New high school football season advice-don't let your babies grow up to be defensive backs

 Extracted from an article  from AANS regarding traumatic brain injury (TBI) data from 2012:

Defensive backs in American football are at the greatest risk for both fatal head injury and serous cervical spine injury.:

"The majority of catastrophic injuries occur while playing defensive football. In 2012, two players were on defense and one was in a weight lifting session. Since 1977, 228 players with permanent cervical cord injuries were on the defensive side of the ball and 55 were on the offensive side with 44 unknown. Defensive backs were involved with 34.6 percent of the permanent cervical cord injuries followed by member of the kick-off team at 9.2 percent and linebackers at 9.5 percent."

Spending even a small amount of time watching high school,college and professional football on TV makes it seem obvious that the vast majority of high impact collisions occur in the defensive zone involving defensive backs and either runners or receivers and on kickoffs.Quarterbacks receive many hits with the helmets impacting the ground and have a significant risk of concussion but apparently have  lower risk of fatal injury or injury leading to permanent disability.Offensive and defensive  linemen may receive more sub-concussive head blows over a game or a season and whatever the long term consequences of that may be  seem less likely to regularly  be involved in high impact collisions and therefore less at risk for serious brain or cervical spine injury. There is a reason for ambulances to be  parked near the playing field of high school football games attesting to the cognitive dissonance of some of  the  parents cheering them on.The EMTs are not on site to help manage sprained ankles.

Don't let your babies grow up to be defensive backs.

Notice: This is a lightly edited and altered version of an earlier commentary on this blog. As  I see high school kids  on the practice field in early August in Texas with heat indices pushing 105 my antipathy to high school and youth football  flares again.

Another football season begins, what do we know about sports related head trauma

What do we know about head trauma in high school and college football?

Mild Traumatic Brain Injury ( mTBI) encompasses the clinical entity of concussion. Concussion is defined as a trauma induced alteration of mental status with or without loss of consciousness.

Considerable research has been published regarding concussion and recently  research has been published about the multiple blows to the head that occur in all levels of football in  the absence of a recognized concussion. These "sub-concussive blows" have become the target for various types of brain imaging and cognitive function testing and the results have raised concern about the long term effects on the brains of highs school and college players.

 Some of what we know is :

1.While conventional MRIs and CTs in concussed high school and college football players are normal , Diffusion Tensor Imaging (DTI) and functional MRI have shown abnormal findings some of which may persist for weeks or months. Additionally subtle impairments of verbal memory and other cognitive tests have been reported in concussion cases persisting past the time during which the player has any symptoms.The long term significance of these finding is not known.

2.Similar imaging findings and cognitive testing results are being reported in high school and college players after a season of participation in football even thought the players had no reported concussive event.

3.We know that football helmets do not prevent concussions.

4.We know that at least  some  college level contact sport athletes decades later show abnormal white matter by Diffusion tensor imaging and lowered test results on cognitive testing but again we don't know if these changes are a predictor of later symptoms of CTE.

 Some of  what we don't know is :

1.We do not know what pathological changes underlie the imaging findings. Do the scan results indicate transient damage and tissue repair without likely long term sequelae? Is there a recognizable subset of these players with these findings who if  they continue to be exposed to multiple head blows over many years will develop Chronic Traumatic encephalopathy (CTE)? How can those who may be destined to develop CTE be distinguished from the vast majority of players who never will  have those problems

From  the wide range of head hit exposures in those NFL players who have been diagnosed with CTE the obvious implication is that there must be a fairly wide range of thresholds. There are reports of NFL players with as little as five years of play showing  typical pathological findings at autopsy. Further there has been at least one case of a college player diagnosed with CTE.


2.the long term cognitive changing on various tests  and brain imaging abnormalities have been   demonstrated  in  contact sport athletes in college and high school who did not experience a concussion.

 After the last high school football season ending there were reports of 13 fatalities.   This is about average for the years following the meaningful changes made in the rules and the instruction of techniques of blocking and less dangerous ways to tackle. Better helmets probably prevent skull fractures but not concussions.Can you imagine the outcry if high school boys were forced to take part in an activity that results in deaths each year?

See here for details  of some  of those deaths. Tragically it seems that two were due to heat stroke, all were not due to head injury.In reading over the cases it seems reasonable to designate two of the deaths to the second hit syndrome.

You see the same parents who carefully made sure their kids did not ride tricycles without  wearing helmets are some of the same ones watching and yelling at Friday night football games and probably do not see the irony  of common practice of there being an ambulance at the stadium. If their son is the victim of the second hit syndrome, probably an ambulance won't help.

