tag:blogger.com,1999:blog-80648215946720552202024-02-20T12:17:36.273-07:00Petulant SkepticNever attribute to malice that which is adequately explained by stupidity.Petulant Skeptichttp://www.blogger.com/profile/03681938271124472357noreply@blogger.comBlogger7125tag:blogger.com,1999:blog-8064821594672055220.post-19426011520009558522023-10-16T19:20:00.003-07:002023-10-16T19:23:47.560-07:00Good Inside Evil; Evil Inside Good<p><i>This story happened a long time ago. I think I've written it online before, perhaps as a Twitter thread that is now long gone. I've rewritten the story here because I think of it often and wanted to be able to share it.</i></p><p>When I was an ICU fellow there was a night shift where I'd been out of the ICU for a week or two and wasn't overly familiar with all the patients. I came in and got sign out and checked in on everyone. Handled things as they went along. Sometime near midnight when there wasn't anything actively requiring my attention I did what I always did and went around and checked in with each nurse.</p><p>Discussing one of the patients, an infant with a severe congenital problem whose solution was failing, the nurse expressed to me her sorrow that we were keeping the child alive just to keep the parents out of jail. I knew this nurse well and it was such a bizarre, jarring thing to hear from her I asked what she meant. She was shocked I didn't already know the context. When I asked what it was she told me to just google the child's last name. The conversation got stilted and I moved on to my other patients.</p><p>After finishing rounds I had time to lay down, but I had taken a nap before my shift and wasn't tired so sitting at my computer I googled the family's name. The first couple results were all about the child abuse allegations and impending trial against my patient's parents, but the allegations didn't include my patient, but another of their children. I don't have words for the feelings those allegations engendered in me but the closest are enraging, infuriating, wrathful.</p><p>I spent the rest of the night mad that the world could let children be so mistreated and furious with the perpetrators and enablers. I also spent the rest of the night extremely angry with myself.</p><p>When I was young(er) and dumb(er) and a medical student I had done a rotation at the hospital that served a large prison complex of both state and federal prisoners. The state prisoners were on a different floor with a different medical service, but the federal prisoners were on the general med/surg floor and cared for by our team. One day an intern and I were idly speculating about what crime a particular patient had committed. Our attending overheard us and angrily interrupted us telling us both, in a tone that brooked no argument, "Never ask that question. The answer to it will never help you take better care of your patient."</p><p>I had remembered that lesson and mostly abided by it; being a pediatrician helped. My patients were rarely the barbarous ones, it was usually someone around them. Another attending, during another tragedy, had taught me to, when caring for abused or mistreated children, focus on creating the most caring and loving environment that I could rather than on the terrible things that happened outside it. The frameshift helped me immensely through the subsequent tragedies that came into my care. I still teach that re-framing now that I am the attending.</p><p>Back to my night in the ICU though. I was angry with myself because I had known that my google search wouldn't help my patient in any way and in fact it may harm my ability to care for the child and family with compassion. I'd given in to my own morbid curiosity for nothing except a sense of righteous anger that helped no one. Truly the definition of a negative-sum endeavor.</p><p>The rest of the night shift went by and there was enough that happened that I never got any sleep but I wasn't busy enough to stop thinking about the google search. I went home and eventually managed to get some sleep before going back to the ICU for the next night. It went by much the same except that when I did my late night rounds the same nurse had the same child and she asked if I'd looked it up. I admitted I had. </p><p>She expressed how wrong it was that we were keeping the child alive just so that the parents could push the trial off longer. I expressed how mad I was at myself for having read about the allegations and how upset I was that people were presuming the only reason the family hadn't let their child die was to forestall justice. Our impressions of what was happening and why were so wildly different it was hard to recognize that they grew from the same set of facts.</p><p>The nurse's perspective that I did not adequately consider then was her hour-to-hour, day-to-day experience trying to manifest that impulse of love and compassion that I talked about earlier. In her care was a child whose life was supported by all the implements of modern medicine, lines and tubes and drains, none of which are comfortable to endure. Her job was to palliate suffering, but for this child there was no therapy sufficient to that end.</p><p>Across our philosophical divide I couldn't believe that the grief I saw and heard from the child's parents was not genuine. Perhaps it's naïve but if I see grief like those parents showed and disbelieve its authenticity I will know it is time for me to retire from caring for patients. Within those parents I saw people who were terribly, terribly flawed but I also saw that despite their flaws they felt tremendous love and grief for their dying child.</p><p>I don't know what the moral of this story is. I know that I think about it whenever I get the sense that a person, or a group of people, are being portrayed as not deserving our compassion.</p>Petulant Skeptichttp://www.blogger.com/profile/03681938271124472357noreply@blogger.com0tag:blogger.com,1999:blog-8064821594672055220.post-45824875410670727172023-08-20T11:38:00.018-07:002023-08-27T18:49:12.876-07:00Respiratory Physiology for Climbers and Mountaineers<div><b>*in progress*</b></div><div><br /></div><div>With intermittent frequency I read trip reports, articles, social media comment threads or whatever from mountaineers and climbers who go to altitude and say many partially correct things about oxygen and altitude with a smaller number of completely wrong things mixed in.</div><div><br /></div><div>Every so often my frustration boils over and I write a comment or reply or DM to someone and try to explain things and correct their misapprehensions. It's happened enough times that I figured I should write down the most salient aspects of respiratory physiology at altitude in a way that (hopefully) makes sense to mountaineers and climbers.</div><div><br /></div><div><b><i>Background</i></b></div><div>As background, I'm a pediatric critical care physician and an amateur mountaineer. The former gives me a lot of expertise in respiratory physiology; as to the latter, I haven't done anything noteworthy but I've done enough rapid ascents from sea level to 4000 meters to have experienced AMS and have spent a lot of time cavorting the mountains.</div><div><br /></div><div>I can't promise that anything in this writeup will help you climb a mountain but I hope that it will help you understand what's going on in your own body at altitude and maybe help you make plans and sound decisions.</div><div><br /></div><div>Also, I'm a barbarian American and our weird meteorological pressure measurements have found their way into our physiology, so my apologies if you've stumbled upon this writeup from the enlightened world. There are plenty of calculators to turn mmHg into kPa if you wish. I will probably also switch randomly between feet and meters when referring to altitude as different domains (climbing, meteorology, etc) have different norms for me.</div><div><br /></div><div>For the most part I'm going to write this without putting in a ton of references because, as anyone who's ever done academic writing can attest, it's an exorbitant amount of work and I trust that all of my readers can operate a search engine. For things that are esoteric, hard to dig up, or from whence I've borrowed images I'll try and put in a link. Much of the primary literature on this stuff pre-dates digital publication so has been retroactively scanned or is otherwise a pain to get ahold of beyond abstracts.</div><div><br /></div><div>With that throat clearing aside, one law of physics that will come up over and over again throughout this discussion that is very important (and thankfully simply and intuitive):</div><div><br /></div><div><i>Dalton's Law</i> says that in any mixture of gasses the pressure that each exerts is proportional to its concentration and all of the proportions add up to the total. Putting this into layman's terms is really easy: all of the parts make up the whole and all of the parts take up as much space as their proportion.</div><div><br /></div><div><b><i>Ambient Air and Barometric Pressure</i></b>:</div><div>Below the tropopause (~36,000 ft) air is well mixed by a bunch of different physical phenomena and its composition is the same over the whole surface of the earth (local pollution notwithstanding) and 20.947% of the molecules in that air are oxygen molecules. Just round it to 21% for your own and everyone else's sanity.</div><div><br /></div><div>As we ascend in altitude the barometric pressure decreases. This is because the atmosphere above us has substance and mass and as we go up, there is less of it above us. Less stuff above getting pulled down by gravity means less pressure. There are a couple of mathematical models that explain how much the pressure decreases as the altitude increases, if you find yourself worrying about this: choose the <a href="https://journals.physiology.org/doi/pdf/10.1152/jappl.1996.81.4.1850">model atmosphere equation</a> (<i>not</i> the standard atmosphere equation) as its output matches measured data much better.</div><div><br /></div><div>As this barometric pressure decreases it doesn't change the composition of the atmospheric air (20.947% of the molecules in the air are still oxygen) but it does mean there are fewer molecules in the air -- including oxygen. This means that there are fewer oxygen molecules inside of our lungs (since the volume of our lungs doesn't change as we ascend in altitude) available for our body to absorb.</div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEg-VaCaUUwq1LjCT5gDSlG5r_M2L5tQnSOXWgCMdx4wDWOB9hha7aJ6ScmhJYFCD5kmC4yhXLmQ2HCZ_r62JpvoMAaJP9T-MM1NCioPrAWzfecG4MmR31XK5gFIpu9qd-3uISBcR9wSlMKipnL8uMXU4JoyyRDOh24fNikCkwYYKcgq-lMxYgDanNLFuPq8" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="787" data-original-width="1328" height="190" src="https://blogger.googleusercontent.com/img/a/AVvXsEg-VaCaUUwq1LjCT5gDSlG5r_M2L5tQnSOXWgCMdx4wDWOB9hha7aJ6ScmhJYFCD5kmC4yhXLmQ2HCZ_r62JpvoMAaJP9T-MM1NCioPrAWzfecG4MmR31XK5gFIpu9qd-3uISBcR9wSlMKipnL8uMXU4JoyyRDOh24fNikCkwYYKcgq-lMxYgDanNLFuPq8" width="320" /></a></div><br /><br /></div><div><br /></div><div>While altitude is, by far, the largest factor in barometric pressure changes that a climber may encounter, there are others which bear mentioning.