Risk/Reward ratios in Medicine

Warning: medical post with an unhappy ending.  Also, statistics.  (eeek!)

Streptokinase.  Credit: Wikipedia

  Recently we had a patient who had a heart attack.  Actually, that's quite common - we often have several in a week.  Absent good reasons not to, we typically treat with streptokinase.  Streptokinase (SK) is an enzyme made by some bacteria (see if you can guess which!) that has an impressive ability to dissolve blood clots.  This makes it useful to dissolve blockages, say, in one of the heart's own arteries (aha! a heart attack).  Miracle, no?
   Well, it's not specific to the coronary arteries, so it can cause blood clots to dissolve everywhere in the body.  There's a constant balance in your body between the clot-dissolving system (which keeps your blood vessels from solidifying) and your clotting system (which keeps you from bleeding from every pore).  SK massively shifts the balance in favor of clot-dissolving.  You can imagine some of the other risks, but the most serious risk is intracranial hemorrhage (a huge, bleeding stroke, often lethal, always horrifically destructive).

The generic risk of dying from a heart attack is roughly 12%.  The risk of intracranial hemorrhage from SK is approximately 0.5%.  Giving SK reduces risk of death by about 4%.  To put that in easier terms:
For every 200 patients I give SK to...

175 patients will receive SK who would've lived anyway. though I like to think they'll have less heart damage.
8 will live who would have died.
16 will die anyway, despite SK, and...
1 will die who might otherwise have lived.

Well. The patient I began with was the one.

Sometimes you know who it is you saved.  In August, and again in September, I had two patients in cardiogenic shock whom I nursed through the night until the SK had its effect and the heart started working again.  Other times you just don't know and you have to trust the statistics that say you've done some invisible good.  But you always know which ones your treatment harmed.

Minority Report

A swiss friend invited the kids over to make special breads for St. Niklaus eve (Dec  5th)

    Last night I took care of an older gentleman (with a heart attack).  His wife related an interesting story.

   Many, many years ago, they were married.  Then he left and moved to India for 20 years.  There, he met and also married another woman.  A few years back he returned  again to Bangladesh and moved back in with his first wife.  She looked me straight in the eye and, clearly imagining what I might be thinking, said. "What should I do? This is Bangladesh."  Her tone was even and completely unaffected.  It wasn't even resigned - just matter-of-fact.

   The subtext was, "What? He's my husband.  He is my standing in society.  No, equality is not a thing to be expected.  Without him I have nothing.  So, I accept that he had/has another wife."

   I knew polygamy existed in BD; this is merely my first up-close exposure to it.  I came home and discussed it with our house helper (who is christian - a small minority here).  She said, "Yeah.  Muslims have too many wives.  1, 2, 3. sometimes more!  Christians and Hindus don't."  That makes it sound like it's everybody - it's not, but it's around.
   What struck me about her comment was the exact same matter-of-fact tone.  Living in a society where you are a small minority (or a powerless group) you can have an identity or set of rules that are completely different from that of society at large, yet you must accept the larger society's rules as fact.

  This is probably how minorities have felt throughout time, from first-century Corinth to modern-day Bangladesh. 

Snapshots

Geek is Chic.  Thanks, Erika!

Sisters.

Just give up now, you're going' down!

I've just finished a few weeks in the hospital of intense every-other call.  Now I'm taking a few days of time-off to spend with Laura, the children and my parents.  The contrast makes me realize just how hard I was working.  I'm not entirely certain I was easy to live with or always present for the children.

But having these days is lovely.  We played frisbee this afternoon and yesterday I kicked a soccer ball with AE (who is surprisingly good!).  I had the chance to look up and around once or twice and to look down at a face that's smeared with a bit of mud and a big smile.

Pachyderm

What nobody's talking about.

A night in the life...

Two call nights ago, after I got home at 9:20pm, I received no further calls all night.  Last night was a another kind of night:

22:30 - go to sleep.

