Wednesday, May 1, 2019
Hands only CPR.
Following an article in the FT
Published: September 17 2010 22:37
Hands-only CPR, at a rate of 100 per minute until the emergency crew armed with automated cardiac defibrillators arrive, was superior to the traditional method of CPR.
Hands-only CPR, at a rate of 100 per minute until the emergency crew armed with automated cardiac defibrillators arrive, was superior to the traditional method of CPR.
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
In April, my good friend the cardiologist in California
It read:
“Thanks to you, I'd had a two year head start on this subject that's only this week published in the popular press. When you first advised me on it, I'd forwarded that info to all my friends. Believe it or not, a GI friend of mine actually saved a life at a wedding last year. Some elderly gent at his table suddenly collapsed to the floor without a pulse. He remembered the article I'd forwarded him and began vigorous CPR without giving mouth to mouth. That gent survived to thank him. Indirectly, of course, he's thanking you.”
My good friend has been interested in the subject of CPR for many years and provided me with some interesting material on the history of CPR, which I share with you below.
1891: The first external cardiac massage in the Western world was reported to be done successfully by Friedrich Maass.
1960: Kowenhoven and Knickerbocker reported their method in JAMA that chest compression was accepted as a method of resuscitation for cardiac arrest.
1966: The first guideline for CPR was published.
1970: Teaching the lay public to do CPR was started.
1974: American Heart Association (AHA) formally promoted the practice involving the combination of rescue breathing and external cardiac massage for cardiac arrest in a ratio of 2:15.
2005: Ewy in Arizona showed that hands-only CPR, at a rate of 100 per minute until the emergency crew armed with automated cardiac defibrillators arrive, was superior to the traditional method of CPR.
My friend immediately drew the attention of his colleagues in Hong Kong to Ewy's work and suggested that the lay public should be taught this simplified method of CPR to encourage bystanders to give aid to victims of cardiac arrest. Many bystanders would otherwise be reluctant to help for fear of contracting AIDS through traditional mouth-to-mouth resuscitation to these strangers.
The AHA was hesitant to accept Ewy's idea in their new guidelines for CPR in 2005, but as a compromise, recommended a ratio of 2 breaths to 30 chest compressions instead.
2007: In March The Lancet reported a Japanese study on a series of over 4000 cases in Tokyo
2008: In April, the AHA finally gave its approval on hands-only CPR from bystanders. The link has a video demo.
To date I could not find any hands-only CPR in NICE and the St John’s Ambulance site is still in the 2/30 era.
Luckily for the wedding guest, his friend did not wait for the AHA recommendation nor any British ones.
History in Traditional Chinese Medicine
403-221 BC: (Warring Kingdoms period) External cardiac massage was practised as a method of resuscitation for victims of suicide by hanging. Some credited this to Bian Que.
6 BC - 221 AD: (Eastern Han Dynasty) The first description of CPR for resuscitation of victims of hanging came from Zhang Zhongjing.
In his Essence of the Golden Chest, miscellaneous therapy #23, he described the method as follows: "Lower the victim gently, don't just cut the rope, and lie him on the blankets. One person should put his feet against the shoulders of the victim and pull on his hair, rendering it taut (to open the airway). One person should put his hands on the victim's chest and compress rhythmically (external cardiac massage). One person should flex and extend the victim's limbs (to promote venous return). One person should press on the victim's abdomen (to enhance intrathoracic pressure during external cardiac massage). ....This method is the best and usually successful."
Zhang Zhongjing's writings were handed down and read by Chinese physicians through the centuries.
1186-1249 AD: (Sung Dynasty) The above passage in Essence of the Golden Chest was cited by Sung Ci in his book on forensic medicine “Washing Away of Wrongs (Xi Yuan Ji Lu)”, which is recognized as the first book of forensic medicine in the world and has been translated into many languages both in Asia and Europe .
There is much we can learn from the past. One may even save a life.
Tuesday, April 30, 2019
Medicine: It May Not Be All In The Mind!
Hong Kong ©2012 Am Ang Zhang
I have often wondered if it would be such a disservice to mankind if doctors were not so understanding of the psychological side of things.
