PERSPECTIVE FLUENZA A(H7N9)AND DIGITAL EPIDEMIOLOGY (MERS-CoV) infections illustrate derstanding of emerging public diatrics, Harvard Medical School O.S.B the strengths of digital disease health threats all in Boston surveillance. In the case of H7N9, Health officials are aware of This article was published on July 3, 2013, at such surveillance has enhanced the catastrophic potential of pan- NEJM. org transparency and helped public demics. The potential for wide health officials to understand the spread infections with MERS-CoV 1 Uyeki TM, Cox N). Global concerns re outbreak more fully. Although in- outside of Saudi Arabia and the formation was sparse in the potential reemergence of H7N9 2. Xu C, Havers F,Wang L,et al.Monitorin MERS-CoV outbreak, digital dis- during next year's influenza sea- avian influenza A(H7N9)virus through na. ease surveillance proved its use- son demand that digital disease tional influenza-like illness surveillance, Chi- a. Atlanta: Centers for Disease Control and fulness: the initial MERS-Cov case surveillance be a part of the re- reports came to light through sponse eid/article/19/8/13-0662_article. htm) Promed-mAil(wwW.pRomedmail Disclosure forms provided 3. Brownstein JS, Freifeld org/direct. php? id=20120920 thors are available with the full text of this Web for public health surveillance.N Engl 1302733). Since the SARs out Med2009;360:2153 break the world has seen substan- 4. Chan EH, Brewer TE, Madoff LC, et a om the Center for Infectious Disease Dy. Global capacity for emerging infectious dis. tial progress in transparency and amics, Department of Biology, Pennsylva. ease detection. Proc Natl Acad Sci U S rapid reporting. The extent of nia State University, University Park (M.S. 2010: 107: 21701 these advancements varies but and the Informatics Program, Boston Chil. 5. Salathe M, Khandelwal S. Assessing vac- dren's Hospital (C.C. F, S.R. overall, digital disease surveillance dia: implications for infectious disease dy is providing the global health neering, Boston University College of Engi- namics and control. PLos Comput Biol g(CC F), the Department of Et 2011;7(10)e1002199 community with tools supporting miology, Boston University School of Public Dol: 10.1056/NEJMpl307752 faster response and deeper un- Health(SR. M ) and the Department of Pe. Copyright o 2013 Massachusetts Medical Society BECOMING A P Mourning on Morning rounds Mounica Vallurupalli, B. S he team started rounds with Ms. L. He believed that she had do-not-intubate(DNR-Dnd order Ms. L, a new patient admit- an infection and had started in- which limited what we could do ted the previous night. Her can- travenous fluids and antibiotics to get her back. The nurse ran cer wasn't responding to treat- overnight. An infectious-disease out of the room to call Ms. L's ment, and she knew she had only specialist was consulted, and nu- family. Her daughter and husband months to live. Just a few days merous tests had been ordered to were on the way They confirmed earlier, she had started having try to arrive at a diagnosis. There that she wouldn,'t want any ex- foul-smelling diarrhea, and last was nothing more that we could treme measures taken to save her. night she began to have trouble do now, but a care plan was in Her heart rate and blood pres- hing ominous signs for place sure picked up after atropine and someone as sick and immunocom- As we started to move on, epinephrine were administered, promised as she was. When she alarms went off. Ms L,'s hand fell but she was still unconscious and finally came to the hospital, she limp, her oxygen mask slid off her having trouble breathing. After she was gaunt and severely dehydrated. face, and she slumped down into stabilized, the team reconvened, Standing outside her door, I saw the bed. Her abdomen stopped just as we did after seeing any oth- her wispy frame struggling to moving. As the alarms continued er patient, and we continued our breathe, and even with an oxygen to sound, her heart rate sank and rounds. But as the team moved on mask, her abdomen was bulging her oxygen saturation began drop- to the next patient, I kept looking outward like a bellows in an at- ping. Her attending physician back to Ms L's room. Her family tempt to quench her thirst for air. raced into the room, and soon the had been called, but when would The on-call intern presented rest of the team surrounded her they arrive? Would she still be his assessment and care plan for bed. She had a do-not-resuscitate- alive? In the past few moments, I N ENGL J MED 369: 5 NEJM.ORG AUGUST 1, 2013
