I’m Back! Reflections on My Detour

Cross-posted at Education Week.

Some of you may have noticed that I stopped blogging two months ago.  I fell off a bike on a small island in the Bahamas, did a lot of damage to my spine and spent the next five weeks in two hospitals.  But, notwithstanding the damage, I was very lucky in many ways.

First, I flew off my bike in front of the home of a doctor who realized right away that I had damaged my neck.  He ran over to the scene of the accident and protected my neck before anyone else in the gathering crowd had a chance to break it, as I was moved off the roadway.  Second, the doctor called the fire and rescue squad and told them to bring a neck brace and board for my back.

Then my wife had the wit to find a Level One Trauma hospital on the Florida coast—Broward County Medical Center—to fly me to by air ambulance.  When I left the islands on that plane, I couldn’t feel much of anything in my arms or legs. Trauma was a good clinical description of my condition.  Most of my systems had shut down.

When the neurosurgeon had taken all of his pictures, he said something I will never forget.  “If you had walked into my office with these pictures and had never had this accident, I would have told you just what I am telling you now; you need to have the operation I am recommending and you need to have it tomorrow.”  He was telling me that I had been an accident waiting to happen.  The vertebrae in my neck had been in severe misalignment for some time.  They were full of calcium deposits from rampant arthritis, which had, among other things, been filling up the holes in the vertebrae through which my spinal cord was supposed to be slithering.  If the thing had fallen apart when I was out in my boat or speeding down the interstate, I might not have been the only one dead.

After a week in intensive care and another in recovery in the Florida hospital, we headed for the Spaulding Rehabilitation Hospital in Boston, one of the best in the country.  I worked very hard there, but, if it were not for what turned out to be one of the most competently staffed and managed organizations I have ever encountered, I would not be writing this blog today.  I was wheeled in on a stretcher unable to walk, feed myself, or even scratch an itch.  Three weeks later, I walked out without a wheelchair, walker or cane.  My doctor told me that few people who have had the kind of damage to their spinal cord I had recover as much of their function as I did.  For that, I am deeply grateful to my wife, the doctor who saw me crash, the Hopetown Fire and Rescue team, the trauma team at the Florida hospital, the whole crowd at Spaulding and the family, friends and co-workers who provided endless support.  Yes, I am very lucky.

And therein lies the reason I am telling you all this. The five weeks I spent in the hospital gave me an unparalleled opportunity to see the medical trauma system in action: how it is structured, staffed and managed.  I had a chance to talk to dozens of professionals in this system about their work, their careers, their training, their credentials, their hopes and their ambitions.  In this medical story, there are important lessons for public education.

When I pitched off the bike, I damaged the nerves that control the body’s core, everything from the bottom of the neck to below my hips: that’s heart and circulatory system, the plumbing system, musculature and so on.  It is as if someone had taken a sledge hammer to my control system for many of my most important functions.  In such a situation, it is critical that a quick and accurate assessment be made of all these systems, priorities be established, a plan be formulated and constantly adjusted in light of the body’s response to the treatment it receives.  The price of a wrong diagnosis, the wrong meds or the wrong quantity of meds, to say nothing of a slip of the knife, can be death.  Get one part of it wrong, and the patient may live, but in a very restricted life, with one or more functions working poorly or not at all.

Trauma hospitals are places that deal with patients who arrive in the condition I just described, presenting systemic injuries that require immediate medical attention to save life and limb.  Physical trauma can involve external injuries, internal injuries or both.  But the National Institutes of Health also recognize various forms of psychological trauma.  Both forms of trauma can cause Post-Traumatic Stress Syndrome, a condition most famously found in war veterans, but, a point I will turn to in a moment, more recently found in children and youth in our inner cities who grow up in circumstances producing trauma no less serious in its consequences than those induced by war.

I was fascinated by the way the Florida Level One Trauma hospital—the Broward County Medical Center—was organized for its core function.  At the top of my team was a group of three trauma doctors.  Trauma is their medical specialty.  Reporting to them are the doctors who specialize in the various systems that might be compromised.  In my case those specialists included my neurosurgeon, my urologists, my cardio specialist and so on.  This team did rounds every day, but not with the patients.  Those of us in intensive care were surrounded by machines, many of them taking over vital functions that we would normally have performed for ourselves, that produced mountains of data from the myriad sensors connected directly to our bodies for continuous readout as well as the measurements taken, or so it seemed, every few minutes by the nurses and nurses’ aides, who then put that data into voluminous reports for the medical doctors to review.

The nurses played the key role in translating the doctor’s diagnoses and agreements on treatment into reality, in real time.  It was up to them not just to follow the literal meaning of their written instructions, but also to understand the reasoning behind the agreements to which the physicians had come, so they could cope with the unexpected and do the sensible thing when something just wasn’t right.

This sounds unremarkable and very straightforward.  But that is not the case at all.  Each of our systems—the circulatory system, for example, or the nervous system—is an extremely complex system in its own right. But the interactions among these systems are constant and no less complex.  We are a system of constantly interacting subsystems.  Imagine now that all or most of these systems are compromised, some of them within an ace of shutting down altogether.  A medication that might greatly improve the functioning of one system might actually shut down another.

