Earlier this season on AMC’s popular drama Mad Men (a series set in the 1960s), a character named Anna is diagnosed with terminal cancer. When viewers see her, the disease has invaded and fractured her leg and, we’re told, she has only a few months left to live. Anna, however, is blissfully unaware of her condition – she believes that in a few weeks she will be dancing again. How can an independent middle-aged woman be diagnosed with cancer and not be aware of it? In this instance, it’s because her sister and doctors have agreed that it is in Anna’s best interest not to know.
When series lead Don Draper learns of the situation, he is, at first, furious. “I'm here now,“ he tells Anna’s sister, “she's going to see some real doctors, and she's not going to live in the dark."
"You have no say in the affairs of this family," the sister replies. "You're just a man in a room with a checkbook." Ultimately, Draper decides to honor her request to "do the decent thing" and leave before he reveals the diagnosis.
Pretty shocking, isn’t it? Could you envision this “decent thing” happening to you? I should hope not. Most readers would agree that it is intrinsically wrong for a physician or family member to decide what personal health information is “good” for an independent adult to know. But, just fifty years ago, withholding health information was standard practice. What has changed? Respect for patient autonomy.
Patient autonomy is one of the four core principles of medical ethics – famously articulated by Justice Benjamin Cardozo in 1914. “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.” But, as accurately portrayed in Mad Men, this basic principle was not widely accepted until the last half century. Before then, there existed a quaint and persuasive notion that doctors were best equipped to make decisions about what information was healthy for their patients and what was not – just as a parent would do with diet choices for a young child. The transformation from a paternalistic, “we know what is best” approach to an autonomous approach was spurred not just by the words of Justice Cardozo, but also by revelations about unethical medical studies (including the “research” atrocities committed in Nazi Germany and the infamous Tuskegee (Alabama) syphilis studies in which infected African-Americans were neither told their diagnosis nor offered treatment.) These abuses made the critical weakness of paternalistic medicine – the potential for abuse in the name of another’s best interests – unmistakable and unacceptable. Nowadays, a competent patient cannot receive a medical intervention or participate in a research trial without autonomously giving “informed consent.”
So, what do you, as a patient or a potential patient, need to know about protecting your autonomy and giving informed consent? Well, let’s consider an example; a common operation like an appendectomy. Before your surgeons can proceed, they must explain to you the procedure’s risks (bleeding/infection), benefits (avoiding appendix rupture), and alternatives (wait-and-see approach). Then, they will have you sign a document to prove that you have been informed and given your consent. What they won’t necessarily do is ensure that you have understood all the details. Studies have demonstrated that, in general, patients’ understanding of consent information is spotty at best – a survey of people involved in a clinical trial of a cholesterol-lowering medication found that only 31% could name the main side effect of the treatment. How informed is your consent if you don’t know what side effects to look out for?
The burden of understanding your medical care does, I’m afraid, fall primarily on you, the patient. And a critical component of this understanding is considering what information is of particular importance to you. The legal standard for disclosure of information is based on what a “reasonable” patient would want to know. But I suggest that your personal standard be your response to a friend’s query, “What the heck is it they want to do to you?” When it comes to an appendectomy, there may not be much variance in how people respond. That may not, however, be the case for other medical tests or interventions.
What about a blood test that could determine if you’re at risk for developing dementia at a young age? This type of test doesn’t exist, but if it did, would you take it? How important would its accuracy be to you and what percentage of “false positives” could you live with? Of course you’d want to know if there were risks involved. But also consider the ramifications of being told that your productive life will be cut short by twenty or so years. Making a choice about whether to know that or not is a very personal calculation. Is this information you would want to know, or is this a case where ignorance is bliss? In this day and age, your doctors cannot withhold a diagnosis of cancer from you, but they may someday be able to offer you a test that predicts your risk of cancer. How much would you want to know? Even if you are young and healthy, it’s never too early to think about what you’d do – or want done. Medical ethics can be sticky, informed consent can seem esoteric, but it’s your consent regarding your health. Embrace your autonomy.
Monday, September 27, 2010
Wednesday, September 22, 2010
Is Smelling Like a Fish Still Worth It? (Marin IJ)
Fish oil has become a popular dietary supplement – one endorsed by cardiologists, Consumer Reports and this column. It contains marine omega-3 fatty acids, known to biochemists as docosahexanoic acid (DHA) and eicosapentaenoic acid (EPA) that are thought to have beneficial anti-inflammatory and anti-clotting properties. But over the last six months, the safety and effectiveness of fish oil has been questioned, leading some to wonder… has the era of fishy burps come to an end? Could it be that the purported benefits of mackerel are actually baloney?
This past March, a group of plaintiffs, including the Mateel Environmental Justice Foundation, filed suit against five manufacturers of fish oil supplements – contending that the products contain levels of polychlorinated biphenyl (PCB) that are above California’s “safe harbor” limit. PCBs (for those, like me, who have a hard time keeping their environmental toxins straight) are industrial chemicals that take an extremely long time to degrade in the environment. Although they used to be widely used, PCBs are now banned. They’ve been linked to cancer (in rats) and to a number of other health conditions. The plaintiffs based their complaint on tests they’d performed themselves – by puncturing fish oil capsules and studying their contents. Their suit alleges wide ranges in PCB concentrations – with some products being well above the reportable level (90 nanograms a day). "The people buying these fish oil supplements,” attorney (and plaintiff) David Roe said “are not being told the PCBs are there." This legal announcement, and the accompanying press coverage, scared the fish oil right on out of some folks.
Then, just last month, The New England Journal of Medicine published the results of a Dutch study (the Alpha Omega Trial) that followed patients who’d previously had heart attacks and who were taking omega-3s (in the form of margarine fortified with marine and/or plant fatty acids). The study subjects (all on standard heart medications such as aspirin) were given small tubs of margarine – with or without different formulations of omega-3 fatty acids – and their intake was tracked by measuring the amount of unused margarine at 12-week intervals. The study followed nearly 5,000 patients for forty months and found no difference in “major cardiovascular events” (such as repeat heart attack or stroke) or in death rates between those who were and those who were not taking omega-3s of any type.
For fish oil advocates, this seems discouraging. And, if you factor in environmental concerns about over-fishing, perhaps it is time to re-consider fish oil. But wait, before you toss out those omega-3 soft gels and discontinue fresh fish Friday dinners, consider some additional perspective.
First, regarding PCBs, there are several reasons not to get too freaked out.
1) No one really knows how dangerous PCBs truly are. Numerous studies have failed to link PCBs to cancer in humans (rats are a different story). And while there is no good data on what a safe level of PCB exposure is, the California reporting limit is far below federal levels.
2) Previous, more comprehensive, studies of fish oil supplements have found limited contamination with heavy metals or PCBs. This is not to say that there aren’t outliers, but the vast majority of fish oil supplements likely contain less PCB than fresh fish or meat.
3) The brands with high PCB levels named in the recent lawsuit are predominantly cod and shark liver oil products. The liver, as you probably know, processes chemicals, meaning that oil from the liver is more likely to contain detectable levels of PCB. Perhaps, and I stress perhaps, it is better to avoid fish liver products.
