ALLAN R. TUNKEL: Well, thanks so much
for the opportunity to speak at your graduation ceremony today.
Really, probably one of the most wonderful honors in my life.
And this was a difficult speech for me to write,
because I wanted to be sure that my remarks would
have some impact on your roles as future physicians.
So I decided to talk with all of you
from my perspective as a patient--
a view from the bed, so to speak--
as I had a personal experience in dealing with a potentially
fatal illness.
Or one that definitely would have been fatal to me
without rapid and appropriate treatment.
So at the time I was 62 years old,
and the date was March 17, 2017.
And I remember that date really well because it was Match Day.
And I was feeling very well during the festivities,
really enjoyed the ceremony-- excuse me--
and then mid-afternoon I noted some muscle aches,
really no other symptoms, although they kept
returning despite analgesics.
So that night, there was a dinner program
at the Biltmore Hotel in Providence
to kick off a weekend symposium at the medical school that
was entitled, The Patient, The Practitioner, and The Computer.
And the theme was how the electronic health record
has impacted communication between patients and physicians
and might also make physicians less humanistic.
So as one of the people who supported the symposium,
I was asked to give some opening remarks.
And I took the opportunity of talking
about a personal experience that I
had had with the electronic health record about five
years earlier.
So at the time, I was Chair of the Department of Medicine
at a teaching hospital in New Jersey.
And I'd just been diagnosed with diffuse large B cell lymphoma.
I was pretty sick at the time, needed
to be urgently admitted to my hospital for chemotherapy.
Now you would think that this diagnosis in and of itself
was an anxiety producing event.
But there was another issue and one that
gave me even greater concern.
This was the week that my hospital was rolling out
their electronic health record.
[LAUGHTER]
So it was a chaotic time.
Everyone was being trained on how to use it.
Would I be able to survive?
Of course, I did.
I got all the right medications.
There were no errors in my care.
I also responded very well to the chemotherapy.
I remain cancer free now after almost seven years.
[APPLAUSE]
So I decide to tell the audience at the conference
about one particular experience regarding the hospitalization.
Because after discharge, I, of course,
decided to go into my hospital record to review my chart.
So on my initial history, there was a question.
The question was pregnancy.
And the box checked was, patient denies.
[LAUGHTER]
Now that's actually an issue on two levels.
The first, I hope is the obvious one.
But the second is that no one ever asked me
if I was pregnant.
And this highlights a potential issue
with the electronic health record.
I'm going to talk it back to this a little bit later.
But now back to March 17, 2017 at the Biltmore.
So about 30 minutes after my remarks during the keynote,
I started feeling lightheaded, was
sweating, a little nauseated.
Definitely feeling like I was about to pass out,
so hurried out of the banquet hall into the lobby.
I didn't lose consciousness, but fell to the floor.
And I just thought it was some sort of vasovagal response,
not sure to what.
I think people attending the keynote noticed something
was wrong, and a number of the doctors followed me out.
So if you're going to pass out, the best place to do it,
by the way, is at a medical conference.
So my pulse was difficult to palpate, was fast.
Really no other symptoms.
Fire rescue was called after intervention by Dr. Schiffman.
And I was loaded into the ambulance and taken to the ER
at Rhode Island Hospital.
I was feeling fine by that time.
Still some generalized muscle aches, but really nothing else.
No headache, stiff neck, chest pain, nothing.
My only medications were aspirin.
And I took valsartan for hypertension.
I'm allergic to kiwi, but I hadn't taken any since 1989.
[LAUGHTER]
No one actually asked me about drug use or sexual activity,
probably because they were afraid of what I might say.
[LAUGHTER]
After all, I was a teenager in the late 1960s.
I had received my yearly influenza vaccine
the previous November.
And I'd gotten the pneumococcal vaccine, as well.
So exam in the ER, my temp was 99.9, heart rate 101,
respirations 14.
My blood pressure was 111 over 72.
We're going to just get into it.
So we want to be sure you're prepared for residency.
My pulse ox was 99% on room air.
All essentially normal, though my pulse
was a little faster than usual.
My lungs were clear.
Nothing abnormal on my exam.
My labs were pretty normal, too, except my white count
was up about 16,000.
Chest X-ray, EKG were normal.
The emergency room attending came
to see me indicating there did not
seem to be any obvious source of bacterial infection or anything
else.
I told her I still didn't feel quite normal,
and after some discussion, she decided
to admit me with plans to have me monitored
and check my lab studies in the morning.
She said there did not seem to be
any reason for administration of the antibiotics.
So since I'm an infectious disease specialist,
I concurred.
[LAUGHTER]
The resident was called to do my history and exam.
He also did not ask me about drug use
or take a sexual history.
