ure, there’s the nursing shortage, and the fact that the population is aging, but does that account for the overwhelming numbers of patients (some 100 million in 1998) flooding emergency departments nationwide?
Only in part.
"Managed care isn’t working," asserts Hopkins Bayview Medical Center’s Emergency Medicine director Edward Bessman. "My patients tell me, ‘I can’t get in to see my doctor for three weeks.’"
Gabe Kelen, director of Emergency Medicine at Hopkins (the department recently celebrated its 25th anniversary), says, "Many HMOs have all but abandoned their patients, and it’s impossible to get follow-up for them, so they keep coming here. We’re the social safety net."
ED volumes were up 10 percent last year at Hopkins Hospital, and the patients coming in were generally sicker. Hospital admissions that start in the ED have been increasing at 1,000 a year for the past five years, a situation that has made inpatient beds in the Hospital scarce.
"We’re having more trouble than we’ve ever had getting patients admitted," says Kelen, "so our limited space is being used as a holding tank for patients."
Now, Kelen has taken two steps to make sure both the sick and the not so sick get good care. This summer the Emergency Department opened its own urgent care center right down the hall, a sort of on-site doctor’s office. With no advertising, the center is already seeing up to 50 patients a day. Those showing up in need of splints, sutures and tetanus shots are in and out, from sign-in to discharge, in 90 minutes on average.
And this month, Kelen’s request to open an Emergency Acute Care Unit will also come true. The unit, which has few precedents in the country, will house patients who require further observation or lengthy diagnostic evaluations for up to 72 hours.
"We’re really hoping that getting control over the back end of operations—meaning a place to put patients for intense diagnostic evaluation and treatment—will help with this patient clogging," says Kelen. "Eventually we hope to develop a whole new subspecialty out of this."
-- Mary Ellen Miller
ho’s the one person who influenced your career most?" That’s the question Mary Ellen Miller, co-editor of Hopkins Medicine’s popular house organ, DOME, periodically puts to faculty who’ve reached the top of their profession. Here’s the fetching response she got from Bill Agnew, head of the Department of Physiology.
When I was 8, my mother remarried, and as a result we moved to a very tough area in Southern California. At the same time, I skipped a grade, and I suddenly had some terrible teachers. I went from being a really good student to losing all my confidence. I couldn’t seem to recover; it lasted three years. But I did read a lot. I read my brother’s high school biology textbook from cover to cover.
A year or so later, in seventh grade, I had this science teacher, Mr. Conti, and it seemed like I knew the answer to every single question this guy ever asked in class. Of course, I had forgotten I’d read that book. One day he said, "Here’s a question I know even Bill doesn’t know the answer to." He held up this weird piece of glassware and asked, "Does anybody know what this is?" I thought for a second, raised my hand and said, "It’s a thistle tube." He just looked at me and wrote something down in his notebook. The next thing I knew, some people visited the class to meet me.
Here I was, this completely D-, C- student who was being interviewed by school officials because they thought I was somehow gifted. It really affected me. Shortly thereafter, I took an advanced math course and got straight A’s. It changed me because I felt like a complete failure until he started paying a lot of attention to me.
There was nothing particularly unusual about the patient admitted to The Johns Hopkins Hospital on May 4 with a fever of 102, a painful liver and tender spleen. Except that this patient, a man in his 30s, was a microbiologist in the government’s biodefense program. And except that he worked in a lab with communicable organisms, and since March, when he first sought treatment elsewhere, he’d not responded to standard antibiotic therapy.
For Trish Perl, Hospital epidemiologist, it was a made-to-order moment. Perl flew into action, ordering isolation for the patient and gowns, gloves and masks for the staff who treated him. She even decreed that the man be kept in an air-controlled room for 24 hours until cultures had grown from the tissue taken from his blood and liver and she had a diagnosis: glanders.
