5.06.2016

The Myth of Islands

An Island is a lie.
On my way to work, I drive along Willapa Bay and pass by the two Islands that can be seen from the mainland. Long Island crowds just feet from the highway that hugs the shore. Heavily forested it stretches away to the horizon, appearing as solid shoreline. Long Island holds a grove of ancient forest and in days past was inhabited with settlements. There is a ferry landing just off the road that used to bring trucks back and forth across the narrow thread of water that separates it from the rest of Washington state.

A little farther on is a defiant little islet several hundred yards from where the tourist pass by on their way to the beach.. The US Geographic survey named it Round Island back in 1858. Locals call it Baby Island. Its shoulders’ hunched and spiked with snags and cedar that burl in the winter storms. Only a few acres of brush and trees, it appears a picturesque myth centered in the waters of the bay. Steep rocks rising from the silver gray waters and lonely alone.

We like to think of ourselves as islands, as individuals, as ecosystems wholly within ourselves. We like to believe that our actions affect no one beyond our ragged shore. We like to believe ourselves surrounded by waters isolated from the world outside. We like to think ourselves individuals, the center of our own solar systems -- centered yet separated by time and space from mothers, wives, children and friends who dip into our orbit for time only to swing away again.

It is easy to feel alone.

It is easy to think that our actions do not shatter the mirrored water that flows around us, yet the decisions we make ripple out into the world.

We see it in politics, where the temptation is to live and let live, assuming no responsibility for the community, the state, the nation or the world.

I hear it all the time. I’ll take care of myself, do what I want, and it won’t affect anyone else. If other people make bad choices, can’t access health care or mental health services or run out of money when they are too old to work, that’s their problem. It won’t affect me.

Yet it does.

I work as a nurse in an emergency room. It is the front line of the consequences of bad choices.

I meet a lot of people who until that moment thought they were islands. Many thought their decisions affected no one but them and them alone.  Some have long suffering loved ones at bedside, others have long since burned those bridges to the mainland. Perhaps they justified this as a way to limit that damage they caused, or perhaps the connection was never very good in the first place.

If not family and friends, there are always the professionals -- the police officers, EMTs, nurses, doctors and socials workers -- who crash in waves trying to make a difference until the last breath.

Every wave recedes taking a little away from the beach and leaving a little of itself behind. Yet, the ocean itself is not unchanged.

I have watched as addiction destroys families and devastates public resources. I have seen suicide shatter communities. I have seen health care professionals struggle to make a difference in the face of increasing needs and decreasing resources.

Studies have shown that nurses experience depression at twice the rate of the general population. Doctors have a suicide rate that is at least twice that of the general population and that rate is even greater for female physicians. The stresses come from long hours, increasing work loads and the crushing expectations of health care systems that are always demanding more and paying less. Unfortunately, few seek professional help.

So too some of the stress comes from our own expectations. Physician Pranay Sinha, in a 2014 essay entitled “Why Do Doctors Commit Suicide?”  in the New York Times explained it this way:

“There is a strange machismo that pervades medicine. Doctors, especially fledgling doctors like me, feel the need to project intellectually, emotional and physical prowess beyond what we truly possess. We masquerade as strong and untroubled professionals even in our darkest and most self doubting moments. How, then, are we supposed to identify colleagues in trouble -- or admit that we need help ourselves?”

Individual strength, resilience  and freedom are cultural virtues in our nation.Yet we achieve most when we come together and recognize our connections and that through those connections our individual decisions have repercussions on the world around us.

This far north the tides are impressive - a dozen feet in sea level change can drastically alter your perspective in a few hours time. When the tide is low, the water drains out of old Shoalwater bay and Round Island is exposed as connected to mainland by mudflats that the unwary may be tempted to walk across.

Drain away the oceans that appear to separate us, and you will find underneath the connections that tie us all together. 

What we do and say and how we act affects those near and far.

How we treat each other and how we take care of ourselves matters.

