Last month, during the Vancouverage of the Winter Olympics, I saw a story that made me stop and yawn. Literally. Apparently speed skater Apolo Anton Ohno, the most decorated American Winter Olympic athlete of all time, has a pre-race routine that includes, of all things, robust yawning. Watching Ohno let loose with a jaw-opening yawn, just seconds before one of the biggest moments of his life, not only triggered my own yawn song, but also made me wonder; why do we yawn?
Obviously, people yawn when they are tired, everyone knows that. But does yawning serve any other purpose than to let your dinner guests know that they have over stayed their welcome? Apolo Ohno thinks so. Ohno told Yahoo Sports that yawning makes him feel better, that it “gets the oxygen in and the nerves out." That sounds good, and I hate to contradict an eight-time Olympic medalist, but it’s not completely true. Yawning, as far as we know, does not improve overall oxygen levels, but it does enhance attention and focus. Based on some recent brain-scan studies, yawning increases the activity of a small area of the brain called the precuneus, which plays an important role in spatial orientation, memory and consciousness. Yawning is also thought to help regulate the metabolism of the brain and serve as a means of achieving empathy within a group setting (interestingly, children with autism-spectrum disorders have an impaired ability to contagiously yawn). Thus, not only is a yawn a good way to keep us from falling asleep on the job, it may also serve to help focus oneself for peak performance. Perhaps there are times then, that rather than greeting a colleague’s yawn with a frown, we should take it as a sign that they mean business.
Of course, as is often said, there is such a thing as too much of a good thing. People who yawn too much may be suffering from pathological yawning – triggered by disease or an adverse reaction to medication. Consider a young woman described by Gilles de la Tourette in 1890 who yawned 480 times an hour – eight yawns a minute – which, given that the average yawn lasts 5 to 10 seconds, is just about non-stop yawning. Clearly, this is neither normal nor beneficial. It turns out that this patient (who also suffered from vision loss and seizures) probably had a tumor of the pituitary gland. Abnormal yawning is also associated with severe migraines, clinical depression, and major stroke. People taking anti-depressants, in particular serotonergic ones (SSRIs such as Prozac), can also suffer aggravating salvos of yawning.
Notwithstanding these exceptions, for most of us, yawning is a useful activity. In fact, some experts encourage yawning – even if you are not tired. Sound impossible? It’s not, just fake a half dozen yawns and the real thing will awaken within you. Dr. Andrew Newberg, director of the University of Pennsylvania’s Center for Spirituality and the Mind and the author of How God Changes Your Brain, writes: “My advice is simple. Yawn as many times a day as possible; when you wake up, when you’re confronting a difficult problem at work, when you prepare to go to sleep and whenever you feel anger, anxiety or stress.” So, how about before the biggest race of your life? I asked Dr. Newberg, and this was his advice: “It certainly is not likely to cause a problem for athletes and the evidence suggests that it will help the brain function. Whether this ultimately leads to better performance makes sense, but has not actually been tested.”
It’s an intriguing concept, and if I can stifle my social phobias I might just give it a shot myself. Who knows, it could be contagious.
Monday, March 29, 2010
Wednesday, February 24, 2010
Fixing the Leak
Not long ago, I noticed water dripping into our home’s crawl space. After a costly visit from the plumber, I received our diagnosis – a faulty Jacuzzi bathtub. For months, water had been accumulating under the tub, resulting in a wet and moldy subfloor. At this point, I was faced with several options, none of them pleasant. I could; 1) remove the tub and subfloor and start over; 2) attempt to repair the tub with a tinkering approach and 3) do nothing and hope for the best. Option 1 would be costly and inconvenient – it would take the bathroom out of service for weeks. Option 2 was not guaranteed to work and, in my estimation, a temporary fix at best. Option 3 did not really seem like an option, because it would lead to more water, more mold and, eventually, certain disaster. And so, I bit down hard, charged a new bathtub, and scheduled demolition and re-installation.
At first, I was quite certain that I’d made the right decision. But then, I started to imagine what could go wrong. What if the contractor showed up smelling like rotten cabbage and tracking dirt throughout the house? What if my wife didn’t like the look of the new tub and demanded that we send it back? What if the plumber wore a shirt that screamed “ER Doctors Suck.” That would suck and I certainly would be tempted to call off the project. But, what would that get me? Nothing more than a wet and moldy mess.