In my opinion, recall the maxim “the dose makes the poison” and don’t be majorly concerned about PCB toxicity in your fish oil. But, what if, as the Alpha Omega Trial suggests, marine omega-3s offer no beneficial health effects? Well, that would be a different story. There are several reasons, however, to doubt this conclusion;
1) The Alpha Omega Trial, despite being a well-designed prospective study, has some weaknesses. These include the forty-month follow-up time – which does not give us a good sense of long-term events. Second, this study focused on a group of patients already on state-of-the-art cardiac treatment. Third, there is the choice of omega-3 delivery. Dr. Alan S. Go, a senior cardiovascular researcher at Kaiser-Permanente, told me “The choice of putting these agents into margarine was rather curious, especially given that the trans fatty acids in margarine are cardiotoxic and perhaps could have blocked any potential beneficial effects.”
2) Multiple previous studies have suggested an array of protective effects from omega-3s – particularly marine omega-3s. These benefits are not restricted to those people who have already had a heart attack – and it may be those at risk are more likely to benefit.
Where then, does this leave us? Well, as is often said in science, further study is necessary. But, Dr. Go and others are still on board the omega-3 boat; “the overall preponderance of evidence supports the efficacy of marine omega-3 fatty acids for reducing cardiovascular events and arrhythmic events - in selected populations - and the benefits of eating more fish with higher omega-3 levels likely outweigh the risks from contaminants (at least currently)."
This doesn’t mean I recommend fishy omega-3s for everyone, but those at risk should consider them (either via diet or supplements). If in doubt, talk to your doctor. I, for one, am not giving up Kirkland Signature soft gels just yet. Given my family history of heart problems and hypertension, I am willing to risk a few nanograms of PCB for a potentially healthier heart; I just hope my wife is willing to risk the olfactory offense of an occasional fishy burp.
This past March, a group of plaintiffs, including the Mateel Environmental Justice Foundation, filed suit against five manufacturers of fish oil supplements – contending that the products contain levels of polychlorinated biphenyl (PCB) that are above California’s “safe harbor” limit. PCBs (for those, like me, who have a hard time keeping their environmental toxins straight) are industrial chemicals that take an extremely long time to degrade in the environment. Although they used to be widely used, PCBs are now banned. They’ve been linked to cancer (in rats) and to a number of other health conditions. The plaintiffs based their complaint on tests they’d performed themselves – by puncturing fish oil capsules and studying their contents. Their suit alleges wide ranges in PCB concentrations – with some products being well above the reportable level (90 nanograms a day). "The people buying these fish oil supplements,” attorney (and plaintiff) David Roe said “are not being told the PCBs are there." This legal announcement, and the accompanying press coverage, scared the fish oil right on out of some folks.
Then, just last month, The New England Journal of Medicine published the results of a Dutch study (the Alpha Omega Trial) that followed patients who’d previously had heart attacks and who were taking omega-3s (in the form of margarine fortified with marine and/or plant fatty acids). The study subjects (all on standard heart medications such as aspirin) were given small tubs of margarine – with or without different formulations of omega-3 fatty acids – and their intake was tracked by measuring the amount of unused margarine at 12-week intervals. The study followed nearly 5,000 patients for forty months and found no difference in “major cardiovascular events” (such as repeat heart attack or stroke) or in death rates between those who were and those who were not taking omega-3s of any type.
For fish oil advocates, this seems discouraging. And, if you factor in environmental concerns about over-fishing, perhaps it is time to re-consider fish oil. But wait, before you toss out those omega-3 soft gels and discontinue fresh fish Friday dinners, consider some additional perspective.
First, regarding PCBs, there are several reasons not to get too freaked out.
1) No one really knows how dangerous PCBs truly are. Numerous studies have failed to link PCBs to cancer in humans (rats are a different story). And while there is no good data on what a safe level of PCB exposure is, the California reporting limit is far below federal levels.
2) Previous, more comprehensive, studies of fish oil supplements have found limited contamination with heavy metals or PCBs. This is not to say that there aren’t outliers, but the vast majority of fish oil supplements likely contain less PCB than fresh fish or meat.
3) The brands with high PCB levels named in the recent lawsuit are predominantly cod and shark liver oil products. The liver, as you probably know, processes chemicals, meaning that oil from the liver is more likely to contain detectable levels of PCB. Perhaps, and I stress perhaps, it is better to avoid fish liver products.
In my opinion, recall the maxim “the dose makes the poison” and don’t be majorly concerned about PCB toxicity in your fish oil. But, what if, as the Alpha Omega Trial suggests, marine omega-3s offer no beneficial health effects? Well, that would be a different story. There are several reasons, however, to doubt this conclusion;
1) The Alpha Omega Trial, despite being a well-designed prospective study, has some weaknesses. These include the forty-month follow-up time – which does not give us a good sense of long-term events. Second, this study focused on a group of patients already on state-of-the-art cardiac treatment. Third, there is the choice of omega-3 delivery. Dr. Alan S. Go, a senior cardiovascular researcher at Kaiser-Permanente, told me “The choice of putting these agents into margarine was rather curious, especially given that the trans fatty acids in margarine are cardiotoxic and perhaps could have blocked any potential beneficial effects.”
2) Multiple previous studies have suggested an array of protective effects from omega-3s – particularly marine omega-3s. These benefits are not restricted to those people who have already had a heart attack – and it may be those at risk are more likely to benefit.
Where then, does this leave us? Well, as is often said in science, further study is necessary. But, Dr. Go and others are still on board the omega-3 boat; “the overall preponderance of evidence supports the efficacy of marine omega-3 fatty acids for reducing cardiovascular events and arrhythmic events - in selected populations - and the benefits of eating more fish with higher omega-3 levels likely outweigh the risks from contaminants (at least currently)."
This doesn’t mean I recommend fishy omega-3s for everyone, but those at risk should consider them (either via diet or supplements). If in doubt, talk to your doctor. I, for one, am not giving up Kirkland Signature soft gels just yet. Given my family history of heart problems and hypertension, I am willing to risk a few nanograms of PCB for a potentially healthier heart; I just hope my wife is willing to risk the olfactory offense of an occasional fishy burp.
A Contested Illness (Marin IJ)
Some years ago, a sinewy chap sought my help for an aggravating condition. This young man was convinced that microscopic bugs were crawling over and under his skin. You can imagine how horrible this creeping sensation would be and it had driven this guy to a frenzy of restlessness. His arms and legs were covered with excoriated sores and fingernail-induced streaks of scarlet. I inspected him from head to toe and couldn’t find evidence of insects or parasites. Then, as I silently puzzled the situation, he handed me a smudged envelope and asked me to carefully look inside. I removed a half dozen pieces of scotch tape, each holding a spattering of blackish specks. These specks, he declared, were the bugs that were tormenting him. I was doubtful, but nonetheless took a close look under a microscope. And while I didn't see signs of movement or anatomic structure, I wasn’t sure what the specks were or where they’d come from. After several minutes of debate, during which my patient wanted answers and I challenged his theory but failed to offer an alternative explanation, I noticed something. His fingernails were crusty. Along the nail bed and under the nail tips I noticed a blackish substance that looked like..."Are you a painter?" I asked him. Well, indeed he was, and it seemed clear to me that he was mistaking paint chips for parasites. But, he remained dubious. I thought he probably had a psychiatric condition called "delusional parasitosis;" he was certain that he had a treatable infestation.
