By the fans, for the fans

My favorite part is batman standing on the roof of a building, looking out at the (C) in the sky.

Hat tip to NPR
Vidders Talk Back to Their Pop-Culture Muses

---

On another note, I heard this story on NPR and I knew that I had to look it up when I got home. How did I find it? Well, I typed in "british vidding NPR" into Google. That's when I realized that Google Search is just like assembling a differential diagnosis -- coming across exactly the thing you're looking for (an answer) by a unique combination of findings. More on this later.

Top Ten: Study Methods and Habits

Medical school is one of those interesting fields where obsessive-compulsive behavior is reinforced and rewarded to no end. While I am not an inherently organized and disciplined person, I decided that I needed to change for the better upon entering med school. Here are some of the strategies that I employ:

1. Buy a lot of different colored highlighters
   I use each color for a specific purpose when I read.  Colors are a fast way of categorizing items. It helps keep me awake if nothing else.  The bonus: having nice colorful notes that are easy to review.
   

Yellow = important facts

Green = examples, lists, subheadings, lab values/Diagnosis, (+)/increasing

Orange = Key Topics/Vitally Important facts

Pink = In contrast to, (-)/decreasing

Blue = Treatment/medications

Purple = difficult to remember names/eponyms



2. Tag chapters in textbooks
   Dog ear or put in little tags for chapters.  When I tag more than the chapters, there's too many slips of paper and it takes a while to find what I want.  I also try to use different colored tabs to represent different things: Red = CV, Pink = OB, Blue = Pulm, Purple = ID, Yellow = Renal
3. Develop concept-maps/case-maps for basic physiology/pathophysiology concepts with integrated management.
   Algorithms are boring and thus, terrible ways to learn.  A concept map that systematically thinks through a problem is much more engaging.  I use C-maps for this purpose.
4. Use mnemonics.  Use them often!
   Mnemonics are highly individual and some do not work at all for anyone else but yourself.  I've done my best to try and share ones that I thought others might appreciate or those that I've heard but were not readily available online.  I made a bank of mnemonics in an excel spreadsheet with the comments as the expanded version -- when I float my cursor over the mnemonic it pops up with the reminder of what it means.
5. Learn how to think.
   Problem-Based Learning helped me develop on the spot differential diagnosis development and consequential workup, diagnosis and management.  I like it when experts tell me how they think through a problem... that's why one of the books I'm reading right now is Learning Clinical Reasoning (Excellent resource; unfortunately, it seems like its no longer in print.)
6. Stay up to date.
   Read medical journals, news and blogs.  Clinical Cases and Images answers the question: "How do you Eat an Elephant?" by setting up Google Reader. I read feeds on the latest articles in NEJM, JAMA, Annals of Internal Medicine, AFP and The Lancet.  Also, I follow some great blogs -- I share the entries that I find of special importance (seen in the sidebar.)
7. Use a multi-monitor setup.
   Buy an extra monitor!  The more desktop real-estate you utilize, the more you can read and learn.  Typically, I use one monitor for reading something and the other monitor for taking notes on the subject.
8. Centralize ALL of your notes.  When I was studying for Step 1, all of my notes went into First Aid.  Now that I'm studying for Step 2 and all of my different shelves, it'll take more than a book to hold my notes.  Which takes me to my next point...
9. Use an online notetaking service.
   Evernote is my all-time favorite application now.  I can put text notes into it as well as pdf files... perfect for clipping key parts all of those articles I'm reading!  It has the benefit of being available on any computer (so I can find my notes on diabetes anywhere I go.)
10. Use a question-bank to keep things in perspective.
    I use USMLE World.
    It is easy to lose track of what might be considered "important/high yield" for exams if you don't use a Q-bank on a regular basis.  Mark all of the questions you get wrong (be honest!) and review those specific topics and questions again.  Repetition is the key to rote memorization... and sometimes that's whats necessary to remember things like drug names.  Ugh!
11. Above all else... Have fun!
    Otherwise you'll just end up wasting time .  :)

Cheers,

Wondering about Wanderers?

Suppose your grandmother wanders out of the house in the middle of the night. What can you do for some peace of mind to keep them safe?

