November 23, 2006

Proxy consent

Is it morally right for society to allow parents of children too young to make their own decisions to deny them the medical attention they require for survival for religious reasons?
  • Yes, it is their child after all
  • No, absolutely not
  • I'm Not Sure

I see this as a question of responsibility. Ultimately, who is held responsible for the death of a Jehovah's Witness child if they get into a serious car accident and need stat blood transfusions in the ER? Is it the person who drove the car? Is it the ER physician? Is it the parents for refusing to give their child blood? Is it God? Everyone has different answers. "It was God's will" is often invoked as a way of accepting the passing of a loved one. However, gods do not swoop down and cast their miracles, blessings and curses down upon us on a daily basis, manipulating our fates in the same way that a storyteller casts roles for his characters and tells them what to say and do. We all have free will to do as we wish.

If we have the power, the capacity and the opportunity to save a life, then I feel that we are MORALLY OBLIGATED TO DO SO. With power comes responsibility, because where we once had no options but to grit our teeth and pray, we now have Choice. We can Choose to alter the fate of a human life in the case of emergency medicine.

Not everyone will choose to follow the same course of action.

"You have the right to choose", the Watchtower says. This biweekly publication for Jehovah's Witnesses originally introduced the ban on blood transfusions in 1945 and since then, it has complicated the treatment for their adherents. While I find it regrettable that JW's would refuse treatment, by the ethical principle of autonomy, they are allowed to do so as long as they give informed consent. This means that they fully understand all of their options and perform a cost-benefit analysis according to their own principles and make a decision. The difficulty underlying this is how it can be applied to young children.

The British Medical Journal has this to say on the subject of proxy consent:

With regard to religious based refusal of blood products by parents, courts in the western world are of the opinion that the child’s welfare is paramount and blood can be given. Consideration should be given to parental views and treatment moderated where possible but if conflict occurs, the child’s interests always come first.

Regarding adolescents, there is no worldwide consensus on the legal position of adolescents refusing blood transfusions, but recent cases suggest that the UK’s approach is probably the most acceptable. While many children raised in JW communities may never experience the "outside world", the judiciary would be wrong not to give them that opportunity. Religion is a powerful persuading voice, but it is also an individual belief. A limited life experience cannot truly give one the opportunity to rationalise a belief that may eventually lead to death.

Archives of Disease in Childhood 2005;90:715-719

Past courts have ruled similarly, citing differences between developed adult beliefs and those of their undeveloped children. In 1944, Prince v Massachusetts set out the reigning legal principle:

Parents may be free to become martyrs themselves. But it does not follow that
they are free, in identical circumstances, to make martyrs of their children...

In 1999, Alexis Demos was a 17 year old who refused to undergo a blood transfusion when she lacerated her spleen after a snowboarding accident. Her decision and that of her family was challenged by physicians and ultimately went to the Massachusetts Supreme Court where they ruled in favor of the physicians. What parents often forget is that they are not solely responsible of their child's welfare; doctors and nurses who care for the patient are emotionally affected as well. The death of a child who would have been saved under any other circumstances rests on their consciences.

However, the beliefs of Jehovah's Witnesses are not to be dismissed or ignored by the medical community. For them, this is not a routine medical procedure, it might be a test of their faith and a gauge for their quality of life. As one Jehovah's Witness told me, "If I receive a blood transfusion, I won't be living in the face of God and it would be better to die than face that." Those are strong words to live by (and die by.) Blatantly disregarding these strong beliefs would violate her autonomy and her personal well-being. Many surgeries can be performed with alternative blood products, saline infusions and "bloodless surgeries" that cater to their particular beliefs.

When I encounter patients with strong faiths, I will ask them about their faith in medicine and their faith in me. If I am going to help them, I think it is important that they believe in me and my dedication to best serve them.

November 20, 2006

The limits of Evidence-Based Medicine

The parachute has not been properly tested to the same degree as evidence-based medicine (EBM)!

BMJ 2003;327:1459-1461 (20 December), doi:10.1136/bmj.327.7429.1459
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials

Study selection: Studies showing the effects of using a parachute during free fall.

Main outcome measure: Death or major trauma, defined as an injury severity score > 15.