</div><div><br /></div><div><b><i>Latitude, Temperature, Weather</i></b></div><div>For a bunch of complicated physics reasons there is a bulge in the atmosphere over the equator which has the effect of increasing the barometric pressure the closer one gets to the equator (when compared to the same altitude nearer the poles) because the troposphere is about twice as thick (5km vs 10km).</div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgLCP67-J6k8D9e7_wInOrPD7-feJIqvMPVyWXbu2cUn3vjutTFkHpyfijGoC5e-nQy07AEUUr30SXhKD_WQv2TSdjJhMIBWuess8p7DAiWeT4wWXYmvw8t2SDEiQ05_Wlext6IIUTxnvJ7pM6XLZrb9-UfmyY9H0u2lH4CthBNMAGyFHgs2UePtAdLMC-u" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="372" data-original-width="517" height="230" src="https://blogger.googleusercontent.com/img/a/AVvXsEgLCP67-J6k8D9e7_wInOrPD7-feJIqvMPVyWXbu2cUn3vjutTFkHpyfijGoC5e-nQy07AEUUr30SXhKD_WQv2TSdjJhMIBWuess8p7DAiWeT4wWXYmvw8t2SDEiQ05_Wlext6IIUTxnvJ7pM6XLZrb9-UfmyY9H0u2lH4CthBNMAGyFHgs2UePtAdLMC-u" width="320" /></a></div><br /><br /></div><div>Anyone with a passing familiarity with meteorology will recognize that it is usually discussed in terms of high and low pressure regions -- the interaction between them being what gives us weather. Depending on where you live and its usual weather patterns a "strong" high or low pressure system will usually deviate from normal by about 25 millibars (domain specific units are very annoying in this sort of cross discipline discussion… 25 millibar ≈ 19 mmHg). As we'll see later a 20 mmHg change in barometric pressure can have dramatic effects on our body's ability to absorb oxygen.</div><div><br /></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiZwCeHEZRSpMYjaL53iIXshzXhREURZ-vVUb48egkmGRxAdz4Rk8Yv-7_CM-hHtOj15jogngtJXusAZ3DfufTeiV62hBO6nLtscQxIUVBTPjKSvUM6j6NmzC5a-5MhNRV5_QD_ZlgYTAiuX8Uo6US6_FoerXV7XqbSux2FVIdvA1HoA2gKX3u_uVpMw_58" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1472" data-original-width="2266" height="208" src="https://blogger.googleusercontent.com/img/a/AVvXsEiZwCeHEZRSpMYjaL53iIXshzXhREURZ-vVUb48egkmGRxAdz4Rk8Yv-7_CM-hHtOj15jogngtJXusAZ3DfufTeiV62hBO6nLtscQxIUVBTPjKSvUM6j6NmzC5a-5MhNRV5_QD_ZlgYTAiuX8Uo6US6_FoerXV7XqbSux2FVIdvA1HoA2gKX3u_uVpMw_58" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Pressure Map (via windy.com on 20 August 2023). Numbers are mmHg. Note the tropical storm and its low pressure center off the coast of California compared to the high pressure center south of Alaska.</td></tr></tbody></table><br />There is also a diurnal (ie day-night) fluctuation to barometric pressure which varies by latitude but is generally small enough to be ignored (the shift is +/- 2.5 millibar (≈1.9 mmHg) at most).</div><div><br /></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiswF7Zuz7Df-ScoEZM8qOeUOkhEBmIFzCGPtSIbyynxL_03Nc7r1gSFY4vOZSHdd10m2aRlAERf0D6oT0hlX340RP2yT-DIZlBoOm-p2lXQoJSvd4MOywgbZWagx3kXwOn_agubE3q1iesKH2uYUbBO933OhAsZ-23fNy2KeenI6fpgKEeP_IntEE4oZNq" style="margin-left: auto; margin-right: auto;"><img alt="" data-original-height="820" data-original-width="948" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEiswF7Zuz7Df-ScoEZM8qOeUOkhEBmIFzCGPtSIbyynxL_03Nc7r1gSFY4vOZSHdd10m2aRlAERf0D6oT0hlX340RP2yT-DIZlBoOm-p2lXQoJSvd4MOywgbZWagx3kXwOn_agubE3q1iesKH2uYUbBO933OhAsZ-23fNy2KeenI6fpgKEeP_IntEE4oZNq" width="277" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><a href="https://books.google.com/books?hl=en&lr=&id=RHE3eVSSomUC">Source</a></td></tr></tbody></table><br />A lot of work has been done developing (<a href="http://www.cohp.org/ak/notes/pressure_altitude_v6.html">for example</a>) mathematical models for the interaction of temperature, latitude, and altitude to determine the difference between physical height and pressure height of a variety of summits. This work builds upon experimental data that has confirmed similar effects. In general the further away a peak is from the equator the more dramatic the difference between physical and pressure heights will be; though, these effects rarely lead to a difference of more than 200-300m to; moreover, since the great ranges mostly lie near the equator this effect usually serves to lower a summit (in pressure terms) rather than raise it. Denali is the big exception with winter conditions generally making the summit ~600m taller in pressure height vs physical height. I'm not aware of any data for Mount Vinson (<a href="https://8kpeak.com/pages/altitude-real-feel">calculations exist</a> -- though these particular ones use the standard atmosphere rather than the model atmosphere) or other more polar peaks, but I'm also not aware of winter ascents of those peaks.</div><div><br /></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhoMqV5mhJK4q0Fr2lvsxBfYWiko8cfj_Bsx8LJMCN8xR1MCMCDWW6OlHxGf46AyzNnmmglpCg-VGB1Dn-oPhCwQKejMBaAt6r5Lb1ljauu7pYv1VAFpE-lCGleMmNSvj0w4Qfp6uT1zZ987N_sT22ZQ2NLVww_Mc3jakeQuBNOPh9FcrYA79N1KKQQBIGe" style="margin-left: auto; margin-right: auto;"><img alt="" data-original-height="474" data-original-width="600" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEhoMqV5mhJK4q0Fr2lvsxBfYWiko8cfj_Bsx8LJMCN8xR1MCMCDWW6OlHxGf46AyzNnmmglpCg-VGB1Dn-oPhCwQKejMBaAt6r5Lb1ljauu7pYv1VAFpE-lCGleMmNSvj0w4Qfp6uT1zZ987N_sT22ZQ2NLVww_Mc3jakeQuBNOPh9FcrYA79N1KKQQBIGe" width="304" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Physical altitude vs pressure altitude values calculated (from the standard atmosphere model) and extrapolated from distant temperature measurements. (<a href="https://8kpeak.com/pages/altitude-real-feel">Source</a>)</td></tr></tbody></table><br /></div><div><br /></div><div><b><i>Respiratory Physiology</i></b></div><div>Now we need to move on to how these pressure differences affect our respiratory physiology and why very small differences in barometric pressure can make such enormous differences to human physiology.</div><div><br /></div><div>Our breathing serves two purposes: 1) to move oxygen molecules from the atmosphere into our lungs (the alveoli within the lung is where gas exchange happens but mostly I will just use the term lung to refer to the part of the lung where gas exchange occurs) and 2) to move carbon dioxide molecules produced by our metabolism out into the atmosphere. Per the title of this article we're talking about oxygen physiology, but it turns out that carbon dioxide matters as well since there's a lot more of it in the air we breathe out than in the atmosphere and it takes up space, so it'll come up later.</div><div><br /></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjazhxb47nqatUFGvY-G8n4TVeY05G-mpt4KsqC3fbgCeOg0Ve9vxMLk0Isg7SBcgTM1qzFDZud9THHIU316uKO9UzkNF7_Hszq9z4WXh2FG7zpUoYJzNRN_D5-_Gfi5dTSF_Sk2fe63Vhl_ImMMhMnyQ8bAWtSA3jEkbkKMmkcgroyXWaOxJQrFmZLBIQn" style="margin-left: auto; margin-right: auto;"><img alt="" data-original-height="708" data-original-width="1043" height="217" src="https://blogger.googleusercontent.com/img/a/AVvXsEjazhxb47nqatUFGvY-G8n4TVeY05G-mpt4KsqC3fbgCeOg0Ve9vxMLk0Isg7SBcgTM1qzFDZud9THHIU316uKO9UzkNF7_Hszq9z4WXh2FG7zpUoYJzNRN_D5-_Gfi5dTSF_Sk2fe63Vhl_ImMMhMnyQ8bAWtSA3jEkbkKMmkcgroyXWaOxJQrFmZLBIQn" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Respiratory system overview (pressures in individuals at rest, at sea level and healthy).</td></tr></tbody></table><br /><div><b><i><br class="Apple-interchange-newline" />Oxygen Absorption and Carrying</i></b></div><div>The main way that our body gets and transports oxygen from the lung is by using hemoglobin which is an oxygen transporter molecule that lives within our red blood cells. Without hemoglobin we wouldn't be able to deliver enough oxygen to our brain or organs. There's even an equation that tells us how many mL of oxygen is in each dL of blood:</div><div>Arterial Oxygen Content = (1.34 x Hemoglobin x Percent Arterial Oxygen Saturation) + (Pressure of dissolved oxygen in arterial blood * 0.003)</div><div><br /></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjgTsIpRn53r2bzKcCy_ExiGXh9QLoGIL0v0qbzy7aQGfFTtYJB0v_E48ig6uA9ZmRmDr_njziC4naFMUK77zudBpe60G_Mhx2dLOwk06N6A2BUjgvri1JuKGan1mjkmhUg5unv1iTm_fWj3m8uYmZm031XM1MXFZjZibHbRFtEUdiuJ_615sA4dtoFE40_" style="margin-left: auto; margin-right: auto;"><img alt="" data-original-height="488" data-original-width="327" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEjgTsIpRn53r2bzKcCy_ExiGXh9QLoGIL0v0qbzy7aQGfFTtYJB0v_E48ig6uA9ZmRmDr_njziC4naFMUK77zudBpe60G_Mhx2dLOwk06N6A2BUjgvri1JuKGan1mjkmhUg5unv1iTm_fWj3m8uYmZm031XM1MXFZjZibHbRFtEUdiuJ_615sA4dtoFE40_" width="161" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Note that almost all oxygen is carried on hemoglobin molecules. (<a href="https://jps.biomedcentral.com/articles/10.1007/s12576-019-00678-5">source</a>)</td></tr></tbody></table></div><br />Whether or not hemoglobin molecules with carry or release oxygen molecules is determined (mainly) by the pressure of oxygen in your blood. This effect is not linear and very non-intuitive. Very small changes in oxygen pressure can make comparatively large changes in the amount of hemoglobin that is carrying oxygen. More on this later.</div><div><br /></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEg3b0eAbtoGkq0jbTCkdpSxTTiFuSY0py3w4Pnu7bcr_L1ihawyNP1ZBxvvFzW3tXGYucnREaMXEYBCNnWbv8git2dRKIu44Y1yPQSe3Xs1dw42ORxZeIzptQyiEBNgOr20G7GaVq1-GjznXQ5toIcguNnOQEY27eft7fTvQlQ-ArQSOZF43gT3peqzgvu4" style="margin-left: auto; margin-right: auto;"><img alt="" data-original-height="273" data-original-width="301" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEg3b0eAbtoGkq0jbTCkdpSxTTiFuSY0py3w4Pnu7bcr_L1ihawyNP1ZBxvvFzW3tXGYucnREaMXEYBCNnWbv8git2dRKIu44Y1yPQSe3Xs1dw42ORxZeIzptQyiEBNgOr20G7GaVq1-GjznXQ5toIcguNnOQEY27eft7fTvQlQ-ArQSOZF43gT3peqzgvu4" width="265" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Standard oxyhemoglobin dissociation curve under usual physiologic conditions.</td></tr></tbody></table><br />When we breathe our nose, mouth, throat, and trachea heat and saturate the air we breathe with water before it reaches our lungs. This is necessary because the tissue in our lungs is very fragile and cold, arid air is quite irritating to the body. It's a problem for people at altitude because of Dalton's law though -- all of that water vapor in the air displaces other gasses, including oxygen.