Great work, Dr. Charles

He discovers a medical cause of his patient's depression: hypercalcemia.

There exists a clever little rhyme in medicine to help students, and then doctors, remember the symptoms of high calcium levels: stones, bones, abdominal groans, and psychic moans. While it’s certainly not good poetry, it did help explain his condition.
“Stones” signify the higher prevalence of kidney stones. “Bones” refer to the leeching of calcium from the skeleton that causes osteoporosis. “Groans” describe the frequent complaint of belly pain. And finally “moans” hint at the common findings of depression, personality changes, and even temporary psychosis for those with high calcium levels.

My father struggled with hypercalcemia when he was dying of cancer. When his calcium levels were high, the difference in his mood and behavior was astonishing. When I see a patient with depression, I always wonder if there's an undiagnosed medical condition. Some other illnesses associated with depression: pancreatic cancer, heart disease, hypothyroidism, Parkinson's disease, stroke, and multiple sclerosis.

Update - An e-mailer responds:  "The very first neurologist that I saw when looking for a diagnosis told me, after running tests, that there was nothing wrong with me but stress and depression. When I asked her if stress and depression was doing 'all this' to my body should I see a psychiatrist, she said 'no, you just need to stop being a baby about being a new mother.'
Her letter to my primary reported it as 'post partum depression'.
Two years later, my drooping eye lids, double vision, shortness of breath, weak arms and legs were finally diagnosed as Myasthenia Gravis."
 

Guest-blogging at Kevin, MD

I was amazed to receive the e-mail: would I "cover" over at Kevin's blog for a few days? (Gulp.) I said, "Sure!" There were a few horrifying moments when I couldn't think of a post (c'mon, shrinkette, there's a vast amount of human behavior to talk about. We never have a shortage of material over here!) After discarding about a half-dozen items, I finally managed to get something posted. Let's see if I can really manage this!

Update: The Cheerful Oncologist is joining me (thank goodness!!). He's a marvelous writer. Thanks again, Dr. Kevin!

Update #2: "Wise and eloquent" - ??!!
I must re-read my blog, to see how he could get that impression.

Coping with illness

"Who are bad copers?" asks one of my most read (and most borrowed) handbooks. "(They) have more problems in coping with unusual, intense, and unexpected difficulties because of the following traits:

1. They tend to be excessive in self-expectation, rigid in outlook, inflexible in standards, and reluctant to compromise or to ask for help.

2. Their opinion of how should people should behave is narrow and absolute; they allow little room for tolerance.

3. Although prone to firm adherence to preconceptions, bad copers may show unexpected compliance or be suggestible on specious grounds, with little cause.

4. They are inclined to excessive denial and elaborate rationalization; in addition, they are unable to focus on salient problems.

5. Because they find it difficult to weigh feasible alternatives, bad copers tend to be more passive than usual and fail to initiate action on their own behalf.

6. Their rigidity occasionally lapses, and bad copers subject themselves to impulsive judgments or atypical behavior that fails to be effective."

So says Massachusetts General Hospital's "Handbook of General Hospital Psychiatry." I've run through this list so many times, with so many patients, that I can recite entire passages verbatim.

Every medical specialty refers patients to psychiatry. Often, the doc has worked mightily to help a patient cope with illness, and has reached an impasse. Psychiatrists become students of coping behavior. What's working, what isn't, and why?

Effective copers share some common traits. They aren't just people who have less to cope with (although sometimes I wonder about that):

1. They are optimistic about mastering problems and, despite setbacks, generally maintain a high level of morale.

2. They tend to be practical and emphasize immediate problems, issues, and obstacles that must be conquered before even visualizing a remote or ideal resolution.

3. They select from a wide range of potential strategies and tactics, and their policy is not to be at a loss for fallback methods. In this respect, they are resourceful.

4. They heed various possible outcomes and improve coping by being aware of consequences.

5. They are generally flexible and open to suggestions, but they do not give up the final say in decisions.

6. They are quite composed, although vigilant in avoiding emotional extremes that could impair judgment.

"These are collective tendencies; they seldom typify any specific individual except the heroic or the idealized. No one copes superlatively at all times, especially with problems that impose a risk and might well be overwhelming. Notably, however, effective copers seem able to choose the kind of situation in which they are most likely to prosper. In addition, effective copers often maintain enough confidence to feel resourceful enough to survive intact. Finally, it is our impression that those individuals who cope effectively do not pretend to have knowledge that they do not have; therefore they feel comfortable turning to experts they trust. The clinical relevance of these characterizations is the extent to which we can assess how patients cope by more accurately pinpointing which traits they seem to lack."

(pages 62-63, Massachusetts General Hospital Handbook of General Hospital Psychiatry by Theodore A. Stern, Gregory Fricchione, Ned H. Cassem (Editor), Michael S. Jellinek, Jerrold F. Rosenbaum. Chapter 7: Coping With Illness and Psychotherapy of the Medically Ill, by Steven C. Schlozman, MD, James E. Groves, MD, and Avery D. Weisman, MD.

"Computer Eye Strain"

At WebMD, a patient writes:

"Last month, as I was working on an extensive computer project, I literally stared at my screen for hours on end. After that I developed pains around my eyes. These pains are intermittent, and I see very minute flashes in the corner of my eyes. Is this severe eyestrain from my monitor or something more serious?"

Here's the ophthalmologist's response:

Computers represent the No. 1 source for workplace discomfort. (Ed.- really?) Much of it is preventable, as you have suggested.
Turn off lights adjacent to the monitor or behind the computer. Illumination from behind the operator works best.
The desktop should be 29 inches from the ground.
Adjust the monitor and/or chair height so that when looking straight at the monitor, your line of sight is directly at the top edge of the screen. This generates a slight downward gaze – most comfortable for long work periods.
Finally, the screen surface should be approximately 30 inches from your face so the intermediate portion of your trifocals focuses properly without requiring excess accommodation from you.
Ask your eye doctor if you would benefit from an eyeglass prescription specifically for the computerscreen working distance...

In other words, I'm doing everything wrong...
Ask Dr. Lloyd -- Computer Eye Strain

The nurses knew

"I have to share your wonder at nurses who know when someone is going to die," says one e-mailer, in response to my Hospiblogging post. "Both of my grandmothers died while in some sort of nursing care (hospital and nursing home), and the nurses were actually the ones who alerted us that the end was near.

"While we were there on vigil, I also noticed that we were not disturbed by hospital staff at all -- they were there if we needed to speak with them, but I was surprised at how "out of the way" they remained for my family.

"My father went to ask one of the nurses how she knew, and she said after a while you just start to notice the signs. I guess (and I'm not a medical expert so obviously I can't say for sure) there are often few medically identifiable signs in such cases in terms of plummeting blood pressure, heart rate, etc. - indeed as in the case of my first grandmother to pass, she was in congestive heart failure for days, and was still being treated until she "took a turn for the worse", as the nurse told us when she called.

"Anyway, it's fascinating perceptability of nurses to see subtler signs of trouble, indeed trouble that's really untreatable, and alerting family members while they still have time to make their peace."

The nurses knew. They shared that knowledge, with sensitivity. Here's one family member who noticed, and is grateful...

