When you read the word “intuition,” what comes to mind?
1) A convenient excuse for acting on impulse
2) A skill molded by experience
3) The Somatic Marker Hypothesis
4) Jamie Foxx’s best-selling album about how to impress women
IF you answered “all of the above,” you are not only a student of the neural basis of cognition AND Jamie Foxx’s musical career, but also absolutely correct. Intuition is everywhere. It motivates a person to do something “because it feels right,” allows people to “follow their hearts,” and gives justification to those who, like a certain former President, tend to “trust their gut feelings.” Each day, whether you realize it or not, you make many choices that are intuitive, ones that just seem to pop into your consciousness – effortless decision-making. But, what is the scientific explanation for intuition, and should intuition be trusted? The answer to the former question involves involuntary bodily responses (such as heart rate) linked to a series of brain connections called the X system. The answer to the latter question has been much debated by neuroscientists. Interestingly enough, neither explanation references Jamie Foxx’s thesis from the single Intuition Interlude…”Oh, since I was a young player talking to the ladies…I just know…It's just my intuition.”
Intuition is indeed multi-faceted and certainly involves multiple areas and pathways of the brain, with romantic impulse processed differently than geometric guessestimation. Nonetheless, scientists are starting to identify distinct areas of the brain involved in intuitive knowledge. For example, functional MRI studies of self-knowledge demonstrate completely different areas of brain activation when someone speaks about something he or she has great experience with (e.g, a soccer player discussing soccer) versus a topic that he or she has only superficial knowledge of (e.g, a soccer player talking about acting). Furthermore, the areas of the brain triggered by experiential knowledge, which have been named the X system (for the ‘x’ in reflexive), also involve the mechanisms for affective cognition, known to most of us as “feelings.” Feelings often manifest themselves in bodily feedback – such as changes in heart rate and sweating. This brings us to an area of debate called the Somatic Marker Hypothesis (stay with me here – it sounds a lot more complicated than it actually is). The Somatic Marker Hypothesis proposes that people often “feel” intuitive knowledge through bodily changes before they are consciously aware of it. Strangely, the focus of the debate regarding this hypothesis has revolved around gambling.
In a recent study published in the journal Psychological Science, Barnaby Dunn of the Medical Research Council Cognition and Brain Services Unit (CBSU) in Cambridge, U.K., and colleagues attempted to determine whether the generation and perception of involuntary bodily responses influenced people’s decisions. The skill of perceiving bodily feedback is called interoception, and it’s quite variable from person to person. (Quick, without feeling your pulse, try and determine if your heart rate is at its normal speed). What is also variable, according to Dunn, is how helpful the interoceptive skill is in assisting with decision-making. For example, his study recreated an experiment called the Iowa Gambling Task (which previously provided the basis for the Somatic Marker Hypothesis). In the task, volunteers wearing heart and sweat monitors chose between four decks of cards with their choices having either positive or negative monetary value. Unbeknownst to the volunteers, two of the decks were profitable (60% payout rate) and two were not (40% payout rate). The researchers tracked decision-making success (picking from profitable decks) over time as well as changes in heart rate and sweating (bodily feedback) and subjects perception of such changes (interoception). Subjects who performed well went home with cash, albeit hamstrung by a un-Vegas-like maximum of $7/person.
The study confirmed previous observations that bodily responses signal new knowledge (such as the identity of a profitable deck of cards) before someone is consciously aware of it. But the study also showed tremendous variability among individuals – both in the ability to perceive bodily signals and in the accuracy of those signals. Thus, as it turns out, intuition, like blond hair or artistic ability, is not equally distributed across the population. This means that people who seem to be lucky and whose hunches pay off, may not really be simply lucky after all. They have a skill like any other. For them, an appropriate mantra may just be “Intuit? Then just do it.”
I imagine the next area of investigation will be on how to cultivate the skill of intuition. Clearly, experience helps a great deal – professionals with years of experience make better reflexive decisions than those just learning a craft. But what about meditation, biofeedback therapy and other methods used to access the innate and identify the subliminal? Is there a Rosetta Stone equivalent for intuition? Not that I am aware of. For the time being, try a daily dose of Jamie Foxx….” I know if it possess you…I know what you feel, you can’t even fight it…It's just my intuition.”
