COMMENTARY

A Paraplegic Doc's Inspiring Comeback After Spinal Injury

Robert Glatter, MD; Daniel B. Grossman, MD, MBA

Disclosures

October 30, 2018

Robert Glatter, MD: Thank you for joining us today. We have an incredible journey and story to tell of Dr Daniel Grossman. He's an emergency physician [at the Mayo Clinic in Rochester, Minnesota] who suffered a devastating spinal cord injury at T7 and T8 in September 2017. He was treated at Mayo Clinic and his care was impeccable. He has since returned to working in the emergency department, and his story should inspire all of us. It's a journey of struggle but also a journey of positivity.

Daniel B. Grossman, MD, MBA: Nice to be here. Thank you.

Glatter: Thanks so much for joining me. It really is quite an honor after speaking with you recently about your experience in the past year. It's been a tumultuous year, I'm sure. I really appreciate your willingness to share that in front of us here at Medscape.

Can you tell me about that day, when you went out for a bike ride and things drastically changed?

The Unexpected Happened--and the Impulsive Reaction

Grossman: I was in northern Minnesota with my friend Ron. It was Labor Day weekend of 2017. We had just wrapped up a long day of mountain biking. We thought about going up one more hard run and decided not to go. The way out of this particular terrain was called Easy Street. We were on Easy Street and the next thing I remember was winding up on the ground.

Glatter: When you first woke up, what type of sensation did you have? Was it tingling? Was it numbness?

Grossman: It was a band-like sensation around my abdomen. I felt, I think, numbness; a band is the best description. I could feel my bike shorts, but I couldn't tell that they were on. I asked Ron to call my brother, who is a neurologist. I said, "I can't feel my legs." He asked, "Are you moving them?" Ron said, "No, you're not moving your legs." It became clear pretty quickly that this was a dramatic injury.

Glatter: At that point, obviously, with your medical training, things started to go through your head. In order to settle yourself down, at any point were you thinking about how to calm yourself down and just go one step at a time? In other words, using mindfulness techniques. Did that ever enter your thoughts or your psyche?

Grossman: Not at all. I immediately went into emergency medicine [mode], where it's command and control, telling people essentially what to do. I asked Ron to call a series of people, including my friends who are emergency physicians whose hospital I knew I would end up at; my folks back at Mayo Clinic, to tell them I could not work my shift the next day; and my family, to [tell them to] get on an airplane. When the paramedics came, I was honestly directing traffic from that point as well. When they loaded me onto a helicopter, I was asking the nurse to give me specific doses of pain medication.

In reality, my adrenaline kicked in and I was functioning as an emergency physician.

Glatter: When you first got into the emergency department, what were your thoughts and who was the first person you encountered?

Grossman: I knew a bunch of folks who worked in this emergency department. It was a fairly somber mood because everybody knew who I was. The helicopter crew, the physicians, the techs, the nurses—they were either familiar with me or I was familiar with them. One of my closest friends was working at that time, and she specifically didn't take care of me.

Then it's surreal. I think many physicians have probably gone through this—to run through a trauma protocol. To have airway, breathing, and circulation called out. Disability identified. To be rolled on your side. I screamed in pain. They very quickly ascertained that it was a devastating spinal cord injury.

Glatter: Do you remember hearing those words? Did people talk to you and communicate that? You obviously knew from your medical training, but what about the idea of being approached as a patient and not as a physician or healthcare provider?

Grossman: I maintained the whole time that I was a patient and not a provider. They took me back to the CT scanner. I went with another good friend of mine. When we came back from CT, the physicians showed me a coronal, a side view, of my CT scan with the injury. It was pretty clear after that. I announced to the room that my friend was in charge of my medical decision-making and that I abdicated to someone who was not going to be on narcotics to make decisions going forward.

This was Sunday of Labor Day weekend; I came out of surgery on Labor Day. They did a spinal fusion. I spent the next couple of days in the intensive care unit.

Phase One of Recovery

Glatter: Take me through the next several weeks and months, and tell me how your recovery played out—the physical issues, the mental issues, what you were going through.

Grossman: The thing that happens with spinal cord injuries is that your hemodynamics change, your temperature regulation changes, and everything is different. I didn't know anything about any of this because it's just not something that we, as emergency physicians, really know the nuances of.

