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.

I have seen doctors and law enforcement officers that I worked with take their own life.

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.

Fix PTSD with "A Jab to the Neck"

With the incidence of PTSD expected to rise with increased combat and military deployment during the past ten years, research into alternative ways to treat this disease are likely to keep appearing in the literature.

As reported in the current issue of Pain Practice, researchers at  Walter Reed Army Medical Center have tried a Stellate Ganglion nerve block instead of anti-anxiety drugs to treat the disorder. As far as I can tell the sample size was all of two, but the research was based on prior reports of success by a Chicago based anesthesiologist, Dr. Eugene Lipov. The authors of the study concluded:

 Selective blockade of the right stellate ganglion at C6 level is a safe and minimally invasive procedure that may provide durable relief from PTSD symptoms, allowing the safe discontinuation of psychiatric medications.

Traditional treatment with therapy and antidepressants can take months to relieve PTSD symptoms, and can cause side effects such as impotence, weight gain, and sedation, Lipov told ABCnews.com. But the block offers another way -- it works within 30 minutes and does not have those side effects. 

While these local nerve blocks have been around for almost a century, they are not without risk. 

Why would a local nerve block work in treating an mental health problem rooted in a traumatic experience? Lipov speculates that traumatic events cause a spike in nerve growth factors.

Other experts cautioned that more research is needed - with a sample size of two, I'd hope so.  Although the ABCnews.com report states the study was placebo controlled, the abstract of the journal article says both subjects got SGB and reported relief. (maybe there's a different study ABC news if referring to, but I'm not seeing it.)

For his part, Lipov is hoping the neve blocks prove a cheap, quick and easy way to address PTSD.

With so many veterans returning from combat plagued by psychological disorders like PTSD, Lipov told ABCnews.com  "I think it's going to be huge in addressing the 'reverse surge' -- all these vets coming back to the country with these psychological problems."

Abstract of the article HERE

Trauma Top Ten - Part Deux!

Okay, still catching up on all the good stuff from the Northwest States Trauma Conference. Here's the second half of Dr. Richard Mullins' Trauma Top Ten studies from 2009 (first half here).

#5
Etomidate and RSI -- already covered this one on full HERE. Basically, researchers have found that Etomidate causes changes in the adrenal system even when used as just a bolus for RSI. Studies compared Etomidate vs. Ketamine for RSI and found that -- particularly for septic patients -- there may be an advantage. Although they found differences in cortisol levels, however, they didn't find much change in outcome. Read the full blog post.

#4
Dealing with Hip Fractures -- This study looked at whether in there was an increase in complications and hospital stay if patient's had to wait to have their hip fractures repaired.  Mullins also reviewed the best imaging to use when trying to identify hip fractures. In other words, find them faster and fix them faster to reduce mortality and morbidity.

Hip fractures in the elderly increase the risk of death in the months and years following the injury. Recently researchers have found that a 48 hour delay in the surgical repair or stabilization of a hip fracture increases risks of complications. Thanks to an aging population, we can expect to encounter twice as many hip fractures by 2040 with 15 percent of the population experiencing this injury by age 80.

However, finding them on plain films isn't always easy. One out of every twenty patients my not have a fracture that you can see on X-ray.

Researchers found MRI to be the gold standard for identifying occult hip fractures. Best practice would then be to get an MRI and to surgery if indicated in the first 24 hours following the injury.

#3
Best Pressors: Dopamine or Norepinepherine - Researchers studied Dopamine vs. Norepinepherine for use in patients low blood pressure due to shock. The premise being that Dopamine will cause more heat problems. Indeed, twice as many patients developed atria fibrillation in the Dopamine group -- however the overall survival outcome was the same.

"A lot of dead patients in this study. This group of patients were all pretty sick ... there was a high risk they were going to die of something," Mullins told the conference. "That may be an indication that we're winning the battle but losing the war with these type of patients."

Mullins added that there is a lot variability in biochemistry that may increase the chances that a particular patient is susceptible to a particular medication. In the future, Mullins said, genetic testing may determine the optimal drug course. That discussion lead right into topic #2.

#2
Genetic Variation Affects Mortality - The secret to a long life -- or at least surviving trauma -- may be as simple as picking your parents. In this study researchers studied trauma patients with genetic variation that changed the production of three specific proteins that have been shown to be crucial to survival when a patient goes into shock. About 20 percent of the population has a Single Nucleotide Polymorphism (SNP pronounced SNiP) where the change in just a single nucleotide is enough to change protein synthesis in a significant way.

Vanderbilt researchers found the death rate in trauma patients studied was half as much in the patients with the abnormal gene. Of the three proteins studied, the one associated with the Beta 2 adrendergic receptor was the most significant player.  Researchers found that the abnormal protein actually provided the patient with survival advantage.

Another study focused on SNPs involved in the complement cascade. Here again there was a significant difference in mortality observed for those with the SNP (20 percent) versus those without the genetic variation (11 percent.) The abnormal genome patients also had higher pneumonia rates.

"In the future, we'll be able to map our genes and decide which drug will have the best effect for you," Mullins said. "The other side of this of course is the privacy issue. I'm sure the insurance company will get a hold of this information and find a way to charge you more based on your genetic profile."

#1
Using Morphine in Trauma to Prevent PTSD - Post Traumatic Stress Disorder (PTSD) can be a long term source of disability following major trauma. Studies have found that up to 25 percent of patients with serious injuries had some level of PTSD one year after the injury. The magnitude of pain, stress and anxiety experienced at the time of injury may create an exaggerated response to stress in the amygdala that potentiates for the development of PTSD long after the event is over. Could medications given at the time of the event decrease the psychiatric stress of the event two years later?

Since the amygdala has opiate receptors, researchers looked at service men and women injured in the war in Iraq to see if there was a difference for those who got morphine as part of their trauma resuscitation versus those who did not. The study excluded those with traumatic brain injuries. The results showed a significant increase in PTSD for those given morphine in the first 24 hours versus those who did not. In fact, the patients without PTSD were more likely to have more severe injury and/or amputation

 Another study supported these findings, demonstrating an inverse relationship between higher doses of morphine and less severe PTSD.

Mullins brought in a different study for perspective on the use of narcotics. A Dutch study looked at the medications given for pain for Dutch and American patients being treated for hip and ankle injuries. The study found that 85 percent of Americans and 58 percent of the Dutch received narcotics while in the hospital. Moreover, 77 percent of the Americans were sent home with narcotic perscriptions. None of the Dutch patients got narcs at home. Outcomes appeared to be similar.

"These studies seem to indicate that narcotics should be administered during the initial phase of evaluation following injury, "Mullins said. "Maybe we should be giving more earlier and less later."