Monday, January 17, 2011
Thursday, December 30, 2010
Excerpt from "Weaning the Vent"
As I slid into an exhausted sleep, memories of the last two and a half years floated past me; the gnawing nervousness I felt during my first ED shift and the amazing girth of my first patient (a woman with mysterious abdominal pain); walking home in bright East Sacramento morning sun after a 12-hour night shift and being ‘chauffeured” to work by Angela for early morning rounds; practicing intubations on surgical patients in the operating room and the horror of chipping a patient’s tooth in the process; a favorite attending teaching me the proper way to place a thumb spica splint and an hour of practicing on Angela at home; taking parents to the quiet room to tell them that their son was dead, a victim of random gun violence, and running after a psychiatric patient who was trying to abscond from the hospital, naked; a patient in the hallway of the ED whose primary complaint was coprophagia (eating shit) while a man with diarrhea raced by, trying, unsuccessfully, to reach the bathroom in time; a frustrated ED attending telling me as I attempted to place a central line catheter, “Ballard, you have bricks for hands,” and a disaffected attending saying “I’ll be napping in my office, call me if anyone is going to die;” cleaning maggots from an old man’s feet and removing scalpels from a young man’s urethra; harassing a crotchety nurse to do her job and being harassed, in turn, regarding my horrific, chicken-scratch handwriting; the glorious feeling of a night off from work and a drunken round of Cranium with friends, and the ache in my stomach before a week-long string of shifts; a wonderful delayed honeymoon to Maui and the simple joy of an overdue vacation with my wife; the feelings of self-doubt and loathing after failing to diagnose cardiac stent occlusion compared to the triumphant feeling of nailing a lumbar puncture on the first try; serving beers and relationship advice to Karl and listening to his panicked phone message the day he misplaced his cell phone; attempting to climb Mount Shasta the day after a night shift and the look of dread on Angela’s face as I slipped and tumbled down a glacier directly past her; the pain of working with a massive bruise and abrasions to my buttocks from my failed mountaineering expedition and the stupidity trying to play basketball the next day; a methamphetamine tweaker strapped to and humping a backboard and a meth cooker whose lab exploded in his face; sick patients of all shapes and sizes and circumstances…
Monday, December 13, 2010
"Donald" from Weaning the Vent
So, it was close to noon by the time we made it to Bed One, where we found a toddler named Donald Merrill. Donald Merrill was, for the moment, my only patient. It was my turn to lead the team. I was fortunate to have inherited a light load of patients, but that would soon change. I was on call that day and night and any kids admitted in the next eighteen hours would be primarily my responsibility. For now, however, Donald was it. I was preoccupied with the morning’s events, namely the disturbing visage of the girl in Bed Seven and Karl’s antics, and so when we arrived at Donald’s bedside I made a rookie mistake.
“Donald Merrill is a three-year-old male admitted from Sutter Delta,” I began “for pneumonia with hypoxia. The patient was brought in by Life Flight with an oxygen sat of seventy percent, but with otherwise stable vital signs. The patient initially presented to Sutter Delta Medical Center with two days of fever and congestion and was found to have a room air sat of ninety-two and an interstitial infiltrate on chest X-ray. He received one gram of Rocephin and was transferred to UC Davis. Overnight, Donald has been on non-invasive ventilatory support with Bi-level positive airway pressure, BIPAP.”
Dr. Connor interrupted me. “Wait, wait.” He gesticulated sideways, as if he might break into the electric slide. “Before you continue, please tell us what Donald’s underlying condition is.” I knew the answer and was about to respond, but someone else beat me to it.
“Ondine’s curse, also known as CCHS, Congenital Central Hypoventilatory Syndrome.” It was Karl. He just couldn’t help himself. “It comes from Greek mythology.”
Dr. Connor coughed loudly, but Karl continued. “The name comes from the tale of the Ondine, a beautiful water nymph. Ondine was wronged by a young lover and in revenge she cursed him. The curse…” Karl appeared ready to launch into a lengthy explanation. Dr. Connor appeared ready to burst a temporal vein.
“Doctor Krumholz,” Dr. Connor cut him off, “let’s allow Doctor Ballard to educate us about Congenital Central Hypoventilation Syndrome.” Karl nodded and flipped his hair again. Dr. Connor grunted, “Doctor Ballard?”
I told the team what I knew about CCHS, which wasn’t much. “CCHS is a rare condition, a genetic disorder,” I stammered, “one that affects automatic respiration.” Later, I would research the condition and its associated mythology. Karl was right, at least mostly right. Ondine was a water nymph, born in 18th-century German, rather than Greek, mythology. She was beautiful, enchanting, and extremely leery of men. Ondine, like other nymphs, could lose her everlasting life under only one circumstance: if she fell in love with a mortal man and bore his children. Despite her caution, Ondine fell in love with handsome young Palemon, who broke off his engagement to a noblewoman to marry her. On their wedding day, Palemon vowed, “My every waking breath shall be my pledge of love and faithfulness to you.” Years later, lovely Ondine bore Palemon a child, a son, and in doing so forfeited her immortality. Immediately, she aged and her transcendent beauty faded. Palemon’s eye wandered and on a fateful afternoon, Ondine heard the familiar sound of her lover’s snore in the stable on their estate. Entering, she found him entangled in a post-coital embrace with his former fiancée. Enraged, Ondine kicked Palemon and uttered a magic curse: “You pledged faithfulness to me with your every waking breath, and I accepted that pledge. So be it. For as long as you are awake, you shall breathe. But should you ever fall into sleep, that breath will desert you.” And so it was that Palemon’s next sleep, preceded by complete exhaustion, was his last. In the 1960s surgeons discovered a condition, following spine surgery, in which patients lost their spontaneous drive to breathe after falling asleep, and it was named after the mythical curse of Ondine. But at the moment, as I boiled with disappointment at Karl’s interruption, I didn’t know any of that.
Since its discovery, a genetic form of Ondine’s Curse had been found – linked in over 90% of cases to mutations to the PHOX2B gene and occurring in one out of 200,000 live births. Most victims died quickly, usually as infants. Donald Merrill was one of only 200 known living patients with CCHS.
Donald had survived to age three for a couple reasons. First, his mother also had CCHS so his family knew, even before he was born, that Donald was at risk. This allowed Donald’s physicians to make the diagnosis before it had fatal ramifications. Secondly, like his mom, Donald had a relatively mild form of the disease. He needed constant respiratory support when sleeping, otherwise his breathing became too shallow. But unlike some (approximately one out of every ten) with Ondine’s Curse, Donald did not need any when he was awake. None, that is, unless his lungs were compromised in some way, such as with an illness like pneumonia.