Note: Much of this posting is a rewrite of another commentary from last year which I shamelessly re-post  now with only  a few additions  because this topic is one I obviously feel strongly about .I used to really enjoy watching professional and college football on tv now I only occasionally watch  just to sample the action to notice obvious head trauma. Professional players increasingly are able to make some effort at an informed decision to play with considerations of the risk to their brains, high school kids and younger much less so. 

Grief Counseling-who benefits? hint- who get paid for it?

Bringing in grief counselors seems to be a fairly common occurrence. We hear about it when a tragedy, such a shooting at a school, occurs. We are told that such specialists are being brought in to do whatever they do to help the students cope with their loss.

There is even an organization through which one can be certified in grief counseling,the American Institute of Health Care Professionals. They also offer other certifications including "Health Care Life Coach".

Apparently the basis of grief counseling has been undermined in recent years by some published data. To add a veneer of fairness I mention this article which critically reviews articles that have claimed actual harm from the process focusing on two papers which they believe are flawed and have unduly damaged the reputation of grief counseling.

A 2007 Newsweek article quotes some research that demonstrated actual harm ( mainly prolonging of the symptoms for which they were treated) from grief counseling and claimed that solid proof on its efficacy is lacking.

Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of the physician and the patients but presumed to define what the relationship of the physician  should be to society. The physician was to strive for social justice and was to act as the "steward of society's " finite medical resources.

Implicit in the stewardship of resources notion is the egalitarian concept of the collectivization of  privately owned resources i.e all of the assets and individual skills that constitute the medical resources. This is the view that resources as a whole should be considered as the common asset of everyone with each to have a right to their share or that the resources are "owned" by everyone.  This notion is antithetical of the notion of private property and seemingly ignoring the key role of  private property concepts as the basis for civilization, At least that is what David Hume,Adam Smith, John Locke and founding fathers thought about the importance of private property.

Owned is in scare quotes because the concept of ownership in a free society with rule of law entails the right of the owner to use his property,to exclude others from use of his property and the right to dispose of the property.If everyone owns the resource then no one owns it and no one could be excluded from use of the property.

All of the  medical resources of the United States cannot in any real sense or legal sense be owned by everyone. So the common ownership rhetoric must be metaphorical and physicians as stewards of the resources must be rhetorical as well. It is a poetic way of saying the physicians should rein in the ever increasing cost of medical care. Further they can do that  by ordering fewer tests and procedures and treatments,that they should abide by recommendations based on studies of cost effectiveness of various medical options, that they should not let their concern and duty to the individual patient override the collective good which will be brought about by doing what is best for the group and what will be best will be determined by the progressive medical elite.Just follow the guidelines,Doc.

The 4th of July, Pride and "How Can I help you/"

This blog is for the most part about medicine and the practice of medicine so quoting extensively from a economist's blog might seem off track and one may wonder what if any is the link to medicine. This recent posting by George Mason University's professor, Don Boudreaux is so congruent with my core beliefs and he expresses them so well  that I have to quote him.

Broudreaux's topic is why, on the 240 th anniversary of the United States, we should be proud to be an American. See here for the entire essay.

Quoting from his blog, Cafe Hayek:

"...I’m proud of the peaceful manner in which most Americans conduct their private affairs.  I’m proud of the widespread respect for private property that continues to govern people’s personal, private relations.  I’m proud of the entrepreneurial spirit that continues to exist among many of my fellow denizens of these United States.  I’m proud of – and deeply grateful for – the innovativeness and entrepreneurial creativity of many of my fellow Americans.  I’m proud that America continues to be a destination for people seeking better, freer lives.  I’m proud that many Americans continue to believe that the most ethical course in life is for each individual to be self-responsible, self-supporting, hard-working, honest, and upright.

I’m proud, in short, of America’s bourgeoisness.  It’s this bourgeoisness that has made America great.  This greatness comes not from bellowing politicians, not from well-weaponed armies, not from arrogant judges, not from meddling bureaucrats, not from pompous Washington and New York and San Francisco pundits; it comes not from anything but the hundreds of millions of ordinary Americans who daily work hard, honor their contracts and other people’s property, cherish their families, friends, and neighbors, and think it perfectly natural to ask strangers in commercial settings “How can I help you?” "

 It has always seemed natural for a physician to ask that same question upon seeing a patient. In fact I recently saw an orthopedics for pain in my calf who asked that exact question.

As I read commentaries about the MACRA proposal and the nearly 1000 pages it takes to describe the process I wonder how long as the bureaucratic interference levels continues to increase and impede medical practice  will it be before that question will be merely perfunctory as more and more time and effort will be drained  away in an effort to go by the rules of " quality care" and properly document them so the reimbursement  will be 3 or 4 % more or less ( see here) and less available to do what is needed to help the patient.

