Multicultural Madness

silk flowersOne of the nicer things about having a blog is the ability to rant periodically about things which are maddening, but utterly out of your control. It is healthy to have an outlet for such frustrations, and although my dog seems to understand and cares deeply when I express my concerns about troubling issues, she doesn’t seem to fully grasp some of their subtleties. Hence I turn to my readers, most of whom are quite a bit more intelligent than my dog–although there have been a few notable exceptions.

The rant of the day has to do with our fine state legislators in the great State of Washington. Their noble accomplishments in the arena of healthcare in the State of Washington have included an utter inability to satisfactorily address the state’s spiraling malpractice crisis, phenomenally high rate of uninsured, the migration of physicians out of the state because of a hostile malpractice environment and dismal Medicaid and Medicare reimbursements, and a punitive approach which attempts to recover the cost of their incompetence by treating all physicians as fraudulent. Be sure–when you hear Democrats talking about how they are going to solve the healthcare crisis–to take a close look at Washington State, where they control both the governors mansion (by coup) and the State legislature. Consider it a crystal ball into what might be accomplished at the federal level.

Nevertheless, our elected officials are currently considering legislation which will utterly transform the healthcare arena in the state–for which I am immensely proud. The State legislature is currently considering, and will likely pass, a law which requires physicians to have a certain number of hours of CME training in cultural diversity. Color me impressed.

Now, not that I am a culturally insensitive fellow–by no means. Some of my best friends are Democrats, after all. And I’m sure, in the big picture, that this is simply a tiny paper cut in healthcare’s death by 1000 cuts in this state. But for some reason, this drives me nearly insane.

Current state licensure requirements in every state mandate that healthcare professionals take a certain amount of continuing medical education (CME). This requirement, though largely unnecessary for most physicians (since they generally are well-motivated to improve their skills and knowledge without state requirements), nevertheless strikes me as at a reasonable requirement for medical licensure. Increasingly, however, the state is requiring that this continuing medical education be on specific, state-mandated topics. The camel’s nose under the tent began with a requirement that a certain number of CME hours be dedicated to education in medical liability. This was part of some sort of previous liability reform, which never accomplished its main goal of reducing medical malpractice and spiraling malpractice premiums, but nevertheless left a silly requirement in state law that physicians spend time thinking about how to reduce their liability–as if this is something they do not think about every minute of every waking day. Now we must dedicate an additional number of hours learning how to be culturally sensitive–which apparently means not telling overweight patients that they are obese, dining out at ethnic restaurants, and being careful to not offend our African-American male patients like telling them that their risk of prostate cancer is higher, or that the cultural diet they prefer is killing them through high lipid intake and hypertension. Keep in mind that most physicians are busy enough that time for continuing medical education, while important, is nevertheless a relatively scarce commodity. Spending time on extraordinarily stupid topics like cultural diversity means your physician is now spending less time at a conference to better manage your diabetes, or cancer, or improve his or her surgical or diagnostic skills. Of course, the moronic social engineers in our State legislature are far more interested in feel-good measures which paint them as “tolerant” and “sensitive” to improve their chances of reelection in a state which values quotas more than quality health care.

Sigh–I’m sure I’ll conform like the rest of my sheep-like colleagues to the new requirements, and rediscover yet again what a worthless, oppressive white male worm I truly am. Let’s just hope that some day, there will still be a few of us sheep left around to take care of sick patients.

Legends of the Call

hunting knifeThis is my call weekend.

Call weekends–where you cover for a host of other physicians, so that the fortunate many may enjoy some time off at the expense of the unfortunate SOB on call–are akin to ritual self-flagellation: long days, longer nights, countless phone calls from emergency rooms and ailing patients, most of whom you know nothing about beyond what they tell you over the phone. If your Karma is good, you may be spared the worst, perhaps even get some sleep. If not, the punishment is severe, and survival until Monday becomes your sole goal in life.

On occasion, however, there are a few lessons to be learned. Such was the case this weekend, my instructor being a most unfortunate gentleman who, alas, had plans far different from being my teacher. This weekend I learned:

  1. Don’t drink to excess.
  2. If you do, don’t try to sober up using crack cocaine.
  3. Don’t visit prostitutes, whether or not you adhere to lessons 1 and 2.
  4. If you do visit prostitutes (and I’m not suggesting that you do–see lesson 3), pay them for their services.
  5. If you refuse to pay them (and I’m not suggesting that you do–see 3 and 4), don’t inform them of this fact while standing around in your birthday suit.
  6. If you decline payment for the services of a lady of the evening, while still in your birthday suit, be sure she doesn’t have rapid access to sharp knives.

I encountered a man, at 2 AM Saturday morning, who embodied the Proverbial addage: “Better to meet a bear robbed of her cubs, than a fool in his folly”–and who managed to make all of the above mistakes, in perfect sequence. The fair maiden, her purity despoiled and robbed of her just desserts, did repayeth said gentleman with the “unkindest cut of all”–a deadly underhand stroke designed to rob him of his manhood. It was, sadly, not a Burma Shave moment, although a close shave nevertheless: while sparing the rod, she spoiled the child–or the children, more accurately–laying them quite naked to the world, neatly bivalving the scrotum while miraculously sparing the jewels.

For those of you with very strong stomachs–or the steely detachment borne of depersonalizing professional training in medicine–here are the operative photographs, before and after the repair.

