Category: Essays

Many years ago, while spending some time in the lab, I had a part-time job in home healthcare. I had three patients. They were all over 85 years old. The only male patient among the three had had a stroke and his loving wife needed help taking care of him. She was an extremely loving woman but of a slight build so it was really hard for her to do all she had to do for her sick husband. They didn’t have kids but the love they had for each other filled the home.
The other patients – two women – provided an interesting case study. They were both in their 90s. One was a widower while the other never married. The widower had spent her life working with the homeless and needy the other used to be an attorney. They both never had children. However, the home of the widower was always warm and welcoming. The other not so. The widower got visits constantly from nephews and nieces. In the year that I took care of them, I met only one relative of the old attorney – a young nephew. He visited once. I gathered there was more family out there but they never visited. The widower was spry, active, witty and sharp. The old attorney not so much. Somehow, she was always ill even though she really had no debilitating chronic ailment.
Over time I wondered what role the family of lack thereof played a role in the health of these patients. The man who had had a stroke was sick but mending nicely from all the care from his loving wife. The widower was was always looking forward to a nephew or niece visiting and looked great for her age in spite of several chronic conditions. The attorney, well…
That year made me think of family a lot. It made me think of the support that family brings. It made me wonder about the warmth it can create and the health benefits.

Years later, I found myself in Kentucky. Now Kentuckians are very family-oriented people. Having my extended family in Ghana, they make me miss them everyday. Each morning in the preoperative area in the hospital, one can see several children and grandchildren waiting to give a grandma a kiss before she goes off for her new valve, fathers surrounded by kids before that knee replacement, mothers with sisters before that mastectomy – all celebrating family and the art of support.
Imagine my surprise one morning when I went to see a patient preoperatively and did not see a soul with him. Of course I had to bore. The man was in his mid-60s. I found out that he was divorced and not in contact with his former wife. He had no children but had one living brother who lived in another state. I asked if the brother was going to be there. He said no. The nurse asked if he had the brother’s number so she could call him and keep him up to date (During surgeries, there is one family member who is kept up to date on the progress of the procedure). He said he didn’t have a number and that they communicated by email! I was stunned. By email?
He went on to have his surgery and did well but all day that day, I couldn’t get him out of my mind. It made me think of family and support….again!
Facing surgery and anesthesia is a very intimidating prospect for most patients. Even tough men who have been through the rigors of war show cracks preoperatively. Having loved ones around helps one greatly through this time. The immediate expression of love and support reassures and raises one’s spirits. To imagine a patient going through this period alone boggled my mind.

Now sometimes family can be a hindrance. Family members can be disruptive and delay decisions on important procedures. Everyone in OB knows of the husband who passes out at the sight of the epidural needle, gets a concussion and unintentionally delays his wife’s care. In all however, family support in times of illness is indispensable.

It is not only in the perioperative period that family support is advantageous. Another important instance where family matters is in the care of people with chronic diseases. Patients with diabetes, cystic fibrosis, mental health problems and even addiction all do better when there is support at home. Several studies show that this support prolongs lives and decreases the incidence of complications. Family helps patient keep their medical appointments, monitor parameters like their blood sugar and blood pressure and take their prescribed medications. They provide the emotional support that is often so direly needed.
Even though the overriding theme in this piece seems to be about family, it is really about support in the time of illness and need. After all those years, I kept seeing the importance of support. Support through the tough times help emotionally but also seem to translate into more stable vital signs, faster healing and better outcomes. Even though it comes easier and more readily from family, in the absence of one, good friends can offer that support. It reminds me of the refrain from the old Bill Withers’ song:

“Lean on me when you’re not strong,
I’ll be your friend, I’ll help you carry on.
For it won’t be long ’til I’m gonna need
Somebody to lean on.”

Over the years one thing is become rather clear – that in the art of healing, support may be the part we physicians cannot control but is direly needed.

The week that started on Sunday, August 21, 2016 was probably significant in that it highlighted the extent of the opioid epidemic in the US.
On Tuesday and Wednesday of that week, there were over 60 overdose cases in Cincinnati alone. In 2 counties in southern Indiana, there were 14 overdose cases between Tuesday night and Wednesday morning. In Mount Sterling in Kentucky, a city of about 7000, there were 12 overdoses on Wednesday alone!
Drug overdoses are up significantly in the US and 60% of them are due to opioids. It is estimated that there are about 16 000 opioid overdose cases a year now. So how did we get here? How did the US come to occupy the non-enviable position of the world’s largest consumer of opioids and opioid deaths?
To understand that, one has to understand what opioids are.