As we reviewed his situation, Donald was asleep in the room. I knew his family situation was complicated – the note from Sutter Delta mentioned that his mom was in treatment for heroin abuse, so I wasn’t surprised that he was alone. Pale and thin, with flat brown hair pressed onto his forehead, he looked sickly, although not critically ill. He wore an oval-shaped mask over his nose and mouth. When Donald exhaled, the mask clouded with mist. His breathing was even and peaceful. It looked normal, but I had to remind myself that if it were not for the mask, Donald might forget to breathe.
Donald’s care was pretty simple, and conscious of the length of our morning rounds, I summarized concisely. “We will continue antibiotics, await cultures and continue BIPAP at 12/4.”
“Wait, wait,” said Connor. “Doctor Ballard, it is important that you are precise. Imprecision is precisely the cause of most medical errors. What, precisely, are the antibiotics and what rate is the BIPAP set at?”
Yikes, more embarrassment. But he was right; the rate of the BIPAP respiratory support was critically important. Normal BIPAP merely assisted each inspiration and expiration with pressure that helped force air into and out of the lungs. But, this alone would not help Donald. He needed his breaths to be triggered on a regular basis. Thus, his BIPAP was set at a pressure of 12/4 (inspiration/expiration) and a rate of ten breaths a minute. I was about to correct my error, when we were interrupted.
“Bed Seven,” said a weathered nurse in pink scrubs, “she is hypotensive and de-sating. I’m worried about her. You need to look at her now.”
“Donald Merrill is a three-year-old male admitted from Sutter Delta,” I began “for pneumonia with hypoxia. The patient was brought in by Life Flight with an oxygen sat of seventy percent, but with otherwise stable vital signs. The patient initially presented to Sutter Delta Medical Center with two days of fever and congestion and was found to have a room air sat of ninety-two and an interstitial infiltrate on chest X-ray. He received one gram of Rocephin and was transferred to UC Davis. Overnight, Donald has been on non-invasive ventilatory support with Bi-level positive airway pressure, BIPAP.”
Dr. Connor interrupted me. “Wait, wait.” He gesticulated sideways, as if he might break into the electric slide. “Before you continue, please tell us what Donald’s underlying condition is.” I knew the answer and was about to respond, but someone else beat me to it.
“Ondine’s curse, also known as CCHS, Congenital Central Hypoventilatory Syndrome.” It was Karl. He just couldn’t help himself. “It comes from Greek mythology.”
Dr. Connor coughed loudly, but Karl continued. “The name comes from the tale of the Ondine, a beautiful water nymph. Ondine was wronged by a young lover and in revenge she cursed him. The curse…” Karl appeared ready to launch into a lengthy explanation. Dr. Connor appeared ready to burst a temporal vein.
“Doctor Krumholz,” Dr. Connor cut him off, “let’s allow Doctor Ballard to educate us about Congenital Central Hypoventilation Syndrome.” Karl nodded and flipped his hair again. Dr. Connor grunted, “Doctor Ballard?”
I told the team what I knew about CCHS, which wasn’t much. “CCHS is a rare condition, a genetic disorder,” I stammered, “one that affects automatic respiration.” Later, I would research the condition and its associated mythology. Karl was right, at least mostly right. Ondine was a water nymph, born in 18th-century German, rather than Greek, mythology. She was beautiful, enchanting, and extremely leery of men. Ondine, like other nymphs, could lose her everlasting life under only one circumstance: if she fell in love with a mortal man and bore his children. Despite her caution, Ondine fell in love with handsome young Palemon, who broke off his engagement to a noblewoman to marry her. On their wedding day, Palemon vowed, “My every waking breath shall be my pledge of love and faithfulness to you.” Years later, lovely Ondine bore Palemon a child, a son, and in doing so forfeited her immortality. Immediately, she aged and her transcendent beauty faded. Palemon’s eye wandered and on a fateful afternoon, Ondine heard the familiar sound of her lover’s snore in the stable on their estate. Entering, she found him entangled in a post-coital embrace with his former fiancée. Enraged, Ondine kicked Palemon and uttered a magic curse: “You pledged faithfulness to me with your every waking breath, and I accepted that pledge. So be it. For as long as you are awake, you shall breathe. But should you ever fall into sleep, that breath will desert you.” And so it was that Palemon’s next sleep, preceded by complete exhaustion, was his last. In the 1960s surgeons discovered a condition, following spine surgery, in which patients lost their spontaneous drive to breathe after falling asleep, and it was named after the mythical curse of Ondine. But at the moment, as I boiled with disappointment at Karl’s interruption, I didn’t know any of that.
Since its discovery, a genetic form of Ondine’s Curse had been found – linked in over 90% of cases to mutations to the PHOX2B gene and occurring in one out of 200,000 live births. Most victims died quickly, usually as infants. Donald Merrill was one of only 200 known living patients with CCHS.
Donald had survived to age three for a couple reasons. First, his mother also had CCHS so his family knew, even before he was born, that Donald was at risk. This allowed Donald’s physicians to make the diagnosis before it had fatal ramifications. Secondly, like his mom, Donald had a relatively mild form of the disease. He needed constant respiratory support when sleeping, otherwise his breathing became too shallow. But unlike some (approximately one out of every ten) with Ondine’s Curse, Donald did not need any when he was awake. None, that is, unless his lungs were compromised in some way, such as with an illness like pneumonia.
