30 December 2010

Five Years. Huh.

In all the recent hubbub around here I seem to have forgotten my fifth blogiversary. Five years. Wow. That's like seventy in blog-years. I'm not super sentimental about milestones like that, but it's not trivial either.

I've long wondered why I continue to blog, what I'm going to "do" with it. I still don't have an answer. My enthusiasm for blogging has waxed and waned over the years. I've seen many great bloggers come and go, including, regrettably, Dr Rob, at least for the moment. For a while, the pressure of having to keep creating content, to get something out there made blogging a chore. Not so much any more. Sven notwithstanding the recent life issues I have found a place of peace with it: I'll write when I have something to say and when I have the time and energy to say it. When not, then I don't force it. That seems to be a good balance for me, and as I don't seem to be in danger of running out of opinions any time soon, it looks like I'll keep putting stuff out there. Whether that's a good thing is for you to judge.

Anyway, it's been a good run so far, and lots of fun. Thanks for dropping by to read, thanks for your support, and wishing all of you a happy new year.

21 December 2010

Science! It Works, Bitches

Randall Monroe, the author of the acclaimed xkcd webcomic is apparently suffering from a serious illness in the family, and I have linked to his posts on it before. I didn't really expect we'd be part of the same club so soon, but there it is. He continues to draw, and this one really hit me home: 

 

Sickness

 

I was thinking the same thing the other day. I am so profoundly grateful that we live in the time we do. Ten years ago, the HER2 receptor was associated with poor outcomes. Now, with the advent of Herceptin, that is much better. The data suggests that Herceptin reduces the risk of relapse by as much as 50% compared to traditional treatment. I spent a lot of time working on monoclonal antibodies during my lab days in the early nineties, and it is painstaking work. (My own lab career was cut short by a couple on incidents, one involving a broken hose and a flood in the lab and another when somehow half the lab became radioactive.)  But the hard work and the science continue to bear dividends, and in this case, we are the beneficiaries.

Yay Science!

 

(also, the tag line is an inside joke for long-time fans of xkcd. The phrase is available at the xkcd store on a t-shirt.)

20 December 2010

Cancer Sucks

This year has been a weird one for me and cancer. In the ER, we see cancer patients pretty infrequently. The occasional chemotherapy with fever, but that's about it. I think the oncologists try hard to keep the patients out of the ER -- to everybody's benefit. But this year, I've had a weird rash of cases where I've made primary diagnoses of cancer in the ER -- several times over and over and over again. In ten years I don't think I've made as many cancer diagnoses as I have this year alone. Just very strange.

Unfortunately, it came home to roost. My wife was diagnosed with breast cancer last week. 

This is an unusual case, in that my wife is quite young, and that the cancer was diagnosed shortly after our fourth child was born. Likely the pregnancy/nursing changes in the breast masked the lump; when she first noticed it, she thought it was perhaps a clogged milk duct. She showed it to her OB, who recommended watching it for a couple of months. When it did not go away, the OB ordered an ultrasound and mammogram (and thank the FSM that she was so meticulous), which showed a pretty obvious, relatively large cancer.

So it's moderately aggressive and locally advanced infiltrating ductal carcinoma. We are expecting it to be Stage 2b or 3, depending on the number of lymph nodes involved (they are palpable and appear enlarged on US). Curiously, the one node they biopsied was clean, so we are holding out hopes they might not be involved. Most importantly, the receptor status is encouraging: ER/PR negative (as one would expect in such a young woman) but HER2 positive. This is good because it opens up some treatment options, notably Herceptin, and avoids the poor prognosis involved in what they call "triple negative" breast tumors.

Having said that, this is going to be a rough road for our family. We anticipate, after staging is complete, a mastectomy followed by chemo and radiation. The chemo will be adriamycin and cytoxan, which I understand to be pretty brutal, for 12 weeks, followed by Herceptin and Taxol for another 12 weeks or so. Having said that, with what we know right now, we believe that there is good reason to expect a cure. 