One option is a MedicAlert + Safe Return bracelet. Here's some information:

Enroll in program: 1.888.572.8566

Report a wandering incident: Call 911 first. Then call 1.800.625.3780. 

MedicAlert + Safe Return enrollment package

For $49.95, with a $25 annual renewal fee, the enrollment kit includes:

* MedicAlert Identification bracelet or pendant
* Wallet card
* "6 Steps to a Safe Return" magnet
* Personal Health Record Summary
* Alzheimer's Association brochure

What are some important considerations for dementia?
Here's a few mnemonics that might be helpful:
Remember the reversible causes of DEMENTIA

Drug intoxication
EtOH
Metabolic (hypothyroidism, order TSH!)
Emotions (screen for depression!)
Nutrition (Vit B1/B12... order B12!)
Tumor/Trauma/"Tension"-Normal Pressure Hydrocephalus
Infection (neurosyphilis, consider RPR!)
Anemia/Atherosclerosis (order CBC!)

I'm very fond of important mnemonics that help me quickly recall things at the bedside, especially if they can be easily detected and treated before it progresses into something much more permanent.


GOMERS go to ground - The Fat Man, House of God. (Elderly people have a tendency to fall.)
There's a ton of mnemonics on falling. IHATEFALLING, CATASTROPHE*... those are too long but you can google them at your leisure.
GMA MOVES is more to my liking.

Gait impairment
Multiple Meds-Polypharmacy
Alcohol and drug use
Medical illness (PNA, MI, anemia, hyponatremia)
Orthostatic/postprandial hypotension
Visual Impairment
Environmental hazards (poor lighting, stairs, rugs, uneven floors)
Syncope, vertigo, presyncope, or disequilibrium

References:
See my post on the Mini Mental Status Exam (ORArL 321 RWD!)
Medical Mnemonics.com
Fall Prevention checklists: Patient Handouts

[edit] * The CATASTROPHE mnemonic is not available on the AAFP article so I've tracked it down for you.
Functional hx after a fall in the elderly
Caregiver/housing
Alcohol (including w/drawal)
Tx (meds & compliance)
Affect (depression, lack of initiative)
Syncope
Teetering (dizziness)
Recent illness/hospitalization
Ocular problems
Pain w/ mobility
Hearing
Environmental hazards

Patient Education

What are some good sites for patient handouts?
Family Doctor.org
ACP's HEALTH TiPS
JAMA's Patient Page
ACOG (OB/GYN) Pamphlets
Pediatrics: AAP Pamphlets
Postgraduate Medicine: The Practical Peer-Reviewed Journal for Primary Care Physicians (AccessMedicine Login required)
American Heart Association: Diseases and Conditions
National Digestive Diseases Information Clearinghouse (NDDIC): Digestive Diseases

What about online resources for proactive patients?
The Google Approach: Patient Education
Health.gov
Healthfinder.gov: U.S. Dept of Health and Human Services
MedlinePlus: Interactive Tutorials
Health research: NIH
ACC: Cardiology education

This is part of an ongoing process to collect reliable health information on core medical topics for Family Medicine. This post will be updated with new information and comments on a regular basis.

It is my goal to easily provide a handout and education for all of my patients in a cooperative and collegial manner... basically, allowing my patients to take charge of their own health!

See my Patient Education Handouts widget* on the bottom of this page as well for more resources.


*Disclaimer: My Patient Education Widget is a series of clips from other sources. I have provided citations where appropriate.

Finding Common Ground

When you run up against a patient who is difficult to talk to, how can you come to a meaningful compromise?

Interest-Based Negotiation and Conflict Resolution:
by Roger Fisher and William Ury’s Getting to Yes

1) Separate the people from the problem.
2) Focus on interests, not positions.
3) Generate a variety of possibilities before deciding what to do
4) Use objective criteria to judge the solution, rather than pit one personal opinion against another.

These tips make a lot of sense and I'm thrilled that my Family Medicine rotation had us read an article on this all-too-important subject. It is difficult to learn these sorts of things... a lot of it is intuitive and to be quite frank, I've had to work very hard because it does not come naturally to me.

