Monday, November 26, 2012

THE SLOW CODE


A friend sent me an article from the Toronto Star (http://www.thestar.com/news/canada/article/1292712--half-hearted-medical-care-for-hopeless-cases) that examines a behind-the-scenes medical practice called the “slow code.” The phrase awakened a dusty memory in me, a list of sarcastic phrases we medical smartasses spoke to one another but were careful never to mention around patients. Like “Five-P Syndrome,” meaning Piss-Poor Protoplasm Poorly Put Together. Or, when some troublesome patient departed, “AMF,” meaning, to put it delicately, “Adios, My Friend.” A “slow code” was cardiopulmonary resuscitation done so desultorily it was sure to fail.

In most hospitals the call for CPR comes over the PA system as “Code Blue” or “Code Three:” a patient is in cardiac arrest, so all hands on deck, stat. The bedside becomes a frightfully dramatic scene, a whirlwind of doctors, nurses, techs, gloved hands, potent drugs slammed through tubing, electric gadgets hooked up.

When I was an ER doc, I participated in plenty of these, and went at each full-bore, even when survival was unlikely. (In fact, unlikely survival is the most likely outcome. A study of ninety-nine thousand CPR attempts found that only two hundred twenty-eight patients, a fifth of one percent, were pulled from death into a normal life. That doesn’t mean we shouldn’t try, only that our expectations need trimming.)

Sometimes the patient is known in advance to be unsalvageable, being too old or frail or irreversibly sick even to survive the trial of CPR. In those instances, the staff would like to have a “DNR,” or do-not-resuscitate, order on the chart, but that’s not always the case, as end-of-life conversations are too seldom conducted. The practitioners who find themselves suddenly at these bedsides do their job, but half-heartedly, hence the “slow code.”

These scenarios aren’t just wasted energy. They can generate gratuitous suffering for everyone involved, especially the staff, who, while cleaning up the post-code mess, wonder what they’re doing in this profession. This all might be avoided were doctors to routinely discuss end-of-life issues with patients and their families. 

One reason they often don’t is that they’re not paid to do so. They’d earn thousands for a brain operation, but not a cent for helping guide people through their darkest hour. A provision in an early version of the Affordable Care Act of 2010 (“Obamacare”) specified paying doctors to hold such conversations. No sooner was this made public than millions interpreted it as “death panels” intent on pulling Grandma’s plug, and the provision was dropped.

As long as we keep end-of-life issues locked in the closet, we’ll continue to slow-code and act in other ways that would make a visiting anthropologist wonder about our mental health.

Thursday, November 15, 2012

THINK BEFORE YOU PINK


Who doesn’t want to find a cure for cancer? We give untold millions to organizations who claim that aim, but how can we be sure if our donations will be used as we wish?

Whatever you want to make of the current Petraeus flap, for example, it bears a relevant sidebar. A woman who’s involved, Jill Kelley, operated the “Doctor Kelley Cancer Foundation” along with her husband, a cancer surgeon. The foundation’s tax forms stated that “it shall be operated exclusively to conduct cancer research and to grant wishes to terminally ill adult cancer patients.” Apparently the group spent all its money on parties, entertainment, travel and attorney fees. $43,317 was billed as “Meals and Entertainment,” $38,610 was assigned to “Travel,” another $25,013 was spent on legal fees, $8,822 went to “Automotive Expenses,” $12,807 for office expenses and supplies, and $7,854 on utilities and telephones. By the end of 2007, the charity went bankrupt, evidently having spent not a penny on research or patient services.

A San Francisco group, Breast Cancer Action (bcaction.org/), tracks spurious cancer funds and organizations with a project called “Think Before You Pink.” I recommend consulting their info before you donate to any outfit that claims to help cancer patients.

Today BCA spotted an unusually outrageous ploy. One of Chesapeake Energy Corporation’s sub-companies, Nomac Drilling, which injects plenty of carcinogens and who-knows-what-else into groundwater with its fracking technology, has decided to support those who have breast cancer. An Oklahoma newspaper, NewsOK (http://newsok.com/drilling-rig-to-raise-awareness-of-breast-cancer/article/3722370#axzz2CJXvjk3R), brightly reports,

“Nomac Drilling is going pink. The Chesapeake Energy Corp. affiliate's newest rig will sport a pink ribbon to support breast cancer awareness.”

Chesapeake Energy recently donated $10,000 to Susan G. Komen for the Cure, and intends to make a similar donation in Ohio, where the pink rig is expected to be sent. Said Nomac’s President, “As we work in areas across the country, we hope this pink ribbon doghouse [sic!] serves as a reminder of the importance of finding a cure.”

