Saturday, August 7, 2010

Excerpt from "Weaning the Vent"

For Savannah Jones, it was not a great night for sleeping, far from it in fact. Savannah sat up straight in her bed in the Pediatric Intensive Care Unit, breathing fast and shallow like a frightened rabbit. She opened her eyes as I entered the room and looked at me wearily. Mist filled the mask over her mouth and nose and billowed with each breath; she was breathing at least forty times a minute, twice the normal rate. Her lungs sounded even worse than before – wheeze, wheeze, crackle, wheeze, crackle – and although her pulse oximetry reading held steady in the mid 90s, I feared it might not stay there for long.

“Crap,” I thought as she hurried out of the room, “this girl needs to be intubated, and soon.” I hustled to the nursing station and paged Dr. Connor. As I waited for the return call, I reviewed, as I had dozens and dozens of times before, the procedural steps of an intubation. Intubation, the technical name for placing a breathing tube in the windpipe, is without a doubt the most crucial hands-on skill that a novice emergency physician must learn. Since the first day of my residency, I had been taught that my job was to “own the airway.” When I first heard this phrase, “own the airway,” I thought it presumptuous – how could a physician “own” a patient’s airway as if it was a commodity? Surely, a person’s trachea was more innately his or her own than a moped or a surfboard? With time, however, I came to appreciate the phrase because it captured the mentality necessary to learn a critical skill. Training in emergency medicine emphasizes, above all else, the skill of airway management and with good reason; when a patient ceases to breathe immediate action is required. Bodily organs deprived of oxygen fare poorly and basic functions, such as the heartbeat, rapidly lose their verve. Depending on factors such as patient age and health, there might be minutes to spare, or maybe only seconds. And this is why the intubation process fills even a seasoned emergency physician with trepidation; because while the procedure is usually straightforward, if things go wrong, they can go very wrong.

“Ballard, I am on my way in,” Connor bellowed over the phone. “Get the airway equipment and drugs at the bedside and call the respiratory tech. Talk to Savannah’s mother, make sure she knows what we are up to. If Savannah crashes, you know what to do.”
“Yep,” I replied, surprised. I hadn’t told him a word about the situation. He just knew that this was going to happen. Obviously, he had been doing this for a lot longer than me, but experience alone didn’t allow an average physician to reliably predict future events. Connor was special.

Savannah’s mother nodded sadly. “Doctor, as I said before, do what you need to do. I trust you.”
She inhaled deeply. “How long? How long do you think she will need the breathing tube?”
“I don’t know. I am sorry, but your daughter’s infection is very serious. It could be a long road.”
“I see,” she muttered softly.
“We will get you as soon as the tube is in.” For a moment, Savannah mother’s worry weighed heavily on my soul, but I didn’t have the time to linger. Savannah’s respiratory rate was nearing 50.

“Okay,” I said to Savannah’s nurse, “we need to get this done now. Push the etomidate, eight
Milligrams. Follow that with the succ sixty milligrams.” I ran through my mental checklist one more time – tube with stylet, suction, syringe, bag and valve, color change detector.

Just after the medications had been pushed and Savannah’s eyes closed with a slight shudder, Connor strode into the room. He looked at me.
“Looks like we are doing this. Ballard, I hope your technique is cleaner than your hair-do.”
I chuckled. I hadn’t even considered my bed head. I was pretty legendary among my peers in my ability, in a short period of time, to get significant bed head. Just 15 minutes of lying in a bed could reliably cause a large puff of my hair to stand straight up. Thirty minutes in bed was guaranteed to leave pillow lines across my forehead. Usually, after I’d been paged in the middle of a nap, I would take a brief swing by a mirror and attempt to temper the follicular uprising. But, in this case, the urgency in Savannah’s nurse’s voice had caused me to skip the mirror. I was thankful that Savannah’s mother had focused her trust on my words and not on my appearance. Connor’s comment calmed my nerves and I focused on my task. We lowered the back of the bed so that Savannah was lying flat and I gently pushed the top of her head down, which popped her chin up slightly. I opened her mouth with my right hand and inserted the L-shaped blade at an angle with my left. I pushed her tongue to the side and the tip slid into the valleculla. I pushed up and out, at a steeper angle than normal, because of where I expected her young vocal cords to lie. And there they were, glistening and outlining the tunnel to a successful intubation.