I’ve been thinking about this dilemma in the context of tomorrow’s televised health care event. The debate over health reform has devolved from focusing on necessity to distraction, distortion and inflamed rhetoric. And, sadly, in the fray many have lost sight of what matters. Much like the leak in my bathroom, the problems with health care in this country – the inequities of care, the runaway costs and the perverse incentives – will not fix themselves. So, it is time to do the right thing, the ethical thing, and the smart thing, and move forward with changing how we view the business of health care. Tomorrow, our elected representatives should take heed of what a former senator once said about health care reform; “At stake are not just the details of policy, but fundamental principles of social justice.”
At first, I was quite certain that I’d made the right decision. But then, I started to imagine what could go wrong. What if the contractor showed up smelling like rotten cabbage and tracking dirt throughout the house? What if my wife didn’t like the look of the new tub and demanded that we send it back? What if the plumber wore a shirt that screamed “ER Doctors Suck.” That would suck and I certainly would be tempted to call off the project. But, what would that get me? Nothing more than a wet and moldy mess.
I’ve been thinking about this dilemma in the context of tomorrow’s televised health care event. The debate over health reform has devolved from focusing on necessity to distraction, distortion and inflamed rhetoric. And, sadly, in the fray many have lost sight of what matters. Much like the leak in my bathroom, the problems with health care in this country – the inequities of care, the runaway costs and the perverse incentives – will not fix themselves. So, it is time to do the right thing, the ethical thing, and the smart thing, and move forward with changing how we view the business of health care. Tomorrow, our elected representatives should take heed of what a former senator once said about health care reform; “At stake are not just the details of policy, but fundamental principles of social justice.”
Sunday, February 14, 2010
Descartes before the horse (Marin IJ)
“Physicians and society are not ready for ‘I have brain activation, therefore I am.’ That would seriously put Descartes before the horse.”
The above statement comes from a New England Journal of Medicine (NEJM) editorial by the esteemed neurologist Allan H. Ropper. Dr. Ropper was referring to an accompanying NEJM study of 54 brain injured patients in which four patients thought to be in a persistent vegetative state (PVS) actually demonstrated the ability to control brain activity – in one case enough to answer simple yes or no questions – via the “activation” images on a functional MRI (fMRI). The study follows on the heels of the story of Rom Houben – a 46-year-old Belgian man thought to have been in a PVS for over twenty years. Recently, doctors, with the help of fMRI, diagnosed Houben with locked-in-syndrome – a rare neurologic condition that prevents the brain’s impulses (intentions to act, speak, etc.) from reaching the rest of the body. With Houben’s case and the newly released NEJM study, we have fresh wrinkles in the centuries old debate of where the brain ends and the mind begins. The question of the moment – as posed by Dr. Ropper – is whether fMRI activation, in the absence of other signs of awareness, is evidence of “life” in the brain? And if it is, what does this mean for the estimated 15,000 Americans currently considered to be in a vegetative state?
To address these questions, let’s first make an important distinction. Research shows that that people who have become “vegetative” due to brain trauma have a greater chance of recovering than those who have ended up “vegetative” because their brains were deprived of oxygen (such deprivation is called an “anoxic” event). Current thinking is that patients in the anoxic group (patients like Terri Schiavo) will either improve in the first three months or, sadly, never. The recent NEJM study supports this thinking in that none of the study’s patients who had suffered anoxic brain injury showed any evidence of being able to modulate brain activity. Among the patients who had suffered traumatic brain injury, however, the evidence was clearly much different. While it was previously thought that patients with traumatic brain injury were not likely to improve after the first year post-injury, Rom Houben’s circumstances and the NEJM study seem to call that one-year-deadline into question.
It seems then that we can expect minimal benefit from using fMRI on PVS patients with a history anoxic brain injury. In cases of traumatic brain injury, on the other hand, fMRI may be useful. But we must keep in mind that fMRI has a critical weakness: its results can only be considered definitive if positive .If the result is negative (no evidence of conscious brain activity), the patient might be asleep. This means that a negative fMRI can, at best, be part of an integrated evaluation process – including history, clinical exam, CT scan, and Electroencephalogram (EEG).