Obviously, this has been a pretty huge shock to our system. It's scary and maddening. We've been shuttling back and forth to tests and doctors' appointments all week.  We have also been suffering from emotional whiplash as we veer from despair to determination and back again. But so far we are holding it together very well. The kids took the news well and seemed to process it at an age-appropriate level. We have been overwhelmed by the outpouring of support from our friends and family. Absolutely everybody seems to want to do something to help. It's humbling, since my wife and I are the sort of people with a mortal dread of imposing on others, but the reality is that we are going to need it. I'll be pretty focused on taking care of my wife, and I'll have to go back to work, and the kids are going to need to get to school, laundry, dinner and the usual stuff will need to be done. So we are going to have to learn to graciously accept some help; the biggest challenge will be coordinating all the volunteers to match our needs.

It could go without saying that blogging will be light to irregular as my priorities have been completely turned upside down. Don't list me as a dead blog -- I hope to come back to my regular, industrial-strength blogging once the treatment is complete, which is probably six months or so.

For those who wish to follow her progress and know what's going on, we have created a journal at the Caringbridge website which you can read.  A lot of our friends -- both real and online -- have asked what they can do to help. We thank you for all your support and warm thoughts. We don't really have a lot of needs beyond those which are local, but we would love to have your notes of support and encouragement for Liza over at Caringbridge. For those who wish to do something more tangible, I would encourage you to donate to a cancer charity. Longtime readers will know that my charity of choice is St Baldrick's Foundation, which raises money for pediatric cancer research, and I do intend to shave again this year. So if you feel the urge to take action, you can click here and donate to St Baldrick's online. And if you have breasts, or know someone who does, remind them to take a moment and do a breast self exam.

Again, thanks in advance for all your kind thoughts.

14 December 2010

Cool

If you read Bad Astronomy you've probably already seen this, but in this NPR article, a writer discussing scale shows a few cool relative maps, and also muses over the tiny area of the Moon which was covered by Armstrong and Aldrin.

 

Map of lunar excursion plotted on a baseball diamond

 

Neil Armstrong read the article, took issue, and responded.

08 December 2010

An Anticipated Relaunch

One of my favorite writers has returned to the blogosphere!  Intueri has relaunched as In White Ink -- The Unwritten Details!  The early posts are promising, as one would expect of a long-time medblogger, and the site design is lovely, as one would expect from the beautiful, minimalist design of the old site.

If you don't recall her, Intueri was the blog of a psychiatrist in training, and contained some of the most beautiful, compassionate writing on the human condition of any of the medbloggers out there. She's done with training now and hopefully back on the beat.

I've added it to my feed reader, and I'd recommend you do as well.

07 December 2010

Instructional Tattoo

From the KIROTV slideshow of The Ugliest Tattoos

I don't endorse, obviously, but it did make me laugh.

Well *that's* a vivid demonstration

In martial arts, there's a lot of talk about the "nerve clusters" as preferred striking points.  People refer to spots in the neck and the shoulders (most typically) as places where you can hit someone and temporarily paralyze them. I've always thought it was a bit of a crock: something dreamed up by people who have spent too much time watching Star Trek and convinced themselves that the Vulcan Death Grip was real. As a physician, I found the anatomy dubious -- sure, there are the brachial plexus and cervical plexus -- but the idea that you could strike them and paralyze someone, to me, seemed like so much magical thinking.

Which isn't to say that the neck isn't a great target. It is. It hurts like crazy when you strike it, it's a vital place where you can really injure someone, and if you control the neck you control the body. So I have tended to accept the nonsense talk about nerve clusters as just meaning "a good place to hit" while quietly not believing the hand-waving superstitious belief in "nerve clusters."

Then I saw this video off of the "Fail Blog:"

 

It's hard to watch that and not conclude that something funny neurologically just happened. The guy has an almost instantaneous total body spasm or convulsion, and drops as if poleaxed. It's not a centrally mediated reflex (like a vagal response); it's too fast. I'm not sure I can really explain it, medically, but damn.

I guess the old masters may have actually known a thing or two after all.

One thing about karate -- it does have a way of keeping you humble.

02 December 2010

On Drug Policy

A commenter posted the following question on the last post, about the economics of drug abuse:

Based on your experience as an ER doctor, I was wondering what your thoughts are on the drug use, specifically the drug war. Do you see legalization as an option for some drugs? What do you think of the Portuguese model of decriminalization and treatment? 

Will drug users just always be drug users? 

Far be it from me to opine on something that's not really my field of expertise. Wait, no, never mind, that's pretty much my stock in trade around here: wildly unsupported opinions about whatever occurs to me at any given moment.  So here goes!