PERSPECTIVE 404 n engl j med 369;5 nejm.org august 1, 2013 (MERS-CoV) infections illustrate the strengths of digital disease surveillance. In the case of H7N9, such surveillance has enhanced transparency and helped public health officials to understand the outbreak more fully. Although information was sparse in the MERS-CoV outbreak, digital disease surveillance proved its usefulness: the initial MERS-CoV case reports came to light through ProMED-mail (www.promedmail .org/direct.php?id=20120920 .1302733). Since the SARS outbreak, the world has seen substantial progress in transparency and rapid reporting. The extent of these advancements varies, but overall, digital disease surveillance is providing the global health community with tools supporting faster response and deeper understanding of emerging public health threats. Health officials are aware of the catastrophic potential of pandemics. The potential for widespread infections with MERS-CoV outside of Saudi Arabia and the potential reemergence of H7N9 during next year’s influenza season demand that digital disease surveillance be a part of the response. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. From the Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park (M.S.); and the Informatics Program, Boston Children’s Hospital (C.C.F., S.R.M., A.F.T., J.S.B.), the Department of Biomedical Engineering, Boston University College of Engineering (C.C.F.), the Department of Epidemiology, Boston University School of Public Health (S.R.M.), and the Department of Pediatrics, Harvard Medical School (J.S.B.) — all in Boston. This article was published on July 3, 2013, at NEJM.org. 1. Uyeki TM, Cox NJ. Global concerns regarding novel influenza A (H7N9) virus infections. N Engl J Med 2013;368:1862-4. 2. Xu C, Havers F, Wang L, et al. Monitoring avian influenza A(H7N9) virus through national influenza-like illness surveillance, China. Atlanta: Centers for Disease Control and Prevention, 2013 (http://wwwnc.cdc.gov/ eid/article/19/8/13-0662_article.htm). 3. Brownstein JS, Freifeld CC, Madoff LC. Digital disease detection — harnessing the Web for public health surveillance. N Engl J Med 2009;360:2153-7. 4. Chan EH, Brewer TF, Madoff LC, et al. Global capacity for emerging infectious disease detection. Proc Natl Acad Sci U S A 2010;107:21701-6. 5. Salathé M, Khandelwal S. Assessing vaccination sentiments with online social media: implications for infectious disease dynamics and control. PLoS Comput Biol 2011;7(10):e1002199. DOI: 10.1056/NEJMp1307752 Copyright © 2013 Massachusetts Medical Society. Influenza A (H7N9) and Digital Epidemiology becoming a physician Mourning on Morning Rounds Mounica Vallurupalli, B.S. The team started rounds with Ms. L., a new patient admitted the previous night. Her cancer wasn’t responding to treatment, and she knew she had only months to live. Just a few days earlier, she had started having foul-smelling diarrhea, and last night she began to have trouble breathing — ominous signs for someone as sick and immunocompromised as she was. When she finally came to the hospital, she was gaunt and severely dehydrated. Standing outside her door, I saw her wispy frame struggling to breathe, and even with an oxygen mask, her abdomen was bulging outward like a bellows in an attempt to quench her thirst for air. The on-call intern presented his assessment and care plan for Ms. L. He believed that she had an infection and had started intravenous fluids and antibiotics overnight. An infectious-disease specialist was consulted, and numerous tests had been ordered to try to arrive at a diagnosis. There was nothing more that we could do now, but a care plan was in place. As we started to move on, alarms went off. Ms. L.’s hand fell limp, her oxygen mask slid off her face, and she slumped down into the bed. Her abdomen stopped moving. As the alarms continued to sound, her heart rate sank and her oxygen saturation began dropping. Her attending physician raced into the room, and soon the rest of the team surrounded her bed. She had a do-not-resuscitate– do-not-intubate (DNR–DNI) order, which limited what we could do to get her back. The nurse ran out of the room to call Ms. L.’s family. Her daughter and husband were on the way. They confirmed that she wouldn’t want any extreme measures taken to save her. Her heart rate and blood pressure picked up after atropine and epinephrine were administered, but she was still unconscious and having trouble breathing. After she stabilized, the team reconvened, just as we did after seeing any other patient, and we continued our rounds. But as the team moved on to the next patient, I kept looking back to Ms. L.’s room. Her family had been called, but when would they arrive? Would she still be alive? In the past few moments, I
