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Sunday, November 6, 2011

The value of silence when a patient dies

 Surgeon and columnist Pauline Chen suggests doctors and nurses should be obliged to pause for silent reflection when someone they are treating dies. It would be good for them, she says, and may make them better carers.
On hospital wards, in the operating room, in clinics and in the intensive care unit, there should be a mandatory five-minute silence when a patient dies.
The doctors, nurses and all who had been caring for the patient at the end would gather around the bedside for those five minutes and reflect in silence on that patient's life and death.
In my experience, there's a moment right after the patient dies when most caregivers, particularly doctors, will scatter - if not in presence then in mind.
We immediately think about going to see the next patient, cleaning the room, getting the body ready to go to the mortuary. Anything to avoid confronting the reality before us because, for those of us who practise in wealthier countries, a patient who dies represents our professional failure.
Continue reading the main story
One reason we don't do a better job caring for the dying is that we hardly ever acknowledge our own responses to those who have died”
End Quote Several years ago, I took care of a young woman who had had a transplant a decade earlier but who was now hospitalised because of a series of infections.
She was slender and blonde, and I can recall how she loved talking about the novels she had read and the way she raised her right hand to her forehead, palm facing outward, to pat her hair.
But on the night she bled to death from an infection that had eroded into a major artery, none of us stopped to remember the lively conversations about literature.
Instead, as soon as she was pronounced dead, we became preoccupied with seeing the next patient, removing the stains from blood that had gushed up to the ceiling and disposing of the used needles and syringes strewn on her bed.
We did not talk about her, the woman who had just died in the room.
Weighed down
I have often thought back to the fact that I did not stop to remember her or acknowledge her impact on me. There was no closure to our relationship, no acknowledgment of her life or my grief.
Continue reading the main story  Dr Pauline Chen laid out her idea on The Forum, on the BBC World Service, and discussed it with literary editor Diane Athill and poet Paul MuldoonThe Forum presents ideas from the world's biggest thinkers every week Broadcast on Saturday at 09:05, 22:05 and Sunday at 02:05 and 15:05Had I lived those moments around her death differently, perhaps the details of her death would not be frozen in my mind as they are now, a few minutes replaying over and over again.
Perhaps by acknowledging her passing I would not be as weighed down by what was lost, even as I continued to care for other patients.
I believe that instituting the five-minute pause for silence after a patient dies will change the way doctors, nurses and other caregivers approach death.
First, it will give closure, as well as respect, to the relationship between that patient and his or her caregivers.
Second, the conscious pause, the act of taking time out, will establish a ritual. And rituals, consistently practised, offer great comfort at difficult moments.
Finally, the five-minute silence will allow caregivers to acknowledge their own feelings.
I am convinced that one of the reasons doctors and other healthcare providers don't do a better job caring for the dying is that we hardly ever take the time to acknowledge our own responses to those who have died. We deny those feelings only to end up constrained by them.
A five-minute pause for silence would allow us to attend to our own grief about a patient who has died and free us to commit ourselves fully to those who will follow.
Pauline Chen is a liver surgeon and author of Final Exam: A Surgeon's Reflection on Mortality. She also writes the Doctor and Patient column for the New York Times.

'The voices started abusing me'

