Overcoming Barriers to Pediatric Pain Management
The measure of a good medical society is the involvement of its members. By that standard, the Worcester District is a great medical society. This year, our members and our alliance have been involved in a wide variety of activities. Our reach is substantial in our community and is growing every year.
Worcester Medicine has grown in stature through the hard work of its editorial board under the direction of Dr. Paul Steen. My patients not only read the magazine in my waiting room, they also comment on the articles. The writing is clear, the subjects well chosen, and the material timely.
Community Immunity was an outstanding collaboration involving many organizations throughout the city. The officials at the state and city levels were thrilled with the exercise as they gathered critical information about our emergency preparedness. The collaboration with the Medical School was particularly gratifying as we became part of the Community Medicine clerkship and involved the Nursing School in training. Attendance at the meetings was great despite our biweekly schedule. Kudos to Drs. Hirsh and Broadhurst for their work on bringing other organizations into our effort. Kudos to the Alliance for its collaboration and work on developing our publicity campaign.
Dr. Abraham continues overseeing our effort to create a secure doctors’ e mail for Worcester. This again is a story of how WDMS bridges differences in competing institutions to find common cause and thus bring important changes to our community.
Editorial space precludes mentioning all our activities. We are justly proud of what we do. We look forward to another productive year and hope to see more of the members getting involved; we have a good time.
Thanks for a great year.
Guest Editorial: Pain Management
Most people have experienced pain at some time in their life. Depending on the circumstances, it may have been acute pain that was relieved quickly by medication, or perhaps it was temporary, if intense, pain that was treated but also mitigated by the promise of a future good, such as the birth of a child. In such situations it may be possible to transcend the experience of pain because of the certainty that it will subside, or because the meaning of the experience is associated with a positive outcome.
Those who suffer from chronic pain, however, face a greater challenge. By its very nature chronic pain is unrelenting, even when intermittent, and often seems meaningless to the sufferer. Any type of pain may occur prominently at the end of life, but the specter of chronic pain can face us at any stage. With chronic pain the afflicted knows that the pain will return, or in some cases may persist unabated, even when there has not been a determined cause. If not treated properly and aggressively, chronic pain can lead to sleeplessness, depression, and more pain, establishing a vicious cycle that drains one’s physical, emotional and spiritual reserves. When someone is suffering from untreated chronic pain, particularly severe pain, nothing else matters.
Fortunately we have an arsenal of treatments to help the pain sufferer, and fortunate it is indeed, for pain is the most common reason for seeking medical attention. Yet we know we can do a much better job of treating pain. This awareness was in evidence at a recent seminar jointly sponsored by Worcester District Medical Society and Better Ending Partnership, held at the Beechwood Hotel on March 19. Entitled “Taking the Practitioner’s Pain out of Pain Management: Practical Aspects of Pain Management for the Non-pain Specialist,” the seminar was attended by 70 people from the central Massachusetts area: practicing physicians, residents, medical students, nurse practitioners, and physician assistants.
During this second annual Louis A. Cottle Medical Education Conference a unique format was employed: a lecture by Dr. Suzana Makowski, palliative care physician at UMass Memorial Medical Center, was followed by a question and answer period, with subsequent time for small groups to discuss prepared case scenarios and real-case consultation with experienced pain management experts. The participants were appreciative of the opportunity to apply their knowledge to concrete situations and to discuss their concerns with someone who has had a wealth of clinical experience in treating pain. Another aspect of the seminar worth mentioning is the emphasis on good pain assessment skills. There’s no substitute for getting as thorough an understanding of what the patient is experiencing as possible so that the appropriate treatment can be prescribed. This requires knowing the right questions to ask, astute listening and observation skills, and time, but in the long run it will save many an urgent phone call or trip to the emergency room when the patient is in the midst of a pain crisis.
Based on the prevalence of pain, national and local pain studies, and the interest in and response to this seminar, it is clear that we need to do a better job of preparing clinicians for competency in managing pain. Medical and nursing schools need to put pain at the top of the agenda for curriculum development. Pain specialists and mentors should be available to the novice practitioner in all health care settings, and expert consultants should be available in the community for those really difficult cases that may otherwise be under-treated or worse, neglected.
We also need to encourage patients to report their pain, and to develop better ways of assessing pain among people who are reluctant to report it. For example, within the diverse social and cultural fabric of central Massachusetts, how do we correctly and adequately take into account the pain experience of members of immigrant and ethnic groups that view the reporting of pain as something to be withheld, as uncomfortable as they might be?
In this second consecutive issue of Worcester Medicine devoted to pain and its treatment we look more closely at the treatment of chronic pain and provide ideas for new or alternative treatments. To help guide the practitioner to seek additional resources we offer “New Pharmacological Advancements in the Treatment of Chronic Pain” and “Osteopathic Manipulative Treatment in Chronic Pain,” as well as “Pediatric Pain Management,” to address pain issues faced by that special and most vulnerable population, children.
It is estimated that 95% of pain can be at least minimized if not controlled. Simply stated, we owe this to our patients, as any physician or nurse who has experienced severe pain will tell you. We hope that these two issues of Worcester Medicine will stimulate all readers to examine their own practices and to learn more about how to care effectively and compassionately for their patients in pain.