First of all, the easy one: Pot. That should be decriminalized. It's not exactly benign, but it's probably less dangerous than alcohol, and it is inarguable that the black market for pot funnels a LOT of money into dangerous drug cartels. More to the point, it's just not the case that marijuana addiction necessarily harms people any more than alcohol, and I think that for consistency if you're gonna prohibit something it should be worse than the things you leave legal. I favor pot because it's largely harmless and my inner libertarian thinks the government shouldn't prohibit an activity absent compelling proof it is in the public interest. Pot fails that standard. Legalizing pot has practical policy benefits that we've all heard hashed to death in the wake of Prop 19, so I won't belabor the point. 

 

But I think that is not what the reader was asking about, and that the real question revolves around the harder drugs: should they be legalized?  In this case, my answer is no, I think they should remain illegal. This is a case where my inner libertarian yields to my inner paternalist. The hard stuff: meth, cocaine and heroin are potent. Really potent. These drugs have such a powerful effect on the brain that they drive behaviors that are all but impossible for people to control. Not all, but a predictable and significant number of people. It robs them of their agency, because the desire to obtain more drugs is so overwhelming that addicts cannot control it. They say meth is so great that all it takes is one time to hook someone for life.  They're too dangerous, and too unpredictable. Nobody who uses them for the first time can predict in advance whether they will be able to use them responsibly and occasionally (which is possible for some) or whether they will become enslaved to a lifelong addiction. Nobody makes an informed decision to become an addict: they make a mistake and get trapped.  And the life-wrecking power of these drugs is so obvious that I don't need to expand on the point, but meth in particular seems to do something to the frontal lobes that fries them; chronic meth users are functionally lobotomized. It's terrible.

So these drugs are so dangerous that I think it is essential that the government continue to make them illegal. But, as I said, the interdiction strategy has completely and utterly failed.  I'm not saying that we should give up on stopping the drug traffickers, but that a lot of resources spent on that effort could be redirected elsewhere with a lot of benefit. Economics dictates that where there is sufficient demand, supply will develop to meet it. Ignoring the demand problem while trying to kill the suppliers is like fighting entropy: it's a futile effort. 

So how do we stop demand? Sure, sure education in schools and "just say no" and all that is good stuff, but it's clearly ineffective. If we cannot prevent the drugs from getting to market, and we can't, then we also can't stop people from experimenting with them. What we need to do is identify the addicts who can be rehabilitated early and dedicate the resources to getting them off -- and keeping them off.

There's loads of evidence that drug treatment works. Not for everybody and maybe not permanently. No cure is perfect. But it massively mitigates the problem, and the return on the investment in drug treatment is equally massive, from the savings in incarceration costs, to less violent crime, to the economic benefits of returning people to the workforce.  So we should be redirecting resources from enforcement/punishment to treatment and rehabilitation.  There are all sorts of smart, proven strategies, from drug courts to needle exchanges to brief interventions in the ER. Unfortunately, it turns out that in times of recession, the first thing that gets cut is social services. Take this recession, in our liberal state: We lost our state-funded in-ER chemical dependency counselors, we lost at least three local detox centers, and we lost the state-run secure detox facility. The police budget is sacrosanct: that's "Public Safety" and woe to the politician who cuts it. But drug treatment? Ah, fuck 'em. Addicts don't vote.

Which is maddening because it's dumb. Why would you cut the cheapest and most effective tool in your arsenal? 

I am obviously frustrated with the current situation, but I should point out that I think a lot of progress has been made in the drug war since the panicky days of the 1980s. Things like needle exchanges were politically controversial -- even radioactive. Now they're accepted and unremarkable (so long as the money is there). Drug courts have gained widespread acceptance. Cocaine, heroin and meth use are all well off their historical peaks. Prescription drug abuse is on the rise, but otherwise, things are steady-to-improving.   It's not all doom and gloom

01 December 2010

The Refugee

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This is the song that made me fall in love with U2, back in 1983. I had all their albums until they lost their way with Achtung Baby, and drifted away after that. But damn, their early music was great.

Market Economics in Action

I've discovered over the years that I really like economics. I never took an econ class in my entire life, since I was pretty focused on the life sciences, but I've picked up a fair amount informally over the years.  Fortunately I have a strong background in statistics and math, and I've done a lot of reading on economics. I wouldn't say that I have any special level of understanding or credibility on the topic. Perhaps it should be noted that my wife took away the checkbook for good reason. But I enjoy it as a topic, as something to read about and a powerful tool for understanding how the world works.