I warned you not to look unless you had a strong stomach … couldn’t resist, could you?

When asked how such a sequence of events might have taken place, our unfortunate teacher responded: “I don’t know–all I did was start down the stairs…”

I, for one, am going to be staying on the first floor for a while, avoiding the stairs at all costs

Everybody Must Get Stoned

subwooferHe was an average-looking kid, maybe 25, what statisticians might call “an outlier”–not quite strange enough to be bizarre, but definitely a bit “out there”–a little “goosey” in mannerisms, pleasant but slightly inappropriate in the things he laughed at, with his facial expressions, and with those other subliminal messages some call “body language.” I entered the exam room, to find him bobbing and tapping to the pulsing sounds emanating from his iPod ear buds–audible only to him, shutting out the world around–except for the chess game he played on his pocket PDA.

Healthy kid, seemed bright enough. Had rolled into the ER a few weeks ago with a classic story: severe pain in the flank, blood in the urine, vomiting–a typical kidney stone. The ER got his pain under control, and sent him home.

“So, how are you feeling now?”

“Pretty good–I think I passed the stone.”

“How’d that go for you?”

“Well, I talked with my buddy, and he told me they use sound waves to break up kidney stones.”

“Yes, they do.”

“So I decided to try that out.”

“How’s that?”

“I went home, and turned up my subwoofer.”

Silence.

“Your…subwoofer? I … I don’t think that would do it…”

“Well, you’ve never heard my subwoofer!”

The stone was gone–resistance was futile. I sent him happily on his way.

But somehow I suspect I could have heard his subwoofer–if I had been within a 10 mile radius of his home, anyway…

PSA Screening

roseA recent article in the Archives of Internal Medicine about using the PSA (prostate specific antigen) for screening for prostate cancer has garnered the attention of some of the medical blogosphere, including Kevin, MD and MedPundit. The full article requires subscription, so I have not been able to read the whole thing, but the gist is that PSA screening, with or without DRE (digital rectal exam) of the prostate does not improve survival times–i.e., men whose cancer is detected using PSA screening don’t live any longer than those cancer is diagnosed by other means.

Color me skeptical about this study — although it’s not entirely a surprising conclusion, either.

PSA is a protein released by prostate tissue which is measurable in the bloodstream. It is not a cancer test–it is a prostate test. This is one area of confusion about this test in many people’s minds. Normal prostate tissue secretes PSA, in amounts roughly proportional to the size of the gland. As the prostate enlarges with age, PSA levels tend to rise, typically rather slowly, due to the growth of a benign tissue called adenoma. This is the stuff which tends to give guys less pressure with urination as they age, as the adenoma may cause a degree of obstruction to the urinary channel. PSA is a rather noisy test as a cancer screen, however: it can be elevated for a host of reasons. Infection or inflammation in the prostate can cause a striking increase in blood levels; instrumentation (such as bladder catheters or endoscopy) can give it a good bump; and of course cancer, which tends to produce more PSA than benign tissue relative to its volume.

Cancer screening is one of those things which sounds great on paper but which suffers from the ravages of statistical math. Let’s say, using simple numbers, that you have a disease, say cancer, which occurs at an incidence of 10 people out of 10,000 (just pulling numbers out of the air). Left untreated, all 10 of these people will eventually die from this disease. If diagnosed early enough, all 10 can be treated successfully, and will not die — at least from this cancer (a very optimistic assumption, but let’s use it for the sake of discussion). So it is obviously desirable to find a way to detect this cancer early enough so that it can be treated before it is too late.

Now let’s say you have a diagnostic test which can detect 9 out of these 10 cancers, if everyone at risk for the disease gets tested. In other words, 90% of the people with cancer will have an abnormal test. That’s called sensitivity: how many people who actually have the disease will have an abnormal test — and 90% (9 of 10) is pretty darn good for most screening tests. So far, so good, right? Well, that’s just the beginning. Let’s say the same test is abnormal in 1 out of 10 people without cancer. This is called specificity: 90% of the people without cancer have a normal test, and 10% have what’s called a false positive. This is also pretty darn good as screening tests go: there’s no perfect test, all have both false positives and false negatives.

Now let’s apply these numbers and see what happens. All 10,000 people get tested; 10 of these statistically have cancer. The test finds 9 of the cancers–this is good (except for the one who gets missed — but that’s why God created trial lawyers). The test is abnormal–therefore indicating cancer — in 1000 people (10% of 10,000) who are in actuality cancer-free.

Whoops.

These 1000 people will need more tests, x-rays, biopsies, etc., to prove that they don’t have cancer — and these subsequent tests also have false negative rates. So of these 1000 people, a few may still have cancer (as far as you can tell), and a whole lot more are worriedthey have cancer, even though the subsequent tests don’t show it, and they don’t actually have it. And, wait–there’s more! The additional tests for the 1000 who do not have cancer, but who have an abnormal screening test, also have problems: they are costly, often uncomfortable, have risks of their own, and even they may not diagnose every cancer. So you end up spending a lot of money, adding additional risk and discomfort, with a whole lot of people to find that relative few who have cancer early enough to treat. Suddenly screening tests for cancer aren’t looking quite so rosy anymore.