Christine McCluskey, RN, a former hospice nurse and administrator, is the executive director of Better Ending Partnership, a community coalition to improve end of life care in central Massachusetts
Osteopathic Manipulative Treatment (OMT) in Chronic Pain
In the U.S., there are two types of fully licensed physicians: a physician either earns the degree of medical doctor (M.D.) or doctor of osteopathic medicine (D.O.). Both professionals complete 4 years of medical school, complete specialty training, and take the same or comparable specialty board examinations. They are different in that a D.O. also studies osteopathic structural diagnosis, osteopathic philosophy and osteopathic manipulative medicine.
Osteopathic manipulative medicine is the application of osteopathic philosophy and structural diagnosis and the use of osteopathic manipulative treatment (OMT) in the diagnosis and management of the patient. In treating a chronic pain patient, an osteopathic physician will use osteopathic manipulation as part of an integrated treatment approach.
Osteopathic philosophy is comprised of four main tenets. 1. There is a structure and function relationship in the body. 2. The body has a self regulating mechanism. 3. Treat the body as a whole. 4. Osteopathic diagnosis and treatment is based on the first three tenets.
An osteopathic structural exam focuses on the neuromusculoskeletal system. Close attention is paid to posture, spine motion, and balance. A palpatory diagnosis is made over the entire body looking for restriction in motion and tenderness in ligaments, joints, tendons, muscles, and fascia. When an abnormality is palpated, OMT can be performed to improve or resolve the dysfunction.
OMT is a manual medical treatment. An osteopathic physician will diagnose and treat the entire body with his/her hands to evaluate ligaments, joints, tendons, muscles, and fascia. The goal of the treatment is to reduce pain, remove restrictions in motion, and improve injury or inadequate function.
There are multiple types of osteopathic techniques. In general, a manual force is applied to a restricted area in order to release the restricted tissues. Techniques can range from gentle to slightly painful. Each treatment varies according to the individual patient’s need. In other words, there are no protocols for a specific diagnosis. For example, the treatment of carpal tunnel syndrome would depend on the osteopathic exam findings and would be different from patient to patient.
In chronic pain, OMT is employed for multiple reasons. It is applied to restore proper posture and efficient use of the musculoskeletal components. OMT also addresses dysfunction in respiratory mechanics, circulation, and the flow of body fluids. It is used to reduce mechanical stresses, balance neural inputs, and eliminate nociceptive drive. Somatic dysfunction in the musculoskeletal system may be a reaction to environmental, socioeconomic, cultural or psychological events, but can in turn reinforce the physiologic stress. OMT addresses somatic dysfunction that has the potential to dysregulate the production, distribution, or expenditure of metabolic energy.
All D.O.s are trained to use OMT to treat and prevent illness or injury including chronic pain. There are specialists who are board certified in neuromusculoskeletal medicine/osteopathic manipulative medicine (NMM/OMM). NMM/OMM is a small osteopathic specialty group and those boarded in this specialty practice OMT mainly as consultants. A large number of osteopathic family physicians and other primary care specialists also use OMT for their patients and some will take outside referrals. Osteopathic physical medicine and rehabilitation specialists often use OMT, especially in their chronic pain patients. Other sub-specialists do use OMT, but it is rare.
OMT is prescribed on a visit to visit basis. The interval between follow ups depends on the medical condition, whether it is chronic or acute, and on the patient’s overall health. The follow up appointment is generally decided upon after each visit. Appointments scheduled in this way results in fewer visits compared with other types of manipulation.
Any patient with chronic pain can potentially benefit from OMT. Consider referring a patient for OMT if he or she has chronic back pain, neck pain, radiculopathy, sciatica, joint pain syndromes, fibromyalgia, traumatic injury, overuse syndrome, carpal tunnel syndrome, costochondritis, extremity pain, TMJ syndrome, migraines, tension headaches, or musculoskeletal pain in pregnancy.
William M. Foley, DO is Director of the OMT clinic, St. Vincent’s Hospital and Assistant Professor, University of New England College of Osteopathic Medicine. He also has a traditional osteopathic practice in Arlington, MA. E-mail: firstname.lastname@example.org
Barriers to Pediatric Pain Management
Pain control in children is a multi-faceted topic that spans many subspecialty medical disciplines and garners debate over treatment approaches and related concerns. Whether in the outpatient or inpatient setting, or in instances of post-surgical care or chronic conditions, the goals of pediatric pain control remain the same: treat the pain while minimizing treatment-related adverse effects. Pediatric pain management has greatly improved over the last 20 to 30 years as advances in medicine include a better understanding of pediatric pain, the availability of newer pharmacological agents and indications, as well as increasing libraries of evidence-based recommendations.
Traditionally, medical professionals have faced a number of misconceptions regarding pediatric pain management. Among these are the beliefs that neonates and children do not feel or express pain as frequently or intensely as adults, or that analgesics produce a greater number of adverse effects in children than in adults.(1) In truth, neonatal nociception is evidenced by 25 weeks’ gestation, and children are just as likely to express pain as are other populations.(2,3) Similarly, as a result of provider-based precaution against potential adverse effects, many children experiencing pain are under-treated with pharmacological agents.
