Friday, April 29, 2011

Asleep at the Wheel

At age 52, Tim had been driving long haul trucks for 20 years and had an excellent driving record with no significant mishaps. He was fairly healthy, but like many men his age, he'd gained 50 pounds over his high school weight with a noted increase in collar and belt size. He'd always snored a bit, but now he was really disrupting his wife's sleep. "Honey!", she'd poke him at night, "You're not breathing, roll over!" She was worried about Tim and irritated that she couldn't sleep listening to him gasp and choke. She'd finally had to move to the sofa to get some needed sleep.

Tim started to have to get up to the bathroom two or three times a night and his throat was as "parched as the Sahara". He would awaken in the morning unrefreshed and often have a headache. His driving scheduled time was regulated for adequate rest time, but he began to feel more sleepy during the day.

On a warm summer day at 2PM on a long stretch of highway, Tim felt overwhelming fatigue. He tried opening the window, turning up the radio volume, singing, and biting his lip. But then he involuntarily closed his eyes - and it was all over. Tim left his side of the road plowing into a minivan. He was brought to our ICU with blunt chest trauma but none of the four persons in the minivan survived.

Tim's chest wall and lungs were bruised so he didn't require a very long stay for observation. The vigilant ICU nurses though made the diagnosis. "Dr. deMaine, this patient has severe sleep apnea. Every time he falls asleep he stops breathing and his oxygen saturation drops from 95% to 60% until he starts breathing again." They estimated this happened at least every minute or so.

We were able to arrange a sleep study at Tim's bedside. The findings, as expected, were dramatic. His breathing slowed or stopped for 10 seconds with a drop in his oxygen levels a remarkable 72 times an hour. With the application of a positive air pressure mask, the apnea completely resolved. When Tim awoke after a night of the CPAP (continuous positive air pressure) he felt refreshed for the first time in years.

Comment: Tim's diagnosis and treatment came too late for the unfortunate souls in the minivan. The delay was emotionally devastating to so many, plus there were economic, legal, and job loss effects. I probably saw my first case of sleep apnea at Philadelphia General Hospital in 1962 when I cared for an obese plethoric patient in heart failure who couldn't stay awake. No one knew what was going on so none of the treatments were helpful.

Finally, in 1982 an Australian doctor, Colin Sullivan, published a paper in the journal Lancet describing the first use of CPAP for sleep apnea. Now sleep labs and CPAP machines are quite common and a new industry in medicine has been born.

But what about driving and industrial accidents. In seeing a number of truck drivers to evaluate for sleep apnea over the years, they would confide to me how that sometimes fell asleep "for seconds" behind the wheel. Indeed frequent micro-naps have been identified by doing brain wave testing on working truck drivers. A sleep impaired driver is as impaired as a drunk driver, but there's no roadside simple test to confirm that impairment.

"Each year, potentially 980 lives could be saved and $11.1 billion in automobile-accident costs could be avoided if drivers who suffer from a disorder called obstructive sleep apnea were successfully treated with continuous positive airway pressure (CPAP), according to a study by researchers at the University of California, San Diego (UCSD) School of Medicine."

Sleepiness has recently been in the news with air traffic controllers found asleep on the job. Falling asleep is not a willful act, but a biologic necessity. When people shift their work hours several times it interferes with their diurnal sleep/wake cycle so they cannot sleep satisfactorily. My take is that these workers should have been evaluated by sleep experts for both shift work disorder and sleep apnea. Perhaps they even had both disorders. Simply firing the workers is no solution. Indeed both the work schedules and the workers themselves deserve more care and attention. We all would be safer!

Monday, April 25, 2011

Your Life Your Choices - Making Your Wishes Known

Alice at 93 knew she was a problem for her sons, but she was not about to leave her beautiful family waterfront home on Lake Washington. She could pay for part time help, shopping and gardening. She loved her privacy and having control of her environment.

She knew that the aortic valve in her heart was very narrow. She had refused a new valve for the last 15 years. But it was now catching up with her. Suddenly one day, she went into acute pulmonary edema. Basically, due to the narrowed outlet valve from her heart the blood backed up into her lungs causing acute shortness of breath. A neighbor rushed her to the ER where she was able to be stabilized without being put on a ventilator. On discharge from the hospital, the doctors met with her three sons and let them know that this scenario of pulmonary edema could recur at any time. Plans needed to be made.

Alice was quite clear that she didn't want CPR, heart shocks or a ventilator. "Boys, I've lived a long life and am ready to kick the bucket when my number's up. I don't want any bells and whistles. Just TLC."

Her sons urged her to have a permanent live in care giver if she wasn't ready for a long term care facility. Or better, to come and live with one of them. As expected she replied, "Listen, this is my life and I get to choose what I want." This left the family which now included three daughters-in-law, 12 grandchildren, and 15 great grandchildren in a quandary. How can she get her wishes and still be safe.