23:47 - the phone rings.  Walk through the fog to the hospital to see a patient with a tender abdomen and discuss the case with the junior doctor.  Order an abdominal Xray (we have no CT scan).

Get called to see two other patients.

Look at the film on a lightbox.

Film shows dilated bowel loops everywhere.  Clinical impression before was probably ileus (temporarily paralyzed intestines after surgery), Xray is consistent.  Discuss why repeating the exam hourly is better than having a CT scanner - you feel the change in abdominal tension and sense whether the pain is increasing or decreasing: "Your hands are better than a CT."

Walk home through the fog at 01:17.  Lay down under the net, but sleep is taking a while...

02:30 - ...nope.  Eyes closed, but no sleep.  Phone rings.  35 year old with very low oxygen levels despite administering more oxygen.

Run while zipping up jacket.

02:37 - teach junior doctor how to intubate (put a breathing tube in the windpipe).   Impressed: junior manages it first try!  Patient extremely ill - frothy pink secretions are bubbling up the tube: Diffuse Alveolar Hemorrhage (DAH) likely.  Requires constant suctioning to keep clear.  

02:45 - a little more story, apparently was drinking some homemade rice alcohol.  Quite a lot of it.  suspect it was adulterated with other chemicals - some pesticides cause DAH.

02:50 - troubleshoot suction machine.

03:12 - one of the guards looks in to see what the excitement is.  Stays to watch a few minutes.

03:30 - patient temporarily stabilized.  Bedside ultrasound confirms it's not the heart, so DAH it is.

03:52 - check on guy with the tender belly.  Improving.

04:00 - DAH again.  Trouble with secretions clogging the tube.  Attempt re-intubation with larger bore tube - won't fit, revert to original tube.  more suctioning.

05:00 - eventful hour.  Patient quite unstable - now on IV pressors to keep blood pressure up.  Having trouble maintaining saturation even with ventilation.  This bodes ill.

05:15 - realize two patients on the ward can see through the door into the ER and have been watching us work the last few hours.  They appear fascinated.

05:32 - we can do no more than we're doing.  As I head home to sleep for an hour or so, I hear the mosque turn on it's PA system and begin the 5:30 Azan (call to prayer).

08:00 - patient with chest pain rolls in, swallow the last of my coffee...

Thanksgiving

Jennie Brownscombe's 'First Thanksgiving'

Happy Thanksgiving!

Tonight I was asked, with about 10 minutes warning, to give a short speech about the history of Thanksgiving in the US in front of about a hundred people with a purpose of tying together the themes of unity and gratitude.  I thought about Peter Willard saying, "Always be ready to....."

Gratitude, in Bangla, is 'shogotom'.   To say, "I'm grateful", you say, "Amar onek shogotom ache."
The interesting thing about the grammar is, were you to try and translate it back to English literally, it would be roughly: "There is a great deal of gratitude of/to me".  What fascinates me about this is that gratitude is external to us, as though we are recipients or conduits of this other thing, this gratitude, that we are experiencing.

The Osler Hearing Aid

Sir William Osler was the father of modern medicine; he wrote the first western medical textbook and founded several major training programs that still exist today - including mine.  He was dedicated to medicine to a degree we seldom see, but he was also a man of letters with a broad knowledge of literature, classical languages and a knack for pithy aphorisms.  One of my favorite is, "Look wise. Say nothing, and grunt.  Speech was given to conceal thought." (You must imagine facing a new patient with a very peculiar story - you need time to think - so pinch your chin, looking thoughtfully over your glasses, and say "hrrmmm.'').

I served on the Osler medical service in inner city Baltimore from 2000-2003.  Serving on 'the O' was exhausting, often difficult, occasionally cruel, but never, ever dull.  Inner city Baltimore was, while not quite as poverty-stricken as Bangladesh, quite similar.  Oh the stories...