Gonzo Emergency Medicine

A tribute to Hunter S. Thompson, by The Cheerful Oncologist:

FEAR AND LOATHING IN THE E. R.
(written in the manner of one Raoul Duke)

Why am I here? Who is this woman in a giant muu-muu, standing before me squeezing what appears to be a copperhead snake in her hands? She spoke to me in some strange language - obviously disrespectful of the country that took her in after a long canoe trip across the oceans. I thought of screaming "Back! Get Back!" but suddenly sat bolt upright and remembered:

I am a doctor...on call in the emergency room of the world's greatest hospital. My shoes were smeared with thick crusts of vomit and blood, as were my pants, except I wasn't wearing any. I must find them, I thought. The lights above my head burned into my skull like the first kiss of the electric chair. I reached for my pistol to shoot at them, but it too was missing. My situation was rapidly deteriorating. I began to sweat like a champagne fountain at a coal miner's wedding.

She continued to bark at me as I stood up and surveyed the room. I had been working since six o'clock the previous evening, and felt like I had been stomped by buffaloes. I desperately wanted to claw my eyes out, but instead hunched over the desk, searching for a pack of cigarettes. What was it - 12 hours of pure massacre, or had I been trapped in this reptile pit for weeks? No one seemed to hear me as I asked for matches and a can of kerosene...

Catallarchy hosts the next Grand Rounds

Send your favorite medical posts here:

We will be the first non-medicine-devoted blog to host (though Jonathan Wilde and I are health care professionals), and know that many of our readers are not in health care. This is actually a good thing - we would like some of next weeks’ submissions to have an “outsiders” flavor. Either as patients, or just interested outside observers, what do people perceive as the real problems and the real strengths of our health care system, whether it be in the realm of delivery, policy, or science? If you have something you would like to submit, please email it to me at trentmcbride_gk8155 - at - yahoo.com by Monday (2/21) evening 8:00 EDT

Hospiblogging at Instapundit: the 5 AM weigh-in

Glenn Reynolds posts about his wife's medical ordeal, and wonders why hospitalization itself must be so arduous (interrupted sleep, bad food, etc.). I wonder how many nurses and doctors will e-mail a response. I think hospitalization has become more difficult for inpatients, for a host of reasons: staffing shortages, increased severity and complexity of illnesses and treatments, and the pressure for shorter hospital stays. Inpatient treatment has become much more focused and intensive, and the patients are feeling it. (Staff feel it, too!)

He asks why his wife must be awakened at 5:00 AM to be weighed. It makes no sense to him. Weight is one of the more critical parameters for a heart patient (if his wife's heart is having trouble, a weight change will send a signal. And all those IV fluids that have been going in...what if they decide not to come out? Sick hearts, lungs, and kidneys can make that happen. You'll see it in the weight.) It has to be measured at the same time daily, and the results entered in the computer in time for morning rounds. It will be assessed with other measures of heart function and fluid balance for the preceding 24 hours.

So, when to measure the weights for each of the 20 or 30 (I'm guessing) patients on that ward? Geena, the RN at Codeblog, can tell you: it must be close to the start of day shift, when docs make their assessments of the previous 24 hours. It can't happen during shift change (usually between 6 AM and 7:30 AM). It can't happen when patients are eating breakfast, or when nurses are passing morning meds. (Too much chaos, not enough staff.) After morning meds and breakfast, they'll measure a weight if they can get it. But by then, nurses are putting out one fire after another. Patients are leaving their rooms for tests and procedures. Docs will already be demanding those weights, which guide treatment decisions for the next 24 hours.

Hospitals look at the schedule and ask: when can we consistently get weights on our patients, and have the results when we need them? The time that worked for their system: night shift, 5 AM. Great for diligent, coordinated, non-negligent, quality care. But from the patient's perspective, it's a mindless, meaningless irritation.

Geena would likely also tell you: that 5 AM weigh-in is not just about weight. Staff are checking so many other things about Glenn's wife at that time: is she arousable (big trouble if she's not!), can she respond verbally, is she strong enough to get on the scale, is her gait steady, is she dizzy, is she short of breath? Sometimes staff enter the room with a scale, and find the patient on the floor, or in a medical crisis, or eloped, or (horrors) dead.

Geena can tell Instapundit all about it, I'm sure...

Addendum: I'm a big Geena fan, and a fan of nurses in general. My first job out of high school: nurse's aide, in a hospital. Yes, I did the 5 AM weigh-ins. I tried to be nice about it...

I remember being completely amazed by the nurses, who always knew when someone was going to die! How did they know?? I was 18 years old and didn't know anything about anything...particularly, I knew nothing about falling blood pressures and diminishing heart rates! But my awe of nurses has never left me.

"Mom, am I bipolar?"

Blondzila's son shocks her with a question. Based on her post (and some e-mails we exchanged), I think she handled it thoughtfully:

I asked him why, where was this question coming from? He explained that a boy he goes to school with, Chris, is bipolar. I asked if Chris takes medicine, and he didn't know. So I tried to explain the details of bipolar symptoms. And believe it or not, I struggled to put them into terms that would both satisfy him and protect myself. I was loathe to have him see me as damaged, just in case he found out that I too am bipolar.
So I hit on a solution. We googled "bipolar disorder questionnaire" and came up with a good one I've seen (and used) before at http://www.dbsalliance.org/.

She's referring to the website of the Depression and Bipolar Support Alliance. They provide a questionnaire that we sometimes use when we're exploring the diagnosis with adults. Making the diagnosis in children is complex and controversial; see here, here, and here.

We went through the questions carefully, and the questionnaire said that he did not appear to have the disorder. I then gave him a verbal example of manic pressured speech and he said "That's Chris."
We also went to another website: http://www.bpkids.org/. A statistic appeared there that a study had shown that 59% of adult bipolar patients believed that their symptoms had first appeared during adolescent or childhood. I did NOT read to him the statistics about the likelihood of the inheritable nature of the disorder. I am not going to allow him to label himself with something that may very well never be.
I'm writing this to you for two reasons:
1) My son had heard of a diagnosis and was wondering immediately if the same applied to him. Teens conform. But there's also a "cool" thing about being different. I'm wondering if there's an element to my son that was kind of hoping he was bipolar, so he could be set apart, be unique in a VERY unique way. When I explained to him about the negative thoughts, thoughts of self-harm beyond your control, I think he cooled to the idea. He asked me if I'd ever thought that way and I told him that I did as a teen (I wasn't going to tell him how frequent that happens to me now - he'd worry himself sick).
Teens are caught in a tension of wanting to strike out on their own and still needing the security of conformity. That can result in some very strange behaviour when seen through a parent's eyes. How many families are using the diagnosis as a straw to grasp, not to be cool, but to explain why their teen is no longer that nice young man they could take to church a few years ago? Doctor doctor, there's something wrong with my son! He never listens anymore and is depressed when I force him to stay in his room as punishment.
2) My son can also be pretty irritable. So I also believe he was looking at his mood changes in that direction and wondering if he did have BP...I reminded him that no matter why he was irritable sometimes, it is important for him to monitor that behaviour and not to place it on the shoulders of others. "It's not fair for you to treat other people badly because you have difficulty not getting irritated..."

Children and bipolar disorder

Thanks to the e-mailers who've forwarded this Washington Post story about the rise in pediatric bipolar diagnosis. I'm not a child psychiatrist, so I turn to colleagues for opinions about this. Most believe that too few mentally ill children are receiving psychiatric help of any kind, and that the incidence of pediatric bipolar disorder is still unknown; furthermore, that children who are diagnosed bipolar are among the most challenging patients in their practices. At the Washington Post online Discussion site, Dr. John McClellan shares his thoughts:

Jon McClellan, associate professor of psychiatry at the University of Washington, is dubious and thinks there may be a rush to diagnose kids as a result of bipolar disorder's status as a cultural phenomenon...