Alice reviewed her Living Will and confirmed her choices for no "heroic" measures. One son was appointed her Durable Power of Attorney with the other two as alternates. But how was this really going to help if 911 was summoned?

They met with Alice's family physician and a social worker to come up with the plan. Alice and her doctor completed and signed a POLST form (Physician's Orders for Life Sustaining Treatment). In Washington State this form is a bright "yucky" green and easy to spot. A set of standing medical orders, this form is honored by Medics, ER's, hospitals, and nursing homes. The POLST form travels with the patient thus essentially putting Alice's wishes in a confirmed medical text.

But what happens if Alice can't breathe and 911 is called again? After contacting the Fire Department and speaking to the Medics, a plan was finalized. She wore a "panic button" around her neck which would summon emergency care. The Fire Department kept a copy of the POLST form in their electronic data base, and arranged for Alice to have a "lock box" on her door. This would allow the Medics to enter her house without breaking the door down. For good measure a copy of the POLST form was given her doctor, the closest ER, and several copies were posted around her house. Alice smiled as she spoke to her family, "Now quit worrying, I may live forever!" They still call and check on Alice twice a day. Alice doesn't think all the fuss is necessary.

Sunday, April 24, 2011

Tough At the End

Jim's path had been leading downhill for years, but Jill stuck with him. The drinking had been so much fun and part of their life beginning as sweethearts in college. Jim was a pretty good athlete, in fact the pro baseball scouts were looking at him. Jill was a cheerleader and they were both part of the party scene on campus where weekend blowouts at the frat house were common.

At the start of his senior year Jim was covering second base when a high throw and a low slide combined to give him a hard collision with the runner stealing second. His knee gave way with a crunch effectively ending his baseball career with torn ligaments and cartilage. It was a severe emotional setback for Jim and Jill. They had pictured a life in the major leagues.

After graduation, they married and Jill settled into an art career, but Jim floundered. He started to drink more and more. Despite this, he functioned well in the business arena and progressed into sales management in a fortune 500 company. The drinking though was becoming problematic and Jill was concerned. Their doctor recommended a combined detox and rehab program but Jim resisted. Jill loved him and supported his decision, but couldn't (or wouldn't) keep alcohol out of the house. Finally Jim's boss contacted Jill and said something had to be done, and Jill agreed.

On a Thursday evening after work at his office, Jim was confronted by his boss, Jill, their children, their pastor and Jim's best friend. A suitcase was packed. Jim was initially confused and a bit angry but could see that he was outgunned. He went into a top rehab center with some initial success.

But the patten repeated many times over the years but somehow Jim was able to continue successfully in sales, being hard driving, personable and skilled. Jill cried, nagged, and tried various programs but Jim always relapsed into heaving drinking. The kids pulled away and had problems of their own. They advised Jill to leave their dad but she wouldn't.

Jim's health began to deteriorate as cirrhosis of the liver developed. His muscles began to lose tone, the belly to swell with fluid and the skin to turn a pasty yellow. The first medical crisis occurred when Jim began to have intestinal bleeding. The liver had become so scarred that blood was diverted to engorged veins around the esophagus. These veins ulcerated and broke loose bleeding which was hard to stop, but with transfusions, medications, and vitamins he finally left the hospital after 10 days of treatment.

Jim and Jill tried AA but Jim still relapsed. Jill knew that she was an enabler but still loved and supported him. As Jim's health declined they had a "heart to heart" about life support and living on machines. Jim was also a smoker and knew emphysema was part of his progressive breathing problems. He was clear that he would accept a breathing machine for a short period but did not want to be kept alive indefinitely on a ventilator. He signed a Living Will and Jill had the Power of Attorney for Health Care.

After several more years of worsening health, weight loss, financial strain, and job loss Jim developed a severe pneumonia which required admission to the Intensive Care Unit and life support of a ventilator. After three weeks on the ventilator, tube feeding, antibiotics and careful medical and nursing care, he was finally well enough to be taken off the ventilator. But over the last year his liver had been worsening and he had lost 40 pounds. His strength was poor and breathing very marginal.

Still in the hospital, he was again having increasing breathing problems and the family was called into conference with the doctors. The doctors said that they could put him back of life support, but that he might never get off. He would be moved on a ventilator to a chronic intensive care unit in another facility where they handled long term patients who might (or might not) eventually get off the ventilator.

With the children and Jill there Don made it clear that he did not want to go back on a ventilator and be kept alive on machines. After the children left though and Jill was alone with him Jim whispered, "Honey have I made the right decision? What do you think? Should I go back on the ventilator?"