 BBC News weeks away from friends and family trying to control the demons in her head.
"The voices started by saying 'I'm your best friend' then they started getting abusive and it got worse and worse..."
Her voice tails off as the memory of that dark period of her life returns.
Fatima is just 16 years old.
She was sitting her GCSE exams when the stress became too much and she started hearing voices. The pressure to achieve, anxiety over her self-image and family issues all combined to send her spiralling into a fragile and disturbed state.
She struggled with psychosis all summer before ending up desperate in A&E.
Her social worker recommended that she visit a residential centre specialising in the treatment of children and young people with serious mental health problems.
At Becton Lodge in Sheffield, she was given medication to calm her down and forced to accept she had a problem.
"The hardest thing was realising I had an illness. That was a big step.
"I've got a lot of help here. I'm trying to understand myself and how to control the voice.
"I realise now that the voice cannot hurt me and I know I can get over it."
Far from friends
But Fatima is not alone in her experience.
Advice is featured on the EPIC Friends website for anxious and depressed young people.
Mental health charity Youngminds says that one in 10 children aged between five and 16 suffer from a diagnosable mental health disorder - about three children in every class.
In Sheffield, recent research suggests that 12% of secondary pupils in the city say they feel very sad or depressed most days.
What Fatima says she missed most in the difficult days of her psychosis was help from friends.
"I lost my friends. I lost contact with them all. They didn't really understand what I was going through and I couldn't talk to them either," she admits.
A new website, called Epic Friends, aims to change all that.
Continue reading the main story
Young people are often forced to attempt to cope with issues like self harm, eating disorders and depression alone while navigating the most turbulent years of their lives”
End Quote Lucie Russell Youngminds Funded by the Children's Hospital Charity in Sheffield, it wants to provide clear information for young people about what to do if they suspect their friends are feeling anxious, depressed or troubled in some way.
An "epic" friend is a friend who notices a problem and is prepared to listen, the website says.
Gill Crow, consultant clinical psychologist from Sheffield Children's NHS Foundation Trust, had the idea for the website and developed the content.
She says friends are very important in a young person's world.
"Young people often turn to their friends. Friends are the ones who notice if they are not eating or becoming reclusive and not going out. They talk more to their peer group than their parents at that age, although parents can underestimate how important they can be.
"Adolescence is a very difficult time of life. A lot of them will be feeling anxious about something. The danger is that they get into a negative spiral, becoming more and more anxious."
Early intervention
The website promotes the idea that recognising you have a problem and talking it over with a friend or an expert is half the battle.
An illustration from the Epic Friends website details how young people can get a mental boost.
And being a good friend is someone who can play the role of adviser and listener.
The website urges young people to find out what kind of friend they are by taking the Epic friendship quiz and it advises them how to cope with the ups and downs of life by, among other things, "running around, getting creative, giving someone a hug, finding time for yourself and letting people know you're not coping".
Lucie Russell, director of campaigns and policy at Youngminds, echoes the sentiments of the website.
"Without support, young people are often forced to attempt to cope with issues like self harm, eating disorders and depression alone while navigating the most turbulent years of their lives.
"More support needs to be given to services that intervene early and give emotional help and support before mental health issues become entrenched.
"Too many child and adolescent mental health services have been reduced to simply helping young people who are very ill. If they were able to intervene earlier this would avoid young people's problems becoming more severe and disabling as they get older."

The woman who swallowed a bullet

 Over the centuries, many important scientific discoveries have been published in the Philosophical Transactions The world's oldest scientific academy, the Royal Society, has made its historical journal, which includes about 60,000 scientific papers, permanently free to access online.
The plague, the Great Fire of London and even the imprisonment of its editor - just a few of the early setbacks that hit the Royal Society's early editions of the Philosophical Transactions. But against the odds the publication, which first appeared in 1665, survived. Its archives offer a fascinating window on the history of scientific progress over the last few centuries.
Nestling amongst illustrious papers by Isaac Newton and Charles Darwin are some undiscovered gems from the dawn of the scientific revolution, including gruesome tales of students being struck by lightning and experimental blood transfusions.
Here are some of the more curious items from the early archive.
Galileo's sketches of the moon from the Starry Messenger, 1610
Dr Wallis from Oxford wrote a paper about a grisly boating accident during a thunder storm in Oxford, which left a "stinking, sulphurous smell in the air". Two students out in a boat had been struck by lightning. One died instantly, the other was "stuck fast in the mud", apparently "with his feet downwards and his upper parts above water". Besides "a numbness" he was unhurt, but had no memory of what happened to him and why he was stuck in the mud.
Dr Wallis also provides a detailed account of a post-mortem examination he and others performed on the dead student. He reports the body had no wounds apart from a series of black marks on his neck, shoulder and chest "as if it had been seared with a hot iron". Some of the buttons on the student's doublet had also been blown off, he added.
The French astronomer Adrien Auzout wrote about what "supposed inhabitants of the Moon" would be likely to see when they look down on earth, including changes of season.
"Methinks, that the Earth would to the people of the Moon appear to have a different face in the several seasons of the year," he wrote. For example, in winter, when "there is almost nothing green in a very great part of the earth", or summer, "when whole fields are yellow".
He also speculated that forest fires would be visible from the Moon. Mr Auzout was elected a fellow of the Royal Society in 1666 and briefly considered constructing a huge aerial telescope 1,000ft (305m) in length to observe animals on the Moon.
Continue reading the main story 1672 Newton's first paper. He made the revolutionary discovery that colour is an inherent property of a ray of light and that white light is a mixture of other colours1752 Flying a kite in a storm. Benjamin Franklin suggested lightning is electricity flowing from the clouds to the earth and that this electricity could be collected artificially by flying a kite into a storm. It worked and didn't kill him'A very curious person studying physic at Leyden' (Leiden, in Holland) wrote about some odd things that happened to people's bodies. These included a student of astronomy whose pores became blocked after spending so many nights star gazing outside in the cold and damp that he was no longer able to sweat.
He also wrote about the tragic case of a 13-year-old girl, who since she was six had filled her pockets with salt and eaten it "as other children do sugar". The tale did not have a happy ending. Eventually she had become "so dried up, and grown so stiff, that she could not stir her limbs, and was thereby starved to death".
Thomas Coxe wrote about an early blood transfusion from one dog to another. He transferred blood from a dog suffering from mange into a healthy one - to see if the healthy dog would be infected.
First he procured "an old mongrel cur, all over-run with the mange" and fed it up with "cheese parings and milk". He then transfused about 14oz or 16oz (397g to 434g) of its blood into the veins of a healthy spaniel. The effect of the experiment was no change in the healthy dog and the mangy dog was "perfectly cured" in 10 days.
Dr Nathan Fairfax wrote about a woman who swallowed a bullet, which was expelled from her body in a very surprising way. The "pale, middle-aged, full bodied" woman had suffered bowel problems and had been advised by a neighbour to swallow two bullets. Apparently this gave her some temporary relief, but then her symptoms returned and she consulted Dr Fairfax's apothecary. He wrote that he gave her some "Lady Hollands powder to take in a posset drink", which made her vomit.
The following morning when using her chamber pot the woman claimed to have heard a "twang" and that along with some urine she saw a bullet, which she believed she had also passed out. The doctor concluded: "It shall be said, that Nature, when put to shifts, finds out strange conveyances to rid the body of what is extraneous and offensive to it".

