Tatooing Medical Directives on our Bodies

Unfortunately I don't know Dr. Ed Friedlander, a pathologist in Kansas City, so I haven't had a chance to ask him about his decision to have "No CPR" tatooed on the center of his chest. If you want to see what his distinctive form of advance directive looks like, the Associated Press article about using tatoos to convey medical information shows him holding his shirt open.

Many people are afraid that their wishes for how medical care should and should not be administered will not be followed. Since the default option in emergencies is to "do everything," folks like Dr. Friedlander who want to let nature take its course when their heart stops have good reason to fear chest pounding and electrical shocking if an ambulance was called for them.

It's just a matter of time until we see a Saturday Night Live routine in which the emergency medical technician gets preoccupied reading an essay on the chest of the person whose side they are called to. Whatever Dr. Friedlander's motive for the tatoo is, he's dramatizing the degree to which many people fear that health care on automatic pilot will (literally) run roughshod over them.

Raw Cranberry Maple Granola

This is a delicious and versatile raw granola that I absolutely love!  It is soooo....easy to make. You will need a dehydrator, a food processor, some nuts & seeds, an apple, dates, maple syrup, orange zest, vanilla, cinnamon and sea salt. You will also need to make some nut milk. The way I like to eat this granola is to put just a bit of it in a bowl with lots of fresh fruit, like chopped bananas, whole blueberries, strawberries, etc. The granola is really heavy, so you don't need much to satisfy you. Then I top it with some fresh raw almond milk-YUMMY and satisfyingly good!!  The granola will stay fresh in the refrigerator for weeks.  You definitely need to give this cereal a try. I know you will love it.

Soaking nuts and seeds and then dehydrating them to their crispy state again, helps aid in their digestion. If you soak or sprout them, then you not only neutralize enzyme inhibitors, phytic acid, and lectins, you also have prepared the nut or seeds for optimal absorption for your body.  This is similar to sourdoughing grains for bread to make them more digestible.

Raw Cranberry Maple Granola

Makes About 10 Cups

Printable Recipe

1 apple, cored and chopped

14 regular dates soaked in 1/2 cup water (save soak water to make paste)

1/4 cup maple syrup

2 tablespoons fresh lemon juice

2 tablespoons orange or mandarin zest

1 tablespoon vanilla extract

1 teaspoon ground cinnamon

1 - 1 1/2 teaspoons sea salt

1/2 cup sunflower seeds, soaked 2 hours or more (drained & rinsed)

1 cup almonds, soaked 4 hours or more (drained & rinsed)

3 cups walnuts, soaked 2 hours or more (drained & rinsed)

1 cup pumpkin seeds, soaked 2 hours or more (rinsed & drained)

1 cup dried cranberries (sweetened with fruit juice)

Directions:

1) In a food processor, place the apple, dates & date water, maple syrup, lemon juice, orange zest, vanilla, cinnamon, salt, and 1/4 cup of the sunflower seeds and grind until completely smooth.  Transfer the mixture to a mixing bowl.

2.) Add the remaining 1/4 cup sunflower seeds, the almonds, walnuts, and pumpkin seeds to the food processor. Coarsely chop the nuts and seeds in a few quick pulses.  Add them to the bowl with the apple mixture, add the cranberries and combine well.

3.) Spread the granola on  the Jelly Roll or Teflex-lined dehydrator trays and dehydrate at 115 degrees F. for 6 to 8 hours.  Remove granola from the Jelly Roll or Teflex-lined dehydrator trays and place on screens.  Continue dehydrating for another 8 to 12 hours, or until the granola is crunchy.  Break into pieces and, once completely cooled, store in an airtight container.  To maintain freshness longer, store the granola in the refrigerator for up to a few weeks. 

Recipe inspired by: Raw Food, Real World. 

 

Should a Student be Disciplined for Being Disrespectful on Facebook?

In discussing ethics with medical students and physicians, it's common for someone to ask: "What does the law say?" I typically respond: "Let's first figure out what we think the right thing to do is. Then we can ask how to do it within the law. If the law says we can't do it, we should check to see if we got our reasoning right. If we still think we got it right, we can consider whether the law can be changed, or if civil disobedience is the path to follow."