Jill replied, "Jim, we've talked about this at length in the past. I think you've made the right decision. Your body is so worn out. I would love to keep you here with me, but it would be so painful to watch them keep you alive on machines where you couldn't talk or communicate. It's a pretty horrible existence. So I support your decision.

So Jill had to find strength to find clarity. Even more challenging was dealing with the doubts of the children. "Mom shouldn't we move him to a different hospital? I'm not sure the doctors have done everything."

Jill, with the support of the Hospital Chaplain was able to reassure the children that everything was being done that was humanly possible, "Dad is dying, he wants to be at peace. He's made his decision and let's support it. It's hard and I'm so sad. Please, let's just go sit with your dad."

Comment: The caregivers of very ill patients get so little attention, but they sacrifice so much and are in such a difficult spot. With addiction, the spouse is caught in a vortex of love, being tough, anxiety, loss, and a whole range of conflicting emotions which affect the whole family unit. In the story above Jill might be criticized for not being tough enough while Jim was heavily drinking and destroying himself, but it's unclear whether leaving him would have changed things. Certainly at the end of Jim's life, Jill's love and respect for him helped prevent a nightmarish outcome of long term ventilator support and health crisis - with the final outcome being still being death. I think we all have a fairly healthy tendency to deny death even though it will happen to all of us. William Saroyen said, "Everybody has got to die but I have always believed an exception would be made in my case."

Wednesday, April 13, 2011

Ce N'est Pas Si Difficle

Case 1: Susie is on a course of antibiotics for a persisting sore throat, the second antibiotic in the past two weeks. Abdominal cramping occurred with persisting diarrhea. The questionably necessary antibiotics were stopped and the diarrhea cleared in a few days. She ended up doing fine.

Case 2: Harry was in the hospital for hip surgery. Antibiotics were given before surgery and for a few days afterward. Explosive diarrhea developed and a stool sample was tested for Clostridium Difficle toxin (the bacteria is hard to culture, hence its name). He was treated with the antibiotic metronidazole and the symptoms resolved. Four extra days in the hospital were required.

Case 3: Bill was diagnosed with Lyme Disease and intensive antibiotics were prescribed. After about two weeks, cramping and diarrhea started. He was given some anti-diarrhea medication but gradually became weak and dehydrated. About three weeks after antibiotics were started he presented with an "acute abdomen" to the hospital and was admitted to the ICU where he was in impending shock. The stool was positive for C Difficle toxin. The colon was dilated and diffusely inflamed. He was not responding to two antibiotics directed at the C Difficle. Something had to be done to save his life. Unfortunately it required a total colectomy (complete removal of the colon) and colostomy to save him.

Case 4: Carol was in the hospital following cancer surgery on the Gynecology Unit. On the third post operative evening she began to have low blood pressure and abdominal cramping with loose stools. At age 79 this frail woman began to gradually go into shock during the night. Her blood pressure hovered around 90 and her temperature was 102. Her urine output was dwindling. Rather than move her to the ICU, a surgical consult was obtained in the morning. An "acute abdomen" of uncertain cause was diagnosed. Later in the day she was taken to surgery. There was no bowel rupture, appendicitis, or dead bowel loops - just diffusely inflamed bowel. She was closed up, sent to the ICU, and within 30 minutes there was diagnosed as C Difficle colitis by an Infectious Disease consultant. She died within three days. A lawsuit ensued.

Case 5: A young doctor looked spiffy in his white doctor's jacket and tie. He saw and touched 12 patients on rounds that morning. He washed his hands only twice, did not don gloves, did not wipe his stethoscope with antiseptic, and had not changed his white coat for two days. He would be horrified to know that MRSA (a virulent staph bacteria), C difficle, and E Coli could be found on his coat, tie, fingers, and even his stethoscope. Four of the twelve patients would have new colonies of these bacteria transmitted to their bodies. One would later develop a secondary serious infection.

Comment: The Hungarian physician Ignaz Semmelweiss was the first physician to prove conclusively that hand-washing prevents hospital transmission of infection. Puerperal Fever (a disseminated strep infection) was a common cause of death in women who had recently given birth. Semmelweiss was not widely believed or accepted during his lifetime and is immortalized in Morton Thompson's book "The Cry and the Covenant". It wasn't until twenty years after the death of Semmelweiss when Pasteur proved that bacteria could cause disease, that hand-washing and sterile technique began to be adopted.

Yet in American hospitals, multiple studies show that simple infection control procedures are often sadly lacking. Have I been guilty myself? You bet! I wore the same white coat for more than a day and didn't routinely wipe down my stethoscope. I saw scrubs (even paper booties) being worn outside the operating room with no guarantee that they would be changed on returning to the OR.

