Tuesday, December 23, 2014

Plethora And Other Reasons Not to Donate Blood (Even if You Are a Gay Male)

Plethora is an excess of something, used in medicine usually to refer to a fluid, especially blood.  Plethoric facies describes a flushed and full red face, overfull with blood.

And so it is with the Red Cross.  It has become plethoric as detailed in this New York Times article from back in August.  Fortunately, we are giving fewer transfusions in medicine, perhaps at long last internalizing the data from the heft of recent studies on the lack of benefits of transfusions in multiple arenas.  This decline in transfusions has led to a surfeit of blood and falling prices per unit, which is leading the Red Cross to hemorrhage employees.

I want to use this post to convince you that you should reconsider whether or not to donate (or transfuse) blood.  Why would a person donate blood anyway?  "Because it's the right thing to do," comes the reply.  Why would a person think that?

Thursday, December 11, 2014

Saith the A-line of the Swan: "There but for the grace of God go I"

I never never never, well, hardly ever use arterial lines (A-lines) anymore.  I just don't need them.  The nurses want them, but I mostly refuse, except in in extremis patients with labile pressures on high dose vasopressors.  (I also rarely "float" that Big Yellow Bird the Swan Ganz catheter.  It simply is rare that it provides information that is useful to me.)  Here are some reasons:
  • A-lines increase the volume of blood drawn (and wasted) for laboratory testing, much of which is gratuitous at best, useless or harmful at worst
  • They further limit already limited patient mobility - of an arm no less - and they are an impediment to getting patients out of bed
  • They fail quite often.  I have yet to determine if this is nursing and RT related or the companies are using different construction that reduces catheter integrity - if you have an opinion on this please comment below
  • They are one more invasive device on the list of potential sources of fever - the narrower this differential is, the better
  • They are not obviously more useful than a non-invasive blood pressure cuff
  • They have all the obvious attendant complications of an invasive device.
So I was happy to see the commentary piece in the November 2014 issue of Chest by Allan Garland calling for RCTs of A-lines (a less measured person may have invoked a moratorium on them).  His piece focuses on the lack of data for them, but gives a nod to the notion of "blind acceptance" of established practices, and status quo bias.  Most critical care physicians trained in largish academic centers where their use is commonplace, whether because of tradition, the desire of senior house officers to teach junior ones (hey, you gotta get your numbers up in your procedure booklet somehow), remuneration for procedures in private practice, or other biases.

If you have not already, for the next few months, try to resist the pleas and sirens beseeching you to place an A-line so that you can experience the alternative reality of an A-line free ICU - if you do, and you pay careful attention, I bet you too will find that they are unnecessary and that the threshold for inserting them should be high and the threshold for removing them should be low.

(John Bradford uttered something like "There but for the Grace of God go I" as he watched a criminal being led to execution - in recognition that the potential for human sin lies in all men.)

Friday, November 28, 2014

The Slave, the Master, Captain Obvious, and Insatiable Searching

I'm going to use some cheeky analogies to prove some points in today's quick post.

Imagine that while you are away, your fire alarm goes off, and the fire trucks come, sirens ablaze.  After an investigation, the brave men in blue determine that there is no emergency, every thing is in order, no fire.  They return to their station and not long later your alarm sounds again.  And again.  And again.  Should they douse your home with water just in case they're missing something?  Or should you disable your alarm?

Recently, I was consulted to assist with "vent management".  A patient was "fighting the vent" and was not ventilating well, with a pH of 7.03.  I arrive and find her deeply sedated on propofol and fentanyl (attempts to kill the fight in her) and breathing slowly at a rate of 8 (hence the low pH and high pCO2.)  Every ventilator mode has been tried, but she "breath stacks" or otherwise "fights the vent" without heavy sedation, which itself depresses respiratory drive so much that she gets a respiratory acidosis.  Turn up the rate, and she's back to "breath stacking."  But alas, she was not fighting the vent at all, she was fighting its alarms and it was fighting her.  A post-operative patient, she had low respiratory system compliance (her chest was stiff) and she was also not relaxing after the initial breath delivery, setting off the alarm and the inspiratory delivery, not exhaling, then taking another breath on top of the prior incomplete one.  Raising the peak pressure limit alarm to 60 stopped this and allowed discontinuation of most of the sedatives.  Now she accepts the breath, albeit at a higher peak pressure.  So was solved the problem that never existed, but was created by the alarm settings and the misguided responses to them. One should always ask oneself as regards ventilator alarms "Who is the slave and who is the master?"