Now let’s look at the economics. Let’s say the screening test costs $20, and the subsequent diagnostic studies needed when the test is positive cost $1000 (fairly conservative numbers, by the way). So our screening test cost $200,000 ($20 times 10,000 tests). The subsequent diagnostics for those found with cancer cost $9000 (9 times $1000). The diagnostic expenses for those with an abnormal test but no cancer is $1,000,000 ($1000 times 1000). So we’ve spent $1,209,000 to diagnose 9 early cases of potentially curable cancer: over $134,000 per cancer found — before it is ever treated.

Whoops.

Now, society or public policy may judge that such an expenditure is justified to save these 9 lives. But we have made other assumptions here which are not always true: that if we detect the cancer early, all those so discovered will be cured; that even if they are cured, that they will live longer (since the list of other things which can kill you is rather long); and that failure to treat the cancer will shorten their lives. These seem reasonable assumptions — but they are more often wrong than not.

Take prostate cancer, which the PSA test is designed to detect. It typically occurs in men over 50 years of age, increasing in incidence with increasing age. It is often very slow-growing–so slow that many men who are diagnosed with prostate cancer end up dying of other diseases–heart attacks, strokes, other cancers, etc. Yet it remains a significant health risk: over 30,000 men die of prostate cancer annually in the U.S–and it tends to be a slow, rather painful way to die for many.

With prostate cancer, nearly every assumption we made in our neat little example above is uncertain. First, there is the problem of selecting the population to screen. Not every population has equal or predictable risk. Men under 50 can get prostate cancer — and often have a very aggressive, rapidly growing variety–but the disease is much less common than in 70-year-olds. Men over 70, conversely, have a much higher incidence, but are far more likely to be managed without aggressive treatment, as other diseases are much more likely to pose a mortality risk. African-Americans are at higher risk than Caucasians–but get screened less. Men with a strong immediate family history of prostate cancer are also at higher risk–but tend to have fast-growing aggressive tumors at diagnosis, and even early detection may not result in cure.

Then there’ s the problem of the sensitivity and specificity of the PSA test itself. Normal values for PSA increase with age, because the prostate generally gets larger with age. But size of the prostate at any age varies widely with each individual, is not necessarily age-dependent — and therefore what is normal for your age group may not be normal for you. There are several different assays (laboratory techniques) which can give differing values on the same patient, making comparison of sequential values tricky. Random variations in single values are also common, often for inexplicable reasons–and can lead to unnecessary evaluation and biopsy in some cases. And lastly, you can have prostate cancer with a normal PSA. A recent large screening study — where biopsies were done on men with normal digital exams and PSA values — found prostate cancer in a surprisingly large percentage of men in whom the PSA and physical exam were entirely normal.

When a patient with an elevated PSA needs further evaluation, this generally involves evaluating the prostate with ultrasound, and often involves a biopsy of the prostate. But ultrasound is only fair at identifying abnormal or suspicious areas in the prostate, and biopsy has a false negative rate (i.e., the patient has cancer but the biopsy comes back benign) estimated at 3-5%.

Now let’s assume we’ve found prostate cancer after a biopsy done for an elevated screening PSA. Our neat little example above implies that treatment of the cancer is performed, leading to cure and a longer life. But it’s not nearly so cut and dry in the real world. Many prostate cancer patients–especially younger ones with more aggressive forms of the disease — may be relatively advanced even when discovered by screening PSA, and treatment may not cure them or prolong their life. Conversely, some men with earlier, less aggressive cancer, may well have never had a problem with the cancer if it had not been diagnosed at all. Others with clinically aggressive disease, which might otherwise kill them in time, die from unrelated causes before the cancer gets to this stage. And although there are some indicators of aggressiveness and prognosis which have some predictive value (extent of disease at diagnosis, initial PSA value, pathologic appearance or Gleason score), crystal balls are in short supply, both for predicting future behavior of prostate cancer, and for the likelihood of demise from unrelated causes.

Is it any wonder that studies of the value of screening with PSA are going to have a tough time sorting this mess out?

Oh, and by the way: this is the discussion you’re supposed to have with every patient who requests a screening PSA, according to the AMA and the NCI. And you wonder why most physicians laugh at such recommendations? Even when you have such a discussion, patients will always opt for the screening PSA. Always. And if they decline to have it done, and later find out they have prostate cancer–you’ll get sued for failure to diagnose it. So much for the big-shot’s recommendations.

So what to do about PSA screening? And why do I suspect this recent study disproving its value is likely wrong?

The answer lies in the big picture, and in experience.

I’ve been around this business for quite a while (surprising but true), and took care of a lot of men with prostate cancer before PSA was available, or widely used. Back in the 70’s, about 70% of men who were diagnosed with prostate cancer were at an advanced–and incurable–stage of the disease. The only tool we had for screening was the digital exam, which can only detect cancer when it is large enough to be felt–in other words, more advanced. In the 1980’s, when PSA began to see widespread use, about 43,000 men a year died of prostate cancer.

Today, the large majority of men diagnosed with prostate cancer are detected at a much earlier stage. In 2005, about 30,000 men died of prostate cancer–a reduction of over one-third in 20 years. What has changed? Not the therapy, really. Both surgery and radiation techniques have improved–but most of these improvements lie in reduction of treatment complications, rather than better cure rates. Chemotherapy has never been effective as a curative treatment, and is not so today–although it is improving at prolonging survival from widespread cancer. Men are better educated about prostate cancer and the importance of getting regular checkups for it–although most men are happy to skip their annual rectal exams when given half a chance.

