The Eye of the Tiger

"We probably thought he was a better guy than he is. I would probably need to apologize to her and hope she uses a driver next time instead of the three-iron.”

-Jesper Parnevik, who introduced Elin Nordegren and Tiger Woods.

I’m not a big golf fan…I really do prefer watching paint dry, because at least you can inhale the fumes…so I’ll admit that I was not following the Tiger Woods story with any great enthusiasm until the tabloids got hold of it. Perhaps my lack of interest is because I’m not a golfer. I’ve played golf twice in my life, which equals the number of times I’ve actually gotten the ball off the ground. One of the shots was beautiful, right down the fairway, the kind of thing you see on the PGA tour. The second one hit a tree. My brother is fond of reminding me that if I had only learned to play golf, I could have done something with my career. This may be true, but I’ll never know. I do know that the former Governor of Kansas and current Health and Human Services Secretary Kathleen Sebelius used to run a few miles every morning down by the Kansas River. As much as I have always liked and respected the Governor (and still do), if waking up at 5 AM to run when it’s a billion degrees below zero on the Kelvin scale means I might get a bigger cubicle, than I’m happy to stay at my level, thank you very much. (Okay, that’s a lie. For the Governor, I’d do it. But only because she’s given me at least thirty free pens at proclamation signings, a gift –giving bonus which prompted Secretary of State Ron Thornburgh to note that if you collect ten, you also get a toaster.)

It was never really a mystery what happened to Tiger. Folks who work in trauma put a lot of stake in describing the mechanism of injury. In essence, based on the visible evidence when paramedics arrive on scene, we can predict how and where injuries are most likely to occur. It’s our own little version of CSI. So when a Cadillac Escalade hits a fireplug just outside the driveway in a residential neighborhood, you already know that it can’t have been going too fast, and that damage to such a heavy vehicle is going to be minimal. You also know that when someone comes upon an accident, they usually run into the house to call 911 and not to grab a golf club in a heroic attempt at rescue. (There is actually an animation from a Chinese news broadcast that outlines the scenario at http://www.youtube.com/watch?v=jV85rD0gfqo.)

So I will make this one additional comment, and then I will leave Tiger alone, because I honestly do believe that he and his family deserve some privacy to work these issues out of the public view, and to determine exactly how much cash Elin will get to not walk out of the house. That being said:

You’re married to a former Captain of the Swedish Bikini Team. By all reports, she is sweet, kind, respectful, and devoted to you. She has borne you two lovely children. She has a twin sister (Ha!). Forgetting the ethical aspect for just a moment, you have no logical reason whatsoever to cheat.

(It may be an apocryphal story, but I’ve always liked what the actor Samuel L. Jackson was reported to think about carnal temptation. “I just ask myself if twenty minutes with this woman is worth half of all my stuff,” he said. “The answer is always no.”)

But if you’re going to cheat, shouldn’t you at least be trying to move on up in the process? (I call the The Jefferson Principle.) You’re the best in the world at what you do. You have a kazillion dollars. You can have any girl you want. But…and let’s be honest here…Rachel Uchitel looks like a caulk gun went nuts in her lips, and Jaimee Grubbs just looks, well, wrong (what in medical term we call an FLK, or “funny looking kid”, where you know something’s not right but you just can’t put your finger on it.) But if these visions are what you really want, you have other options. You can close your eyes, turn off the lights, or learn to start kissing a bulldog. They’ll do just about anything for peanut butter.

I think you can apply this same criticism to other famous miscreants. Rudy Giuliani dumped a perfectly attractive and accomplished Donna Hanover for the somewhat less glamorous Judith Nathan (“Not so much to look at, but she’s such a wonderful personality and good with children” says her mother.) Peter Cook (Christy Brinkley’s last husband), cheating on the Empress of Fishnet with the babysitter? Come on. Governor Elliot Spitzer? Downgrade. Senator John Ensign? Governor Mark Sanford? Senator David Vitter? Ditto, ditto, and ditto. Governor James McGreevy? Well, perhaps my own tastes in partners…namely, women…prevents me from seeing the charms of the latter, but even so he’s not Governor anymore.

(For the record, I believe this theory holds true for women as well. But I also think that women are actually smarter about following The Jefferson Principal then men. There’s a reason why silicon cupcakes bed and marry saggy older men, and why Jessica Hahn chose to sleep with Jim Bakker over the PTL mail carrier. And that’s’ why I’ve never quite understood these romances that pop up from time to time between female guards and male inmates. I understand that guys can portray themselves as something they’re not, maliciously luring good and trusting women into destructive relationships. But in these cases, the guy is in PRISON! I mean, what more of a sign do you want that something might go wrong?)

So if you’re going to have an affair, be sure to follow the model of George and Weezy as you do it. Because you’re going to need some kind of consolation when you lose half your stuff.

You Choose the Story!