As we reviewed his situation, Donald was asleep in the room. I knew his family situation was complicated – the note from Sutter Delta mentioned that his mom was in treatment for heroin abuse, so I wasn’t surprised that he was alone. Pale and thin, with flat brown hair pressed onto his forehead, he looked sickly, although not critically ill. He wore an oval-shaped mask over his nose and mouth. When Donald exhaled, the mask clouded with mist. His breathing was even and peaceful. It looked normal, but I had to remind myself that if it were not for the mask, Donald might forget to breathe.
Donald’s care was pretty simple, and conscious of the length of our morning rounds, I summarized concisely. “We will continue antibiotics, await cultures and continue BIPAP at 12/4.”
“Wait, wait,” said Connor. “Doctor Ballard, it is important that you are precise. Imprecision is precisely the cause of most medical errors. What, precisely, are the antibiotics and what rate is the BIPAP set at?”
Yikes, more embarrassment. But he was right; the rate of the BIPAP respiratory support was critically important. Normal BIPAP merely assisted each inspiration and expiration with pressure that helped force air into and out of the lungs. But, this alone would not help Donald. He needed his breaths to be triggered on a regular basis. Thus, his BIPAP was set at a pressure of 12/4 (inspiration/expiration) and a rate of ten breaths a minute. I was about to correct my error, when we were interrupted.
“Bed Seven,” said a weathered nurse in pink scrubs, “she is hypotensive and de-sating. I’m worried about her. You need to look at her now.”
Monday, December 6, 2010
Treat them like family?
MY FATHER, a pediatrician, tells a cautionary tale.
A family physician, the story goes, agrees to work at a lakeside summer camp for boys. Several days and many bandaged bumps, bruises and bee stings into this service, the campers catch and fry up some perch. As it turns out, the fish is rather bony, and four kids come to the doctor complaining of bones stuck in their throats. One by one, the doctor examines the boys and removes the small slivers of calcium until he gets to the fourth boy. Here, he loses his nerve. He can't get the child to properly open his mouth, and he can't find the bone. Finally, he gives up. This child, he declares, must see a doctor in town. The problem is that the boy is his own son.
I recount this story in order to scrutinize the oft-encountered circumstance in which physicians and other health-care professionals provide medical assistance to friends or family. Today, I'm not talking about lighthearted, curiosity-inducing discussions, but rather situations in which good health may be at stake.
Situations like this are stressful for everyone involved, and for health-care professionals there can be the added stress of a unique inner conflict. On the one hand, we have knowledge -- not only medical knowledge, but also insight into how the system works. On the other hand, we often take on an added responsibility when we attempt to treat loved ones.
Medical evaluation and treatment requires a tremendous amount of weighing risks and benefits. Unfortunately, for many physicians, the simple fact that they are now giving advice to a family member may change their usual risk/benefit calculation.
In particular, physicians in this situation may have a diminished tolerance for making an error of omission -- that is, failing to take action. For instance, we may be reluctant to reassure a family member that everything is going to be fine if there's a chance that we'll find out later that it's not.
And while the term "taking action" has a positive connotation for many, in medicine there are real risks associated with doing so.
According to a 2007 report from the Institute of Medicine, more than half of medical treatments in this country are unproven. Meanwhile, most physicians, patients and malpractice juries tend to overvalue treatment over potential harm from side effects (for example, in most situations the potential benefit of taking antibiotics for a sore throat is much less significant than the potential harm caused by an adverse reaction to those antibiotics). Mix in concern about committing an error of omission, and you may have doctors making unnecessary and risky recommendations to their family members when in fact the clinical situation calls for a doctor with the courage to do nothing.
Medical science is just starting to explore the implications of certain personality qualities, such as risk tolerance, on clinical decisions. A recent study by Dr. Jesse M. Pines, director of the Center for Health Care Quality at George Washington University Medical Center, found that emergency physicians' scores on a standardized risk-taking scale (sample question: "I try to avoid situations that have uncertain outcomes") were associated with significant differences in the clinical management of patients with chest pain. Interestingly, scores on both fear-of-malpractice and stress-from-uncertainty scales were not associated with differences in decision-making.
While this study also did not attempt to judge whether risk-adverse physicians provided better care than risk-tolerant ones, the clear implication is that how physicians perceive risk can affect their decisions. Thus, it stands to reason that physicians giving advice to family members will have an altered risk-taking score -- they are, after all, taking on a new complex level of risk.
Doubt this conclusion? Then ask yourself these questions: "I try to avoid situations that have an uncertain outcome for my patient" and "I try to avoid situations that have an uncertain outcome for my mother."
During my medical training, I was told to treat patients as if they were family. This "grandmother test" was often invoked when considering a treatment or procedure. "Young Dr. Ballard, would you recommend the procedure to your own grandmother?" The assumption was that such an association would lead to better, more-compassionate decisions. Now, I wonder if that's always true.
Do physicians provide better advice to family and friends than to their patients? On the contrary, I believe that in many circumstances the closeness of the situation may cloud our judgment. A number of physicians I asked about this shared my concern.
For example, one said: "I find myself giving so many 'if/then'-type statements and covering every eventuality it really leads to a breakdown in the decisiveness I have when dealing with a patient. Throw in the often odd family dynamics, and you have some pretty crappy advice."
When I contacted Pines, he agreed that medical advice given to family members is often different but asserted that the quality of this counsel depends on the situation.
"The advice might be better in situations where they are very familiar with the family member's medical history," he says. "But the advice could be worse in cases where the doctor may not feel comfortable asking particular questions (like history of sexual partners) and in certain instances feel less comfortable doing a physical exam."