On another note, one consequence of being an ER doc is that you are pretty close to "the street," and I don't mean Wall Street. I mean the folks living and scrounging on the streets. As a matter of functioning in the job, you learn the street jargon, you learn what drugs people are using and why and what the effects of those drugs look like. The other day I saw a middle aged guy brought in for acting really weird. Though everything in his social history argued against it, he just looked like he was on meth. I checked a tox, and sure enough, it came back positive. He strenuously denied any drugs, but eventually gave in and admitted the meth use. I remember in residency walking through downtown Baltimore with a fellow resident and our spouses and we amazed them by serially identifying the likely drug of choice of the various street people we passed, based on casual observation of their behavior. It's just what we do.

Now Baltimore was a heroin town. I remember a statistic that of the population of 700,000, 70,000 were actively using heroin, though I am not sure if that was true. It seemed an underestimate based on the folks we saw at our inner-city hospital. There was a bit of coke and the ever-present alcohol, but heroin was the epidemic. (Ever see The Wire? That show used to send shivers down my back it was so accurate; The Corner is maybe even better.)  Chicago, where I did med school, was more of a cocaine town. But when I moved to the Pac NW, the whole matrix shifted. There was no heroin -- literally none. We had a meth epidemic, and if I am not mistaken, the Pac NW was the first region where meth was really big. Cocaine was also unheard of in our town. A bit of prescription drug abuse, oxycontin and xanax rounded out the stable of abused substances (in addition to the ever-present alcohol). 

So it went for the better part of a decade. We saw an occasional heroin addict, the meth population waxed and waned, and the oxycontin abuse really became frightening in its dramatic increase.  The heroin addicts were a tough bunch -- the only heroin available in our state was "Black tar," which is thick and sludgy and very sclerotic to the veins. Basically it destroys the veins quickly and users have to switch to IM administration, and they got these terrifying deep facial plane abscesses that needed to be drained in the OR. No wonder it was unpopular!  So these users were hard-core, long-time addicts, really committed to their drug. In Baltimore, they had the highly refined "China White" which was practically pharmaceutical-grade and could be used IV for 30+ years. I didn't miss dealing with heroin addicts, but the oxycontin addicts were nearly as challenging to treat.

So it went -- unti recently. Over the last eight months, something changed.  All of a sudden, we started seeing large numbers of herion users, many of them "novice" injectors, still using their veins. Most of them were pretty frank that they had only recently started using heroin, and few of them had any record of ER visits for drugs in the past.  So, amateur economist that I am, I started systematically asking the heroin users how long they had been using, whether and what they had used before, and why they changed. I was surprised how consistent the answers were: they were nearly all former oxycontin users. Until this year, Oxycontin was easily available and cheap in our area. The users knew their doses and were able to carefully calibrate their intake to avoid accidental ODs or other misadventures. Few injected -- most chewed, smoked or simply swallowed the drug. For most, it was safe and simple and they stayed out of trouble (and out of my ER).  Then recently, Oxys became nearly unavailable, and scarcity drove the price way up. Previously, our community had a going rate of about a dollar a milligram for oxycodone, and at the epidemic's peak, the price was half that. Now, I was informed, it was triple, if you could find them at all.  "So we all switched to heroin," one pretty eighteen-year-old with track marks up both her arms glumly informed me.  Heroin was much cheaper, and apparently the local suppliers were more than able to accommodate the sudden spike in demand.

Of course, the dosing of heroin is harder to titrate, being of variable purity and quality, so people started OD'ing more regularly. And injecting causes all sorts of complications like abscesses. And while pill popping (or smoking) can for some be easily hidden from family, track marks are harder to explain away.  So they started appearing in the ER.

There you have it: economics in action. If I were a clever, real economist, I might neatly package the conclusion along the lines of the demand for opiates being relatively inelastic, but the brand (?) sensitivity is low, and once the incidental costs of heroin (inconvenience, lower quality, abscesses, disease, visibility) became lower than the absolute cost of oxycontin, the market suddenly tilted. (That's probably mostly gibberish, but it sounds economish.) As it is, I just shake my head at the sadness of it all and the seeming futility of interdiction as a strategy for dealing with drug abuse. Cut off one drug, and people switch to another, more harmful one. A funny sort of progress.