Years later, I wonder whether this patient and I were meeting at the intersection of a contested illness known (to some) as Morgellons syndrome. You may have heard of Morgellons before; it received some media attention around the time that the Centers for Disease Control and Prevention (CDC) announced they were partnering with Kaiser Permanente to study the syndrome. But more on that later. First, what exactly is a “contested illness”?
To define “contested illness,” let’s start with the concept of “medicalization” – the process by which aspects of the human situation are described and treated as medical conditions or illnesses. For example, bad breath is diagnosed as “halitosis”, and excessive sweating transforms into “hyperhidrosis.” Writes Dr. H. Gilbert Welch in an LA Times editorial: “Everyday experiences get turned into diseases, the definitions of what (and who) is normal get narrowed…we doctors feel increasingly compelled to look hard for things to be wrong in those who feel well.” Lately, the medicalization of society has been driven forward by several dynamics. These include the insatiable market and marketing of personal health and beauty products, and the Internet-enabled organizing capability of condition-specific support groups. When advocacy groups (arguing that they are suffering from a treatable medical condition) collide with skeptics within conventional medical institutions, the result is a “contested illness” such as Morgellons.
Nearly ten years ago, biologist Mary Leitao’s s two-year-old son developed a strange skin condition. He scratched at himself incessantly, creating sores that, upon close inspection, contained bundles of multi-colored fibers. The physicians Leitao consulted were either baffled or skeptical. Frustrated, Leitao set out to educate herself and, in the process, discovered that her son’s symptoms had been described before, as far back as the 1500s. In fact, she found a name for the problem in Thomas Browne's A Letter to a Friend (1690). The letter described a "distemper of children... called the Morgellons, wherein they critically break out with harsh hairs on their backs." Determined to help her son and others like him, Leitao created the Morgellons Research Foundation and its website to disseminate information about the condition. She was surprised when thousands of strangers with similar symptoms contacted her. Pretty soon, Mary Leitao’s frustration had transformed into an advocacy movement. But, experts in dermatology and psychiatry were not convinced – the overwhelming opinion from the medical community was that Morgellons was a variant of delusional parasitosis – a well-described psychiatric condition. According to dermatologist Norman Levine (quoted by Brian Fair in his recent article in Sociology of Health & Illness), “[Morgellons] is not a mysterious disease…If you polled 10,000 dermatologists, everyone would agree [that Morgellons is Delusional Parasitosis].”
As Morgellons became more contested, the CDC, at the behest of some members of Congress, got involved. The CDC chose a middle ground in nomenclature – calling the condition “unexplained dermopathy,” and partnered with Kaiser Permanente to enroll and study patients suffering from “…symptoms including crawling, biting and stinging sensations; granules, threads or black speck-like materials on or beneath the skin; and/or skin lesions…”
And so here we are, several years later, waiting for the results and a peer-reviewed publication. The CDC website states that data collection for the study (which included skin samples from affected patients) is complete and under review by an expert panel. A press officer at the CDC confirmed this status (an inquiry to the Morgellons Research Foundation was not answered).
Whatever the CDC reports, in my opinion the Morgellons story illuminates two distinct points. First, patients’ symptoms should always be taken seriously and symptomatic treatment offered if available. In the case of Morgellons-type symptoms, this means a thorough exam to look for an explanation and (at a minimum) recommendations to alleviate symptoms (such as hydrocolloid dressings, low-dose steroid creams and anti-itching medications). Second, the medicalization of the human condition contributes to the development of contested illnesses and this is not healthy. Is Morgellons the medicalization of a psychiatric condition or is it an unexplained illness? We don’t know. But while it is clear that those with an “unexplained dermopathy” do not feel well, it is also very unclear whether modern medicine is capable of a definitive solution to their problem.
Whatever the answer to the mystery of Morgellons, the dynamics that have made it a contested illness are not going away. I have a feeling that those dynamics will be bugging us for some time.
**Dr. Ballard is not a part of the Kaiser Permanente team involved with Morgellons research.
Years later, I wonder whether this patient and I were meeting at the intersection of a contested illness known (to some) as Morgellons syndrome. You may have heard of Morgellons before; it received some media attention around the time that the Centers for Disease Control and Prevention (CDC) announced they were partnering with Kaiser Permanente to study the syndrome. But more on that later. First, what exactly is a “contested illness”?
To define “contested illness,” let’s start with the concept of “medicalization” – the process by which aspects of the human situation are described and treated as medical conditions or illnesses. For example, bad breath is diagnosed as “halitosis”, and excessive sweating transforms into “hyperhidrosis.” Writes Dr. H. Gilbert Welch in an LA Times editorial: “Everyday experiences get turned into diseases, the definitions of what (and who) is normal get narrowed…we doctors feel increasingly compelled to look hard for things to be wrong in those who feel well.” Lately, the medicalization of society has been driven forward by several dynamics. These include the insatiable market and marketing of personal health and beauty products, and the Internet-enabled organizing capability of condition-specific support groups. When advocacy groups (arguing that they are suffering from a treatable medical condition) collide with skeptics within conventional medical institutions, the result is a “contested illness” such as Morgellons.
Nearly ten years ago, biologist Mary Leitao’s s two-year-old son developed a strange skin condition. He scratched at himself incessantly, creating sores that, upon close inspection, contained bundles of multi-colored fibers. The physicians Leitao consulted were either baffled or skeptical. Frustrated, Leitao set out to educate herself and, in the process, discovered that her son’s symptoms had been described before, as far back as the 1500s. In fact, she found a name for the problem in Thomas Browne's A Letter to a Friend (1690). The letter described a "distemper of children... called the Morgellons, wherein they critically break out with harsh hairs on their backs." Determined to help her son and others like him, Leitao created the Morgellons Research Foundation and its website to disseminate information about the condition. She was surprised when thousands of strangers with similar symptoms contacted her. Pretty soon, Mary Leitao’s frustration had transformed into an advocacy movement. But, experts in dermatology and psychiatry were not convinced – the overwhelming opinion from the medical community was that Morgellons was a variant of delusional parasitosis – a well-described psychiatric condition. According to dermatologist Norman Levine (quoted by Brian Fair in his recent article in Sociology of Health & Illness), “[Morgellons] is not a mysterious disease…If you polled 10,000 dermatologists, everyone would agree [that Morgellons is Delusional Parasitosis].”
As Morgellons became more contested, the CDC, at the behest of some members of Congress, got involved. The CDC chose a middle ground in nomenclature – calling the condition “unexplained dermopathy,” and partnered with Kaiser Permanente to enroll and study patients suffering from “…symptoms including crawling, biting and stinging sensations; granules, threads or black speck-like materials on or beneath the skin; and/or skin lesions…”
And so here we are, several years later, waiting for the results and a peer-reviewed publication. The CDC website states that data collection for the study (which included skin samples from affected patients) is complete and under review by an expert panel. A press officer at the CDC confirmed this status (an inquiry to the Morgellons Research Foundation was not answered).
