One man started using drugs in his 40's. Now at 54 he has recovered and is back working as an iron worker (recently off Medicaid). He laughs at his late start with drugs, and is proud to be on the other side. He is grateful to faith and to a bit of AA.
Another man died in his forties. At his deathbed his brother-in-law sadly said that the patient had drunk "Mad Dog" (MD 20/20) "everyday of his life, every day." Alcoholism, hepatitis C and cirrhosis with coagulopathy had led to a fatal hemorrhage.
In a British qualitative beverage survey, MD 20/20 was an attractive drink to children aged 13-15. (Far from a "bum wine.")
Survey results for MD 20/20...
..."The 577 young drinkers perceived it to have several appealing attributes, including a sweet taste (482), pleasant taste (336), affordability (247), and being well known (410). It was also thought to be popular with people of their age (384); unpopular with people of their parents' age (420); a drink for the inexperienced drinker (261), and easy to drink outside (304). It scored better on many of these attributes than conventional beer (for example, Budweiser; table 5).
"When we gave the subjects a hypothetical choice of drinks (table 6), including a range of soft, energy, and alcoholic drinks, the appeal of MD 20/20 was strongest among 13-15 year old drinkers but declined among 16-17 year olds. In contrast, beer consistently increased in popularity with age."
Why did the patient die? A group in Manchester England suggests diagnostic clues may be revealed with a postmortem MRI. (A "confident cause of death" was made in 87% of 53 patients studied.) An accompanying 2002 editorial points out the difficulties in interpretation of post mortem studies. Problems also arise with logistics.
...heard a private company tonight suggest keys to coding for hospital and office visits. Does seem that coding can workout with common sense use of the problem-oriented record.
Lawrence Weed, who has since branched out, developed the problem-oriented record (SOAP) in the 1960's. Variations happen, like HOAP and BATHE. (The latter is more for empathy than for record keeping.)
Tomorrow night (Wednesday September 17) at the Cincinnati World Affairs Council Dr. Adeed Dawisha speaks on How to Build a Democratic Iraq. The Union Institute and University is at 440 East MacMillan St, near the entrance to I-71-North. Social starts at 6:30, lecture at 7:00. ($10.00 for non-members.)
"Until 1993, Fernald and the Energy Department estimated that 299,300 pounds of airborne uranium emissions were released between 1951 and 1988. Another 169,974 pounds were released into the water.
"In 1993, when the Centers for Disease Control and Prevention looked at the original notebooks kept at Fernald rather than summary reports, the airborne emission estimate tripled to 1 million pounds. The water pollution emissions were raised to 217,800 pounds."
[Tim Bonfield. 1996 (Feb 11). Cincinnati Enquirer]
Bomb Factory
The Fernald plant is just northwest of Cincinnati, not far from the beautiful Miami Whitewater public golf course. The life cycle of nuclear bombs largely began and reached maturity in Ohio. Fernald formed the nuclear material into rods or "ingots." (Fernald got the raw material from just up river at Piketon Ohio where a huge gaseous diffusion plant purified the uranium.) From Fernald the ingots were sent upstate to Ashtabula where they were cut and further processed and shipped back to Fernald. Lastly the product was shipped to the Pantex plant in Texas and packaged as weapons. (More local interest: That Texas plant was managed, for four or five Cold War years, by Procter & Gamble Defense Corporation. P&G is a Cincinnati-based company.)
Robert Del Tredici's photographic history, At Work in the Fields of the Bomb, documents and humanizes the whole process. (While out of print, used copies can be found online). Nuclearfiles.org provides an online gallery of Del Tredici's images.
Health of Workers & Neighbors
The Fernald story is not new. It is one of the largest toxic waste cleanup projects in the world. These bedside.org online links are intended to help people connect some dots of history.
A timeline describes the years of health concerns. (Brain cancer, lung cancer and other solid tumors have been noted with higher incidence in Fernald workers. (An abstract of the University of Cincinnnat's 2003 report on neighbors of Fernald does not mention cancer. I have ordered the full text article.) A map gives some sense of the potential geographic exposure.
In the year 2000 a settlement awarded workers $200,000 each, and neighbors $73 million for life-long medical follow-up.
Getting Better?
Through "Where-are-They-Now" biographies of former workers, the US Government Fernald clean-up website (fernald.gov) paints a more optimistic story (a less-dark portrayal than Del Tredici). The site has its own set of historic images, and information about clean-up. (The site also has its own "privacy" warning.) Some suggest completion of the Fernald clean-up may now be as early as 2005.
Beyond the Cold War
Where are they now? Where are today's weapons and their managers? Paul Shambroom's color photographs show us. His book, Face to Face with the Bomb: Nuclear Reality after the Cold War, was just published by Johns Hopkins University Press. (Thanks to Ralph Cautley for pointing me to it.) Robert Del Tredici reviews the book for the LA Times and puts together more of this history.