As a medical student, I lack a lot of the clinical judgment that my preceptors and residents have. About the only good tool I have on hand comes from being systematic, being thorough and hoping that nothing slips through the cracks. I've found this strategy to be especially effective in dealing with long-winded, opinionated patients. Only students have the luxury of time to outlast patients by performing an exhaustive interview. I plan to use this tool for as long as possible, because in the end, my patients walk away happy knowing that someone listened to them -- even though I might not have offered them everything they wanted.

Psych: Biopsychosocial Formulation Pocketmod

I wish I knew who I could credit for the majority of this information... I got it as a brainstorming handout that's very useful for developing a comprehensive assessment and plan for psychiatry patients.

I made a handwritten version for myself and then I got concerned that I might lose it eventually. What better place to immortalize the these gems than to share it freely with others?

Pocketmod PDF: Biopsychosocial Formulation


Wondering how to fold this document? See my previous post on the subject of PocketMods on the Wards.

Pondering on: Psych diagnosis

I tweeted the following:

Psych disorders: diagnosis with cause or arbitrary definitions w/o reason?

Here's my follow-up on this question.

What is the reason for coming up with a diagnosis?

Initially, the attraction for coming up with a diagnosis is to determine the CAUSE of the disease. It's nice to have an explanation and for a long time, Freud's psychoanalysis gave us causes. Internal conflict of competing and often unconscious desires manifested themselves as various disorders. It was an attractive hypothesis.

However, psychiatry has come a long way since then. Namely, the discovery of a number of psychoactive drugs that are successful at treating conditions.

Suddenly, the underlying predisposing causes and precipitating factors that were the emphasis of a psychiatric visits took a back seat as a set standardized definitions emerged in the form of the Diagnostic and Statistical Manual of Mental Disorders: the DSM for short.

Initially, it started off as a way for psychiatrists to communicate clearly with each other and for researchers to make sure that treatment modalities were consistent. After all, if one psychiatrist called something "schizophrenia" while another thought it was a clear-cut case of "manic-depression," they would have different approaches. And indeed, British psychiatrists were wondering why the rates of U.S. schizophrenia and bipolar disorder were so different from their own.

However, it has now become an engrained part of oh-so-important BILLING. There are codes attached to all of these diagnoses and in order to ensure that they are properly billed, they must be documented to meet criteria. Before, psychiatrists had an intuitive sense from taking a history with the patient and observing them about what the diagnosis is. Now, it has almost become a requisite to slog through a long list of things to establish criteria.

Here's an example of the criteria for ADHD:

A. Either (1) or (2):
(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Inattention
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively
Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Code based on type:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months

Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.

That's a long list to try and wade through!

Indeed, the "checkbox" medicine was the sort of approach that I had taken when I was doing in-patient psychiatry. Unfortunately, a list of criteria is much harder to memorize than some elegant "pathoneurology"/psychoanalysis, unless it's in the form of some handy-dandy mnemonics. For example, I'd routinely hit a few things from SIGECAPS and DIGFAST to rule out depression and bipolar disorders during the interview with some very scripted questions.

My psych preceptor has challenged me to think more about the genesis of the DSM criteria and indeed, many of these so called "criteria" are based on professional opinion with very little evidence or scientific basis. So I've become much more accustomed to a more natural interviewing process and I think that this will help my approach to psych diagnoses much more.

Gout

Gout is one of the few arthritides that is reversible and curable with a few simple dietary/lifestyle changes and drugs.

Current Rheumatology Diagnosis and Treatment elegantly describes it like matches. With flare-ups, the "matches" in the joints light up and cause pain. They can be blown out by NSAIDs, made wet with colchicine and removed entirely with allopurinol. This metaphor is akin to the pathophysiology, with the "matches" representing uric acid crystals precipitating in joint space and lighting up when they get inflamed by the invasion of neutrophils.

On a more clinical note, here's some mnemonics to remember Gout:

A TIC ("thick") red, inflamed joint:
-Trauma, Infection, Crystals

ROPE in your ddx of arthritis:
RA, OA, Pseudogout/Psoriatic, Everything else (some crazy zebras: reactive/Reiter's, Still's, Hemochromatosis, Lupus, Lyme, Whipple's, Behcets, Ochronosis)

When tapping a joint, order 3C's for Synovial Fluid ("CCCnovial")
Cell Count, Culture, Crystals
Synovial glucose is not as sensitive as WBC count (>500-1000) for infection.

