Imagine a family member or friend collapsed in front of you and wasn't moving or breathing. Would you know what to do? Could you help save his or her life? Novato resident Stacey Beltran knew what to do when her uncle Doug Briggs crumpled to the floor this past Christmas Eve. Fred Potter of Tiburon knew what to do when his good friend Steve Sears went down in January 2008. They called for help and started CPR.
Fifty years ago, the closed-chest resuscitation technique (the cardiac component of what is commonly known as CPR) was described by William Kouwenhoven in the Journal of the American Medical Association. Kouwenhoven and colleagues at Johns Hopkins reported a success rate of 70 percent - unheard of in those days - when using the technique to treat hospital patients suffering from sudden heart attack related arrest. The implications were immediate and widespread. "The closed-chest method replaced the 'ghastly' ritual of open cardiac massage (cutting through skin and bone to access the heart). No longer would resuscitation be limited to surgeons bold enough to wield a scalpel," wrote W. Bruce Fye in American Cardiology.
This year the technique of chest compressions combined with assisted respirations celebrates its 50-year anniversary. Since its adoption, CPR has become a staple of care for patients whose hearts have stopped and has been taught to thousands of health-care providers, first responders and citizens. Multiple studies have shown that CPR, particularly
when paired with early use of an electronic defibrillator, saves lives.
Consider a study of 1,667 patients with outside-the-hospital cardiac arrest in King County, Wash. In this group of patients, if CPR and defibrillation (or other advanced life support intervention) were started immediately, the patient had a 67 percent chance of survival.
For each minute that passed without these, the chance of survival dropped by 5.5 percent. Thus, 10 minutes after cardiac arrest, if nothing had been done, the survival odds were 12 percent. In another two to three minutes they were zero.
However, if CPR alone was performed (keeping blood flowing to the brain and vital organs while awaiting help), the odds improved by 2.3 percent a minute - essentially doubling survival at 10 minutes post-arrest.
But, statistics are just part of the story. Sears, owner of Sam's Anchor Cafe in Tiburon, is alive today because Potter started CPR. It was mid-afternoon on Jan. 17, 2008, and Sears was tending to the business side of his restaurant when he collapsed. "My heart had been racing all day," Sears told me. "I remember standing in my office. After that, I don't remember anything."
Potter, a retired engineer-paramedic with Tiburon Fire, was on the deck of Sam's showing his brother the view of the bay when he heard a commotion from inside. Potter handed his cup of coffee to his brother, rushed into the office and started CPR. "The adrenaline was definitely pumping," Potter told me. "I knew what to do, but it was the first time I'd ever had to do it on a good friend."
Moments later Tiburon Fire Battalion Chief Ed Lynch arrived with an automated external defibrillator (AED) - a life-saving device that Potter describes as "easier to use than a cell phone."
Briggs is alive today because his niece knew what to do. Beltran had just taken a course in CPR from Sandy Wargo of Novato Fire. After her sister dialed 911 and got a dispatcher on the line, Beltran put her CPR skills to use.
"All of a sudden, I remembered the steps in CPR É I looked at his chest, hoping for movement, and nothing É so I put my hands together, looked for the spot on his chest and started compressions. I counted aloud just like Sandy taught me to do."
Moments later, the Novato Fire paramedics were on scene and shocked Briggs' heart rhythm back to normal.
Sears and Briggs suffered heart attacks that caused a sudden alteration in heart rhythm called ventricular fibrillation. Both required stents to open coronary arteries and both were home and mostly recovered within a few weeks. They are exactly the type of people - relatively young (under 70) and relatively healthy - who are the best candidates to survive cardiac arrest. But their survival, and that of others like them, is predicated on immediate assistance.
So, would you know what to do? Would you be able to put aside emotion and do what was needed? Or would you just stand there? If you're not sure, there are steps you can take. First, you can sign up for a basic life support course. Second, you can pay attention to where AEDs are kept - you will notice them at the gym, on campus and at the airport. And finally, on June 4 you can come to one of multiple sites in Marin and celebrate CPR's 51st birthday by receiving free (noncertified) training in hands-only CPR and AED use. The training will take less than 10 minutes, and just might help you to save someone's life.
But, don't take my word for it. "It is extremely important," said Sears. "Because without training, people freak out É they don't have the confidence to know what to do. I was fortunate to be in a circumstance where people knew what to do. I hope that my story will motivate people to get out there and get trained."
Friday, March 25, 2011
Wednesday, March 23, 2011
Sleep on it
“In the great green room there was a telephone, and a red balloon, and a picture of - the cow jumping over the moon.” So begins the final chapter of a ritual played out in bedrooms across the land…“Goodnight room, goodnight moon, goodnight cow jumping over the moon.” The soothing repetition of Goodnight Moon and similar verses is employed by millions of parents each night as they send their kids off to dreamland. For many parents, including myself, this is but the penultimate step in an extended bedtime routine. Dinner, bath, pajamas, warm milk (but not so warm to make it too hot), books on the couch, clean teeth, a wave to the stars, a march up stairs, a tuck into bed (making sure to get the pillows propped just so), Goodnight Moon and songs, and, finally, a kiss goodnight. Phew. I know I’m not alone in performing a regimen of this sort – in fact I know many moms and dads who practically obsess about the timing, ritual and quality of their children’s sleep. Why is it so important? Because, as everyone knows, sleep matters. Children whose rest routines are irregular are irritable; transforming from adorable puddle jumpers into barely bearable brats.
This parental commonsense is also backed by strong science. Rats that don’t sleep don’t just become brats, they become dead (within four to five weeks.) And the data isn’t just about rats. Studies demonstrate that sleep deprived people have delayed reactions, difficulty concentrating, and impaired cognition and judgment. This, of course, explains the rationale for sleep deprivation interrogations. Given all this, why is it that a nation so meticulous about its children’s sleep is so careless when it comes to properly resting its adults?
