apply appropriate VTE prophylaxis commensurate with his high risk, and their collective failure in this regard was the proximate cause for his acute deep vein thrombosis and fatal PE.

Scientific principles

Trauma patients are considered to be at high risk for the development of VTE and some form of prophylaxis is universally recommended. Low-dose UFH given subcutaneously has been shown in multiple studies to safely and effectively decrease the incidence of VTE in high-risk groups. For those patients deemed to be at prohibitive risk for bleeding, nonpharmacologic methods of prevention are recommended. IPC prevents venous thrombosis by enhancing blood flow in the deep veins of the legs, thereby preventing venous stasis. IPC also reduces plasminogen activator inhibitor-1 (PAI-1), thereby increasing endogenous fibrinolytic activity.

Despite appropriate prophylaxis, acute VTE can still occur. Full-dose anticoagulant therapy is indicated for patients with symptomatic VTE, and anticoagulation is usually achieved initially with intravenous UFH or weight-adjusted doses of subcutaneous low-molecular-weight heparin. A 2010 meta-analysis of 13 prospective cohort studies and 56 randomized clinical trials demonstrated that the rate of recurrent fatal VTE following the appropriate initiation of full-dose anticoagulant therapy was just 0.4% (Ann. Intern. Med.2010;152:578-89).

Complaint rebuttal and discussion

The defense argued that the approach to VTE prophylaxis in a patient such as DB was a matter of clinical judgment and that, regardless of the strategy applied, acute events can and do occur. The defense highlighted the fact that DB was persistently anemic following his ICU transfer and that the physicians were concerned about possible hemorrhage. The defense also pointed out that DB continued to receive mechanical prophylaxis, which was appropriate.

In addition, the defense explained that DB had his acute DVT diagnosed immediately and he received appropriate full-dose anticoagulation prior to his death; DB therefore had less than a 0.4% chance of dying from VTE, according to the literature. Defense experts opined that, since DB went on to succumb to fatal PE despite adequate therapy, he was somehow different than those who typically respond to treatment and/or VTE prevention. In other words, the defense experts opined that DB would have developed and ultimately died from VTE regardless of what the physicians did or didn’t do in this case.

Conclusion

At the time of DB’s transition of care from the ICU to the regular nursing floor, there was no chart documentation to support the notion that his physicians were concerned about hemorrhage. It is more likely than not that DB had his subcutaneous UFH discontinued for several days by mistake.

Whether DB would still have suffered an acute DVT (along with a fatal PE) had the UFH prophylaxis not been interrupted is unknown. Sadly, DB defied the odds when he did not respond to treatment following the diagnosis of his acute DVT. At the end of the day, the plaintiffs were unable to find an expert to rebut the opinions of the defense in this case and, as a result, the case was dismissed without prejudice.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.

DB was a 22-year-old man who was brought to the hospital after he was found down in the street by police. Witnesses confirmed that DB was a pedestrian involved in a hit-and-run accident with a motor vehicle.

Upon initial assessment at the hospital, DB was awake and alert. Imaging confirmed several rib fractures, a broken right humerus, and two burst fractures of the thoracic spine. In addition, DB had evidence of a pulmonary contusion and a pneumothorax. DB went to the operating room for his spinal injuries and was subsequently admitted by Dr. Hospitalist 1 to the trauma intensive care unit. DB remained intubated and sedated. Dr. Hospitalist 1 documented that DB was at high risk for venous thromboembolism (VTE) and DB received bilateral intermittent pneumatic compression (IPC) of his legs and subcutaneous unfractionated heparin (UFH), 5,000 units every 8 hours, for VTE prophylaxis.

©LeeAnnWhite/thinkstockphotos.com

Over the next week, DB underwent open reduction and internal fixation of his right humerus fracture, along with an additional neurosurgical procedure to further stabilize his spine. DB made progress with respect to his pneumothorax and his chest tubes were eventually discontinued. DB was extubated on hospital day 5. On hospital day 7, DB was transferred out of the trauma ICU. For unclear reasons, DB’s prophylactic UFH was discontinued at the time of transfer. DB continued to wear bilateral IPC devices on his legs while he was in bed.

DB began physical therapy, but he had significant pain control issues. On hospital day 11, Dr. Hospitalist 2 restarted UFH, 5,000 units every 8 hours, for VTE prophylaxis. Two days later, DB was noted to have asymmetric edema of his right lower extremity and Dr. Hospitalist 3 obtained a vascular ultrasound. DB was diagnosed with an acute right femoral deep vein thrombosis. Dr. Hospitalist 3 ordered intravenous UFH 80 units/kg bolus followed by an intravenous infusion at 18 units/kg per hour.

The following morning (hospital day 14), the activated partial thromboplastin time was noted to be 82 seconds (1.5-2.5 thromboplastin time control). At approximately 10 a.m. that same day, DB collapsed while he was up to the commode. A code blue was called, but DB did not respond to resuscitation and was pronounced dead at 10:45 a.m. Autopsy confirmed the cause of death as a large saddle pulmonary embolism.