Glanders, a disease typically found in horses and donkeys, had not been reported in the United States in humans since 1945. But since this man had been working on a vaccine for the disease, the diagnosis had been speculated. Still, Perl took a complete history. She also hosted investigators from the Centers for Disease Control, fielded media calls, filed a report with the city health department, and continued to beat a path to the patient’s door until finally, treated successfully with a tetracyclinelike drug, he was discharged on May 17.
Perl describes herself as a "shoe-leather epidemiologist." Pinpointing problems, identifying risk factors, intervening, reassessing—such are the activities that form the rhythm of her days. Under her leadership, Hopkins has a pro-active program in infection control and epidemiology. In 1997, it was designated by the CDC as one of the nation’s eight centers of excellence in epidemiology, or Epi Centers.
Perl’s message is the following: Nosocomial, or hospital-acquired, infections contribute to patient deaths and can be caused by things health care workers actually do, or don’t do—like washing their hands. And they can be reduced by as much as a third.
Ever since the Institute of Medicine released a report showing that medical errors, a catch-all category that includes nosocomial infections, are the fifth leading cause of death in the United States, costing anywhere from 17 to 29 billion dollars a year, Perl has cited such dollar figures as a way to turn heads. "The institution bears the cost of all these events," she points out. "These are important infections, and you wouldn’t want your mom to have one."
To reduce blood stream infections, Perl pushed for IV teams of nurses specially trained to put in catheters. Her annual flu shot campaign last year resulted in the vaccination of 79 percent of Hopkins’ health care workers, more than any other hospital in Maryland. She launched a Hospital-wide hand-washing campaign and introduced new alcoholic disinfectants in handy portable containers.
Perl’s biggest battle is the one she wages against antibiotic resistance—the super-bugs like methicillin resistant staph aureus (MRSA) and vancomycin resistant enteroccocus (VRE). She and her colleagues have been able to cut MRSA by 30 percent, and in the transplant division, by culturing all patients for VRE and isolating those who turn out to be positive, they slashed VRE rates by some 75 percent.
Hospital infection rates used to be a closely held secret, but Perl regularly reports them. She’s been described as the "conscience of the Hospital," a role that doesn’t always make her the most popular person around. "I’ve learned that, most of all, you’ve got to be visible," she says. "You can’t be effective if you hide in your office, push papers and have policies. You’ve got to be out there."
-- Anne Bennett Swingle
tuart (Skip) Grossman’s a busy guy. He’s a member of three departments—Oncology, Medicine and Neurosurgery—teaches medical students and residents, sees dozens of patients every week and is a neuro-oncology researcher who’s pioneered some of the latest treatments for brain tumors. Still, nothing in Grossman’s schedule keeps him from the noontime activity he considers all-important. At 12 o’clock every day, he joins social worker Matt Loscalzo and nurse practitioner Candice Morrison in the Hospital’s oncology unit, where for the next hour or so, they wind their way from bedside to bedside talking to patients who have indicated they are in intense pain. Grossman, a quiet-spoken man in his early 50s, teamed up with Loscalzo to set up this new service with one mission in mind: easing the agony that too often overwhelms cancer patients.
Pain management has caught the attention of the nation’s physicians, and nowhere is the crusade more apparent than at Johns Hopkins. At the Hospital’s Blaustein Pain Center, innovative treatments for chronic conditions like back and nerve injuries are being introduced regularly, and a new palliative care service focuses on easing the suffering for patients at the end of life. At the School of Medicine, electives on pain management at last are part of the curriculum. Few campaigns, though, are as visible as this cancer pain service, launched last February after years in the making.
Grossman has developed a clear plan for attacking cancer pain. All patients in the oncology units rate their discomfort every morning on a scale from zero to 10, using a tool that works like a crude slide rule. Morrison then visits those who scored over four (seven or above is considered a "pain emergency") and decides which patients she needs to put on the docket to discuss at noon rounds. She, Grossman and Loscalzo probe the reasons behind each of these patients’ distress and come up with a remedy— medication or perhaps radiation—to curb it. This they put forward to the nurses and physicians on duty. Next day, if a patient’s scores don’t go down, the group is back. "Our job," Grossman stresses, "is not to come in and take over a patient’s care but to act as consultants in this one area."