Whatever the CDC reports, in my opinion the Morgellons story illuminates two distinct points. First, patients’ symptoms should always be taken seriously and symptomatic treatment offered if available. In the case of Morgellons-type symptoms, this means a thorough exam to look for an explanation and (at a minimum) recommendations to alleviate symptoms (such as hydrocolloid dressings, low-dose steroid creams and anti-itching medications). Second, the medicalization of the human condition contributes to the development of contested illnesses and this is not healthy. Is Morgellons the medicalization of a psychiatric condition or is it an unexplained illness? We don’t know. But while it is clear that those with an “unexplained dermopathy” do not feel well, it is also very unclear whether modern medicine is capable of a definitive solution to their problem.
Whatever the answer to the mystery of Morgellons, the dynamics that have made it a contested illness are not going away. I have a feeling that those dynamics will be bugging us for some time.
**Dr. Ballard is not a part of the Kaiser Permanente team involved with Morgellons research.
Saturday, August 7, 2010
Excerpt from "Weaning the Vent"
For Savannah Jones, it was not a great night for sleeping, far from it in fact. Savannah sat up straight in her bed in the Pediatric Intensive Care Unit, breathing fast and shallow like a frightened rabbit. She opened her eyes as I entered the room and looked at me wearily. Mist filled the mask over her mouth and nose and billowed with each breath; she was breathing at least forty times a minute, twice the normal rate. Her lungs sounded even worse than before – wheeze, wheeze, crackle, wheeze, crackle – and although her pulse oximetry reading held steady in the mid 90s, I feared it might not stay there for long.
“Crap,” I thought as she hurried out of the room, “this girl needs to be intubated, and soon.” I hustled to the nursing station and paged Dr. Connor. As I waited for the return call, I reviewed, as I had dozens and dozens of times before, the procedural steps of an intubation. Intubation, the technical name for placing a breathing tube in the windpipe, is without a doubt the most crucial hands-on skill that a novice emergency physician must learn. Since the first day of my residency, I had been taught that my job was to “own the airway.” When I first heard this phrase, “own the airway,” I thought it presumptuous – how could a physician “own” a patient’s airway as if it was a commodity? Surely, a person’s trachea was more innately his or her own than a moped or a surfboard? With time, however, I came to appreciate the phrase because it captured the mentality necessary to learn a critical skill. Training in emergency medicine emphasizes, above all else, the skill of airway management and with good reason; when a patient ceases to breathe immediate action is required. Bodily organs deprived of oxygen fare poorly and basic functions, such as the heartbeat, rapidly lose their verve. Depending on factors such as patient age and health, there might be minutes to spare, or maybe only seconds. And this is why the intubation process fills even a seasoned emergency physician with trepidation; because while the procedure is usually straightforward, if things go wrong, they can go very wrong.
“Ballard, I am on my way in,” Connor bellowed over the phone. “Get the airway equipment and drugs at the bedside and call the respiratory tech. Talk to Savannah’s mother, make sure she knows what we are up to. If Savannah crashes, you know what to do.”
“Yep,” I replied, surprised. I hadn’t told him a word about the situation. He just knew that this was going to happen. Obviously, he had been doing this for a lot longer than me, but experience alone didn’t allow an average physician to reliably predict future events. Connor was special.
Savannah’s mother nodded sadly. “Doctor, as I said before, do what you need to do. I trust you.”
She inhaled deeply. “How long? How long do you think she will need the breathing tube?”
“I don’t know. I am sorry, but your daughter’s infection is very serious. It could be a long road.”
“I see,” she muttered softly.
“We will get you as soon as the tube is in.” For a moment, Savannah mother’s worry weighed heavily on my soul, but I didn’t have the time to linger. Savannah’s respiratory rate was nearing 50.
“Okay,” I said to Savannah’s nurse, “we need to get this done now. Push the etomidate, eight
Milligrams. Follow that with the succ sixty milligrams.” I ran through my mental checklist one more time – tube with stylet, suction, syringe, bag and valve, color change detector.
Just after the medications had been pushed and Savannah’s eyes closed with a slight shudder, Connor strode into the room. He looked at me.
“Looks like we are doing this. Ballard, I hope your technique is cleaner than your hair-do.”
I chuckled. I hadn’t even considered my bed head. I was pretty legendary among my peers in my ability, in a short period of time, to get significant bed head. Just 15 minutes of lying in a bed could reliably cause a large puff of my hair to stand straight up. Thirty minutes in bed was guaranteed to leave pillow lines across my forehead. Usually, after I’d been paged in the middle of a nap, I would take a brief swing by a mirror and attempt to temper the follicular uprising. But, in this case, the urgency in Savannah’s nurse’s voice had caused me to skip the mirror. I was thankful that Savannah’s mother had focused her trust on my words and not on my appearance. Connor’s comment calmed my nerves and I focused on my task. We lowered the back of the bed so that Savannah was lying flat and I gently pushed the top of her head down, which popped her chin up slightly. I opened her mouth with my right hand and inserted the L-shaped blade at an angle with my left. I pushed her tongue to the side and the tip slid into the valleculla. I pushed up and out, at a steeper angle than normal, because of where I expected her young vocal cords to lie. And there they were, glistening and outlining the tunnel to a successful intubation.
“Tube,” I said.
I felt it in my right hand. “Steady now,” said Connor. “Keep your eyes on the pearly gates.”
The tube slid in smoothly, and although I didn’t see it pass the cords, I knew it was in.
Connor pushed the plunger on the syringe, filling the balloon. The respiratory tech connected a color detector and a respiratory bag, after a large squeeze, the detector glowed yellow. I listened to the breath sounds – still wheezing and crackling, but present. I listened over the abdomen to be sure and was reassured because I didn’t hear the hollow sound of air blowing into Savannah’s stomach. The respiratory tech began to tape the tube into place and connect Savannah to the ventilator. The nurse prepared to slip a tube into her nose down to her stomach. I looked at the monitor, Savannah’s pulse oximetry was creeping back up, now in the mid 90s.
“Good job, Ballard.” Connor gave me a slap on the shoulder. “Now, let’s find you a comb.”
I laughed in relief and headed towards the call room and then stopped.
“How did you know?” I asked Connor. He smiled. “Simple really, you weren’t the only one who got a call from Savannah’s nurse. We don’t let you rookies have too much latitude. C’mon, let’s get some rest.”
“Crap,” I thought as she hurried out of the room, “this girl needs to be intubated, and soon.” I hustled to the nursing station and paged Dr. Connor. As I waited for the return call, I reviewed, as I had dozens and dozens of times before, the procedural steps of an intubation. Intubation, the technical name for placing a breathing tube in the windpipe, is without a doubt the most crucial hands-on skill that a novice emergency physician must learn. Since the first day of my residency, I had been taught that my job was to “own the airway.” When I first heard this phrase, “own the airway,” I thought it presumptuous – how could a physician “own” a patient’s airway as if it was a commodity? Surely, a person’s trachea was more innately his or her own than a moped or a surfboard? With time, however, I came to appreciate the phrase because it captured the mentality necessary to learn a critical skill. Training in emergency medicine emphasizes, above all else, the skill of airway management and with good reason; when a patient ceases to breathe immediate action is required. Bodily organs deprived of oxygen fare poorly and basic functions, such as the heartbeat, rapidly lose their verve. Depending on factors such as patient age and health, there might be minutes to spare, or maybe only seconds. And this is why the intubation process fills even a seasoned emergency physician with trepidation; because while the procedure is usually straightforward, if things go wrong, they can go very wrong.