“Tube,” I said.

I felt it in my right hand. “Steady now,” said Connor. “Keep your eyes on the pearly gates.”
The tube slid in smoothly, and although I didn’t see it pass the cords, I knew it was in.
Connor pushed the plunger on the syringe, filling the balloon. The respiratory tech connected a color detector and a respiratory bag, after a large squeeze, the detector glowed yellow. I listened to the breath sounds – still wheezing and crackling, but present. I listened over the abdomen to be sure and was reassured because I didn’t hear the hollow sound of air blowing into Savannah’s stomach. The respiratory tech began to tape the tube into place and connect Savannah to the ventilator. The nurse prepared to slip a tube into her nose down to her stomach. I looked at the monitor, Savannah’s pulse oximetry was creeping back up, now in the mid 90s.

“Good job, Ballard.” Connor gave me a slap on the shoulder. “Now, let’s find you a comb.”
I laughed in relief and headed towards the call room and then stopped.
“How did you know?” I asked Connor. He smiled. “Simple really, you weren’t the only one who got a call from Savannah’s nurse. We don’t let you rookies have too much latitude. C’mon, let’s get some rest.”

Brain Shield! (Marin IJ)

Have you heard about the latest medical breakthrough? It’s a miracle cure that reduces the risk of brain cancer by 52.737%! Brain Shield was recently unveiled at the Meeting of those Concerned with Brain Cancer with stunning success. But don’t take my word for it. Annie from Lodi says “What a godsend. This treatment changed my life.” Annie has been using Brain Shield for 13 months and guess what, no brain cancer. Brain (CT) scans have confirmed that Annie is cancer-free. Interested in reducing your risk of cancer? Call 1-878-4-SHIELD.

Sound suspicious? Well, it should, because it’s completely bogus. I’m certain most of you weren’t fooled. But, did you pick up on the specific clues that Brain Shield story is full of bull#$%*? There are a number of them. By discussing each red flag, I hope to provide some tips for cutting through the hype in the medical media. Your health is of the ultimate importance and the quality of the medical news you heed (or ignore) is critical. So, here’s how to discern the valid from the bull #$&*. I thank the Association of Health Care Journalists (AHCJ) for providing the basic principles to work from.

Red Flag #1: Language. Be wary of health reporting that utilizes sensationalistic language. I am not sure that “miracle cures” actually exist, but if they do, they are rare. Antibiotics might qualify. A (hypothetical) treatment to reduce the risk of brain cancer by 53% certainly does not. The vast majority of “breakthrough” treatments and “dramatic” findings are nothing of the sort. Similarly, phrases like “deadly diseases” and “sweeping epidemics” are used to sell media, not to properly inform.

Red Flag #2: The anecdote. Testimonials may be useful in painting a vivid and personal picture of a disease or treatment but anyone who extrapolates the experiences of a handful of people to larger groups is taking a leap of faith. The AHCJ cautions health journalists to avoid the “tyranny of the anecdote,” particularly when the anecdote contradicts the sum of available evidence. An excellent example is the long hyped (and many times disproven) link between vaccines and autism. Causality is difficult to establish and a series of heart-breaking stories about children who developed autism not long after receiving immunizations does not establish a link and absolutely contradicts the vast evidence exonerating vaccines as a causal agent. Similarly, absent more information, readers should not be impressed by the “remarkable story” of Annie from Lodi.