PERSPECTIVE had witnessed a life flickering like been only peripherally involved idents cope with dying patients. 1 a candle in the wind. Had Ms. L. in her case, I also felt a sense of Meeting once every few weeks, ever dreamt that it would end failure. Medically, there was noth- residents have the opportunity to this way? Had she ever imagined ing more we could have done, discuss the emotional impact of that her last moments would be but we had failed to recognize and insights gained from the spent in an ICU among stran- Ms. L 's spirit, her individuality. deaths of their patients. This gers? Or that her death would We had failed to see who she program provides residents with come so swiftly, after months of was in life, and in her final mo- emotional support, closure, and suffering? ments she was alone In the wake communication skills for end-of- Ms. L was virtually alone, even of her death, the intern and I also life care that may help them to though, just feet from her door, suffered alone, grasping for some better empathize with and care for the floor was full of nurses and sort of emotional closure, for critically ill patients in the future. doctors discussing the plans for some sort of meaning in what we As physicians-in-training, we other sick patients. I was partici- did not fully understand learn how to save lives. We learn ating in rounds but all i want- This phenomenon of sadness, about how affects the ed to do was to be by her side, guilt, and a sense of personal body at the fundamental holding her hand, giving her sol- failure at the loss of a patient is a molecular leve most f ace as she died Minutes later, we common form of maladaptive deemphasizes the ways in which got the news. She was gone. And coping, particularly among train- illness and suffering affect others that was it. As one of the doctors ees. 1-3 These feelings are usually -and the ways they affect us stepped aside to dictate her death experienced in isolation, without we care for patients and experi- note, rounds went on. There was guidance from or discussion with ence loss. This omission is par- a spontaneous moment of silence, more senior physicians or col- ticularly unfortunate because our during which we all tried to avoid leagues who might be able to understanding of suffering is so eye contact, looking solemnly at help trainees cope. 2 Losses are fundamental to the quality of the the ground. But nothing more frequent in the iCu, but the work care that we give. Although our was said or done to mark her pace is fast and there's always work continues and rounds go on, much more to be done and many I believe we must find ways to me- Some would say that this pa- more sick patients to care for. moralize the connection between tient's death was peaceful. No Rounds must go on- there isn't patient and doctor in death as in full-code protocol was time to pause for reflection. In life. Medicine is both a science mented. No one bega these circumstances how can one and a human art and when sci- which would have most aly deal with losses of this magni- ence fails answer resulted in several cracked ribs. tude without becoming callous tions, we need the correct tools in We did not intubate her or place and detached? Perhaps that is the order to find meaning elsewhere her on a ventilator, which would inevitable outcome when the loss- -and to mourn only have resulted in a prolonged, es become too commonplace to Disclosure forms uncomfortable death. Yet we have meaning. Yet from the earli- are available with the full text of this arti- failed to acknowledge her pass- est prehistoric funerary practices ce a NEm.org ing, and in doing so we dehu- of hunter-gatherers, such as those From Harvard Medical School, Boston manized her. Some of us were depicted in the caves of La Cha- 1. Khot s, Billings M, Owens D, Longstreth silently suffering from our own pelle-aux-Saints, we have sought WT Jr Coping with death and dying on a neu to find meaning in death through rology inpatient service: death rounds as an The next day, I saw how much memorialization and ritual. It runs Neurol 2011-68-1395.7 Ms. L's death had affected the in- counter to our nature to deny 2. Jackson VA, Sullivan AM, Gadmer NM tern. During a quiet moment after this impulse rounds, he told me how guilty he Finding the time and opportu- deaths Acad Med 2005: 80-648.56 felt- he was second-guessing nity for reflection is challenging. 3. Hough CL, Hudson LD, Salud A, Lahey T, his decisions, the types of fluids One possible solution is the "death sorts R neate ica ds: dents tn the istes he had given, the antibiotics he rounds"that have been held at sive care unit j Crit Care 2005, 20: 20-5 should have chosen. I understood the University of Washington since Dot: 10.1056/NEJMp1300969 his feelings and, despite having 2000 that are designed to help res- Copyright o 2013 Massachusetts Medical Society. N ENGL J MED 369: 5 NEJM.ORG AUGUST 1, 2013
