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Demystifying Medicine One Month at a Time

Category: medical mystery (page 1 of 4)

End of Life Rallies

Let’s say your loved one is at the end of life. She’s 84, with advanced cancer that is no longer treatable.

A decision has been made to put her in hospice–which is a level of care more than an actual location. [Most hospice actually occurs at home.]

The patient waxes in and out of consciousness, sometimes lucid, but mostly not.

While no one is ready for her to die, this end-of-life process brings some solace–it’s what your loved one has indicated she wants, and the time at home without aggressive, often fruitless, medical treatment, allows other friends and family members to make visits and share stories.

One afternoon, she perks up and asks for a sandwich. This is surprising, because she’s barely eaten anything in the last ten days. But we get her that sandwich!

She nibbles at it, happy, but doesn’t eat much of it.

That afternoon, she’s talkative and engaged with others in a way that she hasn’t heretofore seemed able to muster.

Is she making a comeback? Healing from her illness?

More likely, this is what is called “rallying,” and while there’s ample anecdote of its occurrence in situations like this, we have very little understanding of it.

How does it happen? As a recent NYTimes article stated:

Physiologically, experts believe that the mind becomes more responsive when a hospice patient is taken off the extensive fluids and medications such as chemotherapy that have toxic effects. Stopping the overload restores the body to more of its natural balance, and the dying briefly become more like their old selves.

It’s deceiving because we think our loved one is getting better. And while she’s more like her old self, unfortunately, it’s not bound to last. Which is why it can be upsetting for some.

Spiritually, some suggest that the dying loved one is simply readying for transition–making sure that earthly concerns will be attended to in her absence and that final goodbyes may be uttered.

I’ve seen it–and especially in elders afflicted with dementia, it can be heartening to see them rally and seem to know what’s going on–accepting their impending death, and engaging with their loved ones before drifting off.

Holiday Miracles

Dr. Kolbaba and his book

Happy holidays, dear GlassHospital readers.

A book recommendation for the season: If you like hearing positive medical stories, ones that are miraculous even, then order a copy of Dr. Scott Kolbaba’s “Physicians’ Untold Stories.”

Dr. Kolbaba is a longtime internist in Wheaton, Illinois. Over the years he’s experienced things that defy logic and rational explanation. The interesting thing is that neither he nor colleagues shared these stories, fearing ridicule or disbelief, until finally the dam broke.

He spent three years producing the book, interviewing 26 different doctors, all of whom have surprising, heartwarming medical stories.

Dr. Kolbaba includes short biographical material on each of the contributors to his book.

Though the word miracle is used throughout, and the presence of God is alluded to, there is no specific religious tradition espoused in the book–so you can decide for yourself about the degree of providence within.

I hope your holidays bring peace and comfort to you and your families.

The Science of Medicine

Last week I told you of my admiration for Dr. Mona Hanna-Attisha, the Michigan pediatrician and epidemiologist whose strong research and advocacy was able to finally bring a shining light to the problem of lead in the water supply of Flint.

Continuing with a theme, I now bring you the story of Dr. Adriana Melo of Campina Grande, Brazil.

03-zika-doctor-adriana-melo.w245.h368Dr. Melo is an OB-GYN who subspecializes in Maternal-Fetal Medicine (MFM), the branch of obstetrics that deals with high-risk pregnancies.

She lives and works in northeast Brazil, which is less populous and more economically challenged than the southern, more well-known parts of the country (including Rio de Janeiro and Sao Paulo).

Dr. Melo noted an uptick in the number of fetuses with small heads on ultrasound — which is the main tool used by MFM doctors to diagnose babies in utero.

How much of an uptick? A rough look at the statistics shows ONE HUNDRED times the ‘normal’ rate of babies born with microcephaly, the medical name for the condition.

Dr. Melo had a suspicion that the mothers giving birth to these babies all had a common trait: they’d all told her that they’d had the characteristic rash associated with the mosquito-borne Zika virus.

When she tested the mothers for evidence of the Zika virus in their blood, the tests were negative. Not deterred, she convinced public health authorities to test the amniotic fluid of mothers carrying microcephalic fetuses. And indeed a strong correlation was found between exposure to Zika and microcephaly.

It’s this story of a doctor in a somewhat out-of-the-way place using her clinical insight to ‘prove’ a correlation which I find inspiring.

Dr. Melo could have been content to merely diagnose and treat these poor mothers and babies, perhaps simply ‘reporting up’ her findings on the increase in microcephaly. Instead, she decided to push against the inertia of daily medical practice because what she was seeing really bothered her — and as a mother of young children herself, she felt the urge to get to the bottom of the new trend.

If you follow health news, you no doubt have heard a lot about the Zika virus in the last few weeks, including warnings from both the CDC and the World Health Organization. As is often the case with warnings from these organizations, a certain amount of panic ensues — such as women in Latin America feeling that they’re being told not to get pregnant, for example.

