i i 9 12 Chekhov A. Letter to A.S. Suvorin, 1888. Table 1.1 Diagnosis by iteration and reiteration A brief history suggests looking for a few signs, the assessment of which leads you to ask further questions and do a few tests. These results lead to further questions and tests. As this process reiterates, various diagnostic possibilities crop up and receive more or less confirmation. \200\234I feel my heart racing \200\235 \200\224and the doctor immediately puts his finger on the pulse, feels it to be irregularly irregular, and infers atrial fibri llation (AF; see p. 120). He wants to know why there is AF, so he asks about weight loss an d heat intolerance. This suggests hyperthyroidism (p. 298) as the cause of the AF. While he takes the pulse, he notices clubbing of the fingers, so he makes a mental note to do a che st x-ray to see if there are signs of cancer (could this cause the AF? \200\224yes). This r eminds him to ask about smoking: While inquiring about habits, he asks about alcohol, and e licits excessive drinking. \200\234Why now? \200\235 \200\234Because I lost my job. \200 \235 In the time it takes to assess the pulse, the doctor has many promising leads to follo w and is starting to formulate a diagnosis in three dimen- sions: Physical, psychological, and social. The patient \200\231s palms are clammy and the pulse is weak, so the doctor kno ws he must be prompt and decisive, and gently explains that admission for various tests is needed. Whereupon the patient, who has been holding back tears, now weeps. Now holding her hand, as well as continuing to take her pulse, the doc- tor becomes aware of a change in rh ythm. Is this sinus rhythm, brought on by the Valsalva-like maneuver of weeping? So the doc tor now says \200\234Well \200 let \200\231s see how you do over the next hour \200\224yo u \200\231ll feel better for crying. \200\235 \200\234Yes, you \200\231re right, I feel be tter already. \200\235 This is a microcosm of the intuitive world of medicine, which the so lely systematic doctor never knows. He would come on to the pulse only after a \200\234ful l history \200\235 \200\224and would have missed everything. The doctor who can work on man y different levels simultaneously will often be the first to know the diagnosis. 10 Diagnosing by computer Computing power is the only way of fully mapping the interrelatednes s of diseases (e.g., hyponatremia with eosino- philia points to Addison \200\231s disease , and if there is oliguria, the computer \200\234knows \200\235 that oliguria is a feature of shock, and shock is a complication of Addison \200\231s). Prevention Two mottos: \200\234The only good medicine is preventive medicine \200\235 and \200\234If prevent- able \200 why not prevented? \200\235 During life on the wards you wil l have many opportunities to practice preventive medicine, and, unconsciously, you will pas s most of them over in favor of more glamorous tasks such as diagnosis and clever intervent ions, involving probes, scalpels, and imaging. But if we imagine a ward in which scalpels r emain sheathed and the only thing being probed is our commitment to health, then preventive medicine comes to the forefront, and it is our contention that such a ward might produce m ore health than some entire hospitals. Ways of thinking about prevention Preventing a disea se (e.g., by vac- cination) is primary prevention . Controlling disease in an early form (e .g., carcinoma in situ ) is secondary prevention . Preventing complications in those alread y symptomatic is tertiary prevention . The best way of thinking about prevention is to ask \200\234 What can I do now with this patient in front of me? \200\235 On the wards, this w ill often be secondary or tertiary prevention (e.g., blood pressure screening in diabetes, or colonos- copy in ulcera tive colitis [looking for colon cancer], or endoscopic screen- ing for esophageal cancer in Barrett \200\231s esophagus). The first step in prevention is to motivate your patient to take steps to benefit his or her own health by asking Socratic questions. \200\234Do you w ant to smoke? \200\235 \200\234What does your family think about smoking \200\235 \200 \234Do you want your children to smoke? \200\235 \200\234Would there be any advantages in giving up? \200\235 \200\234Why is your health important to you? \200\235 \200\234Is ther e anything more important we can help with? \200\235 \200\234How would you spend the money you might save? \200\235 These types of questions, along with specific strategies in preve ntion (p. 87) are more likely to produce change than will withering looks and lectures on l ung cancer. In summary: In any preventive activity, get the patient on your side \200\224ma ke her want to change. Once you have done this, preventive activities you might promote inc lude: e n i c i d e m