Complaint

DB’s mother was a flight attendant and very familiar with the concept of VTE and VTE prevention. According to her research on the internet, pulmonary embolism (PE) was a "never event" for hospitals and she immediately sought DB’s medical records to ascertain whether appropriate VTE prophylaxis had occurred. Once she discovered that DB had his prophylactic UFH discontinued for 4 days (12 doses of heparin missed), she contacted an attorney and a complaint was filed.

The complaint alleged that the physicians caring for DB failed to apply appropriate VTE prophylaxis commensurate with his high risk, and their collective failure in this regard was the proximate cause for his acute deep vein thrombosis and fatal PE.

Scientific principles

Trauma patients are considered to be at high risk for the development of VTE and some form of prophylaxis is universally recommended. Low-dose UFH given subcutaneously has been shown in multiple studies to safely and effectively decrease the incidence of VTE in high-risk groups. For those patients deemed to be at prohibitive risk for bleeding, nonpharmacologic methods of prevention are recommended. IPC prevents venous thrombosis by enhancing blood flow in the deep veins of the legs, thereby preventing venous stasis. IPC also reduces plasminogen activator inhibitor-1 (PAI-1), thereby increasing endogenous fibrinolytic activity.

Despite appropriate prophylaxis, acute VTE can still occur. Full-dose anticoagulant therapy is indicated for patients with symptomatic VTE, and anticoagulation is usually achieved initially with intravenous UFH or weight-adjusted doses of subcutaneous low-molecular-weight heparin. A 2010 meta-analysis of 13 prospective cohort studies and 56 randomized clinical trials demonstrated that the rate of recurrent fatal VTE following the appropriate initiation of full-dose anticoagulant therapy was just 0.4% (Ann. Intern. Med.2010;152:578-89).

Complaint rebuttal and discussion

The defense argued that the approach to VTE prophylaxis in a patient such as DB was a matter of clinical judgment and that, regardless of the strategy applied, acute events can and do occur. The defense highlighted the fact that DB was persistently anemic following his ICU transfer and that the physicians were concerned about possible hemorrhage. The defense also pointed out that DB continued to receive mechanical prophylaxis, which was appropriate.

In addition, the defense explained that DB had his acute DVT diagnosed immediately and he received appropriate full-dose anticoagulation prior to his death; DB therefore had less than a 0.4% chance of dying from VTE, according to the literature. Defense experts opined that, since DB went on to succumb to fatal PE despite adequate therapy, he was somehow different than those who typically respond to treatment and/or VTE prevention. In other words, the defense experts opined that DB would have developed and ultimately died from VTE regardless of what the physicians did or didn’t do in this case.

Conclusion

At the time of DB’s transition of care from the ICU to the regular nursing floor, there was no chart documentation to support the notion that his physicians were concerned about hemorrhage. It is more likely than not that DB had his subcutaneous UFH discontinued for several days by mistake.

Whether DB would still have suffered an acute DVT (along with a fatal PE) had the UFH prophylaxis not been interrupted is unknown. Sadly, DB defied the odds when he did not respond to treatment following the diagnosis of his acute DVT. At the end of the day, the plaintiffs were unable to find an expert to rebut the opinions of the defense in this case and, as a result, the case was dismissed without prejudice.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.

DB was a 22-year-old man who was brought to the hospital after he was found down in the street by police. Witnesses confirmed that DB was a pedestrian involved in a hit-and-run accident with a motor vehicle.

Upon initial assessment at the hospital, DB was awake and alert. Imaging confirmed several rib fractures, a broken right humerus, and two burst fractures of the thoracic spine. In addition, DB had evidence of a pulmonary contusion and a pneumothorax. DB went to the operating room for his spinal injuries and was subsequently admitted by Dr. Hospitalist 1 to the trauma intensive care unit. DB remained intubated and sedated. Dr. Hospitalist 1 documented that DB was at high risk for venous thromboembolism (VTE) and DB received bilateral intermittent pneumatic compression (IPC) of his legs and subcutaneous unfractionated heparin (UFH), 5,000 units every 8 hours, for VTE prophylaxis.

©LeeAnnWhite/thinkstockphotos.com

Over the next week, DB underwent open reduction and internal fixation of his right humerus fracture, along with an additional neurosurgical procedure to further stabilize his spine. DB made progress with respect to his pneumothorax and his chest tubes were eventually discontinued. DB was extubated on hospital day 5. On hospital day 7, DB was transferred out of the trauma ICU. For unclear reasons, DB’s prophylactic UFH was discontinued at the time of transfer. DB continued to wear bilateral IPC devices on his legs while he was in bed.

DB began physical therapy, but he had significant pain control issues. On hospital day 11, Dr. Hospitalist 2 restarted UFH, 5,000 units every 8 hours, for VTE prophylaxis. Two days later, DB was noted to have asymmetric edema of his right lower extremity and Dr. Hospitalist 3 obtained a vascular ultrasound. DB was diagnosed with an acute right femoral deep vein thrombosis. Dr. Hospitalist 3 ordered intravenous UFH 80 units/kg bolus followed by an intravenous infusion at 18 units/kg per hour.