Grossman has been treating pain for nearly 20 years. Along the way he taught pain management to oncologists all over the world and chaired the committee that wrote the cancer pain guidelines that are now the standard treatment subscribed to by the National Comprehensive Cancer Network. He developed the pain-rating tool years ago after figuring out that patients weren’t getting their pain treated because doctors simply didn’t know how much they hurt. "But pain can be measured," Grossman insists, "and we have measurements going back for years that show the amount of pain that patients with cancer can experience. Every day, about 15 percent in the Oncology Center have an average pain rating of four. That’s a fair amount of pain."
All has not been easy for the fledgling pain service. Among other obstacles, Grossman has had to deal with the so-called "opio-phobia" over using high doses of narcotics to give relief. Grossman makes clear that fears about addicting patients and uncertainty about their tolerance levels are almost always unwarranted. When used correctly, these substances are safe and effective, even at the end of life, he says. "In fact, most of us believe that if you provide people with proper pain medicine, you don’t hasten death, you help them live longer and more actively."
You have the best job of anyone here," a student once told Dave Trabilsy.
"Why do you say that?" he asked. "Because you get to tell people they’ve been admitted to Hopkins."
And that he’s done. Every spring, Trabilsy, who was assistant dean for admissions, placed personal calls to all 220 applicants who made the cut. Sometimes he got them out of the shower, sometimes he rousted them from bed. Some cry, some scream. One even sounded bored. "Uh huh," he mumbled, on hearing the news. Then he pressed his hand against the receiver and emitted an ear-splitting yell.
But what Trabilsy, who is leaving Hopkins after 13 years in the Office of Admissions, remembers most is not his annual series of phone calls but the dazzling array of talent he saw in the applicants. It’s on display twice a week, he says, on interview days, as the endless parade of varsity athletes, student government leaders, musicians and the like converges on Hopkins. On just one day, for example, three Olympic athletes showed up.
Many are so confident they’re not out to impress anyone, not even a dean. One day at lunch, for instance, Trabilsy was seated next to an applicant who was a nuclear engineer.
"So what is it that you actually do?’ Trabilsy asked, conversationally.
The applicant cast him a steely glance and replied: "If I tell you, I’ll have to kill you." (Trabilsy found out later that action-movie afficionados say this regularly!)
That applicant turned out to be Hopkins material—smart (of course), creative, interested in service and committed to medicine, not for its prestige but for its intrinsic value—qualities that the admissions committee, a group of 28 faculty, can spot as quickly as it can compute an MCAT score.
Considering that the attrition rate is about one-half of 1 percent, Trabilsy has no trouble boasting about how well the committee picks, even at the last-minute. A hasty addition made a few years back, when a space suddenly opened up as classes were getting under way in September, is a case in point. A young man in Alabama who’d been put on the alternate list was available. Within 24 hours, he’d loaded his pickup, driven to Baltimore, situated himself in Reed Hall and started classes. He would go on to earn his M.D., his Ph.D., his master’s in public health and another in liberal studies. On the side, he ran marathons.
"That just about sums it up,"says Trabilsy. "That’s Hopkins."
aren Hanifen didn’t blame her patients for being confused trying to untangle the cast of people bringing juice and medication and clean sheets to their hospital rooms. But she did want them to know that it was she who was their nurse. So last fall she got her nurse’s cap out of the closet and wore it to her job at Hopkins Hospital. She was surprised at what a lightning rod she became.
Her colleagues on Nelson 6 were hardly supportive. She endured derisive comments like, What’s that on your head? and worse. Her attire, she was informed, was setting nursing back.
But an interesting thing happened. In the eyes of patients, "it was like I was the only R.N. on the floor," says Hanifen, who has been a nurse for 22 years, eight spent at Hopkins. "Everybody was coming to me with the cap on to talk to ‘the nurse.’"