Results: We were unable to identify any randomised controlled trials of parachute intervention.

Conclusions: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

I got a good chuckle out of reading this. Basically, common sense must prevail over rigid adherence to scientific evidence, development of clinical criteria and other objective quantities. Sometimes EBM can project a total ignorance of human qualities... and I feel that this is the main problem underlying EBM's tense relationship with complementary and alternative medicine (CAM).

EBM and CAM both have the same objectives in mind -- they make the patient feel better. However, one of them demands PROOF. The other just cares if it makes you, the patient, feel better. As it has been shown time and time again, there is a degree of efficacy in placebo, where the mind actually is able to make the body feel better with a useless remedy. The placebo effect is a great friend to CAM adherents, because these people feel like they are regaining some control over their lives and their condition -- in doing something (even if it is nothing) they feel better.

Do EBM and CAM get along harmoniously? No. Do they have to? I don't think so. Orac, the EBM atheist/surgeon and full-time woo-hater, abhors the idea that medical schools have CAM in their curriculum. Even worse, AMSA, the premier med student organization, supports the woo.

I can see why this would trouble him. However, after participating in a retreat with the CAM department at my medical school this past weekend, I am not inclined to take the same hard line that Orac puts us up against. We spent very little time learning about the native medicine. (Which bothered me a lot.) We spent a lot of time learning about the native culture. (Which I have come to realize is the most important part of medicine that we cannot be taught through school.)

I think that it is vital to have CAM in medical school. We shouldn't be "so open-minded that our brains fall out," but at the same time, we need an understanding of these alternative medicines and the culture underlying them so we can be appropriate advisors. We care for the patients and obviously, they care for themselves because they ARE SEEKING TREATMENT... even if it is something that is not science-tested, doctor-approved.

In order to address CAM issues in the clinic, it is important to understand their theories and be accepting, not distainful. (Bedside manner is key!)

It is important to separate the roles of researcher and physician. It is the job of a scientist to be a skeptic -- and a doctor's role is to care. If someone takes their loved one to a reflexologist instead of a doctor with a complaint of "breast lumps" doesn't mean that they are loved any less. It doesn't mean that they are trying to prove something by being different. It does mean that you have to be respectful of their beliefs to regain their trust.

While your opinion is good and you think that it is right... it means nothing if patient has a different opinion of you and allopathic EBM.

November 07, 2006


One of my classmates donated blood for the first time last week. I thought it was very brave of him, considering how he was with needles. We practiced giving shots on each other intramuscularly (IM) and subcutaneously (subQ) with our clinical skills preceptor. He was very nervous about being stuck with a needle for our little blood draw...

"I can draw blood from other people just fine; I'm actually really good at it!" he said. He certainly was adept at taking someones blood. He did have some squeamishness about giving his own, though. He had some traumatic experiences with a gadolinium shot once and he passed out.

So this past Friday, I was waiting in line to donate and someone who was rejected came out of the bloodbank mobile. "One of your classmates just fainted in there!" he told me.

I knew right away who it was.

Some people have a vasovagal response to needles and blood. Emotional stress can trigger the hypothalamus in the brain to reduce their sympathetic "fight or flight" responses. As a result, their blood pressure drops precipitously from sudden slowing of the heart rate and their arteries dilate. Less blood flows to the brain and the decrease in oxgyen causes them to feel dizzy and in my classmate's case, pass out.

As blood flowed painlessly out of the venipuncture in my arm, Tom remarked about his current physiologic state. "My blood pressure was 110/80 before and it dropped to 80/70 when I passed out... now its back up, but now I'm tachycardic with a heart rate of 120!" Normally, the heart rate is between 60-100 beats/minute. "Explain that, pingpong," he asked me.

Ah... reflex tachycardia was likely induced as a way of bringing the blood
pressure back after vasovagal-induced vasodilation. After all, the blood
pressure is dependent on three factors: the heart rate, stroke volume and the
total peripheral resistance. In response to a drop in resistance (caused by the
peripheral blood vessels suddenly opening up and causing the heart to pump less
blood back to the heart,) the heart rate increased to compensate for the

If I were quick on my feet, I would have said something coherent and impressive like that. At the time, I just a bit flustered, hoping that I wouldn't be a victim to syncope (pronouced seen-coh-pee) as well.