Addendum; For an excellent  review of how MACRO will change just the "Meaningful Use" program (and there is much more to it than that) see here.

 h/t to Margalit Gur-Arie on her blog "On Heath Care Technology"

The last refuge arguments for central planning find a home in health care discourse

The economist and historian Dierdre McCloskey put it this way ( my paraphrasing). If some one glanced at what happened in the twentieth century and still believed in the value of central planning, they were not paying attention.

The Marxian dreams and even the subsequent efforts of the market socialists such as Oscar Lange ended badly or sometimes never really got off the ground. Things ended   badly in the case of the USSR and Communist China wherein the promises of greater prosperity and equality ended in mass starvation and mass murder.The 1917-1991 gigantic social experiment was a failure.

 The contrast between East and West Germany and North and South Korea could not be more striking and devastating to the devotees of socialist planning and their advocates  had to find arguments not based on economic success.

The economist Anthony de Jasay in his book Political Economy,Concisely  discusses what he considers to be   the two last refuges of the socialist central planner;the plea for social justice and the doctrine of unequal exchange.

We can find versions of both in the rhetoric of the defenders of the Affordable Care Act (ACA) and in the pronouncements of the medical progressives whose major premise is that medical care is too important and complex to be left to the individual physician and patient and that we must have wise leaders with ideas to replace the traditional "dyad" of the patient and physician as the deciders of medical care .


."The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design." FA Hayek from The Fatal Conceit

Exercise associated collapse

The term exercise-Associated Collapse (EAC) as used by Dr. Tim Noakes of Cape Town South Africa refers to athletes collapsing after completing a marathon or longer event, though the term more generally could refer to anyone collapsing during or after an endurance event.

Noakes writing specifically about the endurance race event collapse is describing a runner who typically finishes the event and then feels lightheaded, possible nauseated and may indicate that he feels like he will faint. The blood pressure is low in the 100 to 110 range with a mild tachycardia in the 110 range. Noakes emphasizes that the appropriate intervention is to elevate the legs or low the head below leg level. This maneuver, in his vast experience will bring about recovery fairly quickly without the use of IV fluids. This approach received some documented support from a small randomized trial recently published by Noakes and co workers. See here for abstract.

Although the runner will be to varying degrees dehydrated, or volume depleted, Noakes indicates that the faint is not due to the volume status per se. Rather the mechanisms he postulates is as follows:

The post exercise collapse ( as opposed to the collapse that may occur while exercising which brings to mind a number of other more serious possible causes ) is due to postural hypotension related to several factors.

With exercise in the heat there is increased blood flow to vessels near the skin leading to a redistribution of blood to the peripheral veins ,more so as the ambient temperature increases.

Next the action of the calf muscles, while exercise continues, will reduce the volume of blood stored in the lower limbs and maintains an adequate venous return to the heart. When exercise stops, the calf muscle mechanism for venous return decreases and blood accumulates in the dilated venous system leading to decreased venous return and hypotension in the upright position.He also suggests that in the trained athlete there is a blunted compensatory increase in heart rate in response to a lowered blood pressure further increasing the likelihood of faint or near fainting.

So the treatment is the standard treatment for what used to be called vaso-vagal faint namely the Trendellenberg position. He believes that dehydration is not the cause and volume repletion is not the treatment, although obviously volume replacement is appropriate but can be done orally.

Noakes in his book ,Lore of Running, 4th edition, says that approach has worked well in his vast experience in the medical tent after the Comrades ultramarathon in South Africa.

Key information to management of the collapsed athlete is the following;

Location of collapse (i.e. while running versus after the race)
Level of consciousness and cognition (altered states suggest something more ominous that benign post exercise hypotension-particularly exercise associated hyponatremia )
Rectal temperature greater than 40C ( 104 F) means heat stroke.

Noakes and others have emphasized the importance of prompt measurement of serum sodium and blood sugar. Serum sodium less than 120 plus altered mental status should lead to administration of 3 % NaCl.

This preventive medicine stuff is not easy

Case in point  is in regard to hormone replacement therapy (HRT) for menopausal women.It has not been easy to get that right.

The stylized facts of the history of that effort briefly are:

Use HRT widely as heart disease will be prevented plus the usual listing of such things as better skin,lessened hot flashes,improved mentation and all of the advantages of being younger rather than older.

Give HRT to almost no one as actually it increases not decreases incidence of heart disease.Yeah we got the sign wrong.And then there was the issue of increased blood clots and cancer risk.

Then  a study demonstrates decreased incidence of clinical heart disease if the HRT is given early after the onset of menopause.The earlier data that demonstrated increased heart disease was derived from a study of older women who received HRT later after the onset of menopause. This suggests that a major determinant of outcome is timing.

See here for the more recent study on HRT in which women received HRT soon after the onset of menopause which demonstrated a decrease in the incidence of clinical heart disease.