You may have heard about the recent Center for Disease Control and Prevention (CDC) report on sleep. Based on a telephone survey of over 70,000 adults, including some 11,000 Californians, over a third of Americans get less than 7 hours of sleep a night. This, as you may know, is less than the minimum amount recommended by the CDC, the National Sleep Foundation and The Sleep Train. An even more concerning finding in this study is that 38% of respondents reported nodding off unintentionally in the last 30 days, and 5% of these people admitted that this had occurred while driving. This suggests that data from the National Highway Traffic Safety Administration indicating that driver fatigue is responsible for an estimated 100,000 motor vehicle accidents and 1,500 deaths each year may actually be an underestimation. As a shift worker, I have personal experience with this. Driving home after a night shift in the ER can be scary, sometimes it seems like my consciousness is on the verge of automatic shut down. For shift workers and parents of young children some level of sleep deprivation is virtually inevitable, but for many others, sleep deficits are preventable and should – for health, safety and sanity reasons – be prevented.
There’s no shortage of advice about sleeping to be found via Google, but to save you the time of sorting through it all, let me give a less than exhausted… I mean exhaustive, review.
So, what follows (with the help of the good people at Quoteland), is a quip-based guide to getting good with sleep.
“The sleeping fox catches no poultry.” -Benjamin Franklin
I am a big Ben Franklin fan, and while he may be technically right on this one, his advice is not applicable to most human beings. Franklin, famously, required very little sleep. And while there are certainly in-born differences between individuals in sleep requirements, there are not too many Franklinesque 30-minute-cat-nap types out there. Far more common is the burn-it-at-both-ends type who ignores her sleep need – piling onto a deficit that can only be repaid at the bedtime bank. To not settle up is to play chicken with health and longevity. If you don’t already know, figure out how much sleep you need to be at your best, and make sure you get it.
“The two best physicians of them all -- Dr. Laughter and Dr. Sleep.”-- Gregory Dean Jr.
Well, I might have to throw Dr. Feelgood into the mix too. But seriously, we are just beginning to understand the physiological functions of sleep – which include encoding memories via nerve-signal repetition; increased cellular production of proteins that are likely involved in repairing damage from stress, ultraviolet light and dietary toxins; and spikes in growth hormone release in young people. Sleep is good medicine.
“You can't stay married in a situation where you are afraid to go to sleep in case your wife might cut your throat. “ -Mike Tyson
Practical advice indeed from Mr. Tyson. How about some other suggestions for ensuring a restful night? The CDC has a list of sleep hygiene tips that include sticking to a regular sleep schedule (just like your kids!), sleeping in a dark and relaxing environment, removing all computer and other gadgets from the bedroom (but keep the white noise machine), and avoiding alcohol, caffeine and large meals within a few hours of bedtime. Another important suggestion is to just say “no” to pharmaceutical sleep aids unless you’re making a sleep transition (such as when coping with travel time changes or the disorientation of being “Sprung Forward”) and have discussed the sleep aid options with a doctor. Some over-the-counter medications may have more side effects than you expect. Instead, mindfulness exercises and yoga might be useful for the sleepless and a comfy mattress seems like a no-brainer.
“Drop, drop in our sleep, upon the heart sorrow falls, memorys pain, and to us, though against our very will, even in our own despite, comes wisdom by the awful grace of God. “
-Aeschylus
I am not sure exactly what this means, although it sure sounds pretty and I think it may be referencing the germination of inspiration. Guess I’ll try sleeping on it.
This parental commonsense is also backed by strong science. Rats that don’t sleep don’t just become brats, they become dead (within four to five weeks.) And the data isn’t just about rats. Studies demonstrate that sleep deprived people have delayed reactions, difficulty concentrating, and impaired cognition and judgment. This, of course, explains the rationale for sleep deprivation interrogations. Given all this, why is it that a nation so meticulous about its children’s sleep is so careless when it comes to properly resting its adults?
You may have heard about the recent Center for Disease Control and Prevention (CDC) report on sleep. Based on a telephone survey of over 70,000 adults, including some 11,000 Californians, over a third of Americans get less than 7 hours of sleep a night. This, as you may know, is less than the minimum amount recommended by the CDC, the National Sleep Foundation and The Sleep Train. An even more concerning finding in this study is that 38% of respondents reported nodding off unintentionally in the last 30 days, and 5% of these people admitted that this had occurred while driving. This suggests that data from the National Highway Traffic Safety Administration indicating that driver fatigue is responsible for an estimated 100,000 motor vehicle accidents and 1,500 deaths each year may actually be an underestimation. As a shift worker, I have personal experience with this. Driving home after a night shift in the ER can be scary, sometimes it seems like my consciousness is on the verge of automatic shut down. For shift workers and parents of young children some level of sleep deprivation is virtually inevitable, but for many others, sleep deficits are preventable and should – for health, safety and sanity reasons – be prevented.
There’s no shortage of advice about sleeping to be found via Google, but to save you the time of sorting through it all, let me give a less than exhausted… I mean exhaustive, review.
So, what follows (with the help of the good people at Quoteland), is a quip-based guide to getting good with sleep.
“The sleeping fox catches no poultry.” -Benjamin Franklin
I am a big Ben Franklin fan, and while he may be technically right on this one, his advice is not applicable to most human beings. Franklin, famously, required very little sleep. And while there are certainly in-born differences between individuals in sleep requirements, there are not too many Franklinesque 30-minute-cat-nap types out there. Far more common is the burn-it-at-both-ends type who ignores her sleep need – piling onto a deficit that can only be repaid at the bedtime bank. To not settle up is to play chicken with health and longevity. If you don’t already know, figure out how much sleep you need to be at your best, and make sure you get it.
“The two best physicians of them all -- Dr. Laughter and Dr. Sleep.”-- Gregory Dean Jr.
