16 May 2014

A Terrible Thing to Learn

It must have been very confusing for you; to be brought to the emergency department by your mother during your fifth week of life. When you overheard your mother on the phone with the nurse hotline before she brought you in, I'm sure the conversation made no sense: "fever," "newborn," "take her to the hospital now." After the nurse in triage took your temperature I'm sure things only got more confusing. You were bustled into an emergency room, you were stung with needles, first to take your blood, then to infuse medicines into your veins.

You were irradiated, and a urine sample taken, before you were bustled out again, this time to the pediatric ward in your mother's arms. You had a room, but you didn't even stop there before being brought to the procedure room. It was there that I slid the needle between your vertebrae and saw the turbid, yellow, sedimented, terrible cerebrospinal fluid drip and drab into a clear plastic tube.

Then it was back to your room, where you were poked again for yet another blood sample. Yet again, the news it bore was terrible. You needed more, different fluids now because you could not maintain your blood sugar. Through all of this your breathing was ragged, your heart rate maxed out, and you never stopped grunting. In every way you could, you told us you were sick.

***

This is one of the many terrible, but blessedly rare, things that we have to learn as modern pediatricians: how to deal with neonates who have fevers. As I near the end of my first year of pediatric residency I have seen a dozen or so infants with fevers. The necessary steps to work these infants up are second nature by now and dictated by a dealer’s choice of criteria laying out the necessary steps (oddly enough the various criteria are named after Northeastern cities: Rochester, Boston, and Philadelphia). Those under 28 days old get the full work up (a panoply of acronyms: CBC, blood culture, CMP, CXR, UA, urine culture, and CSF studies); those older than 28 days may get the whole package, or be spared the lumbar puncture to get cerebrospinal fluid.

Each time I have slid a needle between two vertebrae and collected the pristine CSF within, I have had to remind myself of the statistics regarding these infants. It is nearly impossible to tell—until it is too late—whether they are hiding an infection in the fluid around their brain. Yet, my inexperience lent me something that I did not realize until later: the feeling that discovery was enough, that the inevitable result of ferreting out those 7-9% of well-appearing febrile infants who were hiding serious infections was all it took. After that, it seemed to me, recovery was automatic.

Put another way, I did not understand the terror that my attendings carried with them through every encounter with a febrile newborn. In an era of aggressive prophylactic antibiotics combined with aggressive prenatal surveillance, I had never seen medicine's stark shortcomings. I had never seen how bad things can turn out, even when everything goes right. This is not an indictment. It is simply my realization that I had internalized the same cultural attitude towards medicine that much of society has: namely, that if we have a diagnosis, it is only a matter of time before a full and complete recovery is made.

***

I knew you were sick and I knew that you needed more care than the pediatric ward could provide, so we arranged to bustle you off yet again, to the pediatric intensive care unit. I signed you over to the PICU resident, I told him your story, I told him what we had done, the results of the labs that had been drawn thus far, and what we were waiting for. Then I loitered, for half an hour past when my real role in your care had ended and two hours past when I had been scheduled to leave. As another half an hour passed, I realized I was doing nothing useful and was burning the precious few hours set aside for me to sleep. Before I left, I checked the pending labs one last time. The protein in your CSF was 870, the glucose was less than 2 and there were "many bacteria (gram positive cocci)". As I left I stopped and relayed the new, startlingly bad numbers to your new doctor, and then continued on out of the hospital for the day.

***

The lab results I saw just before I left should have crushed me; however, they did not. They made me feel… thrilled and elated at how we had done everything right, how we now had a diagnosis and that our interventions had certainly saved your life. From here my mind took a shortcut, I saw the timeline of events that led you to my care: that your mother brought you in within an hour of noting your temperature; that you were triaged in the emergency department within five minutes; that you were seen by a doctor 10 minutes later; that you received antibiotics within an hour of checking into the emergency department; from all of that I assumed the rest was a foregone conclusion.