On rare occasions, people I work with will actually admit to reading my blog. (I suppose they don’t suffer enough in my direct presence, and so they need to suffer some more at home. Maybe they’re all Catholic. I'll have to check). Recently, someone asked me why most of the things I write are about the negative side of ED life.

It’s a good question, and if you read what I’ve written over the last few months you might get the impression that everyone who comes to the ED is either a drug-addled alcoholic, an irresponsible systematic abuser of government-sponsored health care, or has a terrible condition about which we can do absolutely nothing. And there’s always an avaricious attorney hovering by the exit trying to drum up business.

The simple fact is that this isn’t even close to the truth. The vast majority of patients who drift through the ED are genuinely nice people, and most of the time you can either make them feel better and let them go home, facilitate their admission into the hospital if needed, or at least reassure them that despite their pain or illness, nothing major is going on today. Every now and then you might even save a life. It does happen, you know. And Security does a very good job of confining attorneys to the far corner of the parking lot.

But I think the reason the “dark side” predominates in my writing is simply because we find that the more unique the situation, and the farther it lies from our own daily lives, the more interesting it can be. It’s a variation of the old adage that Dog Bites Man is not news, but Man Bites Dog is.

I’ll try to prove this to you with a brief example. Here are the stories of two patients who both came in last week within about a half hour of each other. In both cases, I’ll try to stick with a Joe Friday, “Just the facts, ma’am,” approach, and leave out any subjective information as best I can. At the end, you decide which one you’d like to know more about.

Case One: A 27 year old black female came to the ED complaining of vaginal bleeding. She had a LEEP procedure done two weeks ago and was doing fine until she felt a gush of water from between her legs while shopping at Wal-Mart and realized she was bleeding. (The LEEP is done to treat cervical dysplasia, abnormal cells on the surface of the female cervix that might lead to cancer.) The bleeding started about an hour prior to her arrival in the ED.

On exam, there was a large amount of blood in the vagina, and with effort we were able clear out the blood clots and identify the site of bleeding on the lower edge of the cervix. (Most likely what had happened is that in the healing process some tissue had sloughed off a small artery, causing the bleed.) After speaking with the gynecologist on-call, we were advised to try to apply some Monsell’s Solution (a topical anticoagulant) to the cervix to see if that would solve the problem. Unfortunately, the patient continued to bleed, so we called in a physician who was able to anesthetize the cervix and suture closed the blood vessel. No further bleeding was noted, and the patient was able to go home without incident.

Case Two: A 55 year old white female was brought in by ambulance complaining of head and rib pain. She said she had been having a few drinks (“Four Crown Royals”) with her boyfriend. They were riding home on his motorcycle when she said something he didn’t like about a mutual friend of theirs. He elbowed her in the ribs as she was hanging onto the back of the motorcycle. At the next stoplight, she hopped off the bike, and got a passerby to take her home. On her arrival at the home, he slammed her against a glass door, hitting her head and knocking it off the hinges. She then hit him in the face with a frying pan. The police had been called, but left “without doing anything.” She both drank and smoked on a regular basis.

The patient has been in a violent situation for at least three years, and the same boyfriend had hit her twice before, on one occasion breaking her ribs. She still had him in the home because she “can’t afford to evict him.” She was willing to talk to our case management staff about domestic violence resources in the community. She said she had a friend who she could stay with that night for safety.

Her exam showed her to be tender over the left side of the head and the lower right ribs. Her x-rays were all negative. Her alcohol level was one and a half times the legal limit. We gave her IV fluids, thiamine, and multivitamins (part of the standard treatment package for patients with chronic alcohol use, a combination known as a “banana bag” or a “rally pack”), and allowed her to rest quietly in the ED.

We were making arrangements to call her friend to take her home when we were asked to hold her until the police could come to arrest her. Turns out that whacking someone with a frying pan turns you into something called a “primary aggressor.” “He was big,” said the officer, “but she got him good.”

Now you tell me which story, once we add all the subjective layers to it…the sights, sounds, stream-of-consciousness recollections, and pop culture references…is bound to be more interesting? The one where we actually solved a problem and did a very nice lady some real good, or the one with motorcycles, Crown Royal, cops, and a frying pan?

Your honor, the defense rests.

Gleanings

Over the past year I’ve tried very hard to dedicate myself to writing a novel. I make no pretenses of writing the Great American Novel, nor even the Great Florida Novel; and I’d probably be pushing it to even claim a try at the Greatest Novel Within My Zip-Plus-Four Code. I am so dedicated to this task that to date, I’ve got no pages whatsoever under wraps. I do, however, have lots of sticky notes scattered within the pockets of my lab coat and the front pocket of the backpack I take to work. These sticky notes are usually gifts of dug companies, emblazoned with logos for drugs I don’t recall and probably wouldn’t prescribe anyway because most are too expensive for our usual ED clientele. However, they are useful for jotting down writing ideas, which I have apparently done with aplomb over the last few months. And because I want this pile of gummed memorandi out of the house and into the great compost pile we know as the landfill, I have reviewed them for whatever gleanings of knowledge they contain. I have chosen to share these with you because many of them are funny, a few are pithy, and simply retyping these gives me a way to quickly cheat on a blog entry without having to burn any original thought. These selections are also the ones where I could actually read my own handwriting (I am a doctor, you know). So I offer these gleanings for your amusement:

Said by nursing staff to a particular obstinate physician: “They name streets after you. One Way.”