Well, I might have to throw Dr. Feelgood into the mix too. But seriously, we are just beginning to understand the physiological functions of sleep – which include encoding memories via nerve-signal repetition; increased cellular production of proteins that are likely involved in repairing damage from stress, ultraviolet light and dietary toxins; and spikes in growth hormone release in young people. Sleep is good medicine.
“You can't stay married in a situation where you are afraid to go to sleep in case your wife might cut your throat. “ -Mike Tyson
Practical advice indeed from Mr. Tyson. How about some other suggestions for ensuring a restful night? The CDC has a list of sleep hygiene tips that include sticking to a regular sleep schedule (just like your kids!), sleeping in a dark and relaxing environment, removing all computer and other gadgets from the bedroom (but keep the white noise machine), and avoiding alcohol, caffeine and large meals within a few hours of bedtime. Another important suggestion is to just say “no” to pharmaceutical sleep aids unless you’re making a sleep transition (such as when coping with travel time changes or the disorientation of being “Sprung Forward”) and have discussed the sleep aid options with a doctor. Some over-the-counter medications may have more side effects than you expect. Instead, mindfulness exercises and yoga might be useful for the sleepless and a comfy mattress seems like a no-brainer.
“Drop, drop in our sleep, upon the heart sorrow falls, memorys pain, and to us, though against our very will, even in our own despite, comes wisdom by the awful grace of God. “
-Aeschylus
I am not sure exactly what this means, although it sure sounds pretty and I think it may be referencing the germination of inspiration. Guess I’ll try sleeping on it.
Monday, February 28, 2011
Honor Thy Gut (Marin IJ)
The human intestines (the gut) are like something out of a sci-fi movie, a world inside a world with much more intrigue than you might expect. Your gut, comprised of two dozen or so feet of twisting peristaltic tubes, has a mind of its own – looping, gurgling and diffusing its way to digestion. Slow and steady like a caterpillar on the move, the bowel functions in anonymity, until something goes wrong.
Deep in the bowel you’ll find a stew of microorganisms that make the breakdown of food and absorption of nutrients possible. Scientists know this crock-pot of little critters as a mircrobiome and it consists of millions of densely packed bacteria and yeasts, with names like Lactobacillus, Bifidobacterium, and Saccaromyces. In sum, these body microbes outnumber human cells by ten to one! Constantly at work, the gut microbiome serves many crucial functions; it turns food products into usable energy forms such as sugars and short chain fatty acids, it produces vitamins such as Vitamin K and biotin, and it protects against disease in a number of ways. And while we’ve known for some time that microbes play a critical role in the gastrointestinal tract, we are just beginning to appreciate the magnitude of their influence and the uniqueness of their composition on a person-to-person basis. That’s right, your microbiome is unique to you – it’s your own living micro-signature.
So, you may be wondering what you can do to cultivate a healthy microbiome? Recently, I spoke with Lita Proctor, Ph. D, Coordinator of the Human Microbiome Project – a National Institutes of Health (NIH) funded endeavor to catalogue the microbe communities of the human body using sophisticated DNA analysis. The following tidbits of advice are based on her thoughts as well as a sampling of the available scientific evidence.
*You and your microbes will have many more good times than bad. For every microbe-induced sore throat or upset tummy, there will be thousands upon thousands of illnesses that your personalized microbes will shield you from.
*Pro-biotics (live microbes found in products such as Culturelle and Align) do work – some of the time, for some conditions. But we don’t know exactly why. Someday, your medical record may include a full tracing of your genome and microbiome – allowing us to predict and prevent common nuisances (such as antibiotic-associated diarrhea). But until then, consider pro-biotics in certain situations (such when you’re dealing with antibiotic-associated diarrhea) but do so with some caution. Newborns (who begin sterile but start to assemble their own microbiome as they pass through the birth canal) and people with compromised immune function probably should not routinely be supplemented with excess microbes. For more information on pro-biotics, check out the National Center for Complimentary and Alternative Medicine at http://nccam.nih.gov/health/probiotics/
*Pay attention to pre-biotics. No, that’s not a typo. Pre-biotics as the name suggests, are like the precursors of pro-biotics. These nondigestable food ingredients, called oligosaccharides, stimulate the growth and activity of the gut microbiome. They are found in many vegetables as well as in bananas, oats and soybeans. In a recent Italian study, adding pre-biotics to re-hydration fluid for children with diarrhea significantly reduced the severity and duration of symptoms (compared to standard re-hydration fluids). The NIH is actively investigating both pro-biotics and pre-biotics, in fact they have assembled a working group tasked with identifying “gaps and challenges in pre-biotic and pro-biotic research.”
*Keep your calories down. One proposed explanation for our obesity epidemic is that obese people have, over time, preferentially selected (via natural selection, not conscious selection) certain highly efficient gut bacteria. These bacteria are much better at extracting energy from food than the gut bacteria of thin people. The theory is that once you’ve cultivated these super efficient microbes in your GI tract, you’ll extract more calories from your food even when you eat significantly less of it. Perhaps someday there will be an antibiotic for obesity, but in the meantime, best not to overeat. By the way, another in-vogue hypothesis is that a nutrionally-balanced low calorie diet can extend your life span. Animal studies and some preliminary cardiovascular-based studies seem to support this contention. So, live little rather than go big and you might just stick around longer.
*When it comes to cleansing, moderation is key. Don’t go crazy de-toxing, bleaching, and germaphobing. Gut cleansers and unnecessary antibiotic users – this means you. Heard this before? Well’s it’s called the hygiene hypothesis; the contention that modern society, like the town pastor in Footloose, protects us too forcefully from the unclean, depriving our immune system from useful practice and our microbiome from helpful stimulation. So, when you are sick or in the hospital, be sure to strictly follow hygiene standards, but otherwise remember, “Gaia made dirt, and dirt don’t hurt.”