t u o b a g n k n h T i i Primary - and secondary disease prevention General health Cancer screening Vaccination (e.g., flu shot if Healthy eating Colon cancer screening Pap smears Mammography and 11 >65 yrs) Aspirin if vascular disease Cardiovascular risk Regular exercise Advice on smoking reduction and alcohol House and car dangers: Seat belts, accidents, falls, gun safety annual breast exam Osteoporosis prevention if on steroids or postmeno- pausal (calcium, vitamin D, bisphosp honate) Genetic counseling (e.g., if family history positive in two 1st-degree relatives) Sometimes referral to other agencies is needed (e.g., for genetic counseling, contraception , and preconception advice). Concentrate on those preventive activities that are simple, ch eap, and have a complication rate approaching zero. When considering a more compli- cated o r \200\234high-tech \200\235 preventive procedure, be on guard for unintended con- sequenc es, such as colon perforation in colonoscopy. When risk is involved with the preventive str ategy, weigh the procedure in light of the patient \200\231s history and other medical prob lems. Get the patient \200\231s input about whether the preventive measure is right for him or her. Individualized risk communication When counseling a patient about screening tests, communication should be based on a person \200\231s individual risk factors for a conditio n (e.g., age, family history, smoking status, choles- terol level). With some conditions, t his can be achieved with decisional aids or using formulas. A Cochrane meta-analysis sugges ts this kind of individu- alized approach will \200\234not necessarily \200\235 change beh avior, although uptake of screening tests is improved. At least this technique promotes dia log, and dialog opens doors, minds, and possibilities for choice. Informed partici- pation is the aim, not passive acceptance of advice. Improved knowledge, beliefs, and risk percept ions can be achieved with this approach. How clini- cal evidence is presented can make a di fference in certain patient popula- tions. Participatory decision-making is facilitated whe n the physician: \212 Understands the patient \200\231s experience and expectations. \212 Builds partnership. \212 Provides evidence, including a balanced discussion of uncertaint ies. \212 Checks for understanding and agreement. \212 Presents recommendations informed by clinical judgment and patient preferences. Prescribing drugs Before prescribing any drug with which you are not thoroughly familiar, c onsult the Physicians \200\231 Desk Reference (PDR), your local equivalent, or a reliable o nline reference site like Micromedex: <http://www.thomsonhc.com/micromedex2/librarian> Befo re prescribing, ask if the patient is allergic to anything. The answer is often \200\234Ye s, \200\235 but do not stop here. Find out what the reaction was, or else you run the risk of denying your patient a possibly life-saving and very safe drug, such as penicillin, beca use of a mild reaction like nausea. Is the reac- tion a true allergy (anaphylaxis, p. 748 o r a rash?), a toxic effect (e.g., ataxia is inevitable if given large quantities of phenyto in), a predictable adverse reaction (e.g., GI bleeding from aspirin), or an idiosyncratic r eaction ? Remember primum non nocere : First do no harm. The more minor the complaint, the more weight this dictum carries. The more serious the com- plaint, the more its antithesis comes into play: Nothing ventured, nothing gained . Ten commandments These should be writte n on every tablet: 1 Explore any alternatives to a prescription. Prescriptions lead to doct or-dependency, which in turn frequently leads to bad medicine and drives up the expense of healthcare. There are three places to find alternatives: \212 The kitchen : Lemon and hone y for sore throats, rather than penicillin. \212 The blackboard: For example, education ab out the self-inflicted causes of esophagitis. Rather than giving expensive drugs, advise ag ainst too many big meals, eating close to bedtime, smoking and alcohol excess, or wearing o verly tight garments. 12 \212 Last, look to yourself . Giving a piece of yourself, some real empathy, is worth more than all the drugs in your pharmacopeia to patients who are frightened, bereaved, or weary of life. 2 Find out if the patient wants to take a drug. Are you prescribing for some minor ailment because you want to solve every problem? Patients may be happy just to know the ailment is minor. If they know what it is, they may be happy to live with it. Some people do not belie ve in drugs, and you must find this out. 3 Decide if the patient is responsible. If she swallows all the acetamino- phen with codein e pills that you have prescribed for her acute pain at one time, death will be swift. 