</div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgdjVfLiWAAm7gMjADcSgK1hJl50PRpeUdEfehXu6JsUF7kifARzmVTLXFr1VrbrxE-0lgdKUUDP77H_yrwu35eDD_Hnv46dZoIUblVyFleMDbUIQte2-z_5Oi65HQgiDmBOejqb0fIfp9JkCqJ7S-vDkndF4Exm2BSf5gfTPJnUaI5iq3PaUQk5TDxNy79" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="509" data-original-width="578" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEgdjVfLiWAAm7gMjADcSgK1hJl50PRpeUdEfehXu6JsUF7kifARzmVTLXFr1VrbrxE-0lgdKUUDP77H_yrwu35eDD_Hnv46dZoIUblVyFleMDbUIQte2-z_5Oi65HQgiDmBOejqb0fIfp9JkCqJ7S-vDkndF4Exm2BSf5gfTPJnUaI5iq3PaUQk5TDxNy79" width="273" /></a></div><br /></div><div>Similar to the calculation we can do to determine how much oxygen is in someone's blood we can also calculate the amount of oxygen in a person's lung that is available for the body to absorb and use:</div><div>Oxygen pressure in the lung = [(Barometric Pressure - Water Vapor Pressure) * Oxygen %] - [Blood CO2 level / O2-CO2 exchange constant]</div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhVMlXt5P34PRCSrJKNdOm8aC1GC5kevTGOmo--v30ieDoLNGnV6UJt3CL2rW9RWsK5CCjxqNhuBkCOvVFmt1ivFKeARgXDvmcMmp9IJr9ItJ6uQSMDqCUQc0Mqf8O4YrrndkjzuBQU1KeNSmOAEmz1vLytFnO7dtr9pG55ilfyxSx-li722dl1JhxPlx60" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="845" data-original-width="1520" height="178" src="https://blogger.googleusercontent.com/img/a/AVvXsEhVMlXt5P34PRCSrJKNdOm8aC1GC5kevTGOmo--v30ieDoLNGnV6UJt3CL2rW9RWsK5CCjxqNhuBkCOvVFmt1ivFKeARgXDvmcMmp9IJr9ItJ6uQSMDqCUQc0Mqf8O4YrrndkjzuBQU1KeNSmOAEmz1vLytFnO7dtr9pG55ilfyxSx-li722dl1JhxPlx60" width="320" /></a></div><br /><br /></div><div>I promise that the important concepts in this equation are much more straightforward than the complexity of the equation would make it seem. Let's take the terms one at a time and combine them with things already laid out above to bring some important considerations forward.</div><div><br /></div><div>Before we move on to breaking down the components of the equation, we need to note that its output tells us the maximum amount of oxygen pressure inside the air sacs of our lung. For a variety of <a href="https://en.wikipedia.org/wiki/Alveolar%E2%80%93arterial_gradient">physics and physiology reasons</a> we cannot achieve arterial oxygen amounts that are equivalent; <i>there will always be at least a small decrement between this equations's output and our blood's oxygen pressure.</i></div><div><br /></div><div>Discussing the first half of the equation: the FiO2 is the same for everywhere on Earth (~21%). The atmospheric (aka barometric) pressure is what we've talked about at length above that will fluctuate with altitude, season, weather, time of day, and so forth. The water vapor pressure inside our lung will always be the same (47 mmHg) because we heat all our inspired air to our body temperature and fully saturate it with water, thus it represents a fixed loss of available atmospheric pressure. Looking at this equation it becomes clear why supplemental oxygen can make such a big difference when climbing at very high altitudes. Anything that moves the 21% number upward will result in a much larger amount of oxygen pressure within the lung (ie able to be absorbed into the blood stream).</div><div><br /></div><div>As to the second half of the equation we'll start with RQ. Conceptually RQ represents the ratio of carbon dioxide molecules we release to oxygen molecules that we absorb. For nearly all humans (though not infants) eating normal diets (including what people generally consume at high altitudes) it is generally approximated at 0.8 (a variety of studies using direct measurement of human subjects at pressures below 350 mmHg have found a mean value of 0.82). If you want further information Wikipedia's <a href="https://en.wikipedia.org/wiki/Respiratory_exchange_ratio">explanation</a> is sound.</div><div><br /></div><div><b><i>Carbon Dioxide (ie Ventilation)</i></b></div><div>A language note before we dive in: the process of moving oxygen into our body is referred to by physiologists as oxygenation which is simple enough; but the process of getting rid of carbon dioxide from our body is referred to as ventilation. Thus when we someone is discussed as <i>hyperventilating</i> it means they are breathing their carbon dioxide levels down below normal; someone who is <i>hypoventilating</i> is allowing their carbon dioxide levels to accumulate or rise beyond where the body wants them to be.</div><div><br /></div><div>As mentioned conceptually and now mathematically, the amount of carbon dioxide in our blood (and subsequently in our exhaled breath) takes up space that could otherwise be occupied by oxygen. Our body regulates its carbon dioxide pressure within a very narrow range (the normal pressure of CO2 in our arterial blood is 40 mmHg +/- 5) because it is tied to many aspects of our physiology such as: the blood pressure within our lungs, the amount of blood flow to our brain, and the ability of muscles to contract and relax normally are all intricately linked to our carbon dioxide concentration directly or indirectly.</div><div><br /></div><div>As a brief aside, carbon dioxide is the reason you cannot hold your breath very long. At sea level most healthy adults can go 4-6 minutes without breathing before their oxygen levels (measured by hemoglobin saturation) will start to fall, yet most people can only hold their breath for 1-2 minutes. The reason for this is the build up of carbon dioxide which directly stimulates our brain to start breathing. In fact, if one holds their breath long enough, through the excruciating discomfort, the brainstem will force the diaphragm to start contracting despite a person willing it not to.</div><div><br /></div><div>Perhaps obvious, but worth stating clearly: as holding our breath causes carbon dioxide to accumulate, breathing more rapidly (or more deeply, or both) causes our carbon dioxide level to decrease from normal. If you do this long enough a variety of things related to the physiological connections I mentioned above will start to occur (you'll feel tingly, your fingers and toes may spasm, you'll get a headache, you might get nauseous).</div><div><br /></div><div>I've avoided doing math as much as I can in this article (despite the presence of many equations), but working through the alveolar gas equation will illustrate the importance of carbon dioxide at extreme altitudes in a way that words cannot (recall that the result of these calculations is the oxygen pressure available to our body):</div><div><br /></div><div>The alveolar gas equation at sea level (all pressures in mmHg): <br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://latex.codecogs.com/gif.image?\dpi{110}.21(760-47)-(40/0.8)=100" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="19" data-original-width="240" height="19" src="https://latex.codecogs.com/gif.image?\dpi{110}.21(760-47)-(40/0.8)=100" width="240" /></a></div><br /><div><br /></div><div><br /></div><div>On the summit of Mt. Everest (8849 meters):</div><div class="separator" style="clear: both; text-align: center;"><a href="https://latex.codecogs.com/gif.image?\dpi{110}.21(253-47)-(40/0.8)=-7" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="19" data-original-width="236" height="19" src="https://latex.codecogs.com/gif.image?\dpi{110}.21(253-47)-(40/0.8)=-7" width="236" /></a></div><div><br /></div><div><br /></div><br /><div>On the summit of Mt. Rainier (4392 meters):</div><div class="separator" style="clear: both; text-align: center;"><a href="https://latex.codecogs.com/gif.image?\dpi{110}.21(440-47)-(40/0.8)=32.5" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="19" data-original-width="245" height="19" src="https://latex.codecogs.com/gif.image?\dpi{110}.21(440-47)-(40/0.8)=32.5" width="245" /></a></div><br /><div><br /></div><div><br /></div><div>Put another way: if humans do not hyperventilate on the summit of Mt. Everest, there cannot be any oxygen in their lungs (though this is sort of a paradox, since if there's no oxygen in their lung they'd be dead and they wouldn't be producing carbon dioxide…). Even on the summit of Mt. Rainier an oxygen pressure of 32.5 mmHg without hyperventilation would mean a climber has a hemoglobin saturation of only ~60% (see the oxyhemoglobin chart above)!</div><div><br /></div><div>Now that we've worked through the math we can talk about acclimatization, or to put it another way: how our body can fiddle with some things to overcome these unalterable constraints of physics.</div>Petulant Skeptichttp://www.blogger.com/profile/03681938271124472357noreply@blogger.com0tag:blogger.com,1999:blog-8064821594672055220.post-58853552991632783432011-11-14T12:09:00.001-07:002023-08-18T23:13:08.930-07:00The Vets Are Alright (The Rest of Us Are the Problem)<i>This post is cross posted over at the wonderful <a href="http://gunpowderandlead.wordpress.com/">Gunpowder & Lead</a> blog. They're the same post.</i><br />
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As I read through recent <a href="http://www.huffingtonpost.com/2011/11/11/ucla-operation-mend-military-veterans_n_1085252.html">stories</a> <a href="http://www.ksfy.com/story/16025658/wounded-veteran-and-wife-talk-about-making-strides">about</a> <a href="http://www.wired.com/dangerroom/2011/11/veterans-challenges/">military</a> <a href="http://www.stripes.com/war-torn-marriage-family-shattered-by-tbi-ptsd-picks-up-pieces-1.161273">veterans</a> one thing has crystallized for me: the relentless focus on injuries, PTSD, TBI and the soldier's and veteran's general distress.<br />
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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. <a href="http://www.thedailybeast.com/articles/2009/01/17/the-great-plane-crash-myth.html">That is to say</a>, we seem to live in a world where the afflictions of soldiers are covered in the media like airplane crashes, rather than car accidents:<blockquote>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.</blockquote>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.<br />
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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 <i>Washington Post</i> article, <a href="http://www.washingtonpost.com/wp-dyn/content/article/2010/10/01/AR2010100106339_pf.html">Traumatic brain injury leaves an often-invisible, life-altering wound</a>. 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?<br />
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In <a href="http://www.jstor.org/pss/1048170">a 1996 paper</a> Shanto Iyengar, the Chandler professor of Communication at Stanford University, examined how television news influenced viewers' attributions of responsibility for political issues and concluded:<blockquote>By reducing complex issues to the level of anecdotal cases, episodic framing leads viewers to attributions that shield society and government from responsibility. Confronted with a parade of news stories describing particular instances of national issues, viewers come to focus on the particular individuals or groups depicted in the news rather than historical, social, political, or other such structural factors.</blockquote>This relentless focus on anecdotal, emotional cases that have been stripped of their context is immensely damaging in two different, yet synergistic ways.<br />