We had bright blue and yellow disposable stethoscopes on the 'O' used for patients in isolation due to 'superbugs' - multi drug resistant bacteria.  We used to use these stethoscopes to talk to particularly hard-of-hearing patients, like this:

The Osler Hearing Aid, imported to BD

It worked remarkably well.  I particularly recall one elderly african-american gentleman who I could get no straight story about - I'd been told he was demented.  Family was not around and he seemed apathetic - he would neither answer a single question nor even look at me.  I learned later that he'd sunk into this apathy because he'd not been able to have a single conversation in the previous ten years due to hearing loss.

I grabbed an 'Osler hearing aid' and, placing it in his ears, asked, "How are you today, Sir?"

He looked up, startled, and said, "I'm fine, thank you!" and what followed was a relatively standard interview, albeit through a stethoscope.  At the end of the interview, he looked at me, with tears brimming, and asked how much a stethoscope cost and where he could get one.  

I answered, "This one is yours to keep when you leave the hospital."  Several months later I saw him walking down the street in East Baltimore, with a bright blue stethoscope jauntily tossed over his shoulder.

Caffeination

Nothing...nothing quite wakes you up like a running-out-the-door-"Hi and goodbye, kids!"-first-thing-in-the-morning resuscitation.

Look around

Looking up 

Homework 

Twighlight

No Exit

Dude.  Far out.

  I was talking with a friend about 2 weeks ago who came here to do conflict resolution training.

  Discussing how often conflict here runs to violence, often lethal violence, we reflected that when someone tries to take what you and your family need to live (like a plot of land the size of our bedroom) what do you do?  They've only taken it because they already bought off the police, and by the time a court case could be heard you'd've long-since starved.  I understand.

  We, on the other hand, always have an exit.  We have a western passport.  Affluence affords the luxury of gentleness and idealism.

Dr. Jekyll and Mr. Hyde

Best light in the morning is in the hall for Dr. J

  Not really, of course.  J is a pretty upbeat friendly guy no matter the situation.  It's just that sometimes he looks like a studious Dr. J and other times like...

Mr. H

  I wrote in 2011 about how we must permit our children some of their heartaches (and, I might add, their failures!).  It's part of what will shape them and give them compassion for others.  Don't imagine, though, that this means we point them in a general direction and then sit back and watch!

  It is equally important to equip them to handle heartbreak and difficult situations.  Ever been a new kid in a new school, especially where everyone else has known each other for years?  It's really tough.  Though J has a couple of good friends, he's had a few rough spots too - other children have been pretty unkind, "You're so bad at volleyball, you stink!" (he'd never even seen a volleyball before), "You don't understand even the simplest Bangla! (said in Bangla, translated by his friend)", and "If you didn't exist, I wouldn't care."  That last still almost brings me to tears.

  

  A few years ago we worked with Jack for a while on social interactions & cues (and still are) but his response then would have made things so much worse for himself.  Now,  instead, he's experimenting with the things we've been trying to teach him, "I tried just laughing along with them and saying, 'yeah...I don't understand, it's true' but they just pinched me and ran away."... Boy, that worked, huh?.  You know all that, "Sticks and stones may break my bones but names will never hurt me." stuff?  It ain't true.  

  Nor can you expect an 11-year old to have the degree of self-confidence it takes to truly shrug off direct insults the way we adults (sometimes) can.  So instead we work on compassion, "Can you imagine, Jack, why he says things like that?  Who do you think said that first to him?  Was it someone important to him?"

  This doesn't diminish the hurt.  It doesn't change how it feels when somebody crushes you.  To say it just 'smarts' doesn't cover it - you never forget this sort of thing.  But maybe it does change how you feel about them afterward, and maybe it will change the future adult. 

Drawing

An example of how differently my children draw:

Primum Non Nocere

Sorry for the hiatus - it's been quite busy!

A little blurry, sorry

We had a most peculiar case 2 weeks ago.  A patient hospitalized for an entirely unrelated surgical issue developed meningitis.  It was concerning but she got better.

Then a young mother in the hospital developed meningitis.  She had just had a C-section.