Valid qualifying points, but nonetheless, I wonder if we should reconsider the maxim, "Treat patients as if they were family"? How about we change it to, "When they are sick, treat your family as if they were patients"? Or, better yet, like the camp doctor of yore, leave the treatment to someone with less emotional investment.
A family physician, the story goes, agrees to work at a lakeside summer camp for boys. Several days and many bandaged bumps, bruises and bee stings into this service, the campers catch and fry up some perch. As it turns out, the fish is rather bony, and four kids come to the doctor complaining of bones stuck in their throats. One by one, the doctor examines the boys and removes the small slivers of calcium until he gets to the fourth boy. Here, he loses his nerve. He can't get the child to properly open his mouth, and he can't find the bone. Finally, he gives up. This child, he declares, must see a doctor in town. The problem is that the boy is his own son.
I recount this story in order to scrutinize the oft-encountered circumstance in which physicians and other health-care professionals provide medical assistance to friends or family. Today, I'm not talking about lighthearted, curiosity-inducing discussions, but rather situations in which good health may be at stake.
Situations like this are stressful for everyone involved, and for health-care professionals there can be the added stress of a unique inner conflict. On the one hand, we have knowledge -- not only medical knowledge, but also insight into how the system works. On the other hand, we often take on an added responsibility when we attempt to treat loved ones.
Medical evaluation and treatment requires a tremendous amount of weighing risks and benefits. Unfortunately, for many physicians, the simple fact that they are now giving advice to a family member may change their usual risk/benefit calculation.
In particular, physicians in this situation may have a diminished tolerance for making an error of omission -- that is, failing to take action. For instance, we may be reluctant to reassure a family member that everything is going to be fine if there's a chance that we'll find out later that it's not.
And while the term "taking action" has a positive connotation for many, in medicine there are real risks associated with doing so.
According to a 2007 report from the Institute of Medicine, more than half of medical treatments in this country are unproven. Meanwhile, most physicians, patients and malpractice juries tend to overvalue treatment over potential harm from side effects (for example, in most situations the potential benefit of taking antibiotics for a sore throat is much less significant than the potential harm caused by an adverse reaction to those antibiotics). Mix in concern about committing an error of omission, and you may have doctors making unnecessary and risky recommendations to their family members when in fact the clinical situation calls for a doctor with the courage to do nothing.
Medical science is just starting to explore the implications of certain personality qualities, such as risk tolerance, on clinical decisions. A recent study by Dr. Jesse M. Pines, director of the Center for Health Care Quality at George Washington University Medical Center, found that emergency physicians' scores on a standardized risk-taking scale (sample question: "I try to avoid situations that have uncertain outcomes") were associated with significant differences in the clinical management of patients with chest pain. Interestingly, scores on both fear-of-malpractice and stress-from-uncertainty scales were not associated with differences in decision-making.
While this study also did not attempt to judge whether risk-adverse physicians provided better care than risk-tolerant ones, the clear implication is that how physicians perceive risk can affect their decisions. Thus, it stands to reason that physicians giving advice to family members will have an altered risk-taking score -- they are, after all, taking on a new complex level of risk.
Doubt this conclusion? Then ask yourself these questions: "I try to avoid situations that have an uncertain outcome for my patient" and "I try to avoid situations that have an uncertain outcome for my mother."
During my medical training, I was told to treat patients as if they were family. This "grandmother test" was often invoked when considering a treatment or procedure. "Young Dr. Ballard, would you recommend the procedure to your own grandmother?" The assumption was that such an association would lead to better, more-compassionate decisions. Now, I wonder if that's always true.
Do physicians provide better advice to family and friends than to their patients? On the contrary, I believe that in many circumstances the closeness of the situation may cloud our judgment. A number of physicians I asked about this shared my concern.
For example, one said: "I find myself giving so many 'if/then'-type statements and covering every eventuality it really leads to a breakdown in the decisiveness I have when dealing with a patient. Throw in the often odd family dynamics, and you have some pretty crappy advice."
When I contacted Pines, he agreed that medical advice given to family members is often different but asserted that the quality of this counsel depends on the situation.
"The advice might be better in situations where they are very familiar with the family member's medical history," he says. "But the advice could be worse in cases where the doctor may not feel comfortable asking particular questions (like history of sexual partners) and in certain instances feel less comfortable doing a physical exam."
Valid qualifying points, but nonetheless, I wonder if we should reconsider the maxim, "Treat patients as if they were family"? How about we change it to, "When they are sick, treat your family as if they were patients"? Or, better yet, like the camp doctor of yore, leave the treatment to someone with less emotional investment.
Saturday, November 20, 2010
First Page of "Weaning the Vent"
The girl was bloated with fluid and her skin was so white that it was nearly transparent. Plastic tubes, secured with grainy tape, invaded her mouth and nose. Prone and lifeless, she looked like a drowning victim washed facedown on a beach. But she wasn’t at the beach and she wasn’t lifeless – at least not yet. She was in Bed Seven of the Pediatric Intensive Care Unit (PICU) at UC Davis Medical Center, being kept alive by a machine. Her room reverberated with the sound of a mechanical ventilator – also known as “the vent” – doot-doot-doot-doot-doot-doot-doot-doot. The rapid beat was maddening, like Chinese water torture on over-drive. This frenzied rhythm was her lifeline, the music of a high-speed oscillator vent delivering oxygen to her lungs. Doot-doot-doot-doot-doot-doot-doot-doot. Each puff of air was so fast, and so small that the girl’s chest didn’t move.