You don't deal with hot and cold the same. You're in spinal shock for the first few days. I was actually hypotensive, and every time I would try to sit up or they would sit me up for physical therapy, my blood pressure would drop and I would essentially syncopize. That is a really bizarre experience—to know that you are about to have syncope. I was able to have enough wherewithal to know the phases of when my blood pressure was dropping and what was happening to give warning to the team. There were days when the heat in my room would hit a certain temperature and I would be nonfunctional when the heat was over—for example, 80˚.

You have all of these new experiences and new environmental factors impacting you that you didn't even think about before.

Glatter: You seem like an independent person. What was it like having to rely on others in the initial stages after your accident?

Grossman: I have never been particularly good at asking for help. Over the course of the past year, I have had to learn how to ask for help. Certainly, in that subacute period when you're in the hospital, you are fully reliant on other people. You also have to advocate for yourself.

I knew that they needed to give me care. I also knew what quality and standard of care I should expect. If that wasn't happening, then I certainly let someone know.

We spent the first week at the trauma hospital and then transferred to Mayo Clinic in Rochester—the home institution for me with the rehab facility there. I took an ambulance ride down. It was a nauseating experience to spend an hour and a half in an ambulance.

Each transition along the way was full of uncertainty and fear. I didn't always know that was the emotion that I was experiencing; but when a transition grew closer, discharging from one facility to another—which I did several times—or discharging to home, I would become more angry with people and lash out at those closest to me. I started to realize that these are fear reactions when uncertainty is about to happen.

When you're moving from one location to another, you just don't know what to expect next. There's probably an anxiety component, but I think it's largely about how to deal with this uncertainty of a new environment that you're about to enter.

Injury Occurred; Now a Focus on What's Next

Glatter: You're actively recovering. Were you actually thinking about going back to work immediately? Was that something going through your mind?

Grossman: Within the first month, I set a goal of returning to clinical practice within 5 or 6 months; that's what my goal was. If you set really aggressive goals, you can get there.

Folks made a lot of introductions for me to physicians who had had spinal cord injuries before, particularly a couple of emergency physicians. Talking to them and understanding that it was doable just made everything easier. I got emails from other spinal cord injury survivors.

To be honest, I think the biggest thing was my support network of family and friends. I am really, really lucky to have incredible family and friends around me who have been by my bedside from the very beginning and who have continued to embrace me. When you have a support system, it's clear that anything is possible.

Along the way, I think you also have to say, "My goal is to live as independently as possible. All of these things that other people are doing for me, whether that's helping me go to the bathroom or helping me shower, I have to figure out how to do that on my own." As much as possible, I would ask people, "Please stand there, but let me try this myself."

Returning to Work--The Initial Adaptation

Glatter: Take me back to the first day back to work. What was going through your head?

Daniel B. Grossman, MD, MBA
Image courtesy of Mayo Clinic

Grossman: Let me go back a little first. We needed to prove that I could do some of the functional parts of being an emergency physician, so I reached out to folks on the East Coast and the West Coast. Brad Frazee out of Highland Hospital, and Francisco Sanchez, who is a resident at the Harvard program—both had spinal cord injuries and returned to work as emergency physicians.

Francisco had it in the first month of his internship, so he learned how to be an emergency physician after having a spinal cord injury. He took videos of himself in the [simulation] lab at Harvard doing procedures and sent them to me. Then we, Mayo and my colleagues there, actually tried to reenact some of these.

We set up [simulation] in our emergency department at Mayo and practiced intubating, and figured out what worked for my body height and size and for the environment that we worked in. We came up with some hacks that worked and some adaptive techniques. We figured out how to get in and out of the department. We worked with some of our nursing staff to see what the needs were going to be to adapt to the department and for me to adapt my practice style for that.

We knew in advance that there were going to have to be a whole bunch of changes to how I do business and how I practice.

A lot of people have said my return to work within 5 months has been an inspiration. My goal is not to inspire. My goal is, if you're going to be inspired, the question is, what have you done differently?

Glatter: Tell me how you would go about doing a procedure—for example, an intubation. Would they have to adjust the bed? Would there be any special mechanical accommodation for this?