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The first has to do with people's inability to accurately assess likelihood and frequency. As Jason Daly recently <a href="http://discovermagazine.com/2011/jul-aug/11-what-you-dont-know-can-kill-you/">wrote</a> in <i>Discover</i>:<blockquote>Even if a risk has an objectively measurable probability—like the chances of dying in a fire, which are 1 in 1,177—people will assess the risk subjectively […]. If you have been watching news coverage of wildfires in Texas nonstop, chances are you will assess the risk of dying in a fire higher than will someone who has been floating in a pool all day.</blockquote>The actual name for what Daly is writing about is the <a href="http://en.wikipedia.org/wiki/Availability_heuristic">availability heuristic</a> (though it is often referred to as the availability bias), which states simply that people tend to estimate prevalences and occurrences based on how easily they can bring an example to mind.<br />
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Which brings us to news stories like those I linked above, because of their focus on wounded and damaged veterans they make these depictions <i>available</i>. None of these pieces are a problem in and of themselves, but taken together they form our predominant characterization of returned veterans. Moreover, the particular way in which they disseminate this information tends towards the anecdotal and emotional. In a study of the same effect at work in the reporting of automobile accidents using newspaper reports from 1999-2002 Monica Rosales and Lorann Stallones <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2659876/">found</a>:<blockquote>Injury related events are more likely to be covered when they seem to be out of the ordinary, rare, or dramatic. This may lead to presenting such stories as isolated events (episodic), not as a public health concern. This type of reporting may provide the public with an inaccurate perception by overestimating infrequent causes of mortality and underestimating frequent causes.</blockquote>The second effect of our national obsession with wounded veterans is more subtle. As Ethan Watters <a href="http://www.nytimes.com/roomfordebate/2011/10/12/are-americans-more-prone-to-adhd/american-culture-and-adhd">recently wrote</a> in the New York <i>Times</i>, speaking of ADHD, rather than PTSD:<blockquote>What the history of psychiatry tells us is this: Mental illnesses are not spread evenly among populations over time but come and go as unique and deeply complicated combinations of culture and biology. Which symptoms we collectively see as legitimate determines how we individually express internal feelings and unease. Psychiatric historians suggest that every generation has a “symptom pool,” behaviors by which individuals can communicate their distress.</blockquote>While Watters was writing specifically about ADHD, his point applies equally well to PTSD. With so much of our culture shaped by a frenzied media, it's imperative that we recognize feedback loops like this. As the anecdotes become ever more heart wrenching we will only widen and deepen the pool of symptoms by which individuals may express their distress. Clinical psychologist Vaughan Bell recently found this interaction of cultural symptom pools and PTSD <a href="http://mindhacks.com/2011/09/30/swimming-in-the-tides-of-war/">writing</a> about PTSD among demobilized guerrillas in Colombia:<blockquote>While working on a project to rehabilitate ex-members of illegal armed groups, [Dr Ricardo de la Espriella] noticed a striking absence of post-traumatic stress disorder in his patients, despite them having experienced extreme violence both as combatants and civilians. Many had taken part in massacres and selective assassinations, and many had lost companions to equally brutal treatment. There were high levels of substance abuse, aggression and social problems, but virtually none showed signs of anxiety. Intrigued, de la Espriella decided to investigate more closely and carefully interviewed the ex-paramilitary patients again, using the Clinician Administered PTSD Scale, which asks specific and detailed questions about post-trauma symptoms. After this more detailed examination, more than half could be diagnosed with the disorder.<br />
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The reason for why none of these symptoms presented in day-to-day life seemed to lie in paramilitary subculture. While aggression and drug abuse are tolerated, anxiety is taboo to the point where members showing signs of anxiety can be killed by their compatriots for being ‘weak’. This brutal emotional environment shapes the men to neither show nor spontaneously report any form of fear or nervousness.</blockquote>The crucial point here is the feedback between wider cultural views and the individuals who suffer from psychiatric disorders. To be clear this feedback is not an issue of accepting or denying whether these disorders exist. As pointed out by both Dr. Richard McNally:<blockquote>PTSD is a real thing, without a doubt. But as a diagnosis, PTSD has become so flabby and overstretched, so much a part of the culture, that we are almost certainly mistaking other problems for PTSD and thus mistreating them.</blockquote>and Ethan Watters:<blockquote>The really mind-bending fact — the one that Americans can rarely seem to grasp — is that just because these disorders are culturally shaped does not make them necessarily less real.</blockquote>At a time <a href="http://www.washingtonpost.com/business/economy/veterans-unemployment-outpaces-civilian-rate/2011/10/04/gIQAlqLepL_story.html">when</a>, "Veterans who left military service in the past decade have an unemployment rate of 11.7 percent, well above the overall jobless rate of 9.1 percent" it's high time we begin asking ourselves uncomfortable questions about the dark side of our fixation with injured veterans and their struggles.<br />
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Greg Jaffe recently penned <a href="http://www.washingtonpost.com/world/national-security/troops-feel-more-pity-than-respect/2011/10/25/gIQANPbYLN_story.html">a piece</a> in the Washington <i>Post</i> with the headline, "Troops feel more pity than respect." In the <i>NYT</i> retired Army linguist Kristina Shevory <a href="http://opinionator.blogs.nytimes.com/2011/11/09/thoughts-of-a-peacetime-veteran/">wrote</a> of her peacetime service:<blockquote>[T]here’s a growing sense that I’m not a full veteran. I didn’t suffer hundreds of mortar attacks. I didn’t roll over an I.E.D. on patrol in a Humvee. I didn’t watch a buddy step on a land mine and turn into "pink mist."</blockquote>We have already reached a point in our cultural characterization of soldiers that <i>they</i> are beginning to profess their own discomfort and insecurity with it. Unfortunately, these views aren't the canary in the coal mine warning of impending trouble, they are the collapsed mine shaft.<br />
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With our relentless focus on emotionally titillating stories of soldiers and veterans who suffer tragedy, whether they are redeemed by the end or not, we perpetuate a binary view of soldiers: They are either the epitome of professionalism and sacrifice, or they are tragic and broken. Moreover each story serves to deepen the symptom pool, dragging distressed soldiers closer to calamity by forcing them deeper—towards more extreme behaviors—in order to communicate their anguish as the shallower depths become more anodyne.<br />
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These effects don't influence any individual's conscious views or judgements. There is no tipping point to this. It is the gradual accretion of dozens upon dozens of newspaper stories and nightly news segments which ever so gradually steer us toward an ever more dangerous simplification of the men and women who have, and do, wear our country's uniform.Petulant Skeptichttp://www.blogger.com/profile/03681938271124472357noreply@blogger.com1tag:blogger.com,1999:blog-8064821594672055220.post-25364995866706257572011-10-03T23:43:00.003-07:002023-08-18T23:15:30.241-07:00Misdirection by euphemismAs I watched the news a few weeks ago waiting to see if, and then when, the state of Georgia would execute Troy Davis—<a href="http://www.thenation.com/article/163522/killing-troy-davis">a man wrongly convicted at worst, or unjustly sentenced at best</a>—something about the images from outside the prison struck me: The innocuous and anodyne name of the prison, the Georgia Diagnostic and Classification Prison.<br />
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Naming the prison this way asserts that the public should know that this facility is where <i>diagnosing</i> and <i>classifying</i> 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?<br />
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George Orwell, in his <a href="http://georgeorwellnovels.com/essays/politics-and-the-english-language/">famous 1946 essay <i>Politics and the English Language</i></a> 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 <a href="http://en.wikipedia.org/wiki/United_States_Department_of_War">Departments of War</a> and <a href="http://en.wikipedia.org/wiki/United_States_Department_of_the_Navy">Navy</a> into the comparatively docile <a href="http://en.wikipedia.org/wiki/United_States_Department_of_Defense">Department of Defense</a>.<br />
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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.<br />
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Let's examine the word <i>diagnostic</i> closely (<i>classification</i>'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 <i>diagnose</i> 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."<br />
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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 <i>diagnosis</i> and <i>classification</i> are important, the more subtle endorsement is toward the medical usage. It is no accident that <i>diagnose</i>'s usage example invokes the medical profession.<br />
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This is just one particular example of the way language has come to serve the state in obfuscating its abrogation of social responsibility. At the same time that the state systematically offloads responsibility to the medical establishment, it imitates the language of medicine to blur the distinction. Whoa, that wasn't where you thought this essay was going eh? Let me explain.<br />
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Heather Kovich <a href="http://www.guernicamag.com/features/3074/kovich_9_15_11/">recently wrote</a> about her time as a Social Security disability examiner. There are two parallel federal programs that provide disability payments to people, Kovich explains:<br />
<blockquote>[Social Security Disability Income] SSDI, which allow[s] workers to collect their Social Security prior to age sixty-five if they became disabled. In 1974 the program added Supplemental Security Income, or SSI, which provided minimal payments to the disabled, including children, who had not contributed enough to Social Security to qualify for SSDI.</blockquote>How does the system determine who qualifies for this money? Kovich again:<br />