“Ballard, I am on my way in,” Connor bellowed over the phone. “Get the airway equipment and drugs at the bedside and call the respiratory tech. Talk to Savannah’s mother, make sure she knows what we are up to. If Savannah crashes, you know what to do.”
“Yep,” I replied, surprised. I hadn’t told him a word about the situation. He just knew that this was going to happen. Obviously, he had been doing this for a lot longer than me, but experience alone didn’t allow an average physician to reliably predict future events. Connor was special.
Savannah’s mother nodded sadly. “Doctor, as I said before, do what you need to do. I trust you.”
She inhaled deeply. “How long? How long do you think she will need the breathing tube?”
“I don’t know. I am sorry, but your daughter’s infection is very serious. It could be a long road.”
“I see,” she muttered softly.
“We will get you as soon as the tube is in.” For a moment, Savannah mother’s worry weighed heavily on my soul, but I didn’t have the time to linger. Savannah’s respiratory rate was nearing 50.
“Okay,” I said to Savannah’s nurse, “we need to get this done now. Push the etomidate, eight
Milligrams. Follow that with the succ sixty milligrams.” I ran through my mental checklist one more time – tube with stylet, suction, syringe, bag and valve, color change detector.
Just after the medications had been pushed and Savannah’s eyes closed with a slight shudder, Connor strode into the room. He looked at me.
“Looks like we are doing this. Ballard, I hope your technique is cleaner than your hair-do.”
I chuckled. I hadn’t even considered my bed head. I was pretty legendary among my peers in my ability, in a short period of time, to get significant bed head. Just 15 minutes of lying in a bed could reliably cause a large puff of my hair to stand straight up. Thirty minutes in bed was guaranteed to leave pillow lines across my forehead. Usually, after I’d been paged in the middle of a nap, I would take a brief swing by a mirror and attempt to temper the follicular uprising. But, in this case, the urgency in Savannah’s nurse’s voice had caused me to skip the mirror. I was thankful that Savannah’s mother had focused her trust on my words and not on my appearance. Connor’s comment calmed my nerves and I focused on my task. We lowered the back of the bed so that Savannah was lying flat and I gently pushed the top of her head down, which popped her chin up slightly. I opened her mouth with my right hand and inserted the L-shaped blade at an angle with my left. I pushed her tongue to the side and the tip slid into the valleculla. I pushed up and out, at a steeper angle than normal, because of where I expected her young vocal cords to lie. And there they were, glistening and outlining the tunnel to a successful intubation.
“Tube,” I said.
I felt it in my right hand. “Steady now,” said Connor. “Keep your eyes on the pearly gates.”
The tube slid in smoothly, and although I didn’t see it pass the cords, I knew it was in.
Connor pushed the plunger on the syringe, filling the balloon. The respiratory tech connected a color detector and a respiratory bag, after a large squeeze, the detector glowed yellow. I listened to the breath sounds – still wheezing and crackling, but present. I listened over the abdomen to be sure and was reassured because I didn’t hear the hollow sound of air blowing into Savannah’s stomach. The respiratory tech began to tape the tube into place and connect Savannah to the ventilator. The nurse prepared to slip a tube into her nose down to her stomach. I looked at the monitor, Savannah’s pulse oximetry was creeping back up, now in the mid 90s.
“Good job, Ballard.” Connor gave me a slap on the shoulder. “Now, let’s find you a comb.”
I laughed in relief and headed towards the call room and then stopped.
“How did you know?” I asked Connor. He smiled. “Simple really, you weren’t the only one who got a call from Savannah’s nurse. We don’t let you rookies have too much latitude. C’mon, let’s get some rest.”
Brain Shield! (Marin IJ)
Have you heard about the latest medical breakthrough? It’s a miracle cure that reduces the risk of brain cancer by 52.737%! Brain Shield was recently unveiled at the Meeting of those Concerned with Brain Cancer with stunning success. But don’t take my word for it. Annie from Lodi says “What a godsend. This treatment changed my life.” Annie has been using Brain Shield for 13 months and guess what, no brain cancer. Brain (CT) scans have confirmed that Annie is cancer-free. Interested in reducing your risk of cancer? Call 1-878-4-SHIELD.
Sound suspicious? Well, it should, because it’s completely bogus. I’m certain most of you weren’t fooled. But, did you pick up on the specific clues that Brain Shield story is full of bull#$%*? There are a number of them. By discussing each red flag, I hope to provide some tips for cutting through the hype in the medical media. Your health is of the ultimate importance and the quality of the medical news you heed (or ignore) is critical. So, here’s how to discern the valid from the bull #$&*. I thank the Association of Health Care Journalists (AHCJ) for providing the basic principles to work from.
Red Flag #1: Language. Be wary of health reporting that utilizes sensationalistic language. I am not sure that “miracle cures” actually exist, but if they do, they are rare. Antibiotics might qualify. A (hypothetical) treatment to reduce the risk of brain cancer by 53% certainly does not. The vast majority of “breakthrough” treatments and “dramatic” findings are nothing of the sort. Similarly, phrases like “deadly diseases” and “sweeping epidemics” are used to sell media, not to properly inform.
Red Flag #2: The anecdote. Testimonials may be useful in painting a vivid and personal picture of a disease or treatment but anyone who extrapolates the experiences of a handful of people to larger groups is taking a leap of faith. The AHCJ cautions health journalists to avoid the “tyranny of the anecdote,” particularly when the anecdote contradicts the sum of available evidence. An excellent example is the long hyped (and many times disproven) link between vaccines and autism. Causality is difficult to establish and a series of heart-breaking stories about children who developed autism not long after receiving immunizations does not establish a link and absolutely contradicts the vast evidence exonerating vaccines as a causal agent. Similarly, absent more information, readers should not be impressed by the “remarkable story” of Annie from Lodi.
Red Flag #3: Lack of peer review. The peer-review process in the scientific community is far from perfect, and plenty of junk slips through its cracks and into the medical literature. Andrew Wakefield’s seminal publication about the MMR vaccine and autism has become a classic example. But nonetheless, peer-review is a rigorous process – and one that (mostly) discourages researchers from publishing poorly conceived or managed research. Thus, you should put far more trust in medical evidence presented in a peer-reviewed journal (such as the New England Journal of Medicine) than preliminary results that appear in the mass media or at a scientific conference. Research presentations at conferences have not been vetted in the same manner as studies that make it to print in journals. The Meeting of those Concerned with Brain Cancer sounds like a worthwhile gathering, but should not be taken as the definitive source for information about preventing brain tumors.