The aim for the management of chronic tophaceous gout is <6.0 mg/dL of serum uric acid.
Think: <6 to fix.

If the 24 hour urinary uric acid is >800, probenecid can be an alternative to allopurinol. Probenacid is a weak organic acid so it affects the renal levels of other organic acids (ASA, PCN, etc.)
Think: >800, ProbenAcid instead.

USMLE Step 1 score: a pissing contest

What Score do I need for my Specialty?

...
There is one highlight pertaining to USMLE Step 1 scores worth mentioning, located on a chart in the document above (page 16 of the pdf, page 11 in print) There appears to be 2-3 tiers of scores with the most competitive specialties falling under the highest tier. A potential breakdown is:

Tier 1 (Median USMLE Step 1 Scores of 233-243):

* Plastic Surgery
* Dermatology
* Otolaryngology
* Diagnostic Radiology
* Radiation Oncology
* Orthopaedic Surgery
* Transitional Year

Tier 2 (Median USMLE Step 1 Scores of 217-222):

* Internal Medicine
* Pathology
* General Surgery
* Emergency Medicine
* IM/Peds
* Anesthesiology
* Neurology
* Pediatrics

Tier 3 (Medan USMLE Step 1 Scores of 208-213):

* Ob/GYN
* Family Medicine
* PM&R
* Psychiatry

I'm all for reporting what score you need to get to be considered for a specialty you're interested in. However, it really irks me that the most challenging specialties (of breadth) are in the bottom "tier."

It's the culture of medicine, working at its best.

Here's the way it works for those of you who haven't been inducted into the secret society of white-coat-dom:
Everyone pisses and whoever can piss the farthest wins.
The guy who pisses for the longest wins also.
Wins what? The easiest and cushiest lifestyle, of course.
Why? Because that's the reason we all applied for medical school, right? Who wants to work long hours for no reward when you can do elective procedures and break the bank?
Why not let everyone win if they aren't pissing red blood or albumin? That's my win-win definition of a pissing contest -- yay, you can pee healthy!

For some reason I keep talking about piss, but I assure you, I'm not pissed.

Even people who don't subscribe to the "lifestyle" theory of natural residency selection agree with its prestige: it is much more difficult to land a derm or radiology residency spot than it is internal medicine or pediatrics. (The unspoken therefore: the people who go into derm or radiology are smarter/better! Too bad supply and demand economics doesn't drive students into the professions we need the most.)

Now, I'm not bashing people who truly love Plastics or Rad Onc. On the contrary, I DO have a great amount of respect for them for having the ambition that I clearly lack to aim for one of those spots. Me, I'm envisioning myself being content to have a small group of patients that I will help give birth to, raise and grow old with (and blog on the side.)

I still want to do my best and that means:
I will counsel the HELL out of people who are determined to lose weight and start exercising!!
I will be an awesome educator for all sorts of common ambulatory complaints!!
I will strive to catch all of the rare zebras in their horse clothing and send them off to the right specialists so I won't be one of the dull-wits in primarycareville.
I will spend that extra time to see the last-minute walk-in or the guy without insurance.

Why? I decided to become a doctor because I want to do the right thing. That's righteous (hopefully without seeming too self-righteous.)

THAT is a first tier goal in my mind. (GOAL being the key word. I doubt I'll live up to any expectations, but I hope to never lose sight of them.) These goals are much more forward looking than a step board score determining what I will do for the rest of my life.

Polydactyly

Baby Born In Bay Area With 12 Functioning Fingers, 12 Toes

Baby Kamani Hubbard has six-fully formed and functional fingers and toes on his hands and feet. It's called "polydactyly" -- extra digits -- not an uncommon genetic trait, but Bay Area doctors say they've never seen a case so remarkable.

Born at San Francisco's Saint Luke's Hospital three weeks ago, Hubbarb seemed so perfect at birth no one noticed.

"Nurses and doctors, looked so normal they couldn't tell, they told me he was six pounds in good health, that was all they said," said Miryoki Gross, Hubbard’s mother.