If you think you are an island, just wait until low tide.

-30-

This essay was originally written for the The Daily Astorian and published on 4/29/2016.

10.26.2015

Why Food Science is So Bad (And So Often Wrong)

VOX.com Graphic
This week the World Health Organization put processed meat on the list of 478 other things that could cause cancer.

Eating an extra 50 grams of processed meat each day will increase a man's risk of colon cancer by 18 percent from baseline risk over a ten year period.

That said, your risk of getting colon cancer is small, but if you eat 50 grams of processed meat every day, it may increase a bit.

However, the WHO article, which appeared in the British Medical Journal Lancet Oncology elevates processed meats - like bacon and hot dogs to the same carcinogen threat level as tobacco.

Of course, the headline you read this morning probably said something like "Meat Causes Cancer" because leaving out the "processed meat" and the other niggling bits of detail makes for a boring story. Red meat was considered, but the WHO working group was unable to make a link between red meat and cancer.
"Chance, bias and confounding could not be ruled out with the same degree of confidence for the data on red meat consumption, since no clear association was seen in several of the high quality studies." 
Despite that, WHO still listed red meat as "probable" even though they couldn't find clear evidence.

It's worth putting these risks in perspective. The strongest evidence that the IARC uncovered focused on one type of cancer — colorectal — and the risks related mainly to heavy meat consumption. Still, the panel did find that a person's cancer risk "increases with the amount of meat consumed." So if you're eating five hot dogs a day, there's a lot more to worry about than if you have a steak a month. - VOX

That is, of course, just one of the problems with the near daily inundation of reporting we get on nutrition and diet. The research is often poor, biased or stretched to draw the conclusions we wish to draw based on the mood of the moment. We grasp at straws to make conclusions.

The WHO's rulings on carcinogens will likely carry more weight than most nutritional research that makes headlines, but the evidence is still problematic.  That's because studies on dietary changes are difficult. You can either look backwards at self reported or cultural dietary differences. Or you can set up a true double blind controlled study -- which is tricky because it is food. It tastes different.

As the UpShot column in the New York Times explains.
"Almost everything we know is based on small, flawed studies. The conclusions that can be drawn from them are limited, but often oversold by researchers and the news media. This is true not only for the newer work we see, but also the older research that forms the basis of much of what we already believe to be true."
Remember when we thought eat fat made us fat and clogged our arteries? For 30 years we were told that fat was what was wrong with our diets -- so we made fat free products -- replacing the fat with sugar to help it sell. Only to find that there was never much of a connection between eating fat and getting fat at all. Gary Taube's famous piece "What If It's All Been A Big Fat Lie" is a case study in the different factors tugging at what and how we eat.

As Taubes wrote more than a decade ago:
"Scientists are still arguing about fat, despite a century of research, because the regulation of appetite and weight in the human body happens to be almost inconceivably complex, and the experimental tools we have to study it are still remarkably inadequate. This combination leaves researchers in an awkward position. To study the entire physiological system involves feeding real food to real human subjects for months or years on end, which is prohibitively expensive, ethically questionable (if you're trying to measure the effects of foods that might cause heart disease) and virtually impossible to do in any kind of rigorously controlled scientific manner. But if researchers seek to study something less costly and more controllable, they end up studying experimental situations so oversimplified that their results may have nothing to do with reality. This then leads to a research literature so vast that it's possible to find at least some published research to support virtually any theory. The result is a balkanized community -- ''splintered, very opinionated and in many instances, intransigent,'' says Kurt Isselbacher, a former chairman of the Food and Nutrition Board of the National Academy of Science -- in which researchers seem easily convinced that their preconceived notions are correct and thoroughly uninterested in testing any other hypotheses but their own."
This leads to confusing contradictions in what is healthy and not healthy, what is good for you and what will kill you. It takes little in the way of scientific rigor to get on the Good Morning America show with the latest finding.