Later that night my initial elation ebbed and my emotions took a dip. From the highs of feeling that I had helped to make the diagnosis that would save your life I started to think about what those results meant. I knew that the presence of bacteria in your cerebrospinal fluid over an hour after you had received antibiotics was a terrible sign. I knew that the amount of protein and glucose in the fluid indicated an overwhelming infection in and around your brain.

On the first count, that we saved your life, I was right. I have no doubt that a short time longer without antibiotics and you would not have survived. Yet that success is tempered. You will survive, but your life will be unimaginably different. I slept fitfully during your first night in the hospital, every time I awoke in the middle of the night I texted the night resident to get an update on your condition. Every update bore bad news; first you needed to be intubated, you needed drugs to keep blood flowing to your organs, then you started having seizures so yet more medications were added to forestall them. The next day the imaging studies of your brain dredged up words I had not seen since medical school: cerebritis, leptomeningeal enhancement, subdural empyema.

The terrible, sad truth is that much of what has happened inside your tiny fragile body is irreparable. It’s impossible to know what your life will hold. It’s not even possible to predict when you’ll get out of the hospital. What I do know is that you have taught me a lesson that I could not have learned any other way, you have taught me to fear the limits of medicine.

12 September 2013

Physicians Are Not Comptrollers

As a pediatric intern rotating in developmental pediatrics I've been thinking a lot lately about how much of my time is spent filling out paperwork. Not in the sense that I have to document patient encounters, I'm fairly efficient at that and it is a necessary part of the job; what is unnecessary, however, is the amount of time I spend filling out non-drug prescriptions and getting consultations approved.

For instance, I have a patient who has cerebral palsy, it has been awhile since the ankle braces he uses to facilitate mobility were molded and he has outgrown his present pair. In addition to the old pair being less useful they are actively harmful by causing skin irritation that can lead to breakdown. In order to get him new ones I have to place a consult to our clinical case manager, who then gets a visit to the orthotic company approved by the insurance company. The patient then visits the orthotic provider and has molds taken. Next, the orthotic company faxes me a list of the braces they are going to provide him with asking me whether I agree that they are medically necessary. If I sign that one of the particular orthotics is necessary, insurance picks up the tab, if I say it's unnecessary then the family pays out of pocket.

This sounds relatively straightforward and probably reasonable. Here's the problem: The orthotic company has molded ankle and wrist braces for him. I recall examining his wrists and even discussing with his mother that these braces would likely need to be replaced in the future during his office visit.

I'm now in a bind. Obviously this patient will receive a benefit from having new wrist braces, but are they necessary right now? (My signature attests that these pieces of medical equipment are necessary for the patient therapeutically.) It's clear to me that the braces will be necessary in the future, but I also understand that getting the braces in the future will require a visit with me to place another case management consult (or at least a call to the nurse to facilitate a phone call with me so that I can place the consult), another visit to the orthotic company, and then another wait, and another signature from me attesting that the brace is necessary.

13 April 2013

War on an Idiotic Op-Ed

Richard Friedman has written a terrible op-ed on psychiatric prescribing habits in the military in the NYT. I had initially started writing this as a flowery debunking drawing lots of broad conclusions, but in the hopes of actually publishing something I'm just going to go through his piece and tell you why various parts of it are horribly reasoned, just plain wrong, or merely misleading.

Beginning with the beginning:
Last year, more active-duty soldiers committed suicide than died in battle. This fact has been reported so often that it has almost lost its jolting force. Almost.

Worse, according to data not reported on until now [1], the military evidently responded to stress that afflicts soldiers in Iraq and Afghanistan primarily by drugging soldiers on the front lines[2]. Data that I have obtained directly from Tricare Management Activity, the division of the Department of Defense that manages health care services for the military, shows that there has been a giant, 682 percent increase in the number of psychoactive drugs — antipsychotics, sedatives, stimulants and mood stabilizers — prescribed to our troops between 2005 and 2011. That’s right. A nearly 700 percent increase — despite a steady reduction in combat troop levels since 2008. [3]
[1]: This paragraph characterizes completely the reporting of said data. At no point is it systematically laid out. Nowhere are absolute numbers given. Time periods shift at random and the actual data that is reported seems to be randomly chosen. Anyone who thinks this is a sufficient amount of disclosure of new data from which they are going to draw conclusions is a fool, a narcisssist, or both. This incomplete and inadequate reporting is hugely problematic throughout the essay.