I have my own little personal theory about this, which I shared with him as he was recovering:

"Back in the day, if you were attacked with a sword, you would've fallen to the ground and appeared dead, only to rise later on in the battlefield. It's a great survival mechanism..." I said cheerily.

"So, you're telling me that my grandparents were cowards?!?" he said in a somewhat horrified, but joking way.

"NO! I think they are survivors!"

It didn't occur to me at the time that what I said could've been construed as offensive. In retrospect, I realized that it certainly wasn't the most comforting thing to say to a good guy. He's got a great way of approaching his problems, though. Even though he was "black-balled from donating blood for ten years," he wanted to learn more about what was happening to himself. He wanted to turn this negative experience into a positive one.

I like that about my classmates. They are really good at that. Even if it would be his very first and last time donating blood.

Reference: PubMed
Clin Sci (Lond). 1991 Nov;81(5):575-86. The Vasovagal response.

November 06, 2006

2031 and 2048 predictions

Food labels will have been revised to reveal at a glance the overall nutritional
quality of any packaged food. Public school cafeterias will offer healthful
foods in two categories: mixed diets and vegetarian. Organic farming will
represent more than half of all agricultural productivity in the United States,
and 40 percent to 50 percent of the population will be vegetarian.
Some realms of nutrition will have changed much more dramatically.
A friend of mine responded to this estimation with surprise. 50% vegetarians? Well, at the current rate of seafood decline, we'll be out of fish to eat by 2048! (see later link) With mad cow disease and avian bird flu and other nasties, we'll have to rely on Quorn for meaty sustenance.

Nutrigenomic analysis will be part of a standard medical checkup, culminating in
a detailed printout offering tailored recommendations. With this power in their
hands, doctors will be reimbursed for offering dietary counseling, and will be
able to dispense worthwhile advice.
I like the sound of this. We are already modifying diets for the obese, diabetics and patients with coronary artery disease... wouldn't it be better to catch them before they get worse like we do with phenylketonurics? Look at a diet soda to see the dietary warnings for PKU people.

In the year 2031, parents will still tell their children to eat their broccoli
because it's good for them — that convention won't go away anytime soon.

Of course. How cute.

Wilson said if the situation continues as it is, all fish and seafood
creations could be extinct by 2048.

The paper is called "Impact of Biodiversity Loss on Ocean Ecosystem
Services" and features the work of ecologists and economists who studied the
role marine biodiversity plays in maintaining ecosystem services.

I will mourn my loss of shrimp, the most delicious crustaceans to roam the open seas. I suppose I will have to stock up for the next 42 years! ;)

November 03, 2006

Anticholinergic toxic effects

This mnemonic about atropine and scopolamine is rather poetic:

Sleepy as a sloth
Blind as a bat
Mad as a Hatter
Red as a beet
Hot as a hare
Dry as a bone

Bladder n' bowel lose their tone,
While the heart runs alone.

Jimson weed is common in the U.S. and ingestion of its leaves as a herb tea, chewed or smoked, causes these symptoms. However, the long onset makes a lot of users overdose while trying to get a cheap high.... and its not a fun one, as you could probably tell.

Belladonna, or deadly nightshade, is another plant that contains this alkaloid. "Bella Donna" means "beautiful woman," because atropine can be used to dilate the pupils (to simulate arousal.)

You might have been a "bella donna" if you've ever gone to the optometrist or ophthalmologist and they dilated your pupils to inspect your retina!

November 02, 2006

Community Health

There are four main principles of ethics in medicine: beneficence, non-maleficence, autonomy and distributive justice. Beneficence means to simply do good things, while non-maleficence means doing no harm. Autonomy refers to patient empowerment, giving them the right to choose their course of action in treatment.

Many doctors have no problems following the first three principles, even considering that a lot of very stubborn patients make aggravating and even detrimental health choices. However, the last principle proves to be the most difficult one to accomplish in medicine. Distributive justice reflects our Founding Fathers’ ideals on equality in the same way that autonomy reflects our nation’s independence.