Red Flag #4: Lack of perspective. There is a lot of nuance involved in interpreting the numerical significance of medical research. A 52.737% reduction in the risk of brain cancer sounds fantastic until you consider that brain cancer is an extremely rare condition (about 6 cases per 100,000 people). Think about it in terms of the value of your home – a 53% reduction in value is profound if the starting value is high. But what if your house isn’t worth squat (let’s say $100) to begin with? Then a 53% difference is no longer a big deal. Similarly, a 53% reduction in the number of cases of a common medical condition is big news, but a 53% reduction in cases of a rare condition is less newsworthy. Journalists can put this into perspective by giving data about statistical significance (the benchmark as to whether an observation is likely to have occurred randomly or is likely related to an exposure) or – for medical therapies – the number-needed-to-treat. For example, our hypothetical Brain Shield would need to be used in nearly 200,000 people in order to prevent a single brain cancer. When you consider this, you also realize the use of extra decimal points (52.737%) is another red flag. Those extra decimal points are purely for show – a means of making the results seem more robust than they actually are. Genuine data does not require three decimal places – none or one is usually sufficient. Watch out for numbers with drawn out decimals.
Red Flag #5: Too good to be true. No medical treatment is without risk. This is even true of treatments involving basic life substrates such as oxygen, water and salt. Too much of any of these things can be harmful. Thus, any discussion of a medical treatment must mention its risks. The very rough estimate of lifetime risk of cancer caused by a CT scan of the head is one in 2000 – thus Annie from Lodi has actually increased her brain cancer risk by attempting to confirm that her anti-brain cancer treatment is working. Silly Annie.
So, next time you read “stunning” health headlines or stay up for the 11 o’clock news to learn about the latest epidemic sweeping the area, keep these red flags in mind. If you encounter any, tune out, go to bed, and find a different (better) source in the morning. Or if you’re not sure, you can follow the advice of my buddy (and frequent contributor) Dr. Clark Hinderleider and “investigate the reliability of the outlet from which the content is received by using a 'fact-check' source such as HealthNewsReview.org." Whatever you do, I wouldn’t rely on Annie’s advice.
Sound suspicious? Well, it should, because it’s completely bogus. I’m certain most of you weren’t fooled. But, did you pick up on the specific clues that Brain Shield story is full of bull#$%*? There are a number of them. By discussing each red flag, I hope to provide some tips for cutting through the hype in the medical media. Your health is of the ultimate importance and the quality of the medical news you heed (or ignore) is critical. So, here’s how to discern the valid from the bull #$&*. I thank the Association of Health Care Journalists (AHCJ) for providing the basic principles to work from.
Red Flag #1: Language. Be wary of health reporting that utilizes sensationalistic language. I am not sure that “miracle cures” actually exist, but if they do, they are rare. Antibiotics might qualify. A (hypothetical) treatment to reduce the risk of brain cancer by 53% certainly does not. The vast majority of “breakthrough” treatments and “dramatic” findings are nothing of the sort. Similarly, phrases like “deadly diseases” and “sweeping epidemics” are used to sell media, not to properly inform.
Red Flag #2: The anecdote. Testimonials may be useful in painting a vivid and personal picture of a disease or treatment but anyone who extrapolates the experiences of a handful of people to larger groups is taking a leap of faith. The AHCJ cautions health journalists to avoid the “tyranny of the anecdote,” particularly when the anecdote contradicts the sum of available evidence. An excellent example is the long hyped (and many times disproven) link between vaccines and autism. Causality is difficult to establish and a series of heart-breaking stories about children who developed autism not long after receiving immunizations does not establish a link and absolutely contradicts the vast evidence exonerating vaccines as a causal agent. Similarly, absent more information, readers should not be impressed by the “remarkable story” of Annie from Lodi.
Red Flag #3: Lack of peer review. The peer-review process in the scientific community is far from perfect, and plenty of junk slips through its cracks and into the medical literature. Andrew Wakefield’s seminal publication about the MMR vaccine and autism has become a classic example. But nonetheless, peer-review is a rigorous process – and one that (mostly) discourages researchers from publishing poorly conceived or managed research. Thus, you should put far more trust in medical evidence presented in a peer-reviewed journal (such as the New England Journal of Medicine) than preliminary results that appear in the mass media or at a scientific conference. Research presentations at conferences have not been vetted in the same manner as studies that make it to print in journals. The Meeting of those Concerned with Brain Cancer sounds like a worthwhile gathering, but should not be taken as the definitive source for information about preventing brain tumors.
Red Flag #4: Lack of perspective. There is a lot of nuance involved in interpreting the numerical significance of medical research. A 52.737% reduction in the risk of brain cancer sounds fantastic until you consider that brain cancer is an extremely rare condition (about 6 cases per 100,000 people). Think about it in terms of the value of your home – a 53% reduction in value is profound if the starting value is high. But what if your house isn’t worth squat (let’s say $100) to begin with? Then a 53% difference is no longer a big deal. Similarly, a 53% reduction in the number of cases of a common medical condition is big news, but a 53% reduction in cases of a rare condition is less newsworthy. Journalists can put this into perspective by giving data about statistical significance (the benchmark as to whether an observation is likely to have occurred randomly or is likely related to an exposure) or – for medical therapies – the number-needed-to-treat. For example, our hypothetical Brain Shield would need to be used in nearly 200,000 people in order to prevent a single brain cancer. When you consider this, you also realize the use of extra decimal points (52.737%) is another red flag. Those extra decimal points are purely for show – a means of making the results seem more robust than they actually are. Genuine data does not require three decimal places – none or one is usually sufficient. Watch out for numbers with drawn out decimals.
Red Flag #5: Too good to be true. No medical treatment is without risk. This is even true of treatments involving basic life substrates such as oxygen, water and salt. Too much of any of these things can be harmful. Thus, any discussion of a medical treatment must mention its risks. The very rough estimate of lifetime risk of cancer caused by a CT scan of the head is one in 2000 – thus Annie from Lodi has actually increased her brain cancer risk by attempting to confirm that her anti-brain cancer treatment is working. Silly Annie.
So, next time you read “stunning” health headlines or stay up for the 11 o’clock news to learn about the latest epidemic sweeping the area, keep these red flags in mind. If you encounter any, tune out, go to bed, and find a different (better) source in the morning. Or if you’re not sure, you can follow the advice of my buddy (and frequent contributor) Dr. Clark Hinderleider and “investigate the reliability of the outlet from which the content is received by using a 'fact-check' source such as HealthNewsReview.org." Whatever you do, I wouldn’t rely on Annie’s advice.
Can you handle the hype? (Marin IJ)
Flesh-eating bacteria, super-viruses, killer E-coli...Bird flu, swine flu, equine flu… Toxic mold, toxic shock, toxic toys, toxic Tylenol…Salmonella in your peanut butter, heavy metals in your salmon…Cancer from phthalates, tumors from your phone…Autism and vaccines, pertussis and vaccines (lack thereof). The media spits out an endless series of scary health stories, many sensationalized for effect. You’re all familiar with these pieces. I feel downright accosted by some of the headlines: “The toxic mold and the hidden room: a homeowner's nightmare,” (abcnews.go.com), or “The deadly ‘superbug’ that's spreading fast across the country,” (Ophrah.com) and “Talk & die syndrome more common that you think” (cnn.com).