Perhaps fMRI should be considered as part of the work-up of brain injured patients if they do not show obvious signs of improvement within a year of injury? In some cases, these patients may even be able to answer questions, via fMRI, about whether they are in pain or perhaps even communicate their wishes about life-sustaining treatment. This sounds like a beneficial use of fMRI but must be measured against dollars and cents (a single fMRI scan costs approximately $700) and practicality (currently fMRI units are scarce and located primarily at research centers). The experts I contacted agreed that fMRI is not ready for widespread use in the PVS population. Dr. Geoffrey K. Aguirre, an assistant professor of neurology and an fMRI researcher at the University of Pennsylvania, emphasized, “The gold standard has been, and remains EEG. It does a great job of detecting sleep/wake cycles and distinguishing (for example) coma from locked-in syndrome from something in between. The fMRI work is focused upon the particular question of if you can give prognostic information for recovery from vegetative to minimally conscious state.” Dr. Art Caplan, from the University of Pennsylvania Center for Bioethics, also urged caution: “The real challenge is, as better scanning appears, when do we define it as the standard of care for determining PVS, minimal consciousness and death? I think that day is drawing closer but the cost and practicality are very real concerns.”
What are we to make of this? For me, the lesson is similar to that of the Terri Schiavo case; as uncomfortable as it may be, it is best to think about and communicate your wishes and beliefs about life in a PVS ahead of time. You can do so by preparing an advanced directive (living will) that identifies those people who will be responsible for making medical decisions for you (if you are incapacitated) and spells out specific wishes. For example, my living will says: “under no circumstances do I want to be portrayed on television if I am a coma or vegetative state.” I think this is like knocking on wood – if you take care of it ahead of time, it won’t happen. So, make your wishes clear. Talk about PVS with your family and your doctor now; don’t wait until the horse is out of the barn.
For more information on advanced directives go to: http://ag.ca.gov/consumers/general/adv_hc_dir.htm. For most, the California Probate Code Sample Form will suffice.
The above statement comes from a New England Journal of Medicine (NEJM) editorial by the esteemed neurologist Allan H. Ropper. Dr. Ropper was referring to an accompanying NEJM study of 54 brain injured patients in which four patients thought to be in a persistent vegetative state (PVS) actually demonstrated the ability to control brain activity – in one case enough to answer simple yes or no questions – via the “activation” images on a functional MRI (fMRI). The study follows on the heels of the story of Rom Houben – a 46-year-old Belgian man thought to have been in a PVS for over twenty years. Recently, doctors, with the help of fMRI, diagnosed Houben with locked-in-syndrome – a rare neurologic condition that prevents the brain’s impulses (intentions to act, speak, etc.) from reaching the rest of the body. With Houben’s case and the newly released NEJM study, we have fresh wrinkles in the centuries old debate of where the brain ends and the mind begins. The question of the moment – as posed by Dr. Ropper – is whether fMRI activation, in the absence of other signs of awareness, is evidence of “life” in the brain? And if it is, what does this mean for the estimated 15,000 Americans currently considered to be in a vegetative state?
To address these questions, let’s first make an important distinction. Research shows that that people who have become “vegetative” due to brain trauma have a greater chance of recovering than those who have ended up “vegetative” because their brains were deprived of oxygen (such deprivation is called an “anoxic” event). Current thinking is that patients in the anoxic group (patients like Terri Schiavo) will either improve in the first three months or, sadly, never. The recent NEJM study supports this thinking in that none of the study’s patients who had suffered anoxic brain injury showed any evidence of being able to modulate brain activity. Among the patients who had suffered traumatic brain injury, however, the evidence was clearly much different. While it was previously thought that patients with traumatic brain injury were not likely to improve after the first year post-injury, Rom Houben’s circumstances and the NEJM study seem to call that one-year-deadline into question.
It seems then that we can expect minimal benefit from using fMRI on PVS patients with a history anoxic brain injury. In cases of traumatic brain injury, on the other hand, fMRI may be useful. But we must keep in mind that fMRI has a critical weakness: its results can only be considered definitive if positive .If the result is negative (no evidence of conscious brain activity), the patient might be asleep. This means that a negative fMRI can, at best, be part of an integrated evaluation process – including history, clinical exam, CT scan, and Electroencephalogram (EEG).