These are natural occurring drugs derived from opium, like morphine, that work on the opioid receptors in the body to relieve pain or synthetic ones like oxycontin and fentanyl that do the same. Now another kind of opioid, heroin, derived from morphine, has been used purely for recreation for a while but it’s recently become the replacement drug for addicts who cannot get their hands on the synthetic ones like oxycontin. More about that later.
Before the 1990s, doctors used opioids rather sparingly. One can say that pain was undertreated. Narcotics were mainly given to cancer patients. Then in 1980, Hershel Jick published a study claiming that the use of narcotics in 11,882 in-patients led to only 4 cases of addiction. Six years later, Portenoy published his study looking at the use narcotics in non-cancer patients. He claimed that there were no adverse effects. He studied 38 patients! He based his claims on 38 patients!
Even though both studies were highly flawed, they dramatically changed medical thinking and then practice. Portenoy formed the American Pain Society and preached that the risk for opioid addiction was less than 1% – a number he would later confess that he grabbed out of thin air!
The society came up with “Pain as a 5th vital sign” slogan and it caught on.

Into this fray, jumped Purdue Pharma. It launched Oxycontin in 1996. With aggressive marketing, the company promoted this new drug and got all on board.
The Joint Commission got behind the “Pain is the 5th vital sign” movement and the 0 to 10 pain scale with smiley and “wincey” faces was born. By 2004, doctors who undertreated pain faced sanctions. Opioids were being prescribed to all, even outpatients. Later Endo Pharma and Johnson & Johnson would join the opioid party with their own portfolio of synthetic opioids.
Purdue Pharma claimed that oxycontin was a slow-release formulation and would never lead to addiction. Well, we know better now. They had to pay $635 million in fines in 2007 for misbranding and reformulate the dug but by then it was too late.
By 2012, sales of opioids were more than $9 billion a year and in 2013, opioid overdose surpassed car accidents as the number one cause of accidental death.
To combat the indiscriminate prescription of opioids, several states like Kentucky, have enacted laws in the last 2 years that have made prescription of these drugs more onerous. Overnight, all the pill mills which churned out prescriptions for opioids vanished. The poor addicted patients had to find the next best replacement.

Enter heroin!
To make things worse, dealers are now lacing the heroin with illegal fentanyl that is formulated with raw materials from China.
To get how dangerous this combination is, follow me here. The standard opioid for comparison is morphine. Let’s give that a potency of 1. Heroin is about 4-times as potent and Fentanyl 75 – 125-times as potent. Now combine heroin and fentanyl!
So the intricate web of opioids and addiction was woven by Big Pharma and the medical profession around the issue of pain. Pain. Let’s define it:
“A distressing feeling caused by intense or damaging stimuli”, like cutting yourself with a knife or breaking an ankle. It was designed by the body to tell us something is wrong and to find a fix.
Pain is further broken down into acute and chronic pain.
Acute pain is what I described earlier. It comes on fast and is usually from an injury. it is treatable and goes away in days or even in a few months.
Chronic pain is a different animal. It is it’s own disease state because there is really no one reason for it. It is intractable pain that exists for three or more months and does not resolve in response to treatment. It is affected by physical, environmental and even psychological factors. Now acute pain can turn chronic if not treated well.
Opioids should classically be used to treat really bad acute pain like surgical pain, burns and trauma. It should be tapered off and other modalities of pain management used. Opioids should not be used for chronic pain, where there is no end in sight. The only group of patients with chronic pain who should be on long-term opioids should be cancer patients. That unfortunately did not happen and we are in this mess.

A way out might be the use of marijuana. In 2014, Bachhuber et al published a study in JAMA that showed a drop of 25% in opioid deaths in the 3 states where marijuana use is legal. Another paper by Powell’s group supported this. It showed that medical marijuana dispensaries were associated with a 16 percent (and possibly as high as a 31 percent) decrease in opioid overdose deaths. Lastly a study from this past July shows that doctors in states with medical marijuana laws wrote fewer opioid prescriptions.
The use of marijuana for pain might be due to it’s effect of cannabinoid receptors in the brain that modulate pain perception and it’s effect on sodium channels that play a role in pain genesis.

Like the needle-exchange program that was initially frowned on by many, it might be the only way out of this opioid quagmire.
Hopefully we as physicians will learn from this to base clinical decision-making on sound science and resist the aggressive marketing of the pharma industry.

