Just Right Baby Bear?

There is a problem in the modern world, I think: we honestly believe there is an answer to any question we ask if we pursue it with enough effort. It leads to unrealistic expectations and a suspicion that there should be no need to compromise -or if we do, a sense of disappointment that it was necessary. Medical knowledge seems to fall into this trap. We have come a long way, and yet how far there is still to go is often underestimated. Success comes in steady but often unpredictable increments, punctuated with unexpected retrenchments. It was hoped that sulpha and penicillin would mean the end of infectious diseases…

What brought this to mind are a series of papers warning against, for example, relying on supplements for chemoprophylaxis against –among other things- prostate cancer, osteoporosis, and Alzheimer’s disease. There still seems to be no adequate substitutes for exercise, a good healthy diet, or more probably, good genes. For many things we just don’t yet have any answers –except, maybe, healthy lifestyles. No compromises. No shortcuts. Just when we think we have it figured out, we find that we only were in possession of a portion of the answer –what  constitutes  wise choices for healthy living, for example… Sometimes we wander onto the wrong track altogether.

An area in which this is particularly important, is prenatal care. After all, those things that might make sense for the adult mother, may not generalize to her foetus. An obvious example is alcohol. Small amounts consumed outside the framework of pregnancy have a long body of evidence suggesting safety in the adult. Of course even this evidence is now suspect in light of data linking alcohol to a higher incidence of breast cancer. But in pregnancy, even small amounts may have a detrimental effect on the developing foetus. The problem, of course, is that there seem to be many other factors playing a role: metabolic differences from person to person, family to family; and different thresholds,  or different consumption patterns that muddy the water sufficiently to allow all manner of interpretations and rationalizations about its use and safety in any or all trimesters.

The most recent studies have also questioned the safety of yet another medication we used to consider relatively safe for the foetus: acetaminophen (Tylenol is one of its brand names). http://www.huffingtonpost.ca/2014/02/24/acetaminophen-use-in-preg_n_4850454.html and a slightly different take on the evidence: http://www.huffingtonpost.com/2013/11/26/tylenol-during-pregnancy_n_4343319.html   Of course there is often a need for analgesics from time to time –pregnant or not- but there are definite problems during pregnancy with the use of, say, ibuprofen or other NSAIDs –Non Steroidal Anti Inflammatory Drugs: kidney damage, internal bleeding, or even premature closure of a blood vessel, the ductus arteriosus that bypasses the (still unnecessary) lungs in the foetus. Even though the effect maybe transitory, it is probably best avoided. Aspirin (acetylsalicylic acid) can also lead to bleeding and has many similar effects to ibuprofen. So, what’s left for headaches? Morphine? Some other narcotic? No. Acetaminophen, while implicated in liver damage even in adults if overused, was felt to be safe for the foetus. It still probably is, and yet there is some evidence it may be linked to mood disorders and other more difficult to define problems in childhood. It can be, we have learned, an endocrine disrupter –something that might alter the effect or even normal production of hormones.

So what now? Suffer? Wait until the next miracle drug comes along and hope that it will prove safe in the long run? Well, I think that we’re going to have to accept that the use of medications in pregnancy is always going to be problematic. Risky. It is unethical, and totally unacceptable to run controlled experiments –whether blinded, or prospective (looking ahead to see what the results will be) on a developing foetus. Yes, there are animal models that can be tried –also with some ethical issues- but animals are not humans. The results may be misleading and not generalizable, or even applicable to humans. The most believable theories may eventually prove misguided. Or wrong.

Until we find another more satisfactory method of testing medications –complex computer simulations are an intriguing prospect- I suspect that most information in pregnancy will come by using retrospective data –that is, someone (or a great number of people) inadvertently used something and by good fortune, nothing happened to their babies. But the problem with this evidence is obvious. Not a sufficient number of cases may have been reported to make the information  useful. The people using the medication may have had different characteristics that might alter the results for the rest of us. Or, they might have been just plain lucky! Worse –because we might be lulled into accepting the apparent safety of their use- the effects on the baby may not be apparent for months or years to come. Maybe that’s what is currently being described with acetaminophen –although the authors and others have recommended caution in interpreting their data for much the same reasons.

No, I think that for  some time to come, we are going to have to look at medication consumption –especially in pregnancy- using a risk-benefit framework. There will always be some risk, but does the benefit override it? Some things with known risks carry an even greater likelihood of serious illness to the mother if they are not used in her pregnancy –antirejection medications for women with kidney transplants, are one fairly obvious example. There, the risk is likely worth it. It has been similarly argued that antidepressants in some women are essential to prevent either worsening depression and the consequences that it might have on good antenatal care, or even suicide…

But  not everything requires an immediate solution; not everything requires medication.  And it’s helpful if every once in a while, someone calls attention to this -and the fact that nothing should be considered completely safe in pregnancy. Maybe we should concentrate on trying to frame the risk in a fashion that is readily assimilable. Understandable for everybody.