4 Know of other ways your prescription may be misused. Perhaps the patient whose \200\234i nsomnia \200\235 you so kindly treated is actually grinding up your prescription for inject ion in order to get a fix. Will you be suspi- cious when he returns to say he has lost your prescription? 5 Address these questions when prescribing: \212 How many daily doses are there? 1 \200\2232 is much better than 4. \212 How many oth er drugs are to be taken? Can they be reduced? \212 Can the patient read the instructions on the bottle \200\224and can he open it? \212 Is the patient agreeable to enlisting the help of a loved one or care- taker to ensure that she remembers to take the pills? \212 Is the patient taking the medication properly? Check by counting the remaining pills at the next visit. \212 How will the patient refill his prescription? \212 How will you know and what will y ou do if the patient does not come for a follow-up visit? 6 List the potential benefits of the drug for this patient. 7 List the risks (side-effects, contraindications, interactions, risk of allergy). Of any new problems, always ask yourself: Is this a side-effect? 8 Try to ensure there is true concordance between you and your patient e n i c i d e m on the risk \200\223benefit ratio \200\231s favorability. Document your discussion. 9 Recor d how you will review the patient \200\231s need for each drug and quan- tify progress (or lack thereof) toward specified, agreed goals (e.g., pulse rate to mark degree of -blocka de or peak flow reading to guide steroid use in asthma). 10 Make a record of all drugs taken. Offer the patient a copy. t u o b a g n k n h T Is this new treatment any good? (Analysis and meta-analysis) This question frequently arise s when reading journals. Not only authors, but all clinicians have to decide what new treat ments to recommend and which to ignore. Evidence-based medicine recognizes two fundamental principles: (1) the physician must assess the strength and validity of the evidence for the new treatment based on a hierarchy; (2) decision makers must consider the patient \200\231 s values and trade off the benefits, risks, inconve- nience, and costs of alternatives. Use rs \200\231 Guides to the Medical Literature have been created to help the clinician decide whether the results of a research study will help in the care of his or her patients. In a ssessing the use of research, ask the following: 1 Are the results valid? Much must be take n on trust, since many statistical analyzes depend on sophisticated computing. Few papers, unfortunately, present \200\234raw \200\235 data. Look out for obvious faults by asking: i i 13 2 Were comparison groups (experimental and control groups) similar in terms of prognosis an d clinical characteristics at the start of the study? 3 Were patients randomized to the com parison groups? Did random- ization produce groups that were well matched? Were the treatme nts being compared carried out by practitioners equally skilled in each treatment? 4 Was the study placebo-controlled? Good research can go on outside the realm of double-bli nd, randomized trials, but you need to be more careful in drawing conclusions (e.g., for in termittent symptoms, a bad time [prompting a consultation] is followed by a good time, maki ng any treatment given in the bad phase appear effective). Regression toward the mean occur s in many areas (e.g., repeated BP measurement: Because of transitory or random effects, mo st people having a high value today will have a less high value tomorrow \200\224and most o f those having a low value today will have a less extreme value tomorrow). This concept wor ks at the bedside: If someone who is drowsy after a head injury has a high BP, and the next measurements are higher still (i.e., no regression to the mean), then this suggests a \200\234real \200\235 effect, such as increased ICP. 5 Was the study blinded? In a double blind study, both patients and doctors are unaware of which treatment the patient is having. Could patients, doctors, or those assessing outcome have figured out which treatment was given (e.g., by the metabolic effects of the drug)? 6 Is the sample large enough to detect a clinically important difference, say a 20% drop in deaths from disease X? If the sample is small, the chance of missing such a difference is high. To reduce this chance to less than 5%, and if disease X has a mortality of 10%, more than 10,000 patients would need to be randomized. If a small trial that lacks power (the ab ility to detect true differences) does give \200\234positive \200\235 results, the size of the difference between the groups is likely to be exaggerated. This is type I error ; a ty pe II error applies to results that indicate that there is no effect, when in fact there is one. So beware of quite big trials that purport to show that a new drug is equally effective as an established treatment. 