Gynecology nurse: “I’m the Queen of In-Between!”

Noted to angry patient demanding pain medications: “Here’s your requested 5 mg of shut the #$%* up.”

Patient who presented with difficulty swallowing, sore throat, and blood in his semen was considered to have Ron Jeremy Syndrome. (Note: if you don’t get it right away, don’t bother looking it up. Not worth your time.)

Nursing staff: “Just b---h slap me if I ever make the ED my primary point of care for constipation.

Emergency care is the one-night stand of medicine. It’s fun and satisfying, but it doesn’t last long.

Nurse: “I’m a professional mushroom. I stand in the dark and get fed s…t all day long.”

“AA is for quitters…and quitters never win.”

Psychiatric screener: “He’s Off The Wall, and not in the good Michael Jackson sort of way.”

Patient: “You have to give me a prescription for Percocet. I’ve got a (Florida Medicaid) Gold Card.”

Why is it that you cannot eat a Tootsie Roll without drooling? And why is it that we have no compunction eating a tootsie roll, fully recognizing that it looks like an overgrown rabbit dropping?

Nurse reading the newspaper: “I’m checking the obits to make sure it’s nobody we saw last week.”

There was a pop culture magazine on the desk with a picture of a pregnant celebrity on the front. The considerable joy of children aside, clinically pregnancy is a pathologic state. There are changes in hemodynamics, respiratory capacity, and a host of complications and problems unique to the gravid state. So if pathology is beautiful, why don’t we have pictures of tumors and skin lesions and mangled limbs on the cover?

ED Tech: “Let’s not order Chinese. Last time we had it I think I got Chicken Chow Meow. (Or Kung Pow Meow. Or Geneal Tso’s Meow.” ( Or, as the bumper stickers say, “I Love Cats. I Had Two for Breakfast,” and “Cat: The Other White Meat.”)

Parent: “My two-month-old can’t speak.” (Neither could mine when he was that age. Which reminds me, speaking of things that normally can't, of The Child’s favorite talking dog joke:

This 12-year old and his dog go into a restaraunt. The waiter says, "I`ll give you a banana split on the house if that dog can talk!" The kid agrees with this bet.

Waiter: What`s on top of a house?

Dog: "Roof!"

Waiter: How does sandpaper feel?

Dog: "Ruff!"

Waiter: Who was the greatest baseball player of all time?

Dog:"Ruth!"

The Waiter throws the kid and his dog out of the restaraunt with no banana split.

The dog looks at the boy and says, "Do you think I should have said Mantle?"

For the record, said joke was typed into blog by The Child)

Which, in turn reminds me of my favorite talking dog joke, openly stolen from the Bob and Tom Radio Show:

A guy sees an ad in the paper for a $10.00 talking dog. The guy is intrigued by this bargain, so he goes to the home of the dog's owner and asks if he really has a talking dog for sale. "Sure I do," says the owner. "He's out back."

The guy goes into the backyard and sees a dog. "Are you a talking dog?"

"Yep, that's me," says the dog.

The guy is flabbergasted. "You're really a talking dog! This is amazing! But how did you get here?"

The dog answers,"Well, it's kind of a long story. I started out getting trained as a K-9 and rescue dog, but I broke a paw sniffing out the injured on 9/11. Then I did some airport work for the DEA in Miami. Eventually the heat was too much...I've got all this fur, you know...so I moved up north and was a guide dog for the blind. I also had a chance to do some summer stock theater along the way...perhaps you've seen me in Annie?"

The guy runs to the dog's owner. "Of course I'll buy the dog!' he exclaims. "But why are you selling him in the first place?"

"Cuz he's a big fat liar," says the owner.

Nurse discussing toothache patient: “She has summer teeth. Summer there, and summer not.”

Physician Assistant: “Patient is here with back pain after a slip and fall. Guess what store it was in?” (Answer: Wal-Mart. Always Wal-Mart.)

Nurse regarding moaning teenage patient: “She has a case of the IBD’s. You know…I Be Dyin’.”

Patient: "Last time I was here, they lost me twice." (Where? In the broom closet?")

Nurse to physician: "How come your Johnson's levels are up?" (Johnson was a patient. I think.)

Patient: "If the protection fell off, can I get pregnant?" (Yes. Yesyeysyesyesyes. And she was.)

And finally, a note that working in the ED can restore your faith in romance. Just when you think you might be alone in this world, just a look about the ED. When you realize who can get pregnant, and who might have participated in the process…well, it makes you realize that there’s really someone for everybody.