We already have a system that assigns risks of medications in pregnancy from A (generally acceptable, with controlled studies in pregnant women showing no evidence of risk to the foetus) all the way to D (use in life-threatening emergencies only when no other safer drug is available; There is positive evidence of human foetal risk). There is even a class X (Do not use in pregnancy –the risks outweigh any potential benefits. Use something else!)

People are becoming more aware of this classification system as they look their prescriptions up online. It is up to the prescribing doctor  or midwife to simplify it even more for them if necessary. Often that involves putting it into context.

We need a similar classification system that applies to new evidence as well, so that health care professionals can be confident that their information is both timely and reasonable. It serves no one well if the patient or the professional  jumps to unwarranted conclusions based on inadequate evidence, or a poorly performed study.

Medicine is evolving quickly, but I think the most important change should be in the further education of both sides of the healthcare equation that there will always be risks. The unknown will never disappear. And it is naïve to insist that just because something can be framed as a question, there has to be an answer. Or even should be… Maybe that’s just the way it is sometimes…And I, for one, am frequently awed by the feeling of sheer speculative wonder, the mystery, of where geese go when they fly into a fog and their calls slowly fade into the distance. I will not frame it as a question.

Plus ca Change?

You know if you wait long enough, what was old becomes new again. Old fashions become retro and are seriously nouveau. I don’t wear ties or cuffed pants, but I’m sure if I hunted around in the closet I could find something that would make a teenager’s eyes water.

Theories are sometimes like that, although when they return, they somehow look different: different words, different rationalizations, different paradigms into which they have been conveniently slotted. Sometimes they return because of the Law of Unexpected Consequences: the current wisdom has led to an undesirable product. And that’s totally acceptable and indeed what is admirable in science as I discussed in my last blog. It is appropriate that we continually monitor the results of thinking a certain way, re-evaluate even established wisdom when it seems to be leading us astray.

Our problem is that change is often slow. We adapt. We accept that which is only marginally different from what we have come to expect. It is only by stepping back from time to time that we realize how great that change has become and decide whether or not it still meets our needs. Whether, in other words, it is still acceptable.

Okay, plus ca change… There is an article in the March issue of Obstetrics and Gynecology that suggests that it is okay to let a woman labour longer. Not only that, but they should be allowed to push longer in the second stage as long as the baby is not showing any signs of distress. The lead author is a member of the American College of Obstetrics and Gynecology (ACOG) Committee on Obstetric Practice, so it’s imprimatur does carry some weight.

ACOG Guidelines Focus on Reducing Primary Cesarean Deliveries
http://www.jwatch.org/fw108498/2014/02/20/acog-guidelines-focus-reducing…

The impetus for this reassessment, dare I say, is the number of Caesarian Sections that are being done. In itself,  a surgical intervention would not seem to be a necessarily bad thing if it saves the life or the future health of a baby or its mother. There can be downstream consequences to Caesarian Sections that are seldom given much press, though. Caesarians are not a pancea, and not without complications –all surgeries carry their own risks. But in the case of obstetrics, it is often not simply a one-time risk. The mother may desire another pregnancy, and because of the problems she encountered in her first labour, may opt for yet another Caesarian. Or, complications from the first one such as infection or wound problems may necessitate a second Caesarian. The concern doesn’t just stop with the delivery of the first baby…

The question at issue, however, is whether it was actually necessary to intervene in the first place, or whether other factors were at play. Judgement, of course, is a multiverse, subject to all the biases of current wisdom, past experience, and not least, the way it was taught in medical school or the residency program. We seem to be creatures of the algorithm; we feel happiest when we can plot things on graphs. The Friedman curve of cervical dilatation was one of the basics we were taught as medical students: if progress begins to deviate from the nice sensible curve, then do something. All well and good: start some medication to enhance the mother’s contractions, maybe, and then observe. And reassess… The temptation, of course, is to set some arbitrary time limit to the observation and then intervene if progress has not occurred. The study is suggesting that we lengthen that time limit… or perhaps even question  the need for one at all. Patience can be a virtue.

But we need patterns to help us; it has no doubt been to the advantage of our species, to categorize: to identify the growl in the woods, then slot it into a judgment. A reaction. A pattern. So if we don’t immediately see a pattern, we look for one. Or we create one. Of course, the patterns are often arbitrary; we just feel better when one is there.