Yet one week of media blitz based on a small, flawed study could lead to years of misleading information and dozens of diet books as follow up research fails to attain the same level of sensationalism. As the UpShot notes:
"Although it's easy to point fingers and make a case that there are huge gaps in our evidence when it comes to food, it should be kept in mind that it's incredibly hard to do this kind of work. The reason we have to rely on small, poorly designed trials is because that's often all we can get. Because of this, we will probably continue to see results from mostly small, sometimes-flawed, short term studies of nutrients and additives. Treat the results of that research with the respect they deserve, but ignore the grandiose proclamations." 
Required Reading:

Vox has the best coverage with links to critics of the WHO Working Group's conclusions. Wonkblog at the Washington Post puts the issue into the larger perspective of politics and culture.

The WHO's New Warnings About Bacon and Cancer, Explained Vox

Hot, Dogs Bacon and other Processed Meats Cause Cancer, WHO Declares Wonkblog at Washington Post

Gizmodo Does a Good Job explaining Why You Shouldn't Panic

What If It's All Been A Big Fat Lie? Gary Taubes classic

UpShot
Red Meat is Not The Enemy and
Unexpected Honey Study Shows Woes or Nutritional Research

Bloomberg
How Red Meat Joined 478 Other Things That Can Cause Cancer

Carcinogenicity of Consumption of Red and Processed Meat

Scientific Criticism of the WHO report.

8.28.2015

Best Thing on the Worst Day

 via Library of Congress
It was a busy night.

That is saying a lot.

All of our Monday nights are busy these days, but this was bad even by our standards. We had our fastest night shift ER doc working and extra staff, but still the patient's kept pouring in all night long.

We had sick patients too.

It was so bad that we woke up the morning shift doc and brought him in at 4 am because the department and the waiting room were full and the night shift doc was still ten charts behind.

That wasn't the only thing that made it unusual.

It was that rare night in the Emergency Department when all my patients:

1) Have a good reason to be in the ED.
2) Actually appreciated my help.

A night like that can carry you for six months -- it usually has to since it is about as common as hen's teeth these days.

With the onset of the Affordable Care Act,  Emergency Departments have seen huge increases in patient volume. Many more people have access to health insurance under Obamacare, but there has not been a huge increase in primary care providers to see them.

Yet it is not just people with new access to insurance. A 2013 studies found that only about one third of the people who come to the emergency room require immediate attention and 70 percent at that time had private health insurance.

The emergency rooms are filled around the country with non-emergent conditions and unrealistic expectations. We don't dole out narcotics like candy. We don't solve mystery conditions that you've been to every specialist to see. We give toddlers with fevers over the counter medications that parents could have given at home. We get sent patients from clinics because they can't get a same day appointment -- or don't want to wait until morning. People call ambulances because they don't have gas money and don't want to pay for a taxi.

The least sick, it seems, are the most rude and impatient. It is tempting to be rude right back, but that's what they want. They want to start a fight, to get into a tug of war. Something to tell their friends and post on social media. The only way to win that sort of power struggle is to not engage, to not pick up the rope.

Moreover, these days nurses live in fear of the dreaded "Patient Satisfaction Survey." Federal insurers want to pay hospital based on patient satisfaction -- but it is a rigged game. It assumes the patient is a customer in a restaurant, but it is the doctor that places the order. Patient advocacy is the nurse's primary motivator, but sometimes what is best for a patient is not what the patient wants or expects -- because they aren't the medical experts and they don't always want what is best for their own well being.

When our surveys dropped a few years ago, our corporation ran us through a bunch of training to teach us how to be better service workers rather than professionals.

Unfortunately the first day of these classes they explained the methodology of the survey.  Satisfaction with care was rated on 1-10, but everything below an 8 was scored as a "0." The results were not randomized, sample sizes and response errors were big problems.  We were rigged to fail. Why? I suspect is has something to do with the fact that the companies that do these surveys also profit from the consultants and seminars and education products sold to hospital systems that panic at less than perfect scores.