Then another. And quickly, another.

My colleagues involved in the cases noted that each had had spinal anesthesia, from separate, single-use vials, but all from the same manufacturer.  We switched manufacturers and there have been no further cases.  Interestingly, cultures from each patient and from the anesthetic used are all negative.  It's possible it is a 'chemical' meningitis - irritation rather than infection.  Testing is ongoing.

It highlights some of the unreliability of medications and their purity in developing nations.

Autumn

Well.  Rainy season has ended - it's hotter again, but the hope of cooler weather is one the horizon.

Financial counseling

One of things that takes some getting used to, here, is that finances are probably the major consideration in medical care.  We are understaffed, order fewer tests, and make do with less information in order to keep the cost down.  While we have a 'poor fund' at the hospital, the reality is that paying the bill (several days might run $26 US, a week with lots of tests might run $100 US) is a major hardship for many people even though our bills are between 1/2 to 1/10  that of other private local hospitals.

Once the poor fund has determined what you should be able to pay (and they are generous) it's then up to you to find the funds.  That generally means selling something or borrowing from everybody you know.  Now imagine you get sick again: you've already borrowed from everyone you know and that extra 90 cents a week you're able to scrounge after food is busy paying off everyone you borrowed from.  Can you allow yourself to be readmitted?  No.

So it's not infrequent that people go home then, by choice, with very dangerous conditions.  We do our best give them the optimal treatment in the circumstances.  It can be very hard for families to makes those decisions for loved ones: the decision between your uncle's life and everyone else's food is not an easy one.

snapshots

"Look, I'm a carpenter!" 

"I told you it was loose!"

"Oh no, it's degenerated to banana-fights..."

Anachronism

photo credit: Opa

So... an anachronism is something that is out of place in time.

Our kids are our kids and as a result have familiarity with the music we listen to, but it sometimes can be embarrassing or funny.  AE once, in preschool, was caught singing "When I'm 64" by the Beatles and the next week was singing sea shanties.

This morning the first we heard of her was her walking into the kitchen wailing, "I shot the sheriff..." in a very decent imitation of Bob Marley.  I nearly spit my coffee all over the floor.

Ants in the Milk

With the rains, ants moved inside for the summer.  We hope they'll go back out soon.
If you get our email updates you'll know already some of what we've learned.

The very easiest way to get ants out of your milk powder is to make milk and then fish the ants out afterward, because they float.

A few other things we've learned:

1. Ants are everywhere

2. New ant nests can be anywhere: any drawer, any box, behind a book, under a kitchen towel, even inside the kettle (though THAT didn't last long...location, location,location)

3. If there's even a micron of food on the floor, there will be a troop of ants to retrieve it ("How many ants does it take to pick up a bread crumb?")

4. Ants can pass through solid walls.

5."Doc, I constantly feel like there are ants crawling on me...oh, wait...."

6. All ants bite (here)

7. Don't bite ants (anywhere)

8. Don't ask why the rice is crunchy.

9. And finally... Ants appear to like having pool parties - in our water filter.

Photo Medley

The three on the left are short term doctors, the two in the middle live here and you know the shady looking character on the right.












My fellow workers on the medical ward.















Jack and Will are back at paper modeling.

The view from the beach (our friends' roof)

Braille

Doing the dishes by braille

In Dhaka the power would go irregularly (often with the distant 'kaboom' of an overloaded exploding transformer) -it varied, but seemed to go in fits and spurts; sometimes a month would go by without an outage.

Here in Parbatipur it's a daily occurrence - actually multiple times each day.  The hospital has 3 large diesel generators that start automatically.  However, they take a few minutes to spool up so when the power goes, it's about 3 minutes before it comes back on.  We try to take it stride.