Washington, D.C.: I am a child psychologist and have been alarmed at the number coming into my office with the diagnosis of bipolar disorder who, in my opinion, really don't have it. It almost seems like a plot created by managed-care child psychiatrists to make a diagnosis that needs long-term treatment (so that they have ongoing clients and, therefore, make money). One local psychiatrist diagnoses almost every kid he sees with bipolar disorder (and, indeed, he has a very busy practice). The medications used to treat this disorder are poisoning with numerous side-effects and in-and-of themselves look like a disorder (i.e., the side effects). The real question is: Which came first, the diagnosis or the side-effects of the medications (that look like psychiatric disturbance)?

Jon McClellan: I think this is mostly the outcome of physicians trying to treat very complicated kids that do not fit neatly into existing diagnostic categories. It is easier to conceptualize problems as being a single thing, such as bipolar disorder, even if that turns out not to be true. I don't think this issue is the result of medication side effects, although obviously some kids get more activated on certain agents, making it even more complicated. The problem is that although medications offer potential easy solutions, but have not been well studied, nor are they necessarily addressing the underlieing issues involved.

_______________________

Arlington, Va.: Good afternoon -- I read the column on bipolar kids with interest -- while it appeared to show that many parents are grasping at the bipolar diagnosis as a reason for their childrens' misbehavior, the article did not show that, in fact, there are many valid diagnoses of children with bipolar disorder.

My son has been diagnosed with bipolar disorder since the age of 9. He has had true manic states (not just rages) with delusions and hallucinations. In addition, in his depressive state, he has been extremely suicidal.

I believe that writing a story in which both sides of the issue are not fully vetted does the reader great injustice --

While there may be controversy as to the latest "in" diagnosis, this type of article does not do service to the children who truly do suffer from this disorder nor to the parents of the children. Some parents may in fact be grabbing at the lastest fad diagnosis for their child, but there are those parents who struggle to help their child live as normal and productive a life as possible and unfortunately this article does them and their children no service.

Jon McClellan: Hello

Your points are well said. I certainly agree it is very important to identify the disorder when it is present, and initiate appropriate treatment. Part of the dilemma now is that the very definition of how the disorder is being used varies greatly across communities and providers. This is all enormously confusing and frustrating to families, who for the most part do not care as much about what to call it as they do about what to do to make it better.

_______________________

Woodbridge, Va.: I am tremendously frightened for the future of our society, when behavior problems are labeled as one disorder or another, and accountability is lost. Regardless of how real any perceived mental disorder appears to psychiatric practioners, the long-term effect on society as a whole will be a dysfunctional community. Clockwork Orange, perhaps?

Jon McClellan: I certainly hope not. Most clinicians are very well meaning, and trying to do what is best for the child and family. Part of the problem is that psychiatric illnesses are very complicated, we do not have biological markers to define disorders, so the field is vulnerable to subjective opinions about what is a disorder, and what is the best treatment for it. As science moves ahead, some of this will improve.
_______________________

Washington, D.C.: Dr. McClellan,

What do you believe to be the reason for the spike in diagnoses of bipolar illness in young people?

Jon McClellan: I believe the definition has changed. There is little debate that some young children have significant problems with controlling their moods and behavior, the issue is whether that is the same thing called bipolar disorder in adults. Its an important question, since calling it the same thing implies that the same medications work to treat the problems. Why this occurred is complicated, but probably in part because the categories often used to characterize problems in kids do not necessarily capture all the difficulties some kids have. Plus bipolar disorder has well defined treatments, so the diagnosis offers hope to providers and families.

_______________________

Alexandria, Va.: Not only has there been a rise in children diagnosed with Bipolar but also with ADHD. I'm not sure I understand why there has been an increase? Were these same behaviors not present 30 years ago and now are all of a sudden rearing its ugly head and if so, what type of environmental, social, emotional changes are causing such behavior? I believe the majority of the children are misdiagnosed and it is really just big pharmacutical businesses getting big bucks at the expense of our children.

Jon McClellan: This is a very good question, but complicated. In part I think our culture has changed about how we view mental illness, and in some ways the definition of what is normal has narrowed. Expectations for kids has increased. In a world dominated by technology and computers, being able to pay attention and focus is a much more necessary trait. Some of this shift is not necessarily bad. For example, it used to be more acceptable for kids to be physically aggressive, bullies were considered part of life, etc. What used to be "boys will be boys", in many ways is now recognized as a problem because of the impact such behaviors might have on others. However, that doesn't mean such behaviors are the same as having a mental illness.
I don't think this is an organized plot by the drug companies, yet they clearly benefit. Their marketing reflects what we want as a society; better moods, better sex, better social functioning, etc. The difference between treating an illness versus enhancing skills or quality of life has become blurry.

For more of this online discussion, see
"Kids and Bipolar Disorder." WaPo says they're trying to arrange an online chat with an opposing view. To be continued...

Antidepressants and suicide risk

"Adults taking popular antidepressants such as Prozac, Paxil and Zoloft are more than twice as likely to attempt suicide as patients given sugar pills, according to an analysis released Thursday of hundreds of clinical trials involving tens of thousands of patients." At the Washington Post website, epidemiologist Dean Fergusson answers questions about his analysis. Here are some excerpts:

washingtonpost.com: Dean Fergusson, welcome to washingtonpost.com. How does one balance the results of this analysis with the need certain individuals have for taking an antidepressant drug?

Dean Fergusson: That's a good question. Undoubtedly, these drugs bring benefit to many people with debilitating conditions. But, like any drug, it has its risks. And although the risks are rare these are commonly prescribed drugs which make it a public health issue. The study certainly does not conclude that people currently taking these drugs stop taking them. Instead we need to reinforce close monitoring for those who take them and make treating physicians aware of the uncommon risks.

Washington, D.C.: How does your study account for the idea that if someone is being treated for depression they might be pre-disposed to suicide in the first place? Is there a way to predict which patients might commit suicide while on these drugs? I have been taking an SSRI for depression and it's really helped me a lot. It did just what it was supposed to -- keeps me on an even keel and I am able to face the day better and am more willing to do the work of getting over my depression. So I'd hate to see these drugs get an even stronger stigma than they already have when so many people benefit from them.

Dean Fergusson: We evaluated published randomized controlled studies the control groups consisted of either placebo, tricyclic antidepressants, or other therapies (e.g. exercise, psychotherapy). The vast majority of studies excluded patients with suicidal thoughts when assessing eligibility for the trials. As for your last question, I agree, the risks need to be put in the right perspective and balanced with the benefits...
------------------------------
New York, N.Y.: Most reports of suicidal ideation on SSRI therapy have historically occurred in severely depressed patients who appear energized enough to make an attempt they were not capable of before therapy. Shouldn't these patients then be more intensely managed on SSRI therapy rather than the mild-to-moderates as you suggest.

Dean Fergusson: In our study we found consistent rates of increased odds of suicide attempts across three categories of patients: major depression, mild to moderate depression, and "other." The "other" category includes a host of different conditions such as panic disorder, anxiety disorders, sexual dysfuntion etc. This suggests that all patients be monitored by treating physicians.

New York, N.Y.: Why should this particular meta analysis be given more attention than the dozens of other reviews that have been undertaken in the U.S. and Europe, with different conclusions?

Don't these publications just increase the risk that fragile patients will independently terminate their therapy and become unprotected from suicidality at the rates we experienced before SSRIs?

