Category: MEDICINE

WELL BEING

Dr. Gawande’s fundamental point in “Being Mortal” is to provide the elderly or medically challenged the help to live based on a person’s dignity, purpose for living, and as much autonomy as their conditions allow.

Books of Interest
 Website: chetyarbrough.blog

Being Mortal: Medicine and What Matters in the End

By: Atul Gawande 

Narrated By: Robert Petkoff

Atul Gawande (Author, physician-administrator-of-the-u.s.-agency-for-international-development-for-global-health.)

One who has been fortunate enough to have lived long will appreciate Doctor Atul Gawande’s explanation and experience with people of a certain age and the terminally ill of any age. He explains “…What Matters in the End” when one is nearing death is quality of life, not survival that matters.

Quality of life is defined by Gawande as dignity, purpose, and autonomy in one’s last days.

When one is nearing the end of their life, Dr. Gawande has found in his many surgical procedures and interviews that those who have time left to them can be helped by others who assist them as best they can to achieve dignity, purpose, and autonomy. As a physician, Gawande asks what a dying person’s fears are to know what might be done to help them work through those fears. Gawande explains the trade-offs from what care an older person or terminal patient may be given to achieve what is most important to them in their remaining life.

Whether healthy or unhealthy, rational people realize death is part of life.

What “Being Mortal” explains is that the aged or medically challenged wish for as much independence as can be provided by their care. Desired independence is the gold standard for the remaining days or years of one’s life. Whether old or young, healthy or ill, the thought of incontinence, mental confusion, medical or physical limitation makes one fear loss of independence. Each of these maladies can be remedied by family members or properly organized assisted living facilities. Of course, the rub is in the cost of that assistance.

When a family member can no longer be cared for by family members, the medically or age challenged are left with two choices. One is to be institutionalized. The other is to die.

What Gawande explains is that the first alternative can be better and the second is dependent upon family research, financial commitment, religious beliefs, and States’ laws. Gawande notes his choice in the case of his physician-father is a family commitment to offer care as needed with the goal of giving as much autonomy as his aged father can handle. That is a laudable commitment but not what many struggling American families have time or willingness to do.

America has institutionalized elder and medically challenged people’s care to reduce the burden on families.

Gawande recounts the history of institutionalized care in the United States. From family aid to hospitalization to assisted living to hospice to State sanctioned euthanasia, care has evolved for the elderly and medically challenged. What Dr. Gawande explains is that any of these ways of caring must offer dignity, purpose, and as much autonomy as possible to the dying and terminally ill.

Every family has its care limitations, either temporal or financial (sometimes both).

Gawande shows research and preparation is needed to help families adjust to the physical and mental care of a significant other who is too old or too sick to take care of themselves. If a family cannot provide the dignity, purpose, and an appropriate level of autonomy to an aged or ill loved one than the job becomes the work of finding an institutional facility that can. This is where the tire hits the road because there is a cost for that service. Gawande notes there are institutions that can offer the services that are needed but family research and investigation is required.

Once an acceptable care facility is found, the next task is finding how it can be financed.

Gawande does not address cost but infers there are care facilities that are affordable. Dr. Gawande’s fundamental point in “Being Mortal” is to provide the elderly or medically challenged the help to live based on a person’s dignity, purpose for living, and as much autonomy as their conditions allow.

DYING

One may ask oneself is hospice the only humane thing to do for a dying parent. If a parent is able to make a rational decision about continuation of life, would he/she choose to be treated in a hospice or choose to end life on their own terms?

Books of Interest
 Website: chetyarbrough.blog

Dying

By: Cory Taylor (A Memoir)

Narrated By: Larissa Gallagher

Cory Taylor (Australian author, died at age 61 on July 15, 2016, born in 1955.)

Dying: A Memoir author Cory Taylor passes away, aged 61 | The Australian

Cory Taylor confronts the complicated question of what to do when a person knows they are nearing the end of their life. Taylor is diagnosed with terminal brain cancer in 2005. Living with that diagnosis, Taylor recounts her life, religious beliefs, and a commemoration of her family relationships. She thinks of what her life means to herself and others. She waivers between living with her physical and mental deterioration or volitionally ending her life.