What has changed is the widespread use of PSA for early detection.

The bottom line is, there are only three ways to suspect you may have prostate cancer: an abnormal prostate exam, an elevated PSA, or the findings of widespread cancer on other diagnostic tests. The last means the cat’s out of the bag; the first is relatively insensitive until the local tumor is large. But the PSA–often misleading by being abnormal when no cancer is present–is nevertheless how the large majority of men come to find out they have the disease. And this is conclusion is not merely anecdotal medicine–there is good evidence that regular screening reduces the risk of death by prostate cancer.

So what’s a fella to do, given all this conflicting information?

Here’s some recommendations I would make:

  • If you’re under 40, you don’t need a PSA.
  • If you’re over 75, and don’t already have prostate cancer, you don’t need a PSA
  • If you’re under 75, but have other high-risk medical problems (e.g., severe heart disease), you don’t need it.
  • If you have a strong immediate family (father, brother) history of prostate cancer (not just cancer in general), especially if they were diagnosed at less than 60 years of age, get a baseline PSA at 40, another at 45, and annual PSA and DRE after that.
  • If no family history, begin with DRE and PSA annually at age 50.
  • A PSA when you have a prostate infection or urinary tract infection will often be high. Ask your doctor to wait at least 3 months after treatment before checking one.
  • If your PSA comes back high, when previous ones were normal, be sure to have it rechecked before further evaluation. If a repeat comes back normal, have a third one checked 3-6 months later. The trend in PSA values is much more important than any single value.
  • If your doctor feels a lump on your prostate, but your PSA is normal, don’t be too reassured: get in to see a urologist.

Ignore the swirling controversies about PSA played out in paper-thin detail by the media–they have absolutely no clue what they’re talking about. Be a good boy, and get your prostate checked and a PSA. And tell them Dr. Bob sent you.

That Terrible Power

EagleThese have been difficult weeks.

The practice of medicine is one of the most gratifying careers possible, but it is relentless in its demands and unforgiving of imperfections — both those of the patient and the physician. Surgery in particular — while enormously satisfying in its technical and definitive nature for those physicians so inclined and gifted — is at the same time the most humbling of all disciplines. Despite all the training and experience, the knowledge and technical skill acquired through countless repetitions and refinement, things do not always go as planned.

John (not his real name, of course) was like so many others — in good health, early sixties, found to have a rising PSA blood test, which proved to be the harbinger of prostate cancer, fortunately still at an early stage. Presented with the options for treatment, he chose surgery: radical prostatectomy, the total removal of the prostate gland and biopsy of the pelvic lymph nodes — those filters which are the first resting place for cancer cells migrating outside the organ. It was an operation I had performed hundreds of times over nearly thirty years, and promised an excellent chance for cure, with an acceptably low risk of long-term adverse effects.

Surgery began uneventfully, with good exposure of the pelvic organs and lymph nodes, despite his portly habitus which can make such access challenging. The right pelvic lymph nodes were addressed first. Located in a triangular area demarcated by the external iliac vessels — the main artery and vein to the leg — the obdurator nerve (a large nerve deep in the pelvis) and the wall of the pelvic bone below, the lymph glands therein are gently teased and separated from these structures and sent for biopsy.

Surgeons get to know anatomy intimately, and depend on its predictability for safely performing their craft. In this area, the external iliac artery is reliably and predictably located lateral to the vein — farthest to the outside. At times, it can run a somewhat serpentine course, as cholesterol plaques narrow the channel and changes in flow and pressure lengthen and twist the artery. Such variations are also predictable: the artery courses in front of the vein if it moves toward the midline, or else moves away from it, farther toward the outside.

The bulk of the nodes were out in little time, titanium clips sealing the lymphatic channels and small blood vessels which feed them. The final packet was located near the point of the triangle, at the upper part of the pelvis below the vein. Several small vessels were clipped, and these nodes were removed easily as well.

I inspected the nodes, feeling them for firmness that might suggest cancer spread. One node looked peculiar. Hollow. Lymph nodes aren’t hollow.

Shit.

Inspection of the surgical field confirmed my worst fear: I had removed a short section of the external iliac artery, the main vessel to the leg. Located in a highly unusual location: underneath the vein, rather than above and lateral to it — an aberrant knuckle of vascular conduit enveloped in fat and lymph nodes — a section of artery had been cleanly removed with the nodes.

There was no bleeding, and the ends of the severed artery were easily identified and freed up. Fortunately, John did not have advanced vascular disease, and alternate paths for blood flow to the leg were open. A vascular surgeon was contacted, and arrived within 10 minutes. A short synthetic vascular graft was placed to bridge the gap, and full circulation was restored in less than an hour. There was no evidence of ischemia — a dangerous situation where insufficient blood flow and oxygen causes damage to tissue and the release of high levels of toxic lactic acid into the blood.

But the presence of a vascular graft, while salvaging a serious situation, meant something else: the main surgery, the prostate removal, would have to be canceled until the graft healed. To proceed as originally planned would risk contaminating the vascular repair, leading to graft infection — a disastrous complication. The incision was closed, and the patient arrived uneventfully in the recovery room. Two days later, he was home.

