Maggie's Farm

His first death, third year of medical school

I recall my first deaths in medical school, in the ER. Two ambulances, family of four after a parking lot accident. The cool efficiency of the ER senior resident doing five-second triage: the 7 year -old - "Dead."  The ten year-old - "Dead."  The Mom - "Dead." The dad, blue but not grey like the others - "Breathing. Get him in a room and let's work on him. Tube here now, chest tube, EKG, crash cart, IV. Get a surgeon down here. Let's go, team."

In just a couple of minutes the unconscious Dad was intubated, had an emergency chest tube, IV, monitor, etc., survived.

In the Western world, the things that Public Health was invented to address are basically complete. From The disease of ‘public health’ - We are in the midst of an epidemic of lifestyle moralism:

Since the 1970s, however, the World Health Organisation has defined health as ‘a state of complete physical, mental and social well-being’ and demands ‘Health for All’.

Good grief. I suppose that will ensure steady work for the public health people forever.

In a related piece, The Radical Case for Bloomberg's 'Nanny' State

If $300,000 buys you a statistical chance of living a few more days with a terminal cancer, would you take it? Would you take it even if Medicare paid for it - which it probably would?

Cancer chemotherapy is a big business: The Cancer Drug Racket:

What is sobering about this booming business is that, as a group of oncologists wrote earlier this year, "most anti-cancer drugs provide minor survival benefits, if at all." They often (but not always) reduce the size of inoperable tumors, but they rarely eradicate the disease. For relatively uncommon malignancies like testicular cancer, some forms of leukemia, and lymphoma, drugs effectively cure the disease; for the common "solid tumor" cancers (lung, breast, colon, prostate, and so on), which account for the vast majority of annual cases, drugs buy some time-precious time, to be sure, but time usually measured in weeks and months rather than years. And even though many of the newer drugs are less toxic, they often still have to be given with older drugs whose side effects include nausea, hair loss, fatigue, and decreasing blood counts. One anti-cancer drug produces a skin rash so severe and disturbing, according to Saltz, that some patients have been asked by employers not to come to work.

When government gets involved in things, those things become politicized. Same thing goes for medical care. The death panels are meant to be a buffer against popular clamorings, but they won't work.

When it comes to medical care, nutrition, vitamins, exercise, etc, the loudest quacks and cranks tend to prevail:  The Quackish Cult of Alternative Medicine - Dr. Paul Offit's battle against charlatanism

Is there quackery in non-alternative medicine? Sure, but it is mostly unintentional quackery. Docs tend to cling to the most recent information they have read, but most of it proves, in time, to be in error:  Trouble at the lab - Scientists like to think of science as self-correcting. To an alarming degree, it is no.

Best to go with a conservative physician who has a good dose of skepticism and common sense.

The constant fuss about prescribed pain meds is puzzling to me. To Cut Abuse, F.D.A. Is Altering Painkiller Label Rules. I believe that pain relief is one of the best things doctors have to offer the suffering, so I believe in generous opioid use when needed.

Here's what I have learned, over time:

- Abusers of precribed narcotics are a trivial social problem
- Habit-forming opioids can make a lot of people functional
- The biggest social problems with narcotics are their illegality
- Addiction is a psycho-social-spiritual challenge for the individual

What are you views?

Re-posted

It is not only true in medicine, it applies to all statistical research. Here's Why Most Published Research Findings are False.

1 Boring Old Man has been devoting himself to uncovering the Pharma-Psychiatric research cabal, but nobody is really listening. My rule of thumb is to take everything I read with a a few grains of salt.

 Reposted -

Saturated Fat is Not Bad For Your Brain, and You've Been Lied to:

Unfortunately, the advice to eat less saturated fat probably isn't going away anytime soon. Like the baseless ideas that calories are calories, or fat people simply lack willpower, fear of dietary fat has become entrenched in our thinking about nutrition, and won't die no matter how many times it's debunked. But if we're going to be lead to believe that saturated fat is harmful to our brains, the link should be based on more than observational research. I'm certainly not convinced that I need to eat less bacon, anyway.

This is part of why my high-meat, zero carb weight loss program (fixed) works: all calories are not handled the same way (and bacon and eggs are a good, healthy diet breakfast). More here:

Miley Cyrus Gluten Free Diet is a Hoax, and 3 Other Weight Loss Scams

There are and always have been populations around the world who are both poor and very physically active who have obesity rates very similar to those of the United States and other Western societies. Under this paradigm, there are certain foods — mainly carbohydrates — that stimulate an insulin response and cause weight gain. Avoiding these foods is probably a good idea for those of us who easily store body fat.

Like I said, if you want to lose weight, cut out the carbs and eat meat. Calory-counting does not work because it's the insulin that stores the carbs.

Sometimes. 

Emergency help on the street did work for Gerard, but the one time I did a sidewalk CPR the 45 year-old ended up with brain damage, but alive. Of course, the most difficult part for amateurs is to diagnose the need for it. People who turn pale and faint do not need CPR.