Preventive medicine is not rocket science. The rocket scientists know with impressive accuracy where the rocket will come down as the law of physics applicable to that application are pretty well worked out. Preventive medicine is much harder.

addendum: See this essay on the arrogance of preventive medicine by Dr. David Sackett. Preventative ( the once incorrect term is now acceptable) medicine, of course, is a cornerstone of "population medicine" with its arrogance magnified.

Information voltage drop-not just a hospitalist issue

I recently read that hospitalists have a term for one type of failure to communicate namely "information voltage drop"

This refers to the information relevant to the patients discharged from the hospital not reaching the outpatient "health care entities", eg the nurses at the nursing home and/or the doctors who don't go to hospitals i.e. doctors doing the primary care. This would obviously would not be a problem if the physician in the hospital and the physician in the office were the same person as it was typically in the heyday of the general internist.

It is , of course, a multi-two way street, information from the primary care docs do not always get to the hospitalists in a complete accurate form. reports from tests in the hospital may not get to the chart in time for discharge, etc etc.

 A google search yielded 131,000 hits for that term in quotes. The blog "notes form dr.rw" recently discussed the important issue of the drop of key information from the hospital setting to the post hospital care. I has seen it repeatedly in my mother-in-law as she veered  from nursing home  to the ER and then hospitalization.On one occasion her dose of  Remeron (mitazapine) was not given for weeks in the nursing home due to nursing oversight and then started back in the hospital at the dose the docs thought she was taken resulting in near coma and a neuro consult.

Voltage drops can occurs in very short times and distances. I informed at least 6 different medical personnel prior to a invasive cardiac procedure , one not fifteen feet and four minutes before an IV bag was hung containing the same mediation regarding which  I had repeatedly mentioned a personal  allergy.Fortunately the dose of Versed I had received  was low and I  could protect myself.

Does the Conflict of Interest statement in medical journal articles really mean anything?

 I am beginning to think that the answer to the question in the heading is no.Thinking about a article in the NEJM published at the time of the run up to the passage of Obamacare and who the authors are probably shaped my opinion.

In the August 1,2013 NEJM a special report is published entitled "Prescription for Patient-Centered Care and Cost Containment" The authors are Thomas Daschle, Pete Domenici,William Frist and Alice Rivlin.The article predictably is in favor of the Accountable Care Organization and opposes fee for service in medicine. The article is not remarkable  for its content.That could have been predicted from the names of the authors. What I find remarkable- but not unusual or atypical- is that one of the authors who is a principle in a venture capital firm that invests  in health care businesses states that he has no conflicts of interest and that his business interest would not even possibly be conceived as such.

Dr. Frist's credentials are well known as he is an accomplished cardiac and transplant surgeon and former US Senator.His family's association with Hospital Corporation of America is also well known and Dr. Frist is not now associated with that organization. A few minutes of effort on the web yields considerable information about his current business interests at the time of the article's publication.

He is a partner in a venture capital firm, Cressey and Company,which specializes in health care related investments.These following are listed under partnerships on their website: 1)equity partnership in US Renal Care,a large private dialysis enterprise,2)Encompass Home Health,a provider of hospice  and home health care with over 100 locations in 12 states 3)Jazz Pharmaceuticals 4)Select Medical which owns rehab and long care facilities, 5) Spine Wave Inc  6)Strategic Heath Care Program 7) Wound Care Specialists.

Section 5 of the ICMJE form , which authors of articles are obliged to complete and  which can be accessed for all of the authors on the NEJM website states:

"Are there other relationships or activities that readers could perceive to have influenced or that give the impression of potential influencing what you write in the submitted paper?" (my underlining)

Dr. Frist and the others all answered no to each of the questions.

At the very slight risk of appearing cynical I suggest that his relationship with Cressey just might " give the impression of potential influencing" to some readers.  The words potential and impression seems to make that question one that would be hard to answer in the negative if someone were involved in just about any aspect of health care.

 I wonder how many readers might consider the article in a different light if following the article there was a statement that Dr. Frist was a partner in a firm whose income stream is dependent  on various health care entities. I'll bet more than a few readers might just think about the potential of influencing even though Dr. Frist is not on the actual boards of the companies in which he invests nor is he likely to be involved in anyway with the day to day operations of these businesses.Is the ICMJE form and the manner if which the form is answered really provide any useful information to journal readers ?  Do the editors of medical journals need to have any oversight over the ICMJE form answers?Does the COI statements appearing regularly in medical journal mean anything at all?

I am not suggesting that Dr.Frist's views on the various topics covered in the NEJM article were determined or even influenced by considerations of what the author's  recommendations would have on the income streams of the various health care business entities in which he is invested.But it is certainty possible that readers of the article just might get the impression of potential influence if they were informed about them in the COI statement.