A multitude of pharmacological options exist in treating pain across the age spectrum of pediatric patients including, but not limited to, nonopioid analgesics (acetaminophen, nonsteroidal anti-inflammatory agents (NSAIDs) and cyclooxygenase-2 inhibitors (celecoxib) for mild to moderate pain control. Opioid analgesics (including fentanyl and morphine and its derivatives) are frequently used for severe pain in the postoperative setting or for the treatment of chronic severe pain. Adjuvant agents that may be utilized in the postoperative setting include alpha-2 receptor agonists (clonidine), N-methyl-D-aspartate receptor antagonists (dextromethorphan), and local analgesics. In neonates, a 24% sucrose solution is commonly used for pain control during mildly painful procedures, including heel lancing.(4)
Despite medication choice, a fixed dose regimen may be more beneficial when pain is anticipated, since “as needed” dosing regimens do not prevent pain.(5) Practitioners may also opt for oral, rectal, or intravenous routes when feasible, as these routes tend to inflict less pain than intramuscular administration. The appropriate choice of pain control depends on multiple factors including patient age, severity of pain, origin of pain, and presence or absence of contraindications or other complicating factors.
Non-pharmacological options can also be beneficial in helping to diminish pediatric pain. Children benefit from approaches such as age-appropriate pre-procedural teaching, the presence of a familiar comforting object at the bedside, distraction techniques, and music.(5) Frequent monitoring of pain using age-appropriate assessment scales, including the NPASS (Neonatal Pain, Agitation, and Sedation Scale) for neonates, or the Wong-Baker FACES Scale for children ages three and over, is highly recommended.(5,6,7)
A thorough understanding of drug therapy and physiologic development is necessary to adequately and appropriately manage pediatric pain. Multidisciplinary medical approaches to care are also necessary; physicians, pharmacists, nurses, and parents are all essential parts of the medical team in understanding and treating pediatric pain.
Kimberly A. Pesaturo, PharmD, is an Assistant Professor in the Department of Pharmacy Practice at the Massachusetts College of Pharmacy and Health Sciences. Dr. Pesaturo specializes in pediatric practice and can be contacted at email@example.com.
Science Corner: New
Pharmacologic Advancements in the Treatment of Chronic Pain
Chronic pain is defined as pain that persists for longer than 3 months that can be associated with cancer or a nonmalignant process (e.g. radiculopathy). The treatment of chronic pain incorporates the use of both nonpharmacologic and pharmacologic modalities to assist patients in achieving analgesia and improving their functioning and quality of life. Several therapeutic drug classes, including opioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs), play a beneficial role in the management of such pain; however, adverse drug reactions and the development of tolerance to their pharmacologic effects may limit their use in all patients. New advancements in the treatment of chronic pain may offer novel and effective long-term alternatives for patients who cannot tolerate or who fail available pharmacotherapy.
Analgesics used for the management of chronic pain produce analgesia through various mechanisms and to varying degrees. The discovery of the endogenous opioid system in the 1970s prompted the development of morphine and similar analgesics that are considered the mainstay of therapy in the management of moderate to severe acute or chronic pain. More recent recognition of the role of neurotransmitters in pain modulation has stimulated the use of antidepressants for chronic pain syndromes, particularly neuropathic pain. The current understanding of pain processing and modulation has illuminated the role of several additional receptors and neurotransmitters that may offer a unique approach to pain management.
Bicifadine has a similar mechanism of action to other serotonin norepinephrine reuptake inhibitors (SNRIs) in that it enhances and prolongs the actions of norepinephrine and serotonin by inhibiting the proteins that cause their degradation. When compared to other analgesics, it was found to be slightly more effective than codeine and as efficacious as tramadol.(1,2) Clinical trials that have collectively enrolled over 1100 patients have been conducted on bicifadine for the treatment of chronic low back pain (CLBP).(2) Tapentadol is a centrally-acting analgesic with a dual mechanism of action by acting as an agonist at opioid receptors as well as by inhibiting norepinephrine reuptake. Preliminary data has suggested that its analgesic potency is greater than tramadol (an analgesic with a similar mechanism of action) but less than that of morphine.(3) It is currently being studied in patients with moderate to severe chronic low back pain, knee osteoarthritis, and painful diabetic peripheral neuropathy (PDPN). Lacosamide, an anticonvulsant with an unknown mechanism of action, was originally developed for the treatment of partial-onset seizures and has since been studied in PDPN.(4) These products are currently pending approval by the Food and Drug Administration (FDA).
The endogenous cannabinoid system includes receptors that modulate the transmission and processing of peripheral noxious input. Cannabinoid CB1 and CB2 receptor agonists have been shown to have analgesic properties in animal models of inflammation and neuropathic pain (5); however, the widespread distribution of these receptors within the brain coupled with the occurrence of severe adverse effects (e.g. depression) may limit their clinical applicability in humans. Nabilone (CesametTM), a synthetic cannabinoid, was FDA-approved in 1985 for the treatment of chemotherapy-induced nausea and vomiting (although it was not marketed in the United States until 2006) and is currently being evaluated for the treatment of neuropathies associated with diabetes and multiple sclerosis.(6)
When using opioid analgesics for the management of chronic pain, patients will inevitably experience constipation secondary to the stimulation of mu receptors in the gastrointestinal tract. Alvimopan (Entereg®), a peripherally-acting mu opioid receptor (PAM-OR) antagonist, was developed to inhibit the stimulation of these receptors without blocking analgesic effects. In April 2007, data from a Phase III trial of patients with chronic noncancer pain who were experiencing opioid-induced bowel dysfunction (OBD) revealed an increase in cardiovascular and cancer event rates among alvimopan-treated patients.(7) The FDA has placed the drug application for alvimopan on clinical hold pending further review of available safety data.