The following morning (hospital day 14), the activated partial thromboplastin time was noted to be 82 seconds (1.5-2.5 thromboplastin time control). At approximately 10 a.m. that same day, DB collapsed while he was up to the commode. A code blue was called, but DB did not respond to resuscitation and was pronounced dead at 10:45 a.m. Autopsy confirmed the cause of death as a large saddle pulmonary embolism.

Complaint

DB’s mother was a flight attendant and very familiar with the concept of VTE and VTE prevention. According to her research on the internet, pulmonary embolism (PE) was a "never event" for hospitals and she immediately sought DB’s medical records to ascertain whether appropriate VTE prophylaxis had occurred. Once she discovered that DB had his prophylactic UFH discontinued for 4 days (12 doses of heparin missed), she contacted an attorney and a complaint was filed.

The complaint alleged that the physicians caring for DB failed to apply appropriate VTE prophylaxis commensurate with his high risk, and their collective failure in this regard was the proximate cause for his acute deep vein thrombosis and fatal PE.

Scientific principles

Trauma patients are considered to be at high risk for the development of VTE and some form of prophylaxis is universally recommended. Low-dose UFH given subcutaneously has been shown in multiple studies to safely and effectively decrease the incidence of VTE in high-risk groups. For those patients deemed to be at prohibitive risk for bleeding, nonpharmacologic methods of prevention are recommended. IPC prevents venous thrombosis by enhancing blood flow in the deep veins of the legs, thereby preventing venous stasis. IPC also reduces plasminogen activator inhibitor-1 (PAI-1), thereby increasing endogenous fibrinolytic activity.

Despite appropriate prophylaxis, acute VTE can still occur. Full-dose anticoagulant therapy is indicated for patients with symptomatic VTE, and anticoagulation is usually achieved initially with intravenous UFH or weight-adjusted doses of subcutaneous low-molecular-weight heparin. A 2010 meta-analysis of 13 prospective cohort studies and 56 randomized clinical trials demonstrated that the rate of recurrent fatal VTE following the appropriate initiation of full-dose anticoagulant therapy was just 0.4% (Ann. Intern. Med.2010;152:578-89).

Complaint rebuttal and discussion

The defense argued that the approach to VTE prophylaxis in a patient such as DB was a matter of clinical judgment and that, regardless of the strategy applied, acute events can and do occur. The defense highlighted the fact that DB was persistently anemic following his ICU transfer and that the physicians were concerned about possible hemorrhage. The defense also pointed out that DB continued to receive mechanical prophylaxis, which was appropriate.

In addition, the defense explained that DB had his acute DVT diagnosed immediately and he received appropriate full-dose anticoagulation prior to his death; DB therefore had less than a 0.4% chance of dying from VTE, according to the literature. Defense experts opined that, since DB went on to succumb to fatal PE despite adequate therapy, he was somehow different than those who typically respond to treatment and/or VTE prevention. In other words, the defense experts opined that DB would have developed and ultimately died from VTE regardless of what the physicians did or didn’t do in this case.

Conclusion

At the time of DB’s transition of care from the ICU to the regular nursing floor, there was no chart documentation to support the notion that his physicians were concerned about hemorrhage. It is more likely than not that DB had his subcutaneous UFH discontinued for several days by mistake.

Whether DB would still have suffered an acute DVT (along with a fatal PE) had the UFH prophylaxis not been interrupted is unknown. Sadly, DB defied the odds when he did not respond to treatment following the diagnosis of his acute DVT. At the end of the day, the plaintiffs were unable to find an expert to rebut the opinions of the defense in this case and, as a result, the case was dismissed without prejudice.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.

There are at least two ways to consider the meaning of evidence-based apps. One is a category of apps that have clinical trial evidence showing that they are useful, a topic we cover regularly in this column.

Another category, though, is apps that take existing evidence-based guidelines or already-vetted medical information and deliver that to you in a more efficient, convenient package.

Courtesy of the Wound, Ostomy and Continence Nurses Society

One of the latest examples of the latter is the new Evidence-Based Wound Care Guidelines and Fecal Ostomy Best Practice app, sold by the Wound, Ostomy and Continence Nurses Society (WOCN) for iPhones, iPads, or iPod Touch devices. Is it worth the $60 price?

It would cost you at least $160 to buy print copies from the WOCN of the five guidelines included in the app, on management of patients with pressure ulcers, lower-extremity arterial disease (LEAD), lower-extremity neuropathic disease (LEND), lower-extremity venous disease (LEVD), and fecal ostomy.

Or, you could spend a fair amount of time finding and printing the equivalent guidelines in the archives of medical journals or online. The Agency for Healthcare Research and Quality (AHRQ) provides detailed summaries of most of these guidelines on its website, including the major recommendations in each guideline and ratings of the evidence behind those recommendations. You can find the AHRQ pages on management of pressure ulcers, LEND, LEVD, and fecal ostomy, for example. They’re free, but it’s a time-consuming process that leaves you with bulky printouts.

Alternatively, the WOCN offers a free, 12-page, quick-reference guide for management of lower-extremity venous, arterial, or neuropathic wounds that you can download and print for free or, alternatively, consult without printing.