<blockquote>On the basis of a forty-minute interview and examination, I was supposed to determine how disabled an applicant or “claimant” was.</blockquote>One of the crucial distinctions between SSDI and SSI is its funding. SSDI is nothing more than the extension of Social Security benefits to people who are not yet sixty-five, but have accumulated 20 Social Security credits in the past ten years. Since SSI was specifically designed for people who were disabled but had not paid a "sufficient" amount in Social Security taxes it is funded through income taxes. Keep that in mind for later.<br />
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<a href="http://thelastpsychiatrist.com/2010/11/the_terrible_awful_truth_about_1.html">The Last Psychiatrist summed up the situation</a> this way:<br />
<blockquote>The rise of psychiatry [ed: <i>medicine</i>] parallels the rise of poverty in industrialized societies. The reason you see psychiatry in the U.S. but not in Sudan isn't because there's no money for it in Sudan, but because there is not enough money in the US to make some people feel like they're not in Sudan. It is the government's last resort to a social problem it may or may not have created, but has absolutely no other way of dealing with.</blockquote>To paraphrase: The government is no longer responsible for deciding who gets "disability" or not, instead doctors "decide". Moreover the system cloaks its caprice, whimsy, and financial limitations <i>with</i> medicine. Kovich explains (emphasis mine):<br />
<blockquote><b>With the arbitrary nature <i>of the medical determination</i></b>, getting approved for disability probably depends on persistence as much as anything. Most disability applications are initially denied, but many decisions get overturned later.</blockquote>Keep in mind Kovich is <i>an insider</i> here. She's seeing it from the other side of the curtain, and she <i>still</i> thinks that the system's arbitrariness is a flaw. This is because she has fallen prey to the same mistruth as <a href="http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/?pagination=false">Marcia Angell in the <i>NYRB</i></a> (a former editor of the <i>NEJM</i> who makes an astounding number of errors in the piece, but that's for another time). As Angell tells us right up front:<br />
<blockquote>The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007—from one in 184 Americans to one in seventy-six. For children, the rise is even more startling—a thirty-five-fold increase in the same two decades.</blockquote>Angell wants this to be evidence that psychiatry has run amok and must be reigned in. Let me explain why she is wrong, very clearly.<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeHGJjYjRghI4KtDk_NRJjaW1kvo2Jzkc7d9KJXVe6gX1JeaEwMzGVH2G83OQLPR6nt3wJ6zjfbswmA6nZC93-t9mYBBuQwTGa6OOhyphenhyphenw9VakC-MCFAxlsPapJoUiGVwEYLxTC-Xq66WgJG/s1600/TANF_outlays.gif" imageanchor="1" style=""><img border="0" height="229" width="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeHGJjYjRghI4KtDk_NRJjaW1kvo2Jzkc7d9KJXVe6gX1JeaEwMzGVH2G83OQLPR6nt3wJ6zjfbswmA6nZC93-t9mYBBuQwTGa6OOhyphenhyphenw9VakC-MCFAxlsPapJoUiGVwEYLxTC-Xq66WgJG/s320/TANF_outlays.gif" /></a><br />
Aid to Families with Dependent Children + Temporary Assistance for Needy Families<br />
(Welfare)</div><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjj7sESm6icKARxX5_3VPwwdqG45PFz808qi0BrFWNIMEdeFxooP63yyLrROM4gKja2xPIvWeukr-zZmK-0iGEawxcyFA1Np5Q-DYfs2gRzkr-q9rjZoyNjsuNmKFQiQoSor_3ZmIl96RVv/s1600/SSI_enrollment.gif" imageanchor="1" style=""><img border="0" height="217" width="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjj7sESm6icKARxX5_3VPwwdqG45PFz808qi0BrFWNIMEdeFxooP63yyLrROM4gKja2xPIvWeukr-zZmK-0iGEawxcyFA1Np5Q-DYfs2gRzkr-q9rjZoyNjsuNmKFQiQoSor_3ZmIl96RVv/s320/SSI_enrollment.gif" /></a><br />
Supplemental Security Income (SSI) Enrollees</div><br />
The point here is not that many people who used to be on welfare are now on SSI (though it is true). The point is that the system was designed in such a way that precisely this displacement happened. The electorate became intolerant of "welfare", which is a very different thing than being intolerant of, say, "just enough monetary redistribution to keep the poor from <a href="http://en.wikipedia.org/wiki/2011_England_riots">burning things down</a>". When the state realized that it was no longer able to fulfill its anti-riot mandate under the guise of alleviating poverty it added a layer of abstraction and went back to work. In this newer, better construction the state would not be responsible for deciding who gets its anti-riot dollars, doctors would. If you don't believe me, recall that SSI is paid for with income tax dollars; bonus question, what tax streams fund other more conventional welfare programs?<br />
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This is problematic because idiomatic associations like this (i.e. ones that invoke one referent as misdirection away from another) have effects on our behavior that we aren't even aware of. <a href="http://www.wired.com/wiredscience/2011/06/audio-excerpt-incognito/">For instance</a> (emphasis mine):<br />
<blockquote>When people go through marriage registries, they find that people are more likely to marry other people whose first name begins with the first letter of their own first name, so Alex and Amy, Joel and Jenny, Donny and Daisy, these kind of things. And if your name is Dennis or Denise you’re statistically more likely to become a dentist. This can be verified by looking in the dentist professional registries.<br />
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Also, people whose birthday is Feb. 2, are disproportionately more likely to move to cities with the number two in their name, like Twin Lakes, Wisconsin. And people born on 3/3 are statistically overrepresented in places like Three Forks, Montana, and so on.<br />
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Anyway, the point of all this is that it’s a crazy reason to choose a life mate or a city to live in or a profession, and <b>if you ask people about why they made these choices, that probably would not be included in their conscious narrative.</b></blockquote>Eagleman soft pedals it a bit by including "probably" in his statement, but the point is clear: We cannot help but be influenced by these unconscious associations. While Eagleman's examples of the influence these random associations have on our lives are innocuous, it is much less benign when state institutions purposefully manipulate and contort the language to misdirect the public's interpretation of it.<br />
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To bring this back around, what the state is doing when it labels its prisons as "Diagnostic and Classification" prisons or even "Correctional Institutions" is this same thing, on a more subtle scale. By appealing to actions and authorities other than "imprisonment" or "execution" the system is able to imply its own blamelessness. After all, a man executed at the Georgia Diagnostic and Classification Prison <i>must</i> have been diagnosed and classified as worthy of death, right?Petulant Skeptichttp://www.blogger.com/profile/03681938271124472357noreply@blogger.com0tag:blogger.com,1999:blog-8064821594672055220.post-26999203161405909832011-03-10T20:23:00.000-07:002023-08-18T23:15:00.532-07:00Hospitals are not like airports; patients are not like airplanesIn writing blog posts that are critical of other writing one of my goals is not to point to the specific flaws of any particular article. No one has time to discredit all of the specious and nonsensical things that get posted, even by reputable outlets, to the internet each day. One of the things I try, and you can <a href="mailto:petulantskeptic@gmail.com">let</a> <a href="http://www.twitter.com/petulantskeptic">me know</a> if I'm failing, is to point out some of the tricks used to manipulate and/or mislead readers.<br />
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Which brings me to the false dichotomies. For an excellent example there's <a href="http://www.washingtonmonthly.com/features/2011/1103.allen.html">this</a> piece in the Washington Monthly. You don't even have to read past the subhead to find the comparison:<blockquote>Last year there wasn’t a single fatal airline accident in the <i><b>developed world</b></i>. So why is the U.S. health care system still accidentally killing hundreds of thousands? The answer is a lack of transparency.</blockquote>I've added emphasis on a particularly important part here, and I'll get back to it in a bit.<br />
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Among the various passages in which Mr Allen compares medical care to to airport safety one stands out, although the others have similar problems:<blockquote>In no other realm—certainly not any as inherently dangerous as health care—do we accept the argument that meaningful comparisons of results are impossible just because those being compared face somewhat different circumstances. Some airports have shorter runways and are more congested than others; some have to deal with frequent snow or thunderstorms, nearby mountain ranges, or lakes and rivers that attract unusual numbers of flocking birds. No two are exactly the same. Yet we don’t therefore conclude that there is no point in comparing the safety record of one airport versus another, much less say that it is acceptable for a certain number of people to be routinely killed on approach or takeoff. We demand that all airports, and everyone else involved in aviation, do what it takes to get accidents to as close to zero as possible, and that they use reams of performance data to make that happen.</blockquote>The principle problem with this analogy is that pilots of <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhT8Sx3TKBZZ7aG4eQ72RQi72Il0dC8DM1mkuoMldDx1Kn5HwUGd5MXkRgV7bYAbVoYfb5Zw_Ocg6fgUodU3vqyRMuS3Qd_MZ6DxxqEwkTINgAymZQlNIa_0Wzb99dVCtu1N5ibomN5_HKO/s1600/The+Airbus+A380.jpeg">Airbus A380s</a> don't try to land at <a href="http://www.youtube.com/watch?v=uNFNFZq2BFY">Courchevel Airport</a>. Moreover, there are rigorous safety standards regarding airplanes; if your plane isn't deemed to be in good, safe condition you don't take off. Patients in hospitals do not come in with such preconditions; their problems come in varying severity, but equally important is their underlying condition. It's a lot easier to treat a healthy 26 year old for pneumonia that a 78 year old with morbid obesity. In point of fact, Mr Allen's data gathering prescription has been tried. Here's Atul Gawande <a href="http://www.newyorker.com/archive/2004/12/06/041206fa_fact?currentPage=all">reporting</a> on the attempt:<blockquote>For six years, from 1986 to 1992, the federal government released an annual report that came to be known as the Death List, which ranked all the hospitals in the country by their death rate for elderly and disabled patients on Medicare. The spread was alarmingly wide, and the Death List made headlines the first year it came out. But the rankings proved to be almost useless. Death among the elderly or disabled mostly has to do with how old or sick they are to begin with, and the statisticians could never quite work out how to apportion blame between nature and doctors. Volatility in the numbers was one sign of the trouble. Hospitals’ rankings varied widely from one year to the next based on a handful of random deaths. It was unclear what kind of changes would improve their performance (other than sending their sickest patients to other hospitals). Pretty soon the public simply ignored the rankings.</blockquote>An uncomfortable truth in medicine, one doctors never admit to patients, is that much of its practice is capricious. What saves one patient may quite easily kill another.<br />