C Difficle is the latest intruder into our hospital wards and now into the community in general. Often it's no big deal. It was simply called "antibiotic associated diarrhea" until C Difficle was identified as the cause. Usually this toxin producing bacterium is suppressed by normal bowel bacteria. When our modern powerful antibiotics kill off these normal bacteria, C Difficle takes over with its potent toxin which severely inflames the bowel. Stopping the antibiotic is commonly the only thing that needs to be done to make C Difficle subside. But once it takes hold in a weakened subject, it can be deadly as noted.

So what's the answer? Awareness of the condition with early intervention makes most cases fairly mild. But why is C Difficle becoming a hospital acquired infection with increasing frequency. The CDC has guidelines for preventing hospital acquired infections and the Joint Commission on Accreditation has pilot projects. But I think poor Semmelweiss (who went insane at age 47 perhaps from frustration and a nervous breakdown) is still wondering. Is anyone really listening? It's not so difficult (ce n'est pas si difficle)!

So how do we as patients and doctors deal with this. Can we tell our doctors, "Please wash your hands before you touch me?" But it's not just the doctors. How about the nurses, aids, housekeeping, etc.? Maureen Dowd gives her take on "Giving Doctors Orders" in the New York Times. Any comments?

Sunday, April 10, 2011

The Obecalp Effect

Betty was complaining at an escalating rate. She'd been in her nursing home for four years and wasn't happy. She kept coming up with new symptoms like aching, fatigue, nervous stomach, tingling, dizziness, etc. Her daughter Nancy was getting daily calls from Betty and the staff at the nursing home. Multiple trips to the doctor for diagnostic tests had ensued: blood counts, liver functions, X-Rays, thyroid function, plus many others. All were coming back normal. The Neurologist and Rheumatologist had been unable to come up with anything. Betty was getting a bit forgetful but wanted to be in charge of everything - her finances, health decisions, and daily life.

Nancy didn't know what to do. Mom was being demanding and unreasonable, wanting more medications. An antidepressant had made her sleepy and dizzy. She seemed to be sensitive to all medications yet was demanding something for symptom control, "Honey, they just aren't doing anything for me. They're doing nothing to help me. I'm not sleeping and am aching all over."

Nancy and I were on a Board together and she asked me to see Mom in consultation just to review things. I saw Betty in the office. She was well groomed, talkative and demanding, "Doctor, you just have to do something. I'm suffering and no one pays any attention. I think they're all a bunch of idiots, don't you?"

Betty though was pretty sharp. She could talk current politics, knew common dates and events, and could reason fairly well. The tests didn't show any cancer, inflammatory illness, or metabolic problems. In other words, I couldn't come up with anything either.

I broke the "news" to Nancy who said, "Well, can't you just give her a placebo?" Actually, our formulary at that time (a number of years ago) carried a "drug" called Obecalp. As you might have guessed this is Placebo spelled backwards and was doled out now and then but I had never prescribed it. Nancy begged me to try it for her Mom, "It can't do any harm, why not? I know doctors don't want to deceive patients, but I'm desperate and so's Mom!"

With more than a little reluctance, Betty was given Obecalp for her plethora of symptoms. A few weeks later I got a call from Nancy, "Your're not going to believe this. Mom loves her Obecalp. All is well."

It seems like a combination of laying on of hands, belief, a daughter's love, and the placebo effect all played a part in making Mom comfortable. She died in her sleep a few years later.

Comment: The word placebo comes from Latin meaning "I shall please". The placebo effect is real although not well understood. It exemplifies the mysteries surrounding the mind-body connection. Why does it work about a third of the time for real pain? This type of effect points out why it's important to use placebo controls in medication trials where both the patient and researcher are kept "blinded" as to which subjects are using the study medication or the placebo control.

Today, with more modern transparency and autonomy, it would not be considered ethical to prescribe a placebo for a patient. Do you agree doctors should never do this? According to a study reported by the Wall Street Journal a 2008 survey of nearly 700 internists and rheumatologists published in the British Medical Journal, about half said they prescribe placebos on a regular basis. Do we still often prescribe just to provide hope as the patient leaves the office with something in hand other than reassurance? Actually, many supplements, diets, cold remedies, cough medications and antibiotics are often given without convincing evidence proving that they are useful or necessary at all! The patient walks out of the office with a prescription which may be more harmful than a placebo, which at least doesn't have potential harmful side effects.

Recently Harvard created an institute dedicated wholly to the study of placebos, the Program in Placebo Studies and the Therapeutic Encounter. One of the issues they will study is whether placebos should return to be part of standard medical practice!

It was Sir William Osler, one of the founding fathers of modern medicine who said, "The desire to take medicine is perhaps the greatest feature which distinguishes man from animals."

The funeral as we know it is becoming a relic — just in time for a death boom

By   Karen Heller April 15 Ed note: Funerals are changing in ways that will bring culture shock and a shake of the head of s...