In the searing heat of early July, a new resident working with Narath Carlile, MD, MPH, an Integrated Teaching Unit attending physician, asked Carlile about a patient he was deeply worried about. The patient, who had struggled with substance-abuse disorder, presented with body aches, jaundice, fever and abdominal pain. Upon examination, the medical team had noticed a large, tender liver all the way down to the lower abdomen. After getting test results, the patient’s medical team was especially concerned about acute liver failure, which can be life threatening or can require emergency liver transplantation. Carlile called on experts in gastroenterology and was able to get the patient the specialized help this patient needed, resulting in a more favorable outcome.
The experts Carlile called upon are now available for physicians in a more formal, specialized way: the Brigham Inpatient Liver Consult Service, which was created to support physicians who are taking care of patients with chronic liver disease, acute hepatitis and acute liver failure.
Responding to an Acute Need
Thinking back on all that has been accomplished in the last eight months, hepatologist Anna Rutherford, MD, MPH, doesn’t know how they could ever go back to a time when the Brigham was without this service. Originally incorporated underneath the larger umbrella of Gastroenterology, the initiative was brought to life in the form of a separate and distinct consultative service in July 2019. Since its inception, it has provided top-quality care in the diagnosis and treatment of liver conditions and provided educational opportunities for the next generation of liver scientists and clinicians.
“So far, the program has been working really well; maybe even better than anticipated,” said Stephen Zucker, MD, director of Hepatology.
The team includes four hepatologists: Nikroo Hashemi, MD, Kathleen Viveiros, MD, Rutherford and Zucker. Rachel Placzek, PA-C, who has extensive experience in the field of Hepatology, helps to support the team in the outpatient realm while they are on service, and is a crucial member of the team. The team is also assisted by a liver consult fellow — a gastrointestinal fellow who is assigned to round on the Liver Consult Service. Each GI fellow rotates through the liver service, receiving training in liver disease.
On average, the team consults on roughly seven to fifteen inpatients at any given time, and there are new patients almost daily. The team has plans to recruit additional faculty soon.
“Although we are certainly keeping busy, we want to increase our visibility so that the Brigham community knows that the services from specialized hepatologists exist and that we are ready to help,” said Zucker. “Prior to the program’s presence at the hospital, there was not always a liver specialist on hand. We are here now and we are making a difference in the lives of every patient we encounter.”
At Your Service
The Liver Consult Service is distinct from, yet inherently intertwined with, the Gastrointestinal (GI) Consulting Service (part of the same division). While physicians should contact the liver consult fellow directly, if the GI consult service receives a request to evaluate a patient with liver disease, they automatically triage the call to the liver team. The liver team also interfaces with the Bridge Clinic at times because of the common association between liver disease and substance abuse.
The past eight months have brought improvements to the care of patients with liver disease. Zucker explained that they have achieved seamless ambulatory follow up and teaching improvements.
“The program has proven to be a strong recruitment tool for potential trainees,” he said. “We provide focused experience for different levels of medical training and an essential part of their training in liver disease.”
Improvements for Patients
The patient Carlile and colleagues saw over the summer received supportive care and showed improvements in both mental and physical health and was able to be transferred to a psychiatric facility to receive treatment for substance use disorder. The patient has continued follow up within various Brigham and Partners service lines. Although the patient has not been cured and not all of the complications have disappeared, the improvements shown so far are a testament to the supportive care that the Brigham provides its patients. This is especially true when providers are able to take advantage of additional care from services such as the Bridge Clinic, GI Consult Service and the Liver Consult Service.
“All of our decisions are guided by our mission for a healthier world,” said Carlile. “Hospital programs like the Liver Consult Service empower that mission.”