Perhaps fMRI should be considered as part of the work-up of brain injured patients if they do not show obvious signs of improvement within a year of injury? In some cases, these patients may even be able to answer questions, via fMRI, about whether they are in pain or perhaps even communicate their wishes about life-sustaining treatment. This sounds like a beneficial use of fMRI but must be measured against dollars and cents (a single fMRI scan costs approximately $700) and practicality (currently fMRI units are scarce and located primarily at research centers). The experts I contacted agreed that fMRI is not ready for widespread use in the PVS population. Dr. Geoffrey K. Aguirre, an assistant professor of neurology and an fMRI researcher at the University of Pennsylvania, emphasized, “The gold standard has been, and remains EEG. It does a great job of detecting sleep/wake cycles and distinguishing (for example) coma from locked-in syndrome from something in between. The fMRI work is focused upon the particular question of if you can give prognostic information for recovery from vegetative to minimally conscious state.” Dr. Art Caplan, from the University of Pennsylvania Center for Bioethics, also urged caution: “The real challenge is, as better scanning appears, when do we define it as the standard of care for determining PVS, minimal consciousness and death? I think that day is drawing closer but the cost and practicality are very real concerns.”
What are we to make of this? For me, the lesson is similar to that of the Terri Schiavo case; as uncomfortable as it may be, it is best to think about and communicate your wishes and beliefs about life in a PVS ahead of time. You can do so by preparing an advanced directive (living will) that identifies those people who will be responsible for making medical decisions for you (if you are incapacitated) and spells out specific wishes. For example, my living will says: “under no circumstances do I want to be portrayed on television if I am a coma or vegetative state.” I think this is like knocking on wood – if you take care of it ahead of time, it won’t happen. So, make your wishes clear. Talk about PVS with your family and your doctor now; don’t wait until the horse is out of the barn.
For more information on advanced directives go to: http://ag.ca.gov/consumers/general/adv_hc_dir.htm. For most, the California Probate Code Sample Form will suffice.
Sunday, February 7, 2010
Vegetative no more? (Marin IJ)
Sometimes you read a story that is too astonishing to believe. “Just imagine. You hear, see, feel and think but no one can see that,” wrote a Belgian man whose mind had been trapped in a paralyzed body for twenty-three years – unable to communicate to his family that he was not a vegetable. The story of Rom Houben, a former engineering student and martial artist paralyzed and comatose after a car crash over two decades ago, leapt into the news last November and, at first, appeared too incredible to be real. You see, the forty-six-year-old Houben had been recently diagnosed with locked-in-syndrome – a rare neurologic condition in which the brain’s impulses (intentions to act, speak, etc.) are blocked from reaching the rest of the body. Here’s what else you need to know about locked-in syndrome; the vast majority of cases are due to a stroke in a very specific area of the brain (the pons) in which damage is usually detected within days to weeks by an MRI scan. These patients usually can still move their eyes and use them to communicate. If you saw the movie The Diving Bell and the Butterfly you are familiar with how this can work.
Thus, several aspects of Houben’s situation made him unique among locked-in patients; he suffered an accident that caused severe, generalized head trauma rather than a stroke with surgically-precise effects; he was not properly diagnosed for over twenty-years; and he uses faint finger movements – rather than eye movements – to guide the hand of a speech therapist to keys on a keyboard. It is this final difference, the use of what is called “facilitated communication,” that triggered a round of media skepticism. That’s because facilitated communication has ample potential for abuse. According to James Randi, a blogger specializing in de-mystification, the facilitated communication process is a “very intimate participatory action...and tests show that it is a complete fraud, farce, and delusion!” Art Caplan, a prominent bioethicist at University of Pennsylvania, is also dubious; “Sadly,” he wrote in a column for msnbc.com, facilitated communication “has been shown time and again to be unreliable. There is something of the ouiji board about the whole thing.” Shortly after this commentary emerged, communication from Houben and his family abruptly ceased – fueling speculation – too incredible to be true?
But wait, before we write off this story as a farce, consider the circumstances of Houben’s diagnosis. Houben was studied by Dr. Steven Laureys of the Coma Science Group at the University of Liege. Laureys’ evaluation was rigorous – quite different, for example, than Senator Bill Frist’s video-based pronouncement, back in 2005, that Terri Schiavo was not in a persistent vegetative state. Dr. Laureys put Houben through a series of tests, including a functional MRI. What the heck, you may ask, is a functional MRI (fMRI for short)? It’s a specialized brain MRI that creates a visual representation of areas of increased oxygen use in the brain – demonstrating, in essence, which parts of the brain are actively thinking or performing. The “functional” piece of the study is usually teased out by having the patient perform a specific task – such as tapping pictures on a screen (much like the iPhone app “Bugs”) – the areas of the brain being used to identify the picture and tap it will then “light up” on the fMRI.