From the article:

 Many veteran physicians have begun to opt out of the resuscitation practices they often administer to their patients. In a 2012 article published in The Guardian, "How Doctors Choose to Die," retired physician Dr. Ken Murray reveals that members of his profession frequently turn down everything from chemotherapy to CPR.

He notes that years of witnessing and administering "medical care that makes people suffer" leads many doctors diagnosed with terminal illnesses to choose to spend their last months or years at home and without medical treatment. Murray recalls some fellow physicians who go as far as getting tattoos that read "no code" to remind rescuers to forgo any attempts at revival.

Murray is still an advocate for learning CPR, but he warns against hoping for miracles.

Lyme Disease (Borreliosis) is endemic in the Northeast US, and probably always has been. That complicates diagnosis because so many people in the area have been exposed to the germ, and thus show some degree of antibodies to it. Many if not most cases of Lyme are subclinical and never diagnosed.

The spirochete-like bug is transmitted by the bite of a mostly-mouse-born tick called a Black-Legged Tick or Deer Tick. The Tick is much smaller than the common dog tick, and much harder to find on your body. Ordinary dog ticks are harmless, if annoying, and can not be confused with the Deer Tick.

Lyme Disease is readily treated with antibiotics, but about ten years ago one of those disease fads came along, so appealing to hypochondriacs and hysterics, called "Chronic Lyme."

As with other fake disease fads like Chronic Fatigue and, in my opinion, Fibromyalgia, Chronic Lyme believers often made themselves into invalids with vague aches and pains.

I thought the Chronic Lyme fad had passed into the history of medical faddism, but I see this odd and credulous article in The New Yorker: The Lyme Wars. The Lyme-disease infection rate is growing. So is the battle over how to treat it.

There are two serious errors right in the title. The infection rate is not growing: the diagnosis is growing and probably many people with aches and pains are being unnecessarily treated for Lyme just because they have been exposed to it at some point in their life. Second, I have never heard of any credible Infectious Disease doc in New England who had any question about how to treat real Lyme.

Here's one brief index to fad diagnoses but I am sure there is a better, more comprehensive one. The current fad is "gluten intolerance." There are a few quacks out there, but many more crocks.

I think everybody's ideal is to have an internist or family practice doc who knows you well personally as well as medically, and where you can call or come in anytime if you have a concern. For various reasons this has become elusive. 

Based on what I have seen, three trends are growing. The first is the Doc-in-a-Box or, more likely, a PA in a pharmacy.

The second is concierge medicine in which, for a modest annual fee, you have unlimited contact - 24/7 - with your generalist.

The third is generalist docs who will not accept insurance but who charge modest fees and will offer a bill that you can send for your own reimbursement, if any. They can charge modest fees because they do not need to hire a large back office staff for coding and billing.

It's a good idea to have a generalist who knows you and your family. With ObamaCare, I think all three of these modes will grow in popularity, especially the last one. They are all working mostly outside the system. They are not likely to want to make time to see you, however, unless they have met you (except for the PA in a box trend).

Generalist physicians, whether Family Practice, Internal Medicine, or whatever, are the ultimate docs. They see everything, major and minor, and know when to refer. People who want to use their Medicare and Medicaid are going to have a tough time with office visits in the future.

I had always aspired to be a country doc, a generalist, in the New Hampshire countryside, but became too fascinated with what I now do. I had dreams of fixing broken arms, stitching up nasty cuts, treating poison ivy, delivering babies, consoling the terminal, sending appendicitis patients to a surgeon friend, etc. It's kind of funny, but my generalist friends tell me that half of their work is Psychiatry anyway.

With the training I had, I suspect that I could still do those country doc things pretty well, but my malpractice insurance does not cover it. In my training, I caught 42 babies. Some were dangerous and complicated. As I have admitted here in the past, I refused to participate in abortions not because I am so religious but because I did not want it in my memory.

Primum non nocere.

We discussed salt last week. Here's The Bogus Public Health Attack on Sugar

Sugar in soda pop is no more fattening than any other carb, eg fruit, bread, milk, fruit juices like apple juice and orange juice. Nevertheless, it's not a "public health" issue, it's an individual choice issue. I like that light brown granulated sugar in my coffee.

It's brown, so it must be healthier, right?

Salt is one of those things that drive dietary cranks, control-freaks, and ignorant do-gooders nuts.

There really is no reason for that. Most of us docs have been saying this for years and I have made this point here in the past. Salt is an absolutely necessary nutrient for all animals, and very low levels of sodium chloride can make you sick or dead.

The average, normal human body contains around 50 quarts of salt water.

The reason people used to advise "low-salt" diet is because excess dietary sodium is a bad idea for people with kidney failure and congestive heart failure, and people with uncontrolled high blood pressure (with its associated higher risks of heart attack and stroke).

However, salt does not cause those things.

Significantly-high blood pressure is easily dealt with these days. Heart failure will likely kill you in time regardless of what you do (barring a heart transplant), but it is treatable with medicines and some salt restriction.

The new study from the CDC: No Benefit in Salt Restriction.

The American Heart Association is not up to date on the topic: Sodium is Your enemy.