Red Flag #3: Lack of peer review. The peer-review process in the scientific community is far from perfect, and plenty of junk slips through its cracks and into the medical literature. Andrew Wakefield’s seminal publication about the MMR vaccine and autism has become a classic example. But nonetheless, peer-review is a rigorous process – and one that (mostly) discourages researchers from publishing poorly conceived or managed research. Thus, you should put far more trust in medical evidence presented in a peer-reviewed journal (such as the New England Journal of Medicine) than preliminary results that appear in the mass media or at a scientific conference. Research presentations at conferences have not been vetted in the same manner as studies that make it to print in journals. The Meeting of those Concerned with Brain Cancer sounds like a worthwhile gathering, but should not be taken as the definitive source for information about preventing brain tumors.

Red Flag #4: Lack of perspective. There is a lot of nuance involved in interpreting the numerical significance of medical research. A 52.737% reduction in the risk of brain cancer sounds fantastic until you consider that brain cancer is an extremely rare condition (about 6 cases per 100,000 people). Think about it in terms of the value of your home – a 53% reduction in value is profound if the starting value is high. But what if your house isn’t worth squat (let’s say $100) to begin with? Then a 53% difference is no longer a big deal. Similarly, a 53% reduction in the number of cases of a common medical condition is big news, but a 53% reduction in cases of a rare condition is less newsworthy. Journalists can put this into perspective by giving data about statistical significance (the benchmark as to whether an observation is likely to have occurred randomly or is likely related to an exposure) or – for medical therapies – the number-needed-to-treat. For example, our hypothetical Brain Shield would need to be used in nearly 200,000 people in order to prevent a single brain cancer. When you consider this, you also realize the use of extra decimal points (52.737%) is another red flag. Those extra decimal points are purely for show – a means of making the results seem more robust than they actually are. Genuine data does not require three decimal places – none or one is usually sufficient. Watch out for numbers with drawn out decimals.

Red Flag #5: Too good to be true. No medical treatment is without risk. This is even true of treatments involving basic life substrates such as oxygen, water and salt. Too much of any of these things can be harmful. Thus, any discussion of a medical treatment must mention its risks. The very rough estimate of lifetime risk of cancer caused by a CT scan of the head is one in 2000 – thus Annie from Lodi has actually increased her brain cancer risk by attempting to confirm that her anti-brain cancer treatment is working. Silly Annie.

So, next time you read “stunning” health headlines or stay up for the 11 o’clock news to learn about the latest epidemic sweeping the area, keep these red flags in mind. If you encounter any, tune out, go to bed, and find a different (better) source in the morning. Or if you’re not sure, you can follow the advice of my buddy (and frequent contributor) Dr. Clark Hinderleider and “investigate the reliability of the outlet from which the content is received by using a 'fact-check' source such as" Whatever you do, I wouldn’t rely on Annie’s advice.

Can you handle the hype? (Marin IJ)

Flesh-eating bacteria, super-viruses, killer E-coli...Bird flu, swine flu, equine flu… Toxic mold, toxic shock, toxic toys, toxic Tylenol…Salmonella in your peanut butter, heavy metals in your salmon…Cancer from phthalates, tumors from your phone…Autism and vaccines, pertussis and vaccines (lack thereof). The media spits out an endless series of scary health stories, many sensationalized for effect. You’re all familiar with these pieces. I feel downright accosted by some of the headlines: “The toxic mold and the hidden room: a homeowner's nightmare,” (, or “The deadly ‘superbug’ that's spreading fast across the country,” ( and “Talk & die syndrome more common that you think” (

With the frenetic heat of media hyperbole, it’s hard to know which health hazards to be concerned about and which to put on the back burner of the worry stove. Not surprisingly, the public is often confused about health matters, and I really believe the media bears a heavy burden of responsibility for this. Medical reporting suffers from a number of ailments, including outbreaks of misinformation, deficits in understanding and context, and, often, a rush to pronounce conclusions.