With the frenetic heat of media hyperbole, it’s hard to know which health hazards to be concerned about and which to put on the back burner of the worry stove. Not surprisingly, the public is often confused about health matters, and I really believe the media bears a heavy burden of responsibility for this. Medical reporting suffers from a number of ailments, including outbreaks of misinformation, deficits in understanding and context, and, often, a rush to pronounce conclusions.
Take, for example, two stories that sparked a substantial panic this past year. One was the unfortunate death of Natasha Richardson from a seemingly minor head injury and the other was the Food and Drug Administration’s (FDA’s) warning about liver damage due to excessive doses of acetaminophen (Tylenol).
Richardson’s tragic death from an epidural hematoma (bleeding on and around the brain) after falling on a beginner ski slope received widespread media attention, including in this column. The scope of the reporting was varied and from a public health perspective had some beneficial impact. The story reinforced the importance of wearing a helmet during high-risk sports such as biking, skateboarding, and (at least for beginners) skiing. On the flip side, some reports were alarmist and others were dangerously inaccurate. For example, I read an on-line article claiming that clot-busting drugs could have successfully treated Richardson’s brain injury. In actual fact, giving clot-busters to Richardson would almost certainly have hastened her death. Another report recommended that people with head injuries visit their nearest trauma center – which is a good idea for someone who has taken a header off the roof – but not necessary for most minor head impacts. And finally, a rather hysterical blog advised that all patients with head trauma be screened with a CT scan of the head. These and other alarmist stories, such as a Good Morning America feature on a young girl who sustained an epidural hematoma after she was struck with a softball, sent thousands of people to EDs to be checked out for trivial head injuries.
Dr. Brian Walsh from Morristown, New Jersey and colleagues quantified this effect by comparing the number of ED visits for head injury related complaints before and after Natasha Richardson’s death. They discovered that the total number of visits in the ten days after the actress’ death was 73% higher than the number of visits in the ten days prior, while the sum of serious injuries was unchanged. In other words, there was a huge surge in patients with minor head bonks who visited the ED to get checked out. This, of course, is what emergency departments are for, but nonetheless the media let these people down by failing to adequately stress the (well-established) warning signs of serious head injury (such as severe headache and repeated vomiting) and the potential risk of obtaining an unnecessary CT (radiation exposure that is thought to increase lifetime risks for cancer, especially in children). This failure to paint an accurate picture of risks and benefits is one of the five health media deficiencies identified by the American Council on Science and Health (ACSH), an advocacy group dedicated to providing sound health information to consumers.
A second deficiency, recognized by the ACSH and others, is the media’s tendency to gloss over the importance of dose, often altogether ignoring the maxim "the dose makes the poison." An excellent example of this is the media coverage after an FDA advisory panel warned that excessive doses of acetaminophen (Tylenol) could cause liver damage and failure. This statement was intended to raise awareness of the danger of cumulative doses of Tylenol. Truly, it can be hard to keep track of the amount of acetaminophen you’re taking, as it is commonly used as a cocktail ingredient in over-the-counter cold and flu preparations as well as in prescription painkillers such as Vicodin and Percocet. Hence the warning: people taking large doses of these medications, with or without additional Tylenol, are at risk for liver damage. Increased awareness of this risk, as well as changes in physician prescribing patterns (e.g., away from combination medications like Vicodin and towards single drug prescriptions) is desirable. Unfortunately, the message that many patients received, and I heard this many times in the ED, was that Tylenol is a dangerous medication. This could not be farther from the truth – Tylenol is one of the safest pain medications at our disposal and, if used at recommended doses, has far fewer harmful side effects than alternatives such as ibuprofen or naproxen. So please remember – the dose makes the poison. Remember this in regards to Tylenol, lead in children’s toys, mercury in fish, and phthalates in milk. With most environmental or dietary exposures, “everything in moderation” should keep you healthy.
There’s more to write about on the topic of the media and health, and three more ACSH identified deficiencies to cover. But since this column is running out of space and I do not want to violate any principles of responsible health reporting, I will pick up the topic in a couple weeks. In that column, I’ll give tips on how you can become a discerning reader of health news so you can decide for yourself which “scares” to freak out about and which to just forget.
With the frenetic heat of media hyperbole, it’s hard to know which health hazards to be concerned about and which to put on the back burner of the worry stove. Not surprisingly, the public is often confused about health matters, and I really believe the media bears a heavy burden of responsibility for this. Medical reporting suffers from a number of ailments, including outbreaks of misinformation, deficits in understanding and context, and, often, a rush to pronounce conclusions.
Take, for example, two stories that sparked a substantial panic this past year. One was the unfortunate death of Natasha Richardson from a seemingly minor head injury and the other was the Food and Drug Administration’s (FDA’s) warning about liver damage due to excessive doses of acetaminophen (Tylenol).
Richardson’s tragic death from an epidural hematoma (bleeding on and around the brain) after falling on a beginner ski slope received widespread media attention, including in this column. The scope of the reporting was varied and from a public health perspective had some beneficial impact. The story reinforced the importance of wearing a helmet during high-risk sports such as biking, skateboarding, and (at least for beginners) skiing. On the flip side, some reports were alarmist and others were dangerously inaccurate. For example, I read an on-line article claiming that clot-busting drugs could have successfully treated Richardson’s brain injury. In actual fact, giving clot-busters to Richardson would almost certainly have hastened her death. Another report recommended that people with head injuries visit their nearest trauma center – which is a good idea for someone who has taken a header off the roof – but not necessary for most minor head impacts. And finally, a rather hysterical blog advised that all patients with head trauma be screened with a CT scan of the head. These and other alarmist stories, such as a Good Morning America feature on a young girl who sustained an epidural hematoma after she was struck with a softball, sent thousands of people to EDs to be checked out for trivial head injuries.
Dr. Brian Walsh from Morristown, New Jersey and colleagues quantified this effect by comparing the number of ED visits for head injury related complaints before and after Natasha Richardson’s death. They discovered that the total number of visits in the ten days after the actress’ death was 73% higher than the number of visits in the ten days prior, while the sum of serious injuries was unchanged. In other words, there was a huge surge in patients with minor head bonks who visited the ED to get checked out. This, of course, is what emergency departments are for, but nonetheless the media let these people down by failing to adequately stress the (well-established) warning signs of serious head injury (such as severe headache and repeated vomiting) and the potential risk of obtaining an unnecessary CT (radiation exposure that is thought to increase lifetime risks for cancer, especially in children). This failure to paint an accurate picture of risks and benefits is one of the five health media deficiencies identified by the American Council on Science and Health (ACSH), an advocacy group dedicated to providing sound health information to consumers.