(Please feel free to add your own ED gleanings as comments! Thanks!)

Writing Hurts

Writing the blog is sometimes very painful. It’s not because I don’t like to write, because I do. It’s not because it’s difficult, although I do agree with the fictional author in The Angel’s Game who notes that sometimes to write you just have to sit down, squeeze your brain, and see what comes out.

The writing is painful because I can’t tell you the stories I really want to tell.

The good stories, the real stories, the stories worth telling in medicine are not the ones I write for you. The ones you see are the easy ones. They are the stories with set beginnings and endings, stories with no harm and no foul. They are stories that live in a world of black and white, a world where things are both defined and definite, and where thought is not required but is nice work if you can get it.

That’s not the real world of emergency medicine, at least not where the good stuff lies. The world that’s interesting , challenging, where souls are searched, doubts are harbored, and sleep is lost is a world of grays where the edge of the knife is often unseen and days of sheer boredom are punctuated by moments of utter madness. It’s a world of maybes and possiblys, of probablys and I-don’t-think-so’s, a world where every step into the subjective morass we call humanity is haunted by thoughts of doing too much and what we might miss. It’s a world where things just happen, and whether you do or don’t do something about it seems to make no difference at all. It’s a world where people die for no explicable reason, and where people who should be dead, or need to be, aren’t.

The best medical writing in ages past dealt with these very issues. Especially in the days before effective therapy, physicians would write about the real practice of medicine, about comforting the hopeless, trying to make sense of suffering, standing alone against tidal waves of uncertainty, plunging into the unknown chasm between science and faith. But the reader trying to understand the practice of medicine in our times will find nothing but tales of difficult but successful cases, lots of thoughts on the business of medicine, and a slew of soulless technical reports.

The reason is that it’s just become too dangerous to put reality into words. We live in a society where everything is foreseen through hindsight, and where the mists of time do nothing but sharpen the view. We’ve done such a good job advertising medical advances that nothing less than perfection is accepted; if something happens, it must be someone’s fault. And while we may acknowledge that nature may have her whims, we still cast about for someone to blame for her damage. (I think ED folks have an inherent understanding of nature’s victories. We know that when it’s car versus tree, the tree always wins…even if it’s been turned into a telephone pole.)

So why can’t I write the stories I want to tell? It’s because I’m scared to do so. Terrified, in fact. If I tell you these stories, I have no way to know that someone won’t pick up on the tale and trace it back to a patient. Within medical culture, judgment calls are automatic reasons for criticism. Indeed, there’s a whole academic industry called the Morbidity and Mortality Conference in which physicians who have never actually seen the patient nor work in the same field roundly dissect the care provided by another doctor. There’s also the system of Peer Review, which seems much less concerned with improving care than finding someone to take the fall for failures of the health care system. And that’s not even talking about the medicolegal climate, where anything is fair game for a lawsuit and there’s always an expert to tell you you’re wrong. (I say this as someone who’s done expert witness case review). A clinical tale might be traced back to an actual incident, and what is intended as an expression of the real challenges of care becomes ammunition for an assault on my integrity and my livelihood.

So I probably will never be able to write the kind of stories I really want to, at least until the statue of limitations runs out and I’m truly retired for good with all my assets in trust. Until then, continue to enjoy the pieces of fluff I put out. You’ll never really know what you’re missing.

Gingerbread Breasts

I’ve never been able to agree with those who contend that health care should operate strictly along free market principles, and that allowing it to do so without government involvement or competition is the best way to promote health care reform. I don’t believe this because it’s never worked that way before, and the very nature of health care precludes it from operating as a free market entity.

The fact is that you can't look at health care as a marketplace subject to the same market forces as buying a home appliance. The key difference is that health care is accessed differently than other markets. For example, it’s your insurance plan that often dictates your choice of physician or hospital, not your informed consumerism. Your insurance plan may not be your choice, but the only one offered to you by your employer or the government. If your needs are urgent, your choices are often circumscribed by time, geography, and the need for specialty services. The vast majority of expenditures on your behalf go through a single gatekeeper (your personal physician) rather than an individual having free choice of costs, products, and options to review at their leisure. I don't know that I can support the idea of heath care operating as a pure free market system, not because there's anything wrong with the free market, but because health care cannot by its very essence operate in that way except in a very limited realm of choices and services. An employer choosing which health plan to offer employees can do so using free market principles; the employee's use of that policy cannot.