Managed Care and "learned helplessness" and medical professionalism

Health Care Renewal in the Sept.22,2006 posting referenced comments by the editor of The British Medical Journal,Leona Godlee, suggesting that physicians in the British NHS may have been so beaten down by their increasingly dysfunctional system that they seem unable to stand up and fight back as their medical professionalism demands. Roy Poses then links their behavior and some he has witnessed in physician's seeming inability to push back at the administrative forces that are squeezing the life out of American medical case to the concept of "learned helplessness."

From that reference and Google I learned that "Learned helplessness" is a term born in the 1960 psychology experiments in which animals "learned" that they had no control over a given experimental situation. Later, when the animals were placed in a different situation in which they had control, they remained passive and were unable to act . Actually only about 2/3 of the animals learned helplessness in that way, the others were able to solve a simple problem to escape a electric shock.(About 5 % of animals seemed to be rather helpless even before the conditioning.) That work by Martin Seligman lead to a theory of depression.

I have written before about some of the ways that Managed Care has damaged medical professionalism in this country. Examples abound. No longer are consultations routinely arranged by physicians based on their personal knowledge of the clinical expertise of the consultant but rather to someone on the patient's insurance plan. Medications sometimes are chosen more on the basis on the insurance company's pharmacy management's arm formulary than on the basis of the physician's judgment. Time pressures directly or indirectly shaped by HMO and Managed Care have placed physicians in the untenable situation of not having time to deal with the patient's problem(s). Approval for testing and procedures have to be pleaded for.More and more time is wasted checking off boxes purported to capture the "quality" of care that the health care professional delivers that is the future will be more determinative  of the physician's compensation.

In an earlier posting, I considered the notion that not only have the practices of managed care-which would not have occurred if we had not agreed to go along with them-seriously eroded the physician-patient relationship but also the relationship between physicians.

Dr. Godlee's editorial was aimed at the British physicians but are U.S. physicians far behind in the areas of learned helplessness and diminishing professionalism? To not speak out against the practices and structures of managed care that clearly are detrimental to patient care, and to go along to get along would be about as antithetical to medical professionalism as anything I can think of. Some of the current behavior of physicians may well be characterized as learned helplessness but in the early days of managed care our failure to act must have had other origins as we had not yet had time to learn to be helpless Moreover  the new Professionalism, as envisioned by the ACP and the ABIM and the Robert Wood Johnson Foundation  meshes neatly with the learned helplessness . By following guidelines physicians can work for the common good and further social justice all the while not feeling helpless at all. 

Note: Obviously the reference to the BMJ article is not breaking news. In reviewing drafts of earlier blog commentaries I realized I had neglected to post this one.

Worried about your health care?Do not fear, the Medical Platonic guardians are gearing up

Plato envisioned a utopian society ruled by philosopher kings,leaders with ideas. Brilliant and knowledgeable, logical and devoted to the good of the crowd. Even back then the question was raised, "who will guard the guardians?" or "Quis custodiet ipsos custodes?"

The platonic ideal has persisted through the years since Plato pontificated.Currently those whose world view echos Plato are called progressives or [modern day]liberals as opposed to the classical liberals who hold the opposite view.Also, from what I've read the neo-conservative Leo Straus was a bit enamored with some of Plato views on government.

A apparent modern Plato fan is H.J.Aaron who has had three commentaries in the Perspective sections of the NEJM in the last year. He seems to be their go-to guy for his Platonic mindset and particular for  IPAB issues.Here is a link to  a sample of his views.


He praises Congress for their willingness to "abstain from meddling in matters they are poorly equipped to handle." ( Well, that would be a first) He seems to be aware of Public Choice theory (he has a PhD in Economics from Harvard) when he talks about the temptation of Congress to spend money for political ends but seems to have missed the point when he apparently assumes that the IPAB panelists would be immune to lobbying efforts.Clearly, he believes it is a good and desirable thing for Congress to delegate its powers to agencies and other bodies- a view somewhat in opposition  to what James Madison envisioned but a major feature of the administrative state.

He likens the creation of IPAB to the creation of the Fed Reserve which was to be an entity not subject to congressional control set up a governmental entities largely not controlled by Congress.

IPAB is not much in the news currently as the legislative trigger for its activation has not been pulled  but be aware it is still on the books and is available to be the mechanism by which selfless, wise leaders will direct health care miraculously immune to pressure from  lobbyists representing interests that Madison referred to as factions.

Politicalization of medical ethics-you have to ask why and by whom

The politicization of medicine is cogently  discussed  by Dr. Thomas Huddle. See here for an abstract of his article.

First, with the publication of the Charter, Professionalism in the New Millennium in 2002 the notion of social justice was injected into the listing of attributes and behaviors that physicians should exhibit to act professionally.Rather than a well reasoned and documented  argument for such action being presented by the authors, we saw a series of gratuitous assertions.