New formulations for analgesics have been developed to improve patient adherence to medication regimens, enhance drug delivery, and/or minimize adverse drug effects. The controlled heat-assisted drug delivery (CHADDTM) unit contains a powder that when exposed to air generates heat to increase the rate of drug absorption through the skin.(8) The use of this transdermal system allows for drug to be absorbed over 20 minutes or up to 12 hours. Fentanyl CHADD and ketoprofen (ThermoProfenTM) units are currently in clinical trials for the treatment of chronic pain syndromes.(9,10) Buprenorphine, a partial opioid agonist, has received recent attention for its role in the office-based management of opioid addiction and is now being evaluated as a transdermal system for the treatment of chronic osteoarthritis pain.(11) An oxycodone and naltrexone combination (Remoxy) has been formulated using a sustained-released gel cap technology (ORADUR) and is currently in Phase III trials.(12) The advantage of using a pure opioid agonist along with an antagonist allows for analgesia while preventing misuse and potentially diversion.
Although promising pharmacotherapeutic agents and formulations are on the horizon, the management of chronic pain remains a challenge for both practitioners and patients. For example, providers with prescriptive authority may fear regulatory scrutiny when prescribing opioid analgesics for chronic pain, while patients may worry about becoming addicted to them. Moreover, the incidence of adverse drug reactions associated with many analgesics may prevent patient adherence. Until these treatment options are available, individualizing therapy can be considered the best way to promote the safe and effective use of analgesics.
Michele Matthews, PharmD is Assistant Professor in the Department of Pharmacy Practice at the Massachusetts College of Pharmacy and Health Sciences in Worcester, MA. Email: firstname.lastname@example.org
Negligence and the Absence of Evidence
We’ve all heard the truism, “If it isn’t in the medical record, it didn’t happen.” A recent Massachusetts Appeals Court case suggests that sometimes, when something doesn’t appear in the record, something very wrong indeed happened. The decision bears a warning for practitioners tempted to not record troubling events in the medical record: you could be liable for fraud if your intent is to hide possible negligence.
During a vaginal birth, a prolapsed cord led to an emergency Caesarian section, and after delivery, the infant required resuscitation due to a lack of oxygen. Two nurses and a doctor were present during the resuscitation. The baby suffered physical and mental disabilities. Within the seven-year statute of repose for medical malpractice claims, the baby’s parents sued the physician who performed the c-section for malpractice. During pre-trial discovery that took place after the expiration of that seven-year period, one of the nurses revealed for the first time that the medical records prepared by the doctor and the other nurse present during the resuscitation did not note that the baby had been deprived of oxygen for several minutes. The parents then filed a second lawsuit, nearly nine years after the birth, against that nurse and doctor.
This second lawsuit alleged malpractice against the nurse and doctor and that they had fraudulently concealed certain facts by not noting them in the medical record. Specifically, the parents claimed that the nurse and doctor did not record a failed initial attempt to insert a breathing tube into the baby and that he was left without oxygen for several minutes before a second doctor was able to successfully get the oxygen flowing. They claimed the medical record as written by the nurse and doctor suggested that the resuscitation effort proceeded smoothly and without resulting harm to the baby.
The negligence claim against the nurse and doctor was dismissed by the court upon the defendants’ motion as having been filed too late. The court permitted the fraudulent concealment claim to proceed, however, because that claim was for fraud, not malpractice, and thus was not barred by the seven-year statute of repose. In order to prevail on the fraudulent concealment claim, the parents would have to demonstrate that the medical record omissions were intentional, that the nurse and doctor intended to induce the parents to act on the basis of the false medical record, and that the parents in fact did rely on the false record to their detriment, by letting the seven-year period elapse before filing the second lawsuit.
The defendants appealed the trial court’s decision to the Appeals Court, arguing that the claim was essentially one of inaccurate record-keeping in the context of negligent medical treatment. The Appeals Court disagreed, saying, “Here, the plaintiffs allege the intentional and wrongful concealment of a cause of action based on a fiduciary duty of full disclosure, a claim that does not require an assessment of policies or procedures surrounding appropriate record-keeping by a medical provider.” The court also noted that the complaint did not, and did not need to, allege a causal relation between the medical record inaccuracies and the baby’s injuries, further distinguishing the claim from a medical malpractice complaint. However, the court stated, if fraud is proven, then the quality of care rendered would be relevant, but only to the question of what damages should be awarded the parents.
The Appeals Court noted that proving all of the elements of fraud in this case would require inquiry into the “…nature of the defendants’ fiduciary duty to disclose their own negligence, and what, if any, misrepresentations or affirmative steps were made or taken in breach of that duty.” Also, the plaintiffs would have to establish whether the defendants knew or believed they were negligent in resuscitating the baby and whether they intended to induce the parents to refrain from filing suit during the applicable limitations period.