The possibility of a serious illness being missed is of course a major concern when a patient seeks help for one reason or another. To put psychological conditions at the top of the list of possible diagnosis is dangerous. Given the concern over cost in most health care systems, the need to restrict the use of expensive investigation is understandable. However, with clinical reliance on sophisticated investigations especially in modern medical training, the art of physical examination is perhaps lost to this generation of newly qualified doctors. Moreover, the reliance on the internet for information removes the need to make use of the still most powerful computer of them all – the brain. No more effort is made to attempt to download the information into our brain for future parallel processing. As a result, vital and glaring clues are often missed and, worse, dismissed because of over-saturation of information.
The idea that modern medical training requires some time spent in far-flung places where even the stethoscope is a luxury item is a neat attempt to remind future doctors of the importance of clinical judgment based on physical examination. Unfortunately feedback from medical students that I had the good fortune to teach only confirmed my worst fears. Such attachments are more a chance for them to visit exotic places in the midst of a busy course than to hone the skills of medicine on which their seniors were brought up.
Hong Kong:
When I first started in psychiatry in Hong Kong , I was fortunate enough to work with a consultant who had a very firm grounding in General Medicine. A case I shall never forget was a thirty-five year old man presenting with very sudden phobic symptoms. At the time we had just opened in Kowloon our new District General Hospital Acute Psychiatric Unit with thirty acute beds, shared equally between Males and Female admissions. This allowed for some acute screening before the long trek to the only mental hospital in the colony, which was twenty two miles away in the New Territories
It was important to carry out a thorough physical examination on all patients including a thorough neurological test. This particular patient checked out normal on most things except for a positive Babinski (a reflex that can identify disease of the spinal cord and brain) . I was totally baffled but instead of dismissing it I asked my consultant to have a look on the morning round. He carried out a full Neurological.
“Yes, positive Babinski.”
Now how on earth can positive Babinski be related to phobic symptoms?
“We shall need an X-ray urgently, but whatever it is it is not psychiatric”, he declared.
The patient was found to have a special type of very aggressive lung cancer, with extensive metastasis.
He died within six weeks despite some very aggressive treatment at the time.
The sad thing about the case was that being right may not in the end change the outcome. It bore witness to how little we do know and how little we can do even when we do identify the problem.
This case definitely established a principle for my clinical practice. Psychological diagnosis need not be the first diagnosis. Rule out organics first.
Modern medical schools on the other hand pride themselves in concentrating on the role of psychology in bodily dysfunction. It is arguably true that most family doctors do not get to see all the obscure cases we spent so much time studying as a medical student. Yet in time these cases do get to the hospital to be seen by the specialists. Where indeed do they come from? Are they not referred by the family doctors, or are they simply missed and then picked up by the specialists?
Do we as psychiatrists think that it is such a brilliant idea to think “psychology” all the time? Do we really think that people want to see their doctor even when there is fundamentally nothing wrong with them? Is there a grave danger in that assumption?
Health planners seem to assume that most who turn up at Family Surgeries have nothing seriously wrong, and similarly those who turn up at A & E. The latter group are just there because they could not be bothered to see their Family Doctors earlier.
Do we need to apply the money test? Charge a small fee for every consultation for any new condition to exclude malingerers, a sort of “deductible”, in insurance terminology?
Would it not be safer for all concerned that we should remember: “It may not be all in the mind!”
From: The Cockroach Catcher Chapter 40 It May Not Be All In The Mind
Daily Telegraph:
Lisa Smirl, 37, saw three different doctors after she began experiencing a range of symptoms including shortness of breath, wheezing and pain in her arm over the course of a year. But they were all dismissed as anxiety and depression.
By the time the cancer was finally diagnosed it had spread into her brain, bones and liver and was terminal.
In a blog written during her treatment, Cambridge-educated Dr
"For the last year I'd been battling a range of bizarre and seemingly disparate symptoms that had forced me in September 2011 to go on sick leave from my job as a lecturer (assistant professor).
"The diagnosis at the time was anxiety and/or depression. And while I was both anxious and depressed, this was due to the increasingly disabling symptoms that my doctor kept insisting were purely psychological.
"So I was actually grateful for a medical diagnosis that confirmed there were objective, physical reasons behind my illness.
"While in some ways this was a terrible surprise, in another it was a huge relief."
Dr Smirl, who is originally from Canada, first experienced shortness of breath and wheezing in late 2010, which was wrongly diagnosed as asthma.
By September 2011, after developing shoulder and arm pain and experiencing 'visual migraines' – in which she lost her vision for half an hour – Dr Smirl was forced to leave her job. She was diagnosed with depression and anxiety and put on antidepressants.