Subsequently a commitment to social justice was declared to be an ethical imperative in the American College of Physicians'  (ACP) ethics manual. Other professional organizations followed suit pledging at least rhetorical support of the inclusion of social justice into their ethical propositions.

 Dr Huddle, who teaches at University of Alabama Medical School at Birmingham, says in part:

1) civic virtues are outside the professional realm, (2) even if civic virtues were professionally obligatory, it is unclear that civic participation is necessary for such virtue, and (3) the profession of medicine ought not to require any particular political stance of its members.

"Advocacy on behalf of societal goals... is inevitably political".

" civil virtues are outside of the professional realm" and " the profession of medicine ought not to require any political stance".

Requiring a commitment to social justice is clearly  political and requires physicians to take a particular political stance and a particular philosophical position..Advocacy for social justice is one feature of the modern liberal or progressive political stance.Such advocacy is not typically part of the conservative political viewpoint or the libertarian ( aka classical liberal) position.

The notion of justice upon which which the country was founded  was that of the justice embodied in the rule of law,i.e. treating everyone equally under the law. The foundational notion of the social justice line of thinking is essentially that treating folks who are unequal equally is unfair and unjust and therefor there must be societal ( i.e governmental)  effort to mitigate inequality by  re-distributional  and other coercive  efforts of the state.

The physicians who authored the Charter and the ACP's new ethics would appear to be of the progressive belief system  while there are many physicians in the country who are not. A small group of what I have labeled as the "medical progressive elite" have seemingly captured the conversation and are attempting to  profoundly alter traditional medical ethics.To the extent that they and similar minded individuals set the agenda of major medical professional organizations and medical students education they may have succeed. but I wonder how many practicing physicians are even aware of the views that they pretend to be a settled issue.

Why would such an effort be launched and well funded ? Who gains from efforts  to bring about a sea change in traditional medical ethics? The answer to that may be found in the plan that the elite medical progressives later introduced to enable practicing physicians to on  a day by day basis practice social justice.Simple they just had  to follow guidelines .In that way there would be an alleged greater benefit to the collective -although sometimes at the expense of the individual patient-and presto we have a utilitarian form of social justice with the collective and of course third party payers benefiting.Is this the "why"?


Note: An shorter version of this essay had been published previously. I redo it now because sadly a version of social justice seems to be firmly appended to medical ethics,on paper if not in practice and few voices are heard in opposition.I find physicians believing that they should work for the good of the group or the collective or society a very frightening notion, one with a slippery slope  as evidenced by what went on in collectivist societies in the last century.

Presidential Election 2016-the wisdom to choose.

Thomas Sowell laments the choice that we are likely to have in the upcoming presidential election.In a recent commentary entitled "Grim Choice" ,he writes that the November election will offer a choice between a "thoroughly corrupt liar and an utterly irresponsible egomaniac".“



"More than any other time in history, mankind faces a crossroads. One path leads to despair and utter hopelessness. The other, to total extinction. Let us pray we have the wisdom to choose correctly.” 

 Woody Allen

More thoughts on correction of severe hyponatremia

In adults electrolyte issues have traditionally been the arena in which internists ( and I guess now mainly hospitalists) earn their fees. Here is an interesting take on the correction of severe hyponatremia.

Severe ( often defined as less than 120) hyponatremia is typically considered as an medical emergency. Discussions regarding it usually consider acute hyponatremia ( as in runner's hyponatremia) and chronic. In the former some urgency exists in regard to treatment as the concern is brain swelling and catastrophic brain herniation. In chronic, too rapid correction runs the risk of osmotic demyelination.

Beer potomania is part of the differential diagnosis of hyponatremia. This article provides gives data on alcoholic patients with hyponatremia and explains several mechanisms for the low sodium other than what is usually thought to occur in beer potomania syndrome.

At least one labor union fails to recognize the social justice of Obamacare

Apparently the roofers union believed the administration's claim that if you like your health care insurance plan you can keep it. Now they finally seem to have realize the bogus nature of that pre ACA passage ploy.

See here for the union leaders statement asking for repeal of at least some of ACA.

" I am therefore calling for repeal or complete reform of the Affordable Care Act to protect our employers, our industry, and our most important asset: our members and their families.”
 

addendum: My apology. This post clearly is old news .In reviewing my store of unfinished drafts of posting I must have hit the publish button my mistake.5/31/16

The determinates of the stiff aging heart and what if anything can be done

Diastolic heart failure had been for the most part a diagnosis of exclusion.Symptoms and physical signs of heart failure (Hf) and an elevated natriuretic  hormone level in the face of a normal ejection fraction (EF) as determined by echocardiography or  gated myocardial perfusion imaging are the elements of the diagnosis.More recently echo studies of flow through the mitral valve opening have allowed a diagnosis of inclusion based on various indicators of diastolic flow and ventricular filling but evidence of diastolic dysfunction is not sufficient to make the diagnosis of diastolic heart failure with preserved systolic function abbreviated as HFpEF.