In Houben’s case, the purpose of the fMRI was not to look for activity in specific areas of the brain, but rather to look for evidence of any activity at all. Apparently, and the specifics are murky because Laureys and his team have yet to publish the details, Houben’s brain activated in many areas of the cerebral cortex. This is pretty solid evidence that he is awake and that his brain is working, at least to some degree. It was these fMRI findings, then, that led to the attempt at facilitated communication – and its seemingly miraculous results. Without more details and access, it is impossible to know how much of Houben’s communication is real, but it does seem likely that he is awake. And, it also appears likely that his doctors missed this fact for over twenty years. The implications are potentially immense.
There are an estimated 15,000 patients in this country who have been diagnosed as being in a persistent vegetative state. Small studies have estimated that as many as 40% of such patients may have some minimal brain activity. But, are some of these patients fully awake – fully aware that they are trapped inside a body that doesn’t move? My guess is probably not – that Houben’s case, if real, is extremely unusual. But, nonetheless, there are those who may use the Houben case as justification for never removing life-sustaining support – even in a case like Terri Schiavo’s in which there was clinical (seven neurologists) and radiographic (a CT scan showing a severely atrophied brain) consensus of a persistent vegetative state. In a health system in the fast lane to bankruptcy, how many resources should be spent on sifting through thousands of Terri Schiavo’s to find one Rom Houben? This is not an easy question to answer – but it is one that needs to be addressed. To learn more, lock back in to this column in a couple weeks.
Thus, several aspects of Houben’s situation made him unique among locked-in patients; he suffered an accident that caused severe, generalized head trauma rather than a stroke with surgically-precise effects; he was not properly diagnosed for over twenty-years; and he uses faint finger movements – rather than eye movements – to guide the hand of a speech therapist to keys on a keyboard. It is this final difference, the use of what is called “facilitated communication,” that triggered a round of media skepticism. That’s because facilitated communication has ample potential for abuse. According to James Randi, a blogger specializing in de-mystification, the facilitated communication process is a “very intimate participatory action...and tests show that it is a complete fraud, farce, and delusion!” Art Caplan, a prominent bioethicist at University of Pennsylvania, is also dubious; “Sadly,” he wrote in a column for msnbc.com, facilitated communication “has been shown time and again to be unreliable. There is something of the ouiji board about the whole thing.” Shortly after this commentary emerged, communication from Houben and his family abruptly ceased – fueling speculation – too incredible to be true?
But wait, before we write off this story as a farce, consider the circumstances of Houben’s diagnosis. Houben was studied by Dr. Steven Laureys of the Coma Science Group at the University of Liege. Laureys’ evaluation was rigorous – quite different, for example, than Senator Bill Frist’s video-based pronouncement, back in 2005, that Terri Schiavo was not in a persistent vegetative state. Dr. Laureys put Houben through a series of tests, including a functional MRI. What the heck, you may ask, is a functional MRI (fMRI for short)? It’s a specialized brain MRI that creates a visual representation of areas of increased oxygen use in the brain – demonstrating, in essence, which parts of the brain are actively thinking or performing. The “functional” piece of the study is usually teased out by having the patient perform a specific task – such as tapping pictures on a screen (much like the iPhone app “Bugs”) – the areas of the brain being used to identify the picture and tap it will then “light up” on the fMRI.
In Houben’s case, the purpose of the fMRI was not to look for activity in specific areas of the brain, but rather to look for evidence of any activity at all. Apparently, and the specifics are murky because Laureys and his team have yet to publish the details, Houben’s brain activated in many areas of the cerebral cortex. This is pretty solid evidence that he is awake and that his brain is working, at least to some degree. It was these fMRI findings, then, that led to the attempt at facilitated communication – and its seemingly miraculous results. Without more details and access, it is impossible to know how much of Houben’s communication is real, but it does seem likely that he is awake. And, it also appears likely that his doctors missed this fact for over twenty years. The implications are potentially immense.