Imperfection in a field which demands perfection is perhaps the burden a surgeon experiences most deeply, with the most fear and respect. We hope, by endless years of study, preceptorship, practice, and experience, to master that which cannot be fully mastered, to control and manipulate our world to achieve that which is unachievable.

A surgeon who has never made a mistake is a surgeon who has never operated; the doctor who makes no errors must be one who sees no patients. The hard truth — hardest of any we healers, so often arrogant in our knowledge and skill, must swallow — is that we are not perfect — and neither are our patients.

Such untoward events may occur for many reasons, of course: a surgeon’s inexperience, recklessness, or fatigue, or his inattention to detail and proper technique. Aberrant anatomy, prior surgery, body habitus and underlying disease processes lay additional mines which trigger in unexpected ways and at unplanned times. But in many cases — perhaps even most — such ethical, physical or technical failings contribute little or nothing to a bad result or a poor outcome. Such a claim seems self-serving — and perhaps it is; hence I leave judgment of my own performance in this situation to those wiser and more objective than I — but it has been my experience that such is so with most good, talented surgeons with whom I have worked. The power to heal is the power to harm; the competence to cure the capacity to kill.

I have long marveled at an observation I rarely hear made: that a patient, a complete stranger, after one or two short visits, allows a surgeon to perform what is often a high-risk surgical procedure on their body, with something approaching blind trust. Granted, there is trust accrued in the degree, the board certification, the training, and hopefully the reputation of the surgeon you (or more likely, your family doctor) have chosen. But in reality, the information gap is real, and the leap of faith substantial. The “eyeball test” only goes so far: is the personable, knowledgeable professional you meet in the office a ham-handed clumsy oaf in the OR? Is the obnoxious, cold, arrogant technician a highly competent surgeon (a dichotomy often imagined as the norm), or instead a hot-headed impulsive boor whose ego trumps caution in surgery while denigrating all around him? Fortunately, neither scenario is typical — most surgeons are well-trained, professional, and highly competent — but how will you know?

But even among the highly competent, unexpected or adverse events in surgery are closer to the norm than the exception. Most are trivial and inconsequential — the small vessel cut and easily secured, the important suture which breaks and must be replaced, the surgical dissection which proves tedious and time-consuming rather than routine. Even more serious surgical problems may end up having no discernible impact on the outcome of the procedure, the recovery, or the end results. But serious complications are the bane and bale of every surgeon: our perfectionistic natures strain to demand that it not be so, but reality too often intervenes to correct our hubris and false hopes.

The dashed expectations and frustrated hopes of perfection fall hard on all whom surgery touches — the patient, the family, and the physician. For the patient, there is of course the harm done: the surgery aborted; the longer hospital stay; the pain of additional surgery or procedures made necessary; a temporary or even permanent disability; the disease not cured or ameliorated; even — God forbid — death itself. Both families and patients must bear these losses — and often suffer financial setbacks as well, both in medical costs, lost jobs, wages and benefits forfeited. And the question of, why has this happened? How could it occur? all too often go unanswered, or at best only partially so. Such confusion and frustrations often lead to anger — a potent cocktail whose dregs are often drained in the cold glare of courtroom lights.

For the physician, the demeanor perceived as indifferent or callous is rather the intellectualization and rational detachment which allows the surgeon to perform the vivisection which the untrained would find ghastly. But the cost of such steely objectivity comes in the relationships with those harmed, as empathy and compassion must be recruited from the dark closets to which they were banished long ago, orphans of the very training needed to excel in this field.

And beneath the professional veneer simmers also a cauldron of emotions. Smashing the idol of perfectionism comes hard — though a fragile idol it be — as false conviction that care and competence can avert all disasters is dispensed by the errant knife or misplaced scissors, by dense scarring or genetic quirk. The confidence which carries a surgeon effortlessly through daunting technical challenges melts away in moments, as simple tasks become feared challenges in the light of recent failure. The trust so critical to the patient-surgeon relationship is shaken and battered, and may not survive the event. And the fear: of unforeseen secondary complications arising in the future; of judgement and criticism by peers; of angry families and damaged reputation; of legal implications in an environment where lawsuits are the answer to every problem.

For some the worst wounds are self-inflicted, as shame, self-criticism and depression set in. Like the trapped wolf gnawing at his own leg, we wound ourselves further in vain hopes of escaping the pain and seeking freedom from its ensnarement — only to end up weakened, more vulnerable, and less able to stand. And we strike out at those closest to us, those who wish to help, deepening our isolation. The results can be deadly: scratch the surface of physician suicide — a problem more common than generally recognized — and you will often find the self-destruction engendered when perfectionism collides with poor outcomes.

To greater or lesser degree, many of these reactions were mine in the aftermath of this complication. And there was one other: I was angry — angry with God.

You see, I pray before surgery — and I prayed before this one, for guidance, wisdom, and good judgment, as I often do. If you are of a skeptical bent, and disinclined to give weight to such superstition, at least humor me by accepting that such an act might focus the mind and center the soul. But only a fool would deny that there is much beyond our control — and few things teach this lesson more clearly than surgery. It was not always thus: I have lived a life where skills and talent were all that was needed to succeed — a formula which led me inexorably on a downward spiral of failure. So I pray.