But these relationships might change over time.  A few days after the neurosurgeon operated on my neck, the nurse told us that the neurosurgeon had said that I was under no circumstances to be given any blood thinners.  Imagine our alarm, three days later, when I was still in intensive care, we were told by a new nurse that he was about to give me blood thinners!  We told him what the neurosurgeon had said.  The nurse sat down and told us that, in the days immediately following the surgery, the neck is still bleeding from that surgery.  Thinning that blood could easily cause me to drown in my own blood.  But after a few days have passed, the neck begins to heal, the danger of drowning in my own blood recedes, and the greater danger is from the formation of blood clots.

Now you can see why the trauma doctors run the show.  It is their responsibility to put all the pieces together, to make sure the cure offered by one doctor is not also a likely cause of death from another quarter.

I rarely saw the doctors.  It was the nursing corps that took care of me around the clock.  The depth of their knowledge, their professional elan and the pride they took in their work made a deep impression on me.  I had substantial conversations with five of them over the two weeks I was there. All had at least three years of specialized training in nursing.  Of the five, three had mothers who were teachers, every one of whom had told them not to go into school teaching.  Though they were making more money than Florida school teachers, it was not a lot more and it did not seem to be the money that accounted for their career choice.  All had plans to get additional certificates that would qualify them for particular nursing specialties that would confer more compensation and higher status.  They seemed to feel that they had signed up for a real career that offered much more status than school teaching.  Nursing clearly felt like a real profession to them. All of them were aware that nurses were, step by step, taking on many responsibilities formerly held exclusively by medical doctors. The pride was palpable, as was the sense of challenge in getting additional certificates that signified important competencies that were not easy to acquire.  Several of them, when I asked about their choice of career, said something about how much they had liked math and science in school and let me know that they could not have gotten as far as they had in nursing without a strong background in mathematics, biology and chemistry.  Throughout these conversations, I could not help but think about the contrast with teaching on almost every point.  Little wonder that their mothers had encouraged them to go into nursing instead of teaching.

But I digress.  As soon as I arrived at Spaulding Rehabilitation Hospital in Boston, a whole day was spent doing a very detailed assessment of my condition along many different dimensions using a whole series of standard protocols. That was followed by an interview in which I was asked what I hoped to achieve while at Spaulding.  There are two top rehabilitation centers in the United States.  The other one, on its website, says it will do its best to help you live with the disability you have when you leave.  Spaulding’s website says it will devote itself to helping you get as much function back as possible.  Its motto is “find your strength.”  And they mean it.  The purpose of the interview is not just to find out what you are hoping for, but to enlist you in your own recovery.  I could not help but think about the difference these two approaches signify in terms of the expectations both of the caregivers and their patients and the parallel in public schooling.

The intense emphasis on teaming at the Broward County Medical Center was mirrored by what I found at the Spaulding Rehabilitation Hospital.  Each floor at Spaulding was for patients with a particular challenge.  I was on the floor for spinal column injuries.  There were on the order of 20 patients on the floor.  We had one full time doctor whose specialty is spinal column injuries.  I had an occupational therapist, a physical therapist and a speech therapist.  My occupational therapist and my physical therapist each had a clinical doctorate, as required by state law.  The occupational therapist and physical therapist operated as a very close-knit team, providing, at a minimum, three hours of therapy every day, in addition to the myriad other services I was getting.  Every week, the group responsible for me and a small number of other patients met for two hours to pool everything they knew about their charges.

The effect of the teaming at Spaulding is incalculable.  All the professionals were familiar with my challenges, my plan and my progress.  They were all on board all the time and ready to respond to the inevitable twists and turns in the road.  They never missed a beat.

The bottom line?  Do you remember the inner-city kids I described above as victims of clinical trauma?  Imagine for a moment that our states and districts had a way to identify students living in concentrated poverty and the schools they attend.  Imagine further that the state or city could assemble teams of specialists with the kind of training and the level of competence I have described with case management systems just as effective.  Imagine that they were organized as well as the teams at the Broward County Medical Center and the Spaulding Rehabilitation Hospital, with staffs who have had comparable training and as much time to work with one another and one on one with their charges.

The specialties would, of course, be different.  The head of each trauma team would need to be able to call on specialists who could treat possible brain damage, others who could deal with the psychological consequences of the kinds of trauma these young people had experienced, others who could deal with a range of cognitive issues and still others who could bring the resources of the housing authority or the juvenile justice system or social services system to bear, but the intensive, comprehensive, highly integrated approach, drawing directly on a suitably diverse team of highly trained experts working in close collaboration, would be very similar.

I submit to you that the students I am talking about are no less traumatized, clinically speaking, than many of the patients in these hospitals.  They are no less in need.  The care they are given is inadequate, before they are sent into a school system that is in no position to offer them anything like the level of care they need to succeed.  Is it any wonder that so many fail?

Would it be expensive to treat these children as I was treated?  Of course.  But consider for a moment the cost of special education in the United States. There is every reason to believe that, if many of these severely wounded children could get services comparable in their way to what I received, the United States could greatly lower the costs of special education.  But far more important than saving the money would be saving the children.  Wouldn’t that be a fine day?