7 How large was the treatment effect, and how precisely was it measured? 8 Does the study give a clear, clinically significant answer, as well as a statistically si gnificant answer in patients similar to those I treat? Are the likely treatment benefits wo rth the potential risks and costs if applied in the clinical setting? 9 Is the journal peer reviewed? Experts vet the paper before release (an imperfect process, as they have unknown axes to grind \200\224as well as competing interests). 10 Has time been allowed for criticism of the research to appear in the correspondence columns of the journal in question? 11 If I were the patient, would I want t he new treatment? 12 What have the Centers for Disease Control (CDC) or professional organi zations said? Have clinical guidelines been developed as a result of the research findings? Meta-analyzes Systematic merging of similar trials can help resolve contentious issues and explain data inconsistencies. Meta-analysis is quicker and cheaper than doing new studies, and can establish generalizability of research. Be cautious! Bias can result from pharmaceu tical funding or from the meta-analyst \200\231s own assumptions about the topic under stud y. A well-planned large trial may be worth centuries of uncritical medical practice; but a week \200\231s experience on the wards may be more valuable than years reading journals. As William Osler said, \200\234To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all. \200\235 13 This is the central paradox in medical education. How can we trust our own experiences, knowing they are all anecdotal; how can we be open to novel ideas but avoid being merely fa shionable? A stance of wary open-mindedness may serve us best. 14 Resource allocation and distributive justice Resource allocation: How to decide who gets wh at There is a per- ception in the United States that healthcare resources are scarce. When one looks at the availability of organ transplants, critical care beds, home care services, and other potentially beneficial treatments, this appears to be true. Resource allocation is about cutting the healthcare cake \200\224the size of which is given based on how much s ociety is willing to expend on health- care relative to other societal priorities. Making t he cake Focusing on how to cut the cake diverts attention from the central issue: How large should the cake be? The answer may be that more needs to be spent on our healthcare servic es, not at the expense of some other health gain, but at the expense of something else. The percent- age of gross domestic product (GDP) spent on healthcare differs from country to c ountry, and economists debate how much is too much \200 or too little. Slicing the cake In deciding how to slice the healthcare cake, methods have been developed to find a rational basis for allocating resources. One method used by health economists is the QALY. What is a QALY? The essence of a QALY (Quality Adjusted Life Year) is that it takes a year of health y life expectancy to be worth 1, but a year 13 Osler W. Books and men, in Aequanimitas , 2nd ed. Philadelphia: P. Blakiston \200\231s S on & Co.; 1925. of unhealthy life expectancy is regarded as <1. Its exact value is lower the worse the qual ity of life of the unhealthy person. If a patient is likely to live for 8 yrs in perfect he alth on an old drug, he gains 8 QALYs; if a new drug would give him 16 yrs but at a quality of life rated by him at only 25% of the maximum, he would gain only 4 QALYs. The dream of health economists is to buy the most QALYs for his budget. QALYs are helpful in guiding rat ion- ing, but problems include accurate pricing, the invidiousness of choosing between the welfare of different patients \200\224and the problem of QALYs not adding up: If a vase of flowers is beautiful, are 10 vases (or QALYs) 10 times as beautiful \200\224or might the sc ent be overpowering? Eating the cake In their daily practices, the majority of physicians w ill not have to contemplate the larger picture of how society spends its healthcare dollars . They will have to worry about whether the patient can afford the medication just prescrib ed, whether a proposed treatment will be cov- ered by the insurance plan, where their patie nt is on the transplant wait- ing list, etc. How much the everyday clinician needs to facto r allocation of resources into treatment recommendations (i.e., bedside rationing) is a con troversial topic. The physician must resist the temptation to live by the dictum primum non expendere , and should stay focused on serving the best interests of the patient. Part of their responsibility in achieving the patient \200\231s best interests is in providing cost -effective medical care. Physicians and patients should be part of the societal discussion on