But health care can work as a free market for those procedures that are purely elective, like cosmetic plastic surgery. There was a time in medical school that I wanted to be a plastic surgeon. It was during my first year, when we were rotated through community hospitals for the purposes of getting acquainted with clinical medicine. (In reality, it was an excuse for the University to charge us a whole lot more money for the privilege of wearing a lab coat once a week and pretending you were something other than a rank freshman dissecting preserved cats in biology class.) By chance, I was taken in by Dr. Michael Hynes, a plastic surgeon in Kansas City. He would let me watch surgery and follow him during rounds, all heady stuff for a teenager.
I still remember the first surgery I ever got to scrub on. It was an amputation of the lower leg for persistent problems with circulation and non-healing wounds, and he had asked my friend Todd Gwin and I to assist. Our “help” had consisted on holding the leg down by the ankle while he worked some kind of surgical magic just above the knee. We were watching him, fascinated by what he was doing but not yet with enough knowledge to actually figure it out, when he quietly said, “Okay, take that leg and hand ot off to the nurse.”

Todd and I looked at each other in the space between our surgical masks and our scrub caps.

“Huh?”

“Yeah, take it off the table and put it on the cart behind you.”

What we hadn’t realized is that he had just detached the lower leg from the rest of the body. Looking at each other with disbelief and a trace of fear, we slowly started to lift the leg up and could not understand why the rest of the limb from the knee up didn’t come with it. We thought that maybe we had just not lifted it high enough, but not matter how many inches we took the leg above the table the rest of the body stubbornly refused to come along for the ride. And then we were holding this disembodied, waxy leg, now cool to the touch with it’s blood supply severed, looking at it with utter disbelief and in total ignorance of what we should do with it.

“Taking it away today would be good.” Dr. Hynes stayed bent over his work.

So as the rolling table was on my side, Todd shifted to weight of the leg to me. While nurse aides and other caretakers have a keen sense of what it feels like to lift the dead weight of an adult human body, most of us really have no idea. We pick up molded plastic bloodied limbs at the Halloween store to decorate our homes and think it’s something like the real thing. The truth is that the human body is heavy and awkward, that the sprawling limbs and floppy head defy all the rules for lifting weights as a consolidated compact mass. This is all a polite way of saying that I had no idea how much a human leg weighed, and I almost dropped it. By the time I had gotten it over to the cart, I recognized that I should have some kind of profound thought, but nothing came to me except a very clinical, “Whoa, that’s a leg.” Which, I suppose, is precisely the point.

Dr. Hynes was a great guy. While he may have done lots of cosmetic work, most of what I saw was reconstructives…facial fractures, skin flaps, rebuilding pieces and parts. I thought it was fascinating (still do), and that this was what I wanted to do for a living. That was, until I learned that in order to become a plastic surgeon I would have to voluntarily submit to five years of butt-whipping and genital-licking to be a top general surgery resident, and then try to weasel my way into two additional years of the same as a plastics fellow, and suddenly three years of shift-based, not-on-call Emergency Medicine residency seemed a much better deal. And while the ER has been a great ride, that’s still one career decision I regret.

But back to the free market, the glories of capitalism, and the shameless pursuit of ersatz perfection. The hospital where I work will be placing an advertisement in the November 30th issue of the Daytona Beach News-Journal. Entitled “Ten Procedures Specially Priced for the Holidays: ‘Tis the Season for a New You,” it pictures a gingerbread man complete with a list of elective plastic surgical procedures and prices, with arrows pointing to the relevant part of the pastry individual. A facelift is $4,000, and new nose is $2,800, and a mere $3,000 gets your ears pinned back to the sides of yur head. (Interestingly, the most common plastic surgical procedure performed on gingerbread people...dental dismemberment and decapitation, or biting off the arms, legs, and head…is actually not listed as an option, probably because it’s free.) The ad mentions that gift certificates for these procedures are great stocking stuffers, because there is nothing more your beloved wants than a gift that says there’s something fundamentally wrong with you and I’m willing to pay real money to make it go away.

(I showed the ad to a friend of mine who actually is a plastic surgeon. He looked at the picture, thoughtfully pulled down his glasses down over his nose, and with all professional seriousness noted, “$2,920 is pretty good for a couple of decent breasts.”)

It took little effort to think through the ramifications of this proposal. Take the breasts. The line from the printed price to the appropriate part of the gingerbread man pointed to a single red hot where the right breast would be. (Since the gingerbread man also had a bow tie, we’re still a little confused about the gingerbread gender.) So the first question to answer is if the price was for a single breast, because that’s what it pointed to, or for a set of two. And then we wondered what kind of breasts you got for $2,920. Saline or silicon? Paper or plastic? Mix and match?
What about size? Was that the full price to go from A to DD, four sizes up? If you only wanted to go up two sizes, say from a C to a DD, is it only have the price? And why was the price an odd number, like $2,920? If you spent the extra $80 and made it an even $3,000, did you get some kind of bonus item like an extra nipple?

(I don’t have any really good plastic surgery breast stories. The only one worth telling is the time I was out with friends, everyone got a little drunk, and one of our more generously endowed nurses decided it would be educational for us to see just how good a job her plastic surgeon had done on her breasts. So she flashed, and I looked, and the pathetic combination of age, alcohol, and clinical acumen in me meant that I actually was noticing the exemplary symmetry and the lack of obvious scarring rather than the intended humongous perkiness of the effort.)