On July 11, 2011, the Minnesota Court of Appeals ruled against Amanda Tatro in the fascinating case of Tatro v University of Minnesota. The decision is a heartening blend of law and ethics.

Amanda Beth Tatro was a student in the University of Minnesota mortuary-science program, which prepares students to become funeral directors or morticians. The laboratory courses use cadavers that have been donated to the university.

In November and early December 2009, Ms. Tatro posted the following on her Facebook page. I've added some notes in italics:

Amanda Beth Tatro: Gets to play, I mean dissect, Bernie[this is the name she gave to the cadaver. The name comes from the film "Weekend at Bernie's."] today. Lets see if I can have a lab void of reprimanding and having my scalpel taken away. Perhaps if I just hide it in my sleeve . . . .

Amanda Beth Tatro: Is looking forward to Monday‟s embalming therapy as well as a rumored opportunity to aspirate. Give me room, lots of aggression to be taken out with a trocar.

Amanda Beth Tatro: Who knew embalming lab was so cathartic! I still want to stab a certain someone in the throat with a trocar though.[Tatro testified at the Campus Committee on Student Behavior that she was referring to a man who had just broken up with her. But at the campus hearing, faculty members testified that they feared she was referring to them.] Hmm..perhaps I will spend the evening updating my “Death List #5” and making friends with the crematory guy. I do know the code . . . .

Amanda Beth Tatro: Realized with great sadness that my best friend, Bernie, will no longer be with me as of Friday next week. I wish to accompany him to the retort. Now where will I go or who will I hang with when I need to gather my sanity? Bye, bye Bernie. Lock of hair in my pocket.

On April 2, 2010, the Campus Committee on Student Behavior ruled that Tatro should receive a failing grade in the anatomy laboratory class, that she should enroll in a clinical ethics course, that she should write a letter to the mortuary-science faculty on the issue of respect in the profession, and that she should undergo a psychiatric evaluation. Tatro appealed to the court.

Here's the section of the court's decision most relevant to professional ethics:

The university found that Tatro violated rules 6 and 7 of the anatomy-laboratory course rules. Rule 7 states, “Conversational language of cadaver dissection outside the laboratory should be respectful and discreet. Blogging about the anatomy lab or the cadaver dissection is not allowable.” Tatro argues that the evidence does not support findings that she violated these laboratory rules.

..As the university asserts, public comments about “playing” with or taking “aggression” out on a cadaver are inconsistent with the notions of respect and dignity whether they occur in person, on Facebook, in a blog, or via other media.

I believe the court was entirely correct that the university had not violated Tatro's right to free speech. A core component of the profession she was preparing for is respectfulness and discretion. Whether or not the ostensible threats she made should have been taken so seriously (the court concluded that the university was correct to do so), her comments about "Bernie" violate the ethics of her profession. The academic penalty imposed by the Campus Committee on Student Behavior was appropriate. (I don't favor requiring a psychiatric evaluation unless there was a medical reason for doing so that the court record does not convey.)

In entering a profession we "profess" our commitment to the ethics of the profession. The first amendment gives Ms. Tatro the right to speak disrespectfully of "Bernie." But it doesn't give her the right to enter the funeral director profession at the same time!

Hand Washing,Teamwork, and Professional Ideals

Hand washing protects hospital patients from healthcare-associated infections. But on average, adherence to hand hygeine standards is under 40%.

In June, 2008, Northshore Hospital on Long Island started an experiment. It installed motion detectors in the doorways of ICU rooms to monitor entrance of staff, and installed cameras focused on the sink and hand sanitizer dispenser. Video auditors (in India) scored each event. The intervention tested the impact of (a) installing cameras and (b) feedback of results. No individuals were identified. Results were only reported in aggregate form.

In the 16 week prefeedback period, hand hygiene rates were under 10%! At that point, electronic boards were installed in the ICU hallway. Results were given on each shift. To my eye, the board looks cheerful. It shows the date, the target rate (>95%) and gives an electronic pep talk ("Sanitize Hands Upon Entry/Exit of Rooms!"). On May 17, 2010, the day displayed in the photo, it tells the staff: "GREAT SHIFT!!" and gives results for physicians and other health professionals.