cost-savings in the delivery of proven, effective treatments. Distributive justice Distr ibutive justice is that unyielding and perpetually problematic benchmark against which all civilizations must, sometime or other, come to measure themselves. Among the questions that must be asked about distributive justice are: How are rights and responsibilities dis- tri buted in society? Is access to healthcare a fundamental right? Are the benefits and costs o f healthcare being shared fairly across society? In the United Kingdom, even with the Natio nal Health Service, social and geographic inequalities in morbidity and mortality have been recognized for decades. This is called the inverse care law , in which the \200\234 avail ability of good medical care tends to vary inversely with the need for it in the population served. \200\235 14 The inverse care law seems to operate most when medical care is expose d to economic forces. The United States experiences this in its medical marketplace, with r esulting variability in how healthcare is delivered across the country. One example is seen in the Dartmouth Atlas of Health Care: <http://www.dartmouthatlas.org/> Whether new models of payment will enhance access, reduce overtreat- ment, curb spending, and improve quality remains to be seen. Calls for universal coverage of affordable healthcare are still hotly debated. The inverse care law is still in operation, and distributive justice remains elusi ve. e n i c i d e m t u o b a g n k n h T i i 15 Quality and safety Two reports from the Institute of Medicine \200\224 To Err is Human: Bui lding a Safer Healthcare System (2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001) \200\224have helped to shape how we should think about the deli very of healthcare in the new millennium. It \200\231s a hard pill to swallow, but the real ity is that patients can die as the result of medical errors. Iatrogenesis is illness at ou r hands. Knowing that physi- cians are human and humans make mistakes, our responsibility i s to try to 14 Hart JT. The inverse care law. Lancet. 1971;1(7696):405 \200\223412. minimize errors and maximize safety. Errors can occur either because of poor planning or po or execution of a treatment plan. 15 Safety When the healthcare system focuses on safety, t he aim is to reduce accidental injury to our patients. Establishing safe practices is a sha red responsibility, and, when errors occur, we have to learn from them in order to prevent them for the next patient. For physicians to make considerations of safety part of their us ual behavior, several elements need to be in place: Attitude (belief that safety behavior w ill protect patients); perceived con- trol (feeling of self-efficacy and know-how about med ical procedures); and subjective norms (perceived social pressure from the healthcare team or the patient to practice safe behaviors). Another factor that can motivate us is the envi ronment we work in, such as having checklists and standard operating procedures that remind us to think about safety. 16 Quality Changing the healthcare working environment to focus on quality requires applying evidence to healthcare delivery (i.e., best practices), using information technology to automate patient information, influencing physician and patient b ehaviors through how healthcare is paid for, and preparing clinicians to work in new ways. 17 Informatics has tremendous potential to reshape medical practice. The days of paper-base d medical records are fading into the past. Using the Internet to store patient data (for c linical, research, and quality improvement purposes), prescribe medications or order tests, collaborate with distant colleagues, and share health information with patients provides p hysicians with an awesome tool. But a few caveats need to be in place for the busy house of ficer: \212 Verify the information in an electronic record on your own. There is a temptat ion to \200\234cut and paste \200\235 a documented history and physical (in part or in ful l) from someone else \200\231s, but what if they got something wrong (like a fatal allergy) ? 16 \212 Do not just \200\234data dump \200\235 (e.g., for purposes of billing or compliance) . Still strive to make what is entered in the medical record coherent and readable. \212 When entering medical orders, think about the end-user (e.g., the nurse who must inst itute the order). Have you provided sufficient detail to make the instructions understandab le and logical? \212 When electronically prescribing medications, use software to your advantage in calcul ating dosages, checking for drug-drug interactions, and monitoring for potential side effec ts. But double-check your work before finalizing the prescription (lest the nurse or pharma cist calls you later to alert you to a mistake in the order entry). \212 Remember your obligations to protect patient privacy. Keep passwords for access into computerized records or ordering systems to yourself. Resist the urge to post patient-speci fic information on publicly available websites (however fascinating that x-ray looks or gru esome that wound appears). 