Tag: 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.

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.