Taylor, though raised in a Christian household, identifies herself as agnostic.

In the 20th century, it is estimated that 200 to 240 million people identify themselves as atheists or agnostics. In 2013, that number increased to 450 to 500 million, about seven percent of the world population. Taylor chooses medically assisted death.

Having personally experienced a parent’s death and a parent’s physical and mental deterioration, a listener/reader will either condemn or condone a choice of assisted death.

Those with strong religious beliefs are likely to blame a person for killing themselves, while those who are agnostic or atheist are likely to have a different opinion. To some, life is hardship that is a human being’s obligation to either suffer or grow from, with conscious awareness of death’s inevitability. The fundamental question is–does one have the right to choose whether to live or die?

Seeing a parent’s life deteriorate despite the care of an attentive family member is heartbreaking.

Image result for hospice

An example is a son whose mother is dutifully cared for by her husband but recognizes the husband is too aged to handle the mother’s incapacities. What should a son or extended family do? There are hospice alternatives for the mother, but should she have a voice in deciding how she is to be treated? The husband realizes, a care facility is the only practical alternative for her needed care. The son or daughter is married and is consumed by their employment and making a living for their own career and family. The mother may or may not be able to express her opinion. The table is set for institutionalization.

The mother’s response may be to curl up in her new bed, refuse to eat and waste away in the eyes of a loving husband and a career consumed son or daughter.

One may ask oneself is hospice the only humane thing to do for a dying parent. If a parent is able to make a rational decision about continuation of life, would he/she choose to be treated in a hospice or choose to end life on their own terms?

GENERIC DRUGS

Katherine Eban infers the lure of money, power, and prestige, continues to incentivize fudging, if not outright lies, about the effectiveness and safety of generic drugs.

Books of Interest
 Website: chetyarbrough.blog

Bottle of Lies (The Story of the Generic Drug Boom

By: Katherine Eban

Narrated By: Katherine Eban

Katherine Eban (Author, American investigative journalist focused on public health issues.)

Katherine Eban’s book is tedious, but it tells a story that challenges the generic drug industry and exposes the strength and weakness of capitalism. Eban makes one suspicious of the efficacy of generic drug treatments. Society depends on drug discoveries that can return one to health when struck by known and unknown malefactors. At the same time, Eban indirectly attacks capitalism as a primary force for discovery of life saving drug treatments. Capitalism is motivation for drug manufacturers to discover new drugs, but profit motive and human nature incentivize deception that can harm the public.

America’s police department for the drug industry is the Food and Drug Administration.

The difficulty of a policing function is in human nature and an investigators’ effort to find incriminating evidence that proves guilt. The consequences of poor policing in the generic drug industry are loss of health, and sometimes, life. The FDA is responsible for protecting public health by ensuring the safety, efficacy, and security of human and veterinary drugs manufactured or imported to the U.S.

Just as every police force is not perfect, the FDA has made mistakes and failed to uncover evidence for crime. There have been instances of drug manufacturers around the world, including America, that have adulterated approved generic drugs. (A U.S. generic drug manufacturer, KVK Research Inc in Pennsylvania, pled guilty in 2024.) Generic manufacturers and distributors around the world have misled the public on the efficacy and/or addictive qualities of drugs. A primary source of generic drug manufacturing crimes is the lure of increased profitability.

Eban focuses on a pandora’s box opened when the world’s generic drug industry began producing substitutes for previously patented drugs.

Patents for new drugs have a determinate shelf life but expire after a stipulated period of time. One can complain and challenge the price of patented drugs, but patented drugs require a level of scientific experiment and reporting to prove efficacy. When patents expire, there is a rush by generic manufacturers to produce the same drug at a lower cost. The trouble arises when a generic drug’s lower cost is achieved with substituted or reduced ingredients; also, it may be adulterated by poor manufacturing practices.

Eban offers the history of the AIDS’ epidemic to illustrate how generic drugs became supercharged in the 1980s.