These folks always emphasize finding a cure. Nothing wrong with that. But when it comes to identifying and eradicating causes of cancer, they’re curiously silent, and I think I know why.

Tuesday, November 13, 2012

PROP 37 BITES THE DUST


Well, California’s Proposition 37 has come and gone. It would have required foods containing genetically modified ingredients to bear labels stating that. I was all for it, as I’d really like to know what I’m eating.

The genetic engineering industry, including Monsanto, DuPont, and Dow, would rather we didn’t know. Their rationale is that such a label would look like a skull and crossbones to customers who aren’t yet convinced GM foods are safe. To defeat Prop 37, agribusiness and chemical conglomerates spent $46 million to blitz airwaves and mailboxes with negative advertising. They swore on bibles that GM foods aren’t dangerous. They claimed 37’s passage would add an average $400 to a family’s annual food bill. (I felt touched that these infamously greedy corporations were suddenly so concerned about my budget.) Anyway, with a million dollars of ads a day, you can probably convince voters the moon is made of cheese, so Prop 37 lost, 54 percent to 46 percent.

Besides Roundup, Monsanto sells a number of crop seeds resistant to that herbicide. Get it? Farmers can plant “Roundup-ready” soy, spray the field with Roundup, and harvest the crop absolutely weed-free. Never mind the long-term effects of Roundup and its breakdown products on the soil, the crop, and the end-users. For such info, check out these sites:




Monsanto’s goal is short-term profit, no matter what. Maybe you’ve heard that when its GM seeds have wafted into neighboring farms, Monsanto has sued those farmers for copyright infringement. If you’re a family farmer, try opposing a multinational bully’s stable of soulless attorneys.

Opposition to GM labeling is only a small step in the corporate plan to dominate American food. Even now, it’s hard to find soy or corn that isn’t genetically modified. Whether these crops truly are safe or not isn’t the current point, since like other synthetic chemicals now in our environment, we won’t be able to determine their safety for a generation or two. The point is that they aim to be our sole food supplier, and when they're effectively a monopoly, they'll charge whatever they like.

Keeping that horrifying prospect in mind, along with Prop 37’s failure, we can choose to buy food locally, minimize or omit our purchase of processed foods, and know our local farmer. What our family doesn’t grow we buy from a local co-op, which supplies itself from local farms. A strictly organic farming family we often deal with hasn’t applied for any organic label because the hoops they’d have to go through—actually designed for large-scale farms—are too extensive and troublesome. But we know these people, and seeing how they operate, we trust them. That’s a lot more than can we can say of Monsanto.

Thursday, November 8, 2012

GOOD LUCK SHOPPING


As the Affordable Care Act (“Obamacare”) kicks in, tens of millions of Americans currently uninsured will be required to buy medical insurance. To meet this windfall, insurance companies are crafting hundreds of new and varied plans. If recent history is any guide, hardly any policy will be simple and straightforward.

I recently received my annual Medicare and You manual, which explains benefits and limitations, allegedly in plain language. I, with a doctorate in this business, ought to be able to understand the subject easily. But I can’t. I’ve tried for years, and still can’t.

It’s not just my fading neurons at fault. Dahlia Remler, a health economist and professor with a PhD from Harvard, wrote in the Washington Post a couple of days ago (http://www.washingtonpost.com/national/health-science/facing-brain-surgery-a-health-economist-finds-the-health-care-market-hard-to-navigate/2012/11/05/0a931b5c-fcf1-11e1-b153-218509a954e1_story.html?wprss=rss_health-science) that she’s as confused a patient as anyone. She wrote, “My difficulties show how hard it is—even for someone who has studied health-care and insurance issues—to navigate the health-care marketplace, particularly when you have a serious medical condition.”

Medicare is a piece of cake compared to private policies. As a service, not a business, Medicare isn’t allowed to make a profit, while private insurance corporations are legally obliged to give their shareholders a return on their investment. So one has to wonder whether private policies’ lengthy verbiage and labyrinthine rules serve to inform or actually mislead. 

But don’t worry. Some newly formed companies will soon offer, for a fee, to guide patients through the insurance marketplace. I guess if I were an insurance company, I’d start one of these, too, and be quite careful where I referred customers to. Ah, but there I go again, into the cynical shadows.

Anyway, I packed up the Medicare manual and sent it off to a cousin in Ottawa, one of our many Canadian relatives who routinely ask us, “What exactly is wrong with you Americans?” She read the thing and got a good laugh out of it. She gets her healthcare in a national system that covers everything. It’s funded by her taxes. If she were American, she’d pay over $10,000 in premiums for partial coverage. If a Canadian-like system were in place here, she’d pay zero for premiums and about $4,000 annually in taxes for complete coverage. Seems like a no-brainer to me, but God forbid we should copy foreigners.