It is of course unclear, now that the Appeals Court permitted the parents to proceed with their fraud claim, whether the parents would be able to prove all of the elements of their allegation that the defendants failed to disclose certain facts for the sole purpose of hiding their errors and thus depriving the parents of the opportunity to file a malpractice action. What is clear is that the Appeals Court is making a distinction between a fraud claim based on withholding information from the medical record and a medical malpractice claim. If and when the matter proceeds, it will be interesting to see what is made of the practitioners’ “…fiduciary duty to disclose their own negligence…” asserted by the Appeals Court.
In the meantime, physicians and other practitioners will have all the more reason to exhaustively document their actions and other clinical information in the medical record.
PIAM Offers New
Malpractice Insurance Program
Worcester area physician groups now have a unique new malpractice program available to them. The Connecticut Medical Insurance Company (CMIC) and PIAM are launching a special program, the Malpractice Quality Initiative (MQI), for physician groups with superior claims experience. MQI features premium reductions up to 30% off typical occurrence base rates. MQI uses a modified claims made type of coverage which provides a fully paid tail, something new to CMIC. CMIC will also offer its other traditional claims made policy and recently enhanced group malpractice products.
“We understand how difficult it is to maintain a superior claims record,” said CMIC CEO Denise Funk. “Our goal with MQI is to motivate and reward physician groups for such efforts by combining significantly reduced premiums with focused loss prevention and practice management.” MQI will also be offering an added 5% credit for practices using a certified EHR.
Ms. Funk noted, “MQI reflects CMIC’s strong belief in practice technology by adding an extra credit to the already significant savings for physicians using a CCHIT certified Electronic Health Record (EHR) system. CMIC was one of the first malpractice carriers in the U.S. to provide a general credit for the use of an EHR program. MQI takes this a step further.”
Eligibility for the MQI program is based on several factors including practice size (minimum of 3 or more physicians), continued stellar claims experience, board certification, lack of disciplinary actions and willingness to participate in the MQI risk management process.
Michael Morgan, CMIC’s Director of Business Development, said, “MQI will appeal to physician groups with good claims experience that are part of an existing captive insurance program or are considering starting one. MQI can place these groups directly into a program that has many of the features of a captive, such as modified claims made coverage and lower premiums, but without the costs and headaches of starting a captive. MQI may also appeal to smaller groups that may not be big enough to start a captive but may like the special features it has to offer.”
Mr. Morgan continued, “MQI has the ability to offer some features not available from many insurance carriers including captives. For example if an MQI practice is hiring a physician with a claims made policy, CMIC may accept the new physician’s ‘retroactive’ date depending on the previous state of practice. This could help a great deal in the recruiting process. Occurrence forms of coverage and most captive plans are generally unable to offer prior acts.”
For additional information or to qualify your practice for a quote, please call PIAM at (800) 522-7426. More information on the MQI program is available on the PIAM web site at http://www.piam.com.
Off Call: The Irish in Worcester (Part
Two years ago I was researching my family roots at the Worcester Public Library and I ran into Paul Mullaney, the former mayor and judge who grew up in South Worcester. He advised me, “Don’t be surprised by what you find because it was a tough road for many of the Irish who came to Worcester.” I found out how right he was. My father came to America from Carnane in County Clare by himself in 1927 at the age of 17. His grandparents raised him because his father had died. His mother remarried and wanted him to join her in Worcester.
Nothing was said about my grandfather when we were growing up. Going through the microfilm at the Worcester Library, I came upon a chilling newspaper article in the Worcester Daily Telegram dated March 15th, 1912: “Dies From Wounds by Police Club. William T. Lynch Succumbs to Injuries in City Hospital.” It said that my grandfather was at the corner of Colton and Southbridge Sts. with a friend when a police officer told them to move along. Under oath the next day, the officer stated that Lynch had said, “You will have to lay me out before you take me.” “And I did,” was his answer. The officer was suspended and my grandfather died as a result of a fractured skull. He was buried at St. John’s Cemetery on March 17th, St. Patrick’s Day, not far from where my parents are buried.
In Timothy J. Meagher’s book, he talks about walking through St. John’s Cemetery and seeing the names of the famous Irish in Worcester’s history on the stones. There are many more, like my grandfather, with no headstone who are a silent part of the story. My father, also a machinist like his father, would become Director of the Machine Shop at Worcester Boys’ Trade High School for over 30 years. Eight of his children would graduate from college. My mother would become the Vice President of the 1936 School of Nursing at St. Vincent’s Hospital and Senior Head Nurse at Fairlawn Hospital. Her mother’s uncle, Andrew Edward O’Connell, would become President of the Worcester District Medical Society in 1943.
One hundred and eighty two years of history is a little daunting to put down on just a few pages. I’ve referenced experts who have written books and articles on this subject. Born and raised in Worcester and later becoming US Ambassador to Ireland, William V. Shannon authored a book on the American Irish that is a good starting point. My son’s favorite children’s book is Tobey Boland and the Blackstone Canal by Thomas L. Rooney of Shrewsbury. Still, Timothy J. Meagher from Worcester gave us the most detailed book. For me, the person who made the history of the Irish in Worcester come alive was the late Professor Vincent “Jake” Powers of Worcester State College. He didn’t sugar coat anything and he told it like it was. For many of the Irish in Worcester it was not a race to the top but more like one step forward, two steps back.