I want to make it very clear that though there is a STONG ASSOCIATION between the rise in cases of Zika in the tropics of the Western Hemisphere and a concurrent rise in babies born with microcephaly, we must remember: Correlation does not equal causation. The public health agencies issuing travel and birth control warnings, while sounding dire, are making best guesses for us all to minimize our chances of harm. But drowned out in the response is the fact that we don’t yet know for certain that Zika is the cause of microcephaly. That work is ongoing.

For example, many experts think something else may be the cause — perhaps the use of dangerous pesticides in Brazil (that are banned elsewhere). That also sounds plausible since pesticides are used to “control the mosquito vector.” It’s entirely possible that microcephaly is occurring because of a chemical effect.

For now, we must wait and hope that science can show us the true cause of the uptick in microcephaly.

I also think it’s important to remind ourselves of two things about Zika virus: We’ve known about it since the 1940s, when it was discovered in Africa — so though if feels new, it’s really not. Secondly, at least for non-pregnant people, it only appears to cause mild flu-like symptoms and be a self-limited illness (not more than a few days at most).

My advice: Better to save your anxiety for the never-ending Presidential race.

The Inflection Point(s) of Aging

A new column of mine has been posted on NPR’s website about “de-prescribing,” the art of pruning medications from older adults that take too many of them, a condition we refer to as polypharmacy.

Katherine Streeter for NPR

Katherine Streeter for NPR

It’s well-known that being on too many medications can lead to more side effects and drug-drug interactions, so anything medical professionals can do to minimize such negative outcomes is welcome. Thus we revert to our Hippocratic doctrine: First, do no harm.

Contrast that with the competing ethical imperative toward beneficence — to do good for patients. Medical science teaches us that many (though far from all) of the medications we prescribe for chronic illnesses (e.g. cardiovascular conditions) lead to fewer ‘events’ (think heart attacks & strokes), which prolong lives.

As a result, doctors wind up prescribing a lot of stuff — and decades of medical practice and now guidelines and quality metrics push us to do this even further.

One area I’d like to see science help us is in identifying “The Inflection Point of Aging,” which I define as the point in a person’s life when we can pare down ‘aggressive’ treatment of chronic conditions because it becomes counterproductive: when taking the “medically proper” action is likely to cause more harm than good.

This whole notion arises out of recent discourse: As I recently blogged, the SPRINT Trial, which was stopped early because it showed that treating blood pressure even more aggressively than we’d previously thought leads to fewer bad ‘events.’ How low, I wonder, is too low?

Also, an article in the Atlantic by medical pundit Ezekiel Emanuel titled “Why I Hope to Die at 75” emphasized this idea.

Emanuel is a known iconoclast, but I appreciate his efforts to stir up dialogue and get us talking about important issues that we are otherwise reluctant to discuss. In this case, I think his editors at the Atlantic did him a disservice, because the provocative headline of the article caused a furor and detracted from his real message, which was simply this: There comes a point where undergoing standard medical practices no longer makes sense. That point is different for everybody and is dependent on a person’s values as much as their physiology. Emanuel never said he wants to die at 75, merely that he plans to stop seeking medical interventions at that age — two very different ideas.

If you click over to the NPR column, you can see that anecdotally, we care for patients for whom physiology does change — and it therefore doesn’t make sense to keep doing the same things over and over. It’s trite to say it (and you’d be amazed at how challenging it can be to fight medical inertia), but we must think about each patient individually and truly weigh the risks and benefits of adhering to population-based norms and recommendations when goals and bodies change.

Contagion of Yesteryear

Ebola seems to have taken up a significant portion of the news stream as of late.

sars-2003_custom-1ec2de788947040b25f2065b83f3b0e087fe0768-s40-c85

NPR–>Kevin Frayer/AP

It’s understandable, given the breadth of the epidemic (largest ever), the fact that it’s hit our shores, and that it’s so frightening: hemorrhage! death!

I wrote a first-person account of the time I was asked to evaluate someone for SARS, a 2002-2003 novel disease outbreak that originated in China and spread quickly to the West (in the end, only 27 U.S cases and no deaths; in Canada, 251 cases and 44 deaths).

SARS is a descriptive name: Severe Acute Respiratory Syndrome. We subsequently learned that it’s caused by a corona virus and that it’s spread by contact and respiratory droplets.

The outbreak died down as quickly as it flared up, and it’s nary been heard from since.

Here’s the concluding graf from the story–as true for Ebola as it was for SARS:

Today’s Ebola crisis makes clear what the many of us were slow to accept in 2003. It takes clear thinking, painstaking preparation, flawless execution and clear communication to protect the public health.

We can only hope that Ebola recedes and becomes a distant memory, also.

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