Courtesy of the Wound, Ostomy and Continence Nurses Society

All in all, that’s a lot of dead trees to carry around if you want to consult these guidelines while treating patients, unless you have a bulky desktop computer handy. Compare that with the convenience of pulling out your smartphone or tablet to consult the literature on best practices at the bedside, and you can see why knowledge-delivering apps have caught physicians’ imaginations.

How can you know that an app is delivering credible information? The easiest way is to choose an app from a credible organization, such as the Cancer.Net app for patients with cancer, from the American Society of Clinical Oncology. Apps that have been vetted by the likes of the Cleveland Clinic, Mayo Clinic, or Veterans Affairs Healthcare System, for example, typically have been assessed with some quality-control measures. Every app has its flaws, however, so it’s usually worth searching for reviews online to gauge the strengths and weaknesses of various apps, especially when there is more than one available on a particular topic.

For-profit companies have developed some of the most popular evidence-driven apps for physicians. UpToDate claims that its physicians, authors, and editors synthesize the available medical evidence so the app can provide recommendations in primary care, ob.gyn., pediatrics, general surgery, emergency medicine, internal medicine, and all of the internal medicine subspecialties, among others. An individual subscription costs $499/year.

Epocrates offers a free app that provides medication information and lets you look up drug interactions and more, with additional services for a fee. Other apps do the same – Lexicomp is one subscription-based app that allows a 30-day free trial.

How to choose? Again, reviews may be helpful. The physician-run site iMedicalApps compared several medical drug reference apps in a 2010 review, but in app development time, that already seems light-years ago.

Courtesy of the Wound, Ostomy and Continence Nurses Society

If you don’t recognize a company as a credible player in delivering mobile medical information, you can take several steps to assess the app’s trustworthiness. When you look at the app’s description online or in your mobile device’s app store, often the description is short and doesn’t list the reference information that the app relies on, though that’s often included in the app itself.

You’ll find reviews and ratings in the app description, but take these with a grain of salt. These can be anonymous, reflect anecdotal experiences, and may be planted by the developer of the app to make it look good.

Click on the tab for the developer in the app description, and if you don’t recognize the name, make sure there’s a link to a website or at least an e-mail address so you can assess whether the developer has health care expertise.

It’s also worth clicking on the Updates or Version History tab to see if it’s been updated, because good-quality apps usually get frequent updates, typically at least every 6 months, several app consultants said in interviews.

Are you already using evidence-delivering apps? Which are your favorites? Let us know, and we may highlight them in a future column.

[email protected]

On Twitter @sherryboschert

There are at least two ways to consider the meaning of evidence-based apps. One is a category of apps that have clinical trial evidence showing that they are useful, a topic we cover regularly in this column.

Another category, though, is apps that take existing evidence-based guidelines or already-vetted medical information and deliver that to you in a more efficient, convenient package.

Courtesy of the Wound, Ostomy and Continence Nurses Society

One of the latest examples of the latter is the new Evidence-Based Wound Care Guidelines and Fecal Ostomy Best Practice app, sold by the Wound, Ostomy and Continence Nurses Society (WOCN) for iPhones, iPads, or iPod Touch devices. Is it worth the $60 price?

It would cost you at least $160 to buy print copies from the WOCN of the five guidelines included in the app, on management of patients with pressure ulcers, lower-extremity arterial disease (LEAD), lower-extremity neuropathic disease (LEND), lower-extremity venous disease (LEVD), and fecal ostomy.

Or, you could spend a fair amount of time finding and printing the equivalent guidelines in the archives of medical journals or online. The Agency for Healthcare Research and Quality (AHRQ) provides detailed summaries of most of these guidelines on its website, including the major recommendations in each guideline and ratings of the evidence behind those recommendations. You can find the AHRQ pages on management of pressure ulcers, LEND, LEVD, and fecal ostomy, for example. They’re free, but it’s a time-consuming process that leaves you with bulky printouts.

Alternatively, the WOCN offers a free, 12-page, quick-reference guide for management of lower-extremity venous, arterial, or neuropathic wounds that you can download and print for free or, alternatively, consult without printing.

Courtesy of the Wound, Ostomy and Continence Nurses Society

All in all, that’s a lot of dead trees to carry around if you want to consult these guidelines while treating patients, unless you have a bulky desktop computer handy. Compare that with the convenience of pulling out your smartphone or tablet to consult the literature on best practices at the bedside, and you can see why knowledge-delivering apps have caught physicians’ imaginations.

How can you know that an app is delivering credible information? The easiest way is to choose an app from a credible organization, such as the Cancer.Net app for patients with cancer, from the American Society of Clinical Oncology. Apps that have been vetted by the likes of the Cleveland Clinic, Mayo Clinic, or Veterans Affairs Healthcare System, for example, typically have been assessed with some quality-control measures. Every app has its flaws, however, so it’s usually worth searching for reviews online to gauge the strengths and weaknesses of various apps, especially when there is more than one available on a particular topic.

For-profit companies have developed some of the most popular evidence-driven apps for physicians. UpToDate claims that its physicians, authors, and editors synthesize the available medical evidence so the app can provide recommendations in primary care, ob.gyn., pediatrics, general surgery, emergency medicine, internal medicine, and all of the internal medicine subspecialties, among others. An individual subscription costs $499/year.