In the classic physiology text book's 70 kilogram man the stroke volume is 70 ml and the volume of  blood poised  in the left ventricle at the end of diastole is 120 ml, and the volume at the end of systole is 50 ml giving a EF ( 70/120) of 0.58 ( 58%)) where EF = EDV-ESV/EDV, Clinicians like to use the term pre load. Pre load is the end diastolic volume.

But the percentage ejected per beat is not even close to whole story of cardiac pump function  because first the ventricle has to fill and it has become apparent than at least as many patients have filling problems as have lower ejection fractions. The HF from filling problems is known as diastolic failure or in the jargon HFpEF ( heart failure with preserved ejection fraction) as opposed to HFrEF (heart failure with reduced ejection fraction)

Of course all patients with HFrEF also have diastolic dysfunction., i.e.failure of normal filling of the ventricles.

Echocardiography has become the major tool to diagnose  diastolic dysfunction. Doppler techniques measure blood flow early and late in diastole.In the healthy compliant  heart most the flow occurs early and that phase is is designated the A phase and the second phase is the E phase and the E.A ratio has become a useful indicator of diastolic dysfunction. As the ventricle become more stiff , for whatever reasons,the ratio of  E to A decreases and diastolic filling relies more on the atrial kick phase.

A model or  stylized working hypothesis concerning the heart stiffness has been proposed in which  two major elements. are considered: 1) reduced compliance which is defined a change in volume/change in pressure in the left ventricle The relevant pressure is the difference between the left atrial and left ventricular pressure and 2)  ventricular muscle relaxation.

Compliance is assessed to some degree and imperfectly  by the E and A and E/A ratio and the E/E prime ratio while the relaxation is measured by the isovolumic  relaxation  time of the left ventricle (IVRT) This is the  period after the closing of the aortic value and before the opening of the  mitral valve.An increased value denotes poor relaxation.The E/A ratio can be deceptive because as diastolic function decreases,the left atrial pressure may rise to help push the blood into the ventricle which tends to increase the E/A ratio that may have become depressed in an earlier phase of filling problems resulting in a "pseudo-normal" pattern.

To help sort out normal and pseudo normal ratios, tissue Doppler Imaging (TDI) can be helpful. TDI measures the movement of the mitral annulus as it move upwards as the ventricle fills and is designated  as E prime.

It has been recognized that the e/a ratio decreases with aging and some cardiologists recommend using an age adjusted set of value to determine if a value is abnormal just as values for lung function test indices are age adjusted. So is it  normal or is it the case that everyone get a bit of diastolic failure as they get older or for that matter a little bit of lung impairment.It has been suggested than the aging lung is a bit like early COPD.

Several groups of researchers have taken the optimistic view that regular endurance type exercise over the years can help prevent at least some of the age related  stiffness of the heart. There are data that suggest that is the case as at least some groups of older long time endurance athletes have better e/a ratios than their otherwise apparently healthy more sedentary cohorts. However the IVRT does not differ between the two groups, so the impaired relaxation of the myocardium that accompanies aging   does not seem to be mitigated by regular endurance exercise.

The putative underlying cellular mechanisms for increased  stiffness  and the sluggish myocardial relaxation are topics for  another day.Basically the narrative is that myocardial cells die with aging (apoptosis) and the surviving cells hypertrophy plus subendocardial fibrosis develops and maybe long time regular aerobic exercise might mitigate that process a bit.


addendum:5/30/16 Hitting the wrong key lead to publishing a uncorrected version. I think I fixed most of the typos ,etc now .
.

Has medical care reached a near Fubar condition because of the Answering machine?

I argue it may have.

Being a physician and knowing what I know about physicians , the good and the less good, I absolutely hate to go to a doctor. For most of my life I have not had to -now that I have to. I am past being appalled at the near impossibility of having meaningful or for that matter  any communication other than face to face in the office.Some of this failure to communicate is due to the answering machine.

An illustrative real life case.

After the implantation of a pacemaker I experience several somewhat uncommon complications. One week post procedure my heart rate suddenly jumped to 150 . My pacemaker came with a bedside device that enabled me to send data  to the PM center at the hospital .I sent a signal, called the number and was informed by the tech that it looked like I had atrial flutter.   Calls to my EP doctor office were answered by a machine and the only relevant choice was to leave a message for his nurse. No call back in one or two hours and heart rate continues at 150, a value that  exceeded the number that was sent to the PM center earlier. Knowing that atrial flutter is not a real call 911 situation did not keep my anxiety level from mounting.