Martin A. Lynch, CMR is a Senior Therapeutic Consultant at Pfizer, Inc. He can be reached at Doolinboy@yahoo.com.
The Cancer Treatment Revolution. How Smart Drugs and Other Therapies are Renewing Our Hope and Changing the Face of Medicine. David G. Nathan, M.D. Wiley. 2007.
The perfect condition in oncology would be to have no disease. Less quixotically, a happy state of affairs would be to have the means to detect, in all organs and preferably via minimally invasive methods, the pre-malignant state. The Pap smear and colonoscopy have saved many lives by often detecting not frank cancer but dysplasia. We need more such wonderful tools. Meanwhile, great strides in treatment have been made in the past 20 years, some representing the fruits of discoveries rooted in previous decades, others flashing forward with relative speed (Gleevec).
David Nathan has written an account of the new era of cancer treatment that is neither a textbook nor a New York Times version. Rather, this accomplished pediatric oncologist, arguably among the most distinguished in the world, has built his account around a number of case stories. But these are not presented in the usual New England Journal of Medicine format. In each, the author provides the entire spectrum of science and medicine behind the treatment strategy and eloquently weaves the medical oncology axis with the human landscape of the patient and family. Other authors embarking to write on this subject might have followed a timeline narrative, covering the first cancer therapeutic drugs and closing with the newest. Dr. Nathan’s alternative idea is to convey cancer therapy from the perspective of its discovery background, explaining how the science has led to the treatments these patients are receiving. It is a very effective device and one that is consistent with the widely admired expository and didactic talent of the author.
This is the story of the ever advancing successes in the treatment of cancer, not as in the popular dream of “the cure” but in the twists and turns of scientific inquiry made on lab benches and the hard-to-define bedside phenomenon known as clinical skill. In today’s era of “programmed biomedical research” it is well to remember that advances in cancer chemotherapy have not typically come from a linear process. For one thing, there have been dead-ends such as the notion (1946-1980) that most human cancer has a viral etiology. Although this idea turned out to be wrong, the U.S. government’s enthusiasm, manifest as the National Cancer Institute’s Viral Carcinogenesis Program, ended up providing the foundation of information that allowed the molecular biology and life cycle of the AIDS virus to be understood as promptly as it was, partly because of what was known about a related virus that causes adult T-cell leukemia, one of the few viruses known to cause human cancer. Similarly, Sidney Farber, though determined to cure childhood leukemia, thought it was akin to pernicious anemia, an error that led him and his colleagues to the triumphant advent of anti-folate cancer chemotherapy. Dr. Nathan has placed his deep experience and insight into the context of the patient and the often “non-linear” science that had to happen to yield the drugs for their care.
Reading this book one senses that the author is reaching out to many audiences. The lay audience (patients and families) will find little that is too technical. The readers of Worcester Medicine include many primary care physicians who see cancer in its first suspected moment on the front line. They will find much of interest in this book and will sense admiration by the author for their calling. Oncology specialists will read a peer of considerable distinction and will be justifiably inspired by the author’s Solomonic knowledge.
Some believe that cancer chemotherapy is soon to dramatically change, particularly as regards the anticipated advent of “genomically customized” drugs, matched to the drug metabolism and other biology of the individual patient. Time will tell. But in these pages one learns of the extraordinary road yet traveled. As we sadly witness all the warfare and related evils that ravage mankind today, the fact that a relative handful of men and women have over the years tried to treat cancer with chemicals, and have succeeded so well in less than a century, calls for profound gratitude and a moment of deep sobriety about what is important. That is the uplifting thought I had as I closed Dr. Nathan’s superb book. I warmly recommend it.
Sushrut Jangi, medical student in the Class of 2009, has been chosen as the grand prize winner of the Gerald F. Berlin Creative Writing Award at the University of Massachusetts Medical School.
The Gerald F. Berlin Creative Writing Award was established in 2005 by Richard M. Berlin, MD, a poet and Associate Professor of Psychiatry at the University of Massachusetts Medical School. Berlin established the award to encourage creative writing in biomedical and nursing students and residents, and to honor his father, who struggled with a severe chronic illness.
My Father's House in Jalisco
"My first drink," Socorro said looking at me with his great yellow eyes, "was mezcal."
"Ah." He closed his eyes and pushed his body back in the hospital chair, the legs creaking and threatening to break under the weight of a rising memory.
"It was a hot day, my god," he said. "The leaves on the lemon trees by my father’s house in Jalisco dancing like the women that get you into trouble. You been to Jalisco?"
"I haven’t." I pulled out a pad of paper from my white coat pocket and under bilateral lung crackles, I scribbled Jalisco.
He snorted then cleared his throat. He closed his eyes again.
"Jalisco is a beautiful place, great rolling hills, people with brown skin like chocolate moving down the streets, and everything is slow, molasses, and the sky is as blue as agave. None of this," he pointed to the gray window. He paused, then went on. "We sat there under these lemon trees. Hot day, the sun clawing into your skin. And there were wasps everywhere, flying this way, that way." His fingers moved through the air. "“Everything smelled like lemons and honey." He took a great breath. This sent him into a series of coughs, his body heaving, his lungs expanding and collapsing like ancient bellows that had fallen into disrepair. When his fit was over, he grimaced in his chair. He wore only an extra-large Hanes underwear that was stretched across his bottom. He was shirt-less and bare-chested. Crimson and violet boils were scattered across his sternum and veins snaked the expanse of his stomach. The room smelled of his sweat.