n engl j med 369;5 nejm.org august 1, 2013 PERSPECTIVE 405 had witnessed a life flickering like a candle in the wind. Had Ms. L. ever dreamt that it would end this way? Had she ever imagined that her last moments would be spent in an ICU among strangers? Or that her death would come so swiftly, after months of suffering? Ms. L. was virtually alone, even though, just feet from her door, the floor was full of nurses and doctors discussing the plans for other sick patients. I was participating in rounds, but all I wanted to do was to be by her side, holding her hand, giving her solace as she died. Minutes later, we got the news. She was gone. And that was it. As one of the doctors stepped aside to dictate her death note, rounds went on. There was a spontaneous moment of silence, during which we all tried to avoid eye contact, looking solemnly at the ground. But nothing more was said or done to mark her passing. Some would say that this patient’s death was peaceful. No full-code protocol was implemented. No one began CPR, which would have most certainly resulted in several cracked ribs. We did not intubate her or place her on a ventilator, which would only have resulted in a prolonged, uncomfortable death. Yet we failed to acknowledge her passing, and in doing so we dehumanized her. Some of us were silently suffering from our own detachment. The next day, I saw how much Ms. L.’s death had affected the intern. During a quiet moment after rounds, he told me how guilty he felt — he was second-guessing his decisions, the types of fluids he had given, the antibiotics he should have chosen. I understood his feelings and, despite having been only peripherally involved in her case, I also felt a sense of failure. Medically, there was nothing more we could have done, but we had failed to recognize Ms. L.’s spirit, her individuality. We had failed to see who she was in life, and in her final moments she was alone. In the wake of her death, the intern and I also suffered alone, grasping for some sort of emotional closure, for some sort of meaning in what we did not fully understand. This phenomenon of sadness, guilt, and a sense of personal failure at the loss of a patient is a common form of maladaptive coping, particularly among trainees.1-3 These feelings are usually experienced in isolation, without guidance from or discussion with more senior physicians or colleagues who might be able to help trainees cope.2 Losses are frequent in the ICU, but the work pace is fast and there’s always much more to be done and many more sick patients to care for. Rounds must go on — there isn’t time to pause for reflection. In these circumstances, how can one deal with losses of this magnitude without becoming callous and detached? Perhaps that is the inevitable outcome when the losses become too commonplace to have meaning. Yet from the earliest prehistoric funerary practices of hunter-gatherers, such as those depicted in the caves of La Chapelle-aux-Saints, we have sought to find meaning in death through memorialization and ritual. It runs counter to our nature to deny this impulse. Finding the time and opportunity for reflection is challenging. One possible solution is the “death rounds” that have been held at the University of Washington since 2000 that are designed to help residents cope with dying patients.1 Meeting once every few weeks, residents have the opportunity to discuss the emotional impact of and insights gained from the deaths of their patients. This program provides residents with emotional support, closure, and communication skills for end-oflife care that may help them to better empathize with and care for critically ill patients in the future. As physicians-in-training, we learn how to save lives. We learn about how disease affects the body at the most fundamental molecular level, yet our training deemphasizes the ways in which illness and suffering affect others — and the ways they affect us as we care for patients and experience loss. This omission is particularly unfortunate because our understanding of suffering is so fundamental to the quality of the care that we give. Although our work continues and rounds go on, I believe we must find ways to memorialize the connection between patient and doctor in death as in life. Medicine is both a science and a human art, and when science fails to answer our questions, we need the correct tools in order to find meaning elsewhere — and to mourn. Disclosure forms provided by the author are available with the full text of this article at NEJM.org. From Harvard Medical School, Boston. 1. Khot S, Billings M, Owens D, Longstreth WT Jr. Coping with death and dying on a neurology inpatient service: death rounds as an educational initiative for residents. Arch Neurol 2011;68:1395-7. 2. Jackson VA, Sullivan AM, Gadmer NM, et al. “It was haunting . . .”: physicians’ descriptions of emotionally powerful patient deaths. Acad Med 2005;80:648-56. 3. Hough CL, Hudson LD, Salud A, Lahey T, Curtis JR. Death rounds: end-of-life discussions among medical residents in the intensive care unit. J Crit Care 2005;20:20-5. DOI: 10.1056/NEJMp1300969 Copyright © 2013 Massachusetts Medical Society. Mourning on Morning Rounds