But to pray is to expect answers — and with that lies the unspoken assumption that all will turn out as I would wish. And so, it is God’s fault — is it not? — if the outcome is not what I would desire. Did I not have my patient’s best interest at heart in this request? Would not a good God answer this prayer to the benefit of both me and those He entrusted to my care? And so it appears, ipso facto, that God screwed up — and I get to take the heat. Bum rap, it seems to me.

But maybe — just maybe — there is a bigger picture in all this. Maybe I get to learn how little really is under my control. Maybe I learn to depend more on Him than on myself. Maybe — and this is a tough one — my shortcomings, my imperfections, which can cause harm as easily as my skills beget good — can work beneficially in some unfathomable way, even for those who must bear the suffering of these very imperfections. Some of the worst, most painful episodes in my own life have proven in the long run to be blessings unimaginable at the time — perhaps it can also be thus for others, even when I am the instrument of such adversity. A frightening thought, this — a terrible power.

And what of John? His recovery has been smooth, his lymph nodes show no cancer. I have apologized to him and his wife for this adversity, though no harm was intended nor evident neglect present to my knowledge. I have offered to assist with any financial burden thus accrued. And they have decided to trust me to perform the second surgery — which is humbling and sobering in ways difficult to express.

May God be with me then — and always.

A Dark Mercy

There have been growing numbers of stories about the heroism of rescuers and medical personnel, such as this one, who risked their lives and personal safety and comfort to rescue, comfort and evacuate often critically-ill patients in New Orleans. But not all the medical care was directed at saving and healing the sick, as this troubling report indicates (HT: Orbusmax):

Doctors working in hurricane-ravaged New Orleans killed critically ill patients rather than leaving them to die in agony as they evacuated hospitals…

With gangs of rapists and looters rampaging through wards in the flooded city, senior doctors took the harrowing decision to give massive overdoses of morphine to those they believed could not make it out alive.

In an extraordinary interview with The Mail on Sunday, one New Orleans doctor told how she ‘prayed for God to have mercy on her soul’ after she ignored every tenet of medical ethics and ended the lives of patients she had earlier fought to save.

Her heart-rending account has been corroborated by a hospital orderly and by local government officials. One emergency official, William ‘Forest’ McQueen, said: “Those who had no chance of making it were given a lot of morphine and lain down in a dark place to die.”

Euthanasia is illegal in Louisiana, and The Mail on Sunday is protecting the identities of the medical staff concerned to prevent them being made scapegoats for the events of last week.

Their families believe their confessions are an indictment of the appalling failure of American authorities to help those in desperate need after Hurricane Katrina flooded the city, claiming thousands of lives and making 500,000 homeless.

‘These people were going to die anyway’

The doctor said: “I didn’t know if I was doing the right thing. But I did not have time. I had to make snap decisions, under the most appalling circumstances, and I did what I thought was right.

“I injected morphine into those patients who were dying and in agony. If the first dose was not enough, I gave a double dose. And at night I prayed to God to have mercy on my soul.”

The doctor, who finally fled her hospital late last week in fear of being murdered by the armed looters, said: “This was not murder, this was compassion. They would have been dead within hours, if not days. We did not put people down. What we did was give comfort to the end.

“I had cancer patients who were in agony. In some cases the drugs may have speeded up the death process.

“We divided patients into three categories: those who were traumatised but medically fit enough to survive, those who needed urgent care, and the dying.

“People would find it impossible to understand the situation. I had to make life-or-death decisions in a split second.

“It came down to giving people the basic human right to die with dignity.

“There were patients with Do Not Resuscitate signs. Under normal circumstances, some could have lasted several days. But when the power went out, we had nothing.

“Some of the very sick became distressed. We tried to make them as comfortable as possible.

“The pharmacy was under lockdown because gangs of armed looters were roaming around looking for their fix. You have to understand these people were going to die anyway.”

Mr McQueen, a utility manager for the town of Abita Springs, half an hour north of New Orleans, told relatives that patients had been ‘put down’, saying: “They injected them, but nurses stayed with them until they died.”

I find this story deeply troubling at any number of levels. I have written before on my concerns about the practice of active euthanasia (here and here), which arise not merely because of my Christian convictions about its morality, but perhaps equally so because of the great potential danger I see in breeching the moral and social levies which protect us from hubris and the creeping progressive tolerance of evil inherent when crossing them. The weariness of great tragedy saps the spirit, making it all to easy to rationalize the repulsive, to move on to the next horrid scene without reflecting on the last. But sometimes we must stop and focus amid the deadening blur of death and suffering. This story demands such a pause.

I am assuming, first of all, that this story is true–although I have seen no independent confirmation elsewhere. The name of the hospital where this occurred is not given, but it makes one wonder if it is the same facility where 45 dead patients were found abandoned. If it proves true, one must wonder whether there will be less outrage over patients euthanized than abandoned to die–somehow I suspect there might be. After all, they were terminated mercifully, rather than just abandoned–which would be oh, so terribly, terribly heartless.

But of course, if they were euthanized they were abandoned–abandoned by their providers and sworn protectors, those whom they trusted to comfort, heal, and protect them. Granted, the circumstances were horrendous: deprived of power, light, medications, and security, threatened by a mob of barbarians bent on drugs, theft, and destruction–one can hardly begin to imagine the terror, the helplessness, the frustration shared by doctors, patients, and nurses alike. It is easy to judge those who were there, sitting as I am dry, safe and secure, far from this hell on earth. It would be foolish to say that–were I there–my behavior would have been different, more noble, more self-sacrificing, more righteous. I would hope so–but I have been known to underestimate my frailties and potential for moral lapses far too often to be smug or self-righteous: I simply do not know how I would have handled this situation, were I there.