Actually, we try really hard to take it in stride.  Especially when around other people.  If the power goes in the middle of a sentence, or in the middle of raising a bite of food to my mouth, and despite the internal 'jump' I feel, there's no outward sign....if the sentence finishes without a hiccup, or if the bite travels to mouth without the slightest pause, then inside I go, "Woohoo!  I'm so cool!  I totally look like I'm an old hand at this stuff!  I'm so hip I don't even flinch when the power goes out! Yeah!".

Yes, I really am that grown-up.

Unstable SVT

Medical post

It's been a quiet call night - my junior doctor (S) did not call until 5am.

A young man (30 yrs) came with 7 1/2 hrs of chest pain and shortness of breath.  S described the ECG; clearly he was concerned about a heart attack but felt like he was missing something.  His instincts were right: although there were some signs of 'ischemia', or reduced blood flow, on the ECG, the primary issue was an arrhythmia - the heart was beating far too fast.  This was not a clogged artery, but rather a heart that didn't have enough time between beats to get blood flow.  The solution was to try and stop this arrhythmia (a Supra-Ventricular Tachycardia or SVT).

You may be able to see the ECG tracing on the screen of the defibrillator

We tried several maneuvers to 'break' the SVT (culminating in dunking this dignified young man's head in ice water) but ultimately had to do synchronized defibrillation.  We gave him some intravenous valium (so he wouldn't remember) and I handed the paddles to S.  Everyone cleared back from the metal bed frame, S leaned in (looking a bit nervous), pushed the buttons, and.....THUB....for a very long 1 1/2 seconds there was nothing at all.  I think S's heart may have stopped of the same length of time.  Then the heart restarted, in normal rhythm, and the patient's chest pain rapidly receded.

When our hearts don't respond to the usual maneuvers, sometimes they need a shock.

Moo

How are these two pictures related?

A convenient place to dry cooking fuel.

Neurosurgery

Tonight I was called upon to try my hand at neurosurgery for the first time.

Initially it looked bad.  The patient was unresponsive after a serious head injury.

Fortunately, after a highly technical operation of 'stuffing-stuff-back-where-the-stuff-belongs' I was able to complete primary closure with  reasonable cosmetic outcome.

Zebra Crossing

This is a familiar item.  In the US it's a crosswalk, in the UK, a Zebra Crossing (for the stripes).  Of course, here it's funny because it's not even a suggestion of where to cross - nobody knows what it's for.  You cross wherever, just like cars and trucks drive wherever.

W mentioned yesterday that he was thinking of when we'd be back driving in the States, about how we'd be on the, "Right side, I mean, correct side of the road."  which occasioned gentle remonstrance.    While there are things that happen elsewhere that are genuinely wrong, most things that we think are, "Wrong, Unnatural, and Bad." are really just, "Different."  It honestly doesn't matter which side of of the road you drive on, and there really are good reasons why even the left side is just a suggestion.

Many times, if you catch yourself thinking, "That's Wrong, Unnatural and Bad." do a quick double take and you may find it's just "different".  Newlyweds often encounter this!  Two people, from different 'cultures' (families) always have different ways of doing things:

"Don't load the dishwasher that way!"

"Why?"

"It's the wrong way!  They fit more naturally this way."

"But that's not the right way to do it!"

"Yes it is!"

It is very important, of course, to recognize that not everything falls into the 'different' category.  Some things genuinely are wrong.  But you'd surprised how much what we take for granted as, "The right way...." is just "Our way".

One Word

Lice.

Breezy

If by some chance you put it a request at the weather bureau for cooler weather for us, thank you!  The last three days have been delightful, at least up here in Parbatipur.  I was worried about the folks in Cox's Bazar (where cyclone Komen made landfall) but a friend down there assured me it's not bad.
So we've had relatively cool weather and a breeze for several days - it's beautiful.

Declaration

Something occurred the night before last.   I hesitate, but feel compelled to write.  It'll be necessary that I relate this in as detached a way as possible; you'll understand why.  I've never written about something like this before and what I write might disturb some.
As a preamble: I know death - I have seen many, many people die over the last 18 years and it happens quite a bit here.  My job is trying to help them dodge it for a while, but that is frequently not possible.