Grossman: No. You change how you position yourself. One of the problems is when you're working out in space [hands stretched out in front of him, leaning backward], you lose a lot of your balance. What we actually do is put a strap around me that holds me back against the chair and then I can use my hands in space without difficulty. That's for central lines. That's for intubations. Then you actually have to—because I'm offset from the patient—move the patient into my lap. You put pillows or blankets there, move the patient forward, and then you can intubate them. It's actually a fairly natural position. You're just being held backwards with a strap.

The other part is, fundamentally, to ask for help. I used to be a very efficient provider—room to room, back writing orders. That makes it more difficult. You have to wheel out of the room. You have to figure out how to maintain good hand sanitization and not touch the wheels after touching the patient. Each of these little steps along the way takes a bit of practice change in figuring out how to make it work.

I have had to learn how to ask for a lot of help from our nursing staff, our residents, and colleagues to make sure that the bed is moved over so I can do a physical exam properly or ask, "Can you please bring the ultrasound into the room in advance?" so I can do what I need to do. A year ago, I would just run and get the ultrasound and figure out how to do it. Asking for help is, for me, a gigantic hurdle that I've had to get over.

You also can ask the patient and their family members for help. I have become more comfortable directing and asking them for help as well so that I can see them.

Conversations With Patients

Glatter: How do patients and families respond to you when you enter the room in a wheelchair? Does it create an instant connection for you?

Grossman: There are these different distributions. Kids seem nonplused. They often ask why I'm in a wheelchair. Then we have a great conversation about wearing helmets and how I would have been dead without a helmet. The parents love that. Elderly patients straight up ask you, "What happened to you? Why are you in a wheelchair?" There are different filters that people use.

Often, people look at me, look at the wheelchair, look at me, look at the wheelchair, and then I just say, "The answer to the question that you're wondering about is, I fell off my mountain bike."

Glatter: Right off the bat?

Grossman: Right off the bat. Just have the conversation and be honest. There is no doubt that they understand [about having their own] set of experiences, and maybe I can't relate exactly to them, but I understand what it's like to be a patient and I understand what it's like to be in pain and to struggle. The reality is that probably most physicians, most people, have gone through something. Mine is obvious. Other people's may not be. It's forced me to have more empathy for patients and to slow down.

You know that move where you want to be done with the conversation with the patient and you start to back up? We all do it, right? We all start to exit the room. I can't do that as well. I can't wheel backwards, so I actually have to finish the conversations with the patients and then exit. It's just a different interaction.

I also think that, for patients, it's a bit weird when you knock on the door and then the first thing coming through the curtains is a pair of shoes. They're a little surprised to see an attending physician—anyone—come in in a wheelchair.

Glatter: Right, but the empathy and the understanding and the bond that you form with patients, that they know that you've been through an incredible journey, a struggle to be where you are now... I think that in and of itself forms a bond that is unbreakable.

Grossman: One hundred percent. For patients in wheelchairs, it's undeniable. For a lot of other patients, they actually apologize that they're there. They say, "You obviously have gone through something. What I'm going through right now is minor." They want to acknowledge my trauma, essentially. There's a little bit of explaining to people that we all go through something and we're here to help you. That's why I'm there, too.

Physical and Mental Barriers Faced: Spending Energy on What Matters

Glatter: What are the biggest physical issues and challenges for you? Just getting around on your day off? Being able to navigate?

Grossman: A lot of it is time management, actually. I used to hop out of bed half an hour before a shift, shower, and go to work. That's a 2-hour process now. Between using the restroom, showering, and getting dressed, all of these things take longer. Crossing the street. These are all time periods that take a lot longer than one would imagine. That is one of the biggest barriers.

That is accompanied by an uncertainty because you don't quite know how long it's going to take you to do certain things. If you're doing transfers, moving from a toilet to a chair, or a chair to a shower chair or to a bed, all of these things carry some degree of risk. You want to make sure you are doing these as safely as possible. If you're soaking wet, there's an increased amount of risk. Everything takes longer. You just have to be conscious of being safe at every turn.

Glatter: This makes your upper body strength so important because doing all of these moves—you're doing them every day, but you have to be in certain condition to do them.