Finally , knowing this was my ep doctor's clinic day my wife and I decided to go to the office and insist on seeing the physician . As it turned out the flutter has stopped by the time I saw the doctor.

The answering machine has turned into a situation in which the patient is given two options-leave a message and hope that you will get a reply sooner than the next or call 911 (or head directly to the ER on your own) . 

Medicine and the first rule of economics and the first rule of poltics

Thomas Sowell tells us that the first rule of economics is:

We live in a universe of scarcity and there will be trade-offs. and

The first rule of politics is to ignore the first rule of economics.

In this column by Thomas Sowell we see examples of how the economic rule is ignored by offers of pie . I suggest there are offers of pie in the sky in regard to medical care and financing.

Can we have decreased medical cost and increased quality? No problem- all we need in a governmental single payer.(Interestingly the Medical Home advocates sometimes make that same promise although recent analysis from the Congressional Budget Office concludes they really can't tell if it will cost more or less.) Also more recently we are told if were pay for value not volume the same miracle will occur.

I first read about the notion of increasing quality while decreasing cost or at least containing cost in medical care in a series of article in JAMA by Dr. DM Eddy over ten years ago. The bait and switch trick here was for Eddy to redefine quality as the greatest good for the greatest number. Eddy's series of articles seemed mainly to deal with the topic of decision analysis, an area that Eddy had apparently specialized in after foregoing a surgical career but his major thesis was/is that the goal of a health care system should be to maximize the health of the group and individual physician's concern about individual patients is misplaced.Eddy seemed to claim there would be no trade off , we would have both higher quality and lower cost., by simply redefining quality.Of course he is suggesting a system with its own major dangerous  trade-off, namely the nebulous,loose and ambiguous good of the collective ( which will be in the eye of the elite in charge of the medical enterprise) over the much more easily discerned good of the individual.

Enter the decision analyst who can determine what is maximal health and how best to allocate or cost shift to achieve the maximal health of the group. He spoke of health care as a closed system and that it was a "zero-sum"game where for the good of the collective some patients may well be worse off, but although regrettable that is necessary for the greater good the details of which will be worked out by competent decision analysts.

This was an early proposal by the progressive medical elite  for a overt rationing of care that  self identified very smart people would be able to devise for the greater good of the herd. Eddy may well deserve a role in that group of smart people. The rationing that is part of the Independent Advisory Board ( IPAB) which was  part of PPAC but not yet activated  would be, I think, more of the covert rationing variety wherein there would be no explicit announcement of a utilitarian mandate but the board would rather simply say what was effective and ultimately what would be paid for by the third party- government and that would be leaped upon also by the third party private insurers. DrRich ( in a no longer active blog ) had a lot to say about that , see here.

Eddy's polemic is now more than  ten years old and rarely read but others have forged ahead in his footstep. Enter the folks and ABIM , ACP and ABIMF and their program to change medical ethics ,make physicians be considered stewards of a collectively owned medical resource base and  nudge and if necessary coerce physicians to dutifully follow guidelines that should boost the bottom line of the third party payers .

Some of the reasons why (at least some) older runners have decreased heat tolerance

Stimulated by my own frustrating inability in recent years to run as far on my weekend "long runs" as I could just 3 or 4 years earlier I began to search for some physiological reasons. For years I would run  a slow 18-20 miles on Saturday or Sunday throughout the years but in  last 2 years I have basically crashed  around 14-15 miles and was generally wiped out the rest of the day loosing weight from a pre run of 160 to a post run of 152 to 154 in warm to hot weather conditions and having a postural BP decrease indicative of volume depletion.

So far I have found evidence in the literature that at least 4 factors might play a role

1.A age related decreased in nocturnal ADH ( Arginine vasopressin) may cause a nocturnal polyuria.

2.Increased rate of glycogen utilization in older runners.

3.Lower levels of body water in older people.

So that my body water in the morning  was lower to begin with as more water lost in the evening preceding the run and my glycogen stores were more rapidly depleted even after some efforts at glycogen loading  leading to some limiting level of dehydration and glycogen depletion.The relatively meager liver glycogen stores are used during sleep.

4.Decreased V02 max with aging. The  carbohydrate (CHO)/fat mixture changes as a person exercises more intensely and at some percentage of 02 max ( often quoted as about 60%)  fuel source shirts to mainly CHO and little fat so that CHO stores ( glycogen) are more quickly depleted).So maybe in a misguided effort to run a bit faster than I should be,I get glycogen depleted quicker, i.e. after fewer miles have been run. So lower V02 max leading to  quicker glycogen depletion.

 Dehydration in the older runner likely leads to to lower blood pressures post long hot run  as the stiffer ventricle and central arteries respond to decreasing  blood volume with exaggerated blood pressure changes- sort of a Starling curve thing. This of course is an effect and not a cause of volume depletion.