Take, for example, two stories that sparked a substantial panic this past year. One was the unfortunate death of Natasha Richardson from a seemingly minor head injury and the other was the Food and Drug Administration’s (FDA’s) warning about liver damage due to excessive doses of acetaminophen (Tylenol).
Richardson’s tragic death from an epidural hematoma (bleeding on and around the brain) after falling on a beginner ski slope received widespread media attention, including in this column. The scope of the reporting was varied and from a public health perspective had some beneficial impact. The story reinforced the importance of wearing a helmet during high-risk sports such as biking, skateboarding, and (at least for beginners) skiing. On the flip side, some reports were alarmist and others were dangerously inaccurate. For example, I read an on-line article claiming that clot-busting drugs could have successfully treated Richardson’s brain injury. In actual fact, giving clot-busters to Richardson would almost certainly have hastened her death. Another report recommended that people with head injuries visit their nearest trauma center – which is a good idea for someone who has taken a header off the roof – but not necessary for most minor head impacts. And finally, a rather hysterical blog advised that all patients with head trauma be screened with a CT scan of the head. These and other alarmist stories, such as a Good Morning America feature on a young girl who sustained an epidural hematoma after she was struck with a softball, sent thousands of people to EDs to be checked out for trivial head injuries.
Dr. Brian Walsh from Morristown, New Jersey and colleagues quantified this effect by comparing the number of ED visits for head injury related complaints before and after Natasha Richardson’s death. They discovered that the total number of visits in the ten days after the actress’ death was 73% higher than the number of visits in the ten days prior, while the sum of serious injuries was unchanged. In other words, there was a huge surge in patients with minor head bonks who visited the ED to get checked out. This, of course, is what emergency departments are for, but nonetheless the media let these people down by failing to adequately stress the (well-established) warning signs of serious head injury (such as severe headache and repeated vomiting) and the potential risk of obtaining an unnecessary CT (radiation exposure that is thought to increase lifetime risks for cancer, especially in children). This failure to paint an accurate picture of risks and benefits is one of the five health media deficiencies identified by the American Council on Science and Health (ACSH), an advocacy group dedicated to providing sound health information to consumers.
A second deficiency, recognized by the ACSH and others, is the media’s tendency to gloss over the importance of dose, often altogether ignoring the maxim "the dose makes the poison." An excellent example of this is the media coverage after an FDA advisory panel warned that excessive doses of acetaminophen (Tylenol) could cause liver damage and failure. This statement was intended to raise awareness of the danger of cumulative doses of Tylenol. Truly, it can be hard to keep track of the amount of acetaminophen you’re taking, as it is commonly used as a cocktail ingredient in over-the-counter cold and flu preparations as well as in prescription painkillers such as Vicodin and Percocet. Hence the warning: people taking large doses of these medications, with or without additional Tylenol, are at risk for liver damage. Increased awareness of this risk, as well as changes in physician prescribing patterns (e.g., away from combination medications like Vicodin and towards single drug prescriptions) is desirable. Unfortunately, the message that many patients received, and I heard this many times in the ED, was that Tylenol is a dangerous medication. This could not be farther from the truth – Tylenol is one of the safest pain medications at our disposal and, if used at recommended doses, has far fewer harmful side effects than alternatives such as ibuprofen or naproxen. So please remember – the dose makes the poison. Remember this in regards to Tylenol, lead in children’s toys, mercury in fish, and phthalates in milk. With most environmental or dietary exposures, “everything in moderation” should keep you healthy.
There’s more to write about on the topic of the media and health, and three more ACSH identified deficiencies to cover. But since this column is running out of space and I do not want to violate any principles of responsible health reporting, I will pick up the topic in a couple weeks. In that column, I’ll give tips on how you can become a discerning reader of health news so you can decide for yourself which “scares” to freak out about and which to just forget.