Dean Fergusson: The difference is that our study includes many more patients and studies. When looking for uncommon risks, we need to evaluate many many patients. I believe the earlier meta-analyses found the same trend yet lacked "statistical" power to rule out chance. Our study presents the most extensive evidence to date, uses observations in published trials, and uses a conservative definition of suicide attempt (i.e the authors of the study had to report it as a suicide attempt). As for obseravtional studies assessing trends, they are prone to many biases.

As for your last question, the message should be strongly stated that patients do not stop therapy. However,if they have concerns, speak to their physician...
_______________________

Washington, D.C.: Are the SSRIs more likely to be associated with suicidal thoughts and actions than the older TCAs? And did any of the studies you looked at specifically screen the participants for suicidal thoughts or actions vs. waiting for spontaneous reports?

Dean Fergusson: We found no difference in suicide attempts between SSRIs and tricyclic agents. We did not evaluate suicidal ideation or thoughts. As for screening, the vast majority of studies did not enroll patients with suicidal thoughts or risk. In other words, they were not eligible for the study...

_______________________

Bethesda, Md.: Wouldn't those suffering from depression have a much higher rate of suicide whether they were on drugs or not? Isn't there also a HUGE amount of evidence that these drugs have helped many more people come out of depression and thus prevented many more suicides? Sorry to sound harsh, but this study sounds like bunk to me ...

Dean Fergusson: You raise a very good point. It is very hard to tease out the effects of the disease form the effects of the drug. Depression is linked to suicide and we tried to ascertain whether SSRIs were as well. To control for this, we only examined randomized controlled trials which are the most valid method for determining risk or benefit of a drug. When evaluating the best quality evidence, we found an increased risk in attempts on SSRIs compared to placebo across different types of patients (those with major depression, mild to moderate depression, and those with conditions other than depression). The effect was consistent across all groups...

_______________________

washingtonpost.com: The American Psychiatric Association says that drug-induced suicide fears are vastly exaggerated. Would you please comment.

Dean Fergusson: We need to keep in mind that the risk is small but the risk is shared by millions of people prescribed SSRIs. Thus, on an individual level, the risks are rare but across the population taking SSRIs this results in quite a few events. As for the results, we are confident in our conclusions. By no means is this definitive evidence. We need large randomized controlled trials with long follow-up periods to end the debate.

The second Skeptics Circle...

is now in session at Orac's Respectful Insolence:

Away from the revelry of the main bar, in a dark, wood-paneled meeting room in the back of an old tavern frequented by scholars and scientists, the smell of beer and hamburger mixed with the musty but odor of the old wood paneling as the gathered members of the Skeptics' Circle murmured among themselves. The air was ripe with anticipation, as St. Nate, Founder and President of the Skeptics' Circle approached a podium set up at one end of the long table around which everyone sat...

Finding another bicycle

At The Cancer Blog, Michelle Dellino is posting about her ovarian cancer:

"Does anyone have any suggestions on how they may have dealt with the mental and emotional strain of a recurrence while trying to maintain a “normal” daily life?"

My patients have similar questions, so I'm captivated by her post. Here's one comment:

I was pronounced terminal in Feb96.
FIrst I went into shock. Numbness.
Luckily as my disease progressed, pain movitated me to search for better Tx than I was being offered and I found some. Not cures but ways to exend things.
So how do I 'deal with it'.
- Look at the big picture.
[ A favorite ..
'The man asked God how much time he had left?
God answered " Time enough to make a difference." ]
- Help others.
I go to support groups and contribute to
my cancer internet help list..
- Daily prayer / mediation.
I go to Mass daily. I find it really helps to
pray with others.
- I work my disease and medical staff.
I spend hours a day getting smart on my disease.
While I don't expect to be as smart as my doctors,
I work hard to be smart enough to ask
good questions. And make sure the many who
provide medcial support all work on the same page,
in a a logical manner.
I try to make them all see the big picture. I make it
hard for them to only see / work my cancer.
... and more...

And how do their doctors cope? Here's the Cheerful Oncologist:

You don't hear much about this in the media and therefore, dear reader, perhaps you have concluded that the mood of doctors is calm and secure, but let me reassure any doubters out there:
The practice of medicine still is intellectually and emotionally grueling...

He lists his "nightmares" - the disappointments, the treatment failures. Then he adds:

Since I have not named this blog The Frightened Oncologist, you may ask "How do you reconcile these distressful aspects of practicing medicine with your chirpy title?"
Ha!
Ever heard of the term fortitude? "Strength of mind that enables a person to encounter danger or bear pain or adversity with courage."
That, my readers, is the secret - if you don't have fortitude, you won't last long in this profession. Fortitude is the power that allows an oncologist to extract himself from the wreckage of discouragement, find another bicycle, and begin again to pedal uphill toward the place where his responsiblity and his patients await.

Grand Rounds XXI

is up, at Sumer's Radiology Site. He has lightened the tone with cartoons, including one that will provoke controversy. The posts are excellent, so be sure to check it out!

Ranting at the psychiatrist

What's it like when a helpful med is no longer tolerated, because of a medical problem? For bipolar patients, the news can be agonizing. Blondzila at Sanity Optional shows us her frustration, fear, and turmoil:

I said well, if the valproic acid is causing my liver problems...

You interrupted: I doubt that it's the valproic acid.

Why?

Because it wouldn't cause your spleen to be enlarged as well.

WHAT!?

Your test results show moderate (technical word for spleen enlargement). That wouldn't be caused by the valproic acid. I've NEVER had a patient with those kind of results so I really don't think it's the Epival.

My head was immediately full of static. White noise. I couldn't think, I couldn't concentrate. DONT YOU UNDERSTAND? Do you NOT realize how people like me think? Do you NOT know that this kind of information, and dropped on my head in the manner you did, will make me obsess on it until it is all I'm thinking of, to the detriment of most other things including sleep?

So, you said. What do you want to do with your medication?

white noise
can't think

I don't know. You have to understand that I'm also starting a new job on March 1. I can't have myself be unstable. I need to be sure I'm on an even keel.

What do you want to do with your medication?

white noise white noise white noise

I turned my head to look out onto the dark street below and watched the snaking line of brake lights heading up the hill.

I'll tell you what my suggestion would be, you said. Let's cut the valproic acid in half (WHAT?!?!?!?) and see how you are.

white noise gets louder and panic drops in from the sky - meds in half means i'm gone

My leg starts jiggling up and down, my fingers tapping against my knee. Wind it up baby, you're winding me up. And somewhere I think you know it too, you dusky little leprachaun. You were pushing my buttons because I'm not fitting into your mould of a good compliant patient. My body isn't reacting to the medication the way all your others are and you don't like being wrong.

What do you want to do with your medication?

white noise STOP white noise
dammit I'm scared

The panic was getting worse but I knew I had to say something. I measured my words and tones carefully, like a conductor trying to slow down a runaway orchestra. I could feel the tears in my throat, backing up and up. I could feel myself vibrating inside like a tuning fork, ready to get up and sprint out of there.

Did I wince when I read this? Oh, yes I did. Very much. How many of my own patients have had the same thoughts, and kept silent?

Thank you, Blondzila. In my clinic, I'll be listening for the white noise...

My Vitamin O

She had tears in her eyes. "I can't afford my medications. I had to buy my Vitamin O."

Pardon me, what vitamin was that?

"Vitamin O. It's expensive but they say I need it so I can get enough oxygen."