And we love to measure things in that search –measure and then analyse. But in a sense, we’ve again arbitrized a tiny section of the whole and generalized from it. Think of putting a grid over a window overlooking, say, a street –but only concentrating on one tiny section of it –ignoring the rest. In square 1C there is are 106 green things that look like leaves, and they sometimes move randomly. And since that’s all we can see, we conclude that we’re dealing with a forest, and that there might be an animal in the tree making it move. Or maybe wind… We convince ourselves we have discovered something profound. Well, maybe we have, but it seems to me that what would  be far more profound would be to take away the grid and realize we were only measuring a small segment of a far larger, far more diverse whole.

Sometimes we do that, but more often we get caught up in minutiae –especially if they fit into the current paradigm. Or we can make them fit. We need to step back every now and then. Clear our minds. Look at the whole… Why did we think we should set limits on labour? Why did we feel we should give up in the second stage after pushing for a certain length of time? Did this ever make sense if mom and baby were okay? Is this one of the reasons women are feeling more comfortable with midwives, or electing non-hospital births?

Even as an obstetrician with a rather lengthy career, I hesitate to say I told you so, but it’s the wide tie coming back into fashion again… or are they already back? The caveat for all of these recommendations is –of course- that there are no other impediments to continuing the labour, or the pushing. Mothers get exhausted. So do babies… So do doctors. And it’s this latter category that we have to be careful about. There may be no reason for intervention in the labour other than frustration.

Lack of progress is a highly charged observation in labour, and even more so after an hour or two of pushing without seeing much success. It can lead to decisions that, in less emotionally and physically exhausting circumstances, might be made differently. And that is where the nurse, midwife, or doctor has to step back from the drama. Has to try to divorce herself from the fray and consider what is truly in both the baby’s and mother’s best interest. Has to try not to succumb to the frustration thickening the air. A word of encouragement from a trusted caregiver goes a long way to diffusing tension. Sparking renewed determination. Inspiring hope…

But I thought we all knew this.

Science and Simulacra

One of the problems with Science for many people is that it keeps changing its mind. We are in an era when to say that an idea is scientifically proven is to imply that something profound has been uncovered: a truth has been revealed that is forever irrefutable. It is a time of global angst, when religions and cultures appear to be at odds with each other; only science seems to have anything to say that can transcend boundaries: something reliable to believe in.

Now we learn that yet another theory –i.e. that mammography would reduce deaths from cancer by detecting them sooner and at an earlier stage- doesn’t seem to be valid : http://www.bmj.com/content/348/bmj.g366 or perhaps a more readable summary: http://www.jwatch.org/fw108466/2014/02/12/annual-screening-mammography-produces-overdiagnoses-no?query=pfw  Maybe this might have been better described as a scientific hope than a fully fledged theory; nonetheless it does not inspire confidence that we are on the right track…

But it is in the very nature of science to be open to refutation and revision. Paradigms shift and new theories replace older ones… So what can we believe? Is science wrong?

Philosophy offers some insights, and how we view reality lies at the heart of it. There are many ways of apprehending reality. Realism is perhaps the most pervasive nowadays: the common sense view that scientific theories say verifiable things about the world –stuff out there exists and even if we aren’t able to see it (a quark, or a lepton, say) we can measure it. But there are other ways people have viewed reality –everything from Descartes’ Cogito ergo sum (there is something out there but we only know about it through our senses, and they –as in the case of, say, hallucinations- may be deceiving us), to what has come to be called instrumentalism –Science just measures things and theorizes about them (somebody else can worry about whether or not they are real).

As I suggested earlier, since theories and paradigms change –and always have- why should we believe that the ones currently in vogue are correct? And if they’re constantly subject to revision, then how then can we believe they are telling us anything about reality? Well for one thing, the scientists say, the technology engendered by them works doesn’t it? That’s surely a testament that we’re on the right path. And yet how can we balance the discrepancies? It’s a terrible pickle we’re in if we try…

But theories don’t talk about real things, only our interpretations of theories do. Science is usually couched in mathematics, hidden in numbers, but meaning –interpretation- requires metaphor.  We are creatures of stories, myths, legends… It’s only through these that we make sense of our world. Numbers almost have a separate reality –they describe our world, but they don’t really live where we live. To an extent, they are contingent on metaphor to have any descriptive function.

So, what does all this obfuscation have to do with the value of mammography? The problem of being told one thing today, only to have it rescinded –no, revised– the next? Well, as I see it, reality is still obscure: we think we understand it, think we are wearing it –and yet, like an onion, it has many other layers, deeper layers…

I’m struck by the prescience of that allegory told by Plato so many years ago. You know it: the one about the Cave. Prisoners are chained in a cave and only able to see the shadows of objects cast on a wall from a fire behind them. These shadows, they think, are real –indeed, it’s all they’ve ever known. But a prisoner escapes the cave and sees the world outside where he can finally appreciate what is truly real… Maybe the shadows have prepared him somewhat, but only when he is outside can he understand that what he had been calling real were, at best, approximations. Some were no doubt better than others, but simulacra nonetheless.