There are an estimated 15,000 patients in this country who have been diagnosed as being in a persistent vegetative state. Small studies have estimated that as many as 40% of such patients may have some minimal brain activity. But, are some of these patients fully awake – fully aware that they are trapped inside a body that doesn’t move? My guess is probably not – that Houben’s case, if real, is extremely unusual. But, nonetheless, there are those who may use the Houben case as justification for never removing life-sustaining support – even in a case like Terri Schiavo’s in which there was clinical (seven neurologists) and radiographic (a CT scan showing a severely atrophied brain) consensus of a persistent vegetative state. In a health system in the fast lane to bankruptcy, how many resources should be spent on sifting through thousands of Terri Schiavo’s to find one Rom Houben? This is not an easy question to answer – but it is one that needs to be addressed. To learn more, lock back in to this column in a couple weeks.
Monday, January 18, 2010
Do you know an anorexic?
What killed Brittany Murphy? Ever since the 32-year-old actress died last month, rumors regarding the cause of her death have sprouted like weeds in spring. Media reports have suggested poorly controlled diabetes, prescription drug abuse, and complications from anorexia. As to the latter, Murphy was skinny, one look at the tabloid photos makes that clear, but was she anorexic? The results of her autopsy are pending but, realistically, we may never have a definitive answer to that question. Certainly, I am in no position to speculate one way or another. Nonetheless, this tragedy provides an opportunity to think about anorexia nervosa – a poorly understood and deceptively deadly condition. In a culture in which obesity is rampant, it is important to appreciate the distinction between applauding those who avoid the bulge and identifying and helping those who go too far.
Anorexia is more than just being skinny or being a diet or exercise nut – it is a psychological condition defined by distorted body image and associated with low self-esteem and poor coping mechanisms. It affects both women and men and usually does so at a young age. Anorexia comes in two major variations – the restrictive type (severely cutting back on food intake) and the binging and purging (bulimia) type. Both are associated with other psychological conditions and often go undiagnosed for years. Think you know someone with anorexia? You probably do – one out of every two people does. And although most anorexics struggle in secrecy there is a “Pro-ana” movement out there that defends anorexia as a lifestyle choice – which makes about as much sense to me as choosing to be a paranoid schizophrenic.
Make no mistake; anorexia is a serious illness with serious medical complications. People with anorexia can develop osteoporosis, thyroid problems, decreased infection-fighting capabilities, body salt imbalances, heart arrhythmias, severe bloating, and seizures. They are also at increased risk of suicide. In fact, the death rate among anorexics may be as high as 20% – meaning that one in five people with anorexia will die prematurely from complications associated with the disease. This mortality rate is far higher than rates associated with highly publicized health threats such as the swine flu and high blood pressure (hypertension). And this winter, while you’re worried about missing work because of a cold, consider that anorexics are at a far greater risk of dying during cold weather due to infection or hypothermia.
This case report from Medical Emergencies in Anorexia Nervosa (Jane Morris and Chris Freeman) paints a typical and tragic picture:
“A 26 year old hairdresser took up running, started an extreme diet and lost weight swiftly over eight months, steadfastly refusing help. She finally presented to the hospital with chest pains. At this stage her BMI [body mass index] was 13.5 [low end of normal is 18.5]…She declined all food in the hospital but tolerated an IV [intravenous] line. She believed that as a result of this she had gained weight. She died in her sleep the following week, the night after swimming ten lengths of her local pool.”
Are you concerned that someone you know is on the brink of this type of calamity? How do you know whether someone might be suffering from the anorexia? Here are some clues:
- Refusing to eat in front of others or eating slowly and very little
- Preparing elaborate meals for family and friends but not eating anything themselves
- Continued dieting, despite being very thin and having already achieved significant weight loss
- Obsession with exercise combined with extreme dieting
Unfortunately, identifying someone who needs help may be easier than persuading them to seek help. The key is to bring the issue to light, in a constructive rather than confrontational manner. Be aware that denial is common, especially when it comes to the serious health risks associated with anorexia. I spoke with Dr. Irina deFischer, a Kaiser family physician and eating disorder expert: “It is important to involve parents, other family members, loved ones, and friends in getting patients into treatment – these patients are often not motivated to seek treatment on their own because they don't perceive that the eating disorder is hazardous to their health – there is a strong societal message that eating ‘healthy,’ losing weight, and exercising a lot are good things, and they get a lot of strokes for being thin and looking good.” This re-enforcement, of course, is counter-productive, especially since treatment for eating disorders – whether it be therapy and/or medication – is far more effective early in the disease process than after the illness has been simmering for years.