The police are sometimes accused of settling prematurely on a suspect, at the exclusion of other possibilities, thereby leaving the real perpetrator free to commit other crimes.  In medicine we would call this premature closure, or search satisficing.  But the opposite of that may be delayed closure or insatiable searching.  Imagine that we have a prime suspect with a motive, and have video evidence of the crime - we can see whodunnit, and there is no evidence of accomplices or other conspiracies.  What police chief would allow his detectives to waste resources going out trying to find other possible suspects in this case?

Now, suppose a previously healthy young woman is exanguinating and goes into shock and multisystem organ failure during her resuscitation and massive transfusion.  Her LFTs (Liver Function Tests) go through the roof, as is seen in shock causing "shock liver".  Why on Earth would a provider order a viral hepatitis panel and an autoimmune panel in this patient?  What are the chances that this exanguinating trauma patient coincidentally has viral hepatitis instead of or on top shock liver?

A young patient with normal renal function develops post-operative shock and renal failure.  Should you order a renal ultrasound to check for obstruction?  What are the chances this patient has a predictable complication and spontaneous urinary obstruction or obstruction instead of the usual complications from shock?

A patient has a witnessed aspiration, say, from overdose.  There are bilateral infiltrates on CXR.  "But we should get a CT, maybe he has PE (pulmonary embolism), too."  And maybe he's gestating an alien fetus in his cecum.

Sometimes Captain Obvious needs to come rescue us from insatiable searching.

Sunday, September 28, 2014

Utter Rubbish: A Call for a Moratorium on the 4 AM Blood Draw

The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself.  Therefore all progress depends on the unreasonable man.  - George Bernard Shaw

Depending on the week and the driver, I am often awakened around 4 AM when one of several delivery trucks backs into the driveway of the restaurant beside my house, 15 feet from my bedroom.  Rankled, I have been known to open the window and have words with the driver, who, in my opinion, should park on the street, thus creating a distance between our house and his beeping, rattling, diesel-idling, polluting truck with its slamming ramps and gates and whatnot.  Because he mindlessly prioritizes a minute or so of his time over my and my wife's uninterrupted sleep.  Sometimes, we just get back to sleep before the next truck comes and awakens us again.

In relating this story to my father, he told me that the residents of a Northeast Ohio municipality recently passed a city ordinance banning the picking up of garbage before a certain hour, because of complaints of the noise and disturbance that the rubbish trucks cause at earlier hours.  Immediately drawing the analogy of the 4 AM phlebotomy visit in the hospital, my father wonders why, in the era of customer service, we subject the sick of society to this indignity and injustice while they're in the hospital.  And the answer is that I don't know.  A quick Google search is of little help.

There are two likely and possibly related reasons for the 4 AM blood draw.  First, in days of yore, physicians rounded very early in the hospital and then went to their office or to the operating room.  They wanted the lab results by the time they rounded so they could complete the rounding task and move on to others and not worry what Mrs. Jones' creatinine was all morning.  So, in essence, we have historically been awakening patients at 4 AM for physicians' convenience.