"Carlos was smaller than me. Fast and curious."
"My brother, poor bastard. He’s dead now. Killed by the local militia for trafficking. They shot him through the neck." "I’m sorry to hear that."
He moved in the chair. Scratched his thin cheek with his nail, his skin like paper. Then he reached up to his nose, and with his thumb and middle finger, he adjusted his nasogastric tube. "He was a foolish boy who loved life. It was his idea that hot morning to go into town. Our father kept a stash of pesos in a brown shoe tucked under the bed. Carlos crept underneath and fished the money out while I stood in the hallway and watched for my father’s shadow in the kitchen. My brother ran towards me smiling with the fistful of coins. We held the pesos under our noses and smelled them, like shoe polish, and something else, the smell of all the strange adult hands they had passed through. Whether it was good money or bad money, we didn’t care, it was ours, ours to spend on anything we chose, and that morning we were like gods, Carlos and I, stealing away from the house and running to the town."
Carlos, I scrawled under Jalisco.
He looked up at me, writing on my pad. "What are you writing there?"
"Names of the places and people you are describing."
"You need it for your medical report?"
"I might," I said.
"It will help you treat me?"
"Yes," I said.
"Bring me a basin."
I ran forward with a kidney bowl and watched him vomit a green-yellow color into it. I looked up at the arboreum of clear bags on his IV pole swinging above his head. When he was finished he began to cough. I reached to call for his nurse, but he shook his hands at me. "I’ll be okay," he said. "I just need to rest."
I walked to the window and looked outdoors at the white hills with crooked New England houses frozen into the landscape. The lake that spread before the hills was black with small continents of ice sheets drifting on its surface. Right underneath the window, I saw the smokestack beside the hospital that puffed out a modest stream of smoke – the Incinerator – we called it jokingly in our first year of medical school, where we imagined they burned all of the deceased.
Soccoro began to speak again from behind me. "We ran to
the town that morning, with the money in our dirty hands. Like gods. We saw
everything in the town. As though our eyes were rinsed with soap and water.
Everything bright and burning before us. The tianguis. The sound of a
hundred dialects. Flowers, fruits, rusted bells, the brush of ocean wind and
the spark of fire pits, flutes and pipes, boots, young girls singing with
their new voices, lemon pops, barrels and barrels of rum, real sugarcane.
And the people! There were sailors and their mistresses, jugglers and sword
swallowers, men with no legs, magicians: it was the entire world in one
morning," he said. He sat back and sighed.
He grinned and showed me the soft yellow shells of his teeth, the enamel cracked and long gone.
"There was a girl from the village selling drinks underneath a small awning. A lavender dress hiding her legs. Poor thing. Not a smile for us. She was beautiful.” He pointed up to the TV in the corner of the room on which a Latin soap opera was playing. “Nothing like that. But she was part of our day."
"What was her name?"
He shook his head. "There are women you have loved?"
"When you’re a dying man like me, you won’t remember any of their names. But," he said, grasping at the air, "small things about them will float back to you, and you’ll grab at whatever you can – the way they ate, or some lovely argument you had, or the feel of their breasts." He coughed again, brown sputum, that he wiped away with his napkin. "A wild mind God has given us."
"If you think back," I told him, "you will remember more."
"No," he said. "It’s a gift that we forget." He blinked. "She stood between morning and evening. Her face in half-light and shadow. An apothecary. For behind her were what seemed to us thousands of bottles, some dark, others as white as milk. Poisons and solutions. We knew, both Carlos and I, that it was here that we would spend our money."
"And she gave you the mezcal."
"Yes, but we had no money for the glasses, only for the bottle. We had nothing real to drink from, no caballito, no glass, just our dirty hands. She saw our faces and she disappeared under the counter and produced lemons from under the counter. Like gold they were. She split them right in front of us and handed one half to Carlos and one half to me. We ate the flesh of the lemons and then opened our hands. She poured the mezcal right into the cups of our hands and we tilted our heads back and let it burn our throats, the lemon flesh still on our tongues, the sun biting our red faces, my god, it was my first and last good drink. And then I fell."
"From the fire of the mezcal. I fell to my feet, right there before my baby brother and this strange and wonderful girl and my head hit the stones on the ground."
"You passed out?"
"I don’t know what happened. The next thing I remember was my father standing in front of me in my bedroom, asking me where I had been. I told him I’d gone to the village to buy books for Carlos. What books, he asked me. Real books, I told him. Fat ones with big spines. Literatura. Don Quixote. Even English books. Tom Sawyer. I thought the smell on my breath would betray me. But it didn’t. The mezcal rested quietly on my tongue. Already it had begun speaking for me."
Socorro looked up at me. "You know what he did then, my father? He told me that he was proud of me. For looking out for Carlos’ education. And he was proud of Carlos too, for bringing me back home safely. I couldn’t believe it. We had tricked our father, stolen money, and drank mezcal and he was proud of us! He told us to go out into the orchard, gather some lemons, and then come in to have the evening meal."
