The Stroke / TPA Master

Last year academic year I spent one out of every four days working in an inpatient neurology service that mostly cares for stroke patients. I was not The Stroke Master, nor the TPA Master. These were tongue in cheek nick names that we reserved for our most academically venerable and personally inspiring attending who would occasionally attend and supervise the care of stroke patients.

 Instead I was a mid level medical lieutenant with faculty above me but also with a junior resident and medical students under my almost always goal oriented direction.  When students and interns would join me on rotation, immediately after our first morning teaching conference, I would explain our three main goals as a team: take care of patients, learn (aggressively) and try to have fun in the process.  Invariably making the “expectations talk” so short  quickly dispatched the worry of the overbearing upper level and always made everyone more at ease. Finally I would add one unofficial but not negligible goal: “get stuff done, and get out on time”.

In retrospect learning, enjoying the camaraderie of the neurology team and even working efficiently proved to be the easiest goals to define and attain. Treating stroke patients on the other hand was a lot more nuanced since the treatment of stroke is a lot more difficult.  The only rigorously studied acute treatment for “low blood supply” or ischemic stroke is IV TPA, a very potent clot busting drug. Unfortunately IV TPA can only be given safely within 3 hours of onset of symptoms, and in our center about 90% of patients are outside the window on arrival.

Advertising of the highest order?

The hospital I work in recently launched a high profile marketing and re-branding campaign. Such a move was unprecedented for our hospital and caught some by surprise.  After all we are the only academic hospital, the largest regional referral center and to we already operate at greater than 100% capacity. So what was the need for a glitzy, aggressive advertising campaign? Even more surprising was that the first adds went on TV during the Superbowl. Yes, you read that correctly. The academic medical center I work in, a non-profit institution, now had its own Madison Avenue campaign along side the biggest of American big business.

The adds were slick and quite dramatic: critically ill patients, determined staff and a narrative of hope and conquest set amidst griping religiously themed music. So I was essentially looking at myself on TV, but clearly that is not what the hospital feels like both for patients and employees. This discrepancy between reality and its representation in marketing campaigns is all but expected in popular culture. But hospital advertising is relatively new. Should the same licence to embellish your product by granted by default to hospitals that also advertise. I don’t think so.

Physicians in addition to helping patients get better also have the less glamorous job of guiding people through illness, disability and severe loss. In this second mission, setting expectations to reality is so important it can not be under-emphasized. So what I struggled with, is that where society often tends to have already unrealistic expectations of physicians, here we have a multimillion dollar campaign that for the sake of name recognition and referrals is willing to further inflate expectations. That is not a responsible policy.

Biden and Palin debate rapid response reaction

On Palin:

• One story dominates for Palin: she easily exceeded expectations. This pauses the the string of negatives for the McCain camp and is an opportunity to try to relaunch the campaign on firmer footing.
• Palin was more aggressive than expected in trying to discredit Biden’s credibility. She has some success when repeating although factually incorrectly her traditional mantras about big government and taxes, and whiffed completely when she attempted to correct the senator on how to chant about oil drilling.

On Biden, with a more complicated mission in hand, a couple more comments:

• Biden also avoided a humiliating gaffe. He looked authoritative, in great command of the facts, while also showing a human, and open side of him.  His opening up when talking about his son after the car crash, is probably the most memorable moment of the debate.
• Biden’sdiscipline was inconsistent although given his reputation he could have done much worse.  Early on he was right on message talking about the middle class and the economy, but then inexplicably got bogged down talking at length about issues voters are not likely to connect with like Bosnia and Darfur. Early on he brought up Obama on message but later in the debate he seemed to get carried away off message. 
• While the idea of Biden as advisor and witness to Obama’s character was credible after the debate, it is not clear that Palin will convince America of her role as partner in reform. Her folksiness probably will reinforce doubts about her.

Palin vs Biden: The Gaffomatic Face-Off

Despite a dramatic advantage in experience it will be hard for Biden to “win” the debate.

The first reason is that expectations for Palin could not be any lower. Last week was quite possibly one of the worst weeks for an American politician in recent history(money and sex scandals excluded). If Palin manages to come off as a credible on stage she gets back some legitimacy as a candidate. The media that loves a good story let alone Republican operatives will jump on this as a triumph and “I told you so moment”. You can see the headlines already “Palin avoids mistakes, ready to be VPOTUS”.

Biden could also struggle to hit the right tone when he faces  a fresh faced mother of five that despite her hard edged political views still inspires empathy and identification among women around the country. A heavy handed jab by Biden might be grounds for a rebuke on stage reminiscent of Geraldine Ferraro’s accusation of G H.W Bush of condescension in 1984.

The third item is a wild card. The McCain camp has been trying to play the refs like its nobody’s business. They have also found a way to play the ref of todays debate, Gwen Ifill, by accusing her of being in the tank for Obama for writting a book on black politicians and implicitly for being black. Palin did not blink and vowed, that this flap will just make her try harder.

So maybe if Biden can’t win, then the alternate scenario is that Palin cedes by continuing her self inflicted political suicide.

Change and the greatest generation

Watch out everybody, there is a new sheriff is town! After 30 years, our influential, successful and frankly inspiring department chair has stepped down. This is a very big deal for the hospital.