Wednesday, September 10, 2014

Helping Those Who Won't Help Themselves: The Role of Personal Responsibility in Medicine

Give a man a fish, or teach him to fish.
It is a well known secret in medicine:  many of those we care for are unconcerned with their own care, as evidenced by their revealed preferences.  "What medications are you on?" the physician asks.  "I don't know, doc," comes the reply.  "Why are you on carvedilol?"  "I don't know."  "What was your last HgbA1C?"  "What's that?"  We have encouraged physicians and other professionals in the healthcare system to take responsibility for every aspect of patient's care to the peril of patients' own interest and investment in their care.  How often do you enter a room and find a patient researching their illness and its treatment, rather than surfing the internet or watching TV?  Is your patient more concerned with the timing of the next dose of antibiotic or the next dose of dilaudid?  How often do your patients keep detailed records of their past medical history?  Why does the intern or resident or PA or NP schedule follow-up appointments for patients, rather than the patients do it themselves prior to discharge?  Why must so many patients be coaxed out of bed and working with physical therapy?  The actions of patients reveal their preferences.  Those who are invested in their own care take responsibility for it and are knowledgeable.  Those who would rather watch television than work with physical therapy reveal other priorities and preferences.

All the hubbub about healthcare and health disparities has entirely glossed over the role of personal responsibility and accountability in medicine.  Some may find it inexcusable that many patients have so little investment in their own health care, expecting instead that the government, their insurance company, and the healthcare system at large allows them to abdicate their own personal responsibility without consequences.
(I am not here referring to people who are unable to care for themselves, but rather those who are perfectly capable but who shirk the responsibilities.  If you cannot accept this and wish to accuse the author of "blaming the victim" read no further.  Yes, the victim of disease is being blamed for any lack of personal responsibility that is contributing to poor health.)

If there is a lack of personal responsibility in medicine, there are several important implications that we should be concerned about.

Thursday, September 4, 2014

Mindless Medicine: The Importance of Minding Your P's and C's

I see far too much mental laziness in medical practice these days.  I will give some examples below.

To teach the residents mindfulness in diagnostics and therapeutics, I used to tell them to mind their P's and C's:

  • Problem:  What is the major malfunction that we are dealing with?
  • Proof:  Do we have proof of the problem or diagnosis?  Is there uncertainty, or are there other possibilities?
  • Cause:  How did this problem come to be?  Why is this happening?  Is there a deeper cause?  An even deeper one?
  • Cure:  What interventions should be employed to treat the problem(s) identified?
Sometimes I receive a call from the ER to admit a patient and the "presentation" if you would call it that amounts to rattling off a list of the laboratory abnormalities.  "What is the problem?" I ask.  "He's going to have to come in," is the reply.  No, my friend, moving the patient out of the ED is YOUR problem.  I'm asking what is the PATIENT'S problem.  You are here, after all, to serve the patient, right?  Some ERs appear to be evolving into glorified triage centers, with a primary focus on differentiating those who can be sent home, flown out, or admitted, rather than centers focused on making expedient and prompt provisional diagnoses so that time sensitive therapies can be administered post haste.

Saturday, August 9, 2014

We Must Suffer: Moral Hazard in Modern Medicine

I was first introduced to the concept of moral hazard in Rich Rubin's book In an Uncertain World.  He describes the deliberations within the Treasury and the Executive branch during the Mexican and Asian debt crises of the 1990s about whether the US should bail out the sinking currencies of these countries to prevent larger repercussions throughout the world's economies.  Moral hazard is the risk that those bailed out economies would not "learn their lesson" and the bailout would serve as encouragement to take similar risks in the future, repeating the crises and the need for future bailouts.  The concept of moral hazard resurfaced again during the recent economic crisis in the US, brought about by large US banks and their promiscuous lending practices.

Moral hazard and the decisions that it may influence have an inherent omission bias:  while I cannot force an alcoholic to take disulfuram (without a court order), the alcoholic cannot force me to provide him with alcohol.  The status quo is the moral reference frame.

Moral hazard stems from a fundamental underpinning of human behavior:  we learn appropriate avoidant behaviors through pain.  Children with a mutation that prevents them from feeling pain have short lifespans because they do not learn appropriate avoidant behaviors, as detailed in this poignant NYT article.  It is a striking article, and I don't think a person could have a full appreciation of moral hazard until they read it, so please do.

If there is moral hazard in general, it certainly exists in medicine as well.  I will illustrate this through several examples.

