Wednesday, February 26, 2020

M + M: Morbidity and Mortality Conference

© Am Ang Zhang 2018



I had a most enjoyable time on a Viking Ocean Cruise to return to the sad case of a Doctor being struck off. Reminds me of the book I read by Gawande: 




In one of the most moving passages in the book, Gawande’s father, in hospice, rises from his wheelchair to hear his son lecture at their hometown university. “I was almost overcome just witnessing it,” Gawande writes.

........Gawande offers no manifesto, no checklist, for a better end of life. Rather, he profiles professionals who have challenged the status quo, including Bill Thomas and other geriatricians, palliative-care specialists, and hospice workers. Particularly inspiring are the stories of patients who made hard decisions about balancing their desire to live longer with their desire to live better. These include Gawande’s daughter’s piano teacher, who gave lessons until the last month of her life, and Gawande’s father, also a surgeon, who continued work on a school he founded in India while dying of a spinal tumor.
He’s awed not only by his father’s strength, but by the hospice care that helped the dying man articulate what mattered most to him, and to do it. Gawande thinks, as he watches his proud father climb the bleachers, “Here is what a different kind of care — a different kind of medicine — makes possible.”

What would lawyers say about M + M:

- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 


I read Gawande when in Peggy's Cove and posted about his book Complications! Honestly, I did not know Gawande was giving the Reith Lectures. 


Peggy's Cove: Charm & Complications!

What a charming place: Peggy's Cove of Halifax.

The Cockroach Catcher was finishing reading the book Complications and such charming old landscape reminds him of the old traditional medical training he received and how some doctors still do. Like the author of this book.

The book reads more like a collection of blog posts and in fact it was. Yet it was real and touching. Sometimes it was brunt and brutal. and after all doctors are as human as anyone. Complications includes those doctors themselves may suffer: mental illness and alcoholism as well as the serious cardiac condition of the author's young son.

We, doctors make mistakes and please we must be allowed to sort them out without affecting career or worst, future medical behaviour.

A great book for doctors in particular and when on holiday in a charming place.

 (Metropolitan Books, 288 pages, $24), a collection of 14 pieces, some of which were originally published in The New Yorker and Slate magazines, Gawande uses real-life scenarios – a burned-out doctor who refuses to quit; a terminal patient who opts for risky surgery, with fatal results – to explore the larger ethical issues that underlie medicine. He asks: How much input should a patient have? How can young doctors gain hands-on experience without endangering lives? And how responsible are these doctors for their mistakes?
While “Complications” is full of tragic errors and near misses, the book is not intended to be an expose. Rather, Gawande asserts, it is meant to deepen our understanding of the intricacies of medicine. “In most medical writing, the doctor is either a hero or a villain,” he says, with an edge in his voice. “What I am trying to do is push beyond that and show how ordinary doctors are – and at the same time show that what they can do is extraordinary.”
John Freeman, Copyright (c) 2002 The Denver Post.

Quotes


- ‘There have now been many studies of elite performers – international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth – and the biggest difference… is the cumulative amount of deliberate practice they’ve had.’


- ‘We have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seem to help. But there is still getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of a colon… the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented… By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden behind drapes and anesthesia and the elisions of language.’ 


- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 

Saturday, February 15, 2020

Celebrity & Other Suicides: Maudsley & Lithium!

One of my ex-juniors, now retired, called to ask if I have read about another celebrity suicide. How very sad! If we look back there has been many such suicides and it is sadder that many are very talented people.                  


Dr. Baldessarini of Harvard:


“Lithium is far from being an ideal medicine, but it’s the best agent we have for reducing the risk of suicide in bipolar disorder,” Dr. Baldessarini says, “and it is our best-established mood-stabilizing treatment.” If patients find they can’t tolerate lithium, the safest option is to reduce the dose as gradually as possible, to give the brain time to adjust. The approach could be lifesaving.
In recent write ups about antidepressants, there is no mention of Lithium. The Cockroach Catcher first worked with one Australian Psychiatrist that worked with Cade and I was, so to speak, very biased towards Lithium. Yes, Lithium has side effects that might be serious. But hang on, you get to live to experience it. Think about it.
"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

One might ask why there has been such a shift from Lithium.
Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?
Could it be the fact that 
Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.