Or perhaps it did, but her body was too swollen for me to notice. If she’d been on a traditional ventilator, there would have been no question of if and when breaths were being delivered. Now in my third year of residency training in emergency medicine (EM), I was comfortable with operating traditional ventilators. They made sense to me. Just like with my favorite remote control, I knew where the important buttons were and when to use them. Traditional vents calmly and predictably delivered breaths, and there were only a handful of variables (namely the percentage of oxygen and the frequency and volume of air delivery) that I needed to consider. Traditional ventilators were reassuring, in a morbid sense; no matter how sick or sedated a patient was, the sight of inhalation and exhalation was comforting. Breath in, breath out. Not so with high-speed oscillators, which dispensed tiny puffs of air ten times each second. Doot-doot-doot-doot-doot-doot-doot-doot. I knew the percussive rate aimed to keep the girl’s lungs from collapsing under the weight of the fluid in and around her chest, but this didn’t change the fact that the body in Bed Seven looked more like a horrible science experiment than a living child.
As I listened to a manicured blonde resident named Lesley present the case, I averted my eyes out the 7th-floor window. It was a grey February morning and mist had settled into the skeletons of the sycamore and maple trees. The streets were wet and lawns brown with winterized turf. I could almost smell the muddy grass and taste the soggy air; it was an excellent day to be on a couch, or at a movie, or in a hot tub. And, I supposed, since I had no choice about it, it was a fitting day to start a month-long rotation in the PICU with a 30-hour on-call shift. As I meditated on the dull day, I felt eyes on me. I glanced towards the chairs by the window – they were squeezed into a corner among boxes of ventilator tubing, blankets and other clutter. The girl’s mother, professional dressed with reddish-blond hair that rested on her shoulders, met my gaze. Her soft hazel eyes held a look of bewilderment mixed with exhaustion. Ashamed, I turned back to the girl, but her barely human form was no less awful. In my two and a half years of residency, I’d seen hundreds of awful things: gruesome injuries, grotesque infections and the blank stares of the newly dead. This was the worst.
Or perhaps it did, but her body was too swollen for me to notice. If she’d been on a traditional ventilator, there would have been no question of if and when breaths were being delivered. Now in my third year of residency training in emergency medicine (EM), I was comfortable with operating traditional ventilators. They made sense to me. Just like with my favorite remote control, I knew where the important buttons were and when to use them. Traditional vents calmly and predictably delivered breaths, and there were only a handful of variables (namely the percentage of oxygen and the frequency and volume of air delivery) that I needed to consider. Traditional ventilators were reassuring, in a morbid sense; no matter how sick or sedated a patient was, the sight of inhalation and exhalation was comforting. Breath in, breath out. Not so with high-speed oscillators, which dispensed tiny puffs of air ten times each second. Doot-doot-doot-doot-doot-doot-doot-doot. I knew the percussive rate aimed to keep the girl’s lungs from collapsing under the weight of the fluid in and around her chest, but this didn’t change the fact that the body in Bed Seven looked more like a horrible science experiment than a living child.
As I listened to a manicured blonde resident named Lesley present the case, I averted my eyes out the 7th-floor window. It was a grey February morning and mist had settled into the skeletons of the sycamore and maple trees. The streets were wet and lawns brown with winterized turf. I could almost smell the muddy grass and taste the soggy air; it was an excellent day to be on a couch, or at a movie, or in a hot tub. And, I supposed, since I had no choice about it, it was a fitting day to start a month-long rotation in the PICU with a 30-hour on-call shift. As I meditated on the dull day, I felt eyes on me. I glanced towards the chairs by the window – they were squeezed into a corner among boxes of ventilator tubing, blankets and other clutter. The girl’s mother, professional dressed with reddish-blond hair that rested on her shoulders, met my gaze. Her soft hazel eyes held a look of bewilderment mixed with exhaustion. Ashamed, I turned back to the girl, but her barely human form was no less awful. In my two and a half years of residency, I’d seen hundreds of awful things: gruesome injuries, grotesque infections and the blank stares of the newly dead. This was the worst.
Is it bad to crack your knuckles? (Marin IJ)
For many of us, the body is like an old car. It’s always surprising us with its new sounds, sensations, and unexpected breakdowns. And it’s constantly providing material for investigation. Yes, the human body is a fascinating, unpredictable machine. At the same time, medicine is a fickle art and an imperfect science. For answers to medical questions, there’s always WebMD and “Doctor” Google, and an abundance – perhaps over abundance - of other online health information and advice. But when it comes right down to it, most of us still prefer the face-to-face interaction and in-person opinion of a health professional. Typically we think this interaction occurs in the sterile environment of a physician’s exam room, or perhaps on the phone with an advice nurse. But often, medical opinions are garnered in very unusual places – at dinner parties, the gym, and via Facebook messages.
Health professionals are accustomed to fielding medical questions from family, friends and acquaintances. I certainly am and I’m often intrigued by the curiosities these questions unearth. Have any of the following questions occurred to you? (The answers are adapted from my favorite cocktail party reference, Why Do Men Have Nipples by Mark Leyner and Billy Goldberg, M.D.).
“Is it bad to crack your knuckles?” (Not in moderation, and it sure is satisfying.)
“Can hot tubs make you infertile? (Probably not, and wouldn’t they still be worth it?)
“Should you put steak on a black eye?” (An ice pack is just as good unless you are really set on attracting attention from turkey vultures.)
“Can you swallow your tongue?” (No, you’d have to chop it out first.)