And I was left on the stretcher in the ER hooked up
to the monitor wearing my blood pressure cuff
that would intermittently inflate and deflate.
It was around midnight this time.
And I decided to try to fall asleep.
About 1:30 in the morning, I awoke and turned my head
toward the monitor.
My pulse was now 130 beats per minute,
and my blood pressure was dangerously low at 75 over 50.
Now I was febrile and getting short of breath.
The oxygen level of my blood had decreased to 92%.
I called for the nurse to get the ER physician.
Turned out to be Dr. [? Rugus. ?]
He increased-- good, yes--
thank you, Dr. [? Rugus. ?] He increased the rate of fluids,
ordered a stat CT scan of my chest, abdomen, and pelvis.
After taking cultures of my blood--
good work, cultures first--
he started antibiotics.
The CT scan--
I wouldn't have let him start them
without the blood cultures.
The CT scan showed a new right lower lobe pneumonia,
but was otherwise normal.
And after four liters of fluid, my blood pressure
was unchanged, still dangerously low.
Now I'm sent to the critical care area of the ER
where I meet a new group of physicians.
The resident places a central line
in my right internal jugular vein
and adds a drug called norepinephrine to raise
my blood pressure.
Then I'm sent to the ICU because I'm in septic shock.
So by the time I reach the ICU at 6:00 in the morning,
the ICU staff works to get me situated.
New labs were drawn.
My oxygen saturation is dropping.
And when my labs returned, I asked the nurse
for the results.
My white count was now 2,600, which is below normal.
I remember saying to her, this is not good.
Meaning that my own immune system was being overwhelmed,
not doing a great job in helping to control my infection.
My other labs were not looking good, either.
My breathing was becoming more labored.
I was placed on high flow oxygen.
And I remember saying to my nurse,
I thought I was likely going to be intubated and placed
on a ventilator.
She then said something to me that
has stayed with me to this day.
She said, Allan, I've been watching people breathe
for 27 years, and there's many other things
that we can do first.
I then got placed on BiPAP to help keep my lungs
expanded, really uncomfortable by the way.
Did the trick.
By midday, I'd received 9 liters of normal saline.
My hands were swollen.
Norepinephrine was maintaining my blood pressure,
but could not be stopped.
The Infectious Diseases Service was consulted.
Probably because I'm a Dean.
I must have something much more exotic
than a simple community acquired pneumonia.
They did not make any changes to my antibiotics.
Asked me if that was OK with me.
I said, that sounds like a good plan.
So next day, my white count's about 8,100.
A lot of bands, my platelets are dropping again.
Not good.
The residents were in to see me early each day.
I now had decreased breath sounds and crackles
at the right base on exam of my chest,
clear signs of pneumonia.
Now, as you all know, I'm an educator.
And I suggested that they should check me
for something called egophony.
And what that is, you put your stethoscope
over an area the lung where there's pneumonia.
And you ask the patient to say "ee".
And what the physician hears is a loud "A" sound
through the stethoscope.
So I then proceeded to tell them how egophony was discovered.
How did anyone ever figure out when you put a stethoscope
on the chest over an area pneumonia,
why do you ask the patient to say "ee"?
So whenever questions of this source
comes up in the history of medicine,
there are three major requirements.
A British missionary, a far flung land,
and lots of serendipity.
So in this case, there was a British missionary
named Shibley, who in the 1920s was practicing
missionary medicine in China.
So part of his job consisted of auscultating
the chests of patients while they were saying 1, 2, 3.
And since the patients were Chinese,
the Mandarin dialect for the number 1
was pronounced "ee" in a province
where Shibley was working at that time.
So the "ee" turned into an "A" whenever there was pneumonia.
So the residents listened.
Nobody ever checked me for egophony.
And they were probably just thinking
about all the other sick patients they needed to see
and were ready to move on.
During my time in the ICU, many people
started coming to see me.
And I was very happy when they all stopped by.
It certainly was hard to rest.
The weekend was over.
My new attending physician said no one except family
and my care team was now going to be allowed to come by.
I needed to rest.
A sign was placed on my door.
No visitors except family.
Sleeping at night was very difficult.
ICU bed was very uncomfortable.
I don't like to take medications,
but the resident convinced me to take some zolpidem, which
is Ambien, at night.
And I was sleeping so badly, I asked him
for the hallucinogenic dose.
Over the next several days.
I started feeling better.
The team was able to get me off BiPAP, wean off
the norepinephrine.
After a week in the ICU, I was transferred
to the general medicine unit to complete my antibiotics.
Now a new resident saw me, did her own history.
She asked me about drug use and sexual activity.
But she had been one of our Brown Medical students.
She knows I would not have liked it if she were not complete.
And over the next few days, I began ambulating more.