Three companies in India and one in South Africa began working with the Clinton Foundation to offer an AIDS’ generic drug that fell to a cost of $.40 per day when patented AIDS’ drugs cost as much as $8,000 per year. Millions of people were at risk, none more than those who live in Africa. However, the effectiveness of the generic drug came under suspicion. It was found that data was being falsely created by India and Africa. It was manufactured data that falsely reported generic drugs effectiveness in treating AIDS. The generic African and India manufacturers were cutting corners in production to increase profits. No one checked the effectiveness of the produced drugs and posted false patient reports. Because the data was not based on patient experience but on falsely created data, it became unclear whether the drug was working. Without any reports showing the generic drug’s effectiveness, incentive grew to continue reducing costs. Manufacturers pushed production, compromised AIDS ingredients, and falsely reported treatment results of patients.

Dinesh S. Thakur (Received the Joe A. Callaway award for Civic Courage in 2014.)

Eban explains how Dinesh Thakur. a former executive at Ranbaxy Laboratories, became a whistle blower who “spilled the beans” on falsely created data sent to the FDA.

Thakur was the Director and Global Head of Research information & Portfolio Management at the Ranbaxy company. He began asking questions of the people reporting the generic AIDS Drug efficacy data. Thakur found that 50% to 100% of information on generic AIDS drug’ efficacy was manufactured and not related to actual use by AIDS sufferers. Ranbaxy Laboratories pleaded guilty of falsifying information in 2003. Ranbaxy agreed to pay $500 million to settle their guilty plea.

Despite the Ranbaxy settlement, the author shows generic drug misinformation is still being produced. Further reviews by FDA inspectors found continuing violations of protocol and testing of generic drug manufacturing and reporting.

Ranbaxy is no longer an independent company. It was purchased by Sun Pharmaceutical Industries Ltd in 2014. Eban explains how FDA inspectors fell victim to India manufacturers malfeasance by accepting luxury hotel accommodations and gifts that clouded their judgement about the companies they were investigating. A bad report from an FDA inspector could and did cost millions of dollars to companies that produced tainted generic drugs.

Eban explains the FDA has changed their policy of giving advance notice of inspections while inferring inspectors are advised to avoid conflicts of interest in their inspections. One takes this inference with reservation because human nature is an immutable force.

The incentive for increased profitability by reducing the cost of manufacturing generic drugs continues to threaten the public. Eban infers the lure of money, power, and prestige, continues to incentivize fudging, if not outright lies, about the effectiveness and safety of generic drugs.

BRAIN SURGERY

Two points that offer the greatest value in Schwartz’s history of brain surgery is that those who survive become different human beings, sometimes disabled or cognitively impaired. The second–those who need a neurological operation should look for an empathetic doctor who limits his/her excision of brain matter to what science knows of its consequence.

Books of Interest
 Website: chetyarbrough.blog

Gray Matters (A Biography of Brain Surgery)

By: Theodore H. Schwartz

Narrated By: Sean Pratt

The largest part of Dr. Schwartz’s book is about the history of brain surgery. The first chapters address his education for brain surgery and the history of well-known Americans who died or might have survived from its practice. It addresses the consequences of brain trauma of modern times but leaves tumor and disease treatment for the remaining chapters. “Gray Matters” is about the 19th and 20th century history of brain surgery, how it evolved, and the pioneers who most influenced the author. Schwartz personalizes brain surgery by explaining how he treated what he estimates to be over 10,000 patients.

  • William Macewen (1848-1924) Scottish surgeon who pioneered neurosurgery,
  • Harvey Cushing (1869-1939) American neurosurgeon–father of modern neurosurgery,
  • Wilder Penfield, (1891-1976) American-Canadian neurosurgeon–noted for mapping the brain,
  • Carl-Olof Nylén (1892-1978) Swedish otologist who pioneered microsurgery with a surgical microscope he designed,
  • Wolfgang Draf (1940-2011) German otolaryngologist who pioneered Skull Base Surgery using sinuses as the avenue of entry to the brain.

Schwartz identifies Wiliam Macewen (upper left photo) as the pioneer of neurosurgery. He notes Harvey Cushing (upper right photo) is referred to as the “Father of Modern Neurosurgery”. Cushing was the first to employ X-rays to diagnose brain tumors and introduced the use of the elector-cautery device to minimize blood loss during surgery. Dr Wilder Penfield (middle left photo), a Canadian neurosurgeon pioneered brain mapping by stimulating the brain with mild electrical shocks. Brain mapping gave neurosurgeons a guide that let them know what areas of the brain would be affected when making decisions on diseased tissue removal. Microsurgery on the brain is pioneered by Carl Nylen (middle right photo) in the early 1900s. In modern times, Dr. Wolfgang Draf (bottom photo) began using a skull cap microsurgery device to remove brain tumors through nasal passage access. This less intrusive form of brain surgery is used and detailed by the author.