These types of questions are nearly universally interesting (the fact that Nipples was a best seller is sufficient evidence of this) and usually harmless banter. But, if you’re searching for real medical advice from that doctor friend you bump into at Whole Foods, here are some helpful guidelines for inquiry.
1) Know her specialty. A urologist is very different from a neurologist, even though the names sound quite similar (just ask any hospital operator). Thus, you should try to avoid asking a neurologist about a flaccidity issue that is better suited for the talents of a urologist.
2) Know the limits. Lighthearted questions are fine, and most physicians don’t mind them. Many of us enjoy telling our war stories in return. I certainly do. By the way, did I ever tell you about the time that…But, unless you truly think you are in danger, it is best not to casually invoke certain words or phrases. “Heh doc, it sorta feels like there is a big ol’ elephant on my chest,” and “You know, this really is by far the worst headache of my life,” are statements that may cause your physician friend to have a major change in sphincter tone.
3) Know when to stop. If M.D.-in-line-at-the-post-office says “You should really talk to your doctor about that,” what she’s really saying is either [A] that sounds serious and I don’t want to be responsible for you not getting it checked out in a formal medical setting or [B] That is totally out of my realm of expertise, I have no idea what you are talking about, and I’d much rather talk about Buster Posey.
Can you curl your tongue? Does your daughter seem to have bionic hearing? Will your cousin’s eleventh toe be genetically passed on to his offspring? Are you convinced 99-year-old Aunt Mabel is still ticking because she drinks a thimble of scotch with breakfast? These are interesting, fun conversations that physicians often like to engage in. But a party is not the best place to talk about potentially serious medical issues. That said, I look forward to seeing you at the neighborhood holiday cookie exchange. Then I can tell you about that time…
Health professionals are accustomed to fielding medical questions from family, friends and acquaintances. I certainly am and I’m often intrigued by the curiosities these questions unearth. Have any of the following questions occurred to you? (The answers are adapted from my favorite cocktail party reference, Why Do Men Have Nipples by Mark Leyner and Billy Goldberg, M.D.).
“Is it bad to crack your knuckles?” (Not in moderation, and it sure is satisfying.)
“Can hot tubs make you infertile? (Probably not, and wouldn’t they still be worth it?)
“Should you put steak on a black eye?” (An ice pack is just as good unless you are really set on attracting attention from turkey vultures.)
“Can you swallow your tongue?” (No, you’d have to chop it out first.)
These types of questions are nearly universally interesting (the fact that Nipples was a best seller is sufficient evidence of this) and usually harmless banter. But, if you’re searching for real medical advice from that doctor friend you bump into at Whole Foods, here are some helpful guidelines for inquiry.
1) Know her specialty. A urologist is very different from a neurologist, even though the names sound quite similar (just ask any hospital operator). Thus, you should try to avoid asking a neurologist about a flaccidity issue that is better suited for the talents of a urologist.
2) Know the limits. Lighthearted questions are fine, and most physicians don’t mind them. Many of us enjoy telling our war stories in return. I certainly do. By the way, did I ever tell you about the time that…But, unless you truly think you are in danger, it is best not to casually invoke certain words or phrases. “Heh doc, it sorta feels like there is a big ol’ elephant on my chest,” and “You know, this really is by far the worst headache of my life,” are statements that may cause your physician friend to have a major change in sphincter tone.
3) Know when to stop. If M.D.-in-line-at-the-post-office says “You should really talk to your doctor about that,” what she’s really saying is either [A] that sounds serious and I don’t want to be responsible for you not getting it checked out in a formal medical setting or [B] That is totally out of my realm of expertise, I have no idea what you are talking about, and I’d much rather talk about Buster Posey.
Can you curl your tongue? Does your daughter seem to have bionic hearing? Will your cousin’s eleventh toe be genetically passed on to his offspring? Are you convinced 99-year-old Aunt Mabel is still ticking because she drinks a thimble of scotch with breakfast? These are interesting, fun conversations that physicians often like to engage in. But a party is not the best place to talk about potentially serious medical issues. That said, I look forward to seeing you at the neighborhood holiday cookie exchange. Then I can tell you about that time…
What does the term “palliative care” mean to you? (Marin IJ)
What does the term “palliative care” mean to you? Do you think about metastatic cancer, depression and Death Panels? About funerals and estate planning? Most likely, you don’t think about palliative care at all, or would very much prefer not to. But chances are, at some point, you’ll be faced with a decision related to palliative care, for either yourself or a family member.
The term “palliative care” is derived from the Latin palliare, which means, “to cloak,” and refers to treatment aimed at relieving symptoms and pain rather than effecting a cure. Hospice (perhaps a more familiar term to many) is a type of palliative care that is usually reserved for people in the end stages of terminal illness. Palliative care, on the other hand, may be offered to anyone who has a serious illness —regardless of life expectancy. The basic philosophy behind them both is the same. My wife Angela, a volunteer for Hospice By The Bay, described it this way.
“When everything important to a person is being stripped away by illness, it’s vital to give them the chance to hold onto dignity and autonomy, to receive compassion, to be comfortable, to be home, and to have as much quality of life as possible.”
I agree with my wife (imagine the trouble I would get into if I didn’t); this is a humane way to deal with serious illness. But I also recognize why many people choose to fight end-stage illness, no matter what the cost in terms of side effects and suffering. It’s a very personal calculation, but new evidence is suggesting that it need not be a stark “either-or” choice. This is because new data indicates that some patients with terminal illness may live longer with palliative care than with more aggressive treatment.