Friday, July 11, 2014

Should DNR be the Default Resuscitation Order After a Certain Age? The Case of Arnold Relman

"Oh lente, lente, currite noctis equi."  - Christopher Marlowe, The Damnation of Doctor Faustus

In at poignant and pithy piece in the New York Review of Books this year, the late Arnold Relman, former editor of the NEJM, described his experience breaking his neck and having cardiac arrest three times in the trauma resuscitation bay.  Because Relman was a visionary and outspoken pioneer in the movement to recognize and reduce medical waste and runaway spending (according to his recent obituary in the NYT) I thought it would be timely rather than disrespectful to evaluate the last year of his life after his accident as a case study on the utility of resuscitation in advanced age (I will not here attempt to define advanced age - only to posit that it exists at some cutoff that could be defined statically or dynamically).

Monday, June 23, 2014

No Code, Slow Code, 45 Minute (Purgatory) Code: Responsibility and Accountability in Attempted Resuscitation from Death

Physicians can abdicate their responsibilities as reasoned guides for patients making decisions at the end of life and as gatekeepers of resuscitation practices in many ways:

  • By failing to address "Code Status" at all, letting patients be "Full Code" by default (and by failing to work as a profession to reconsider or change the default)
  • By asking, in a matter-of-fact manner, "if your heart stops, do you want us to do CPR to try to restart it" without discussing the probability of success and the likely outcomes, both immediate and longer term, in the (often unlikely) event of success
  • By failing to probe the reasons why a code status election that is at odds with their (and/or the nurses') judgment has been made; i.e., taking for granted the legitimacy of a Full Code declaration when doing CPR will clearly or likely be futile
  • By discussing the issue of code status solely from an agnostic position, as though there is no right or wrong election, when in fact the physician has a strong belief about what is appropriate and what is not (such as Full Code nonagenarians, elderly patients with hemorrhagic stroke, those on the ventilator with multisystem organ failure, those with metastatic cancer, etc.)
  • By defaulting to a Slow Code as a dissimulating compromise for the conflict between the documented code order and their sense of what is medically appropriate
  • And the topic of this post:  by conducting a 45 minute code without reevaluating, during that time interval, the premises upon which the Code Blue was initiated, and without integrating the new information that accrues during the resuscitation attempt

Friday, April 4, 2014

Dated but Not Outdated: Why the Pager Endures as a Means of Physician Communication

In this post on the Huffington Post yesterday, Sachin Jain, a physician and presumably a technophile, bemoans the enduring use of pagers among physicians, labeling pager carriers as outdated and failing to leverage available technology to make communication more efficient.  As a devoted pager carrier, I will enumerate the many reasons why the pager is a preferred communication modality for many physicians, and the ways in which Dr. Jain is missing the point.

  1. Patient Safety.  I work in the ICU.  If there is something that the RN needs to inform me, s/he needs to know that I have received the message.  If said RN (or intern or resident or other physician) pages me and I respond, they know I know.  If instead they send a text message or leave a voice mail, they do not know that I received the message.  They assume I did, and move on to other tasks.  If I did not receive the message, time sensitive things can get missed or delayed and that's a big safety issue.

Saturday, March 22, 2014

Antifragile but Exposed: A Framework for Understanding Disease that Can Improve Diagnostic Decision Making

Ruination IPA by Stone
It is said that the history reveals the diagnosis 90% of the time, but it is not stated why this is so.  Herein I will explain the logic behind this aphorism.

I used to tell residents that most of the time, the diagnosis is something common, or something related to something we already know the patient has.  In addition, when teaching history taking, I told the medical students to view history taking as an exercise in determining what the patient is exposed to in his or her environment, for these exposures weigh on the probabilities of potential diagnoses.  These principles explain the basis of the history aphorism.

Nassem Nicholas Taleb was right in his book Antifragile - evolution has made our species beyond robust - antifragile, a term which he coined.  We resist disease, we repair injury, we get stronger when exposed to stress (the antifragile principle).  But there are ailments that humans suffer for which evolution has not worked out a defense or a solution, or those which result because evolution is helping the same organisms which attack us become antifragile just as it selects us for antifragility.  This is why infectious maladies are at the top of the list for adult (and I suspect pediatric) internal medicine admissions.  Pneumonia, UTI, URI, etc.

