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an online version of the magazine Fall 2008
Learning Curve

Learning Curve

Heroism Not Made for TV


By Daniel Munoz, M.D. '04


Illustration of scared patient
    Illustration by Sherrill Cooper

I watched the Hopkins series on ABC with measured interest. Though it was an anemic sequel to the initial documentary eight years ago, there were occasionally inspiring elements this time around.

But amid the emergency room chaos and operating room excitement, I could not shake the feeling that something crucial was missing.

Most of the work we do and certainly the most compelling stories we encounter in the hospital do not fit neatly into the stylized mold. To be sure, they lack the vivid imagery and screenplay heroics that appeal to a TV viewer with a remote in their hand and hundreds of channels from which to choose. But these segments, which were either left on the cutting room floor or perhaps overlooked from the outset, provide a sobering glimpse into a broken system and into the core of our professional mission.

Much of medicine is, or should be, an exercise in crisis aversion, less sexily described as “preventive care.” How do we prevent cancer? Heart attacks? Strokes? Amputations? How can we provide care to people in a way that obviates the downstream need for dramatic rescues and heart-pounding action? We will always need physicians skilled in these rescues (I am training in cardiology, a field where careers are spent managing the sequelae of years of imperfect dietary and behavioral patterns). Admittedly, some illnesses are simply not preventable, at least not in ways we currently understand. But just a few examples illustrate the opportunities for real improvement that stare us in the face.

Billy grew up in East Baltimore. He is 51 years old, but his kidneys only lived to be 42. After years of biologic assault by uncontrolled blood pressure and drug use, his kidneys surrendered. He was started on hemo-dialysis via a large catheter inserted most recently through a groin vessel. His diet of cigarettes and alcohol continued, taking painful, regular aim at his pancreas. As a result, Billy is in a chronic state of discomfort and irritability, debilitated further by his dependence on lengthy dialysis sessions. He is unfailingly confrontational and unpleasant. And to escape the daily drudgery that has become his life, he visits local emergency rooms on a rotating basis, complaining of abdominal pain. Batteries of blood tests and imaging studies come back negative. And while his pain is investigated, he usually gets what he wants: pain medicine. Not Tylenol or Motrin, but narcotics like morphine or Dilaudid. We counsel Billy aggressively. We beg him to allow us to help with his addictions. He refuses help, voicing displeasure with our care. We discharge him and the cycle begins again.

Beverly grew up in West Baltimore. She is 41 years old. Her pancreas hasn’t made insulin since she was in grade school. Taking insulin for her diabetes has always been a nuisance to Beverly, as has showing up for doctor appointments. Instead, she shows up in the emergency room with profound dehydration, nausea, and metabolic derangements all stemming from her skyrocketing blood sugar. She has suffered internal bleeding, small strokes, and kidney damage. Each time we pull her back from the precipice, we try new ways of getting through to Beverly. The most perplexing thing is that she gets it. She can recite our instructions back to us. She knows what is medically necessary to stay out of danger. But she consistently ignores our recommendations and her own understanding of the consequences.

I survived my residency. Billy and Beverly did not. Billy was eventually banned from the resident inpatient service after he threatened staff and sprayed blood from his dialysis catheter in a failed attempt to get narcotics. Six months later, he died. Beverly finally succumbed this year to the ravages of her diabetes after a prolonged ICU course here at Hopkins. The reason for her final admission to the hospital was severe ketoacidosis, a dangerous complication of poorly-controlled diabetes.

In neither case was the diagnosis a mystery. In neither case was the appropriate treatment unavailable. Both of these spirals were avoidable, had we succeeded in helping Billy and Beverly overcome social, personal, psychological stumbling blocks to staying healthy. 

During an outpatient clinic early in my residency, Dr. Locke, one of my clinical mentors, shared an important lesson. Perhaps the most heroic thing we do as doctors is to keep patients well enough such that late heroics aren’t necessary. He emphasized the importance of “routine” interventions: the blood pressure check, the cholesterol check, the diabetes screen.

The jarring, traumatic, and invariably sad trajectories of patients like Billy and Beverly provide incentive for what ultimately is the most life-altering intervention for our patients: keeping them out of danger in the first place.

Now if we could only make that into gripping prime-time television. *


Daniel Munoz, M.D., is a first-year fellow in the Division of Cardiology.

 Get a Life!?
 Washing Out My Distressed Genes
 Guardians of the Heart
 Sleep Interrupted
 Circling the Dome
 Medical Rounds
 Annals of Hopkins
Class Notes
 After the Prize
 Learning Curve
Johns Hopkins Medicine

© The Johns Hopkins University 2008