Epocrates offers a free app that provides medication information and lets you look up drug interactions and more, with additional services for a fee. Other apps do the same – Lexicomp is one subscription-based app that allows a 30-day free trial.

How to choose? Again, reviews may be helpful. The physician-run site iMedicalApps compared several medical drug reference apps in a 2010 review, but in app development time, that already seems light-years ago.

Courtesy of the Wound, Ostomy and Continence Nurses Society

If you don’t recognize a company as a credible player in delivering mobile medical information, you can take several steps to assess the app’s trustworthiness. When you look at the app’s description online or in your mobile device’s app store, often the description is short and doesn’t list the reference information that the app relies on, though that’s often included in the app itself.

You’ll find reviews and ratings in the app description, but take these with a grain of salt. These can be anonymous, reflect anecdotal experiences, and may be planted by the developer of the app to make it look good.

Click on the tab for the developer in the app description, and if you don’t recognize the name, make sure there’s a link to a website or at least an e-mail address so you can assess whether the developer has health care expertise.

It’s also worth clicking on the Updates or Version History tab to see if it’s been updated, because good-quality apps usually get frequent updates, typically at least every 6 months, several app consultants said in interviews.

Are you already using evidence-delivering apps? Which are your favorites? Let us know, and we may highlight them in a future column.

[email protected]

On Twitter @sherryboschert

There are at least two ways to consider the meaning of evidence-based apps. One is a category of apps that have clinical trial evidence showing that they are useful, a topic we cover regularly in this column.

Another category, though, is apps that take existing evidence-based guidelines or already-vetted medical information and deliver that to you in a more efficient, convenient package.

Courtesy of the Wound, Ostomy and Continence Nurses Society

One of the latest examples of the latter is the new Evidence-Based Wound Care Guidelines and Fecal Ostomy Best Practice app, sold by the Wound, Ostomy and Continence Nurses Society (WOCN) for iPhones, iPads, or iPod Touch devices. Is it worth the $60 price?

It would cost you at least $160 to buy print copies from the WOCN of the five guidelines included in the app, on management of patients with pressure ulcers, lower-extremity arterial disease (LEAD), lower-extremity neuropathic disease (LEND), lower-extremity venous disease (LEVD), and fecal ostomy.

Or, you could spend a fair amount of time finding and printing the equivalent guidelines in the archives of medical journals or online. The Agency for Healthcare Research and Quality (AHRQ) provides detailed summaries of most of these guidelines on its website, including the major recommendations in each guideline and ratings of the evidence behind those recommendations. You can find the AHRQ pages on management of pressure ulcers, LEND, LEVD, and fecal ostomy, for example. They’re free, but it’s a time-consuming process that leaves you with bulky printouts.

Alternatively, the WOCN offers a free, 12-page, quick-reference guide for management of lower-extremity venous, arterial, or neuropathic wounds that you can download and print for free or, alternatively, consult without printing.

Courtesy of the Wound, Ostomy and Continence Nurses Society

All in all, that’s a lot of dead trees to carry around if you want to consult these guidelines while treating patients, unless you have a bulky desktop computer handy. Compare that with the convenience of pulling out your smartphone or tablet to consult the literature on best practices at the bedside, and you can see why knowledge-delivering apps have caught physicians’ imaginations.

How can you know that an app is delivering credible information? The easiest way is to choose an app from a credible organization, such as the Cancer.Net app for patients with cancer, from the American Society of Clinical Oncology. Apps that have been vetted by the likes of the Cleveland Clinic, Mayo Clinic, or Veterans Affairs Healthcare System, for example, typically have been assessed with some quality-control measures. Every app has its flaws, however, so it’s usually worth searching for reviews online to gauge the strengths and weaknesses of various apps, especially when there is more than one available on a particular topic.

For-profit companies have developed some of the most popular evidence-driven apps for physicians. UpToDate claims that its physicians, authors, and editors synthesize the available medical evidence so the app can provide recommendations in primary care, ob.gyn., pediatrics, general surgery, emergency medicine, internal medicine, and all of the internal medicine subspecialties, among others. An individual subscription costs $499/year.

Epocrates offers a free app that provides medication information and lets you look up drug interactions and more, with additional services for a fee. Other apps do the same – Lexicomp is one subscription-based app that allows a 30-day free trial.

How to choose? Again, reviews may be helpful. The physician-run site iMedicalApps compared several medical drug reference apps in a 2010 review, but in app development time, that already seems light-years ago.

Courtesy of the Wound, Ostomy and Continence Nurses Society

If you don’t recognize a company as a credible player in delivering mobile medical information, you can take several steps to assess the app’s trustworthiness. When you look at the app’s description online or in your mobile device’s app store, often the description is short and doesn’t list the reference information that the app relies on, though that’s often included in the app itself.

You’ll find reviews and ratings in the app description, but take these with a grain of salt. These can be anonymous, reflect anecdotal experiences, and may be planted by the developer of the app to make it look good.

Click on the tab for the developer in the app description, and if you don’t recognize the name, make sure there’s a link to a website or at least an e-mail address so you can assess whether the developer has health care expertise.