Once electronic reporting of aggregate performance was given, adherence jumped from under 10% to the mid 80s. The results were sustained for two years.

The report in Clinical Infectious Disease doesn't speculate on what drove the change. There were no financial incentives and no monitoring of individual performance.

So what happened?

Here's my guess. Very few hospital workers doubt the importance of hand hygiene. But resolving to do better is like our New Year resolutions to lose weight or improve ourselves in other ways - easy to vocalize but hard to carry out.

The cameras without feedback accomplished nothing. But daily feedback reminded staff of where it stood relative to its ideals. And the aggregate reporting told staff that everyone was on board. In other words - an experience of unity in relation to professional ideals.

That's like the congregation singing a hymn together and praising the God they adhere to! The electronic board wasn't a voice from heaven, but it spoke to the flock every day on every shift. On a bad day it must have been like the chorus from Messiah - "All we like sheep have gone astray."

I hope a journalist or a qualitative researcher delves into the human side of the statistical story the article tells. We might learn important lessons about what helps us put our healthcare ideals into action.

Raw Dairy-Free Chocolate Pudding

You are going to love this delicious chocolate pudding.  The taste is so amazing! After opening a beautiful Thai coconut, you remove the liquid and scrape out the yummy coconut meat.  You will be using the coconut meat for the pudding and reserving the liquid for your smoothies.  A delicious smoothie to use the coconut water in is 'Raw Coconut-Creamsicle Smoothie'.

Dairy-Free Chocolate Pudding
Printable Recipe
Serves 2
1 cup coconut meat
6 dates (soaked for 15 minutes in 6 Tbsp. water) Save soak water.
2 - 3 Tbsp. raw cacao
2 Tbsp. grade B maple syrup 
1 Tbsp. vanilla extract
pinch of sea salt

Put coconut meat, dates, soak water, maple syrup, vanilla & sea salt in blender.  Blend until smooth and creamy.  Chill in refrigerator.
(Recipe inspired by Raw Food, Real World)

Raw Coconut-Creamsicle Smoothie - Fight that Cold & Cough!

I hope all of you are having a healthy winter so far.  Everywhere I go I hear people coughing and/or talking about being on antibiotics.  So far, I have been staying healthy this winter.  I have been focusing on a lot more raw foods and making sure I get plenty of green barley juice to strengthen my immune system.  I bought a big beautiful coconut and decided to create two recipes from it.  I am posting my original creation - Raw Coconut-Creamsicle Smoothie today and will post my recipes for chocolate pudding on Wednesday.  Both these recipes can be made from one coconut.  Having colds in mind, I tried to combine ingredients in this smoothie that will help you to recover quickly and relieve symptoms of your cold or flu. Read all the health information below and you will be amazed at what the ingredients will do to help you.  If you have never opened a young coconut, it is extremely easy and fun.  You can buy young coconuts at the health food store or at an Asian market.  At the Asian markets you can buy inexpensive (under $10.00) a cleaver knife that will help you to open the coconut. First wash your coconut. I then grab the cleaver with my right hand and hit the coconut with the lower edge of the knife all around the top of the coconut (see picture below), until it starts to break open. Keep your left hand out of the way while you are doing this. You then lift the lid you have created, pour out the coconut water, and scrape out all the young coconut meat with a spoon. Some people like to remove some of the outer shell of the coconut before starting to hit it with the cleaver, but I actually skipped this step and it opened right up for me.  Once I remove the coconut meat, I usually rinse the pieces to remove any part of the shell.  I was able to get about 2 1/2 cups of coconut water and about 1 good sized cup of coconut meat from my young coconut, but this varies with the size of your coconut.  When picking out your coconut make sure the coconut has a hard bottom, as few imperfections as possible and when you shake it, you don't hear any water moving around.  This means you have a nice sealed and sterile coconut. You will use the coconut water in your smoothies and the the coconut meat for the chocolate pudding recipe I am posting on Wednesday. I hope you enjoy the recipes and are staying healthy!!  Make sure you get enough rest every night and stay away from refined foods.