Friday, March 21, 2014

The Hits are Recorded, the Misses are Not: How the Culture of Medicine and the Third Party Payer System Foment Waste and Inefficiency

It doesn't make sense, but that's how we do it.  Usually, if you want to judge the calibration of a decision maker, you tally hits and misses both, not just the hits.  If you fail to record misses, a high hit rate might just signify a lot of swings.  But in medicine, we are taught to ignore misses.  It's only hits that count.  This doesn't make sense because it encourages overtesting and waste.  If surgeons practiced this way, all heck would break loose, everybody would be cut open and organs wantonly plucked from them.

There is a physician at a Midwestern institution who is known to come on service and order an echo bubble study on several (all?) patients the first day he is on service.  He has doubtless impressed a generation of medical students when the occasional PFO (patent foramen ovale) is found and he gets to wax prolific about shunts and other mechanisms of hypoxemia for a few minutes as they listen with fawning and rapt attention.  What they do not know is that he finds PFOs about 10% of the time he orders his echos, and this is just above the rate of PFOs in the general population.  He's basically finding PFOs at random.

Wednesday, March 12, 2014

No MOC for Me: Why I'm Not Signing Up For Maintenance of Certification

By the end of this month, holders of ABIM (American Board of Internal Medicine) and ABMS (American Board of Medical Specialties) board certifications are supposed to sign up for "Maintenance of Certification" a requirement that costs a bunch of fees and poses a bunch of busywork problems for physicians.  In general all I have heard in terms of reactions from colleagues are frustrated groans and begrudging acquiescence.  But I refuse to sign up for MOC.  Here are the reasons why.

Firstly, I am not required, for my employment, to have a board certification.  Nor am I for any other reason.  The only institution which can "force" you to have board certification is your employer or a hospital credentialing committee.  So, if somebody's gonna be the guinea pig, it may as well be me.

Sunday, February 23, 2014

Jahi McMath: Poster Child for Medical Futility, or Scapegoat?

I periodically check for news updates on Jahi McMath, and today I found this news report that suggests that Jahi McMath is still alive, or at least that her heart is still beating, more than two months after she was declared dead on the basis of "brain death."

Based on the commentary on previous posts here and on PCCMcentral.org debating this issue, I can say the following:
  1. Jahi McMath is legally dead on the basis of an incontrovertible and unequivocal diagnosis of brain death.  I have no doubts in this regard.
  2. Jahi McMath has a beating heart and thus is not considered to be dead on the basis of the intuitions and opinions of her family and some others.
You may choose #1 or #2 above.  I personally don't care how you choose.  But I'm interested in the differences in reasoning and opinions among those who choose #1 and those who choose #2.

"No! Not NARCAN!" Exclaimed the Woman Not Breathing and Being Bagged

I will begin this post with a little anecdote.  It was about ten years ago at Johns Hopkins Hospital and I responded to a "Code Blue" on the step-down unit.  There was a woman, about 30 or 40 years old with several chronic medical problems who had stopped or nearly stopped breathing.  I was at the head of the bed delivering bag-mask ventilation (bagging; using the Ambu-bag, the first responder kinda thing).  We were preparing to intubate (insert a breathing tube into the trachea) the patient when an astute co-fellow, L.R., came on the scene and inquired as to whether the patient might be overdosed on narcotics.  He said aloud "should we try some Narcan?"  (Narcan counteracts the effects of narcotics and can cause arousal of a patient overdosed on them.)  This patient who was comatose, not breathing, and unresponsive in spite of being bagged and poked and prodded by the numerous staff who responded to the emergency, suddenly awakened and exclaimed, vehemently and audibly through the bag-mask ventilation:  "Nooooo!  Not NARCAN!"  Apparently, even a near-death experience is not as fearsome or worthy of arousal as reversal of the effects of narcotic medications.