Of course infectious diseases are still major killers and interventions like vaccinations and antibiotics undoubtedly save millions of lives. But let’s take time to celebrate the good little guys, too. Let’s thank the microbes that ferment grapes and hops, produce yogurt and cheese, and raise lofty loaves of bread. And let’s be proud of our personalized squadrons of sustenance-processing magicians and give them a helping hand every once in a while. If you find yourself in a digestive rut, go ahead and cultivate that gut!
Deep in the bowel you’ll find a stew of microorganisms that make the breakdown of food and absorption of nutrients possible. Scientists know this crock-pot of little critters as a mircrobiome and it consists of millions of densely packed bacteria and yeasts, with names like Lactobacillus, Bifidobacterium, and Saccaromyces. In sum, these body microbes outnumber human cells by ten to one! Constantly at work, the gut microbiome serves many crucial functions; it turns food products into usable energy forms such as sugars and short chain fatty acids, it produces vitamins such as Vitamin K and biotin, and it protects against disease in a number of ways. And while we’ve known for some time that microbes play a critical role in the gastrointestinal tract, we are just beginning to appreciate the magnitude of their influence and the uniqueness of their composition on a person-to-person basis. That’s right, your microbiome is unique to you – it’s your own living micro-signature.
So, you may be wondering what you can do to cultivate a healthy microbiome? Recently, I spoke with Lita Proctor, Ph. D, Coordinator of the Human Microbiome Project – a National Institutes of Health (NIH) funded endeavor to catalogue the microbe communities of the human body using sophisticated DNA analysis. The following tidbits of advice are based on her thoughts as well as a sampling of the available scientific evidence.
*You and your microbes will have many more good times than bad. For every microbe-induced sore throat or upset tummy, there will be thousands upon thousands of illnesses that your personalized microbes will shield you from.
*Pro-biotics (live microbes found in products such as Culturelle and Align) do work – some of the time, for some conditions. But we don’t know exactly why. Someday, your medical record may include a full tracing of your genome and microbiome – allowing us to predict and prevent common nuisances (such as antibiotic-associated diarrhea). But until then, consider pro-biotics in certain situations (such when you’re dealing with antibiotic-associated diarrhea) but do so with some caution. Newborns (who begin sterile but start to assemble their own microbiome as they pass through the birth canal) and people with compromised immune function probably should not routinely be supplemented with excess microbes. For more information on pro-biotics, check out the National Center for Complimentary and Alternative Medicine at http://nccam.nih.gov/health/probiotics/
*Pay attention to pre-biotics. No, that’s not a typo. Pre-biotics as the name suggests, are like the precursors of pro-biotics. These nondigestable food ingredients, called oligosaccharides, stimulate the growth and activity of the gut microbiome. They are found in many vegetables as well as in bananas, oats and soybeans. In a recent Italian study, adding pre-biotics to re-hydration fluid for children with diarrhea significantly reduced the severity and duration of symptoms (compared to standard re-hydration fluids). The NIH is actively investigating both pro-biotics and pre-biotics, in fact they have assembled a working group tasked with identifying “gaps and challenges in pre-biotic and pro-biotic research.”
*Keep your calories down. One proposed explanation for our obesity epidemic is that obese people have, over time, preferentially selected (via natural selection, not conscious selection) certain highly efficient gut bacteria. These bacteria are much better at extracting energy from food than the gut bacteria of thin people. The theory is that once you’ve cultivated these super efficient microbes in your GI tract, you’ll extract more calories from your food even when you eat significantly less of it. Perhaps someday there will be an antibiotic for obesity, but in the meantime, best not to overeat. By the way, another in-vogue hypothesis is that a nutrionally-balanced low calorie diet can extend your life span. Animal studies and some preliminary cardiovascular-based studies seem to support this contention. So, live little rather than go big and you might just stick around longer.
*When it comes to cleansing, moderation is key. Don’t go crazy de-toxing, bleaching, and germaphobing. Gut cleansers and unnecessary antibiotic users – this means you. Heard this before? Well’s it’s called the hygiene hypothesis; the contention that modern society, like the town pastor in Footloose, protects us too forcefully from the unclean, depriving our immune system from useful practice and our microbiome from helpful stimulation. So, when you are sick or in the hospital, be sure to strictly follow hygiene standards, but otherwise remember, “Gaia made dirt, and dirt don’t hurt.”
Of course infectious diseases are still major killers and interventions like vaccinations and antibiotics undoubtedly save millions of lives. But let’s take time to celebrate the good little guys, too. Let’s thank the microbes that ferment grapes and hops, produce yogurt and cheese, and raise lofty loaves of bread. And let’s be proud of our personalized squadrons of sustenance-processing magicians and give them a helping hand every once in a while. If you find yourself in a digestive rut, go ahead and cultivate that gut!
Thursday, February 17, 2011
Saturday, February 12, 2011
Stroke of Genius? (Marin IJ)
If your normally stoic mother were to call and say, “Honey dear, I seem to have a bit of a conundrum. I’ve suddenly developed numbness and weakness on the entire left side of my body.” How would you respond? If you’d call 911, then -- ding-ding-ding -- you are on the money. Sudden weakness on one side of the body is highly suggestive of a stroke or transient ischemic attack (TIA). In this situation, your mom needs to be seen as quickly as possible in an Emergency Department (ED). But does it matter what type of hospital she is seen at? Well, this is a matter of debate, but evidence now suggests that, yes, it could matter.
Over the past decade, spurred by recommendations from the American Stroke Association and the affiliated Brain Attack Coalition, hundreds of hospitals across the country (more than 700 actually) have received certification as “primary stroke centers.” The rationale for this paradigm shift in stroke care is primarily based on two observations. One: despite improved preventive care, stroke remains a leading cause of death and the leading cause of disability in this country. Two: much like with a heart attack where the saying goes “time is myocardium,” there are clock-dependant treatments for acute stroke too. You might say, “time is brain”. And while the leading emergent stroke treatment (an intravenous blood thinning medication called t-PA) has been a topic of significant debate, its use in patients with ischemic stroke (stroke caused by clot or decreased blood flow rather than by bleeding in the brain) within 3-4 hours of symptom onset is now largely accepted as the standard of care.