Young Coconut Water is an antibacterial, antifungal and antiviral, which means you can help reduce the effect of colds, and the flu by drinking it. This drink is high in potassium. Potassium is our central electrolyte which regulates so many of the bodily functions. Drinking coconut water will certainly help your potassium levels providing 294 mg per serving.You will also be amazed to know that through drinking one cup of coconut water, you'll receive over 2.5 grams of fiber.

Pineapple has Bromelain - The "Magic" Ingredient Found Only in Pineapples and Papayas
This tropical fruit is just one of two fruits found on the planet that contains Bromelain. Pineapple juice contains an enzyme called Bromelain. It's health benefits are numerous:
1. It's effective in reducing the body aches and pains you may feel when you have a cold.
2. Bromelain is an anti-inflammatory. It kills bad bacteria and fights infections. Drinking pineapple juice when you have a cold will help soothe and heal a sore throat and reduce swollen glands.
3. Pineapple juice helps to thin mucus and congestion so your body can expel it easier. The bromelain helps calm annoying coughs as well.
4. Drink pineapple juice when you have a cold and it will help settle a nauseous stomach.
5. Pineapple juice has also been used to treat other respiratory ailments such as bronchitis, hay fever, asthma and pneumonia.

Mandarin Oranges - The USDA tested mandarins from 10 different micro climates in Placer County and found that they contain six to seven times the amount of synephrine, a naturally occurring decongestant, than other citrus fruits.

Lemon has been used as a medicinal treatment since the days of ancient Rome. Lemon juice has been used as a cold remedy for ages. The lemon contains over eighty percent of the daily recommended value of Vitamin C. This is from the juice of one lemon! Vitamin C has been shown to boost the immune system. When more white blood cells are present to fight infection, the life of the offending virus is cut short.

Bananas are high in magnesium, a mineral that may help fight off colds and flu.  Stress hormones drain magnesium from the immune systems cells and impair their ability to fight off viral invaders.

The young Thai coconut I purchased! Beautiful white coconut meat and lots of water.

Save your coconut meat and use it for your chocolate pudding. Watch for recipe this week.

 Raw Coconut-Creamsicle Smoothie
Printable Recipe
Serves 2

1 cup young coconut water
2 lemons (juiced)
1 cup fresh or frozen pineapple chunks
1 banana
3 mandarin oranges (peeled)
1 tsp. vanilla extract
1 cup ice


Place all ingredients in blender and blend until smooth and creamy.  Enjoy!!

Complementary Medicine in Australia - an ethical analysis

400 scientists and doctors have attacked the 19 Australian universities that teach, or give degrees in, complementary and alternative medicine (CAM):

 Such courses involve so-called ‘complementary or alternative medicine’ masquerading as, and sitting side-by-side with, evidence-based health-related science courses. We take the view that those universities involved in teaching pseudoscience give such ideologies undeserved credibility, damage their academic standing and put the public at risk.

The controversy is half scientific, half ethical.

We health educators should be honest. A lot of medical and nursing care is based on evidence. That evidence, and the sciences that allow the evidence to be developed, should, and do, form the center of the curriculum.

But much of what we physicians and nurses do is based on belief and tradition. That doesn't mean we shouldn't do and teach these things. But we should be honest with ourselves and our students about when our practices aren't evidence based. Non-evidence based practice isn't limited to CAM!

Controversy over CAM isn't new. In the early 20th century organized medicine was horrified by the growth of Christian Science. Wise physicians recognized that the emergence of Christian Science reflected a sense that something was missing in "conventional" medicine. That hunger is still present. More than 1/3 of U.S. adults use "alternative" medicine techniques. I'm sure the same is true in Australia.

Gerald Caplan, my mentor in community psychiatry, taught me a valuable lesson about CAM. He experienced intermittent low back spasm, for which he had treatment with a chiropracter. Dr. Caplan told me:

The chiropracter takes low back pain seriously and lays on hands. The orthopedist is bored by it unless he can operate. I think chiropractic theory is nonsense, but chiropractic treatment gives me relief. Bringing relief is our goal in medicine.