But still I must ask: you killed them? Actively, deliberately, methodically? What has occurred here, it seems, steps over a line clearly blurred by the panic, fear, and hopelessness of a terrible storm and its even more horrible aftermath–the opportunism of human evil in the face of Nature’s wrath–into the realm of a darkness far deeper than wind and water and chaos could wreak. Have you not countered evil with evil? “And if Satan cast out Satan, he is divided against himself; how shall then his kingdom stand?”

Could not the morphine you used to end their lives be instead used to ease their pain, their fear, as you stood by their bedside doing what little you could to comfort them? It takes far more morphine to kill than to comfort. Could you not stand and defend them against the looters, the rapists, the thugs–though ill-equipped you might well lose your safety, your well-being, even your life. There is a word for those who act thusly, defending the weak against the strong at the cost of their lives: heroes. Did you not, by actively terminating their lives, avoid the shameful option of abandoning suffering and dying patients to save yourselves? They were condemned to die by their disease, by the untimely fate of a hospital in harm’s way, by social chaos and raging mobs. You are alive today because you expedited their inevitable death. But your life, so secured, is not enobled by this act: you may indeed find forgiveness, but the act remains: a dark mercy, an act of weakness, heinous forever.

The interview in The Mail is redolent with the special pleading and specious arguments so common among those who have compromised principles for expediency, and by those who justify any and all such moral relativism. The paper protects the anonymity of those who so acted “to prevent them being made scapegoats for the events of last week.” Scapegoats? Whose sins are you carrying into the desert, if not your own? What was the proximate cause of their death, if not your syringe?

The doctor informs us: “This was not murder, this was compassion. They would have been dead within hours, if not days. We did not put people down. What we did was give comfort to the end.” Aahh, compassion–I’ll have a double dose, please. Com-passion: “to suffer with”–this is its root, its meaning. To suffer with a patient, to experience their pain while strengthening their spirit–that is compassion. To stand in the breach, between the looter and the lost, to suffer that they may be spared–that is compassion. To stay with a dying patient, when the lights are out and you have no treatment to offer–that is compassion. To stop their breathing with an overdose so that you can escape without abandoning them to die alone may be rational, understandable, defensible, even arguably reasonable–but it is not compassion. Words have meanings: I know what murder means, what compassion involves, what comfort entails–and they are not the same.

The doctor informs us: “It came down to giving people the basic human right to die with dignity.” Death with dignity–is that indeed our right? Who ordains such a right? Who enforces it? What about the bloated bodies floating face down in sewage-laced water, drifting down streets in the company of dead rats and fire ants–is that dignity? Who stole their right to die with dignity? Would you have injected them also to save such an indignity? And how is it we now define “dignity” as the right to die when and where we want–or when our doctor thinks it’s best? Is not dignity instead dying with inner grace, strengthened by those around you, comfortable that your life has been lived with meaning and purpose–though your body be racked by pain–in the presence of others who care? Many died just this way in Katrina–under circumstances just as horrid and terrifying and degrading as the good doctor experienced. They died with dignity–brutally, but with nobility, grace, and courage, saving and protecting family members, pets, friends, strangers.

The doctor informs us: “You have to understand these people were going to die anyway.” Yes, I do understand–and that is true of every living breathing human on this planet. But your patients died early–in your time, not theirs, under your hand, not that of a looter, nor the ravage of a disease, nor the savagery of storm. Your hand, doctor. Who granted you this right, this power?

But someone in this story sees through the hollow rhetoric, the noble talk, the faux compassion: “Mr McQueen … told relatives that patients had been ‘put down’, saying: ‘They injected them, but nurses stayed with them until they died.'” America, meet your new compassion, your new dignity: the nurse will stay by your side after your doctor puts you down.

Now, perhaps this story is a tabloid fabrication. Perhaps–so often the case–the truth of the situation was mangled beyond recognition by truncated quotes, Dowdian ellipses, or the pure fabrication that passes for journalism in our oh-so-enlightened 21st century. And I was not there–would my behavior have been that much different? I don’t know. Tragedy rips the scab–covered by layers of makeup and cheap jewelry–from the deep wounds of the humans spirit. It may reveal bleeding, and pain, and health, and healing–or the putrid aroma of rotting flesh and festering maggots. A white coat does not bestow deity, but bespeaks instead service and sacrifice–and the dark horrors of a dying hospital do not change this simple truth.

Emergency Medical Kit

Flowers
In an earlier post on Katrina and preparing for an emergency, a commenter asked an excellent question:

As a doctor, what would you recommend [for an emergency medical kit] for usually healthy laymen?

The answer: it depends. (don’t you just hate answers like that ?)

But it does–it depends on a number of different things:

  • Where are you located geographically?
  • What sort of emergency or emergencies are you likely to encounter?
  • How many people are likely to require medical care?
  • What is the health or health problems of those affected?
  • What is your level of medical expertise?
  • What kind of injuries or medical problems would you expect in a disaster?