Ah...do you have it with you? Can I see it?

"No, it's at home."

Who said you needed it?

"Some man. Or something in the mail. I don't remember."

We turned to the computer on my desk, and googled "Vitamin O."

"There, that's it." We read it together:

FTC Attacks "Stabilized Oxygen" Claims

Stephen Barrett, M.D.

Various products referred to as "stabilized" or "aerobic" oxygen," are being marketed with claims that they can cure disease by increasing oxygen delivery to the cells. Some claim that "oxygen deficiency" or "oxygen starvation" is an underlying cause of disease and has been increasing because the oxygen content of the earth's atmosphere has been decreasing and junk food does not contain enough oxygen [A, B, C, D]. These claims are absurd -- for several reasons.
• There is no reason to believe that the products actually deliver oxygen to the body. It is possible to use an electric current to add a tiny amount of oxygen to water, but to access it, a human would need gills.
• Even if they could, taking oxygen into the stomach through a liquid, pill, or food would not significantly raise the body's blood level of oxygen.
• Oxygen enters the bloodstream through the lungs. The body adapts to what it needs by changing its breathing rate.
• The oxygen content of air is not changing and remains constant at 21% regardless of the weather.
• If enough oxygen is available to sustain life, the body will extract what it needs from the air and deliver what is needed to the cells. Blood returning to the lungs contains surplus oxygen.
• "Oxygen deficiency" is not an underlying cause of disease.

Two-ounce bottles of "3%"or "5%" solutions cost about $20 per bottle. Earth Portals also markets a higher-priced "super-oxygenated solution at 25% . . . for serious competitive athletes and individuals looking to get the maximum oxygen into the blood stream." At least a dozen companies have marketed such products.

The FTC Reacts

On March 11, 1999, the Federal Trade Commission filed suit...The FTC says that the product appears to be nothing more than salt water.

The defendants had claimed that "Vitamin O," when taken orally, enriches the bloodstream with supplemental oxygen. The ads state that Vitamin O consists of "intact oxygen molecules in a liquid solution of distilled water, sodium chloride and trace materials."

And there, next to this link, were online ads for "Vitamin O."

She looked confused. "Don't I need oxygen in my blood?"

Tell you what, I said. We'll measure the oxygen in your blood, and see how you're doing.

"How much will it cost?"

Nothing. We'll check oximetry...this machine we have. You just might have enough oxygen already, you know? Maybe you don't need that vitamin. If you really need more oxygen, we'll get it for you, in an oxygen tank. Medicare should pay for that.

"Oh, thank you, thank you!"

(based on an encounter, which has been altered and fictionalized to protect confidentiality. See disclaimer in sidebar.)

The urge to eat crayons

John, from Washington State, sends this item from The Korea Herald:

"Dear Annie: I am a 35-year-old woman with four children, an advanced degree and no serious health problems, but I have compulsively and secretly been eating crayons for months. I don't mean chewing on a crayon here and there. I mean eating an entire 64-count box, and doing it several times a week. I can't stop, and I don't know why I'm doing this. I am too embarrassed to tell my doctor, because I know he'll think I am crazy. The box says the crayons are non-toxic, but I'm really eating a lot of them. And this is a really dumb question, but are they fattening? Why am I doing this? Am I crazy? Please help. -- Crayon Freak"

This comes via Dave Barry's Blog. There's a spirited discussion in the comment thread, including some dining tips ("The Red-Violet is excellent with herb butter and paprika").

The question, "Are they fattening?", suggests further issues to explore, but the advice columnist ventures a diagnosis of pica. Patients with pica eat "non-food substances." Here are DSM-4 criteria, and here's an article from eMedicine:

Pica is an eating disorder typically defined as the persistent eating of nonnutritive substances for a period of at least 1 month at an age in which this behavior is developmentally inappropriate (eg, >18-24 mo). The definition occasionally is broadened to include the mouthing of nonnutritive substances. Individuals presenting with pica have been reported to mouth and/or ingest a wide variety of nonfood substances, including, but not limited to, clay, dirt, sand, stones, pebbles, hair, feces, lead, laundry starch, vinyl gloves, plastic, pencil erasers, ice, fingernails, paper, paint chips, coal, chalk, wood, plaster, light bulbs, needles, string, and burnt matches.

Although pica is observed most frequently in children, it is the most common eating disorder seen in individuals with developmental disabilities. In some societies, pica is a culturally sanctioned practice and is not considered to be pathologic. Pica may be benign, or it may have life-threatening consequences.

I'm doubtful that the crayons will do much harm, but I would be asking a lot more questions, and not just about eating habits.

I'm more worried about this performance artist, who goes beyond the compulsive ingestion of crayons. She's eating a wall of an art gallery:

Five days a week, Ms. Katrencik consumes a section of wall 1.956 inches square and three sheets of drywall thick, for a total of about 8.5 cubic inches of drywall; she rests on Sundays and Mondays. Each meal takes about half an hour. She began on Jan. 1, to ensure that there would be a sizable hole before the (exhibit) opening on Jan. 28, and will keep it up until the exhibition closes on Feb. 27, at which time she calculates the hole will be large enough to stick your head through. She usually gnaws directly on the wall, working away at a sizable, eye-level hole, and avoids eating when the public is present. Video of her ingestion is included in the exhibition; she also removes some of the plaster and bakes it into loaves of bread, which are available for gallery visitors to sample. "Part of it is that I'm really broke," she said, "so this is a way to get the gallery to cover my food costs."

...So how is this diet affecting her health? "I try not to think about it," she said. "Instead, I look at the things in the wall that are good for me, like calcium and iron." One of the main components of drywall is calcium sulfite, she noted, a mineral that can be found in tofu, canned potatoes and some baked goods. She said that she had not had any digestive problems, but was careful to eat a lot of vegetables to balance the binding effect of the plaster. And the taste? "This drywall tastes pretty chalky," she said. "I prefer cast concrete because it has a more metallic flavor. You can taste the iron."

I'm wondering why the gallery is allowing this to occur...

The next Grand Rounds...

is at Sumer's Radiology Site.

Medical grand rounds on 15-2-05 on my site!!

Medical grandrounds will be posted on Sumer's Radiology Site on 15-2-2005 early morning. All medbloggers are invited to post their post at-sumerdoc-at-yahoo-dot-com...

All are cordially invited to this Carnival of the best in medical blogs!!

Skeptics' Circle update: posts wanted!

Orac at Respectful Insolence is hosting the next Skeptics' Circle:

It's hard to believe, but the second edition of The Skeptics' Circle is a mere six days away. It will appear on Thursday, February 17. St. Nate got the ball rolling last week with a fine collection of skeptical blogging. He set the bar high. With your help, I hope to continue the tradition.

...I'd like to have at least a dozen good skeptical posts to showcase. My thoughts on the sorts of posts I'd love to see are here, and St. Nate's original guidelines are here. So, this weekend, if you're a blogger and you've written something skeptical or demonstrating critical thinking skills about urban legends, the paranormal, quackery, creationism/intelligent design, psychic phenomena, or other topics worthy of applying Occam's razor and a skeptical eye to, please send it in. Send the URL/permalink to orac_usa at hotmail-dot-com. The deadline will be 9 PM EST on Wednesday, February 16. Late submissions will be considered at my discretion if I haven't finished putting the Circle together at the time they are received.

My favorite comment about the Circle: "Ah, but how do we know it's a circle?" (from Doing Things With Words.)