(While looking for online links to images of Shambroom's work I found this announcement for a meeting today in Washington DC for the Cold War International History Project at the Woodrow Wilson International Center for Scholars.)
This morning Joel Shapiro's sculpture, Untitled 1995, struck me as a running person. It looked like a runner. I was jogging.
Saw the sculpture first from the little hill called Prospect Point (dedicated to Hal Hiatt, psychiatrist at UC) behind the Vontz Center on the medical school campus. Try the spiral walk up that hill. Take a look down at the sculpture. Then walk down for a close-up look. Watch your brain interpret the sculpted shapes from these different angles.
To help a patient's family faced with end-of-life decisions, Father James F. Bresnahan (now at Dartmouth and formerly at Northwestern), suggests that providers help the family talk about "...what mother would want" rather than frame the discussion as a needed decision about the absolute "best action."
At today's Grand Rounds, Father Bresnahan cited a helpful case history, the case of Mrs. J who again is on a ventilator with irreversible lung disease. Her critical care physicians are talking with her son, Mr. G, about palliative care decisions.
Prendergast TJ, Puntillo KA. Withdrawal of Life Support: Intensive Caring at the End of Life. JAMA 2002;288:2732-2740.
Excerpt from Prendergast Case History [link to abstract]
[The physicians] might have approached Mr G as follows: "We need to understand what your mother would want in this situation. We can bring medical information and an understanding of prognosis, and you can bring knowledge of who she is as a person and how she has viewed her life. Together, we can try to make the best decision for her."
These two standards for surrogate decision making—substituted judgment and the best interests of the patient—represent essential shifts in both perspective and moral responsibility.[38] Mr G felt burdened by the perceived responsibility to decide whether this was the day that his mother would die. His real task was less onerous: he was in the best position to help the physicians to understand his mother's wishes. Because Mrs J's physicians focused the discussion on actions rather than on Mrs J's prior wishes or best interests, Mr G perceived, rightly or wrongly, that he was left with responsibility for his mother's death. Shifting the perspective to the patient's wishes is crucial to effective decision making at the end of life.[39] Family members whose own grief prevents them from deciding to limit treatment may affirm the appropriateness of limits out of respect for their loved one's wishes. By speaking for their loved one and not for themselves, family members may truly substitute the patient's decision for their own and that positive affirmation may make their loss more bearable. This shift in perspective is the difference between the language of "giving up" on someone, which inevitably carries extremely negative connotations, and that of "letting go," which allows a more self-effacing, even altruisitic, interpretation.
References for this excerpt
38. Miller DK, Coe RM, Hyers TM. Achieving consensus on withdrawing or withholding care for critically ill patients. J Gen Intern Med. 1992;7:475-480.
39. Prendergast TJ. Withholding or withdrawal of life-sustaining therapy. Hosp Pract (Off Ed). 2000;35:91-92, 95-100, 102.
Care-Team Talks
Father Bresnahan also emphasized the importance of the care-team building a common understanding of the direction of care for each individual case. He suggests meetings of doctors and nurses (even without the family). This prompted me to start thinking about ways to routinize team meetings since they can be cumbersome to set up. Can the institution define roles to ease the process? Could a physician write a simple order: "Please set up a team meeting for end of life planning for Wednesday at 8:30". Someone could routinely pass the word and gather the folks. Intensivists, pulmonologists or others could help establish a standard "meet-up" process to better fit their schedules.)
A Chair at the Bedside
After his lecture our group was reminded of a simple, effective intervention: a chair at the bedside with you in it, listening. A chair with you in it can hold respect for autonomy, a chance to confirm patient/family understanding & goals, possibly a moment for empathy, and simply is respectful.
Rich links to information about Amyotrophic Lateral Sclerosis (ALS) can be found on Science magazine's website. Spanish research shows mouse ALS-like disease modification using Insulin Growth Factor (IGF-1). This needs verification, but raises hopes. (The Science post from August 8th grants full-text access to everyone.)
Fiddler/violinist Mark O'Connor performs with the Cincinnati Symphony Orchestra on October 17th at 11:00am and on the 18th at 8:00 pm.
How do you spell torsades de pointes? (torsades, torsade, toursade, polymorphic ventricular tachycardia?)
To see how others spell it, I did a search on MDconsult. (Whether you search on "Torsades" or "Torsade" the same references return.) Three of the first ten books that return on MDconsult use "Torsade" without the "s." But more popular, in seven out of ten, is "Torsades" with an "s." In all cases the "pointes" ends with an "s." (None spell it "toursade" with a "u" except for me in an earlier post. A Google search on that misspelling, "Toursade" with a "u," returns the old bedside.org post along with some jewelry and flatware descriptions.)
Google translation: torsade = twist, torsades = twists
Capitalization is an easier question, none of the ten books capitalize the term.