So, hence a certification process to improve, integrate and standardize care – spanning from the pre-hospital setting (ambulance response) to after hospital discharge. This process, primarily administered by the non-profit hospital accreditation body known as The Joint Commission, is rigorous, multidimensional and requires annual or biannual site visits. I won’t bore you with excessive details, but if you are interested, you can visit The Joint Commission’s website at http://www.jointcommission.org. Here in Marin County, we have two certified primary stroke centers, Kaiser San Rafael (certified in 2008) and Marin General Hospital (certified in 2010). Novato Community Hospital is affiliated with a stroke center (California Pacific Medical Center) in San Francisco.
Despite the time and resource-intensive nature of stroke certification, up until recently there has been limited data to justify the effort – especially in the community hospital setting. However, that is starting to change. A study out of Finland of over 60,000 patients with ischemic stroke (published last year in the journal Stroke) found improved one-year mortality rates in those patients treated at hospitals meeting stroke center standards. Closer to home, a study of 358 stroke patients seen at San Rafael Kaiser between January 2007 and July 2009 found that after stroke certification there was a 15% increase in the percentage of patients arriving at the ED early (within 6 hours) after stroke symptom onset – although this did not equate to greater use of t-PA. These pieces of evidence, though, are rather soft and difficult to generalize to the U.S as a whole. That is why a recent investigation of New York hospitals, published last month in JAMA, may become a cornerstone study for the stroke center movement.
Dr. Ying Xian and colleagues compared 30-day death rates for over 30,000 patients admitted to hospitals with acute ischemic stroke between 2005 and 2006. The researchers discovered that those treated at a state-certified stroke center (with criteria similar to that used by The Joint Commission) had modestly better mortality rates (10.1% versus 12.5%) than those who were not. This mortality benefit persisted at one year past hospitalization. The researchers also found a nearly three-fold higher rate of t-PA use in stroke centers. Importantly, they did not find a mortality benefit when comparing the outcomes of patients with two other life-threatening conditions (heart attack and major gastrointestinal bleeding). This suggests that stroke centers (at least in New York) are not across-the-board better hospitals than non-stroke centers, but that they do provide better care for stroke patients. Thus, while other investigations are ongoing (including a comprehensive one within Kaiser Northern California) and it remains to be seen if the New York numbers are reproducible nationwide, this does appear to be a pretty convincing justification of the stroke center model.
So, let’s return to that call from your normally stoic mother with sudden numbness and weakness on left side of her body. Several years ago, a survey of Michigan adults used virtually the same language and asked respondents what they would do. A mere 42% stated they would call 911. Rates for calling 911 were also low for two other classic stroke presentations “Sudden trouble speaking or understanding what is being said,” (51.5%) and “Sudden trouble seeing in one or both eyes” (20%).
This study demonstrates that we have work to do in educating the public about the signs and symptoms of stroke. Keep in mind that there are many odd sensations that are not suggestive of stroke – generally feeling week, isolated tingling without weakness, and vision problems associated with pain. For these symptoms, be assured that the risk of stroke is low. But if you experience the symptoms mentioned above and/or sudden and severe headache, or non-alcohol related loss of coordination (more info at http://www.strokeassociation.org) -- it is time to give your local emergency medical services ( EMS ) a call. EMS response is the first step in the stroke center model of integrated care. And while the jury is still out in the assessment of stroke centers, everyone should know that timely medical evaluation for people with suspected stroke is beneficial.
To help remember, think ‘time is brain.” But that doesn’t exactly roll off the tongue does it? How about “act fast so that you don’t croak when you stroke,” or “if in doubt, give EMS a shout”? No matter your preference, I do hope you’ll take a moment to learn more about stroke.
Over the past decade, spurred by recommendations from the American Stroke Association and the affiliated Brain Attack Coalition, hundreds of hospitals across the country (more than 700 actually) have received certification as “primary stroke centers.” The rationale for this paradigm shift in stroke care is primarily based on two observations. One: despite improved preventive care, stroke remains a leading cause of death and the leading cause of disability in this country. Two: much like with a heart attack where the saying goes “time is myocardium,” there are clock-dependant treatments for acute stroke too. You might say, “time is brain”. And while the leading emergent stroke treatment (an intravenous blood thinning medication called t-PA) has been a topic of significant debate, its use in patients with ischemic stroke (stroke caused by clot or decreased blood flow rather than by bleeding in the brain) within 3-4 hours of symptom onset is now largely accepted as the standard of care.
So, hence a certification process to improve, integrate and standardize care – spanning from the pre-hospital setting (ambulance response) to after hospital discharge. This process, primarily administered by the non-profit hospital accreditation body known as The Joint Commission, is rigorous, multidimensional and requires annual or biannual site visits. I won’t bore you with excessive details, but if you are interested, you can visit The Joint Commission’s website at http://www.jointcommission.org. Here in Marin County, we have two certified primary stroke centers, Kaiser San Rafael (certified in 2008) and Marin General Hospital (certified in 2010). Novato Community Hospital is affiliated with a stroke center (California Pacific Medical Center) in San Francisco.
Despite the time and resource-intensive nature of stroke certification, up until recently there has been limited data to justify the effort – especially in the community hospital setting. However, that is starting to change. A study out of Finland of over 60,000 patients with ischemic stroke (published last year in the journal Stroke) found improved one-year mortality rates in those patients treated at hospitals meeting stroke center standards. Closer to home, a study of 358 stroke patients seen at San Rafael Kaiser between January 2007 and July 2009 found that after stroke certification there was a 15% increase in the percentage of patients arriving at the ED early (within 6 hours) after stroke symptom onset – although this did not equate to greater use of t-PA. These pieces of evidence, though, are rather soft and difficult to generalize to the U.S as a whole. That is why a recent investigation of New York hospitals, published last month in JAMA, may become a cornerstone study for the stroke center movement.
