Dr Blair Schwartz : On listening to your grandmother

(21-04-2024)

Long before The Last Ambulance there was Big Medicine. One of our contributors was Dr. Blair Schwartz. He wrote the following piece in 2012 and I recently asked Blair if he could write a new introduction so that we could re-publish 'On listening to your grandmother' in The Last Ambulance. - HN

Dr. Blair Schwartz is an Associate Professor of Medicine and attending critical care medicine physician at the Jewish General Hospital. He received his medical degree from McGill University in 2006, and continued at McGill to complete residency and fellowship training in General Internal Medicine and Critical Care Medicine. Thereafter, in 2013, he completed a Master of Health Sciences degree in the Graduate Training Program in Clinical Investigation at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland where his training focused on Patient Safety and Quality Improvement methodology.

Since joining the intensive care division in 2013, his clinical interests have included in-hospital resuscitation practices, palliative care in the ICU and Medical Aid in Dying, in addition to a general Critical Care practice. He is the medical lead for the in-hospital resuscitation team and Chair of the Internal Medicine Morbidity & Mortality Committee, both at the Jewish General Hospital. His research focuses largely on interventions and protocols to improve the safe delivery of care to hospitalized patients, with a particular interest in medication related adverse events.

Dr. Schwartz is regularly involved in teaching medical students, residents and fellows on a variety of critical care topics, both at McGill University and at the Jewish General Hospital, and has an interest in leveraging technological means to deliver didactic materials in a non-traditional format.

2024 Introduction

It has been 12 years since I wrote this piece.

Facing life and death daily in the ICU, the importance of knowing about patients, their values and their wishes remains as important to my clinical care, as smoothly cannulating a patient for ECMO (Extra Corporeal Membrane Oxygenation).

This piece today hits even closer to home when I recall my personal experience with the importance of always listening to your bubby (yiddish word for grandmother).

I was out of town with my family in a region with no cell phone reception, when I got an urgent email from my chief; “Blair, your bubby is in emergency with an intracerebral bleed, call me NOW!”

I immediately jumped in my car and started the 20-minute drive to where I knew my phone would work. As an intensivist, I knew what the management of this bleed would involve and the outcome.

On my drive, my mind drifted back to a recent conversation I had with my bubby. We were sitting in her kitchen, eating cinnamon twist cookies (that I did not have the heart to refuse) and drinking instant coffee (that my espresso snob palate, refrained from commenting on). A friend of hers had recently suffered a stroke and she had visited her; she shared with me her feelings on seeing her friend with such deficits, a shadow of her former self and looked me in the eyes and said, “That’s not what I want.”

When the first bar lit up on my phone, I called the hospital for an update. She was awake but somnolent. My amazing hospital family, upon hearing she was my bubby, had called our neurosurgeon and intensive care team to rally into action in a desperate fight to save her life.

I thanked my colleagues for their diligence and compassion, and together with the rest of my family, shared my Bubby’s wishes with the team. We instead opted to focus on keeping her comfortable and she had a beautiful death on palliative care, consistent with her wishes.

Speak to your patients, their family, their friends, and your own loved ones.

Learn what their values are as it comes to severe illness and injury.

And now, as always, listen to your grandma.

The original 2012 piece : On listening to your grandmother

As a fairly new attending physician, I’ve taken to the habit of asking some of my more senior colleagues for tidbits they wished they had known when starting out. One wise practitioner told me, to never forget to practice some “grandmother medicine”.

Having grown up in a traditional Jewish family, my mind instantly darted to the miraculous curative powers of homemade Chicken Soup and the admonition to put on my scarf lest I catch a cold. While the medicinal properties of Chicken Soup are undeniable even in the absence of a randomized control trial, this wasn’t quite what my colleague was referring to.

He was talking about Bubbemycin.

While Bubbemycin sounds like something you take an injection of to treat the clap, its role in treating patients is irrefutable. The colloquial translation of this Yiddish expression refers to tall tales, but literally means grandmother stories, and it is from this definition that I’ll operate.

My colleague was referring to the kind of information your grandmother garnered when you brought a friend to meet her: How did you meet him? What does she do for a living? Who are his parents? What does he enjoying doing in his free time?… also referred to as “getting to know someone inquisition style”.

In healthcare we all too often focus on disease. We focus on its pathophysiology, what our protocol tells us to do in response, or resuscitating to specific goals. Attaining clinical stability, or a semblance thereof is a primordial goal. However, when time allows, it is only by getting to truly know the person with the disease that you can ever hope to truly treat them.

I remember as a young paramedic working in Montreal’s infamous Ice Storm being flummoxed by the undue resistance and at times abject fear I faced as I made the rounds to evacuate seniors from their now heat-free apartments. I failed to appreciate that asking someone for their ID number (Medicare) and hurrying them to a waiting bus, might have a different interpretation for a Holocaust Survivor…. lesson learned.

As a junior ICU Fellow I had received a patient in transfer for shock of unknown etiology from a peripheral hospital. The young patient was known to our center’s transplant clinic and came by ambulance surrounded by her husband and children. Like a good intensivist I promptly began appropriate resuscitation and began my workup, ultimately culminating in a diagnosis of extensive Necrotizing Fasciitis (aka Flesh Eating Disease). I rallied the troops, called the surgeon and prepared to go to war with this newly discovered enemy. The extent of her disease meant she was likely to lose her entire leg up to the pelvis. I went to explain my diagnosis and plan to the family.

After presenting my case, her family started telling me about the woman who lay intubated in my ICU. She had spent several years on dialysis waiting for her kidney transplant, a process she told her children she found absolutely unbearable. As they began to tell me how she was before she was sick and how miserable she was during times she was dependent on others, I was able to get a perspective for this woman, her nature and her spirit. I was proposing a procedure that had a small chance of saving her life. It would be a life in a wheelchair with a protracted rehab course just to allow her to sit in that chair.

Together, we chose not to treat the disease, because we had taken the time to get to know the patient WITH the disease…

Suffice it to say, grandma is often right.

Now go put on your scarf.

Be well, Practice Big Medicine.

Blair