UK hand transplant search begins

  David Savage had a hand transplant in the US. Surgeons in Leeds have begun the search for a patient to take part in the UK's first hand transplant.
Leeds Teaching Hospitals NHS Trust has written to plastic surgeons across the country asking them to recommend patients.
The first hand transplant took place in France in 1998. Since then, 60 more operations have taken place worldwide.
Doctors believe the first UK operation will be performed at Leeds General Infirmary within a year.
Leeds already has a reputation in reattaching hands for people who have had them cut off.
Prof Simon Kay, consultant plastic surgeon, said transplanting a hand from a donor was "exactly the same" as the techniques already practised at the hospital.
He told the BBC: "Only when you speak to people who've lost a hand can you realise what a devastating thing it is, losing both hands is absolutely incapacitating.
"Now for those people there is real hope of restoration of natural appearance, natural feeling, natural function."
He is working with NHS Blood and Transplant to work out how best to identify potential donors.
Earlier in the year, the National Institute for Health and Clinical Excellence issued guidance on hand transplants. It warned of a shortage of evidence about the safety and effectiveness of the procedure.
As a result it said the operation should take place only in centres with highly experienced surgeons and that patients should be warned of the risks.
"In particular the need for and risks of long-term immunosuppression, and the fact that functioning of the transplant may be both delayed and limited," it said.

Trials of diabetes breath tester

 Children with type 1 diabetes need at least four finger-prick tests a day Children with type 1 diabetes in Oxfordshire are to be the first patients in England to have their blood sugar levels tested using their breath.

Oxford Medical Diagnostics is working in partnership with the city's children's hospital to test its new desktop device.

The machine can accurately measure tiny amounts of the chemical acetone on a patient's breath.

This can then be used to estimate how much insulin is needed.

Paediatric consultant Julie Edge said staff at the hospital were excited about the trial, which was likely to start in the spring.

During the six-month trial, children will still have to take finger-prick blood tests. The results of these will be compared with the breath test to see how closely they match.

Children with type 1 diabetes need at least four finger-prick tests a day and sometimes up to 10 in very small children.

Dr Edge said: "A hand-held meter that would just say what your [blood sugar] level is would be really helpful."

Diana Davies, from Oxford Medical Diagnostics, said: "It's well known by doctors that the sweet, fruity odour of acetone in your breath is an indicator for diabetes.

"We can extrapolate that to develop a device that is capable of measuring the blood glucose levels."

If the trial is successful, the company hopes to develop a portable hand held prototype.

Why disgust is a healthy emotion

 Disgust at uncontrolled sneezing, for example, is one of our main defences against infection. The facial expression for disgust is universal. We can all picture the contorted, horrified face which communicates a feeling of revulsion and loathing.

Spiders, slimy creatures, mucus and faeces can all provoke this feeling. Our reaction is to distance ourselves from the cause.

As a result, feelings of disgust help us to avoid, or at the very least recognise, the things that make us feel this way - and for a very good reason, psychologists say.

When it comes to infectious diseases, disgust has evolved to help us steer clear of sick people, dirty water, vomit, body fluids and all the other stuff that makes us react "Yuck."