Our department has been one of the few in our medical center that because of robust NIH funding, publications and educational programs has international reputation and prestige. Therefore the Dean has a lot at stake in choosing new leadership. Specifically, if things do not go well, there goes one of the best departments in a hospital that is pushing hard to break through the ceiling of national prominence.

Days ago, our new chair was introduced and on day one layed out his vision for the department. The new strategic plan calls for comprehensive changes in inpatient services, outpatient services, integration with allied surgical services, and aggressive recruitment of basic science oriented faculty. Wow! Did you get that. That is pretty much everything that we do!

A response to the defining public health issue of our time

In a previous post (Category Nutrition) I noted that obesity is the defining public health issue of our time and that part of the problem is the “perma blitz” of junk food advertising in the United States. A legitimate question is whether a public health campaign promoting weight loss and more healthy eating habits would work.

In Mexico a government campaign appears to be doing exactly that.  Of course the proof is in the pudding, but if in the United States 25, 000,000 folks lost 4lbs each this could be a 100 million lb of cumulative weight loss. As we speak, the epidemiologic trends of obesity and related diabetes, vascular disease and kidney disease are marching on, and our generation of physicians will need to find ways to reverse these trends.

The debate: Is McCain angry?

Early thoughts on the first presidential debate of the cycle:

• The John McCain that showed up is decidedly better than the John McCain that has been campaigning the previous week. As a physician, after witnessing such consistent inconsistence, I was expecting to hear even the slightest signs of early cognitive decline.  Not at all. Despite limited preparation time, McCain was fluent on all the issues, agile, and mostly on the offensive.
• Barack Obama legitimately shared the stage and held his own against a former POW, and 20 year veteran of the senate. This was a basic yet crucial test. Consistency in the next two debates along with a spiraling economic crisis would seemingly have Obama in a strong position to close the race.
•  Now all the attention shifts to Gov. Palin. If McCain had a bad week, she had a catastrophic week. Defying conventional wisdom, instead of getting better with each interview, Palin completely tanked on her sit down with Couric. Several senior republican commentators broke ranks and withdrew support from Palin. This must be excruciatingly painful for the McCain camp. The only upside is that debate expectations for her will be very low, just like they were for G.W Bush in 2000. The downside is that if she fails as badly as she did last week, baring a big foreign crisis, it will be the beginning of the end of for McCain/Palin.

 

Its not only what you got…

A 55 year old man came to see me at the resident clinic today for what was essentially not a second but a fifth or sixth opinion on his headaches.  I’ll be honest, this type of consult doesn’t usually turn out well. Why would I be able to fix, what several other physicians could not? But that was irrelevant. This was my one o’clock appointment, the patient had driven 150 miles and was ready to have that headache taken care of.

His history started 7 years ago with worsening frontal headaches that given a strong family history, visuals aura and chronic non progressive nature were most consistent with transformed headache due to mild medication overuse. Some more questions revealed a positive depression screen and stress from work and family as a major precipitant of these headaches. This was enough to take a different approach than Mr. X’s previous physicians.

Mediterranean Diet MVP

In a previous post I noted that a lot of mass produced bread has corn syrup. I will add here that is has no fiber, its full of air as it has so many rising agents, and it has a very long list of mysterious ingredients that should make you say: what the h-ll is going on here, eating this just does not make sense”. Well, to your right you see the perfect antithesis: Cretan barley rusk.  

This is a long time staple of the Cretan Mediterranean diet. This particular kind is made with  whole grain barley and wheat flour, salt and yeast. Yes that is it! The result is a golden,  fiber filled rusk that has an incredible earthy stone aroma. Bread does not usually smell like that.

Finally when ready to eat, rehydrate with good old H20, add fresh tomatoes, feta, oregano and olive oil and you are there. In my humble opinion, there are not many places to go.

The irony here is that since this is a rusk, ie a re-baked bread that is completely dehydrated, its shelf life is months. So it competes with bionic Pepridge Farms bread, without an ounce of preservatives. Respect brother, respect.

The marketing perma-blitz “Its not fast food, its Wendy’s”

A walk through our hospital wards helps identify what is the main public health problem we are dealing with. In sub-Saharan Africa the HIV/AIDS epidemic is  catastrophic. In the own country, the obesity epidemic is catastrophic. Simply put, the foods we eat are highly processed and calory dense, and the average lifestyle has become very sedentary. Add to this a permanent marketing blitzkrieg for junk food and you have an epidemiological tsunami.

The results are scary. In the stroke wards we are seeing the usually geriatric illness of stroke transform into a disease that often strikes the young. In the ICUs I have seen a few patients that have accumulated so much fat around their chest that they have difficulty exchanging oxygen for CO2 and thus get into a sleepy state called CO2 narcosis. These patients would require long term ventilation or surgery to produce an opening in the neck from where its easier to breath.

The point of this, is that I do not understand why as a society we are letting this happen. Why is Coca Cola so acceptable? Why can McDonald’s use perfectly sculpted Olympic athletes to market new “death on a plate” breakfast items during the Beijing Summer Games? Why are there significant amounts of sugar in most mass produced breads and buns at your local supermarket? Why is there corn syrup sprinkled just about everywhere in this country?