Although perhaps closer to the entrance to the cave, we are still imprisoned, still mistaking shadows for what they represent. For reality. For now…

 

Homo Alarmus

I have had alarm fatigue for quite some time now – years probably.  It’s something that kind of sneaks up on you from behind.  Silently. Like  a shadow in the moonlight, you’re not aware you have it until someone points it out. Tells you that it is interfering with seeing things already obscure.

It is difficult to give it much credence as I vacation here in New Zealand where the only alarms are muscular from too much hiking, or maybe gastrointestinal from innocent dissipation. And yet even the memory is painful. Tachycardic. It does what alarms were designed to do: alert me that something is wrong –even when it isn’t. It arms me for action –unspecified at first, but choosable in the long game.

In its original form, an alarm is what kept us safe from the beasts in the woods, the monsters in the cave, or the throat that howls in the night. But there is a more modern variety that is even more specific and it is legion. There are alarms everywhere: they annoy us on our phones, we are scattered by horns, warned by sirens, and alerted that an hour has passed by the little beeps on our watches.

Personally, until somebody drew my attention to them, I was fine with alarms. I mean, where would we be without them? Still asleep probably. Or late.

Homo alarmus is what we are. But unlike the other honorific -homo sapiens- our proclivity to use alarms in order to function properly certainly doesn’t set us apart from anything  -except maybe rocks, or dead leaves. Even an amoeba responds to noxious chemicals and turns away. Noxious smells do that to me.

No, we humans have become greedy for stimuli, and have decided that those alarms Nature has already proffered  are not enough. We have determined, in a continuing spasm of hubris, that we need more. That’s okay, I suppose, but how many more do we really need? Yes, I guess it’s a good idea to have something that tells us that somebody is phoning, or is at the door, that we left the lights on in the car, the keys in the ignition,  or that the smoke from the barbecue is now in the house, but do we really need our watch telling us when a new hour begins? Or that the seventeenth Email is currently available for viewing?

I think we have to decide what we want –or need- to be alarmed about. No sense using up adrenaline because the car alarm went off when somebody brushed against it. I want a goodly stock of it left for when I hear a rustle in the bushes, or a growl in the woods. It’s called the ‘flight or fight’ system and it’s what keeps species alive.

Alive –not neurotic.  We all get tired of alarms. Wish them away. We want the ability to be able to function in silence –or at least the silence that allows us to think things through without distraction.  Alarms can become noise. From the moment we awaken –to an alarm, maybe- we are assailed by noise -informing us, entertaining us, distracting us, warning us. And we learn to ignore it. To focus. To do otherwise would threaten both our sanity and our ability to respond appropriately to really important stimuli. To lose focus is to drown.

And yet we do lose focus when it is constant; like an unpleasant odour –a pulp mill near where we work or live, for example- we adapt to it and get on with our job without noticing what anyone else just arriving might find overwhelming. And traffic: those that live in the city don’t notice it; the horns and noisy vehicles go unremarked. Unreceived. To constantly attend to them would lead to burn-out. Fatigue. The noise is no longer the alarm it might be if it were sprung upon us suddenly. And yet, this is how it should be: change should be the alarm, not noise. Not simply the volume or complexity of sound. Otherwise, it doesn’t serve to alert. It becomes background –‘white noise’. Our brains adapt: they fatigue with trying to interpret something that has ceased to be novel.

Alarm fatigue is an interesting consideration as we go about our daily lives. But we all knew it was just a matter of time before they would creat a problem in the workplace, as well. And there can be serious consequences that might not immediately spring to mind in that setting:

http://www.cmaj.ca/site/earlyreleases/9jan14_alarm-fatigue-a-top-patient-safety-hazard.xhtml

Medical device alarms are the main subjects in this report -especially in hospitals. When it comes to health and patient safety, there can never be enough warning about things going awry -right? Well if they are confusing, ignored, or go off too frequently then they have not lived up to their promise. More alarms don’t necessarily create safer conditions. They become traffic noise heard through the window. Horns are horns; beeps are beeps: collectively, they too easily fade into the background.

Maybe less is more… Maybe, for a start, muting all alarms except for those that are really important and privileging them should be considered. Obviously hard decisions would have to be made, but they might include cardiac arrythmias in an ICU, say. Or similarly, fetal heart rates below a certain threshold on monitors in the maternity ward.

The object is not to monitor less, but monitor more effectively. More attentively. Let us go back to a time when alarms really meant something: act. Now! Too much adrenaline is like too much coffee: pleasant for a while, then irritating. Dangerous.