There are three primary reasons why physicians should learn about CAM. (1) Many of our patients use CAM, and we should understand what they're doing in order to be able to advise. (2) We need to understand, from their perspectives, what felt needs CAM is addressing and what they hope to get from it. (3) Even if - like Gerald Caplan - we don't believe CAM practice is based on hard evidence and sound theory, we can sometimes learn from the way CAM practitioners carry out their practice.

Unfortunately, one of the Australian Universities manifested the same kind of arrogance that disturbs me when I see it in medicine. (I've interlaced my comments in bold italics.):

Students are taught the science-practitioner model and our aim is to produce graduates who are critical thinkers. [so far so good!] This enables them to distinguish between fad and genuine innovation in the discipline as practitioners, intelligent consumers of research and promoters of the scientific method. [even better!] A clear distinction is made in all of our courses between areas for which the evidence is clear and those in which the science has not caught up with accepted practice and where sufficient evidence has yet to be accumulated. [This is way off base. The speaker is assuming that "accepted practice" is based on science, and the science just hasn't "caught up" yet. That's religious faith, not critical thinking.]

(For previous posts about CAM, see here, here, and here. For the New York Times article from which I learned about Australia, see here.)

Treatment Options for Urinary Incontinence

The loss of bladder control is a common and embarrassing problem for many women, but it’s actually very common, affecting women of all ages.

Symptoms of urinary incontinence can range from leaking urine when coughing, sneezing or exercising to the sudden urge to urinate. Some women also experience pelvic pressure, which can signal a variety of bladder or pelvic conditions and should be checked by a physician.

For women suffering with urinary continence, Penn Urogynecology offers a variety of treatment options to help them get back to living again with improved bladder control.

Read more about Penn Urogynecology and treatment options

Capturing a More Accurate Picture of Breast Health

It’s a revolutionary way to perform mammograms: combining traditional mammography with 3D technology to give a more accurate picture of breast health. It’s called digital breast tomosynthesis (DBT) and it’s being used for breast cancer screening and diagnosis at Penn.

DBT captures images using traditional X-ray technology moving along a small arc around the breast and recording images at different depths and angles. The images produced have  an unprecedented amount of clarity and detail, reducing the false-positives and false-negatives often associated with traditional 2D mammography. That means less unnecessary imaging, stress and fear for patients. Penn Medicine offers DBT combined with personalized, multidisciplinary care at the Perelman Center for Advanced Medicine for breast cancer screening.

• Read more about Digital Breast Tomosynthesis 
• Find a Penn Radiology location close to home

5 tips to prevent heart disease

February is National Heart Month. Heart disease, the number one killer of adult men and women in the United States, includes coronary artery disease, arrhythmias and congenital heart disease. Despite its prevalence, there are ways to reduce the risk for heart disease. In fact, the best defense against heart disease is a commitment to a heart-healthy lifestyle.

Take these steps to help prevent heart disease:

Exercise
Exercise is one of the best ways to become healthier and reduce the risk for heart disease. According to the American Heart Association, all it takes is 30 minutes a day, five days a week to reap the positive benefits of exercise for the heart.

Don’t smoke or use tobacco
Tobacco negatively impacts every organ in the body, but it is particularly harmful for the cardiovascular system. The chemicals in tobacco smoke increase the risk of atherosclerosis and can damage the heart. For people struggling to quit, Penn’s Comprehensive Smoking Cessation Program can help them curb the habit safely and comfortably.

Eat right
Maintaining a healthy diet is easier said than done for most people, but it is crucial for a healthy heart. Eating properly protects the heart from disease, controls blood pressure and prevents type 2 diabetes and some types of cancer.

Maintain a healthy weight
Obesity is an epidemic in this country with more than one third of adults qualifying as obese, according to the Centers for Disease Control and Prevention (CDC). Obesity is linked to many diseases including heart disease. For people who cannot manage their weight through exercise and diet, weight loss surgery may be a good option. Learn more about the Penn Metabolic and Bariatric Surgery Program, which offers multidisciplinary care and the latest surgical procedures to help patients reach and maintain their weight loss goals.