But despite a dramatic weight loss, Dr Smirl claimed three different family doctors refused to consider her symptoms in connection with each other.
In November 2011, a year after she first started having symptoms, she was finally diagnosed with cancer after a doctor agreed to send her for an X-ray.
Dr Smirl, who went on to complete the Great North Run to raise funds for a cancer charity in November 2012, wrote on her blog: "I can't prove it, and this is just my opinion, but I have no doubt in my own mind that my misdiagnosis was in large part due to the fact that I was a middle aged female and that my male doctors were preconceived towards a psychological rather than a physiological diagnosis.
"It is so easy to say that someone's symptoms are 'anxiety' related if they are a little bit complicated, unclear or unusual. Don't repeat my mistakes.
"You know when something is wrong. Find another doctor that you connect with and who takes your concerns seriously. Get referrals. Get tested. Refuse to be dismissed."
USA
My good friend told me about a case that was first thought to be a psychiatric one. It was a severe case of Trichotillomania (hair pulling disorder) that had to be admitted to a mental institution compulsorily.
This is the same friend who alerted us to the radiation dose of some routine health checks.
Trichotillomania is not a condition that requires compulsory admission, so why in this case?
"The patient was sure someone was trying to harm her."
Oh! Acute paranoid psychosis. That makes sense. Anything else? I suppose she had to be on the most up-to-date anti-psychotic and anti-obsessional drugs.
No, before they could pump these drugs into her, her friend bailed her out, against medical advice, and got my friend to see her.
Great friend!
But what could have caused the hair loss?
Polonium?
No way, she was not a spy!
Yes, it was poisoning, not by Polonium, but by Thallium. That was what my friend’s investigation showed.
Thallium has been a noted poison favoured by Secret Services and one famous Graham Young in England. He poisoned his stepmother at the age of 14 and then other members of his family. He was caught and sent to Broadmoor, a maximum security mental hospital in England.
Miraculously he was declared “cured” and released. Nice justice as my friend’s patient was detained by being a victim and they let the perpetrator go despite his diary claiming he planned to kill one person for every year he spent in Broadmoor!
Young then proceeded to find employment as a shopkeeper at Bovingdon, Hertfordshire, where his co-workers were one by one struck by a mysterious illness nicknamed “the Bovingdon Bug”. One died but Young’s arrogance brought his downfall. He challenged the doctor dealing with the “Bug” in a public meeting as to why Thallium poisoning was not considered!
At one time, Thallium was used as a rat poison as even the rats could not detect it by taste. Now it has been banned in most countries but still poses a health risk.
As recently as 2007, two women, a mother and a daughter, who were both born in Russia but became American citizens, had Thallium poisoning on visiting Russia. They survived. The mother is a medical doctor.
It turned out that my friend’s patient was being poisoned by her partner. Prussian Blue was prescribed as the remedy and she survived, sort of, with residual neurological damage due to delay in diagnosis and appropriate treatment.
Paranoid psychosis indeed!
Just remember: it may not be all in the mind.
This is the same friend who alerted us to the radiation dose of some routine health checks.
Trichotillomania is not a condition that requires compulsory admission, so why in this case?
"The patient was sure someone was trying to harm her."
Oh! Acute paranoid psychosis. That makes sense. Anything else? I suppose she had to be on the most up-to-date anti-psychotic and anti-obsessional drugs.
No, before they could pump these drugs into her, her friend bailed her out, against medical advice, and got my friend to see her.
Great friend!
But what could have caused the hair loss?
Polonium?
No way, she was not a spy!
Yes, it was poisoning, not by Polonium, but by Thallium. That was what my friend’s investigation showed.
Thallium has been a noted poison favoured by Secret Services and one famous Graham Young in England. He poisoned his stepmother at the age of 14 and then other members of his family. He was caught and sent to Broadmoor, a maximum security mental hospital in England.
Miraculously he was declared “cured” and released. Nice justice as my friend’s patient was detained by being a victim and they let the perpetrator go despite his diary claiming he planned to kill one person for every year he spent in Broadmoor!
Young then proceeded to find employment as a shopkeeper at Bovingdon, Hertfordshire, where his co-workers were one by one struck by a mysterious illness nicknamed “the Bovingdon Bug”. One died but Young’s arrogance brought his downfall. He challenged the doctor dealing with the “Bug” in a public meeting as to why Thallium poisoning was not considered!