Have you done your neurobics today? (Marin IJ)

There’s a woman at my gym who walks on the treadmill. Backwards. Why the heck does she do that? Not because the view is better and not in protest of the television that sits atop the machinery. Not to keep the wear on her sneakers even or to draw attention to herself (although she accomplishes both.) No, she walks backwards for the neurobic benefit. That’s right, neurobics – aerobics for the brain. And while walking backwards on a treadmill may not be a particularly safe exercise, the basic concept behind it is interesting.
The term “neurobics” was first introduced by neurobiologist Lawrence C. Katz about ten years ago along with the hypothesis that mental exercises, especially those that tax the brain in novel ways, can stimulate the growth of new dendrites and neurons. The theory is that most people perform many actions by routine – the processes are hard-wired by repetition into the brain’s mainframe. Routines like how you tie your shoes or answer the phone or walk on the treadmill are performed with little conscious thought. By switching things up and challenging your brain to orchestrate tasks or thoughts in different ways, you may be able to improve the cognitive (aka thinking) function of your brain.
Intrigued? You’re in luck. Dr. Katz, in collaboration with Manning Rubin, has written Keep Your Brain Alive – a book describing 83 neurobic maneuvers (“cross-training for the brain”) for people over the age of forty. The drills, which are designed to fit into your daily routine, include writing or brushing your teeth with your non-dominant hand and starting the ignition of your car with eyes closed (please remember to open them before you start driving). These are simple changes, not the New York Times crossword or advanced Sudoku, but Katz and others are convinced there is a benefit. But you probably don’t need a new book to teach you neurobics – how about using nothing but facial expressions to communicate during dinner, typing an e-mail without looking at the keyboard, or walking backwards on the treadmill?
Is there any solid evidence that neurobics help cognition? When I recently perused the medical literature I didn’t find much evidence supporting the specific practice of neurobics. This doesn’t mean, of course, that neurobics aren’t valuable; it just means that they haven’t been adequately studied.

Research has shown, however, that “cognitive engagement,” such as regular reading, learning a musical instrument or playing card games, is associated with decreased risk of cognitive decline and Alzheimer’s dementia. (This from an exhaustive NIH review prepared by scientists at the Duke Evidence-based Practice Center.) Physical activity also seems to have a benefit. A recent article in Clinics in Geriatric Medicine reviewed dozens of studies on the topic, many of which enrolled thousands of participants. The bottom line, according to the authors: “Increasing evidence suggests than an active life has a protective effect on brain functioning in the elderly population,” however no quality study to date “has shown that regular physical activity prevents dementia.”

With the U.S. population aging – over 70 million Americans will turn 65 in the next two decades – brain health is sure to become a major priority for physician and scientists. If we can keep this population active and productive well past the age of Social Security, there will be major benefits for individuals and society.
I asked a neurologist friend what he thought about improving brain health. Neurobics – well, he’d never heard of them. Physical activity and plenty of Vitamin D – good ideas for anyone of any age. Antioxidants in the diet to neutralize free radicals? Absolutely. “Tell your readers,” he told me “to eat blueberries.” A tasty thought, but I wouldn’t suggest eating them while walking backwards on a treadmill.

Flop-Roll-and-Face-itis (Marin IJ)

For the last few weeks, each dawn has awakened with the planet’s greatest team competition on television with vuvuzela horns as a brain-buzzing soundtrack.
As a fan, this World Cup has been thrilling to watch. As a physician, however, I’ve found it puzzling. Each morning, I witness an epidemic of a peculiar type of injury. Soccer players, some of the fittest of all athletes, fall to the ground after the slightest hint of contact – and proceed to roll around, hands clamped to their faces as is they’re mourning the death of a loved one. These men are stricken, horribly, for seconds to minutes at a time, and then bounce back to their feet as if nothing has happened. It’s odd actually, and I must admit that my Emergency Department (ED) experience hasn’t given me a clue as to what this mysterious soccer affliction (shall we call it “flop-roll-and-face-itis”) might be.