15 Kohn LT, Corrigan JM, Donaldson MS, eds.; Committee on Quality of Health Care in America , Institute of Medicine. To Err is Human: Building a Safer Healthcare System. Washington, D C: National Academies Press; 2000. 16 Foy R et al. The role of theory in research to develo p and evaluate the implementation of patient safety practices. BM J Qual Saf . 2011;20(5):4 53 \200\223459. 17 Committee on Quality of Health Care in America, Institute of Medicine 20 01. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: N ational Academies Press; 2001. Psychiatry on medical and surgical wards Psychopathology is common in colleagues, patients, and relatives. Current mental state Gently probe a patient \200\231s thoughts, as you migh t explore a new garden. What is in bloom now? Where do those paths lead? What is under that stone? Focus on: Appearance, speech (rate, content), affect (withdrawn? anxious? suspiciou s?), mood, beliefs, hallucinations, ori- entation, memory (recall of current events, presid ent \200\231s name), concentra- tion. Note the patient \200\231s insight and the degree of your rapport. Observe nonverbal behavior. Depression This is common, and often ignored, at great cost to well-be- ing. \200\234I would be depressed in her situation \200 , \200\235 you say to yourself, and so you do not think of offering treatment. The usual biological gu ides (early morning awakening, change in appetite, loss of weight, fatigue, and loss of ene rgy) are common on general wards. Screening questions for major depression are : \200\234A re you depressed (or sad or blue)? \200\235 If so, the follow-up question, \200\234Have yo u found that you aren \200\231t enjoying activities that you normally enjoy doing, or that you have lost inter- est in doing much? \200\235 If yes to both questions, there is a 95% c hance the patient has depression. There may also be guilt and feelings of worthless- ness. Do not neglect to ask the patient if he or she has thought about suicide or has passive dea th wishes. Don \200\231t think it \200\231s not your job to recognize and treat depression . It is as important as pain. Try to arrange activities to boost the patient \200\231s mora le and confidence and encourage social interaction. Communicate your thoughts to other memb ers of the team: Nurses, physi- cal and occupational therapists \200\224as well as the pati ent \200\231s loved ones (if the patient wishes). Among these, your patient may find a kind red spirit who can give insight and support. Counseling, psychotherapy, and/or antidepres- sants may be appropriate in some patients. Help guide your patient to the treatment that is right for him or her. Alcohol This is a common cause of problems on the ward (both the res ults of abuse and the effects of withdrawal) (p. 229). The violent patient Ensure your own and others \200\231 safety. Do not try to physically restrain violent patients until adequa te help is available (e.g., hospital security guards). Prevent violence by being aware of i ts early signs (e.g., restlessness, earnest pacing, clenched fists, morose silences, chanti ng, or shouting). Try to keep your own intuitions alert to developing problems. Common caus es: Alcohol intoxication , drugs (recreational or prescribed), hypoglycemia , acute confusi onal states (p. 353). Once help arrives, try to talk with the patient to calm him \200\224a nd to gain an understanding of his mental state. Find a nurse who knows the patient. Assess for causes of delirium by measuring oxygen saturation level and blood glucose, or give IV dextrose stat (p. 782). If not hypoglycemic, before further investigation is possible, drug s may be needed (e.g., haloperidol 2 mg IM; monitor vital signs closely). If a rational ad ult refuses vital treatment, it may be as well to respect this decision, provided she is \200\234competent \200\235 (i.e., she is able to understand the consequences of her actions and what you are telling her, she is able to retain this information, and she can form the belief that it is true). Decision-making capacity is rarely all or nothing, so don \200 \231t hesitate to get the opinion of an attending physician or psychiatric consultant. Enli st the persuasive powers of someone the patient respects and trusts. Physical restraints Fa miliarize yourself with hospital policies, local proce- dures, and laws pertaining to the u se of physical restraints. Consider sitters and chemical restraints before resorting to phy sical restraints. A confused, violent patient may need to be physically