I do think sales like these are a good idea, and not just because they help jump-start the local economy. I know that personally, when I was “on the market,” as it were, I could easily spend at least this much money in meals, movies, and jewelry just trying to get a good long look at a single set of breasts. Imagine spending the same amount of money, and then getting to own them? What a deal! That is, as long as they don’t run off with the undercarriage.

Flying Fish

The hospital where I work has been conducting a series of seminars designed to enhance the patient and family experience at our facility. The effort is motivated by several factors. One is certainly to support the hospital’s mission as a place of care and comfort for the community. However, because health care is now very much a business, there are other, less altruistic reasons for doing so. In a competitive marketplace, the facility where patients and families feel most comfortable has the opportunity to take more of the market share of work. And the federal government is compiling data regarding customer satisfaction with health care facilities through the Consumer Assessment of Healthcare Providers and Systems Hospital Survey (H-CAHPS). The stated goals for the survey are for public reporting to enhance the transparency of care and provide incentives for hospitals to improve their performance. But the unspoken bottom line is that at some point in the future, scores will be used to modify reimbursement patterns. This concern makes it key for facilities and their employees to understand the H-CAPHS system and align themselves in such a way as to insure that scores are as high as possible.

So last month off I went to my scheduled session at 0730 (it sounds more important in military time) after working a particularly nasty night shift. Fortified with two cups of hot tea, I found a place in the back of the room where I figured I could hide when the lights went down and the Sandman stopped by for his imminent a visit. I was careful to choose a spot beneath an air conditioning vent as well, for I’ve learned over time that the sound of air blowing through the ductwork can mask all but the most sonorous respirations.

(This meeting-sleeping parallel is not new to me. During medical school, the daily Noon Conference was held in a large amphitheater with raised tiers surrounding a central dais. Each tier featured a continuous desk with a lowered skirt that extended along the perimeter of the tier facing the speaker. Behind the desks were swivel chairs attached to the table legs. What this meant in practice was that when the theater was full…which it always was because 1) attendance was required and 2) attendance was required…is that you could lay down on the floor on the uppermost tier and take a nap completely blocked from view by anyone except the three people sitting in the chairs just above your head. I took full advantage of this fact every day for the two months of my annual internal medicine rotation. This skill was not unnoticed by my classmates, who awarded me the “Rip Van Winkle” Award three years in a row. To date, I am the only repeat winner in the history of the school.)

The first order of business was to fill out a name sticker with the one word that describes how you felt at that very moment. Being a generally truthful sort, I wrote TIRED in large capital letters. Turns out that was the wrong answer, and I earned a reproach from the trainers who oozed early-morning glee in a pathologically perky manner. (I’m still working out exactly which organ exudes glee.) It turns out that the correct answer was HAPPY or ENTHUSED or BLESSED, and if I had been thinking I could have applied these words equally well. I was indeed HAPPY to be off shift, and ENTHUSED to be going home, and BLESSED by the fact that case management workers exist to find nursing homes for patients in the middle of the night.

The centerpiece of the presentation was motivational video that I’ve seen several times before. It’s been making the corporate rounds, so perhaps you have too. It’s the one about workers at the Pike Place Fish Market in Seattle who make a cold, nasty job into something fun by laughing, joking, shouting, and flinging fish into the air. The point of the video is that you choose your attitude towards you job. In theory, this works well. In practice, however, it’s a bit more difficult to pull off. During one of my stints as a bureauocrat we decided we would enhance our workplace by tossing file cabinets as a teamwork game. Windows were broken, alarms went off, and the local police did not seem like we had made their job any more fun. (I think they just chose the wrong attitude, but given that law enforcement officers can singlehandedly ruin my car insurance rates they can choose any attitude they want and it’s perfectly okay with me, sir or ma’am.)

The group was then invited to talk about ways they can make work fun. I apparently was called on to proffer a suggestion, and I must have said something. The truth is that I was so tired I have no idea if I did or not. I recall watching the fish soar through the rainy skies of the Pacific Northwest, and then I was seeing a packet of crackers in front of me just before a red squeezey trinket careened off my head. It must have been a “carrot-and-stick” sort of thing.

Another party favor I got to take home was a pre-printed card to remind me that “Kindness is Contagious.” Having been indoctrinated throughout medical training that contagious things ought to best be stamped out as quickly as possible, I’m still working through this concept. I also received some notecards that I’m supposed to give to someone when I see them do something of particular value to the health care team. I’ve already pre-written a few, such as “Thanks for graciously cleaning up that bodily fluid spill last night. Lord knows I wasn’t gonna touch that,’ and “I appreciate your kind and considerate help in cold-cocking the patient who came at me with a stick.”

In the end, a good time was had by all, and I was able to go home and rest with my free package of snack crackers and the soft plastic squeezy thing which the Residential Cat promptly took apart. Tomorrow before my shift I’m going down to Hull’s Fish Market and getting three pounds of mullet. If throwing one big fish around is good for morale, imagine the effect of forty smaller ones. It’s a way to spread the joy even farther. Especially if I hide them in various places where they won’t be found for a few days. Just think of what that’ll do for morale!