[2]: I have no idea how data which shows a massive increase in psychoactive medication prescriptions can be turned into data saying that those prescriptions were given to troops who were "on the front lines." I'm not saying that there are no troops who receive psychoactive medication "on the front lines," but the construction of this entire sentence gives the misleading impression that the entire increase in psychoactive prescriptions was accounted for by troops "on the front lines" with absolutely no attendant evidence.

While I think many people may find it intuitive that troops "on the front lines" not be taking psychoactive medication, a bit more thought will raise some interesting questions regarding that intuition. Should all troops with a diagnosis befitting treatment with psychoactive medications be removed from "the front lines"? Would we be better off with those same troops, with those diagnoses, not receiving medication? How would the answers to these two questions affect the military's ability to meet the objectives set forth by our civilian leadership?

[3]: In this passage Friedman somehow, and without any subsequent explanation, asserts that a drop in combat troop levels ought to have lead to a decrease in psychoactive prescriptions, rather than the "giant" increase that we have seen. I'm serious, that's what he said, go read the passage again.

The first error here is that Friedman is using different temporal spans for the period during which psychoactive prescriptions grew, and the period during which combat troop levels have been decreasing. This is why his blithe reporting of this new data is such a problem. Setting aside the preposterous assumption that falling combat troop levels should lead to a decrease in prescriptions (more on this in a moment); how much of the rise in prescriptions came between 2005 and 2008 when combat troop levels were not being steadily reduced? Without knowing this it's impossible to assess whether his last sentence is wrong about the data, or simply wrongheaded by its assumptions. (While we're at it I would not characterize troop levels at any point during the Iraq or Afghanistan wars as "steadily" changing, in either direction).

Why should falling combat troop levels lead to a stable, or falling number of prescriptions for psychoactive medications? It may seem intuitive that fewer people experiencing combat equals fewer people to be diagnosed with psychiatric illness, but that's unfortunately not how it works. In the case of traumatic brain injuries and other physical injuries that may (or may not) have attendant psychiatric manifestations it may be true (though it's arguable). In the case of psychiatric illnesses such as depression, anxiety, and post-traumatic stress disorder the association is not as clear cut. Moreover, many of these conditions take years to manifest themselves, other times it may take years for sufferers to seek help for a psychiatric condition. This time delay is a well known and documented aspect of PTSD, particularly among people involved in violent conflicts. Friedman's blasé glossing of this fact is inexplicable to me.

The much shorter version of the preceding three paragraphs: It does not at all logically follow, as Friedman says, that falling combat troop levels should not lead to an increase in psychoactive prescriptions. (Moreover what constitutes "combat troops" in irregular wars?)

30 March 2012

Required reading

I don't post much any more, I could blame being busy, but I'm not that much more busy than before. I just haven't had much to say lately. As always I have been reading a lot.

In any case, the reason I decided to post today was to beseech y'all to read this:
The Madness of SPC Weichel.

14 November 2011

The Vets Are Alright (The Rest of Us Are the Problem)

This post is cross posted over at the wonderful Gunpowder & Lead blog. They're the same post.

As I read through recent stories about military veterans one thing has crystallized for me: the relentless focus on injuries, PTSD, TBI and the soldier's and veteran's general distress.

Based solely on the media's portrayal of returning soldiers and veterans one would believe them all to be fragile individuals whose lives may shatter at the slightest additional trauma. However, the vast majority of soldiers return healthy and capable, even if they are forever changed by their experience serving. That is to say, we seem to live in a world where the afflictions of soldiers are covered in the media like airplane crashes, rather than car accidents:
Page-one coverage of airplane accidents was sixty times greater than reporting on HIV/AIDs; fifteen hundred times greater than auto hazards; and six thousand times greater than cancer, the second leading killer in America after heart disease.
To be sure, PTSD, TBI, amputations, automobile accidents, plane crashes, and cancer deaths are all very real and very tragic but it's long past due that we consider the consequences of our relentless focus on the those afflicted by war because they are real as well.