It’s also worth clicking on the Updates or Version History tab to see if it’s been updated, because good-quality apps usually get frequent updates, typically at least every 6 months, several app consultants said in interviews.

Are you already using evidence-delivering apps? Which are your favorites? Let us know, and we may highlight them in a future column.

[email protected]

On Twitter @sherryboschert

Dr. Rupa Marya is a typical academic hospitalist for about half the year, managing acutely ill patients and teaching residents at the University of California, San Francisco, Medical Center. But the rest of the time, she’s traveling the world and writing music with her alternative rock band, Rupa & the April Fishes.

Dr. Marya has been a hospitalist at UCSF since she finished her residency there in 2007. Her focus has been on examining health and disease patterns based on social determinants, and communicating with patients about end-of-life care decisions. She also works at a free clinic in San Francisco’s Mission district, the Clinica Martin Baro, where UCSF medical students and faculty provide low-cost primary care to low-income and undocumented patients.

Denis Beaumont

Over the last 7 years, Dr. Marya and her bandmates (Aaron Kierbel, Safa Shokrai, Misha Khalikulov, and Mario Alberto Silva) have recorded four albums that draw on different genres and languages. The lyrics, whether in French, Spanish, or English, have a romantic sound but tackle thorny social issues ranging from the struggles of immigrants to the government’s practice of rendition. Listen to their music here.

In an interview with Hospitalist News, Dr. Marya explains how she is able to juggle two challenging careers and get the best out of both worlds.

Question: When did you decide to seriously pursue both music and medicine as careers?

Dr. Marya: Throughout my education, I was equally drawn to science and the humanities. I developed these interests in a parallel fashion throughout college, where I studied molecular biology and political theater. I didn’t clearly see a path until I was in my intern year of my medicine residency at UCSF. I spoke with my program directors about my belief that I would be a better physician if I could find a way to balance my work as an artist and that my art would thrive if I could find a way to maintain my development as a physician. They have supported my exploration ever since, and after residency, I came on as a faculty member with this schedule that is divided between my time working on music and my time at the hospital.

Question: How do you juggle the demands of working in the hospital and also touring and recording with your band?

Dr. Marya: I work 4-6 months a year in the hospital and the rest of my time with the band. We have been touring 5-6 months a year for the past 7 years. I could not do this without the full support of the division of hospitalist medicine at UCSF. The leadership and culture of our division is incredible in creating a place in which physicians are encouraged to manifest their full potential and to bring that experience to the table with who they are as physicians and educators. Bob Wachter, our division chief, was my residency director and now continues as a mentor and leader of our division. If every hospital had a leader like him, we’d have a more inspired health care system.

The lifestyle of being a hospitalist works in perfect balance for me. I love managing the acuity of illness, having the opportunity to teach, and getting the unique lens into social situations that hospital medicine gives. Being with patients at times of important transitions as well as learning about the determinants of social and physical disease are inspiring to my work as an artist and thinker.

Question: How do you think music affects the way you treat patients?

Dr. Marya: Music teaches me how to listen. I feel the deeper I get into my practice of music, the better listener I am. There’s a flexibility to my mind that I also attribute to my work in art that helps me in more challenging clinical problems. When I come back to the hospital from the road, I feel refreshed and excited, each time.

There are times when I say, whether on stage looking out at an audience or leaving the room after a profound exchange with a family, "I can’t believe this is my life!" I feel grateful to all the people who have helped me, taught me, and shown me the way – patients, mentors, managers, agents, audience members, sound crew, backstage helpers, my band, and my family.

Question: You write your own music. Do you ever get song ideas from your interactions with patients?

Dr. Marya: I believe at the root, my music is inspired by the transitory nature of life and the demand I feel to celebrate that life in us when it is here. Every contact I have with someone’s true experience, stripped of pretense and raw in front of me, is inspiration. Being at the transition of life and death – sometimes in a person’s home, sometimes in the hospital, sometimes on the side of the road – that highlights this intensely special moment of being alive right now and being in the presence of another being. To be witnessed and to witness. To accompany someone in their journey. These things are what inspire and fuel my art.

Question: What’s next for you and your band?

Dr. Marya: Indianapolis. A tour of Europe this summer. I will be speaking and the band will be performing this year at TEDMED. I am currently recording an album of string quartet versions of my songs arranged by brilliant composer Mark Orton, together with Todd Sickafoose and Quartet San Francisco. We are trying to build a better model for sustainability for artists, which is truly difficult in an age in which people believe in some way that music should be free. We hope to be touring Asia, Central America, and Australia before next summer.

Question: What advice do you have for young physicians who have an outside interest they want to continue?

Dr. Marya: Discover and make space for your bliss – it will cost you something, but do not be afraid of that cost because your bliss is what will make you a truly incredible clinician. Whatever will bring you bliss will be of utmost importance to your patients because your joy and balance will radiate to them in the time they most need it. It will also bring you the patience to see how you can best accompany them in their need. Do not be afraid to articulate your unique path and to seek support along the way.

