Monday, March 26, 2007

A fevered Earth

I don’t know who first thought of describing global warming in terms of a fever, but when Al Gore used the language while testifying before Congress last week, it really caught my attention. By suggesting a medical nature to the problem, he moved it from the purview of physicists, engineers, and environmental scientists to that of the medical community. Are we not the ones trained for and equipped to handle fevers? At Gore’s invitation, I’d like to think about this problem from a medical perspective and see if doing so can contribute something to its understanding and management.

The most important thing we know about fevers is that they cannot be ignored; they are a surefire sign that something is wrong, and that’s why we regard the temperature as the first vital sign. It is a powerful tool for stratifying the severity of medical problems. Without a fever, a cough is merely a bronchial irritation, but with one it is a pneumonia. A swollen joint from trauma is not an emergency, unless it is accompanied by fever, in which case the joint is presumed to be septic and must urgently be drained. The body has a highly refined control mechanism for temperature, and when it runs off course it is not by accident: we are obliged to assume that some pathologic tampering has occurred. For hospitalized patients, the minimum work-up required for a fever includes a chest x-ray, urine analysis, urine culture, and blood culture. A persistent fever of unknown origin may lead to CT scans, lumbar punctures, ultrasound evaluations, white blood cell scans, and often will trigger the initiation of empiric antibiotics. These are not pleasant things; they are painful and costly. The consequences of an undiagnosed and untreated fever are simply too great, however, for a fever ever to be brushed off.

Some fevers are iatrogenic, or man-made. They are caused by reactions to medications or as a result of i.v. lines and foreign bodies, and they are the best fevers to have because they are easily reversible by stopping the medication or removing the foreign body (granted, if it’s your prosthetic heart valve that’s causing the fever it’s not a good thing). If somebody says wait, you can’t prove that the fever is iatrogenic, and if they are right, you worry more, because natural causes of fevers tend to be more severe and difficult to treat. Flesh-eating bacteria, for example, will not stop their feasting if you simply ask them nicely. A fever of unknown origin is particularly worrisome because it suggests a deep-seated occult infection or inflammatory disease. It lurks and taunts and wears down the patient and her physician, defying diagnosis and thereby defying all sense of security. Two diagnoses are unnecessary– a single diagnosis is sufficient with fever and allows your searching to stop, but without that diagnosis you can never reassure a patient that her fever is benign.

This brings us back to the Earth. The Earth’s fever is caused either by carbon dioxide, as Mr. Gore and many suggest, or not, as many others suggest. Let us hope that Mr. Gore is right. The consequences of an undiagnosed and untreated earthly fever are catastrophic, and if we are not able to identify the problem quickly and address it appropriately, we may very well have a disaster coming. The Earth’s fever must be assumed to be pathologic; with a fever the burden always lies upon the medical team to prove that the fever is benign, rather than with the patient to demonstrate that the fever is malignant. Can Joe Barton and James Inhofe really reassure us that global warming is harmless? If they are to do so, they must first be able to provide us with a diagnosis. I don’t mind that they cast doubt on carbon dioxide as the cause of global warming, but what disturbs me is that they seem to find those doubts reassuring. Those doubts should be terrifying. If carbon dioxide indeed is not the culprit, we must raise the alert and vigilantly renew our scientific efforts until the true diagnosis is found. Until then, carbon dioxide toxicity remains the best working diagnosis and we should treat it aggressively.

Barton, Inhofe, and others who deny that global warming is a serious problem find themselves in an awkward position that we encounter frequently in medicine: that of holding a stance that by the nature of its incredible convenience is inherently suspect. They find themselves in the position of the medical resident who, after evaluating a patient with headache and fever, decides that a lumbar puncture to rule out meningitis is not necessary. This resident, even though he may have made a perfectly valid clinical decision, will face close scrutiny in the morning simply by virtue of the fact that he chose a clinical pathway that let him avoid a difficult and time-consuming procedure. His judgment and integrity are called into question, and in knowing this, the resident in advance must make sure that he stands on very solid ground. I ask Barton and Inhofe to imagine themselves as this medical resident, and to evaluate their positions in the same way that he might.

With headache and fever, though, lumbar puncture and antibiotics are almost always necessary. It’s considered preferable to make the diagnosis by LP than by autopsy. With global warming also, the consequences of a missed diagnosis are so great that we must err on the side of over-treatment. With an issue so complex, we are unlikely ever to arrive at absolute certainty regarding its causes and very best plan of treatment. However, we cannot afford to let our doubts stall us; after Katrina, such inaction would be utterly inexcusable. Granted, time will reveal the true nature of the Earth's fever – whether it is a passing fancy or a trend, malignant or benign, curable or not. Learned from the other side, though, that knowledge would be oh so unsatisfying.

Monday, March 19, 2007

Redirection is what’s required

Sometimes we shoot ourselves in the feet in internal medicine by overly glorifying the blocking of ER admissions. Granted, it takes a strong resident to convince an ER attending that the patient actually doesn’t need admission to the medicine service but in fact would be better served either on another service or back in his or her own bed. The feat therefore confers some distinction on the resident who accomplishes it. The euphoria of pulling it off, in fact, can be quite intoxicating; besides marking your growing strength as a resident, it means you’ll have one less patient to admit and comforts you that occasionally justice and reason can prevail even in the ER. It’s easy to proudly notch the block on your belt and think about how you’ll tell the story to your medicine buddies in the morning. The problem, though, is that going into each admission evaluation wanting to block anything possible does a poor job of addressing patient needs and creates a hostile atmosphere in the emergency room.