People with kidney stones will often rock back and forth in misery, unable to find a comfortable position. Patients with migraines frequently hold their hands to their faces, to shield their eyes from the light. Narcotic abusers may shift dramatically from a pose of comfort to one of excruciating distress when they realize they are being watched. But, in terms of traumatic injury, these soccer-induced spells are original. Take the Brazil-Portugal game, a defensive struggle that ended in a 0-0 tie. In this game, between two elite teams, there were more stricken players then quality shots on goal. For example… a Portuguese player feels a soft hand to his back and is launched onto the ground, arms splayed, emulating Dicaprio in The Titanic. His head rests on the ground for a moment and then he rolls to his back, his hands go to his face, he flexes his knees and rotates back and forth on the turf. What is hurt? Is it his head? Is it his Achilles tendon? The referee runs in with a yellow card for the Brazilian who touched him, and suddenly the Portuguese player is cured. He pops up, ready for another run on goal. Later, a Brazilian takes cleats to the heel and falls to the ground, clenching both ankles with his hands, and rolls, 1, 2, 3, 4, 5 times! What an odd injury this is! The announcer, a Brit, dryly takes note; “If you roll around a lot you are not as hurt as if you are lying still, in real pain.”

Could it be that these players are faking their injuries? I asked Dr. Joseph Centeno, an orthopedic surgeon and sports medicine specialist at Kaiser-Permanente. "Let's put it this way,” he replied, “I've never had to operate on a flopper." Next, I talked to my brother, Chris Ballard, a writer for Sports Illustrated who covers the NBA. Had he ever seen this type of injury in the sport of basketball? “Only on rare occasions,” he said, “and strangely enough it seems to only afflict European or South American players such as Vlade Divac or Manu Ginobili.”

But, all ridiculous theater aside, I should note that serious injuries do occur in the game of soccer. Many stars, including Ballack of Germany, Essien of Ghana, and Beckham of England, are sitting out the World Cup with physical ailments. And here in the U.S., as soccer gains greater popularity as a youth sport, thousands of kids are suffering knee, ankle, face, and head injuries. Each year, approximately 75,000 children ages five to 14 are treated in EDs for soccer-related injuries – more than the number of visits due to gymnastics, ice hockey and skiing injuries combined. Of these, many are knee injuries, particularly anterior cruciate ligament (ACL) tears. The ACL tear is a serious impairment that usually requires surgery and extended rehab, so it is worth taking note that the risk of this injury can be minimized by reducing the yearly load of play (in other words, taking some time off) and employing structured warm-up before play.

Of greater concern, however, are soccer-related head injuries – as even minor ones can have cumulative consequences. Head trauma, of course, is a problem in many sports, but soccer players are exposed in a rather unique manner because they are trained to repeatedly strike a rapidly moving ball with their unhelmeted craniums. A Canadian study, recently published in the journal Injury, found that 15% of soccer-related ED visits were for head injuries, of which 11% (of these) were concussions. Another Canadian study found that a disturbingly high number of youngsters (age 12-17) playing team soccer had evidence of concussion (over 50%) and that this percentage was significantly lower in those wearing protective headgear. A third study, published in the journal Neurosurgery, found decreased neuropsychological scores and reaction times in professional soccer players who had suffered a head injury the day before – even when these players claimed they did not feel any ill effects.

So, does any of this help explain the puzzling frequency of dramatic injuries at this year’s World Cup? I think it does. Some of these players, it seems, are damaged by years of forceful headers and contested corners. And thus, they have developed the deluded judgment that turf flopping is an acceptable strategic play (and one that the referee and the public won’t notice). From a purely clinical standpoint, they are wrong. The intent of flop-roll-and-face-itis may be difficult for a referee to recognize in real time, but with a remote control and a little clinical perspective, it’s a remarkably easy diagnosis.