Sunday, April 23, 2017

Executioner/Doctor

There was a very bad op-ed published in the NY Times Saturday by the writer/cardiologist, Dr. Sandeep Jauhar.  It's called "Why It's OK for Doctors to Participate in Executions" and that pretty much tells you all you need know.  If you were to  read something online entitled "Why It's OK for Rapists to Babysit Your Child" you would feel the same filthy layer of scum descend upon your skin as I felt when I read Dr Jauhar's inexplicable ode to Doctors of Death.

The piece comes on the heels of a recent decision by the good ol' state of Arkansas to execute 8 men on death row over the next 11 days--- not because their crimes were particularly heinous or irrefutable, or just from sheer coincidence, or some other fluke of timing in the sentencing--- but rather because the state's supply of IV drugs used in executions is due to expire by the end of the month.  There's enough in that last batch, apparently, to knock off 8 inmates.  So...while the iron is hot....

Dr Jauhar makes the error of assuming that capital punishment will never go away, that all we can do as a society is to figure out ways of rendering it in a less mendacious, less barbaric, more telegenic fashion.  And who better to assure that a lethal drug cocktail will be administered with elan and efficacy than a practicing physician?  After all, medical errors are the 3rd leading cause of death in our great country! Allegedly.

I need to break Dr Jauhar's piece down paragraph by excruciating paragraph.  It's the only way to do this with any justice.  Here's one paragraph:
The three drugs in Arkansas’s execution protocol — midazolam; vecuronium bromide, a paralytic used during surgery that halts breathing; and potassium chloride, which stops the heart — are administered intravenously. The execution procedure therefore requires the insertion of catheters, controlled injection of lethal drugs and monitoring of a prisoner’s vital signs to confirm death. This makes it important that a doctor be present to assist in some capacity with the killing.
What is it about "insertion of catheters, controlled injection of lethal drugs, and monitoring of a prisoner's vital signs" unequivocally necessitate the presence of a physician?  The next time I witness an actual real live doctor place a peripheral IV in a patient, inject a medication all by himself, and then check a set of vital signs will be the first in at least a decade of practice.  There is nothing about the act of lethal injection that is inseparable from physician presence.  The idea that basic procedures performed every day by nurses and EMT personnel cannot be duly done without a physician watching over their shoulders is both condescending and ill-informed.

Here's another paragraph:
 The American Medical Association, however, strongly opposes physician participation in executions on ethical grounds. Selecting injection sites, starting intravenous lines and supervising administration of lethal drugs, the association says, violate a doctor’s oath to heal or at least to do no harm. Doctors who defy the association’s guidelines face censure and the threat that a state medical board might revoke their license, though it is doubtful such punishment has ever been carried out. I disagree with this view. Though I oppose capital punishment as a matter of principle, as a doctor I believe physician presence at executions is consistent with our mandate to alleviate suffering.
Who edited this piece? Here we have a physician outlining the American Medical Association's firm stance opposing any physician participation in lethal injection executions and then, blithely, distancing himself from that view while still claiming to hold a higher moral ground---- he only wants to alleviate suffering!  That's obnoxious, man.  You want to stick a doctor in a death chamber with vials full of instant death and call yourself a hero because you are allowing for the state to eradicate a human in a way that seems quiet and unobtrusive and clean.  Even the kids can come out to watch.  Watch the bad man go to sleep, Johnny.  See?  See how peaceful he looks?  Is that a smile on his lips?  He's happier now!  His sin has been purified! Christ has smited him!.  Satan has him now!