At one time, Thallium was used as a rat poison as even the rats could not detect it by taste. Now it has been banned in most countries but still poses a health risk.
As recently as 2007, two women, a mother and a daughter, who were both born in Russia but became American citizens, had Thallium poisoning on visiting Russia. They survived. The mother is a medical doctor.
It turned out that my friend’s patient was being poisoned by her partner. Prussian Blue was prescribed as the remedy and she survived, sort of, with residual neurological damage due to delay in diagnosis and appropriate treatment.
Paranoid psychosis indeed!
Just remember: it may not be all in the mind.
Tuesday, April 23, 2019
Brexit & Coffee: Fakes and Failures!
With clear evidence that politicians ignore professional advice and that looming Brexit is going to harm patients when there is uncertainty about the availability of certain life-maintaining medications from Insulin down. I am reprinting what I have written about how ignoring professionals cost the French dearly over the construction of the Panama Canal.
Panama has been associated with some fabricated plots. There were the John Le Carre book The Tailor of Panama that was turned into a film, the location shoot of the Quantum of Solace (in Panama, doubling as a country in South America), and the Canoeist faking death, just to mention a few.
Then there was the coffee scandal.
In 1996 in California, a certain Michel Norton, owner of Kona Kai Coffee was sentenced to 30 months in prison. Apparently for an extended period of time (some reckoned a decade may not be an over estimate), cheaper and “lower grade” Panamanian and Costa Rican coffee were used to pass off as “Pure Kona Coffee”.
Cheaper, certainly, as you would not otherwise be doing it. But, INFERIOR? I think many would certainly dispute that. I do not think you can really use an inferior product to pass off as something superior and fool people for long.
Cheaper, certainly, as you would not otherwise be doing it. But, INFERIOR? I think many would certainly dispute that. I do not think you can really use an inferior product to pass off as something superior and fool people for long.
So the Ambassador of Panama in Washington D.C. wrote to the New York Times:
To the Editor:
I read with amusement about the indictment of a coffee supplier on selling fraudulently marked beans to retailers (news article, Nov. 13).
Without making light of the charges, I am pleased that the coffee buyer for Peet's Coffee and Tea is uncertain that he can tell the difference between the ''cheaper'' Panamanian beans allegedly substituted for the more expensive Kona.
Panama's coffee is among the world's best. In fact, members of my staff have seen Panamanian beans for sale at high-end coffeehouses for little less than Kona. Perhaps we can arrange a taste test of Kona and Panamanian coffee for the sellers mentioned in the article. I am sure that no one will be more pleased with the results than my native coffee growers.
Panama Coffee is now world famous.
Poor Theresa May, she is not so lucky with Brexit but perhaps she is rich enough not to worry too much about her insulin!
It is a common practice for politicians to ignore professional advice. As The Cockroach Catcher, his wife and friends cruise across this greatest of all human endeavour, he likes to re-post one of the Panama Posts.Sometimes they might get away with it; sometimes it led to failure, gross failure as in the case of the French attempt at building the Panama Canal.Can we really learn anything from such a colossal failure?
We learn little or nothing from our successes.
They mainly confirm our mistakes, while our failures,
on the other hand,
are priceless experiences in that
they not only open up the way to a deeper truth,
but force us to change our views and methods.
Panama Canal © 2008 Am Ang Zhang
Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.
Extracted from the Official Website: Panama Canal Authority /French Construction
In 1879, Ferdinand Marie de Lesseps, with the success he had with the construction of the Suez Canal in Egypt just ten years earlier, proposed a sea level canal through Panama. He was no engineer but a career politician and he rejected outright what the chief engineer for the French Department of Bridges and Highways, Baron Godin de Lépinay proposed, a lock canal.
The engineer was no match for a career politician:
“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”
“The resolution passed with 74 in favour and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”
The French failed in a spectacular fashion.
Cost to the French: $287 Million (1893 dollars) or $6.8 Billion (2007 dollars)
Many reasons can be stated for the French failure, but it seems clear that the principal reason was de Lesseps’ stubbornness in insisting on and sticking to the sea level plan. But others were at fault also for not opposing him, arguing with him and encouraging him to change his mind. His own charisma turned out to be his enemy. People believed in him beyond reason.
Could any of us learn anything from this experience?