Healthcare workers will find this amusing for its irony, and I could use it as a segue to a soapbox soliloquy about the dangers of narcotics, but I've already blogged that rant.  Here,  I'm simply using it as a segue to a discussion about the use of Narcan drips in the treatment of overdosed patients.  I was taught during a toxicology rotation in my residency a clinical saw that can be summed up as "If there's an antidote, give it."  Years of experience and reflection have borne out the wisdom of this adage.  Narcan and other antidotes are often benign and as I have discussed in other posts, their benefits even in uncertain cases often outweigh their potential harms enough that they should be given.  Narcan is especially useful when available to heroin addicts, when used by first responders in the field, or when used as a "test" of whether depressed consciousness is due to the effects of narcotics (as part of the "coma cocktail").  But when the decision has been made to admit a patient for observation after an overdose with prolonged effects, the question arises:  should we start a Narcan drip?

Sunday, February 16, 2014

You Are the Hunted: Eat What You Kill Versus the Salary Model (Let Others Do the Killing, My Eats Are Free)

"It's hard to get a man to understand something when his salary depends upon his not understanding it."  - Upton Sinclair

This week, a popular NYT article describes how physicians are flocking to salaried positions in hospitals and healthcare systems in order to preserve their incomes amid reimbursement cuts, and to protect themselves against the vagaries and uncertainties of the healthcare landscape in the age of Obamacare.  For those not used to thinking about physician remuneration, I will give a brief synopsis.  There are basically two models of physician earning, and hybrids of the two.

The "Eat What You Kill" Model
Yes, this is the colloquialism commonly used to describe physician reimbursement in a pure private practice model.  An analogy to hunting for survival, you get to bill for, and keep the collections from, patient encounters that you pursue.  The harder and the more often you hunt, the greater your bounty.  Here are the problems with this model:

Saturday, February 8, 2014

Behind Closed Doors Lurk Proxy Wars: Is Visitation Really About Visitation?

I decided to rewrite this today, on January 30th, 2016, after thinking about it for almost two years.

The previous post took on the heretical task of making the case against wide open visitation in the ICU without restrictions.  I took that stance for several reasons.  First, I'm a heretic and an iconoclast, and I believe that free thinking, rationality, and good judgment and decision making require all angles of a debate to receive their due - my goal is to keep the dialogue fire stoked.  Related to this, I sensed (and still sense) an agenda - open visitation is being pushed for ideological or financial reasons (yes, the almighty dollar - patient satisfaction scores are tied to Medicare reimbursement), professional associations such as the AACN are pushing the issue, and substandard data are being touted to support this agenda.  Next, it was and is my belief that because of the agenda, nurses' (and physicians') dissenting voices are being shamed into a collective hush by The Man, as it were, and that this censorship needed redress on this blog (it got redressed in 60,000 views and over 100 comments to the original post, still visible below.)  Furthermore, this institutionalized censorship may cause pervasive Hawthorne effects in any nursing survey that is done on the topic.  Finally, it was and is my view that if open visitation is the stated goal, there may be subgoals that are driving the desire for open visitation, and satisfaction of these subgoals through other means may be superior to open visitation for making everybody happy.  That is, desire for unrestricted visitation may be the symptom of an underlying disease and treating the underlying cause (such as poor communication) may cure both the disease and its symptoms.

Even if these considerations are cogent, reasonable and rational (which does not mean that they lead to the correct conclusions), there was a significant omission from my train of thought, small hints of which were peeking through from the text.  If some physicians and nurses don't want open visitation, maybe that too is the symptom of a deeper underlying disease that likewise could be addressed in other specific ways - and it thus follows that restricted visitation is not necessarily the solution that their symptoms demand either.

Saturday, January 25, 2014

Doctorin' with Double Effect: The Ethics of Withdrawal of Life Support and Oxygen in Dying Patients

There has been a lot of discussion about the ethical nuances of withdrawal of life support and provision of medications that relieve suffering but accelerate death, but precious little about an important aspect of end of life care that comes up all the time - what are our obligations regarding provision of oxygen to dying patients?