I was able to maintain my oxygen saturation
without supplemental oxygen. I was
going to get out of the hospital as quickly as I could.
The ideology of my pneumonia and septic shock wee
actually never determined.
However, I'm sure I had pneumococcal sepsis,
a classic presentation.
So now here comes the reflection part.
I'm going to give you a few, five to be exact.
First, getting back to the electronic health record.
The hospital chart is not always accurate.
So of course, I looked at my chart again.
Seemed to be a few inaccurate dates that got carried over.
Seemed to be some copying and pasting.
Even in later notes from a week after my admission,
some notes indicated that already completed tests
were still pending.
Or the note from the dietician that I
had a cholecystectomy in 1999.
As far as I know, I still have my gallbladder.
I did, though, I had a vasectomy in 1999.
Well, they're both ectomies, right?
Close enough.
[LAUGHTER]
However, on a positive note, in almost every description of me,
I was described as a pleasant, 62-year-old gentleman.
And that made me happy.
And I think that was accurate.
So the message to all of you is to be accurate in completing
the health record.
And rely on information that you personally
take from the patient.
Second-- and with all due respect to everyone else,
and of course acknowledging that the approach
to a patient's care is a team effort--
the nurses are the most important people
in the hospital.
They spent the most time with me,
gave me great care, especially in the ICU.
The nurses are the heart and soul of any hospital.
And in addition to spending the most time with me,
they ensured that through this difficult experience,
I was able to maintain my dignity when everything
about being in the hospital involves
others taking care of your every need and a loss of dignity.
And you're going to learn a lot from the nurses
and other members of the health care team.
Ask them what they think and benefit from their knowledge
and expertise.
Third, is that recovery from a serious illness
takes a long time.
So a friend of mine is Head of Critical Care at the National
Institutes of Health.
And he sent me a note during my hospitalization.
And he made several important points.
The first was that physical rehabilitation
is a lot harder than it appears in terms
of returning to the original state of activity.
And to be honest, I did not think
it would take months to feel better.
But he was right.
I should have known this, because even
for minor activities in the ICU, I needed assistance.
I needed help setting up in bed and two people
to pull me up in bed.
And for weeks, almost doing all activities
was a strain and quite stressful.
His second point was that cognitive abilities take
weeks or months to recover.
I didn't initially believe that either, because I was awake
and alert throughout my hospitalization,
although most certainly had periods
of hypertension and hypoxemia.
I would say that I was not back to normal for about three
to four months.
Fortunately, because I'm a dean, I
have a job that does not require intact cognition.
[APPLAUSE]
Right, Dean Elias?
OK.
Yes.
(CHUCKLES) Perhaps, I was even better at my job.
Of course, I decided not to do any patient care
until I was ready.
Wound up not doing my inpatient time that
was scheduled in June.
Fourth, I want to talk about impact on others.
So this was my major concern during my hospitalization
and relates to my wife's illness.
So about 15 years earlier, she was
diagnosed with a disease called Idiopathic Cerebellar
Degeneration, which has progressed over the years,
leaving her wheelchair dependent.
On top of that, she has had multiple strokes
over the prior three years, which have
made the situation even worse.
In fact, before my illness, she had spent a week
in the hospital then eight weeks in rehab
after her fourth stroke.
And I'm her primary caregiver and need
to spend my first day in the ICU arranging
for extended home care for her.
And that experience, I think, helped
me to understand how hospitalizations can disrupt
people's lives to a greater extent
than I had previously imagined.
And my wife, not my health, was my major concern.
And I was worried what might happen
to her if I did not survive.
It really put things into important perspective for me.
Finally, were there any positive aspects to all of this?
One was that I was overweight.
I wound up losing about 15 pounds.
It was really embarrassing to look at my chart
and see that my body mass index was elevated,
and it was in red numbers followed by an exclamation
point.
[LAUGHTER]
The other positive aspect relates to my family.
As you can imagine, my two major illnesses
have had a significant impact on them, but also
in some positive ways.
Our family has always been very close.
Excuse me.
But in many ways my illnesses have enhanced our relationships
and enriched our lives.
So I'm truly fortunate in this regard.
We cannot always say the same for many others whose lives
have been devastated, who do not have the emotional support they
need in order to recover.
Unfortunately, throughout your careers,
you'll see many patients who do not have the support.
And you need to expand the effort
to help them through these life altering events.
So this is my main message to you
as you move forward in your careers.
Enhance the lives of your patients.
This may happen at bench, the bedside, in the community,
or through advocacy, or maybe through all of these and more.
Your patients will be the batter for it.
Well, that's all I have to say, and hope
this summary of my experiences and reflections were useful.
Remember, I will always think of each of you
as one of my students, no matter where life takes you.
My best to everyone.
Thank you.
[APPLAUSE]