Your medical needs in an emergency will vary–at least to a degree–based on where you are located, and what type of disaster you are likely to encounter. For example, the Southeast, the Gulf and Florida are at obvious risk for hurricane. Wind and structural damage are likely, but flooding risk will depend on whether you are near a body of water (and don’t underestimate the potential for a small creek to become a raging river). Out West, earthquakes are much more likely, which tend to result in structural damage and fire (from electrical and gas line disruption). If you live in a major urban area, large-scale terrorism (biological, chemical, or nuclear) are more likely than in a small midwest town–where tornadoes, flash floods, or severe snow conditions might be a far greater risk.

Your climate may also have an influence on your medical needs–dehydration being more likely in hot climates, hypothermia in cold.

Your medical condition–and that of those in your family–should also be considered. While most people will not be at risk missing routine prescriptions for hypertension, high cholesterol, or many other conditions for short periods (1-2 weeks), people with diabetes (especially those requiring insulin) can get very sick very quickly without their medication and monitoring equipment, for example. If you are unsure how critical your prescription is in such an emergency, ask your doctor.

It is worthwhile considering (unpleasant though it may be) to consider what might happen, in terms of possible injuries, during a disaster. Some are obviously worse than others, but all should be thought through when preparing:

  • Lacerations–breaks in the skin, minor or severe, which pose a risk of infection, or in some cases serious bleeding;
  • Fractures (broken bones)
  • Sprains–injured and painful tendons which can limit mobility
  • Burns–usually from fire, electrical, or chemical injury–although severe cold (frostbite) is similar in many ways
  • Temperature-related dangers–hypothermia, heat prostration
  • Infection–usually a risk from other injuries, although contaminated food and water are a risk as well.

Some basic medical supplies should be in every emergency medical kit. The most important which come to mind are:

  • Wound dressings. These come in a variety of forms, and gauze bandages (separate squares, typically 4 x 4 inches) or rolled in 1 to 3 inch width are the most common, and should be available. Another excellent wound dressing is Tegaderm–a clear adhesive film dressing, which has the advantage of being waterproof, and which will remain adherent for many days. It is excellent for small lacerations, burns, or blisters.
  • Compressive dressings. This includes Ace wraps in several widths, and elastic bandages which can conform to irregular areas. These are very useful for sprains or for keeping pressure on wounds to control bleeding.
  • Antiseptics. Cleaning a burn or open injury early is the best preventive measure for preventing infection. Iodine-based solutions (such as Betadine solution–not the scrub, which has soap), hydrogen peroxide, and rubbing alcohol are all excellent disinfectants and readily available.
  • Topical antibiotics. Neosporin, Polysporin, Triple antibiotic cream or ointment.
  • Surgical tape. Paper and cloth tape to hold dressings or splints in place. Paper is easier on the skin but adgeres poorly when wet.
  • Bandage scissors. These heavy scissors are invaluable for cutting tape and dressings, or cutting off restrictive clothing.
  • Instant cold packs. Reduce swelling and pain with early injuries.
  • Survival blankets. Even in warm climates hypothermia can be a risk with prolonged exposure. These blankets can be lifesavers. A sleeping bag is an alternative, although it may be difficult to get an injured individual in and out of these.
  • Latex exam or surgical gloves. These come in various sizes. Sterile gloves are a luxury but clean latex gloves will serve well in most circumstances, and don’t need to be rotated.
  • Simple surgical tools. Tweezers, hemostats, small iris or similar surgical scissors, can be very useful for extracting wood, metal, or glass fragments, cleaning dirty wounds, or performing open heart or brain surgery (just joking about the last). They can be sterilized by boiling or with rubbing alcohol to a safe degree of sterility for an emergency.
  • Splints. These are important to stabilize fractures or severe sprains.
  • OTC Drugs. Aspirin, ibuprofen, Benadryl or similar antihistamine, hydrocortisone cream.

There are no doubt other things (which my medical readers or others may suggest), but this would seem to cover the basics pretty well. Most of these items are inexpensive and can be easily purchased at local stores or over the web.

Store these items in a sturdy container, such as a toolbox, tackle box, or similar container that will survive some banging around. Consider a waterproof container if you are at risk of floods or water damage. And consider where you are going to keep this kit: if your house is destroyed by fire or collapses, and your medical supplies are inside, all your preparation is for naught. Duplication is a good idea, at least for the most critical items–keeping one in a structurally safe place in your home, one in your car–and don’t forget about work.

Most of the items I’ve mentioned above are quite stable over time, and shouldn’t need replacing often. Peroxide and the OTC medications can probably be rotated every few years and remain safe and potent. If you need to store critical prescription medication, you will need to be much more proactive on keeping these up to date, as most medications outdate in a year. Plan to rotate these on your birthday or some other easily-remembered date.

Such an emergency kit will cost you less than average Seattlite spends on mochas a week, and can be assembled in very little time. Take the time and effort to get one of these together–it may save your life.

Update: A little sleep has brought to mind several more items:

  • Normal saline for irrigation, and a syringe (an ear bulb will work fine)
  • A tourniquet–actually something of a mixed bag. It can be lifesaving in severe bleeding from an extremity, but you have to have have some idea how to use it. A length of latex rubber hose will work fine.
  • And everyone should get the basic skill of CPR–both for disasters and general safety.