restrained to preve nt harm to himself or others. Reevaluate the need for restraints periodically. e n i c i d e m t u o b a g n k n h T i i 17 Difficult patients \200\234Unless both the doctor and the patient become a problem to each other, no solution is found. \200\235 Great aphorisms, like this one from Jung, can both i nspire and unsettle us, because they resonate with truth. But all great aphorisms also harb or some untruth. Jung \200\231s aphorism is untrue for half our waking lives: For an anes- thesiologist, there is no need for the patient to become a problem in order for the anesthe tic to work. Half our waking professional lives we spend as if asleep, on automatic pilot, following protocols or guidelines to some trite destination \200\224or else we are dreaming of what we could do if we had more time, proper resources, and perhaps a different set of colleagues. Our settled and smug satisfaction at finishing a rotation without any problems is so often a sign of failure. We have kept the chaos at bay, but if we had Jung in our poc kets, he would be shaking us awake, derailing our guidelines, and saluting our attempts to risk genuine interactions with our patients \200\224 however much of a mess we make of it, and however much pain we cause and receive. (Pain, after all, is the inevitable companion t o lives led authen- tically. 18 ) To the unreflective doctor, and to all average minds, thi s interac- tion is anathema, to be avoided at all costs, because it leads us away from anes thesia, to the unpredictable, and to destinations that are unknown. So, every so often, try being pleased to have difficult patients: Those who become a problem to us, those who ques tion us, those who do not respond to our treatments, or who complain when these treatments do work. Very often, it will seem that whatever you say, it is wrong: misunderstood, mis- q uoted, and mangled by the mind you are confronting \200\224perhaps because of fear, lonelin ess, or past experiences that you can only guess at. If this is hap- pening, shut up \200 \224but don \200\231t give up. Stick with your patient. Listen to what he or she is saying \200 and not saying. And when you have understood your patient a bit more, then negotiate, cajole, and even argue \200\224but don \200\231t bully or blackmail ( \200\234If you do no t let your daughter have the operation she needs, I \200\231ll tell her just what sort of a mother you are \200 \200\235). When you find yourself turning to walk away from your pati ent, turn back and say, \200\234This is not going very well, is it? Can we start again? \200\235 Realize that the anger or disap- pointment that they hurl at you may not be direct ed at you at all \200\224you may just be the closest target, the scapegoat, for their upset . Learn how to keep your emotional distance without becoming emotionally distant. And don \200\231t hesitate to call in your colleagues \200\231 help: Not to win by force of numbers , but to see if a different approach might bear fruit. By this process, you and your patien t may grow in stature. You may even end up with a truly satisfied patient. And a satisfied patient is worth a thousand protocols. 18 Death: Diagnosis and management Death is Nature \200\231s master stroke, albeit a cruel one , because it allows geno- types space and opportunity to try on new phenotypes. Our bodies and minds are these perishable phenotypes \200\224the froth, on the wave of our genes. Thes e genes are not really our genes. It is we who belong to them for a few decades. As our neu rofibrils begin to tangle, and a neonate walks to a wis- dom that eludes us, we are forced to give Nature credit for her daring idea. 18 \200\234Some say that the world is a vale of tears. I say it is a place of soul making \200\235 \200\224John Keats \200\224the first medical student to formulate these ideas abou t pain. They did not do him much good, because he died shortly after expressing them. But h is ideas can do us good \200\224perhaps if, each day, we try at least once for authentic in teractions with a patient, unencumbered by professional detachment, research interests, def ensive medicine, a wish to show off to our peers, or to get though the day with the minimum of fuss. Of course, Nature, in her haphazard way, can get it wrong: People often die in the wrong or der (one of our chief roles is to prevent this misordering of deaths, not the phenomenon of death itself). Death is not our enemy. A life well lived is the goal of every man, and our goal should be to help our patients achieve this as much as possible. As Osler said of the healing professions, \200\234And, finally, remember what we are \200\224 useful supernume raries in the battle, simply stage accessories in the drama, playing minor, but essential, parts at the exits and entrances, or picking up, here