It’s not that the unflappable Hanifen is looking for converts, just for a way "to differentiate us as nurses." When she worked in Florida and Hawaii, the color of her scrub top was her job identifier. At Hopkins, she had to take matters into her own hands.
So far, she’s received only positive comments from patients and families. "People stop me in the hallway and say, ‘It’s so nice to see a nurse with her cap. We can tell you’re proud of your cap.’"
She is. "It’s a personal choice," she admits. "It makes me feel good to know that my patients know who their nurse is, and that I worked long and hard to earn this. So that’s why I wear my cap. I’m one of the last dinosaurs that do, and I’m going to continue."
or Tom O’Toole, the internist who’s been named interim director of the Johns Hopkins Urban Health Institute, the most exciting thing about his new role is the chance to use the hallmarks of academia— research and teaching—to benefit the struggling East Baltimore community that surrounds the medical campus.
With deans from the Schools of Medicine, Public Health and Nursing pledging a total of about $1 million annually, the Institute plans initially to focus on treating and preventing substance abuse to rid East Baltimore of the drug scourge, voted by the community its number one enemy.
In the end, the model program, conceived by University President Bill Brody, aims to form a partnership between faculty and community leaders to promote health and prevent illness in one of the most disease-ridden areas of the nation.
"Faculty need to do better at targeting research to issues that community residents have identified as major concerns," O’Toole emphasized, "and then translating the results into products that can improve health here. There’s a lot of untapped funding available out there to support community-based research— from the NIH, to the Centers for Disease Control and private foundations like Robert Wood Johnson."
Besides providing direct care, faculty also will be able to work on training medical students and house staff to tailor their health care to the needs of this neighborhood. But the bottom line, O’Toole emphasizes, is that: there has to be close collaboration with neighborhood residents. "The community needs to feel ownership in this initiative."
They have long since passed on, but Alfred Blalock and Helen B. Taussig, the famous duo who in 1944 pioneered the "blue-baby" surgery, live on—through their plants. Taussig’s night-blooming cereus and Blalock’s African violet still remain in the Hospital and are being cared for by successive generations of cardiologists and surgeons.
Almost 40 years ago, Taussig kept the night-blooming cereus—which blooms rarely and then only nocturnally—in her greenhouse. Hopkins lore has it that one evening in the mid-1960s, when the ephemeral white blossoms finally began to burst open, she telephoned her junior faculty and invited them over. One by one they drove down the narrow wooded lane that led to the house on Lake Roland. Taussig then ushered the group to the darkened greenhouse where the mysterious transitory blooms with their pale yellow stamens were unfolding as the group watched.
When the famous cardiologist retired in 1965, she gave her cereus to ophthalmologist David Knox. Some 20 years later, Knox showed up one day in the heart clinic with the plant, looking for someone to take over his caretaking duties. The cardiologists gave the plant a new home in an office on Brady 5 where it remained until the light-filled Outpatient Center opened. Today the plant, unruly and clambering to the ceiling, aptly occupies a choice corner window in the Outpatient Center’s pediatric cardiology offices, watched over by staff and faculty cardiologists like Jean Kan and Tom Traill.
Blalock’s African violet, meanwhile, has remained at Hopkins from the day in 1964 the famous surgeon presented it to Vivien Thomas, his surgical assistant. Thomas tended the plant on his Blalock 12 windowsill. When he retired in the early 1980s, he split it in two and gave half to the chief of cardiac surgery at the moment and half to Jean Queen, his lab coordinator. Queen, now a 31-year Hopkins veteran, went on to present cuttings to fellows and residents with ties to Blalock. For years, her own half prospered, but last year it died, despite her ministrations.
The other half—a bit leggy but looking far younger than its years—blooms today on Blalock 6 in the office of cardiac surgeon-in-charge, Bill Baumgartner. Baumgartner asked social worker Helen Michalisko, who has a greener thumb than he, if she’d care for the plant, and for some 15 years, she’s watered and fertilized it, turned and dusted it, repotted, propagated and loved it.