Surprisingly, I have found more wholehearted support for my work in medicine than in the music industry, which is far more conservative than the culture in medicine. Do not believe the naysayers. And never be afraid to articulate your truth, no matter how contradictory it may seem. It will help everyone around you to be more courageous and through that, we can develop a system of more humane and intact health care as visionary caregivers.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

[email protected]

On Twitter @maryellenny

Dr. Rupa Marya is a typical academic hospitalist for about half the year, managing acutely ill patients and teaching residents at the University of California, San Francisco, Medical Center. But the rest of the time, she’s traveling the world and writing music with her alternative rock band, Rupa & the April Fishes.

Dr. Marya has been a hospitalist at UCSF since she finished her residency there in 2007. Her focus has been on examining health and disease patterns based on social determinants, and communicating with patients about end-of-life care decisions. She also works at a free clinic in San Francisco’s Mission district, the Clinica Martin Baro, where UCSF medical students and faculty provide low-cost primary care to low-income and undocumented patients.

Denis Beaumont

Over the last 7 years, Dr. Marya and her bandmates (Aaron Kierbel, Safa Shokrai, Misha Khalikulov, and Mario Alberto Silva) have recorded four albums that draw on different genres and languages. The lyrics, whether in French, Spanish, or English, have a romantic sound but tackle thorny social issues ranging from the struggles of immigrants to the government’s practice of rendition. Listen to their music here.

In an interview with Hospitalist News, Dr. Marya explains how she is able to juggle two challenging careers and get the best out of both worlds.

Question: When did you decide to seriously pursue both music and medicine as careers?

Dr. Marya: Throughout my education, I was equally drawn to science and the humanities. I developed these interests in a parallel fashion throughout college, where I studied molecular biology and political theater. I didn’t clearly see a path until I was in my intern year of my medicine residency at UCSF. I spoke with my program directors about my belief that I would be a better physician if I could find a way to balance my work as an artist and that my art would thrive if I could find a way to maintain my development as a physician. They have supported my exploration ever since, and after residency, I came on as a faculty member with this schedule that is divided between my time working on music and my time at the hospital.

Question: How do you juggle the demands of working in the hospital and also touring and recording with your band?

Dr. Marya: I work 4-6 months a year in the hospital and the rest of my time with the band. We have been touring 5-6 months a year for the past 7 years. I could not do this without the full support of the division of hospitalist medicine at UCSF. The leadership and culture of our division is incredible in creating a place in which physicians are encouraged to manifest their full potential and to bring that experience to the table with who they are as physicians and educators. Bob Wachter, our division chief, was my residency director and now continues as a mentor and leader of our division. If every hospital had a leader like him, we’d have a more inspired health care system.

The lifestyle of being a hospitalist works in perfect balance for me. I love managing the acuity of illness, having the opportunity to teach, and getting the unique lens into social situations that hospital medicine gives. Being with patients at times of important transitions as well as learning about the determinants of social and physical disease are inspiring to my work as an artist and thinker.

Question: How do you think music affects the way you treat patients?

Dr. Marya: Music teaches me how to listen. I feel the deeper I get into my practice of music, the better listener I am. There’s a flexibility to my mind that I also attribute to my work in art that helps me in more challenging clinical problems. When I come back to the hospital from the road, I feel refreshed and excited, each time.

There are times when I say, whether on stage looking out at an audience or leaving the room after a profound exchange with a family, "I can’t believe this is my life!" I feel grateful to all the people who have helped me, taught me, and shown me the way – patients, mentors, managers, agents, audience members, sound crew, backstage helpers, my band, and my family.

Question: You write your own music. Do you ever get song ideas from your interactions with patients?

Dr. Marya: I believe at the root, my music is inspired by the transitory nature of life and the demand I feel to celebrate that life in us when it is here. Every contact I have with someone’s true experience, stripped of pretense and raw in front of me, is inspiration. Being at the transition of life and death – sometimes in a person’s home, sometimes in the hospital, sometimes on the side of the road – that highlights this intensely special moment of being alive right now and being in the presence of another being. To be witnessed and to witness. To accompany someone in their journey. These things are what inspire and fuel my art.

Question: What’s next for you and your band?

Dr. Marya: Indianapolis. A tour of Europe this summer. I will be speaking and the band will be performing this year at TEDMED. I am currently recording an album of string quartet versions of my songs arranged by brilliant composer Mark Orton, together with Todd Sickafoose and Quartet San Francisco. We are trying to build a better model for sustainability for artists, which is truly difficult in an age in which people believe in some way that music should be free. We hope to be touring Asia, Central America, and Australia before next summer.

Question: What advice do you have for young physicians who have an outside interest they want to continue?

Dr. Marya: Discover and make space for your bliss – it will cost you something, but do not be afraid of that cost because your bliss is what will make you a truly incredible clinician. Whatever will bring you bliss will be of utmost importance to your patients because your joy and balance will radiate to them in the time they most need it. It will also bring you the patience to see how you can best accompany them in their need. Do not be afraid to articulate your unique path and to seek support along the way.