I have to go to another paragraph before I start writing 3000 words in the voice of a Evangelical Christian from Little Rock talking to his kid at a state sanctioned execution:
A lot can go wrong during lethal injections. In 2014 in Oklahoma, to cite just one gruesome example, a 38-year-old convicted murderer named Clayton Lockett writhed in pain at his execution, clenching his teeth and straining to lift his head off the pillow, according to witnesses, after a botched injection into a vein in his groin.
A lot can go wrong?  Even with lethal injection?  State sanctioned murder for more civilized and  sophisticated tastes?  You don't say!   You mean that when dangerous drugs are given off label for purposes they weren't meant for that sometimes things can "get a little hairy"?  That's some wild and wacky shit.  Short side tangent here: Do you know why vecuronium is always included in lethal injection cocktails?  Because it is a strong paralyzing agent.  My anesthesiologist colleagues often use it to render a patient completely still when I perform abdominal surgery.  The purpose of the drug in a death chamber is pure optics.  The third drug administered, the actual killer, is generally a lethal dose of potassium chloride.  Once injected it causes a massive myocardial infarction--- which is excruciating.  Even the injection of KCL into the veins itself will make it feel like your arm has been lit on fire.  So to spare us the "theatrics" of a condemned man writhing and groaning in agony while strapped to a gurney, we give the paralyzing agent as cloak; to hide the unsavory awfulness of what an execution actually entails.

Here's 2 paragraphs in a row:

Sunday, April 9, 2017

Sunday Poem


Baked In





There is a sadness baked into existence.

Without it there’s no flavor.

You’d never know what to savor
Or how to wait for joy’s recrudescence

Your cupboard is a cage
Where it sits in darkness
Next to the cinnamon, pepper and sage.
Take what you need, cook your own catharsis

A pinch here, a dash there
Taste it as you stir the mixture
You always add more as time goes along
There’s no limit, you can’t do it wrong.
Some gets added when you turn your head---
It’s serendipity!
Never was a written recipe
Try to recall what mother once said

Put it in the oven and let it bake.
There’s no timer, it’s imprecise.
No way to know when the swirl of sadness coalesces
With the rest and then rises.
A taste you can only imagine will have to suffice

Look outside in the early pre-dawn, dark as sable,
Rows of homes with kitchen lights on.
All of us awake, anxiously waiting at tables
For our cakes to get done


4/9/17

Listening

From Erich Fromm's The Art of Listening:

  1. The basic rule for practicing this art is the complete concentration of the listener.
  2. Nothing of importance must be on his mind, he must be optimally free from anxiety as well as from greed.
  3. He must possess a freely-working imagination which is sufficiently concrete to be expressed in words.
  4. He must be endowed with a capacity for empathy with another person and strong enough to feel the experience of the other as if it were his own.
  5. The condition for such empathy is a crucial facet of the capacity for love. To understand another means to love him — not in the erotic sense but in the sense of reaching out to him and of overcoming the fear of losing oneself.
  6. Understanding and loving are inseparable. If they are separate, it is a cerebral process and the door to essential understanding remains closed.
 Some useful advice in there for the working physician.  It may not improve your patient satisfaction scores.  Press-Ganey is unlikely to have a metric that measures one's adherence to the above.  But a concentrated effort to focus on your patient's narrative with open mindedness, imagination, empathy and love sure seems like a good way to be a better doctor.

It's the best part of the job, really.  Once the OR lights go off, the post op orders are written, you finally sign out of the EMR for the night, what you will remember most are all those moments in time when you sat in a room alone with other human beings and listened to them tell you not only what hurt but what things were like before the pain started. Past and current lives and loves.  What the future might hold.  Expressions of gratitude and disappointment.  You will hear special and unique kinds of humor and anger and fear.  In a minute of side wise glances between spouses you will see the theretofore hidden dynamics of an entire relationship.  In short, you will experience the transformation of the human into the Human.  Real known people will emerge from the great mass of anonymity that we mindlessly push through every day like prairie grasses.  And all you have to do is sit there with patience and an open heart, ask a few questions, and just.... listen.