Some felt it has to do with how little money is to be made from Lithium. After all it is less than one eighth the price of a preferred mood stabilizer that has a serious side effect: liver failure.
Some felt it has to do with how little money is to be made from Lithium. After all it is less than one eighth the price of a preferred mood stabilizer that has a serious side effect: liver failure. 


Maudsley and Lithium

First, why a small group from the Maudsley Hospital in the 1960s could, in an almost malicious manner, have sown scholarly confusion about the true effectiveness of lithium. Aubrey Lewis, professor of psychiatry and head of the Maudsley, considered lithium treatment “dangerous nonsense” (). Lewis’s colleague at the Maudsley, Michael Shepherd, one of the pioneers of British psychopharmacology, agreed that lithium was a dubious choice. In his 1968 monograph, Clinical Psychopharmacology, Shepherd said that lithium was toxic in mania and that claims of efficacy for it in preventing depression rested on “dubious scientific methodology” (). Shepherd also scorned “prophylactic lithium” in an article with Barry Blackwell (). Moreover, Shepherd was publicly contemptuous of Schou. He told interviewer David Healy that Schou had put his own brother on it, and that Schou was such a “believer” in lithium that he seemed to think “really there ought to be a national policy in which everybody could get lithium”



 Atacama where Lithium is extracted  © Am Ang Zhang 2015

Lithium: The Gift That Keeps on Giving in Psychiatry

Nassir Ghaemi,  June 16, 2017
At the recent American Psychiatric Association annual meeting in San Diego, an update symposium was presented on the topic of "Lithium: Key Issues for Practice." In a session chaired by Dr David Osser, associate professor of psychiatry at Harvard Medical School, presenters reviewed various aspects of the utility of lithium in psychiatry.
Leonardo Tondo, MD, a prominent researcher on lithium and affective illness, who is on the faculty of McLean Hospital/Harvard Medical School and the University of Cagliari, Italy, reviewed studies on lithium's effects for suicide prevention. Ecological studies in this field have found an association between higher amounts of lithium in the drinking water and lower suicide rates.

These "high" amounts of lithium are equivalent to about 1 mg/d of elemental lithium or somewhat more. Conversely, other studies did not find such an association, but tended to look at areas where lithium levels are not high (ie, about 0.5 mg/d of elemental lithium or less). Nonetheless, because these studies are observational, causal relationships cannot be assumed. It is relevant, though, that lithium has been causally associated with lower suicide rates in randomized clinical trials of affective illness, compared with placebo, at standard doses (around 600-1200 mg/d of lithium carbonate).
Many shy away from Lithium not knowing that not prescribing it may actually lead to death by suicide. As such all worries about long term side effects become meaningless. 
Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?APA Nassir Ghaemi, MD MPH
  • In psychiatry, our most effective drugs are the old drugs: ECT (1930s), lithium (1950s), MAOIs and TCAs (1950s and 1960s) and clozapine (1970s)
  • We haven’t developed a drug that’s more effective than any other drug since the 1970’s
  • All we have developed is safer drugs (less side effects), but not more effective
  • Dose lithium only once a day, at night
  • For patients with bipolar illness, you don’t need a reason to give lithium. You need a reason not to give lithium  (Originally by Dr. Frederick K. Goodwin)


Cade, John Frederick Joseph (1912 - 1980)Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.
In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.
And many lives too!
I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here.      It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.Could Lithium be the Aspirin of Psychiatry? Only time will tell!
Latest: British Journal of Psychiatry

Sunday, February 9, 2020

Anti-NMDAR or Autoimmune Encephalitis:$1 Million Investigation:


In the new world of AQPs, should CCGs be paying for doctors that did all kinds of investigations and still did not know what was wrong with you? What if your illness is so new that very few of the new breed of tick-box doctors know nothing about?

As we are now suppose to follow guidelines and protocols, where would new disease come in? Not that long ago, Legionnaires was declared by a psychiatrist as mass hysteria until he also caught it. Would we now be able to discover Helicobacter pylori without some maverick experimenting on himself!

Hospital Medicine has its place in the medical world and most Bright Young Things are after the Pride in world class medicine. 