So we are taught how to be kind and patient with people exhibiting behavior that would get them kicked out of the lowest dive bar in town.

This night was different.

My patients were sick. I had a brain damaged man having increased seizures because of a change in his medications. I had a cancer patient on chemotherapy with a fever -- he and his wife were kind and jolly despite a terminal diagnosis. He kept making jokes as I accessed his port and drew blood cultures.

"I'm terminal," he said. "What else is there left to do with my time, but laugh as much as possible?"

Late in the night I helped with a trauma patient. An elderly lady had fallen down a flight of stairs. She was on Warfarin and had a head bleed, broken ribs and hemo-pneumo that required a chest tube. She was deteriorating. We moved her to a trauma bay to get her chest tube in and possibly intubated for the flight to Portland.

The room was filled with nurses and techs -- so often when you have a sick patient, the staff appears when you need it most.

So I lingered to cover the other rooms and found myself standing with the woman's husband in the hall. I brought him a chair, which he leaned on, but did not want to sit.

This is nursing sometimes, standing with a family member while they come to realize how this night will never leave their memory.

The doctor came out -- and behind them, I saw the Lifeflight crew shouldering their bags and walking away. Our doc had got a call back from the receiving hospital. He was told by the neurologist that the prognosis was so poor that it was not worth risking a helicopter flight.

The doctor returned to the room to put in the chest tube and I stood with the husband as he started to cry. I just stayed there, stayed present with him and we talked.

He had bad nights before. He was a World War II veteran. He had been wounded twice and saw the war end while he was in Austria. The first time he had been wounded, he pulled the shrapnel out himself and kept going. He explained that if he was medivac'd out, he would have lost contact with this unit.

"Those were the guys you were fighting for," he said. "Those were the people who had your back. You didn't want to leave them. They're your family."

While nothing like combat, his story made me think of how the whole department pulled together when there was a disaster or trauma, or critically ill patient that needed extra hands, extra help.

In the room, three nurses and two techs helped the doctor secure the chest tube which quickly drained the blood from the woman's chest and allowed her lung to re-inflate.  The radiology tech stood by with the portable chest x-ray, respiratory therapists were at bedside.

All that staff in that one room meant that somewhere a call light wasn't being answered as quickly as would otherwise have been the case. Someone was waiting for a warm blanket. Other less acute patients were still waiting to be seen. Our critical care of this one patient would probably reduce our patient satisfaction surveys.

Most nights I'm the charge nurse, directing traffic and solving problems and rarely doing hands-on care. I love my one or two nights a month where I get to take care of patients. It reminds me why I got into this business in the first place.

When I first got into medicine -- as a volunteer EMT -- someone told me that I'd have the opportunity to be the best thing on the worst day of someone's life.

Being present doesn't have a billing code. Standing with a family member at a horrible moment during a tragic night might not move the needle on a patient satisfaction survey.

Yet sometimes, that's what nursing is.

-30-

Further Reading:
The Problem with Satisfied Patients
Seven Things You May Not Know About Press Ganney Statistics
Emergency Room Visits Continue to Climb
The Ten Types of ER Patients
The Yelp-ing of Emergency Rooms

2.02.2015

Things You Didn't Know About Opiates

image stolen from American Apothocary
The Atlantic has a great infographic about the history of opiates in both medical use and abuse. It is full of historical revelations including:

  • Laudanum was first formulated in the 1500s and is still available today by prescription.
  • Heroin was formulated to be a less addictive alternative to morphine.
  • Free samples of heroin were mailed out to try and help morphine addicts kick the habit. 
  • Oxycodone was created as a less addictive substitute for heroin. 
Dig a little deeper and you'll find that:
  • The whole infographic is actually advertorial created by Purdue Pharma 
  • Purdue Pharma manufactures Dilaudid, MSContin, OXYcontin and other opiates. 
What Purdue doesn't sell is Suboxone - a medication that blocks both the craving of opiate addiction and the side effects of withdrawal. With critics pointing to evidence that 12 Step programs don't work for 90 percent of addicts.  Why aren't more people using Suboxone to help kick the habit? Dying to Be Free is a long-form article on addiction and overdose that asks that question while telling the story of an addict who tried to make it on his own and failed. 