Grossman: You have to be healthy and you have to make sure that your muscles are actually in good form and that you don't end up with a rotator cuff injury. What I'm probably not doing enough of in life as I balance different parts of my career is actually spending time on my physical health. I know that's a missing part of what I do. Both physical health and mental health are gaps in where I'm putting energy right now, that for long-term health need to be solved.

Glatter: What do you use personally to motivate you to bring yourself up? Is there anything specific you'd say that you focus on?

Grossman: Usually, it's the goals of what needs to get done, whether that's solving a problem for a patient or solving a business strategy problem, and then putting my energy behind that. Then, finding a group of people who I know that I can call when I have a really bad day, just to tell them that I'm having a really bad day. That vulnerability is a new part of my life that I have wholeheartedly embraced.

A lot of people have said over time that my return to work within 5 months has been an inspiration. I think it's really important to recognize that my goal is not to inspire. My goal is, actually, if you're going to be inspired, the question is, what have you done differently? Have you decided to spend more time with your children? Have you decided to go out and change healthcare somewhere as a result of watching this? What has it motivated you to do, watching someone like me recover from an injury and go back to work? I think that's always a question that's worth asking.

Epidural Stimulation, Stem Cell Research: Offering Hope

Glatter: What are your thoughts on new research about epidural spinal cord stimulation and what direction it's going in?

Grossman: There's a whole bunch of research right now around spinal cord injuries.[1,2,3,4,5,6] Epidural stimulation, for me, is pretty exciting. It's in really early phases. They've implanted a whole bunch of epidural stimulators at various locations, including Mayo Clinic. To me, it is the most likely potential solution for walking again, which is the end goal for most people.

There are other goals along the way. How can you improve bowel, bladder, and sexual function? For many people, how do you improve your blood pressure control so that when you get up, you don't feel lightheaded and feel like you're going to pass out? Although walking seems like the goal everyone should have, the reality is that there are some incredible quality-of-life issues that, if we can come up with therapies along the way that impact that, those are huge gains as well.

Glatter: Do you think that in your lifetime you will be able to appreciate the benefits of this spinal cord stimulation?

Grossman: I expect so. It's really early. There's investment going into it and folks are really excited. There are people who are walking who have epidural stimulation. I think that is going to be the most likely innovation. Remember, it's super early. The devices they're using for it weren't even designed for this. Once we see that it has the potential to help, the medical device community and the entrepreneur community will actually start designing for the intervention that needs to happen.

Glatter: Do you think that spinal cord research that looks at stem cells will have an impact in your lifetime?

Grossman: Today, they're totally separate. There are a lot of either stem cell studies or interventions being done around the world. The challenge is that the uniformity of protocols may be lacking or the environment in which they're being done may not have a standardization component. I think that spinal cord stem cell implants or stem cell use is going to have a role, and we will have to see how that expands over time.

Personal Pursuits: Helping Patients

Glatter: Can you tell me about some of your other interests beyond your clinical work in the emergency department?

Grossman: A long time ago, I decided that I wanted to have a career as both a physician and a business leader. I set myself up, starting in medical school and business school through residency, trying to build multiple muscles. From residency, I did a fellowship in international medicine and spent time working clinically all over the world.

Now, I'm at a start-up health insurance company where I get to use the clinical side and the business side to try to shape how we build new models of health insurance.

I spent a significant amount of my time while I was in the hospital battling insurance companies. I have a lot of empathy for folks who may have difficulty navigating that system, because it is a difficult system to navigate. If we can find ways to make the insurance part of healthcare delivery more personal and simpler, I think that will be a dramatic improvement to the care-delivery continuum.

Glatter: Clearly, there are issues between providers and insurance companies, with friction being an issue in terms of administrative issues. I understand that your company is providing an additional avenue to help patients deal with insurance companies more directly.

Grossman: We're working on it. The other thing is, we really have to take a patient-centered view of this. Some days, I spent more time on the phone with insurance companies than I did in physical therapy while I was in the hospital. That's a really inefficient use of a patient's mental energy when you're in recovery. Figuring out how to treat the patient as a human being in this whole process is a really important component of changing the insurance paradigm.

Glatter: Thank you again for joining us. This has been an incredible experience. You inspire me and inspire our audience, I'm sure, in so many ways.

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