Liz Ditz, of I Speak Of Dreams, sends e-mail:

My goodness. Today seems to be "let's talk about depression day." I had lunch with a friend today. Two weeks ago a mutual friend committed suicide. This friend was a year older than I am (55) and was very much part of a net of love and respect. He was a good father and husband, a leader in his men's prayer group, and part of warm and loving family. His wife's brother had recovered from a hellacious alcohol and cocaine problem, 15 or 20 years ago, so the family circle was no stranger to pain and struggle and redemption. Despite this love and affection, the friend dove under a train in motion. The big question at lunch was "Why"? Why would you so hurt your family and friends? Why did he walk and walk down the railroad right-of-way that runs through this sleek, privileged Silicon Valley town, just to leap from leafy hiding into the noise and metal?

Into the noise, and metal, and annihilation. We're left to guess why. For clues, I turn back to my previous post, "I was just going to take all my medications."

Liz goes on:

In talking with non-psychiatrist physicians, I find a touching faith in the magic-bullet nature of medication.

(I love that sentence!)

But maybe they have to....protect themselves from a sense of loss. Here's an essay from a woman who left medicine for elementary school education:

Gone were the days when I could spend two hours getting to know a new patient as a person. The constraints put on me by insurance and government restrictions required that I see more in less time. Neurological diseases are often complex, unpredictable--and progressive. I needed time to explain the potential benefits and the limitations of medications, surgery or therapy. This time was no longer available. I had enjoyed collaborating with my patients, hearing their concerns, considering their unique situations. But those opportunities were fading, replaced by hurried answers and minimal collaboration.

(more at http://www.middleweb.com/INCASEdocteach.html_

I wonder if the kind of depression I seem to have (the first episode I clearly remember being in 3rd grade) will someday be viewed like other chronic conditions that wax and wane...

A clue for me that I am in an "more affected by depression" phase is an inability to initiate needed work. This plagued me in college, of course, and I didn't understand the mechanism, so berated myself for laziness and lack of discipline. I look at my 16 yo daughter now (who is very self-motivated) and wonder....if I hadn't felt so shamed by these episodes of, of, of, well it is like not being able to find the keys to your car, really, it is not procrastination but the inability to start. I wonder about finding a self-help group online for these episodes...

I e-mailed back: are you sure that you want this on my blog? Here's her reply:

Post away. No, really, do. People who have asthma don't get all tongue-tied when their disease acts up and they have to medicate or are otherwise affected. Nobody expects the asthmatics to get on without their inhalers...

I think if a society got more matter-of-fact about neurological malfunctions (which is what I regard my depression to be) maybe the shame and the hidden costs would be less. At any rate, I believe easier-to-find workarounds would be in place.

So I've posted away. Thank you, Liz. It's an honor to do so.

"I was just going to take all my medication"

At Albany Medical College's FP Student Blog, a med student meets a suicidal patient:

I had an odd feeling while interviewing a patient for a routine follow up on depression medicine. She told me that the meds were not even touching her depression - she had tried almost every medicine out there. Perhaps because of her visible hopelessness I asked her if she'd ever thought about hurting herself. She said she thought about it all the time. I asked her if she'd decided how she would do it. She said, "I was just going to take all of the medications I have" (she has a lot)...

Suicide is a larger problem than most people realize with a prevalence of 10-12 in 100, 000. Click here for some more disturbing epidemiology and info. However, not all depressed people will commit suicide and not all attempters are necessarily depressed (i.e. they may be hearing voices (like Mike) commanding them to harm themselves). Although it can be associated with depression, suicide is a whole other animal that FP docs need to know how to recognize and treat.

Kudos to the med student for the mental status exam, and for asking about suicide. I wasn't able to access his resource (registration required), but here are some thoughts:

First, I hope that FP's have psych consultants who can help them. Second, I hope they aren't relying too much on screening tools and "no-harm contracts." Their track records are poor.

So, how to assess and treat suicidal patients? I can't say it better than Dr. Jan Fawcett, who has researched this topic extensively:

"No one has been able to show that suicide is predictable in individuals," Fawcett (said). And to add insult to injury, research has shown that people often either don’t communicate or flat out deny suicidal intentions to a mental health professional before they attempt suicide, Fawcett said.

"This is important, because many professionals seem to think that if someone denies suicidal intent, they won’t commit suicide—that is far from the truth."

For instance, Fawcett participated in a study led by Katie Busch, M.D., in which they examined the medical records of 76 inpatients from different hospitals who committed suicide either as inpatients or immediately after discharge.

What they found in the charts surprised them: 78 percent of patients denied suicidal thoughts and intent as their last communication to mental health professionals before their suicide. "Many clinicians use a patient’s denial of suicide to relieve their anxiety [about the suicide]," noted Fawcett. "But this denial is not to be relied upon..."

People who plan to commit suicide are much more likely to communicate their intent to the people with whom they are close..."We better interview the significant others and believe what they say," added Fawcett.

When Is Risk Greatest?

Clinicians should assess patients for suicide during times of greatest risk, Fawcett said. One of these times is within a week after admission to or discharge from a psychiatric hospital, and another is during times of abrupt clinical change—the sudden worsening or even improvement of a patient’s mental status.

Other risk-increasing situations include the experience of real or anticipated loss, patients with bipolar disorder who enter a mixed state, and the onset of alcohol or substance abuse.

Suicides occur in patients diagnosed with a broad range of disorders, Fawcett pointed out. In 1997 researchers Brian Barraclough, M.D., and Clare Harris, Ph.D., at the University of Southampton’s Community Clinical Sciences Research Division reviewed the literature and found that people with a spectrum of psychiatric disorders were at significantly elevated risk for suicide. People with eating disorders, for instance, are 23 times as likely to take their own lives, people with major depression 20 times as likely, and people with bipolar disorder, 15 times.

Fawcett said there are also risk factors that may occur independently of a person’s psychiatric diagnosis that could heighten the risk for suicide, such as depression, anxiety, agitation, panic, hopelessness, and anhedonia.

Chronic or Acute?

Once a clinician determines that a patient is at risk for suicide, he or she must then decide whether the patient is likely to commit suicide within days or weeks or may not attempt suicide in the near future but within the next year or two.

Placing patients into acute- or chronic-risk categories is crucial, Fawcett said, because patients in each group have unique traits that require specific interventions.

He discovered this unexpected clustering of risk indicators as principal investigator of the NIMH-funded Collaborative Study on the Psychobiology of Depression, in which he and his colleagues collected prospective data on 954 patients with mood disorders, 85 percent of whom were hospitalized. The results of the study appeared in the August 1991 issue of the American Journal of Psychiatry.

By the 10th year of the study, 34 patients in the sample committed suicide. Almost a third of the suicides occurred in the first year.

When Fawcett examined the risk factors for those who committed suicide, he found that the more typical risk factors—suicidal ideation, suicide plans, and a history of attempts, for instance—predicted suicide in two to 10 years from the time of the initial patient interview.

But those who committed suicide within the first year of the interview had different risk factors, such as severe psychic anxiety, in which people ruminate about bad things that may happen to them, insomnia, moderate alcohol abuse, and severe anhedonia and agitation.

Focusing the Intervention

In light of what he has learned through research and years of work with inpatients, Fawcett said, "My goal is to get an assessment of severe anxiety to be a routine part of suicide assessment."

Clinicians must be aware, however, that anxiety and agitation in at-risk patients are intermittent. In addition, Fawcett noted, anxiety is not always apparent. "Some of the worst anxiety is often delusional, and people who look put together may have the delusion that they are going to be punished. . .so you have to ask the right questions."