The Washington Post reports that there are limitations on prescribing Suboxone because of it's potential for abuse -- even though it is safer that Methadone on prescription pain killers. Some doctors who prescribe Suboxone think the limits are arbitrary.  

"We don't have a patient limit for anything else we do," one MD told the Washington Post. "I can prescribe oxycodone to a thousand patients." 

 A Brief History of Opiates it really is pretty interesting.
Why is Suboxone so hard to get? The Washington Post
Dying to Be Free from the HuffPo
The Cause of Addiction is Not What You Think (at least in rats) by author Johann Hari for the HuffPo



1.24.2015

Do We Need C-Collars?


I was first on scene. An extended cab pickup with trailer was in the ditch on its side. Snow was falling, but the ditch was full of icy water. A woman was standing outside the truck "my husband is trapped inside." I had my partner call for extrication help. I opened the back door of the truck and a Rottweiler dog came flying out, barking, but eager to get out of the overturned rig.

 It was easy to see why. Water was pouring into the cab from a broken passenger window. 

"I can't get out." The driver -- from the passenger side of the front seat called when he saw me. "My arm's stuck."

 Broken plastic from the headliner had his arm trapped. He couldn't have been wearing a seat belt, so he was thrown across the front seat when the truck went over. His head and chest and left arm were out of the water -- which was strewn with debris and chunks of ice. The rest of him was hidden underwater. He might have had a leg entrapped as well.

The water was rising.

I slid into the truck. Standing on the transmission console, and holding on to the steering when, I crouched down, trying to keep myself out of the icy water. I pulled at the hard broken plastic until his arm came free.  The water was coming up, at least six inches in the past few minutes. With the help of another firefighter we pulled him out of the truck. As he emerged from the vehicle he said "my neck feels crunchy." 

"Grab a C-collar," I said from still inside the drowning truck. "And get him on a board." 

He ended up having a cervical spine fracture -- a couple of them in fact -- and yet this awkward, frantic extrication made his injury no worse. 
Portland Attorney George Cottrell's patent drawing for C-collar 1964
Is the use of Cervical Collars in trauma about to go away?

We are in the comment period on scientific evidence for the new American Heart Association guidelines which are set to change in 2015.

On the agenda is a recommendation against c-collar use. Other countries are already eliminating the c-collar from trauma guidelines except in the extrication of some unconscious patients.

Since the AHA drives so much of what we do in prehospital care, if this gets adopted it will mean a big change in practice.

It's a long time coming, but the evidence to support the c-collar just isn't there.

The C-Collar has been around for at least 30 years. In pre-hospital care, anyone involved in a major penetrating or blunt force trauma automatically gets a hard plastic splint around their neck.

The idea is that cervical spinal injuries are often asymptomatic until one little movement severs the spinal cord. Better to put on a c-collar ASAP as a precaution.

Now, however, the routine use of C-collars in trauma is being challenged.

That's because the science supporting the use of the c-collar is pretty weak. In fact there is no evidence it does any good in terms of preventing exacerbation of spinal cord injury. At the same time, it is not as benign as originally believed.

That said, changing away from cervical spine immobilization will likely be a hard thing for some in trauma community to accept. It has become ingrained in our algorithms. Spine boards and c-collars are what we do to trauma patients because, well, because it is what we do. Right?

Roll up on a car wreck and one EMT grabs c-spine while the other fits a collar. The patient doesn't come out of the car until he or she is awkwardly rotated and strapped to a hard board.