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What makes this comparison so terribly <i><b>wrong</b></i> is that Mr Allen himself knows about these issues, he even prefaces the above excerpt by glibly brushing the issue aside, "But these are adjustments that can be made, and made all the more fairly and definitively the more data we have about just who is receiving what treatments and with what results." Not to put too fine a point on it, Mr Allen is simply wrong. In countless cases one patient will survive what killed dozens before, and vice versa. Medicine is not nearly as amenable to the types of statistical "adjustment" that Mr Allen prescribes, nor the industrial safety pushed by former treasury secretary, and gloated over by Mr Allen, Paul O'Neill.<br />
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Furthermore, let's recall the subhead where I added that emphasis. Mr Allen in this case is not in fact comparing health care to aviation safety, he is comparing health care to <i>records of</i> aviation safety. This is akin to oft-maligned practice in medical research of abandoning, or burying, studies that do not show desired results and pushing only those that do. In this case Mr Allen tells us that airline safety has been able to achieve remarkable increases by virtue of its openness and transparency. His evidence? The records gathered in an open and transparent system. Except that there are significant segments of aviation safety that are not included in his database of developed world incidents.<br />
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Worsening the dichotomy further is the nature of each practice. Malcolm Gladwell, in his book, <i>Outliers</i> detailed the conditions present in most plane crashes:<blockquote>In a typical crash, for example, the weather is poor— not terrible, necessarily, but bad enough that the pilot feels a little bit more stressed than usual. In an overwhelming number of crashes, the plane is behind schedule, so the pilots are hurrying. In 52 percent of crashes, the pilot at the time of the accident has been awake for twelve hours or more, meaning that he is tired and not thinking sharply. And 44 percent of the time, the two pilots have never flown together before, so they’re not comfortable with each other. Then the errors start—and it’s not just one error. The typical accident involves seven consecutive human errors. One of the pilots does something wrong that by itself is not a problem. Then one of them makes another error on top of that, which combined with the first error still does not amount to catastrophe. But then they make a third error on top of that, and then another and another and another and another, and it is the combination of all those errors that leads to disaster.</blockquote>While Mr Allen tells us that there is a database that tracks even when pilots make wrong turns on runways, he either isn't aware or omits that such an error, by itself, is not particularly likely to cause an adverse event. Contrariwise, in medicine single mistakes are often enough to cause an adverse event. In fact, Mr Allen mentions a checklist used to manage infections from central line placement. The five steps are all tantamount to ensuring that the central line is placed sterilely; the problem with sterility though, is that skipping any one of these steps likely to render the observation of the others moot.<br />
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Where <i>Outliers</i> conjectured that increases in aviation safety have been realized because of the industry's push to get junior flight officers to speak up, Mr Allen asserts that transparency is <i>the</i> reason that airline safety has improved:<blockquote>If the airline industry and its regulators had clung to the [calling average good enough], the average rate of airline fatalities would likely be little better than it was in the 1950s, when flying was at least three times as dangerous, on average, as it is today.</blockquote>What's notable about this, beyond its assertion of causality, is that it makes no sense. Imagine that we did not start keeping strict aviation safety records until the 1970s, but everything else remained the same. Would we now imagine that there were no safety improvements between 1950 and 1970? No. To be fair, Mr Allen does propose that we institutionalize a system allowing any team member to anonymously report errors and near misses; it is not, however, mentioned as responsible for the increase in aviation safety.<br />
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Beyond the problems with this dichotomy there are other issues in Mr Allen's reporting. Take his indictment of hospital infection rates in nursing home patients:<blockquote>[Some will say] that the reason their hospital has such high infection rates is that many of their patients come from nursing homes, where lethal bacteria are rampant. <i>(In the case of our investigation, I always pointed out that we were reporting the infections that their own employees had marked as not present at the time the patient arrived, meaning they were acquired in the hospital itself.)</i></blockquote>The caveat here, which I've italicized, is wholly inadequate. Sure, the intake nurse noted that particular <i>infections</i> weren't present in a patient upon intake. What Mr Allen surely knows, because he discussed it earlier in the piece, is that bacteria–even drug resistant strains–can be carried by asymptomatic patients. Here's how I know that he knows this:<blockquote>[A] commonsense method used throughout Europe to drive down the number of hospital-acquired MRSA infections: swab the noses of patients before they are admitted, and if they test positive for MRSA, isolate them from other patients.</blockquote>In medical parlance these patients are <i>carrying</i> MRSA, they are not <i>infected</i> with it. This is an important point because nursing homes, much like hospitals, result in many people becoming carriers of pathogens they were not before. As anyone who has ever had conjunctivitis in one eye and spread it to the other with their own fingers can tell you, infections can quite easily come from <i>you</i>.<br />
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This harkens back to my earlier point about how to collect information on these things that means something. If I have a patient who carries MRSA in his nares why should my hospital numbers reflect a <a href="http://en.wikipedia.org/wiki/Nosocomial_infection">nosocomial</a> case of MRSA infection simply because he picked his nose and then also picked at his sutures? While he may have acquired that infection <i>in</i> the hospital, he did not acquire it <i>because</i> of the hospital, or the medical care–excepting that it may be the reason for his sutures.<br />
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It is undeniably true that there are issues and substantial room for improvement. The aforementioned Atul Gawande even wrote a book stating a prescription plainly in its title, <i><a href="http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0312430000/">The Checklist Manifesto</a></i>. There is <a href="http://www.sciencebasedmedicine.org/?p=8540">plenty</a> of evidence that installing checklists does wonders in ameliorating many of the problems Mr Allen rightly raises. What is often missed on this issue–and other related topics–by non-health care professionals is the sheer capriciousness of a lot of medical practice. In large part this is due to the way that we culturally approach medicine; however, that does not make perpetuating the misunderstanding acceptable.Petulant Skeptichttp://www.blogger.com/profile/03681938271124472357noreply@blogger.com0tag:blogger.com,1999:blog-8064821594672055220.post-22950550186104285022011-02-14T10:52:00.003-07:002011-02-18T12:20:41.531-07:00How problems in WTUs are like drug interaction deathsMedical issues in the military seem to be getting a lot of press attention these days, so I feel it's important to take a look at the genesis of these problems, specifically <a href="http://www.nytimes.com/2011/02/13/us/13drugs.html?pagewanted=all">the polypharmacy issue</a> and <a href="http://www.pittsburghlive.com/x/pittsburghtrib/news/s_721598.html">the troubles with Warrior Transition Units</a> (WTUs). The policies leading to these problems have been well intentioned, yet there seems to be little thought or care for how and why they've gone so far astray, although there is plenty that they <i>have</i> gone astray.<br />
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Before delving into the issues I mentioned above, let's use a more well known example of these "second order effects." During the toughening of drug sentences in the late 1980s the Anti-Drug Abuse Act made prison sentences proportional to the <i>quantity</i> of illicit substance that a dealer was holding when arrested. The thinking behind such laws is straightforward: stiffer sentences for bigger time drug dealers. At first blush this sounds like a solid enforcement strategy; however, both <a href="http://college.holycross.edu/RePEc/eej/Archive/Volume32/V32N4P629_646.pdf">in theory</a> and <a href="http://www.esr.ie/vol41_4/02_davies.pdf">in practice</a> these laws had the unintended consequence of incentivizing dealers to hold smaller <i>quantities</i> while still being able to meet demand. Dealers responded to this by placing a new premium on purity. If they could sell their customers half the weight for the same price, they faced a lighter sentence if/when they were arrested. In this way drug laws that were designed to curtail large scale drug dealing had the perverse effect of increasing drug purity, which itself has many second order consequences (higher overdose rates, increased addiction potential, etc).<br />