Surprisingly, I have found more wholehearted support for my work in medicine than in the music industry, which is far more conservative than the culture in medicine. Do not believe the naysayers. And never be afraid to articulate your truth, no matter how contradictory it may seem. It will help everyone around you to be more courageous and through that, we can develop a system of more humane and intact health care as visionary caregivers.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

[email protected]

On Twitter @maryellenny

Dr. Rupa Marya is a typical academic hospitalist for about half the year, managing acutely ill patients and teaching residents at the University of California, San Francisco, Medical Center. But the rest of the time, she’s traveling the world and writing music with her alternative rock band, Rupa & the April Fishes.

Dr. Marya has been a hospitalist at UCSF since she finished her residency there in 2007. Her focus has been on examining health and disease patterns based on social determinants, and communicating with patients about end-of-life care decisions. She also works at a free clinic in San Francisco’s Mission district, the Clinica Martin Baro, where UCSF medical students and faculty provide low-cost primary care to low-income and undocumented patients.

Denis Beaumont

Over the last 7 years, Dr. Marya and her bandmates (Aaron Kierbel, Safa Shokrai, Misha Khalikulov, and Mario Alberto Silva) have recorded four albums that draw on different genres and languages. The lyrics, whether in French, Spanish, or English, have a romantic sound but tackle thorny social issues ranging from the struggles of immigrants to the government’s practice of rendition. Listen to their music here.

In an interview with Hospitalist News, Dr. Marya explains how she is able to juggle two challenging careers and get the best out of both worlds.

Question: When did you decide to seriously pursue both music and medicine as careers?

Dr. Marya: Throughout my education, I was equally drawn to science and the humanities. I developed these interests in a parallel fashion throughout college, where I studied molecular biology and political theater. I didn’t clearly see a path until I was in my intern year of my medicine residency at UCSF. I spoke with my program directors about my belief that I would be a better physician if I could find a way to balance my work as an artist and that my art would thrive if I could find a way to maintain my development as a physician. They have supported my exploration ever since, and after residency, I came on as a faculty member with this schedule that is divided between my time working on music and my time at the hospital.

Question: How do you juggle the demands of working in the hospital and also touring and recording with your band?

Dr. Marya: I work 4-6 months a year in the hospital and the rest of my time with the band. We have been touring 5-6 months a year for the past 7 years. I could not do this without the full support of the division of hospitalist medicine at UCSF. The leadership and culture of our division is incredible in creating a place in which physicians are encouraged to manifest their full potential and to bring that experience to the table with who they are as physicians and educators. Bob Wachter, our division chief, was my residency director and now continues as a mentor and leader of our division. If every hospital had a leader like him, we’d have a more inspired health care system.

The lifestyle of being a hospitalist works in perfect balance for me. I love managing the acuity of illness, having the opportunity to teach, and getting the unique lens into social situations that hospital medicine gives. Being with patients at times of important transitions as well as learning about the determinants of social and physical disease are inspiring to my work as an artist and thinker.

Question: How do you think music affects the way you treat patients?

Dr. Marya: Music teaches me how to listen. I feel the deeper I get into my practice of music, the better listener I am. There’s a flexibility to my mind that I also attribute to my work in art that helps me in more challenging clinical problems. When I come back to the hospital from the road, I feel refreshed and excited, each time.

There are times when I say, whether on stage looking out at an audience or leaving the room after a profound exchange with a family, "I can’t believe this is my life!" I feel grateful to all the people who have helped me, taught me, and shown me the way – patients, mentors, managers, agents, audience members, sound crew, backstage helpers, my band, and my family.

Question: You write your own music. Do you ever get song ideas from your interactions with patients?

Dr. Marya: I believe at the root, my music is inspired by the transitory nature of life and the demand I feel to celebrate that life in us when it is here. Every contact I have with someone’s true experience, stripped of pretense and raw in front of me, is inspiration. Being at the transition of life and death – sometimes in a person’s home, sometimes in the hospital, sometimes on the side of the road – that highlights this intensely special moment of being alive right now and being in the presence of another being. To be witnessed and to witness. To accompany someone in their journey. These things are what inspire and fuel my art.

Question: What’s next for you and your band?

Dr. Marya: Indianapolis. A tour of Europe this summer. I will be speaking and the band will be performing this year at TEDMED. I am currently recording an album of string quartet versions of my songs arranged by brilliant composer Mark Orton, together with Todd Sickafoose and Quartet San Francisco. We are trying to build a better model for sustainability for artists, which is truly difficult in an age in which people believe in some way that music should be free. We hope to be touring Asia, Central America, and Australia before next summer.

Question: What advice do you have for young physicians who have an outside interest they want to continue?

Dr. Marya: Discover and make space for your bliss – it will cost you something, but do not be afraid of that cost because your bliss is what will make you a truly incredible clinician. Whatever will bring you bliss will be of utmost importance to your patients because your joy and balance will radiate to them in the time they most need it. It will also bring you the patience to see how you can best accompany them in their need. Do not be afraid to articulate your unique path and to seek support along the way.

Surprisingly, I have found more wholehearted support for my work in medicine than in the music industry, which is far more conservative than the culture in medicine. Do not believe the naysayers. And never be afraid to articulate your truth, no matter how contradictory it may seem. It will help everyone around you to be more courageous and through that, we can develop a system of more humane and intact health care as visionary caregivers.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

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