Get regular health screenings
Regular health screenings are important to identify potential health issues before they become problematic. For many conditions, early detection improves the chances for more effective treatment or even a cure. The CDC recommends several suggested health checkups.

• View heart healthy events presented by Penn Heart and Vascular 
• Learn about your risk for cardiovascular disease
• American Heart Association's Seven Simple Steps to a Healthy Heart Program

Educative Journalism in Massachusetts

Apropos yesterday's post, this editorial from today's Boston Globe is interesting. I've interlaced comments of my own in bold italics:

EVEN BEFORE this year’s grand debate about containing health care costs begins on Beacon Hill, a pointed disagreement has broken out among key players in the state health care arena.

The health plans fear that legislative meddling is opening holes in the very cost-controlling arrangements that a recent law required, while legislators contend they are simply looking out for individuals who might be hurt by policy changes. The editorial makes clear that this is a classic "good vs good" conflict. Constraining costs is an ethical responsibility, since health care costs deplete wages, small business viability, and the state's capacity to fund other public goods. But protecting vulnerable people from unintended impacts of policy decisions is also an ethical responsibility.

There is nothing wrong with trying to minimize disruptions on patients from changes to their insurance plans, but the recent proposal to give certain patients the right to keep receiving treatment at higher-cost hospitals is too broadly written. Until it is clear just how many people would be exempted from policy changes, and how that might add to insurers’ costs, the Legislature should hold off, lest it undermine its own goal of making health care more affordable. If I'd written the editorial I wouldn't have used the phrase "insurers' costs." Those costs are passed through to the businesses and public agencies that purchase insurance. The public doesn't always understand that health plans - especially the regional not-for-profit health plans Massachusetts has - are essentially purchasing agents for the public and private entitites that provide health insurance to their constituents.  

The year before last, the Legislature passed a law requiring insurers to offer limited networks, which restrict plan members to certain hospitals and doctors, and tiered networks, which charge plan members more for using more expensive providers. The moves provided lower-cost insurance options for families and businesses, albeit by limiting patients’ choices of doctors and hospitals. Over the past two years, average annual premium hikes have shrunk from a projected 16.3 percent to 2.3 percent.

But this year, at the behest of Representative Steven Walsh, House chairman of the Joint Committee on Health Care Financing, and other influential legislators, the Legislature passed a budget rider making exceptions for some members of such plans. Walsh says he’s concerned that patients who were undergoing treatment at Children’s Hospital, the Dana-Farber Cancer Institute, and the Floating Hospital under the terms of their previous plans be able to continue their treatments there without bearing large cost increases. He contends that the budget language is crafted to apply to only a relatively small number of patients; he doesn’t, however, have a reliable estimate of just how many.

Although the legislative intentions may well be good, this episode is a cautionary tale.

The insurers, for their part, worry the language would allow a much larger number of patients with chronic conditions to sidestep plan features designed to rein in costs. They also worry that this action sets a bad precedent for future legislative interventions; already, lobbyists for major hospitals are seeking ways to keep their patients while still receiving higher reimbursements from insurers. It will likely now be left to the Patrick administration to work out a compromise.

Although the legislative intentions may well be good, this episode is a cautionary tale. Health care policy is so complex, and with so many moving parts, that it’s best to work out problems beforehand rather than fix them later. In this case, it’s easy to imagine a relatively small number of people with serious illnesses in the midst of rigorous treatment at Children’s, Dana-Farber, or Floating Hospital having a legitimate need to continue seeing the same doctors. I know from research I've done on the appeals process that continuity of care is a common concern for patients and clinicians. When you look at individual situations in detail it's clear that there's a continuum from long term/high complexity treatments in which deep relationships have been created over time to relatively clear cut treatments that could quite reasonably be transferred to another site. The editorial writer(s) recognize this continuum and make a nuanced argument.

But until Walsh and other sponsors can say just how many beneficiaries there are, and be certain that other patients will not be able to use the law to get treatment at their institution of choice without having paid for that option, the Legislature should avoid meddling with a reform that truly has worked.

This is a thoughtful, well-informed editorial. This kind of educative journalism has been an important contributor to the relatively collaborative way in which the state is dealing with the volatile conflicts that any serious health reform effort must tackle.