I spent most of Thursday night at the bedside of an older woman in cardiogenic shock - life threatening low blood pressure from a very large heart attack.  I'm happy to say she survived the night and was improving by the morning (an RVMI, for you medical types).

While I was caring for her, one of the nurses ran in, rattled off something in high-speed Bangla and ran out.  I didn't catch it, but it was easy to hear the urgency.  I followed him to the bedside of a young man, NZ, who was in septic shock on pressors (continuous infusion of medicine to raise the blood pressure - a form of life support).

NZ was in agonal respirations.  Agonal respirations are the last few, slowing, reflexive breaths of a body in which the heart has previously stopped pumping.  They are unmistakeable; the duration varies, but I often note them for a couple of minutes after asystole begins (circulatory death).

He was already on the maximal treatment we could provide (we don't have a ventilator available at this time), so given our very limited abilities and his desperate illness, I had concluded earlier that, should he deteriorate, CPR and 'heroic measures' would be futile.  I stood watching at him for a moment, then leaned in to check for a carotid pulse, listen to his chest, and complete my job.  There were no heart sounds and there was no pulse.  I reported to the staff that he had died and I looked at my phone so I could officially declare the time of death.

As I looked down I saw the nurse who had called me, praying.  As I looked up I saw the patient take in an entirely different kind of breath.  I quickly reached out and rechecked the carotid - there was a pulse where there had been none.  His respirations began rapidly changing in character.  I listened for heart sounds then grabbed a blood pressure cuff - 60/30.  I looked up in consternation, looked back down and rechecked - now 110/60.  After some minutes, he opened his eyes and asked for some water.


Please don't comments on this post: I need a little time to just think about it.

Whining

OK. I don't normally like to complain, but the 'RealFeel' temperature today was 124degF.

Pukur

The Pukur is where we swim as a family with the local water snakes.  With the recent rain it's really filled up and the boys have been practicing back-flips off the little platform.

This Close

It's after one, and I'm about to drop off.  This post is not for kids.

So... doctors have 'clouds'.  Imagine a little cloud that follows you around - kind of like Charlie Brown.  If you have a black cloud, you seldom sleep on call and it's always busy.
If you have a white cloud, you usually sleep and have quiet call nights.

During residency I was voted runner-up for "Most likely to develop bedsores while on call".  It may not have been meant entirely kindly (most of the awards weren't) but I think I took it pretty well.  :)
I've always had a white cloud.   This past week, though...

The first night was the worst night of my professional career for mortality.  I lost four patients in one night.  While I'm told it's not that uncommon here, I've never even come close to that many deaths in a single night before.

The next call night was again crazy - no deaths, but I came home spattered with blood and some other stuff.  You remember "ER"?  I always said that real life wasn't quite so fast-paced.  Well, it can be.

Tonight is quieter.  I expect to lose one, or less likely, two.  You are close to death here.  So close, it's as if you were sitting down for coffee and a chat with it regularly.  My part is delayed - I must wear a cloak of professionalism to insulate me when I need to function despite being a few feet from a wailing mother and baby whose husband-father is dying under my hands.  But if you are the family, or the patient it's really close and really personal.

Do you have questions in your life you prefer not to think about?  Are there big ones: the life-changers - that you ought to think about but it's easier not to?  Don't put them off.  There's no time like the present and they are worth answering.

It's Raining...

...and we have eleven children in our apartment.

Trouble

Pancoast's

There may be a few more medical posts these weeks as I am working a lot while 2-3 other docs are away.

That big white thing in the upper right lung (your left) shouldn't be there.  It is a medical student quiz question: a Pancoast's tumor.

These cancers often damage very specific nerves and medical students the world over memorize the rhyme, "Meosis, Ptosis, and Anhidrosis".  Ptosis (toe-sis) is a droopy eyelid on the affected side.

In his case there is nothing I can do aside from offering consolation.