But his dad Kris Hubbard noticed this spectacularly rare case of polydactyly: 6-perfect fingers on each hand and six perfect toes on each foot, which went well beyond a general trait that runs in his family.

This is pretty exciting. It seems as though there are some autosomal dominant forms of polydactyly... and it is likely that baby Hubbard will have offspring with polydactyly as well. Possibly leading to a new generation of artists and musicians!

I am reminded of two things.

1) Gattaca. There's a scene where the Black Mambo and Batman are listening to a pianist and she comments: that's a piece of music that can only be played with six fingers.

2) Elementary school. I knew a girl that had an extra pinky on one hand. We kind of made fun of her for it, but it was really unobstrusive. I think that this kid'll have a different experience because his extra fingers/toes are functional! Sure, he'll be different and therefore weird, but its cool to think that he'll also have supported parents, since dad had polydactyly also.

References:
Online Mendelian Inheritance in Man: Polydactyly. http://www.ncbi.nlm.nih.gov/entrez/dispomim.cgi?id=603596

Starfruit

Starfruit, aka Carambola.

I've seen a few of these things at the open market. I was never brave enough to try one, but they are described as "sweet without being overwhelming and extremely juicy. The taste is difficult to compare, but it has been likened to a mix of papaya, orange and grapefruit all at once" by someone on wikipedia.

Grapefruit is a good way to phrase it, since it has similar health effects. Grapefruit and starfruit juice inhibits liver enzymes involved in the breakdown of certain drugs through the Cytochrome P450 system. (Namely, CYP3A4,5,7: the most important metabolizing enzyme of the bunch.)


The blue slice of the pie is BLOCKED by starfruits and grapefruits!

Not only that, but it can create a lethal buildup of oxalate crystals in the kidney in patients with kidney disease. Oxalate crystals are the same byproduct from ethylene glycol poisoning, the treatment for which is hemodialysis and fomepizole (or ironically, ethanol.)

How can you spot someone with starfruit toxicity? Typically, they will present with persistent hiccups, vomiting, neurologic problems, and occasionally convulsions.

Treatment for starfruit poisoning consists of prompt hemodialysis. Surprisingly, even though starfruits have a lot of potassium, intoxicated patients were not shown to have hyperkalemia.[1]

I'm certainly not trying to fearmonger with this post, merely inform. I'm going to give starfruits a try the next time I see them as a part of my pledge for better health. They sound tangy and delicious!

[1] Intoxication by star fruit (Averrhoa carambola) in 32 uraemic patients: treatment and outcome

Photo by AZAdam

Quantum Thought Mechanics

Discover Magazine: Is Quantum Mechanics Controlling Your Thoughts?

One of the most significant quantum observations in the life sciences comes from Fleming and his collaborators. Their study of photosynthesis in green sulfur bacteria, published in 2007 in Nature, tracked the detailed chemical steps that allow plants to harness sunlight and use it to convert simple raw materials into the oxygen we breathe and the carbohydrates we eat. Specifically, the team examined the protein scaffold connecting the bacteria’s external solar collectors, called the chlorosome, to reaction centers deep inside the cells. Unlike electric power lines, which lose as much as 20 percent of energy in transmission, these bacteria transmit energy at a staggering efficiency rate of 95 percent or better.

The secret, Fleming and his colleagues found, is quantum physics.

...

Electrons moving through a leaf or a green sulfur bacterial bloom are effectively performing a quantum “random walk”—a sort of primitive quantum computation—to seek out the optimum transmission route for the solar energy they carry. “We have shown that this quantum random-walk stuff really exists,” Fleming says. “Have we absolutely demonstrated that it improves the efficiency? Not yet. But that’s our conjecture. And a lot of people agree with it.”

...

Stuart Hameroff, an anesthesiologist and director of the Center for Consciousness Studies at the University of Arizona, argues that the highest function of life—consciousness—is likely a quantum phenomenon too. This is illustrated, he says, through anesthetics. The brain of a patient under anesthesia continues to operate actively, but without a conscious mind at work. What enables anesthetics such as xenon or isoflurane gas to switch off the conscious mind?

Hameroff speculates that anesthetics “interrupt a delicate quantum process” within the neurons of the brain.

...