The ER attending, after all, can sniff a block attempt from miles away. We complain that they can’t be talked to—that they won’t listen—but it’s hard to blame them entirely when we are the ones that have conditioned them to be that way. Sometimes you can almost see them bristle as you approach them, and that’s because they know your intentions exactly. Just as a Washingtonian knows when approached on a walk by a street person that the request will be for money, so too does an ER attending know when approached by a medicine resident that a block is desired. Maybe the admission was legit, or maybe it was soft—a “review of systems” admission (based upon an incidental finding on the history and physical questionnaire) rather than a “chief complaint” admission. In any case, the attending’s better judgment is being questioned, and a notch on your belt is one against him or her. In all fairness, a bit of resistance should be expected.

I’m not sure all the tension is necessary, though. There don’t have to be notches at all, and there doesn’t have to be a medicine versus ER mentality. Just thinking of ourselves all as members of the same patient care team opens the door for communication and the sharing of our respective expertise. That’s why I don’t celebrate blocks or high five my intern in front of the ER attending when a patient planned for admission gets dispo’ed home. In fact, the block is a maneuver I’d like to wipe out of both my playbook and vocabulary. I’m the last one to wish for unnecessary hospitalizations, but sometimes redirection, rather than obstruction, is what’s required.

Sunday, March 11, 2007

A hypothetical question

Let's say you were suddenly granted the magical power to wipe one human disease off the face of the earth, as if it had never existed. Which disease would you choose and why?

Before I give my answer, let me explain why the question interests me. I’ve noticed that there seems to be a lack of thought and communication in medicine regarding the implications of disease. As physicians we hand out diagnoses left and right without really explaining what those diagnoses are going to mean to our patients. What does it mean, for example, to live with diabetes, or coronary artery disease, or rheumatoid arthritis? How devastated should you feel if you are given one of those diagnoses, and how will the diagnosis change your life? To the extent that we do answer these questions, we tend to downplay the impact to our patients. “It could be worse,” we might say, or we may neglect to tell them some of the more depressing details of their new condition. How likely, for example, would we be to tell a 50 year-old woman newly diagnosed with rheumatoid arthritis that she is now much more likely to have a heart attack and that her life expectancy has just dropped by 4 years? In the semi-dispassionate setting of this blog, I’d like to open a more frank discussion about which of mankind's diseases are its worst enemies.

The question also comes to mind in part because of the controversy surrounding the HPV vaccine. Many conservatives, apparently, are against universal vaccination because they feel that it would encourage sexual promiscuity. Presumably, if they had the power to eliminate the virus simply by pushing a button, they would pass on the opportunity. Never mind the thousands of women who die from cervical cancer every year around the world; their fate apparently is a necessary reminder that sex should be reserved for marriage. I wonder, would these people also decline the chance to remove the world of HIV? It’s a mystery to me how with such attitudes the religious right can still be considered to hold the moral high ground in this country.

But let’s talk diseases. Here are some considerations:

Scope – how many people does the disease affect, and how many does it kill?
Demographic – does it affect young or old people?
Preventability/treatability – can it be prevented and/or treated?
Potential for cure – does a cure seem to be just around the corner anyway?
Sin factor – does it strike indiscriminately or is it related to drinking, smoking, drug use, over-eating, and/or philandering?
Personal – has the disease affected my family or people that I care about?
Chill effect – does the disease have any particularly terrifying aspects?

My answer:

Stroke kills an extraordinary amount of people (second worldwide) from early middle age to old age. It has taken down some of the world’s foremost leaders including Woodrow Wilson, Franklin Roosevelt, Winston Churchill, and Ariel Sharon. We know how to reduce its incidence by treating blood pressure, cholesterol, and aneurysms before they rupture, but it’s a disease that we are unlikely to be able to control to any great extent in the near future. It strikes indiscriminately but with a predilection for certain families; if you belong to such a family, your life is lived in fear, and if you don’t, well, you shouldn’t make the mistake of thinking that you’re safe.

What’s really frightening about stroke, though, is its debilitating morbidity, which comes swiftly and without warning. A listless limb isn’t such a huge loss, but when you lose cognitive function – the ability to think and speak, your memories, your personality even, then you’ve lost something sacred. The feeble thoughts that enter your brain can no longer be trusted, and the you that people used to know and love is no longer you. What could be more damaging to a person’s dignity than having his or her very identity destroyed by disease? In an instant, one can go from an intelligent, articulate, fully self-sufficient individual to a lifelong invalid, unable to care even for one’s own most basic needs. With all of the uncertainty and potential for suffering in life, if just the mind could be protected, I think that would be of the most added benefit and comfort.

Any other takers?

Sunday, March 04, 2007

Futile hoping

As residents are we really so different from our patients, who hope against hope that their diseases might be miraculously cured?

On Mondays, we say, "It's too early in the week for people to get sick."
On Tuesdays, we say, "Stranger things have happened than a quiet Tuesday."
On Wednesdays, we say, "In the heart of the week, people are too busy to seek medical attention.”
On Thursdays, we say, "Last Thursday wasn't bad, maybe this one won’t be either."
On Fridays, we say, "The excitement of the coming weekend should make any illness more tolerable.”
On Saturdays, we say, "Thank goodness the clinics are closed and won’t be sending us any patients; it should be a light day."
On Sundays, we say, "Very few problems can’t wait until Monday."
On wet, rainy days we say, "No patient is going to brave this miserable weather to come to the hospital."
On beautiful, sunny days, we say, "Who would ruin such a gorgeous day by coming in?”
In the spring we say, "People in bright spirits rarely become ill."
In the summer we say, "Good thing it’s the slow season for hospital admissions!"
In the fall we say, "The fresh air should keep people healthy.”
In the winter we say, "Maybe the cold will keep the patients at bay."

Actually, we don't say any of these things, we only think them, because uttering them would be to invite disaster; we’re a superstitious lot.

Oh, the power of positive thought!