Consider the study by Dr. Jennifer S. Temel and colleagues published this past August in The New England Journal of Medicine. The authors compared two randomly assigned groups of patients with metastatic lung cancer – an aggressive care group (defined by no or late referral to palliative care and/or chemotherapy within the last 2 weeks of life) and a palliative care group (early palliative care integrated with standard oncology care). As expected, they found that those who received early palliative care had higher quality of life scores and lower levels of depressive symptoms. The goal of palliative care is, after all, to improve or maintain quality of life. Surprisingly, however, they also found that the palliative care group lived longer – more that 30% longer (11.6 months versus 8.9 months). Even when we keep in mind that this study examined patients with only one, specific subset of lung cancer, the ramifications are striking; palliative care may offer a chance to live longer and live better.
Other research supports this concept – Dr. Stephen R. Connor and colleagues have reported that patients with congestive heart failure and advanced cancer live longer with hospice care (remember, hospice is palliative care given to a certain segment of terminally ill patients) than without it. Recent journal articles have also reported on the successful integration of palliative care into both the oncology and intensive care environments. And, there are the anecdotal stories. Art Buchwald, former Washington Post columnist, wrote a book (Too Soon to Say Goodbye) chronicling one such story. Buchwald, on hospice for end-stage kidney failure, was expected to die within weeks, but instead survived nearly a year, becoming known at hospice as “The Man Who Would Not Die.”
So, knowing this, perhaps we need to re-define and re-frame the concept of palliative care. Dr. Robert J. Lavaysse, Director of Inpatient Palliative Care at Kaiser-Permanente San Rafael offered me one such description.
"Palliative care is about bringing the patient and their families' values and goals to the fore as the driver for medical decision-making. It is also about alleviating symptoms. We are understanding that these conversations need to happen upstream and not in the last few days, weeks or months of life." And this is an important point – palliative care is more than just narcotics for those on the brink of death – it is about providing support in illness – relieving pain and suffering, bringing family together, provide psychological support, and thinking about living wills and estates.
Hopefully the term palliative care is one that will keep its distance from your life, but should it encroach on you or your loved ones, I hope this column has helped you to understand it benefits – both those that are long established and those that we are just now unearthing.
For more on Palliative Care
www.getpalliativecare.org
The term “palliative care” is derived from the Latin palliare, which means, “to cloak,” and refers to treatment aimed at relieving symptoms and pain rather than effecting a cure. Hospice (perhaps a more familiar term to many) is a type of palliative care that is usually reserved for people in the end stages of terminal illness. Palliative care, on the other hand, may be offered to anyone who has a serious illness —regardless of life expectancy. The basic philosophy behind them both is the same. My wife Angela, a volunteer for Hospice By The Bay, described it this way.
“When everything important to a person is being stripped away by illness, it’s vital to give them the chance to hold onto dignity and autonomy, to receive compassion, to be comfortable, to be home, and to have as much quality of life as possible.”
I agree with my wife (imagine the trouble I would get into if I didn’t); this is a humane way to deal with serious illness. But I also recognize why many people choose to fight end-stage illness, no matter what the cost in terms of side effects and suffering. It’s a very personal calculation, but new evidence is suggesting that it need not be a stark “either-or” choice. This is because new data indicates that some patients with terminal illness may live longer with palliative care than with more aggressive treatment.
Consider the study by Dr. Jennifer S. Temel and colleagues published this past August in The New England Journal of Medicine. The authors compared two randomly assigned groups of patients with metastatic lung cancer – an aggressive care group (defined by no or late referral to palliative care and/or chemotherapy within the last 2 weeks of life) and a palliative care group (early palliative care integrated with standard oncology care). As expected, they found that those who received early palliative care had higher quality of life scores and lower levels of depressive symptoms. The goal of palliative care is, after all, to improve or maintain quality of life. Surprisingly, however, they also found that the palliative care group lived longer – more that 30% longer (11.6 months versus 8.9 months). Even when we keep in mind that this study examined patients with only one, specific subset of lung cancer, the ramifications are striking; palliative care may offer a chance to live longer and live better.
Other research supports this concept – Dr. Stephen R. Connor and colleagues have reported that patients with congestive heart failure and advanced cancer live longer with hospice care (remember, hospice is palliative care given to a certain segment of terminally ill patients) than without it. Recent journal articles have also reported on the successful integration of palliative care into both the oncology and intensive care environments. And, there are the anecdotal stories. Art Buchwald, former Washington Post columnist, wrote a book (Too Soon to Say Goodbye) chronicling one such story. Buchwald, on hospice for end-stage kidney failure, was expected to die within weeks, but instead survived nearly a year, becoming known at hospice as “The Man Who Would Not Die.”
So, knowing this, perhaps we need to re-define and re-frame the concept of palliative care. Dr. Robert J. Lavaysse, Director of Inpatient Palliative Care at Kaiser-Permanente San Rafael offered me one such description.
"Palliative care is about bringing the patient and their families' values and goals to the fore as the driver for medical decision-making. It is also about alleviating symptoms. We are understanding that these conversations need to happen upstream and not in the last few days, weeks or months of life." And this is an important point – palliative care is more than just narcotics for those on the brink of death – it is about providing support in illness – relieving pain and suffering, bringing family together, provide psychological support, and thinking about living wills and estates.
Hopefully the term palliative care is one that will keep its distance from your life, but should it encroach on you or your loved ones, I hope this column has helped you to understand it benefits – both those that are long established and those that we are just now unearthing.
For more on Palliative Care
www.getpalliativecare.org
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