He speculates that the action unfolds like this: When certain key electrons are in one “place,” call it to the “left,” part of the microtubule is squashed; when the electrons fall to the “right,” the section is elongated. But the laws of quantum mechanics allow for electrons to be both “left” and “right” at the same time, and thus for the micro­tubules to be both elongated and squashed at once. Each section of the constantly shifting system has an impact on other sections, potentially via quantum entanglement, leading to a dynamic quantum-mechanical dance.

I did my best to try and preserve a few key passages of the article for you.

Basically, what it's saying is that through the process of quantum mechanics, life follows a path of least resistance, the shortest possible route, through a bloom of possibilities as reality collapses in and chooses the best one. This goes to show, in my mind that we do live in the best possible world!

Not only that, but quantum mechanics makes the seemingly impossible possible -- namely that greatest mystery of all -- consciousness. Through a similar process of quantum calculation in neuronic wiggling, Dr. Hameroff proposes that our neurochemistry is influenced in a way to optimize our circuitry. I've posted in the past about quantum mechanics. I find the topic absolutely fascinating, because of the mind-boggling weird science involved and what it implies in our world. My slim grasp of the topic informs my philosophy: we live in a macroscopic cause-and-effect world as we see it, but this is all undermined by a submicroscopic boiling chaos of potential (and optimization!)

It affirms and informs previous comment I had made:

It is cool to think that [consciousness] is an aggregation of quantum activity that takes off as massive butterfly effects in our heads. I don't think that this necessarily implicates the additional driving meta-physical force of consciousness, nor does it happen continually. Every so often, metaphorical dominoes are dumped out onto a table and a few of them align, waiting for the quantum flutterby. This is the exception, not the rule.

hat-tip to Medgadget
Image by LoreleiRanveig

Dilemma: Care of an Unresponsive Patient with a Poor Prognosis

NEJM Clinical Decisions Case:
Care of an Unresponsive Patient with a Poor Prognosis
Arthur S. Slutsky, M.D., and Leonard D. Hudson, M.D.

A 56-year-old homeless man was found having a seizure and was transported to the hospital. He was found to have a subarachnoid hemorrhage and acute hydrocephalus. He underwent intubation, and mechanical ventilation was started. ... The patient's condition did not improve over the next 3 days, and both the neurologist and the neurosurgeon opined that he had a chance of approximately 80 to 90% of being in a long-term persistent vegetative state and a chance of 5 to 10% of any recovery. His prognosis, at best, was to have a severe disability that would leave him dependent on care by others.

In this picture:

* A son who, under the law of the state, was the legal next of kin for making medical decisions if the patient was unable to do so himself. The son described the patient as "a fighter" who would want aggressive care until the prognosis was much more certain.
* A brother and a mother. They were all in agreement that the patient would not want to live in a state in which he would be largely dependent on others for daily care and would have severely impaired cognition.
* A counselor at a homeless shelter with whom he had talked at least every couple of weeks. The counselor came to see the patient and related that the patient had told him that he wished to avoid hospitals and that "when his time came" he wanted no aggressive medical care.

Given the lack of improvement in the patient's neurologic state, the extremely poor prognosis for any meaningful recovery of cognitive function, and the high probability of cancer, the care team strongly believed that all aggressive and supportive measures should be discontinued and the goals of care changed to those of providing comfort. The brother and mother, who had been quick to respond to queries from the beginning, agreed with the shift to comfort care. However, the son, who had become increasingly difficult to contact and rarely returned telephone calls from the caregivers, disagreed. He had hardened his position, wanting full aggressive-care measures to be taken, including clipping of the aneurysm.

What would you do?
1) Continue Aggressive Care and Pursue an Ethics Consultation with the Patient's Surrogate
2) Write a Do-Not-Resuscitate Order and Transfer the Patient to a Skilled Nursing Facility
3) Withdraw Life Support on the Basis of Substituted Judgment

Cast your vote!

---

My response:

I chose three online. To demonstrate my convictions, I've provided my extended comments below.
This case shows that decisions cannot be made with broad brush-strokes (all decision making must be handled exclusively by legal next of kin). Rather, it must be understood in the context of the case. The son with durable power of attorney (DPOA) is "holding the line" so to speak, on the basis that his father is "a fighter" who would desire aggressive care until a prognosis was much more certain.