If you have high blood pressure, get it under reasonable control with your doctor. If you have organ failure (eg kidney or heart failure), or have some other ailment, do whatever your doc says. If you're healthy, enjoy your salt. It makes food taste better.

One recipe tip: I always season a salad with salt and pepper. It makes rabbit food taste almost good. Don't get me on the topic of whether green salad is "healthy." (It's neither healthy nor unhealthy. It's just filler.)

I never have done so even though stretching makes you look like a serious athlete. Reasons Not to Stretch

Jumping Jacks or Jump Rope are excellent warm-ups, if one wants it.

I posted about epigenetics a few weeks ago: Epigenetics in Metazoans.

Here's a good example from pigs: Why Cloned Animals Aren't Identical.

I've been preaching this since long before Gary Taubes' books came out. That's because I have a colleague who studies the physiology of insulin. From what I know, Taubes is right. A quote re Dietary Incorrectness at Powerline:

Taubes disputes the connection between dietary fat and high cholesterol. He challenges the thesis that dietary fat is detrimental to our health. He rejects a balanced diet. He advocates a high-fat diet. He opposes dieting. He doesn’t object to exercise, but he asserts that it makes you hungry. It’s almost funny. He is the dietary equivalent of politically incorrect.

Taubes is a serious science reporter, not a crank. As I say here ad nauseum, and as Taubes explains, if you want to get trim, quit the carbs. None. That includes fruit, which isn't any good for you anyway. It's just sugar. As the man says, after 14 days off all carbs they will not appeal to you so much anymore. (There is an addiction-like quality to carbs.) And if you want to be fit, youthful, sexy, intelligent, and vigorous, then exercise or do physical work too. If you want to lower your triglycerides, get better genes or take Lipitor.

It's not complicated. It's a free country, food is cheap and exercise is free. Do what you want to achieve the goals you desire. Don't tell me it's hard to do, because everything in life is hard to do except eating, surfing the net, and watching TV.

A simple jump rope is possibly the best cardio exercise device one can own. It is also the cheapest and most portable.

Jumping rope will burn also 11 calories per minute (more than anything else) while offering almost total body fitness. If you have the fitness and endurance to jump rope for half an hour, you can burn off one candy bar or one donut but few people could go that long even if they wanted to. At a very fast pace, maybe a donut in less than half an hour. However, nobody I've seen can go that long.

At my gym, it's mainly men who jump. Amazon has all sorts of jump ropes. Many people like the beaded ones and the weighted ones.

Done properly on the toes, it's a low-impact exercise. Most people seem to jump in 30-second to three- or six- minute stints. It is demanding for people over 25.

 Here's 3 Benefits of Jump Rope Fitness

10-Minute Jump Rope Cardio Workout

Jumping rope for boxers

If you google jump rope exercise you will find hundreds of articles about technique and the benefits.

In The New Yorker, a Boston physician studies The Cheesecake Factory in an effort to decide whether Big Medicine can be more efficient and effective than the usual: Big Med. It begins:

It was Saturday night, and I was at the local Cheesecake Factory with my two teen-age daughters and three of their friends. You may know the chain: a hundred and sixty restaurants with a catalogue-like menu that, when I did a count, listed three hundred and eight dinner items (including the forty-nine on the “Skinnylicious” menu), plus a hundred and twenty-four choices of beverage. It’s a linen-napkin-and-tablecloth sort of place, but with something for everyone. There’s wine and wasabi-crusted ahi tuna, but there’s also buffalo wings and Bud Light. The kids ordered mostly comfort food—pot stickers, mini crab cakes, teriyaki chicken, Hawaiian pizza, pasta carbonara. I got a beet salad with goat cheese, white-bean hummus and warm flatbread, and the miso salmon.

The place is huge, but it’s invariably packed, and you can see why...

I'm no fan of Big Med - I practice Cottage Med and I prefer to do it my own way. However, it's a fascinating article and actually makes me want to try a meal at The Cheesecake Factory too. I had thought of it as a kind of cheesy place, but I love wasabi-crusted tuna as long as it is just seared.

Keller seems to have written his glowing essay about the Liverpool Protocol, How to Die, without talking to any practicing American doctors. He is writing as an advocate of Obamacare, and speaks as if American doctors won't let people die while the English people will.

If he had spoken with American doctors, he would know that most American internists do something very similar with patients whose condition is hopeless, and do so routinely. Daily. Everybody dies. American hospitals have plenty of patients with "DNR" (Do Not Resusitate) orders on their charts, and hospice units and hospice centers are common in the US.

I see two exceptions, occasionally. One is when the family or patient is adamant about "Do anything and everything." These tend to be people who don't know much. The second is with some terminal cancer patients. I have seen terminal cancer patients, with widespead metastatic disease in the ICU, dying while the latest cancer chemotherapy is still being pumped into their veins. It's pitiful.

Generally, doctors know when to give up and do not view death as an enemy. Unfortunately, Bill Keller seems to be addressing a straw man.

Keller should read this: Why Doctors Die Differently - Careers in medicine have taught them the limits of treatment and the need to plan for the end. Doctors know when they're a goner, and when their patients are too. Most docs do not offer false hope, and do wrong when they do.