So, if indeed Brittany Murphy suffered from anorexia, she likely had suffered for years and reached an age at which successful intervention would have been very tricky. Take a moment to consider that and whether there is someone you can help now – before it is too late.
Some web resources:
http://www.beyondhunger.org/events.html/
http://www.nationaleatingdisorders.org/
http://www.something-fishy.org/
Thursday, December 31, 2009
Tips (Marin IJ)
Unless you’re a masochist, a trip to your local Emergency Department (ED) is most likely an unpleasant proposition. Such a journey is replete with anxiety-provoking features; an impersonal waiting room, sharp needles, blood (often your own), shrill alarms, and uncertainty about what’s coming next.
It’s not surprising, then, that most people don’t consider the logistics of an ED visit ahead of time. But they should. Not doing so is like going into the backcountry without a “ten essentials” survival kit – things will probably turn out fine, but you’ll be awfully bummed if they don’t. Fortunately, with some simple preparations, you can minimize both the risk and the hassle of a sudden illness.
Last weekend, during a busy ED shift, I asked a patient what the worst thing about his visit was. “I think you know,” he replied, “…it was the wait.” Sadly, that captures an unavoidable reality about Emergency Departments and brings me to my first tip – be prepared to wait. Of course, most of you know this already. But nonetheless, some people still think that an ED functions like a restaurant – first come, first served. This is simply not true – many different variables determine who gets seen and when, but the bottom line is that we triage based on severity; the more life-threatening your illness appears to be, the quicker you will be seen. Thus, if you come to the ED with a gouty toe, expect to wait, but if you have a crushing chest pain and are asked to wait, something is wrong and you should speak up. And if your gouty toe can’t stand the ED waiting room, you might consider alternatives– your regular physician offers personalized and (usually) cheaper care. A visit to the web (Kaiser members can visit http://www.kp.org/) or a call to a health advice line can offer helpful perspective. If you do end up on your way to the ED, bring a book or perhaps your Christmas Kindle. I recommend loading Complications by Atul Gawande.
Speaking of complications, one that makes all emergency physicians nervous is aspiration –vomiting stuff from your stomach to your lungs. This is of particular concern during procedures that need sedation. So, if you’ve taken a bad tumble and your arm is as floppy as a fish, avoid stopping at the drive-thru on the way to the hospital. If you do eat or drink anything, it may delay your procedure by up to six hours.
While food is off the table at this point, clean underwear is not. Most patients in the ED will be expected to strip down to their skivvies, (in order to get a complete physical exam) so you might as well make a point of donning a clean set. Like underwear, another thing that should be up-to-date as you enter the ED is your list of medications. You will undoubtedly be asked about your meds, so rather than relying on your memory, have a card ready in your wallet. Be sure you include over-the-counter medications and supplements and note any drug allergies. Given the ubiquitous computer, this may seem unnecessary. But, believe me, it is extremely helpful – I trust diligent patients’ written records of their medications more than the ones I find on my computer screen.
Once you’ve made it through triage, set your cellphone to vibrate and get ready to tell your story. This is vital – how you communicate with your doctor at this juncture will go a long way towards determining the appropriateness of your work-up. Once a medical professional (doctor or nurse) arrives, start with compliments (we all like them!) and avoid gender stereotyping – there are many male nurses and a whole lot of female physicians, and most of us dress very much the same. After you’re done with the pleasantries and have figured out who is who, be clear about why you came to the ED and about your expectations. In the ED, we are very good at recognizing and treating emergent medical problems, and not so good at treating chronic ones. So, tell us what is new and, when you are being questioned, stick to that subject as much as possible. For example, you are likely to befuddle your doctor if you interrupt his line of questioning about abdominal discomfort to tell him about years of foot pain.
Finally, as the visit unfolds, consider this; more tests do not necessarily mean better care; questions about your diagnosis and treatment are better at the end of your visit than the beginning; and every pet owner should have a back-up pet sitter. Amazingly, pet care seems to be (in my unofficial estimation), the #1 reason why people leave the ED against medical advice. I’m an animal lover myself, still, it is hard to understand why someone having a heart attack leaves the hospital so that they can take Barky out for a pee. But, it happens frequently. So please, set up an emergency pet-care system – a list of people who can take care of your pet while you take care of yourself. Don’t be afraid to ask hospital personnel to help you make those phone calls. Better to stay in the hospital for a day or so then to stoically make it home for one last walk with Barky.
