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.

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."

24 May 2011

Why we all want to justify rape (sometimes)

In the wake of Dominique Strauss-Kahn's arrest on attempted rape charges last week a furor arose over apologia written by Ben Stein and Bernard-Henri Levy. (In case you're wondering why I didn't write about this sooner… I had finals and an ACLS class, oh and I have a board exam in a month.)

Occasionally mentioned—usually in passing—as this saga has unfolded is the (United States') general media portrayal of rape. In particular there have been a few mentions of this (recently notorious) NYT story on the vicious gang rape of an eleven year old girl by eighteen men. As Roxane Gay at The Rumpus did a masterful job dissecting the story I will just quote one of Gay's paragraphs that synopsizes the NYT's troubled reporting.
The overall tone of the article was what a shame it all was, how so many lives were affected by this one terrible event. Little addressed the girl, the child. It was an eleven-year-old girl whose body was ripped apart, not a town. It was an eleven-year-old girl whose life was ripped apart, not the lives of the men who raped her. It is difficult for me to make sense of how anyone could lose sight of that and yet it isn’t.
As usual I find the the way these events were reported on interesting. However, I find why they were reported this way to be a lot more interesting.

06 May 2011

Why properly understanding how stuff works is important

Constitutionally I can only handle studying for so long at a stretch without going crazy. However, with board exams looming nearer every day I shifted my normally wide ranging leisure reading to focus on things that are medically relevant and help to reenforce many of the bits of information and/or concepts that I'll be tested on.

Which is why I'm currently reading The Excellent Powder: DDT's Political and Scientific History. The third chapter entirely pertains to widespread misunderstanding among policy makers of how DDT works. To quote the chapter summary:

04 May 2011

The myth of Muslim conspiracy theories

In the wake of Osama bin Laden's death the media can't say enough about conspiracy theories: how our actions are creating them, what they are, who believes what, and so on. Strangely absent from their fascination is their own role in their creation and persistence. Dutifully playing along is Matthew Gray, a writer at Foreign Affairs, who brings us a backgrounder on what is already a growing trend—Muslim conspiracy theory spotting. His piece will likely set some of the terms for the future conversation because he goes one step further and, as his subtitle indicates, purports to explain, "Why falsehoods flourish in the Muslim world."

The piece is not devoid of value; however, it's impossible to talk about who is susceptible to a "conspiracy theory" without clarifying what you mean by the term, as well as the more straightforward "conspiracy." Take, for instance, this assertion of Mr. Gray's:
One reason the region is so susceptible to conspiracy theories is that it has been subject to an unusually high number of actual conspiracies in the past.
What Mr. Gray is referring to here is not the disproportionate number of conspiracies that have taken place in the Middle East, instead he is referring to the number of coups that have occurred. Even more specifically though, he is referring only to coups engineered by foreign governments. This is all well and good in that foreign operatives (particularly those of clandestine services) engineering coups provide solid examples of one type of conspiracy.