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These negative results to well intentioned laws, policies, and practices are often overlooked but incredibly important. The much maligned WTUs serve as an excellent example of how a well intentioned (well designed, even) system can be victimized by other system-wide issues. Created in the wake of <a href="http://www.washingtonpost.com/wp-dyn/content/article/2007/02/17/AR2007021701172.html">the Walter Reed scandal</a> in 2007 they were intended to be units where soldiers could convalesce before returning to their units without the bureacracy of medical holding units. When the Pentagon initially set these units up they included policies for expediting the replacement of soldiers sent to WTUs. Here we need to pause and revisit the environment all of this was occurring in: it was arguably the lowest point in the public perception of the Iraq and Afghanistan operations and the Army was having trouble meeting its recruiting goals, so standards <a href="http://www.usatoday.com/news/nation/2007-08-12-recruit-education_N.htm">were slipping</a> somewhat.<br />
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To put these various pieces more concisely, you had an overstretched military, a burgeoning problem with un(der)-qualified soldiers, and a new program that allowed for the rapid replacement of a soldier if they could be medically dispatched to a WTU. Commanders planning for an upcoming deployment had few options for their truly problematic soldiers (along with their actually injured); they could begin proceedings to medically discharge a soldier (a bureaucratic nightmare that takes quite some time) or they could transfer them to a WTU and receive an able replacement in time for deployment. Thus commanders were acting in their own (and the mission's) best interests by filling the WTUs with their drug addicts and malingerers. The consequences of this are <a href="http://ricks.foreignpolicy.com/posts/2010/06/16/former_pentagon_personnel_official_the_warrior_units_are_holding_tanks_for_misfits">well</a> <a href="http://ricks.foreignpolicy.com/posts/2010/06/17/here_s_how_screwed_up_the_army_s_warrior_transition_units_are_genuinely_sick_soldie">documented</a>. WTUs became toxic environments ill-suited to actual recovery by soldiers who want to return their units. The situation got so bad that many Purple Heart recipients were <i>resentful</i> of being sent to WTUs.<br />
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News stories about this, detailing the <a href="http://www.pittsburghlive.com/x/pittsburghtrib/news/s_721603.html">troubles</a> and <a href="http://www.pittsburghlive.com/x/pittsburghtrib/news/s_721735.html">glimmers of hope</a> belie an understanding of the <i>systemic</i> causes, instead focusing solely on the first-order issues, those that are immediately attachable to the WTU itself. While it is absolutely true that the first-order problems need to be solved. For instance, the staffs of these units need to be adequate in numbers as well as training. More importantly (in my view) is that unless, and until, the time consuming (both in length and officer/NCO attention) process of discharging unfit soldiers is remedied any fix is temporary.<br />
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It must be made clear that if we attempt to fix the problem of commanders "dumping" malingerers into these units by changing WTU-centric policies it will merely punt the discharge problems to the future. The issue will lie dormant until another next well intentioned policy accidentally allows an end-run around the problem. The unfortunate collision of well-intention WTUs and the reality of medical discharges has shown an underlying, systemic problem that needs addressing.<br />
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The polypharmacy issue among soldiers is similar, except that the systemic problems it reveals are much wider and deeper. The reason there is a problem with polypharmacy among civilians and soldiers alike is the continued balkanization of medicine as a practice. To digress for a moment, in early 2008 the NIH began the Undiagnosed Diseases Program which does precisely what you would intuit from its name. It brings in patients from around the country who have had exhaustive medical workups and run into dead ends. These are not cases the family doctor couldn't handle, these are cases that no doctor in a metroplex could figure out. (As an aside, the program <a href="http://www.nytimes.com/2011/02/03/health/research/03disease.html">recently</a> "discovered" its first novel disease.) The <i>NYT Magazine</i> ran <a href="http://www.nytimes.com/2009/02/22/magazine/22Diseases-t.html?pagewanted=all">a piece</a> about the program back in 2009 about a woman there as one of their first patients. What has always stuck out from the piece is this passage:<blockquote>At least 16 specialists had traipsed past Stiers's bedside in the previous four days; almost all of them managed to carve out time for the spontaneous meeting. Not surprisingly, the dermatologist suggested a dermatologic diagnosis, Vogt-Koyanagi-Harada syndrome. The nephrologist, James Balow, still liked his kidney diagnoses. The rheumatologist didn't want to rule out Sjogren syndrome just yet. "Any other specialists around here who want to explain your own favorite organ?" [Dr.] Gahl asked with a little chuckle.</blockquote>Dr. Gahl's joke is not really a joke at all, it truly is the way that doctors are forced to think. A myriad of issues contribute to this, but to put it succinctly: there is simply too much information for doctors to know everything. As a relavent example, the variety of drugs has grown so large that medical students are taught the mechanisms for particular classes and within that class individual drugs are generally distinguished only by one or two characteristics unique to them. Obviously this is an organized way to teach the information, but it also serves to partition the drugs into discrete boxes that are only occasionally linked by interactions and contraindications.<br />
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Simultaneously doctors are taught that drugs treat discrete pathologies and older less-selective drugs are inferior, they're even referred to as "dirty." Indeed, aspirin, one of the most widely used drugs in the world, <a href="http://www.medicalprogresstoday.com/spotlight/spotlight_indarchive.php?id=1039">would not be approved</a> today. The combined effect of this is to teach and constantly reenforce the view that diseases and drugs are akin to bulls eyes on a firing range. Different bullets can be used for each target in order to fix each problem individually. The reality is more akin to the joints on a bridge truss. Individually targetting one or two may have no impact on the integrity of the bridge, but disrupting too many can be catastrophic.<br />
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Any efforts at solving the polypharmacy issue that do not acknowledge this underlying, structural issue are doomed to failure. Patients do not know enough to choose which drugs are important and doctors are trained to have tunnel vision regarding the pathology in their area and in front of them.<br />
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Often times these second order effects are unpredictable or paradoxical. That they occur should not dissuade us from attempting changes and fixes though. What we need to learn is the need for iterative change. After a new policy or procedure is implemented we must be attentive to what structural issues it reveals, not only in itself, but in the now augmented antecedent as well. Failing to recognize these problems results in makeshift solutions that merely postpone its reemergence. In the words of Mr. Henry, my 5<sup>th</sup> grade teacher, "There's always time to do it right the first time." In the case of more intractable problems, like the balkanization of medicine, often the acknowledgement of the problem in the first place is helpful in avoiding the attendant pitfalls.Petulant Skeptichttp://www.blogger.com/profile/03681938271124472357noreply@blogger.com0tag:blogger.com,1999:blog-8064821594672055220.post-31482554339057381512011-01-20T14:05:00.006-07:002023-08-18T23:13:56.905-07:00Breaking down the Army's suicide dataPart I: What does the data say?<br />
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There's a lot of grist to Wednesday's <a href="http://www.defense.gov/transcripts/transcript.aspx?transcriptid=4756">news briefing</a> with Gen. Chiarelli on the 2010 Army suicide statistics. As usual, everything I write is my own opinion, unvarnished.<br />
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Looking past the <a href="http://www.washingtonpost.com/wp-dyn/content/article/2011/01/19/AR2011011902969.html">headlines</a> telling you some suicides were up and some where down I want to point out an underemphasized point that Gen. Chiarelli made during his briefing:<br />
<blockquote>So the numbers [...] have really only focused on this group, both the Army Reserve and the Army National Guard, to collect this data for about five years.</blockquote><br />
<a name='more'></a>Here's my calculation of the suicide breakdown from the news briefing and what papers are reporting (I'd guess the numbers are correct +/- 2, but Gen. Stultz's numbers were "inaudible" in the transcript so I can't verify). These include both confirmed and suspected suicides. There were 343 overall Army surveillance suicides. Of those, 157 were active duty soldiers (17 of whom were US Army Reserve [USAR] or Army National Guard [ARNG]), 101 non-AD ARNG, 40 non-AD USAR.<br />
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First let's talk about the ARNG/USAR suicides. One important note that ties back to Gen. Chiarelli's quote above: there was no focus on data collection for the ARNG/USAR until 2005. Here's the data series for non-AD ARNG/USAR suicides going back to calendar year 2003: CY03: 16, CY04: 15, CY05: 29, CY06: 33, CY07: 61, CY08: 43, CY09: ~65<sup>1</sup>, CY10: 141. This leaves us with nearly a ten-fold increase in non-AD suicides over the past seven years.<br />
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It's impossible to separate how much of the increase is merely an artifact of the increased surveillence,<sup>2</sup> but some part of it is. Supporting this assertion is the data for active duty suicides which has trended upwards at a much steadier rate since 2004 (04 was slightly lower than 03). In any case, we cannot attribute all of this increase to the surveillence (indeed, nothing substantive has changed between 2009 and 2010 in this respect) so what can we figure out?<br />
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To begin with, there is a <a href="http://www.ncbi.nlm.nih.gov/pubmed/20088060">substantial delay</a> between returning from a deployment and the manifestation of psychiatric distress (PTSD, MDD, others)<sup>3</sup>. It's important to keep this in mind when judguing the success (or lack thereof) in the Army's ongoing efforts to treat these symptoms. Even with the draw down in Iraq increasing dwell times and lowering the operations tempo we cannot expect to see immediate reductions in suicide or associated conditions.<br />