Are We Keen on the Nicotine Vaccine?

From the Internet last week:

Nicotine Vaccine May Help Smokers Quit

The National Institute on Drug Abuse, a division of the National Institutes of Health, gave Nabi BioPharmaceuticals a $10 million grant to take its anti-nicotine vaccine, NicVAX, to clinical trials. Officials want to confirm its effectiveness, monitor side effects, compare it to commonly used treatments and collect information that will allow the drug treatment to be used safely…

NicVAX is designed to stimulate the immune system to create antibodies that latch onto nicotine molecules in a smoker's bloodstream, preventing nicotine from entering the brain. Trapped outside the brain, the too-large molecules of nicotine can’t trigger the addictive pleasure chemicals invoked by smoking tobacco. …

The results of initial trials on 1,000 patients has been promising and caused few side effects. Nabi BioPharmaceuticals reports that 35 percent of those given the vaccine have been able to remain smoke-free compared with only 10 percent of patients who received a placebo.

(Nicole Straff, AOL Health, November 13, 2009)

I’ve written previously on The Blog about the benefits of vaccinations, and about the need for patients to assume some degree of responsibility for their own health behaviors. So when I read the on-line notice as I sipped my early morning Dunkin’ Donuts Vanilla Chai (Note to Company: Why can’t I get any size larger than medium?), my interest was piqued. The idea of a vaccine for nicotine addiction, and the use of a quick technological fix to prevent the health effects of cigarette use, appealed to every public health bone in my body. (Admittedly, these moments are getting fewer and fewer as I get farther from that phase of my life. Yet every now and then one of these residual ossicles lodges in my throat and I have to resort to the Heimlich Maneuver of Public Concern to get it out.)

Pharmacologic therapy for addictions is not a new idea. There are lots of therapies out there to help manage acute overdoses of medications such as narcotics (Codeine, Lortab, and Percocet) and benzodiazepines (Valium and Ativan). There are also a host of treatments to help manage both narcotic and alcohol withdrawal symptoms, and specific pharmacologic regimens have been developed to provoke acute withdrawal in a supervised setting under sedation or anesthesia to speed up the detoxification process. (This is actually a pretty good business as well; an outfit in Michigan offers a one hour detox under anesthesia for only $6,700. The on-line brochure notes that operators are available 24 hours a day, 7 days a week. And of you order now, we’ll throw in the Showtime Rotisserie Oven and this amazing spiral slicer. Call today!)

Less common, however, are medications that are given on the front end to inhibit the addictive behavior. Many people are familiar with the fact that heroin addicts are often treated with methadone, an artificial analogue of the street drug prescribed by a physician. In theory this takes the addict off the street and facilitates a slow and gradual withdrawal; in reality, it substitutes one addictive drug for another, and while it does take folks off the street it puts them into the ED on nights and weekends when the Methadone Depot is closed. (True story: About three months ago I was working a night shift and the police brought in an empty shipping carton containing twelve one liter bottles of methadone elixir. But it’s not addictive, right?). There are implants that can provide some assistance by blocking the effect of opiates as well, but their long-term success in preventing recidivism is not yet established. And while certain antidepressants (Chantix) have been used to assist with smoking cessation, it’s uncertain whether their effect is really related to the antagonism of nicotine or on managing the mild situational depression that often accompanies attempts at lifestyle change.

There is also a medication out there to prevent alcohol abuse. It’s called disulfiram (Antabuse), and its use was quite the rage when I was in training. What it does is block the metabolism of alcohol so when a person taking the drug uses alcohol, there’s a buildup of acetaldehyde formaldehyde in their system. Acetaldehyde is the main ingredient of a hangover, and the patient who swigs a beer while on the drug has an immediate (5-10 minute) and quite potent hangover complete with sweating, shaking, flushing, nausea, violent retching, and a feeling of being generally unwell (I use that term because I’m not sure “crappy” is a word befitting medicine, and I can’t in good conscience refer to a bowel-product in a family publication.) Recall that the closely related formaldehyde is the stuff they use to pickle dead fish and fetal pigs in jars on the wall in high school biology, and you can figure that you probably don’t want any of that in you. Disulfiram isn’t used much anymore. The official reason is that there are so many products with alcohol in them (mouthwash, liquid medications, etc), that patients were inadvertently pushed into reactions, which was admittedly unfair to them. However, my own theory is that nobody takes it anymore because it stops alcoholics from drinking, and if I’m an alcoholic the last thing I’m going to do is take something that going to make me sick when I drink. In my experience, most alcoholics would like to have their hangover the old-fashioned way, so compliance with Antabuse is usually abysmal. Personally, I wish it would make a comeback, and specifically that they would develop an injectable form for use in the ED. I can’t help but think that if we could induce a violent hangover in some of our more chronic alcoholic patients rather than just letting them sleep it off, they might be more motivated for treatment.