Dr. Ying Xian and colleagues compared 30-day death rates for over 30,000 patients admitted to hospitals with acute ischemic stroke between 2005 and 2006. The researchers discovered that those treated at a state-certified stroke center (with criteria similar to that used by The Joint Commission) had modestly better mortality rates (10.1% versus 12.5%) than those who were not. This mortality benefit persisted at one year past hospitalization. The researchers also found a nearly three-fold higher rate of t-PA use in stroke centers. Importantly, they did not find a mortality benefit when comparing the outcomes of patients with two other life-threatening conditions (heart attack and major gastrointestinal bleeding). This suggests that stroke centers (at least in New York) are not across-the-board better hospitals than non-stroke centers, but that they do provide better care for stroke patients. Thus, while other investigations are ongoing (including a comprehensive one within Kaiser Northern California) and it remains to be seen if the New York numbers are reproducible nationwide, this does appear to be a pretty convincing justification of the stroke center model.
So, let’s return to that call from your normally stoic mother with sudden numbness and weakness on left side of her body. Several years ago, a survey of Michigan adults used virtually the same language and asked respondents what they would do. A mere 42% stated they would call 911. Rates for calling 911 were also low for two other classic stroke presentations “Sudden trouble speaking or understanding what is being said,” (51.5%) and “Sudden trouble seeing in one or both eyes” (20%).
This study demonstrates that we have work to do in educating the public about the signs and symptoms of stroke. Keep in mind that there are many odd sensations that are not suggestive of stroke – generally feeling week, isolated tingling without weakness, and vision problems associated with pain. For these symptoms, be assured that the risk of stroke is low. But if you experience the symptoms mentioned above and/or sudden and severe headache, or non-alcohol related loss of coordination (more info at http://www.strokeassociation.org) -- it is time to give your local emergency medical services ( EMS ) a call. EMS response is the first step in the stroke center model of integrated care. And while the jury is still out in the assessment of stroke centers, everyone should know that timely medical evaluation for people with suspected stroke is beneficial.
To help remember, think ‘time is brain.” But that doesn’t exactly roll off the tongue does it? How about “act fast so that you don’t croak when you stroke,” or “if in doubt, give EMS a shout”? No matter your preference, I do hope you’ll take a moment to learn more about stroke.
Sunday, February 6, 2011
Weaning the Vent *Excerpt from Chapter 1*
“Assessment and plan,” declared Lesley, who was wrapping up her presentation to our small team of physicians. “Angelina Andriola is a previously healthy fourteen-year-old girl acutely ill with presumed sepsis of unknown origin with systemic inflammatory response syndrome. She is on day two of broad spectrum antibiotics – nafcillin, cefotaxime and flagyl. She is hemodynamically unstable… ” Lesley spoke with meticulous cadence, and I suspected that she was a meticulous physician – the type who arrived two hours before morning rounds and knew your patients even better than you did. Staring intently at her clipboard, oblivious to the imploring eyes from the corner of the room, she finished ,“…and is on an epinephrine drip to support blood pressure and on maximum ventilatory support with an oscillator ventilator. Since admission to the PICU, we have been unable to wean the vent.”
“Okay,” said our attending physician, Dr. Connor, in a baritone. “Here’s what we are going to do...” Dr. Connor – and as my superior I was expected to call refer to him formally as Doctor – was a bear of a man, stout through the chest and neck; not exactly the waifish, Mickey-mouse-tie-wearing pediatrician of my internal stereotype-oscope. He had a bushy goatee and the faint stubble of a receding hairline. I’d heard from other residents that Dr. Connor was an excellent clinician and tolerant teacher, who occasionally transformed into a volatile autocrat. “I want to turn Angelina over. Let’s get her off her stomach, flip her supine, and let’s see how she does. If she can’t maintain her oxygen sat above ninety, we’ll have to turn her back prone. And, let’s try and get a feeding tube down so that we can get her some nutrition. Now,” he said while rotating towards the girl’s parents, who were standing attentively nearby “Questions?”
“Yes, Doctor.” The girl’s mother started to speak but her father, a pale man with a grey speckled beard and intense red-rimmed eyes, interjected. I studied him for a moment and thought, oddly, of Richard Dreyfuss.
“Absolutely, I have questions,” he said. “You have to explain some of this in layman’s terms. What does ‘hem-o-dy-nam-ically unstable’ mean, and what about ‘su-pine’ and ‘prone’? What, exactly, does it mean that Angelina is on ‘maximum vent-il-atory support.’” His recitation of these medical terms was impressively and surprisingly accurate. He continued, “and that you are unable to ‘wean the vent’? Are you telling us that there isn’t anything more you can do? It seems to me that it is a complicated way of saying that there’s not much more that you can do for Angelina.” His reddened eyes began to glisten faintly. “You do realize, don’t you, that Angelina was perfectly healthy before she arrived at this hospital?”
Dr. Connor paused, as if stifling a sigh, before replying. “Mr. Andriola, we haven’t run out of options for treatment, but your daughter is extremely sick and requires the very highest level of support for her hemodynamics – her heart rate and blood pressure – and from the ventilator. Her oxygen saturation…her blood oxygen level, is very tenuous. So far, we haven’t been unable to wean, that is reduce, that support. But we will keep trying. So far, your daughter has done much better on her stomach, in the prone position, than on her back.” He pivoted towards Lesley, “Doctor Gallagher, could you spend some time with Angelina’s parents this morning? Okay, who’s next?”
And with that, our small pack of physicians – Dr. Connor, myself, and three other residents moved out of the room. I looked back as we left and saw Mr. Andriola, mouth twisted open. In front of him lay his daughter, Angelina, no more vibrant than a lump of coal. I watched as the girl’s mother stepped forward and gently kissed her daughter on the head.