The withdrawal of life support is an activity (a commission) that is ethically protected because patients' autonomy and right to refuse treatments overrides the harm (death) that comes about when physicians act to withdraw life support.  This in itself is interesting because most states prohibit euthanasia (or the provision of prescriptions that enable patients to take their own lives), which is in essence a commission (as opposed to an omission) that accelerates death.  I'm struggling to understand the distinction, except that the withdrawal of life support restores the patient to a "natural state" and allows nature to take its course, whereas the provision of a prescription to allow a patient to overdose is a commission that seems to interfere with nature.  (Jonathan Baron has written extensively about our preference for "natural states" which often leads to worse outcomes.)  That takes care of the natural versus human distinction (which of course ignores that humans are part of nature), but I still struggle to understand why the patient in Oregon has to administer his own overdose, unassisted by a healthcare professional - what's the difference between a healthcare professional assisting with the administration of an overdose and accelerating death, and his removing life support and thus accelerating death, if both acts are in deference to patient autonomy, and both are commissions, and indeed both are direct actions, as opposed to indirect ones?  Maybe it's because you can act directly and cause harm in respect of autonomy as long as you restore a natural state (withdrawal of life support), but you cannot act directly to cause harm in respect of autonomy by causing an unnatural state (medication overdose).  I think this stream of consciousness has led me to the distinction.  Maybe.  The devil is in the details.

Monday, January 6, 2014

The Girl is Brain Dead but the Emperor Has No Clothes

Oh, my, what a predicament.  Jahi McMath has been released from Oakland Hospital to the custody of the coroner and her family.  She has been issued a death certificate.  And she's being transferred to an undisclosed care center, where it is hoped she will begin receiving artificial nutrition.  This is the height of both irony and tragedy.

The comments by physicians and bioethicists in the CNN articles all harken to the idea that there appears to be no error, she meets criteria for brain death and thus she's "legally dead."  This misses the point.  Her parents don't care if she's "legally dead."  The legal definition does not comport with their own intuitions about death and her mother says as much.  She will accept that her daughter is dead only when her heart stops beating.  I can understand why a person may take this stance.

Sunday, January 5, 2014

Real (Cardiac) Death and Invented (Brain) Death: The Oakland Case

This article in the January 4th, 2014 New York Times reports on the tragic case (the "Oakland Case") of a 13-year-old girl who suffered complications from elective surgery in early December 2013, whose condition deteriorated and who has been declared brain dead.  While it is not articulated directly in the article, her parents appear to object to the medico-legal conceptualization of brain death and they wish to force the hospital to continue to provide care for her.  A judge has placed an injunction against the hospital, prohibiting them from removing her from life support (in this case, this most likely means mechanical ventilation) until Tuesday January 8th, 2014. The medical establishment at the hospital where she is/was a patient has clearly taken the path of defending the concept of brain death and their rights and responsibilities under the laws concerning brain death -they have refused to insert a tracheostomy or a permanent feeding tube into the girl - and they may have, and we may be tempted to, ascribe her parents' behavior to anger, grief, bereavement, etc.  But I think this case illuminates some broader issues about bioethics, brain death, and organ procurement.

For those unfamiliar with the medico-legal definitions, brain death is a diagnosis that is made after severe brain damage from a variety of insults.  It is a very specific diagnosis that is based on a host of physical examination techniques and sometimes corroborating diagnostic studies, and it means that there is evidence of irreversible cessation of ALL brain function that has been caused by total lack of blood flow to the brain.  A patient who is declared brain dead is legally dead.  I have diagnosed brain death dozens of times.  The medical mantra is that, properly diagnosed brain death always means that there is NO brain function and that "real death" (that is, cessation of heartbeat) will inevitably ensue in coming weeks or months as the body cannot continue to  function without brain function.  But isn't this interesting!  That we need to reassure people that "real death" will inevitably ensue seems to reveal that we recognize that brain death is not real death, but that it will, after time lead to real death!  (Of course, all paths lead to real death, eventually.). Clearly this landscape is fertile ground for cognitive dissonance.  Let's explore why.