To combat severe agitation and anxiety, Fawcett recommended that clinicians use high-dose benzodiazepines such as lorazepam and alprazolam. However, this treatment is not well suited to patients with borderline personality disorder.

Lithium has been found to be associated with a reduction in suicide attempts. In 2001 Ross Baldessarini, M.D., a professor of psychiatry at Harvard Medical School, reviewed 33 studies from 1970 to 2000 and found that long-term lithium treatment yielded 13-fold lower rates of suicide and reported attempts than without it or after it was discontinued.

Clozapine has also been found to reduce the risk of suicide attempts, Fawcett noted.

Behavioral interventions may also be helpful, albeit understudied in relation to suicide. "I believe that cognitive-behavioral therapy is another important weapon in the fight against depression and suicide," Fawcett said.

Fawcett then presented good news and bad new to meeting attendees: "Is suicide preventable? With the treatment of acute risk factors, suicide can be prevented on a short-term basis," but it is far more difficult to treat people who are at long-term, or chronic, risk for suicide, because these patients may lack the symptoms, such as agitation or severe anxiety, that can be targeted with specific medications.

For an interview with Dr Fawcett, click here. For more resources from the American Association of Suicidology, including info for patients, click here.

Talk therapy?

Mr. Sun! sends word of Radio La Colifata, a popular radio program run by mental patients. Live from a Buenos Aires mental institution:

This is Radio La Colifata, which in Buenos Aires slang means Crazy Radio - the first radio show in the world to broadcast live from a mental hospital...

"The radio releases you and the wall around the hospital no longer exists. The antenna knocks it down (says one patient)".

More than a therapy, the show has proven popular with an estimated 12 million listeners.

Taxi driver Hector Eduardo Costa listens as he works through the night.

He says: "They aren't so crazy as people often think. They say things that are spot on. Sometimes they write poems, sing songs, and it is very interesting."

Away from the media limelight, the hospital says the show has had great therapeutic results.

Thirty percent of patients who participate are released, and not one of these patients who continues outpatient therapy at Radio La Colifata has been readmitted.

That compares with two-thirds of patients being readmitted if they do not continue outpatient therapy with the radio, its creator Mr Olivera says.

The Radio La Colifata team are now trying their hand at television, with their debut on Canal 7, as part of its health programme.

Patient Hugo Norberto Lopez is presenting as part of his outpatient treatment.

He believes Radio La Colifata plays an important educational role in society: "It de-mystifies mental illness.

"In my district, I thought they would say: 'Hey, look at the crazy guy,' but it's the opposite. They embrace me in the streets and congratulate me. It shows people are beginning to understand."

If you're fluent in Spanish, the Radio La Colifata website should be interesting...

(Mr. Sun appears to be an astute observer of character and behavior. One example: in "Meet the parents," he memorably describes "the twelve stereotypical youth sports parents present at nearly every game.")

Grand Rounds XX is up...

at Dr. Enoch Choi's Medmusings. Dr. Choi braves a flight to Singapore with two toddlers, while putting together this week's roundup of medical blogs. Be sure to check it out!

"My cancer has recurred..."

For courageous affirmation of hope in the face of illness, look no further than The Cancer Blog. Michelle Dillino writes:

Last week I wrote about the fear of recurrence. And sometimes that fear is well founded. Today I have received confirmation that my ovarian cancer has recurred. I first wondered why I can’t just trade bodies with someone else, but then upon further thought decided that I wouldn’t want to. The body I have now is the one that’s gotten me to where I am today, and it’s the one that will help me make it through these next treatment and eventually back into remission again.

How to tell her family? How to cope with their disappointment and fear? At first, she hesitates. But she concludes that they need (and want) to know, and that she needs their support. At this stage in her illness, she has gained strength and knowledge that will help her recovery.

I wonder how she reached that point. (Michelle, I'm not expecting an answer! You have more than enough to deal with.) Dr. Bernstein has e-mailed a moving post from a cancer patient who tells us something about that struggle:

Popping Cancer Job Update: It's okay to be sad.

Whenever I post something to the effect that "Cancer is bumming me out today," I get a bunch of emails and comments to the effect of "Buck, up, little camper - God will provide! God loves you! Be happy! I'll pray that you stop being sad!"

Well, sad is an appropriate response to cancer sometimes. My doctors are all saying I have a great, healthy, positive attitude about my disease, but they are also aware that I have a potentially fatal illness that has spread far and rapidly and that sometimes I'll be less-than-joyous about that.

Sad is ok. Feeling the way you feel is ok, until it becomes destructive. I'd worry about me if I went around all day with a goofy grin and never looked at the negative consequences of cancer.

I say all that to say this: I'm sad right now.

My doctors have said I am forbidden to visit shut-ins, crowds and especially hospital patients. The dearest old lady in our church (this lady and her equally-dear husband "adopted" Stephanie and I) had a heart attack today.

I, as her pastor, couldn't visit her.

How in the world can I pretend to call myself a pastor and NOT visit people I love who are ill? Answer: I can't. I am filing for disability as soon as the denomination can get me the papers. Any trained monkey in a suit can preach. That's not my calling.

My calling came when I had cancer a long time ago and found myself, remarkably, pulling myself up the hallway by my IV pole to visit the other cancer patients who were in the same foxhole I was. I would sit with them through their treatments and sometimes just quietly BE with them.

Upon being healed, I found out that the world is full of people, all of whom are hurting in their own way. I didn't have any real pastor skills, but I hoped I could make a difference in their lives, and so here I am.

Except that now the center of my call has been taken from me.

So don't tell me God loves me. Don't tell me you'll pray that my spirits will be lifted. Don't tell me you're rooting for me.

Something central, and defining, in my life is gone, and I miss it. Just let me be sad.

There it is: "Just let me be sad." We rush to console and offer encouragement. But it's misguided to insist that one must not be sad, and that one must not grieve.

The psychiatrist in me whispers that we don't want to miss a treatable depression.

But the psychiatrist in me also says: what some need most is someone to listen, and to let us be sad.

The Mad Hiker?

That's what he calls his site. He posts beautiful photos of his hikes in the Pacific Northwest and beyond.

Wish him a speedy recovery from his heart condition, please. (He says that hiking and photography are great stress relievers.) I wonder if he's really "mad"...

Calling all medbloggers...

Dr. Choi at medmusings is hosting the next Grand Rounds. He has an early deadline:

Although i'll be hopping a 20 hour flight to see my in-laws in Singapore, i'll arrive just in time to highlight the best in the medical blogosphere, and I was hoping to hear before i left Sunday night about the posts you'd like in next week's Grand Rounds. I'll be posting when i arrive, sometime in the wee hours of tuesday morning. Yup, it takes 20 hours, 2 transfers, and 2 wriggling toddlers, to go and visit the in-laws. But great Chinese New Year's food is awaiting our skip across the pond.


calling all medbloggers to enochchoimd-thoughts AT yahoo dot com...

The ordeal

My new patient stretched his faux-fur paws, and sighed. "I need to talk," he said quietly.

I studied his chart. Age: two months. Height: fifteen inches. Born in Vermont. Recently released from restraints, and still under commitment?

"I felt fine before they put the straitjacket on me," he said. "And the first five minutes weren't bad. Then I said, 'Okay, ha-ha, take this thing off me.'

"But they didn't..."

Please go on, I said.