There you go, tips from someone who’s been there before. I hope you won’t have to put them to use.
Wednesday, December 23, 2009
Letter to Santa (Marin IJ)
Doctor I.M. Igloo North Pole Community Health Clinic, North Pole
Dear Mister Claus,
I am writing to ask your indulgence with a manifesto of unsolicited advice. Being mindful of the vast amount of correspondence you receive, I nonetheless ask that you pay close attention to this letter, as it is of immense importance. Truth be told, it may be a matter of life or death.
Mister Claus, you are too fat. That is impolitic, I know, but based on the data from your most recent check-up, you are, without a doubt, morbidly obese. Mr. Claus, have you heard about the BMI? No, this is not new Xbox lingo; it is your body mass index. And yours is unsightly; like a gift wrapped in toilet tissue. Based on your height and weight you have a BMI of 44 – which is far above the normal range of 25 to 30. This, I’m afraid, places you in danger of myriad medical conditions: diabetes, high blood pressure, heart disease, and arthritis, to name a handful. It also amplifies the chimney-related occupational risk you face each December 24th. In sum, this is a great jolly health disaster just waiting to happen.
Mister Claus, perhaps you saw the recent Harvard study published in the New England Journal of Medicine? The authors calculated future life expectancies based on current and historical data and found that the heavy tide of obesity will likely wipe out all of the societal benefits of smoking cessation efforts. I shall quote Susan T. Stewart, Ph.D., lead author on the study; "In the past 15 years, smoking rates have declined by 20 percent, but obesity rates have increased by 48 percent. If past trends continue, nearly half of the population (45 percent) is projected to be obese by 2020." Now, this is a sensitive topic for many people, and I recognize that, genetically speaking, people come in all shapes and sizes. Maintaining a healthy weight is much easier for some than for others. But, nonetheless I fear that you have chosen image over sensibility.
So, Mister Claus, because I am greatly concerned for your well being (not to mention that of the world’s children), I have put together a holiday wish-list for your health.
1) Mini-size the portions. I have heard that Mrs. Claus makes a delicious potpie and that your home is filled with candy canes and sugarplums. Temptation is everywhere in your cozy nook of the world. All I would ask is that you keep the portions reasonable and only eat when you are hungry. One more thing, don’t feel obligated to politely consume each tasty morsel left for you above the fireplace – save some for the Grinch, his frame can spare an extra cookie or two. And, for goodness sake, have some broccoli with your potatoes – not only does it help fill you up, but it also contains phytochemicals that may help ward off diabetes, heart disease and obesity.
2) Pay attention to the calories when dining out. Eating well on the road is tough, I don’t have to tell you that. But, you should know that most people grossly underestimate the number of calories in a restaurant meal. Restaurant chains may soon be required to calorie-label their menus. In the meantime, you might consider gifting yourself a copy of Eat This Not That! 2010. This useful tome gives you an idea of the calories in common restaurant meals. For instance, the grilled chicken and avocado club at the Cheesecake Factory brings home over 1700 calories (better split that with the Missus). And, one last thing, when you park the sleigh at the convenience store, just say No-Nos to the Ho-Hos.
3) Don’t let the reindeer do all the work. Or the elves for that matter. A year’s worth of armchair-based supervision followed by a night of sitting in a sleigh is appallingly sedentary. Like many people, I am sure that you find it difficult to carve out dedicated time for exercise. So, why not make exertion part of your work? You may have seen the recent evidence that suggests that men who walk or bike to work enjoy better health than those who do not (even when controlling for other types of physical activity). I recommend that you outfit your sleigh with a bicycle apparatus – that way you can give Prancer and Dasher and the boys a little assistance, while servicing your waistline at the same time.
4) Every now and again, consider your own happiness. You may laugh for the children and smile for the camera, but I suspect that your mental health is not as robust as you would have us believe. Research has shown a link between obesity and depression, although it is hard to know which leads to the other. But, whatever the causal link, I am confident that you will find greater contentment with lesser corpulence.
Mister Claus, thanks for your tolerance with my badgering counsel. Your time is valuable, that I know, but so is your continued good health. Indulge less, live better.
Sincerely,
Dr. I.M. Igloo
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