So, in my recent research on Anti-NMDA Receptor Encephalitis, I came across a book by Susannah Cahalan. In Hospital, her doctors did loads of tests and investigations but could not find out what was wrong with her. The cost mounts up and her insurance had to pay for these negative investigations. Luckily she worked for NY Post and her insurance covered most of the fees.

NPR:
November 14, 201211:00 AM

In 2009, Susannah Cahalan was a healthy 24-year-old reporter for the New York Post, when she began to experience numbness, paranoia, sensitivity to light and erratic behavior. Grasping for an answer, Cahalan asked herself as it was happening, "Am I just bad at my job — is that why? Is the pressure of it getting to me? Is it a new relationship?"

But Cahalan only got worse — she began to experience seizures, hallucinations, increasingly psychotic behavior and even catatonia. Her symptoms frightened family members and baffled a series of doctors.

On some of the symptoms she exhibited at the hospital:

"I slurred my words. I drooled. I didn't have proper control over my swallowing ... I kept my arms out in unnatural poses. At one point, I was like the Bride of Frankenstein — I kept my arms out rigidly. I was slow. I could hardly walk, and when I did, I needed to be supported ... I started [acting] very psychotic. I believed that I could age people with my mind. If I looked at them, wrinkles would form, and if I looked away, they would suddenly, magically get younger. And I believed that my father had murdered my stepmother. I believed all these incredibly paranoid — a huge, extreme example of persecution complex. And then as the days went on, I stopped being as psychotic, and I started entering into a catatonic stage, which was characterized by just complete lack of emotion, inability to relate, or to read, or hardly to be able to speak."

As weeks ticked by and I moved inexplicably from violence to catatonia, $1 million worth of blood tests and brain scans revealed nothing. The exhausted doctors were ready to commit me to the psychiatric ward, in effect condemning me to a lifetime of institutions, or death.

Pride & World Class Medicine:

The head doctors started speaking of a mythical miracle man named Dr. Souhel Najjar. "He would find out what it is," they would say. They even nicknamed him "Dr. House."

My mom requested that we meet this Najjar in person. And after two spinal taps came back with high white blood cell counts -- an abnormal occurrence that signifies brain swelling -- the case was officially passed on to Najjar, a Syrian-born neurologist, neuro-pathologist and epileptologist at NYU Medical Center.

When he came to speak with us, my family was buoyed by his confidence.

He grasped my hands and said, "I'm going to find out what this is and fix it."

Then he handed me a pencil and a piece of paper.

"Draw a clock," he said.

I grasped the pencil and made a circle. Feeling a little confused and put on the spot, I drew in the clock face.

My mother and father gasped.

All the numbers were written on the right side of the clock face, and no numbers were on the left side.

NAJJAR now had five clues as to what was overtaking me: the seizures, the catatonia, the high blood pressure, the high white blood cell count in my spinal taps and the bizarre clock. It was preliminary proof that the right side of my brain (which controls the left side of the body) was inflamed. He believed it was some sort of autoimmune encephalitis, or the swelling of the brain caused by an attack by rogue antibodies.

He decided to send my blood and spinal fluid to a well-respected neuro-oncologist from the University of Pennsylvania named Dr. Josep Dalmau to test to see if rare antibodies were present.

But we had to wait two weeks for the results.

In the meantime, a brain biopsy would be necessary, Najjar said. They would need to cut out a piece of my temporal lobe.

After the surgery, the blood work and spinal fluid came back positive for rare antibodies called anti-N-methyl-D-aspartic acid receptor, or anti-NMDAR encephalitis. The name signifies that the receptors in the frontal lobe, responsible for cognitive reasoning, and the limbic system, or the emotional center of the brain, are under assault by the immune system.

My body was attacking my brain.

Penn's Dr. Dalmau had discovered these antibodies in 2003. Until then, people suffering from my madness were misdiagnosed, likely ending up in mental hospitals, if not dead. Experts aren't sure what causes it, though they believe it's genetic, not environmental.
Najjar estimates that nearly 90 percent of those suffering from autoimmune encephalitis go undiagnosed.

Cahalan's new memoir is called Brain On Fire-My Month of Madness.                                

Chapter 29  The Power of Prayers                                       


Brain on Fire