Surely, this is a sentiment we can all agree with -- fighting for someone we love. However, the clarity of the prognosis and possibility for recovery is understood by all (but him) to be minimal at best. The prognosis was declared by a neurologist and neurosurgeon to be ~80-90% of being in a long-term persistent vegetative state and a chance of only 5-10% for any recovery! Even if he did recover, he would no longer be independent, something inconsistent with his values.

The father has not formally declared any DPOA, but it becomes apparent that the son is estranged and the counselor from the shelter is more familiar with the patient's desires. The son is exhibiting a common grief reaction of denial, withdrawing himself from the situation while simulataneously insisting that everything be done. Given the family support from the mother and brother and the coinciding words by the counselor, I would elect to place the decision-making in their hands and withdraw life support and provide hospice for the patient and family counseling. A full discussion of the SAH and subsequent coma should be initiated with the family with maximal encouragement to have the son attend!

Fast Food Economics

Maybe you've heard the commercials for 3conomics by a certain fast food company.

Here's a personal story of another fast food chain and how they run things.

I order a Jumbo Burger and a soda (needed food on the run before evening Urgent Care clinic since I didn't make any sandwiches for the day.) She tells me "Would you like to get our Jumbo deal? You'll get fries and two tacos with it and it will be cheaper." (emphasis mine!)

BWA? I hesitated because I'll be honest, I was tempted. Ooh, more food for less money? I turned it down knowing that my stomach could not hold more than a burger. Besides, America is fat enough as it is. I needed to take a stand.

"Just trying to save you money," she told me.
"Well, I think it's ethically irresponsible for your restaurant to offer more food for less money. I'll eat what I can eat." I replied.
She cocked her head to the side, obviously surprised to be under attack by proxy, but conceded. "Yeah, sorry," she said as I drove off.

By the way, the burger was delicious. I went home that evening and had a salad with carrots to make amends. :)

Personal Healthcare

One of my old high school friends just started working in Maui and she invited me to a Health Fair in Makawao. It was "hippie fare," but I dig that sort of thing even though I do not go to the spiritual and quasi-religious extent that many of the health-conscious organic food eating, yoga stretching vegetarian/vegans do. Listening to a lecture on "Defensive Medicine" really got me back in touch with my passions. The speaker was well-educated, respectful of the medical profession (one of my main concerns with visiting the Health Fair) and paid me a few compliments on being "one of the most thoughtful and bright people" he met today. (I'm such a sucker for positive praise.)

I'd like to eat more healthy, which means less processed foods, less red meat, more fresh leafy greens (I love the Superette nearby for its cheap stuff!)
I'm fine eating commercial crops though.
I'd like to sign up for yoga, since I haven't been keeping up with my 43things.com resolution to practice it everyday.

I want to make people healthy.

A lot of my clinic time, especially in Family Medicine, is spent counseling and educating patients. I'm still a student myself in these matters (and I hope to always consider myself a student and learner in this regard!) so I'm still settling in as an educator. I do love to talk about it with people though... it's just a matter of finding an angle and doing so without the outside pressures of time (and my inexperience) weighing in.

So I'm going to make a commitment to increase my personal wellbeing, here and now. That means more exercise daily, healthier meals (Maui is a supportive place for that) and more reflection on basic health topics that the public is interested in.

The "Defensive Medicine" topic was really about preventive medicine, how to care for yourself so you don't have to go and see the doctor. I agree with this idea; healthy people make the best patients :) The only downside as I see it now is that there's not much to learn and read about in terms of pathology when I get home.

Diet and Exercise.

Diet: I've taken up drinking tea and V8. I crave V8 now... which is ironic since I used to wrinkle my nose whenever I'd see my dad gulping that stuff down as a kid. I'm making a lot of home meals, to reduce my processed food intake and increase my veggies. I'm buying fruits in smaller amounts so I don't feel stressed out about eating a half dozen bananas in a day so they don't rot. I'm contemplating more HawaiiDiet type stuff by Terry Shintani. Becoming familiar with it for my own life makes sense, if I'm going to recommend similar dietary changes to my patients!

