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Critical Condition
Cases don’t get much more complex than they are at Johns Hopkins. No one knows that better than the physicians themselves.

Taylor Riall, a GI surgeon who performs approximately 400 operations a year, knows first-hand how sick patients are at Johns Hopkins.
What she wouldn’t give for an appendectomy. A simple gallbladder. A routine hernia, for heaven’s sake! Instead, day after day, surgeon Taylor Riall finds herself operating on gravely ill patients with terribly complex conditions.

Riall is assistant chief of service (ACS) on a one-year faculty fellowship in gastrointestinal surgery. Having completed her residency training at Hopkins last year, she is now an instructor on the faculty, with her own patients and her own OR time.

In this one year, Riall is expected to perform approximately 400 operations. Many are complicated, high-risk surgeries involving the gastrointestinal tract, pancreas and liver. Some have names just as exotic as the procedures themselves: “pancreaticoduodenectomy” (removing the pancreas head along with part of the duodenum, a.k.a. the Whipple procedure), or a “roux-en-Y” (joining parts of the small intestine in the shape of the letter Y).

By the end of January, Riall had already completed more than 200 operations. Looking back over her log, she ticked off the cases she’d done in just one week this winter: “A roux-en-Y bypass for a patient with bile duct blockage. A total abdominal colectomy on a patient who was bleeding to death in the MICU. I took a guy into the operating room with stab wounds to the chest and a pneumothorax. I explored a patient and found unresectable cancer in the pancreas. I did a Whipple on a patient with pancreatic cancer. I did an appendectomy.” Oddly enough, of them all, the most unusual was the appendectomy. Out of all her cases logged, only five have been appendectomies.

“The referral base here is incredible,” says Riall. In part, the influx of unusual cases from far and wide is what made her residency so rich. “There are few residents who finish with the type of case mix I had here.”

Case mix. It’s a term health care economists use to describe the typical blend of cases found in a hospital at any given time. How to capture it accurately has been a topic of much discussion for several years in the state of Maryland.

Patients traditionally have been categorized in specific disease-related groups in order to measure the cost of the relatively similar services they require. These groupings, however, typically do not account for the severity of their illnesses.

Increasingly, this complexity is being taken into account when measuring case mix. “It’s a way to label patients in a clinically and financially homogeneous manner,” says Paul Allen, director of health information management for the Health System. “It’s important because case mix drives what we charge patients.”

Health care finance experts like Allen employ elaborate coding practices to develop indexes that reflect the nature of a hospital’s case mix. But the anecdotal accounts of physicians in the trenches–-like Riall–-also go a long way to revealing what makes Hopkins different from other hospitals, different perhaps, even from other academic medical centers.

For the desperately ill children in the pediatric intensive care unit, therapies are high-tech and high-intensity.

Pediatrician Megan McCabe came to Hopkins from New Haven on a three-year fellowship in the pediatric intensive care unit. A graduate of Georgetown University School of Medicine, she had trained at Yale. For her fellowship, McCabe wanted Hopkins. That would be the place, she surmised, where she could receive the most comprehensive training.

“That has turned out to be true,” McCabe says, during a rare moment when she is not with a patient. The volume in the PICU is higher, the unit is bigger, the turnover is faster. One big difference is that the ORs here are much busier, and there’s so much cutting-edge surgery going on. We get more surgical cases and more complicated ones,” says McCabe, citing the complex tracheal and bladder reconstructions she frequently sees.

“We get calls from as far away as North Carolina, New York state and Michigan asking us to accept patients,” says McCabe. “We get kids in clinical trials with complications from bone marrow transplants. They’re immunosuppressed, at high risk for infection. They might have renal problems or liver dysfunction. They might not have functioning bone marrow. They can develop respiratory failure.”

Her colleague in the PICU, fellow Kristen Nelson, is taking care of patients the likes of which she never saw at Louisiana State University, where she was chief resident in pediatrics. She’s had three burn cases, as Johns Hopkins is soon to become the pediatric burn center for Maryland. And she’s had the sickest children of all: the cardiac patients.

She’s cared for a 1-year-old with undetermined heart failure in need of a heart transplant and on a miniature ventricular assist device known as the Berlin Heart. The device has been used only a handful of times in the United States.

“To some degree, I was prepared for this,” says McCabe. “But you can never be totally prepared for how complicated the patients are. It’s been a very steep learning curve.”

Michelle Kittleson is a third-year fellow on the heart failure service. She came here from Brigham and Women’s Hospital in Boston. “There are a lot of incredibly sick and complicated patients at both places. But what stands out more than anything else about Hopkins is the number of transfers we accept from other hospitals where treating physicians simply cannot manage the patients any longer given their complex medical issues.”

That scenario is all to familiar too Dorry Segev, a fellow in transplant surgery. Segev does whole-organ transplants (liver, pancreas, kidney), including the revolutionary incompatible kidney transplants in which recipients are matched with donors of different blood types. “Very few centers in the country are doing them,” says Segev. “These are horribly sick patients who have already had five or six transplants in the past. They are not only medically challenging, but also surgically challenging because scar tissue has to be dissected out.”

“Doing a kidney transplant here is more difficult than anywhere else,” he says. “How sweet it would be to get a straightforward kidney transplant. When it happens, we all revel in it.”

With it all, Segev isn’t complaining. “I wanted the acuity; I knew where to find it.”

—Anne Bennett Swingle

 

 

 

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