Sunday, April 2, 2017

A Nation in Pain

This past week, Governor John Kasich of Ohio issued an executive order limiting the amount of opioids doctors and dentists can prescribe to no more than a 7 day supply.  Failure to comply could result in disciplinary action, including loss of license.  Exceptions exist only for patients with cancer or those enrolled in hospice programs.  For all the rest, it represents a hard full stop.  No longer will the chronic pain sufferer, the woman status post lumbar back fusion x 3, be able to get a prescription for a month's supply of oxycodone with 3 refills.

On the surface this appears to be a reasonable initiative.  We are undoubtedly in the midst of a true crisis in terms of opiate/opioid abuse in this country.  It is a crisis that disproportionately affects the poor, the downtrodden, across large swaths of flyover rural America.  Something must be done, any reasonable elected official would say.  Over 50,000 Americans died last year as a result of an overdose.  Overall life expectancy declined last year for the first time in nearly 30 years, a decline mainly attributable to middle aged males and females from lower economic and educational attainment strata dying sooner.  Suicide and overdose have been targeted as culprits in this real "American carnage".

But what I am uncomfortable with is the evolving narrative that the entire crisis was fomented by evil "pill mill" doctors lining their pockets with cash as their patients spiraled into despair and degradation .  Certainly, bad apples are out there.  But anecdotal stories about physician malfeasance fail to adequately explain the opioid epidemic.  Why does it exist?  Why are so many Americans turning to escapist options to dull their pain?  What is this constant throbbing ache, this intermittent sharp twinge, that afflicts so many?  Why are so many from very specific geographic areas, from very specific socioeconomic stations seeking relief from a great contagion of pain?

It's easy to say: those damn doctors.  Bad doctors can be fixed.  They can be demonized as scourges upon society.  All stories flow easier with an identifiable villain.  But it's much harder to say: the structural/cultural/economic foundations of our country have been slowly eroding over the past 35 years and as the ramparts come tumbling down, those left exposed, vulnerable to the ravages of life's uncertainties will then turn to something, anything to assuage pain, numb anxiety.  A life lived in a state of constant uncertainty and despair breeds hopelessness.  And for many, escape becomes the only reasonable solution.

Since we embarked upon a path of free market globalization, our nation has seen a rise in income inequality that puts the Gilded Age to shame.  As the following graphs show:

Source: Emmanuel Saez, Center for Equitable Growth, June 2015
Source: Striking it Richer: The Evolution of Top Incomes in the United States, Emmanuel Saez, June 2015
Source: Institute for Policy Studies and AFL-CIO analysis of Bureau of Labor Statistics average hourly earnings data and corporate proxy statements, 2016

And how did this occur?  How is it that, in the richest, most wealthy nation in recorded history, so much of the fruits have gone to so few of its citizens? The answers of course, reside outside of what this blog post can elucidate, but the common theme revolves around wealth concentration and restricted distribution.  We have all driven by the shuttered factories in the heartland.  Those jobs shipped off to third world countries in the 80's and 90's will never return.  No longer can a male of mediocre intellectual talents just sign up for a job out of high school at the local Ford plant or the rubber tire factory and plan to settle in for 25-30 years of solid pay with good benefits and be able to raise a family, send his kids to college, retire at 65 with a 7 figure pension.  Those days experienced by the baby boomer generation, are almost mythically unattainable by the bulk of Americans in the heartland today.

And so what happens?  What happens when a man or a woman cannot honorably earn a living?  When the costs of higher education go up 400% over 25 years?  When health care expenses skyrocket beyond affordability and, in the absence of employer based insurance, become the driving etiology of bankruptcy and financial catastrophe?  What happens?  Is it simply of case of legions of evil doctors descending upon these wracked plains of a nation and unleashing their addictive and destructive medicines?  Is that the narrative we ought to go with, in the face of so much contrary evidence of systematic instability?