In a paper published in Philosophical Transactions for the Royal Society B, Dr Val Curtis, from the London School of Hygiene and Tropical Medicine, argues that avoidance behaviour is essential to prevent the spread of all the major current and recent infectious diseases which present a threat to humans.

Diarrhoeal diseases, respiratory tract infections, malaria, measles, HIV, tuberculosis and parasitic worms can all be avoided by thinking about aspects of hygiene, Dr Curtis says.

Continue reading the main story
We only develop an understanding of disgust around the age of two or three years old.”

End Quote Prof Graham Davey University of Sussex Washing hands and food can prevent diseases like cholera and hepatitis A, avoiding sex with others who are infected helps prevent the spread of HIV, while keeping a distance from people with influenza or measles is a sensible move to reduce the risk of infection.

"The idea of contacting or consuming infectious substances such as saliva, faeces or vomit, or of intimate contact with those known to be carrying infection is deeply uncomfortable to even contemplate," writes Dr Curtis.

"Self-limitation of such behaviour is so automatic and intuitive that it is often ignored as the front-line in our defence against disease.

Continue reading the main story

Aids - sexual fluids, body fluids

Diarrhoeal diseases - faeces, dirty water, contaminated food, vomit

Hepatitis - faeces, dirty water, contaminated food, vomit

Leprosy - skin lesions, nasal mucous

Measles - rash, sores, nasal and throat secretions

Plague - pustules, sick people, refuse, rats, fleas

Rabies - saliva, infected animal, dog, bat

Syphilis - rash, skin lesions, especially on genitals, insanity

Tuberculosis - nasal mucous, spittle, droplets, stale air

Source: 'Why disgust matters' by Dr Val Curtis, Philosophical Transaction of The Royal Society B

"Without disgust and the hygienic behaviours it elicits, then, infectious diseases would cause far more morbidity and mortality in our own - and in all free-living animal - species."

Something as simple as hand-washing with soap could save over a million lives a year globally, the paper says, just by stopping the transmission of disease.

Disgust is often used to get this message across in public health campaigns.

The UK government's information leaflet at the time of the H1N1 influenza outbreak in 2009 shows a human sneeze exploding directly towards the reader, spraying bodily secretions in all directions.

Its purpose was to encourage better hygiene and more sensible use of tissues.

The British Heart Foundation's most successful campaign showed the impact of smoking on the arteries by depicting cigarettes dripping globs of fat.

Disgust at small creatures can turn into an irrational phobia.

A recent study showed that the greater the disgust felt at such pictures, the greater the likelihood that people would have tried to, or succeeded in, stopping smoking.

So while disgust prevents us coming into contact with germs and viruses that might cause us to become ill, it can also feed our anxieties and lead to obsessive behaviour.

Graham Davey, professor of psychology at the University of Sussex, says disgust is not an innate emotion.

"We only develop an understanding of disgust around the age of two or three years old. Babies stick anything in their mouth before then and only learn when they see their mothers' facial expression signalling disgust at something they have done."

Disgust can also colour our view of something and make us act irrationally, particularly when it comes to phobias of small animals.

Continue reading the main story
I would be greatly in the debt of the man who could tell me what would ever be appealing about those damp, dark, foul-smelling and revoltingly tufted areas of the body...”

End Quote Stephen Fry Spider phobias are very common and yet spiders in the UK are not harmful. Neither are rodents, creepy crawlies or insects, but they all trigger feelings of disgust and are often the cause of phobias.

"People tend to have phobias about animals which aren't necessarily harmful," says Prof Davey.

"It's different from fear. It is basically a disease-avoidance emotion - disgusting animals or objects tend to be vehicles carrying disease.

"But the spider is entirely innocent. It has a historic link with disgust and people tend to think they have venomous bites, which they rarely do, so there is not much rational grounds for that fear."

There is also evidence that disgust is involved in many mental health problems, including eating disorders, sexual dysfunctions, claustrophobia and psychosis.

Prof Davey said: "Some people have high sensitivity to disgust and that can be blown up into full-blown anxiety disorders.

"These can disrupt every part of a person's life, often getting in the way of work and relationships."

Stephen Fry, who has declared himself celibate in the past, is quoted in Dr Curtis's paper describing how disgust played a part in his decision to abstain from sex.

"I would be greatly in the debt of the man who could tell me what would ever be appealing about those damp, dark, foul-smelling and revoltingly tufted areas of the body that constitute the main dishes in the banquet of love.

"Once under the influence of drugs supplied by one's own body, there is no limit to the indignities, indecencies and bestialities to which the most usually rational and graceful of us will sink."

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