and there, a strutter, who may have t ripped upon the stage. \200\235 19 Causes of death Homicide, suicide, accident, or natural causes. Diagnosing death The pronouncement of death is an important respon- sibility of the physician. The physical exam done to diagnose death is a key symbolic ritual that brings c losure to the patient \200\231s life and closure for the physician, members of the healthca re team, and, most especially, the patient \200\231s family. Death is determined by the abs ence of pulse and respira- tions, no auscultated heart sounds, and fixed pupils. If a patie nt is on a ventilator, brain death may be diagnosed even if the heart is still beating, via brain death criteria that entail the irreversible absence of brain function, particularly in the brainstem. Death of the brainstem is recognized by establishing the absence of crani al nerve and respiratory reflexes. The Uniform Determination of Death Act recognizes that d eath can be diagnosed by neurologic criteria. In addition to evidence of a catastrophic bra in injury, the following prerequisite criteria must be met: \212 Deep coma with absent res pirations (hence on a ventilator). \212 The absence of drug intoxication and hypothermia ( <32 C). \212 The absence of hypoglycemia, acidosis, hepatic failure, and electrolyte e n i c i d e m t u o b a g n k n h T i i 19 imbalance. Tests: For determination of brain death, the following tests should be per- formed by quali fied personnel. Repeat the tests after a suitable interval \200\224at least 6 hrs, although sometimes 12 \200\22324 hrs is required to confirm irrevers- ibility of the coma. It is of ten recommended that a neurologist perform the confirmatory tests. \212 Tests to establish that brainstem reflexes are absent: \212 Unreactive pupils. Absent corneal response. \212 No oculocephalic reflex (Doll \200 \231s eye test). \212 No vestibulo-ocular reflexes (i.e., no eye movement occurs after or during slow injection of 60 mL of ice-cold water into each ear canal in turn). Visualize th e tympanic membrane first to eliminate false negative tests (e.g., due to wax). \212 No motor response within the cranial nerve distribution should be elicited by adequat e stimulation (e.g., absent facial grimacing when pressing on supraorbital ridge). \212 No gag reflex or response to bronchial stimulation with a catheter to the level of the carina. \212 Additional tests: \212 No spontaneous or reflex motor responses to noxious stimuli. There should also be no autonomic response to noxious stimuli or vagal stimulation. Spinal reflexes are not relevan t to the diagnosis of brain death. \212 Positive apnea test: No respiratory effort in response to hypercarbia. A tube is inse rted through the endotracheal tube to the level of the carina 19 Osler W. Doctor and Nurse, in Aequanimitas , 2nd ed. Philadelphia: P. Blakiston \200\231 s Son & Co.; 1925. in order to deliver continuous oxygen at a rate of 2 \200\2234 L/min. The ven- tilator is d isconnected, allowing P a CO 2 to rise to \211 60 mm Hg or more (for patients with COPD, a rise of 20 mm Hg above their baseline). P a CO 2 typically rises at a rate of 3 mm Hg per minute. Patients should be monitored for any hemo-dynamic instability during the test, and the test should be stopped if SBP falls by \211 20%, cardiac arrhythmias emerge, or the patient becomes hypoxic. Other considerations: Ancillary studies may be needed when the prerequisite criteria cannot be met (e.g., the patient is receiving sedative or anesthetic infusions). An electroenceph alogram (EEG) recording is not a standard requirement, unless brain death is to be diagnose d within 6 h of apparent cessation of brain activity. Cerebral blood flow studies (e.g., wi th isotope angiography) are helpful when the patient is receiving treatments that sup- pres s cerebral metabolic activity. Organ donation: The point of diagnosing brain death is partl y that this allows organs (kidney, liver, cornea, heart, or lungs) to be donated and remove d with as little damage from hypoxia as possible. Do not avoid the topic with loved ones. M any are glad to give consent and to think that some good can come after the death of their relative, that some part of the relative will go on living, giving a new life to another pe rson. After death Inform the patient \200\231s attending and consultants. Meet with the pat ient \200\231s next of kin and offer emotional support. Ask if they want an autopsy. Autops y permission may be granted (in order of priority) by spouse, adult child, parent, sibling. Sign death certificates promptly. If DOA or within 24 h of admission, or the cause is viol ence, trauma, accident, neglect, surgery, anesthesia, therapeutic mishap, drug/alcohol over dose, sui- cide, poisoning, or is unknown or suspicious, inform the Coroner/Medical Examine r. 20