(To be frank, there are other examples of punitive theory in which I fervently believe. For example, gonorrhea can be treated equally well with either a painful injection in the posterior or with a dose of oral medication. If you’re the one passing the disease around, or if you’re just being a jerk, guess which therapy you get?).

But there’s never been a vaccine that regulates behavior leading to long-term health problems. The concept is fascinating. By blocking the passage of nicotine through the blood-brain barrier, we stop the stimulation of nicotine receptors in the brain. If the receptors are blocked, there’s no pleasure from smoking. The idea opens the door to a world of possibilities. Can we do the same for the metabolic products of alcohol, preventing them from affecting the brain and blocking the pleasant feelings of Cap’n Jack? How about narcotics? A biochemical stimulant that produces obesity? Sound waves at the frequency of Glenn Beck’s voice?

Like most things, the idea of a vaccine against behavior is easier said than done. This use of technology also opens up an entire spectrum of ethical issues. Let’s say that we are, in fact, able to regulate behavior with vaccines. Do we want to? Is it right to do so? How do you give informed consent for behavioral change when the end result may be permanent? What does it do to the concepts of autonomy and free will? And as our knowledge of immunology and neurochemistry gets more specific, can we develop vaccines to block other behaviors not related to poor health? I don’t know that I’d go as far as to invoke George Orwell’s 1984, but it’s pretty easy to see where the argument is headed. Clinically, there’s a problem here as well. It’s entirely possible that a drug addict who got an anti-narcotic vaccine has a broken leg six months later. Even I’d be hard pressed to say that the patient should be denied the beneficial effects of pain medication simply because the vaccine is already “on board” and doing its stuff. (I think the people I work with would tell you I’m a relatively hard person to get narcotics from, but I do have my limits. My theory has always been if you break something, lose something, bleed somewhere, have cancer, or let me stick a sharpened piece of stainless steel somewhere into your body, you can have all the pain medication you want.)

There’s also a flip side to the coin. Vaccines designed for clinical purposes can be perceived as facilitating undesirable behavior. We’ve seen this with the advent of the Human Papilloma Virus (HPV) vaccine. Clinically, this is great thing. We know that cervical cancer is a leading killer of young women, and that cervical cancer is caused in large part by infection with HPV. HPV, in turn, is fairly ubiquitous in our society, so it makes sense to offer the HPV vaccine to all girls and young women in order to diminish their risk of cancer. While there are still some issues to work out…namely if there are long-term effects, and if boys who are carriers of HPV should get vaccinated as well…this is a wonderful innovation and the first in what we hope will be a virtual cornucopia of preventive immunotherapies for malignant disease.

How can something this good get tuned on its head? Well, HPV is contracted through sexual contact. And if we make unprotected sex safer, that might encourage more teenagers and unmarried people to have sex. That’s not right. And if that happens, there might be more abortions. That would also be wrong. Clinically, I would argue (and have done so) that while it’s true that there may be less risk of cervical cancer, there are still plenty of other reasons to discourage sex outside of a long-term monogamous relationship. Things like unwanted pregnancy, gonorrhea, syphilis, hepatitis, and AIDS come to mind. But you can see the politics at work here, can’t you?

In the long run, I suspect the story of the nicotine vaccine (at least the form currently in trials) will be a lot like the tale of the gastric banding procedure. The “fatpass” (official medical term) decreases the size of the stomach so less food can be taken in at each meal, therefore decreasing total caloric intake and inducing weight loss. That being said, I’ve seen hosts of patients who had the procedure and, after initially losing poundage in the triple digits, have put most of it right back on. This happens because their underlying issues with food and lifestyle cannot be solved with surgery, and so they learn to compensate for the procedure by eating the same volume of food, but eating smaller amounts more frequently. (One of my ED doc colleagues is a perfect example of this. The day after his gastric bypass, someone called to see how he was doing. He was eating a pan of brownies, but with the bypass he could only eat them only one at a time.)

The article described a success rate of 35% in getting patients to remain nicotine-free. Checking out the company’s web site, the trials have lasted only 6-12 months. And while a short-term return of 35% is surely better than nothing, it’s still only 35%. People who are successful with permanent weight loss after gastric bypass surgery are those who also change their diet, lifestyle, social circles, and self-perceptions. If the vaccine helps only a minority of smokers to quit, there must be a host of other reasons for tobacco use besides the nicotine kick. While the vaccine can be part of the solution…and if it passes clinical trials, I’ll be proud to be a cheerleader…it is a single piece of the puzzle which also includes higher prices on tobacco products, clean indoor air legislation, enforcement of underage tobacco purchases, expansion of smoking cessation programs, and public education. My fear is that in this technology-happy, quick-fix society, those strategies shown to have real impact on the health effects of tobacco use will be lost.