“Okay,” said our attending physician, Dr. Connor, in a baritone. “Here’s what we are going to do...” Dr. Connor – and as my superior I was expected to call refer to him formally as Doctor – was a bear of a man, stout through the chest and neck; not exactly the waifish, Mickey-mouse-tie-wearing pediatrician of my internal stereotype-oscope. He had a bushy goatee and the faint stubble of a receding hairline. I’d heard from other residents that Dr. Connor was an excellent clinician and tolerant teacher, who occasionally transformed into a volatile autocrat. “I want to turn Angelina over. Let’s get her off her stomach, flip her supine, and let’s see how she does. If she can’t maintain her oxygen sat above ninety, we’ll have to turn her back prone. And, let’s try and get a feeding tube down so that we can get her some nutrition. Now,” he said while rotating towards the girl’s parents, who were standing attentively nearby “Questions?”
“Yes, Doctor.” The girl’s mother started to speak but her father, a pale man with a grey speckled beard and intense red-rimmed eyes, interjected. I studied him for a moment and thought, oddly, of Richard Dreyfuss.
“Absolutely, I have questions,” he said. “You have to explain some of this in layman’s terms. What does ‘hem-o-dy-nam-ically unstable’ mean, and what about ‘su-pine’ and ‘prone’? What, exactly, does it mean that Angelina is on ‘maximum vent-il-atory support.’” His recitation of these medical terms was impressively and surprisingly accurate. He continued, “and that you are unable to ‘wean the vent’? Are you telling us that there isn’t anything more you can do? It seems to me that it is a complicated way of saying that there’s not much more that you can do for Angelina.” His reddened eyes began to glisten faintly. “You do realize, don’t you, that Angelina was perfectly healthy before she arrived at this hospital?”
Dr. Connor paused, as if stifling a sigh, before replying. “Mr. Andriola, we haven’t run out of options for treatment, but your daughter is extremely sick and requires the very highest level of support for her hemodynamics – her heart rate and blood pressure – and from the ventilator. Her oxygen saturation…her blood oxygen level, is very tenuous. So far, we haven’t been unable to wean, that is reduce, that support. But we will keep trying. So far, your daughter has done much better on her stomach, in the prone position, than on her back.” He pivoted towards Lesley, “Doctor Gallagher, could you spend some time with Angelina’s parents this morning? Okay, who’s next?”
And with that, our small pack of physicians – Dr. Connor, myself, and three other residents moved out of the room. I looked back as we left and saw Mr. Andriola, mouth twisted open. In front of him lay his daughter, Angelina, no more vibrant than a lump of coal. I watched as the girl’s mother stepped forward and gently kissed her daughter on the head.
Monday, January 31, 2011
Listen to this
IF YOU'RE A PARENT, does the following scenario sound at all familiar? Your 18-month-old child catches a cold and after a few days of seemingly harmless sniffles, she morphs from a happy and inquisitive toddler into a dreadful beast — fragile, volatile and screaming when she should be sleeping.
Once a water baby, she's now deathly afraid of the bath; not wanting water within an American Girl's reach of her head. Already a picky eater, all of a sudden the only food she'll accept is dried fruit and the resulting "runs" obliterate the family's diaper reserves. Acetaminophen calms the situation, but a couple hours later it's back to hysteria-hood.
Not ringing any bells? Consider yourself fortunate (and warned) because this exact metamorphosis happened to my daughter several years ago. Of course, like any parent, I attempted to diagnosis the situation. After considering some possibilities (such as personality inception and possession by the devil), I settled on the most likely malady — otitis media, aka an ear infection.
Ear infections are quite common in children younger than 3, primarily because the anatomy of the young ear (specifically that of the Eustachian tube between the middle ear and back of the throat) doesn't allow for effective clearance of fluids. In youngsters with the sniffles, middle ear fluid often bottlenecks, allowing bacteria from the nose and throat to migrate into the ear.
So, suspecting an ear infection, I decided to do ... nothing. I thought I was being astute, as I was following the advice of the American Academy of Pediatrics. I was in "watchful waiting" mode, considered a viable alternative to antibiotics for many children with ear infections because the majority of these infections get better on their own.
Unfortunately, after 48 hours, watchful waiting had turned into witchful watching, and even though my daughter had not developed a fever, it was time to stop playing doctor with my own family. The pediatrician who examined her ears observed that they looked "extremely painful" and asked, "Wow, does she scream all night long?" Yes, I replied, she sure does!
Hayley took her first dose of antibiotics that afternoon and by the next morning the beast was gone, replaced by a (mostly) happy and inquisitive toddler. I was shocked with how quickly her symptoms improved and suddenly appreciated the words of dozens of parents who had sworn to me that antibiotics did help with otitis media. With this experience in mind, I can't say I was particularly surprised by the recent study that provided, for the first time, solid evidence that some children with ear infections do, in fact, get better faster with antibiotics.
The study, published in the New England Journal of Medicine, was led by Dr. Alejandro Hoberman from Children's Hospital of Pittsburgh. In it, the researchers examined the symptoms of 291 children (age 6 to 23 months) with ear infections who either did or did not receive an antibiotic (amoxicillin clavulanate, also known as Augmentin) for 10 days. They found, across several measures (including the composite Acute Otitis Media Severity of Symptoms [AOM-SOS] scale) that the group receiving antibiotics fared better in the short-term, with a faster time to symptom improvement and significantly lower rate of persistent infection. On the other hand, the kids receiving antibiotics suffered a 25 percent rate of diarrhea, versus 15 percent with the placebo group and there was no significant difference between two groups in the amount of painkiller used.
The authors summed up their study:
"(A)mong children 6 to 23 months of age with acute otitis media, treatment with amoxicillin clavulanate for 10 days affords a measurable short-term benefit ... (that) must be weighed against concern not only about the side effects ... but also the contribution of antimicrobial treatment to the emergence of bacterial resistance. These considerations underscore the need to restrict treatment to children whose illness is diagnosed with the use of stringent criteria."