Dr. Kris S. Moe (Board certified surgeon at UW Medical Center, University of Washington Facial Plastics and Reconstructive Surgery.)

Schwartz explains one of his most important training experiences was in Seattle Washington with Dr. Kris S. Moe. Moe pioneered what is called transorbital neuroendoscopic surgery (TONES) that influenced the field of minimally invasive neurosurgery. Schwartz explains how Moe would test patients during an operation to identify areas of the brain being affected during treatment for tumor removal. Schwartz gave the example of a series of pictures shown on a monitor seen by the patient during surgery. The patient is asked to name the object in the picture as the surgeon is operating to determine whether the tumor being excised affects his/her ability to identify the image. In Schwartz first attendance at one of these surgeries, he accidentally spilled the pictures across the operating floor. Moe directed him to reassemble the pictures and went on with the surgery when they were reassembled. The embarrassed Schwartz admired Moe because he never brought the incident up after it happened and completed the operation without criticizing Schwartz.

Two points that offer the greatest value in Schwartz’s history of brain surgery is that those who survive become different human beings, sometimes disabled or cognitively impaired. The second–those who need a neurological operation should look for an empathetic doctor who limits his/her excision of brain matter to what science knows of its consequence.

BRAIN TRAUMA

Schwartz’s book implies the NFL’s prevention and protocols for brain trauma are a cost of doing business. Sadly, this seems similar to the American public’s misinterpretation of the “right to bear arms” and its resistance to gun control.

Books of Interest
 Website: chetyarbrough.blog

Gray Matters (A Biography of Brain Surgery)

By: Theodore H. Schwartz

Narrated By: Sean Pratt

Theodore H. Schwartz (Author, American medical scientist, academic physician and neurosurgeon.)

“Gray Matters” feeds a curiosity for those interested in the human brain. Written by a brain surgeon, it offers a clearer understanding of brain function while offering insight to the causes and consequences of brain trauma. The author has treated many patients with brain infections and trauma and offers analysis of athletic, gun-related, and accident injuries of people who have died from or survived brain trauma.

Schwartz explains the arduous education for one to become a brain surgeon and how physicians surgically treat brain disease and trauma.

He explains how long hours as an intern are required after spending years to become an academically qualified physician, let alone surgeon. Not only are the hours long but acceptance into an internship is highly competitive and difficult to achieve. That seems counterintuitive in view of the public’s need for qualified medical help. One suspects the fundamental cause is the cost to the hiring hospital and the staffing required to teach new physicians.

The brain is protected by a skull, three layers of membrane, cerebral spinal fluid, a blood barrier, skin, and a scalp.

These structures, cells, and tissues protect the brain from physical damage and infections so the brain can provide organic function, thought, and action. Physical or infectious damage to the brain can affect any one of these natural human’ functions.

ABRAHAM LINCOLN
JOHN F. KENNEDY
ROBERT F. KENNEDY
JAMES BRADY
GABIELLE GIFFORDS

Schwartz reviews incidents of gun-shot brain trauma of famous figures like Abraham Lincoln, John F. Kennedy, Robert Kennedy, James Brady, and Gabrielle Giffords. He notes the differences in the bullets used as well as the power of the weapons to explain the damage done. He argues John Kennedy had no chance of survival while suggesting Lincoln, because of a lower power weapon, might have survived with today’s advances in treatment. However, he suggests Lincoln would have lost much of his skill as an orator and political theorist because of damage to a particular part of his brain from Booth’s attack. Schwartz believes Robert Kennedy might have lived with more rapid and qualified treatment but would have been physically and mentally disabled. James Brady, Ronald Reagan’s press secretary, lost speech clarity and physical mobility because of his brain trauma. Similar consequences occurred with Gabriell Giffords’ injuries, but she relearned how to walk, talk, and perform basic tasks. Schwartz notes the only positive political accomplishment to come out of these violent acts was the Brady Handgun Violence Reform Act.