There has to be a good reason that we do all that, right?
"Whilst the immobilization of alert and co-operative patients may appear intuitive, and is strongly based on tradition, it is not supported by a reliable body of evidence," wrote Jonathan Benger, a professor of Emergency Care in Bristol, England. "We are unable to find any reports of acute deterioration in an alert and co-operative patient with cervical spine injury as a result of a failure to immobilize shortly after injury. 
As blogger Sanscrit noted in "The Curse of the C-Collar:"
The cervical collar has become a curse. It’s seen as the shining proof of good quality trauma care. No ambulance service dare deliver a patient to a trauma bay without a cervical collar. Not based on trauma mechanism or patient symptoms, but solely based on fear of criticism from the in-hospital ATLS-trained trauma team leader. Don’t get me wrong, ATSL has done a lot of good – but it can also be slow to adapt to new trends, and implement interventions in a dogmatic way instead of patient case based. Knowing ATLS is not an excuse to stop thinking.
Recent journal articles have pointed out that there are a lot of assumptions that have lead to the proliferation of c-collar use. A lot of science, however, is knocking those assumptions down one-by-one.

The first assumption is that trauma patients often have c-spine injuries that are not detectable. The evidence however doesn't bare this out. Studies have found that 0.7 percent of patient's considered high risk for head and neck trauma had significant c-spine injuries.

Everybody gets a collar -- yet less than one percent actually wind up having c-spine injuries.

Like any broken bone - if we think it is broken, we want to splint it. The c-collar is that splint, right? Yet we collar people even without evidence of c-spine injury as a precaution.

So what about those 0.7 percent of patients that end up having c-spine injuries? Does a c-collar applied in the field decrease complications? Does the c-collar do what it is intended to do?

So far the science says no.

Limited studies comparing immobilized vs non-immobilized patients have thus far found that there is no decrease in neurological damage from c-spine immobilization.

How can this be? 

In the awake patient, the patient will self-splint and gentle manipulation and transport won't make things worse. Tissue swelling also helps reduce movement in the patient who is not awake.

Drunks are somewhere between awake and not-awake. It is notoriously hard to get a collar on a drunk. Most of them rip them off once they are off the backboard and we don't invite physical altercations trying to keep them on. In my experience even the drunks that ended up having c-spine injuries didn't make things worse by not having a collar on.

Finally, if you have ever seen a collar on a drunk, you know it doesn't really restrict the movement of the neck all that much.

Yet, the pre-hospital c-collar is all about the precautionary principal. As Sanscrit wrote:
OK, OK, so spinal injuries aren’t that common, cervical collars don’t really immobilize the neck, and collars have never been proven to affect clinical outcome – but how about we just put the collar on anyway, to be on the safe side… It sure couldn’t do any harm?
This is an important point-- the underlying motivation for medical treatment is to first do no harm. Can a c-collar make things WORSE?

Studies have shown that c-collars increase pressure on jugular veins which increase Inter Cranial Pressure (ICP). Increasing ICP in a patient with a head injury is bad. C-collars also make the airway more difficult to manage and increases aspiration risk.

These are all bad things.

So how to we balance those risks with the potential prevention of worsening spine fracture?

Easy! There does not appear to be any benefit. So there is nothing to balance.

Cadaver studies have shown that having a c-collar in place actually makes neck injuries worse. Dead bodies were given a neck injury then placed in a c-collar. Imaging studies showed that the collar increased the fracture crease by more than 7 mm. 

The collar we put on millions of trauma patients every year has no proven benefit, no proven protection against secondary injuries. Still, we put it on with the A in ABC and take focus and time from more important interventions. For the patient with a high suspicion of spine injury, careful handling is needed – but not a cervical collar. For all other trauma patients, they will more than likely be better off without the collar. 
Further Reading


From Sanscrit's excellent blog:

The curse of the c-collar

Progress in Spinal Injury Managment

Comment on the new draft AHA/ILCOR SEERS HERE