Hermione: "You pay a great deal too dear for what's given freely". -
(Act I, Scene I). The Winter’s Tale.
President Jimmy Carter: Time
Panama:
Panama Canal: Diseases & Failures.
Thursday, April 18, 2019
First Emperor, Animal Farm & Allyson Pollock
“For centuries, the brutal and tyrannical reign of Qin Shihuangdi, First Emperor of China, was summed up by a four-character phrase, fenshukengru 焚書坑儒, ‘He burned the books and buried the Confucian scholars alive.’”Anthony Barbieri-Low: 21st Sammy Yukuan Lee Lecture. See also: The Independent.
Forty years ago, Colin Douglas, geriatrician and novelist, when on a gap year in a remote secondary school in post-colonial Ghana, was summoned by the headmaster and informed that "we had in our library a book the government didn't think we should read." The book was of course Animal Farm.
Here in The BMJ, he reviewed Allyson Pollock’s Book, NHS plc.
"Allyson Pollock describes her experience in November 2001 at the hands of the House of Commons Health Select Committee, then just refreshed by an influx of New Labour ultras, including one Julia Drown MP, a former health service manager. Against the advice of the committee's chairman and clerks, Ms Drown tabled a rant aimed at undermining Professor Pollock and her Health Policy and Health Services Research Unit at University College London. In the chairman's view such an attack on an individual witness was unprecedented and wrong, yet it nevertheless (by virtue of a nasty but neat little bit of committee footwork) appeared in the final report of an inquiry into the implications of the private finance initiative (PFI) for the NHS.”
Allyson Pollock must count herself lucky for not living in China during the reign of The First Emperor although she did leave the England
“……if you are old enough, or even just curious enough, to wonder whatever happened to the British NHS as first conceived, you might find NHS plc a useful little book. An excellent early reputation—for cost effectiveness and equity based on integrated services, minimal management costs, and a vast and intensely practical pooling of risk—dwindled slowly. This was firstly because of chronic and insidious underfunding, later because a notional internal market began to take it apart, and finally (though the word may still be slightly premature) because of the current assault: a burgeoning, divisive, sometimes mendacious for-profit marketisation of a healthcare system that was once an admired public provision and a right of citizenship in the United Kingdom.”
Regarding PFI he continued:
"Since it was Pollock's views on the PFI that so upset its proponents, it is worth summarising them briefly. Costs are now intrinsically higher, because of capital borrowing at higher rates than those available to government, because of cash hungry consultancies and the vast transactional and monitoring costs of countless contracts, and because—for the first time on a large scale in the NHS—commercial profits must be made. To accommodate all these new costs clinical services have been scaled down, while matching assumptions about increased efficiency are only variably delivered. All this, along with the rigidity of a trust based strategy for building hospitals and the locking in effect of contracts fixed for decades, seems to Pollock and many others at best a bad bargain, at worst a naive betrayal that opens the NHS to piecemeal destruction and the eventual abandonment of its founding principles. And all over the country PFIs—greedy, noisy, alien cuckoos in the NHS nest—gobble up its finances and will do so for the next 30 years.”
"Foundation trusts (‘public benefit corporations’—what?) will further disrupt any attempts to build effective local health services, drive the balance of care in the wrong direction, and almost certainly get choosy about the patients they treat. All this will least benefit elderly patients, whose care as our population ages ought to be explicitly identified as the core commitment of our NHS. Will elderly people be surprised? I doubt it. Their long term care was totally abandoned by the NHS in England United States
I have to thank Dr. Grumble for pointing me to this site that has a write up too.
Rupert Read wrote in OurKingdom:
“When I was at Oxford taking PPE 20 years ago, my best friend was Simon Stevens, who went on to become Tony Blair's key health policy adviser. Back then, he was a socialist. Now, he is Chair of United Health Europe, one of the US 's giant corporations profiteering from the break-up of the NHS, and angling to take over doctor's surgeries across the UK
Why do we still have the great books of Confucious and other scholars? They have all been memorised by scholars and The First Emperor could not kill all of them. When he failed to achieve eternal life and died, the scholars just re-wrote these books again.
The last words go to Colin Douglas:
“Professor Pollock, with the help of many colleagues acknowledged in a list that reads like a roll of honour for services to the real and now threatened NHS, has written a brave, necessary book. And because you know the government thinks you shouldn't read it, you probably should.”
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