Schwartz goes on to explain non-traumatic brain injury from infection and stroke to traumatic brain injury from Shaken Baby Syndrome (SBS) to Chronic Traumatic Encephalopathy (CTE) with Second-Impact Syndrome often seen in athletes. Diagnosis of SBS from a shaken baby’s head has changed to include the shaking accompanied by impact with a hard surface.

Diagnosis of CTE and Second-Impact Syndrome in sports are still being defined. The return of football players to the field of play is a judgement call by a sideline physician which raises questions about qualifications, let alone judgement.

The NFL initially objected to the brain trauma threat of their sport based on improved protective equipment.

However, Schwartz writes they have increased their protocol for injured players and have paid over a billion dollars to former athletes suffering from symptoms of brain trauma. Some big names in football like Junior Seau, Frank Gifford, Ken Stabler, and Tommy Nobis were autopsied after their death to show they suffered from CTE.

The lure of fame and money are unlikely to change elite athletes desire to compete despite the threat of brain injury. Schwartz’s book implies the NFL’s prevention and protocols for brain trauma are a cost of doing business. Sadly, this seems similar to the American public’s misinterpretation of the “right to bear arms” and its resistance to gun control.

PSYCHOSIS

Psychiatric illness is disturbingly believable and terrifying. Human psychosis ruins lives if not properly diagnosed and treated.

Books of Interest
 Website: chetyarbrough.blog

The Night Guest 

By: Hildur Ingveldardóttir Guðnadóttir

Narrated & Translated By: Mary Robinette Kowal

Hildur Ingveldardóttir Guðnadóttir (Icelandic Author, classical cellist, and composer –awarded an Academy Award, two Grammies, and an Emmy.)

The multi-talented Guðnadóttir has written a chilling tale of psychosis in “The Night Guest”. In one sense, it is a reflection of sexual equality, but it also reveals how complex and dangerous it is to be human. This fictional story is about an attractive single woman who is unable to peacefully sleep through the night. Every morning, she wakes up with a tiredness that sticks with her through the day. On some mornings she finds bruises or scratches on her arms and has no idea of why she feels so tired. She sees several doctors and finally finds one that takes her symptoms seriously.

Her doctor runs tests and finds nothing seems to explain the tiredness. The doctor asks her if she is depressed. The woman says she feels sad sometimes but not particularly depressed. The doctor recommends she see a psychiatrist, but she chooses to ignore the advice.

The tiredness, odd bruises, and scratches on her body continue to appear, i.e., after sleep and in the morning. She comes across an article that tells her of sleepwalkers that don’t realize they are sleepwalking at night after falling asleep. She is convinced that explains her symptoms and asks her doctor for sleeping pills. The doctor reluctantly agrees and provides a prescription. Initially, the treatment seems to help, and the young woman resumes her life, meets a new boyfriend, and begins to feel everything is okay.

The author explains the young woman is a lover of cats but notices that lately the cats in her neighborhood have become afraid of her.

When she approaches them, they hiss and raise their backs. She is mystified by their response. As the story progresses, listeners find she was involved with the owner of a company for which she works. He is married and the relationship is ended with some acrimony. The two avoid each other at the workplace but the still-married man tries to resurrect their relationship. The young woman is involved with another man and has no interest in resuming a relationship with a married man.

She returns to her belief that her sleeplessness is caused by her sleepwalking and decides to monitor her behavior with a video recording devise.

She reviews the recording to find she wakes up and leaves her bedroom for hours at a time. She is wearing a pedometer to measure the steps she takes and finds it is several thousand steps more than what it was at the end of her day. What makes her discovery ominous is that the recording shows a conscious and alert person that has to be her, but she feels that person is entirely different from herself.

The woman’s tiredness returns, and she finds one morning that all of her sleeping pills are gone. Her former married lover disappears. Her current lover tells her to never contact him again without an explanation. The denouement of the story is horrifying. Explanation of her psychiatric illness is disturbingly believable and terrifying. Human psychosis ruins lives if not properly diagnosed and treated.