Exercise: I used to bike to and from the hospital as my exercise. It was one of my favorite parts about living in downtown Honolulu. I don't have a bike now and this half of the equation in my health is DEFINITELY lacking -- as all med students can attest to, this is the biggest part of the struggle. I don't have to worry about staying in shape, as I lack any sort of shape to begin with. I resemble a one-dimensional shape. I've got a page of exercises for the Ultimate Fat-Burning No-Equipment routine which is ideal for the home-centric exercise I desire.

Octuplet mom "obsessed" with kids -- all 14 by IVF

Octuplets' Mom "Obsessed" With Having Kids:
Her Mom Says All 14 Of Unmarried Daughter's Children Resulted From In-Vitro; Ethics Debate Rages On

The woman who gave birth to octuplets this week conceived all 14 of her children through in-vitro fertilization, is not married, and has been obsessed with having children since she was a teenager, her mother said.

A physician has clear ethical responsibilities to primum non nocere, first do no harm. In-vitro fertilization is a process in which eggs are collected from the mother, the "shell" is cracked and sperm are incubated with them in a "test-tube" environment. When an embryo is ready, it is placed in the mother. It is not guaranteed that this embryo will implant itself on the endometrial lining, nor that it will persist to full-term. To increase the likelihood of a successful pregnancy, the U.S. allows up to TWO embryos to be implanted (except in unusual circumstances.)

EIGHT embryos were implanted in this woman! What sort of infertility condition does she have that warrants this risk to herself and her babies?!?

Angela Suleman said her daughter always had trouble conceiving and underwent in-vitro fertilization treatments because her fallopian tubes are "plugged up."

That doesn't count for squat. If she has no uterine anatomic defects or dysregulation in her menstrual cycle (problems involving the ovaries)... it doesn't make sense to me that she needs this! Except for the fact that she's obsessed -- clearly something that a physician should discuss in depth with a mother-to-be. At the very least, a referral to a good psychiatrist as this obsession clearly was affecting her relationship with her parents.

There were frozen embryos left over after her previous pregnancies and her daughter didn't want them destroyed, so she decided to have more children.

Her mother and doctors have said the woman was told she had the option to abort some of the embryos and, later, the fetuses. She refused.

Her mother said she doesn't believe her daughter will have any more children.

"She doesn't have any more (frozen embryos), so it's over now," she said. "It has to be."

....
Ah. Now the story is being made more clear, although in somewhat oblique terms. Here's a mother who believes that it would be unethical to discard her other embryos. I can imagine what this discussion went like with the doctor.

"Doc, how many embryos do I have?"
"We have eight embryos left over from your previous IVF."
"Doc, I'm pro-life. I don't want to kill these babies. Will you implant all of them?"
"Uhm, ok."

Sarcasm aside, this woman's belief (after artificially creating embryos) about the sanctity of life endangered her own life and those of her children. Most people are not aware that as women age, many embryos do not even make it to term due to chromosomal abnormalities, failure of implantation, etc. We do not blame women for these silent miscarriages. The idea of being "pro-life" is attractive because of its simplicity... but the reality of the situation is that "life" itself begins on a spectrum of convening factors. It's not merely the union of an egg and sperm. The full extent of this topic should be the subject of another post -- and if I'm going to compose my thoughts well enough to make a statement that I'd stand behind, it would have to be a damn good one.

Yolanda Garcia, 49, of Whittier, said she helped care for Nadya Suleman's autistic son three years ago.

"From what I could tell back then, she was pretty happy with herself, saying she liked having kids and she wanted 12 kids in all," Garcia told the Long Beach Press-Telegram.

"She told me that all of her kids were through in vitro, and I said 'Gosh, how can you afford that and go to school at the same time?'" she added. "And she said it's because she got paid for it."

Aaand this speaks of even more ethical grayness. I really feel bad for this lady now. Not only is she single with fourteen kids, at least one of them has special needs. I don't get it though. She was paid to do what? Donate eggs? Participate in an experiment for multiple gestation pregnancy? This story has opened up so many doors to all sorts of controversies in medicine, it's quite incredible. Even more so because I imagine that the general lay-public has enough understanding to wonder at technology producing octuplets but not enough to feel the chill of incompetence in doing so.