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Also salient to this issue is a point Gen. Stultz brought up, "Less than half of [the soldiers who commited suicide] had deployed. It’s just what Ray said; it’s something else going on in their lives." In fact, looking at past years this isn't very strange. Among active duty suicides there has been a relatively consistent distribution between suicides that occur during deployment, post deployment, and in those with no deployment history. This leads me to a slightly different conclusion than Gen. Stultz and many media outlets: Increased suicidality may be a consequence not of any aspect of non-deployed military life, but instead an association with the demographic groups the Army draws from. An insightful column touching on this topic was <a href="http://ricks.foreignpolicy.com/posts/2010/12/08/you_can_go_strangle_yourself_with_that_yellow_ribbon">written</a> by a Marine who served four tours in Iraq. I'd urge you to read the whole thing, but it is worth quoting him at some length here:<br />
<blockquote>Prior to signing up, most of my friends asked themselves how they could pay for college growing up in the poorest class. What if you are not a great student or a superb athlete? You probably won't get that education through McDonald's and you definitely won't get it from the school or your minimum wages of your dual working parents. As we all know, it is almost impossible to get a job now without a good-looking diploma from a decently named school. And how do you get healthcare without a decent paying job?<br />
[...]<br />
More than three quarters of the men I served with didn't have any choices if they stuck around their hometowns. I am trying to make you remember what life was like at 17 or 18 and you didn't think there was a way out of the situation you were born into. Here is what I saw and was told: Some young men fled gang life in poor areas like Chicago, Redlands, Compton, San Bernardino, Watts or Portland (crimes they committed or crimes to be committed on them); some wanted US citizenship after having arrived from Latin America, Europe, or Africa; some fled religious and sexual persecution (yes there are gay marines and some are from Texas); some got off the isolated encampments known as Reservations; I had Marines escaping child abuse; some guys hated the farm life; and the mediocre athletes knew they didn't have the NFL talent now required to play at even the lowest junior university.<br />
[...]<br />
The Marines I know didn't have the luxury of thinking hard about other choices like Pat Tillman. In retrospect, most said they had no other choices.</blockquote><br />
We must acknowledge that some percentage of military members feel that they joined the military, at least in part, due to a lack of alternatives. More than merely belie the notion that our soldiers, sailors, airmen, and marines are all uncoerced volunteers this does a great deal to characterize the socioeconomic circumstances affecting large swaths of this country. Indeed, the USAR and ARNG advertising campaigns explicitly cite the money, training, and other benefits attendant to joining up.<br />
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The reason I bring this up is that there are many papers examining the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2698248/">relationship</a> of <a href="http://www.ncbi.nlm.nih.gov/pubmed/16420711">suicide</a> (<a href="http://www.ncbi.nlm.nih.gov/pubmed/19527162">and suicidality</a>) to <a href="http://www.ncbi.nlm.nih.gov/pubmed/16318657">socioeconomic</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/1496080">circumstance</a>. <a href="http://www.dcoe.health.mil/Content/navigation/documents/SPC2010/Jan13/1545-1715/Gahm%20Reger%20-%20Improvements%20in%20Suicide%20Surveillance%20-%20the%20DoD%20Suicide%20Event%20Report%20(DoDSER).pdf">Data</a> from the Department of Defense's Suicide Event Report found that the demographic traits most associated with suicide were (in suicides per 100k individuals):<br />
<blockquote><code>High school diploma/GED or less (29.1), AA degree or tech cert (25.1), HS grad (16.4), 4 year degree (9.8)<br />
Being divorced (27.6), Married (15.9), Never Married (15.2)<br />
Rank E1-E4 (20.1), Rank E5-E9 (14.8), Officer (10.2)<br />
Age < 25 (20.1), 40+ (15.7), 26-29 (13.7), 30-39 (12.1) White (17.4), Black (11.9)<br />
Regular (16.9), N. Guard (14.4)<sup>4</sup></code></blockquote>Putting all that together it becomes evident that the same risk factors one finds in society at large are mirrored in the increased suicide rates of ARNG/USAR members. It may be that when Gen. Carpenter said, "We are really [...] the canary in the mine shaft, especially for us in the National Guard because we recruit in local communities and we are a reflection of those communities" he was understating the case. This may seem like an easy conclusion to draw (and one I wasted a lot of words on), but it has been completely overlooked in nearly every discussion of these numbers I have read beyond the Gen. Carpenter quote above.<br />
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Leaving the discussion of ARNG/USAR soldiers without deployment who have committed suicide, I want to move on to those who <i>had</i> deployed. In a brief <a href="http://petulantskeptic.blogspot.com/2011/01/perniciously-blaming-low-morale-for.html">post</a> yesterday I asserted, "<i>Combat</i> causes PTSD," as it pertained to my point in that post it was true enough. As usual it's actually much more complicated, but I think it is useful to look seperately at those who commit suicide (or suffer PTSD, MDD, etc) after/during a deployment <i>ex</i> their never-deployed peers. This is a rudimentary way of examining whether there is something peculiar to the experience of deploying to war, and its attendant stresses, that changes occurrence rates, or if Army suicides merely occur at a similar rate to the general population because that's where they draw their members from.<br />
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Using Gen. Stultz's figure<sup>5</sup> of appoximately half ARNG/USAR suicides being among those who <i>had</i> deployed we get approximately 70 suicide victims among Gen. Chiarelli's 156 to 181,000 ARNG/USAR soldiers mobilized each year. Choosing the average (168.5k) leaves us with a suicide rate of <b>41 per 100,000 people</b>. Doing a similar calculation for the active duty Army (and using Gen Chiarelli's estimation of 2/3 of soldiers who commit suicide being deployed or having a history thereof) gives us 105 suicides out of 569,000 for a rate of <b>18 per 100,000 people</b>. Clearly something is going on here.<br />
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Unfortunately, I don't know what it is. I'm just a blogger though, so I can offer some conjecture and point to some questions that need to be asked in figuring out why their rate is nearly twice that of their regular Army peers. <a href="https://www.armywell-being.org/skins/WBLO/display.aspx?action=download_resource&mode=User&ModuleID=2a285ab0-5db1-4f36-9b91-f2263c973c32&ObjectID=a7a01e5b-9d1d-4a22-9e0a-668a2d6068c9&AllowSSL=true&IgnoreTimeOut=true">Demographically</a> nearly 13% more regular Army soldiers are married than either their ARNG or USAR peers. I can't find data that shows the number who are divorced, but there is a wealth of data showing that young single males are the most at risk group for suicide. Considering the regular Army's marriage "advantage" over ARNG/USAR is most pronounced among the enlisted ranks it stands to reason this has some effect. In a similar vein, unemployment has been associated with increased suicide rates, a stressor that afflicts ARNG/USAR soldiers but not regular Army soldiers; Gen. Carpenter brought this up int he context of the 81st Brigade, "[W]hen they came back, they had an unemployment rate of around 33 percent." There may yet be other demographic trends that could yield more insight.<br />
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Clearly there's no single explanation for the sky high suicide rate among ARNG/USAR soldiers who have deployed, it does seem reasonable that the various risk factors exist among them in a synergistic fashion though. They may not have regular contact with peers who share similar experiences, they may feel alienated as they reintegrate, the acceptability of help for psychological trauma preached in the regular Army is largely absent from public discourse, and help may not be as readily available to them as it is to those in the regular Army. We need to begin asking quesitons about ARNG/USAR soldiers' access to health care, support groups, and so on.<br />
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I realize this post may be unsatisfying as it raises more quesitons than it answers. However, I think it's very important to have a clear understanding of what this report (and past ones) do and do not say in advancing treatment of suicidal soldiers.<br />
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Check back in a few days for part II, wherein I will talk about some of the Army's recent inititives to not only help soldiers in acute mental distress, but avoid putting them there in the first place. In that post I will also talk about the suicide rate's plateau in 2010 (describing a -3% change as a decrease is overly generous), its history, and what we might expect in the future.<br />
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<sup>1</sup> For the life of me I can't find Army data for CY09, but everyone is reporting that CY10's 141 was nearly double, so I'll ball-park it at 65.<br />
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<sup>2</sup> It would be incredibly useful to compare ARNG/USAR suicide data to that of the general population (especially among those who had never deployed). Unfortunately it can't be done because of the very long lag time in population wide surveillance data. The CDC's most recent <a href="http://www.cdc.gov/ViolencePrevention/suicide/statistics/index.html">suicide data</a> is from 2007.<br />
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<sup>3</sup> Throughout this post I'm going discuss suicide specifically but also use indicators such as suicidality and psychiatric conditions (e.g. PTSD and MDD) when talking about the mental health of troops. As I have mentioned in other posts suicide itself is very rare (in the general population there are approximately 19 per 100,000 people annually) and by its vary nature makes retrospective causal assessment very difficult. There are very strong associations between the metrics I will use, but if you think I've erred please let me know in the comments or <a href="mailto:petulantskeptic@gmail.com">email me</a>.<br />
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<sup>4</sup> I suspect that this data is different because of its age (2008) as well as it being DoD wide.<br />
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<sup>5</sup> These figures are estimates, and pretty crude ones at that.Petulant Skeptichttp://www.blogger.com/profile/03681938271124472357noreply@blogger.com0