Health disparities are a growing problem in our nation that can only escalate without a few policy and cultural changes. Universal health care is something that we have difficulty “buying into” because of our capitalist thinking… but the way our economy runs should not dictate the level of care that we administer to our citizens. Only recently have I start considering this equality of care as a true, guiding ethical principle alongside “do no harm.”

When I first heard about medical schools offering “free clinics,” I was very excited to be a part of something like that. I did not know what distributive justice was at the time -- I only saw it as an opportunity to get early hands-on clinical experience while being capable of providing a community service in healthcare to an underserved community. In my opinion, this provision is vital in the creation of a bond between students (like myself) and the people we would be seeing in our later years. I have a special interest in Primary Care, so learning how to cultivate this sort of connection was very important to me.

Much to my surprise and delight, My Medical School opened up the “Homeless Outreach and Medical Education (HOME) Project” at the Next Step transitional shelter right next to campus! A few months later, I matriculated. I showed up to the clinic the week before orientation started to get a feel for what we would be doing and I knew at once that this was something I wanted to be a part of. After going through interview after interview with various community health organizations during orientation week, I was selected to be a part of HOME. On my first day as a HOMEy (as we affectionately call ourselves,) I got to draw blood from a family medicine resident, before I even started my curriculum in medical school! I love the sorts of positive experiences and opportunities that HOME provides for us, bridging the gap between the science and clinical aspects of medicine with the art and community aspects.

We learned about community resource mapping and the importance of communicating with various organizations. We learned how to conduct valid surveys which would play into the first phase of our community projects, the needs assessment surveys. Dr. O was very gung ho about involving us in various projects to help the homeless. A few of the projects we are working on involve setting up various clinical services in the areas of dental health and mental health. The project that I am working on involves a mobile clinic that will go out on the road and take health services to the people who need it most. Since the future of the Next Step shelter residents is uncertain next year when the warehouse contract expires, I thought that it was very important for us to be able to go out on the road and see patients.

Last month, we had the opportunity to do just that. HOME set up a tent in a beach park with the “Helping Homeless/Hungry Have Hope” H5 program. We offered blood pressure screenings and first aid alongside the food and entertainment that H5 brought along. We had volunteers to spare, so a bunch of us went roaming through the homeless campsites with needs assessment surveys. The beach residents had a lot of very interesting stories to tell and I left with a sense of sadness and resolve. There were so many children there, just like those at Next Step, who are denied so many things and it is not their fault! The same applies for many of the adults as well, who cannot afford a home or even work at a job. One veteran I met wants to go back to work as a longline fisherman, but he needs surgery before that can be done. As a veteran, he only can get this surgery at an army hospital, but they won’t cover the cost. Another woman I met cannot go to work because she is afraid of losing her government benefits if she tries to raise her income for her family. It is a vicious cycle of poverty, but it is my hope that we can alleviate the problems for a few of these people to make a lasting positive difference in their lives.

We had a Halloween carnival for the kids of Next Step, transitional home to 92 homeless children. It took a lot of planning on the part of the medical students and Dr. O, but we had an incredible amount of support in terms of donations and manpower. I helped organize our volunteers and I also helped make some of the games. The children really enjoyed themselves and a lot of them spent the time cycling through the bouncy castle over and over and over again. Each health-related game came with a set of prizes they could win and their bags already started off with so much toys and candy, it was no wonder that many of them struggled to carry around their big bags of loot around. It was ironic that we had so much candy while we were trying to teach them about healthy habits and perhaps the kids knew that too. One MS-III told me "I asked the kids if they wanted any Reese's Pieces and they just wrinkled their noses... but when I asked them if they wanted pencils, they were really excited about that!"

What I love the most about HOME is the enthusiasm and dedication that everyone involved has and what I admire the most is the way that they excel at the tasks they are put to. Each Tuesday night, we set up clinic and see about two dozen patients in a few hours with just a handful of medical students! The attendings are all very open and friendly with us. It is a good time to get to know the third-years during their family practice rotations and sometimes we get to step beyond doing vitals to perform basic parts of the history and physical examination under their supervision.

I feel that HOME is a great integrating experience that ties in what we learn from clinical skills and basic science lectures with the psychosocial aspects of medicine (the “touchy-feely” stuff) that we discuss in our small group sessions and I am glad to be a part of it!