Governor Kasich and Senator Portman in my home state, have made the opioid epidemic a priority in terms of legislation and executive orders.  I am not so cynical as to doubt their motivations.  They see the pain and suffering in so many of their constituents and want to alleviate it, to the extent they are able.  But these measures are akin to the crackdown during the War of Drugs.  We ended up incarcerating millions of Americans (mostly minorities, mind you) without having any impact on drug use, especially in the areas where the crackdown was most targeted, i.e. the inner cities.  Prohibitionary measures simply don't work.  The evidence from the 1920's and then from the 1970-2015 War on Drugs era is irrefutable.  You cannot simply criminalize or police your way to complete abstinence.  The black market will always step in to fill the gaps in supply.  And the greater you restrict access, the more the black market will place its foot upon the throats of those clamoring for a fix.  The vicious cycle will continue.  The drugs will be less regulated, stronger, more dangerous.  More will die.  More will go to jail and be forever stained with a felony tag.  It would be a tragedy to repeat the same mistakes we've made in the past for this new scourge.

The real issue, the potentially fixable issue, is one of demand.  Why are all these Americans turning to the escapism offered in the form of heroin or prescription opioids?  And how can that demand be addressed?

We know that 20% of Vietnam veterans were addicted to heroin during the war.  But only a small percentage continued to use heroin once they returned home to America, back to jobs and wives and existential stability.  We know that in Portugal and Switzerland, opiate addicts can go to "clinics" for heroin injections early in the morning on their way to work.  That many of them eventually simply stop using the drugs as they become more and more integrated back into stable and meaningful life routines.  In America opt to do things differently.  Marijuana is categorized as a  Schedule I substance (no accepted medical use).  Addicts are treated as derelicts, scum of the earth.  We continue to incarcerate more people for drug related offenses than the rest of the world combined.  And nothing has changed, nothing has improved, despite the trillions of dollars spent on this ill-advised "war" over the past 35 years.

A nation writhes in pain.  No one can avert their eyes from it.  Our ER's fill up nightly with overdoses.  The young and middle aged are dying in unprecedented numbers.  A plague is upon us.  You can regulate doctors a little more, I guess.  You can repudiate the idea that "pain is the fifth vital sign", as the American Medical Association has done.  But you can not simply tell people that they are not hurting.  You cannot erase the pain of dislocation, uncertainty, economic catastrophe.  You cannot tell a man with three kids, a drug habit, trapped in rural middle America, that the pain he feels every morning in his back, his joints, his heart and soul is somehow not real.  That he ought to feel shame.  That it is somehow all his fault.  

You can threaten doctors.  You can cut off the legal flow of a few bottles of prescriptions drugs.  But it won't stop the pain of the millions with no prospects and no hope.  Kasich's order is a band-aid applied to a gaping hemorrhaging wound.  It's something, I guess.  But it isn't nearly enough.





Sunday Poem

The Pattern of this World

Romans 12: 1-2  Therefore, I urge you, brothers and sisters, in view of God’s mercy, to offer your bodies as a living sacrifice, holy and pleasing to God—this is your true and proper worship. 2 Do not conform to the pattern of this world, but be transformed by the renewing of your mind. Then you will be able to test and approve what God’s will is—his good, pleasing and perfect will.


She lie wasted and hollow eyed and thin
A skeleton hung with threadbare robes of skin
The CT scan showed free air, extravasation
I rushed in, found her swallowed by sheets and blankets
Alone, shivering, at the last way station


She showed me the spot where it hurt
And I found the other places, here, and over there.
She grimaced as her abdomen stiffened
And then smiled, as if to apologize, a soul imprisoned---
Anorexia, drug abuse, years of imperfect will


Later on she lie splayed on the OR table arms extended
As if an offering on a cross, a life expended.
The hard lights shined truth on her naked flesh
The tattooed verse etched in Olde English across her pale chest


Her bowels were limp and gray and lifeless
Like the newspaper left out in a rainstorm
The words smeared and meaningless.
Handle gently, all falls apart; words, world, body---
The patterns lose form

4/2/17