"You can't imagine what it's like. You can't feed yourself. You can't toilet yourself. My paws started to hurt...I was totally powerless.

"Our union said they were trying to get us released. We saw protesters outside the store. I got anxious..."

Was he aware of the controversy? Some thought that he symbolized harsh and inhumane treatment of the mentally ill. They feared that his company sent a message: that it's fine to make light of a mental patient's most anguished moments.

"What? No, all I knew was that I was tied up, and I couldn't stand it.

"Fortunately, my legs were free. I jumped off the display case and ran out of the store. A protester from NAMI saw me and set me free. I lost her phone number. This is the worst experience I've ever had..."

We read his commitment paper. It cited poor appetite, poor sleep, and racing heartbeat. Did he have those symptoms?

"No, well, maybe a little," he said. "I have nightmares, too. Have I really been committed?"

I reassured him that no judge had signed his commitment form. He seemed much relieved. We discussed possible diagnoses and treatments. I cautioned him that psych meds were not approved by the FDA for toys.

"Well, I'd prefer to avoid meds anyway," he replied.

We settled on a plan: a physical exam by Dr. Charles; an EKG, to assess his racing heart; basic labs, including a thyroid test; and continued psychotherapy. If he needs any help with his commitment paper, he should contact Curious JD.

He seemed pleased with that.

A day too beautiful for blogging

After a brief, foggy but unusually dry winter, spring flowers are emerging in Eugene. Crocuses and azaleas are blooming, and the daphne can't be far behind. If you've never been to Oregon, I invite you to explore here and here. My house is hidden in this picture somewhere, but the fog has lifted. This is the mountain that we glimpse from our front yard.

Why sit in front of a computer on a day like today? Is it blogging anxiety? Is it blogging obsession? (Hat tip: Caltechgirl.) Or is it...ridiculous? Perhaps the answer will come to me. I'm going out now! Blogging later.

Scams and scamming scammers III

How would you try to convince the military that you were unfit for duty? A Norwegian physician tried this:

The doctor rubbed sour cream in his hair, poured sticky liqueur in his shoes, spilled beer on his clothes and sat in a closet smoking 40 cigarettes at once in a bid to convince the military that he wasn't fit mentally for service, the Fredrikstad Blad newspaper reported Thursday.

And just to be sure he looked and felt his worst, he stayed awake for two days before his physical, the newspaper said.

As part of Norway's compulsory military service, veterans, such as the doctor, can be called back for refresher training or longer service.

"I used a made-up life story about how things had gone downhill from being a student in medical school to be being down and out," the doctor told the newspaper on condition his name not be published.

The ruse worked too well:

He was so convincing that the military doctor alerted the national health authority about the man they had licensed to work as physician.

An analysis of his records, however, showed that not only was he not insane, but he had received high marks from his patients, the newspaper said. Now, the doctor is facing likely disciplinary action from the military and the medical board.

In a letter to the Norwegian Board of Health, obtained by the newspaper, the doctor claimed his behavior was no worse than that of many patients.

"It is well known that the information a patient gives his doctor seldom is based on reality," the letter said.

The First Skeptics' Circle is up

We've all observed the Internet's capacity to spread uncritical thought. A medical journalist has now organized a response: a Carnival of Critical Thinkers, at Saint Nate's Blog. Medical bloggers are well represented there: Dr. Charles, Medmusings, Orac, and (ahem) others. There are posts about diverse topics, including some that are totally new to me. Thanks to Saint Nate for organizing this!

Chocolate without guilt?

Nigella Lawson argues "In Defense of Poor, Maligned Chocolate":

We all know the allure of forbidden fruit, but chocolate seems to suffer from its naughty-but-nice image. The cocoa bean is both lusted after and demonized, so much so that eating anything made from it is often deemed a deviant pleasure: sweet, rich, fattening, sinful.

I argue for the solemn dignity of the cocoa bean...Arguments in favor of the health attributes of a foodstuff we generally think we should avoid can sound suspicious, but certain facts are undeniable: bittersweet chocolate with a minimum of 70 percent cocoa solids is rich in phosphorous, potassium, magnesium, iron and antioxidants that can protect against cancer and heart disease. On top of that, chocolate also contains phenylethylamine, a chemical that induces a sense of well being and happiness.

But I think the best argument for the chocolate mousse and cake here is that you cannot truly say you live well unless you eat well. (NYT)

Does chocolate still seem like a guilty pleasure? Try Slate's approach: assess the finest chocolates, and publish the results. Replace guilt with altruism and scientific inquiry (sort of). Readers are invited to replicate their results:

"If you are reading this, it means—Oh dreaded day!—that I have finished this piece. When again will my work consist solely of buying and eating high-end chocolates?" asks Ms. YiLing Chen-Josephson. "When again will I be the life of every party, dispensing pricey bonbons in exchange only for a rating and some commentary? Let us hurry on to the methodology section before I become too despondent...

"In total, I tested 11 boxes of chocolates, from those brands that have outposts at malls around the country, such as Godiva and Lindt, to those with only hometown stores, such as Gearharts and Jacques Torres."

She asked 19 blinded "testers" to assign points to the various specimens, based on taste, aesthetics, and "navigation" (i.e., layout and descriptive features of the chocolate box).

Will JournalClub analyze her methodology and results...and does he need any testers?

The ultimate spin doctor

"Is my treatment working?" The Cheerful Oncologist delivers the news to his patient:

Obviously my job is easy if the report is reassuring, but what if the cancer has not responded to therapy? When an x-ray reveals a meager response, how does an oncologist share this information without delivering a crushing blow to the hopes of his patient? The truth is, the manner in which I counsel a patient is one of the little-known quirks of the field of cancer care. Depending upon my facial expression, my body language or my demeanor in general, my answer - even if it contains discouraging news - may still calm the anxious face in front of me. Like an actor I may choose the role I wish to play that day - rescuer or villain, optimist or cynic. I can attach my own personal slant to the interpretation of the x-rays that may cause the patient to vow to fight on, or simply give up.

On this day - strange but true - I am the ultimate spin doctor.

(This is rapidly becoming one of my favorite blogs. Each post is a gem.)

Not just for Valentine's gifts

Britain's National Health Service is considering a return to mechanical restraints, says the Guardian here and here: "The use of straitjackets to control mental patients has long been discredited in Britain as inhumane and dangerous. So why has the NHS been examining whether to introduce controversial state-of-the-art mechanical restraints?"

The straitjacket, the restraining garment that came to symbolise the harsh treatment of mental health patients, may return, with the NHS considering its reintroduction in a modern form.

Some members of an influential government group looking into how to manage violent and aggressive patients have been in talks with a US firm that manufactures and sells restraints. The group includes police and health service officials.

A member of the group, who asked to remain anonymous, said there were "clear signs of moves to re-introduce mechanical restraints as standard. That restraints could once again be in wide use is seriously worrying."

Handle With Care, the US company at the centre of the controversy, sells a range of restraining products, including a "ParaBed" that secures a patient's arms, feet and torso, leaving them incapable of movement. The devices, marketed under the name, Soft Circle Products, are on sale only in the US, but the firm's owner, Bruce Chapman, is aiming to break into the UK market.

Mr Chapman, a former psychiatric nurse who was stabbed in the chest while trying to subdue a patient during a violent incident in the 70s, defended his products. "With my products, properly supervised, the patient is safe and is treated with respect."

Grand Rounds is up...

at Daily Capsules. Check out the best of recent medical blogging. Sue Pelletier has done an excellent job!