While the media's predilection for rare and extraordinary stories has been well documented what's more important than the coverage itself is the nature of the coverage. For example: this October 2010 Washington Post article, Traumatic brain injury leaves an often-invisible, life-altering wound. This article is typical for its genre, coming in at nearly 3,000 words, yet devoting only a few sentences to any sort of wider context. We are told the raw number of diagnoses of TBI since 2000, then given another, larger, number from a RAND corporation study. Completely missing is any sense of scale. Do those 180,000 (or is it 300,000?) soldiers represent 1%, 10%, or 90% of individuals at-risk for TBI?

03 October 2011

Misdirection by euphemism

As I watched the news a few weeks ago waiting to see if, and then when, the state of Georgia would execute Troy Davis—a man wrongly convicted at worst, or unjustly sentenced at best—something about the images from outside the prison struck me: The innocuous and anodyne name of the prison, the Georgia Diagnostic and Classification Prison.

Naming the prison this way asserts that the public should know that this facility is where diagnosing and classifying occur. While it's undeniably true that those terms do accurately convey some of the actions that the Georgia Department of Corrections carries out there, it begs the question: Why are these functions of this prison so vital as to claim space in its very name?

George Orwell, in his famous 1946 essay Politics and the English Language said, "In our time, political speech and writing are largely the defense of the indefensible." It is a coincidence of history that only a year later the United States would consolidate the belligerently named Departments of War and Navy into the comparatively docile Department of Defense.

The labels a culture applies to its institutions serve a purpose beyond mere identification: they signal the purpose and expectations by which we should judge them. This is why those two superfluous words in the Georgia prison's name are so important. They were not chosen lightly, nor were they included in the prison's title carelessly.

Let's examine the word diagnostic closely (classification's particulars ought to be self evident afterward). Beyond its definition, the verb diagnose is notable because it is overwhelmingly used to indicates a label applied by an authority. To wit: the OED's first usage example for diagnose is, "doctors diagnosed a rare and fatal liver disease." One can easily construct other common usages, e.g., "the mechanic diagnosed the problem with the car."

No matter the usage example, they all refer to situations where higher-information individuals (or professions, or institutions) apply a label to something. To put it more simply, diagnosis is an act of profound authoritarianism. While the authoritarian implications of both diagnosis and classification are important, the more subtle endorsement is toward the medical usage. It is no accident that diagnose's usage example invokes the medical profession.

14 September 2011

One thousand and seventy words about mental healthcare

I'm currently doing a psychiatry rotation at an outpatient behavioral health clinic which primarily serves the substantial indigent population here. I've tried to sit down and write about the experience but all that comes out is a structureless jeremiad about the tragedy of a shredded safety net and those with psychiatric problems.

Rather than subject you to that I'd rather just present this chart by Bernard Harcourt (much more here):

03 August 2011

JAMA and the NYT don't understand PTSD

The New York Times has a new article about a recent study examining the adjunctive use of Risperdal in treating PTSD. Specifically, patients who were already taking a serotonin reuptake inhibitor either were, or were not, given Risperdal as well. Via a variety of metrics they were then assessed after six months to see if the Risperdal made a difference.

Let's begin where the article does, with its headline, "Drugs Found Ineffective for Veterans’ Stress". First of all, the study only examined one drug (granted, it did so in conjunction with a myriad of others, but its findings all relate to one drug), making the Times' use of the plural deeply wrong. In case you want to excuse the writer (Benedict Carey) and just blame the editor for a careless headline, here's the first sentence, which abuses the plural as well, "Drugs widely prescribed to treat severe post-traumatic stress symptoms for veterans are no more effective than placebos and come with serious side effects, including weight gain and fatigue, researchers reported on Tuesday."

Not only does the sentence abuse its subject to over sensationalize the story, the entire second half exaggerates the research findings upon which this article is based. The research author's only comments on the side effects of Risperdal were, "Adverse events associated with risperidone were not serious."