A second deficiency, recognized by the ACSH and others, is the media’s tendency to gloss over the importance of dose, often altogether ignoring the maxim "the dose makes the poison." An excellent example of this is the media coverage after an FDA advisory panel warned that excessive doses of acetaminophen (Tylenol) could cause liver damage and failure. This statement was intended to raise awareness of the danger of cumulative doses of Tylenol. Truly, it can be hard to keep track of the amount of acetaminophen you’re taking, as it is commonly used as a cocktail ingredient in over-the-counter cold and flu preparations as well as in prescription painkillers such as Vicodin and Percocet. Hence the warning: people taking large doses of these medications, with or without additional Tylenol, are at risk for liver damage. Increased awareness of this risk, as well as changes in physician prescribing patterns (e.g., away from combination medications like Vicodin and towards single drug prescriptions) is desirable. Unfortunately, the message that many patients received, and I heard this many times in the ED, was that Tylenol is a dangerous medication. This could not be farther from the truth – Tylenol is one of the safest pain medications at our disposal and, if used at recommended doses, has far fewer harmful side effects than alternatives such as ibuprofen or naproxen. So please remember – the dose makes the poison. Remember this in regards to Tylenol, lead in children’s toys, mercury in fish, and phthalates in milk. With most environmental or dietary exposures, “everything in moderation” should keep you healthy.
There’s more to write about on the topic of the media and health, and three more ACSH identified deficiencies to cover. But since this column is running out of space and I do not want to violate any principles of responsible health reporting, I will pick up the topic in a couple weeks. In that column, I’ll give tips on how you can become a discerning reader of health news so you can decide for yourself which “scares” to freak out about and which to just forget.
Have you done your neurobics today? (Marin IJ)
There’s a woman at my gym who walks on the treadmill. Backwards. Why the heck does she do that? Not because the view is better and not in protest of the television that sits atop the machinery. Not to keep the wear on her sneakers even or to draw attention to herself (although she accomplishes both.) No, she walks backwards for the neurobic benefit. That’s right, neurobics – aerobics for the brain. And while walking backwards on a treadmill may not be a particularly safe exercise, the basic concept behind it is interesting.
The term “neurobics” was first introduced by neurobiologist Lawrence C. Katz about ten years ago along with the hypothesis that mental exercises, especially those that tax the brain in novel ways, can stimulate the growth of new dendrites and neurons. The theory is that most people perform many actions by routine – the processes are hard-wired by repetition into the brain’s mainframe. Routines like how you tie your shoes or answer the phone or walk on the treadmill are performed with little conscious thought. By switching things up and challenging your brain to orchestrate tasks or thoughts in different ways, you may be able to improve the cognitive (aka thinking) function of your brain.
Intrigued? You’re in luck. Dr. Katz, in collaboration with Manning Rubin, has written Keep Your Brain Alive – a book describing 83 neurobic maneuvers (“cross-training for the brain”) for people over the age of forty. The drills, which are designed to fit into your daily routine, include writing or brushing your teeth with your non-dominant hand and starting the ignition of your car with eyes closed (please remember to open them before you start driving). These are simple changes, not the New York Times crossword or advanced Sudoku, but Katz and others are convinced there is a benefit. But you probably don’t need a new book to teach you neurobics – how about using nothing but facial expressions to communicate during dinner, typing an e-mail without looking at the keyboard, or walking backwards on the treadmill?
Is there any solid evidence that neurobics help cognition? When I recently perused the medical literature I didn’t find much evidence supporting the specific practice of neurobics. This doesn’t mean, of course, that neurobics aren’t valuable; it just means that they haven’t been adequately studied.
Research has shown, however, that “cognitive engagement,” such as regular reading, learning a musical instrument or playing card games, is associated with decreased risk of cognitive decline and Alzheimer’s dementia. (This from an exhaustive NIH review prepared by scientists at the Duke Evidence-based Practice Center.) Physical activity also seems to have a benefit. A recent article in Clinics in Geriatric Medicine reviewed dozens of studies on the topic, many of which enrolled thousands of participants. The bottom line, according to the authors: “Increasing evidence suggests than an active life has a protective effect on brain functioning in the elderly population,” however no quality study to date “has shown that regular physical activity prevents dementia.”
With the U.S. population aging – over 70 million Americans will turn 65 in the next two decades – brain health is sure to become a major priority for physician and scientists. If we can keep this population active and productive well past the age of Social Security, there will be major benefits for individuals and society.
I asked a neurologist friend what he thought about improving brain health. Neurobics – well, he’d never heard of them. Physical activity and plenty of Vitamin D – good ideas for anyone of any age. Antioxidants in the diet to neutralize free radicals? Absolutely. “Tell your readers,” he told me “to eat blueberries.” A tasty thought, but I wouldn’t suggest eating them while walking backwards on a treadmill.
The term “neurobics” was first introduced by neurobiologist Lawrence C. Katz about ten years ago along with the hypothesis that mental exercises, especially those that tax the brain in novel ways, can stimulate the growth of new dendrites and neurons. The theory is that most people perform many actions by routine – the processes are hard-wired by repetition into the brain’s mainframe. Routines like how you tie your shoes or answer the phone or walk on the treadmill are performed with little conscious thought. By switching things up and challenging your brain to orchestrate tasks or thoughts in different ways, you may be able to improve the cognitive (aka thinking) function of your brain.
Intrigued? You’re in luck. Dr. Katz, in collaboration with Manning Rubin, has written Keep Your Brain Alive – a book describing 83 neurobic maneuvers (“cross-training for the brain”) for people over the age of forty. The drills, which are designed to fit into your daily routine, include writing or brushing your teeth with your non-dominant hand and starting the ignition of your car with eyes closed (please remember to open them before you start driving). These are simple changes, not the New York Times crossword or advanced Sudoku, but Katz and others are convinced there is a benefit. But you probably don’t need a new book to teach you neurobics – how about using nothing but facial expressions to communicate during dinner, typing an e-mail without looking at the keyboard, or walking backwards on the treadmill?
Is there any solid evidence that neurobics help cognition? When I recently perused the medical literature I didn’t find much evidence supporting the specific practice of neurobics. This doesn’t mean, of course, that neurobics aren’t valuable; it just means that they haven’t been adequately studied.
Research has shown, however, that “cognitive engagement,” such as regular reading, learning a musical instrument or playing card games, is associated with decreased risk of cognitive decline and Alzheimer’s dementia. (This from an exhaustive NIH review prepared by scientists at the Duke Evidence-based Practice Center.) Physical activity also seems to have a benefit. A recent article in Clinics in Geriatric Medicine reviewed dozens of studies on the topic, many of which enrolled thousands of participants. The bottom line, according to the authors: “Increasing evidence suggests than an active life has a protective effect on brain functioning in the elderly population,” however no quality study to date “has shown that regular physical activity prevents dementia.”
With the U.S. population aging – over 70 million Americans will turn 65 in the next two decades – brain health is sure to become a major priority for physician and scientists. If we can keep this population active and productive well past the age of Social Security, there will be major benefits for individuals and society.
I asked a neurologist friend what he thought about improving brain health. Neurobics – well, he’d never heard of them. Physical activity and plenty of Vitamin D – good ideas for anyone of any age. Antioxidants in the diet to neutralize free radicals? Absolutely. “Tell your readers,” he told me “to eat blueberries.” A tasty thought, but I wouldn’t suggest eating them while walking backwards on a treadmill.
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