It is with these stringent criteria that the issue gets tricky. The investigators in Hoberman's study were specially trained in examining the middle ear and, in some cases, their diagnoses were assisted with otoscopic photographs. In the normal clinical setting, such ideal circumstances do not always exist and children often require protracted wrestling and/or earwax removal before a doctor can even get a glimpse of the middle ear. Thus, decisions about antibiotic treatment must sometimes be made with imperfect information.
Also, there is the part about bacterial resistance; a major concern in general and especially with broad-spectrum antibiotics (ones are effective against a wide range of bacteria) like Augmentin. Typically, and in the case of my daughter, initial treatment for otitis media is with a more-targeted antibiotic such as amoxicillin, with Augmentin reserved for children who do not improve. To use Augmentin in all children with ear pain would eventually lead to a major resistance problem.
So, where does this lead us regarding antibiotics for ear infections? I asked Dr. Cindy Chung, chief of pediatrics at San Rafael Kaiser and she recommends the following guidelines for parents: "60 percent to 75 percent of ear infections get better by themselves and so it's not wrong to 'watch and wait,' but this approach is best reserved for kids older than age 2 because of higher complication rate in younger kids and the fact that children are harder to interpret when they can't speak."
From experience, I have learned that there are ways that young children communicate — such as persistent screaming — that indicate a certain treatment plan loud and clear.
Once a water baby, she's now deathly afraid of the bath; not wanting water within an American Girl's reach of her head. Already a picky eater, all of a sudden the only food she'll accept is dried fruit and the resulting "runs" obliterate the family's diaper reserves. Acetaminophen calms the situation, but a couple hours later it's back to hysteria-hood.
Not ringing any bells? Consider yourself fortunate (and warned) because this exact metamorphosis happened to my daughter several years ago. Of course, like any parent, I attempted to diagnosis the situation. After considering some possibilities (such as personality inception and possession by the devil), I settled on the most likely malady — otitis media, aka an ear infection.
Ear infections are quite common in children younger than 3, primarily because the anatomy of the young ear (specifically that of the Eustachian tube between the middle ear and back of the throat) doesn't allow for effective clearance of fluids. In youngsters with the sniffles, middle ear fluid often bottlenecks, allowing bacteria from the nose and throat to migrate into the ear.
So, suspecting an ear infection, I decided to do ... nothing. I thought I was being astute, as I was following the advice of the American Academy of Pediatrics. I was in "watchful waiting" mode, considered a viable alternative to antibiotics for many children with ear infections because the majority of these infections get better on their own.
Unfortunately, after 48 hours, watchful waiting had turned into witchful watching, and even though my daughter had not developed a fever, it was time to stop playing doctor with my own family. The pediatrician who examined her ears observed that they looked "extremely painful" and asked, "Wow, does she scream all night long?" Yes, I replied, she sure does!
Hayley took her first dose of antibiotics that afternoon and by the next morning the beast was gone, replaced by a (mostly) happy and inquisitive toddler. I was shocked with how quickly her symptoms improved and suddenly appreciated the words of dozens of parents who had sworn to me that antibiotics did help with otitis media. With this experience in mind, I can't say I was particularly surprised by the recent study that provided, for the first time, solid evidence that some children with ear infections do, in fact, get better faster with antibiotics.
The study, published in the New England Journal of Medicine, was led by Dr. Alejandro Hoberman from Children's Hospital of Pittsburgh. In it, the researchers examined the symptoms of 291 children (age 6 to 23 months) with ear infections who either did or did not receive an antibiotic (amoxicillin clavulanate, also known as Augmentin) for 10 days. They found, across several measures (including the composite Acute Otitis Media Severity of Symptoms [AOM-SOS] scale) that the group receiving antibiotics fared better in the short-term, with a faster time to symptom improvement and significantly lower rate of persistent infection. On the other hand, the kids receiving antibiotics suffered a 25 percent rate of diarrhea, versus 15 percent with the placebo group and there was no significant difference between two groups in the amount of painkiller used.
The authors summed up their study:
"(A)mong children 6 to 23 months of age with acute otitis media, treatment with amoxicillin clavulanate for 10 days affords a measurable short-term benefit ... (that) must be weighed against concern not only about the side effects ... but also the contribution of antimicrobial treatment to the emergence of bacterial resistance. These considerations underscore the need to restrict treatment to children whose illness is diagnosed with the use of stringent criteria."
It is with these stringent criteria that the issue gets tricky. The investigators in Hoberman's study were specially trained in examining the middle ear and, in some cases, their diagnoses were assisted with otoscopic photographs. In the normal clinical setting, such ideal circumstances do not always exist and children often require protracted wrestling and/or earwax removal before a doctor can even get a glimpse of the middle ear. Thus, decisions about antibiotic treatment must sometimes be made with imperfect information.
Also, there is the part about bacterial resistance; a major concern in general and especially with broad-spectrum antibiotics (ones are effective against a wide range of bacteria) like Augmentin. Typically, and in the case of my daughter, initial treatment for otitis media is with a more-targeted antibiotic such as amoxicillin, with Augmentin reserved for children who do not improve. To use Augmentin in all children with ear pain would eventually lead to a major resistance problem.
So, where does this lead us regarding antibiotics for ear infections? I asked Dr. Cindy Chung, chief of pediatrics at San Rafael Kaiser and she recommends the following guidelines for parents: "60 percent to 75 percent of ear infections get better by themselves and so it's not wrong to 'watch and wait,' but this approach is best reserved for kids older than age 2 because of higher complication rate in younger kids and the fact that children are harder to interpret when they can't speak."
From experience, I have learned that there are ways that young children communicate — such as persistent screaming — that indicate a certain treatment plan loud and clear.
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