"Then what?" I asked.
"That’s it," he said. "We went out to the lemon trees, and with the ocean viento bringing salt to us, we picked the fruit from the the trees until it grew dark."
"He never knew?"
"He never showed it."
"You speak like a poet Socorro."
"We are all poets on our deathbeds."
"You aren’t going to die right now."
He stared at me. Glanced out the window. Outside, snow had begun to fall. He began to cough. "They all rush to your side you know."
"The dead come back to you flushed in color to carry you home and you almost feel as though they have been with you your whole life"
"You aren’t going to die tonight. We’ll take care of you here."
"Bring that thing here around your neck."
I pointed to my stethescope. "This?"
"Show me how it works."
I took it off from around my neck. He took the instrument into his hands and fumbled with it for several minutes. "Let me help you," I said, taking it from him, helping him put it on. Tufts of hair poked out from his brown ears, and beads of sweat had collected like glass marbles on his brow. The smell from his body was rank and nearly overpowering.
"This finds your heart, eh?" he asked, placing the bell on his chest.
"It’s difficult to hear on you."
"I’m a fat man," he said.
"Well," I laughed.
"No, I know this. My heart is buried deep inside. You must be a good doctor to be able to find it." He closed his eyes and listened. It was quiet in the room for several minutes. The hands of the clock moved on the wall. The snow hissed on the hot vents on the hospital roof. The phlebotomist’s cart clattered in the hallway.
"I hear it," he said finally. "It’s whispering. Socorro, Socorro, Socorro."
He took the stethescope off. "This is some magic that you practice, finding the lost hearts of men. Will you do this for your whole life?"
"I think so."
"You will travel?"
"Yes, I hope to."
"Will you go to Jalisco?"
"I might," I told him.
"You won’t," he said. "But now you will carry the name of that place with you. The knowledge that once, my father built us a home there. Put it away in your files, in your charts."
"I will, Socorro."
"Why is my body yellow?"
"Your liver," I told him. "It’s failing."
"No," he said, shaking his head. "It is the juice of the lemon trees at my father’s house in Jalisco," he said. "It is surging now in my body."
He closed his eyes. He slept for awhile. When I came back to check on him the next day, he was in the intensive care unit still asleep. Encephalopathic, our attending said. Mental confusion. "Where are you right now?" the attending asked him, shaking his shoulders. "Tell us where you are right now."
"In Jalisco," Socorro murmured, opening his golden eyes in a moment of pure clarity, plainly, as if it were a stupid question.
"You see," the attending said smiling, looking back at us.
I walked home that evening in my winter coat, the snow falling fast and strong. I saw the smokestack rise beside me sending plumes of white clouds into the sky, like an exhalation, a breath that held our reluctant and witheld grief. I walked home with this thought, the ice in the black lake cracking and freezing again, the world around me glowing, and in a small act of retribution in my room I began to write.
In Memoriam: WDMS Remembers its Colleagues
Dr. Catherine Brennan
I have known Dr. Catherine Brennan for the last four years. I saw her for the first time during Medical Grand Rounds. Although she was retired, I admired her for active attendance and participation. She was very enthusiastic and eager to learn new developments in medicine.
Even though she was not practicing, her passion for her patients was admirable. She was a very caring and compassionate physician who kept in touch with her patients. Even during her difficult times, she always remembered her patients and how much she missed practicing medicine.
I remember Dr. Brennan as a compassionate, caring and a friendly individual. She will be missed.
Kala Seetharaman, M.D.
Paul V. O’Leary, MD
Dr. Paul V O’Leary died in his 86th year while in retirement on Cape Cod. His wife, Susan O’Leary of East Dennis, MA, and nine children, including Dr. Alice O’Leary, a pediatrician who followed her father into the practice of medicine, survive him.
Paul was born and raised in Worcester, graduating from the then Classical High School and the College of the Holy Cross. He entered the United States Navy as a Lieutenant at the beginning of World War II. Serving on a transport landing ship, he took part in the Battle of the Leyte Gulf and the invasion of Okinawa. Following his military service, Paul entered Tufts University School of Medicine. His postgraduate training was in obstetrics and gynecology at the former Boston Lying-In Hospital and the Bellevue Hospital in New York City. He then returned to Worcester to begin an association with Dr. Herbert Hedberg, Chief of Obstetrics and Gynecology at Worcester Memorial Hospital. Following Dr. Hedberg’s retirement, Paul continued in solo practice, establishing one of the busiest obstetrical practices in Worcester; it spanned over forty years. It is estimated that he delivered over 8000 babies, many of whom were the babies of the babies he had delivered!
Paul was extremely devoted to his patients. Often, because of sedation, they were unaware that he remained in personal attendance throughout labor. Paul was a member of the Medical Staff of St. Vincent Hospital where his services included beneficent prenatal care and delivery for unwed mothers.
For many years, I had the privilege of being Paul O’Leary’s covering colleague. We substituted for each other when the other was not available. There is no heavier professional responsibility than to be an understudy at the time of confinement for a colleague whose patient, after nine months, is bonded in trust. My patients who were cared for and delivered by Paul O’Leary in my absence always felt he met or exceeded their satisfaction index ~ and they were grateful.
Saul Lerner, MD