“No disorders have employed so many quacks, as those that have no cure; and no sciences have exercised so many quills, as those that have no certainty”.
– Charles Caleb Colton

The placebo effect is a powerful thing. The belief that a substance can alleviate an ill has the power to do just that in about 30% of the population. The more benign the ailment e.g. aches and pains, cold, the easier is this effect. Things get a little tougher when an ailment is more complex in nature. Throughout the years, there have been men and women who have exploited the placebo effect to sell “snake oil” to unsuspecting patients. Sometimes, they have been able to sell their worthless products sans even a placebo effect – all they needed was the force of their nature and the glibness of their tongue.

The original snake-oil salesman was Charles Stanley. In the 1900s, Clark Stanley was known for his snake-oil. He claimed his concoction was a blend of snake-oils and that the recipe was from an old Indian medicine man. He would draw crowds to his rattlesnakes-killing sessions, where he would then sell his snake oil for 50 cents a bottle (about $10 today). He claimed it could cure toothaches, ankle sprains, neuralgias and most other ailments. In 1917, the Feds seized a shipment of the snake oil and analyzed it. Well, they found it contained 99 percent mineral oil and 1 percent beef fat, with traces of red pepper and some turpentine to give it a medicinal smell. His business was shut down.
My favorite quack of all time was John R. Brinkley – a man who never went to medical school but somehow managed to buy a medical degree. One day, he observed two goats mating and marveled at the sexual prowess of the ram. He then came up with a theory – if one transplanted the testes of the ram into the human scrotum, the patient will acquire the sexual prowess of the ram. What? Well, he opened his first goat-testes-transplant clinic in 1918. Forget that he wasn’t a doctor, knew no good surgical or sterile techniques. Forget that the idea was stupid and ridiculous. Well, he was inundated with patients, opened more clinics all over the country and made millions. Later he touted the transplant as a cure for almost every ailment. His first patient even got his wife pregnant. He advertised on the radio. He entered politics. Finally in 1938, he was sued for malpractice, lost and later died in 1942 a pauper.

These days, with FDA oversight being the way it is, such concoctions and ridiculous procedures are tough to sell without approval. There are still lots of quacks in the world of alternative medical treatments, supplements and diagnostic devices. One of them is Elizabeth Holmes.
In 2003, at the age of 19, she dropped out of Stanford’s chemical engineering program. She had the nugget of an idea and she planned to use this idea to change the world. The idea was to build a machine that could use tiny drops of blood from pricking a finger to run blood test instead off the ‘gallons’ that those ‘draculic’ phlebotomist draw. She founded a company initially named “Real-Time Cures”. In February 2005, she bagged $5.8 million from a venture capitalist and another $9.9 million year later. She changed the company’s name to “Theranos”, an amalgam of “therapeutics” and “diagnostics”.
By the summer of 2014, she had raised $400 million and the company Theranos was valued at $9 billion. Since she owed 50% of the company, as of the of summer 2015, at the age of 31, she had a net worth of $4.5 billion! She also had her machine named “Edison”.
There was only a small problem with this Ms Holmes’ idea – it was not scientifically viable but her investors did not seem to know or care. Since she founded the company, she had refused to either discuss her ideas with anyone in the medical community or publish any papers on work done based on this idea or tests with the Edison device. In the medical community, there were great doubts about her work.
Outside this community though, Ms Holmes was being feted as the next big thing. She received one honor after the next. Her speaking engagements ranged form TED Talks to lectures at Harvard. She adorned the covers of Fortune, Forbes, and Inc. and others. She was profiled in The New Yorker. The Board of Theranos had people like Henry Kissinger, George Schultz and Bill Frist as directors. She was going to revamp how testing was done. She was going to build devices that could test for hundreds of diseases from a same sample of blood. The sky was the limit.
When she was asked about the technology and science behind her Edison blood-testing machine for the 2014 New Yorker article, this is what she said:
“A chemistry is performed so that a chemical reaction occurs and generates a signal from the chemical interaction with the sample, which is translated into a result, which is then reviewed by certified laboratory personnel.”
This got the attention of the veteran Wall Street Journal reporter, John Carreyrou. He started investigating the company. On October 16, 2015, the Journal published the article:
“HOT STARTUP THERANOS HAS STRUGGLED WITH ITS BLOOD-TEST TECHNOLOGY.”
It was the first in a series of articles that blew the lid off the scam. He found the Edison did not work so Theranos used the blood-testing machines made by Siemens and other medical device companies for it’s tests. The tests that were done with the Theranos machines in clinics that they had opened in Arizona had results that were way off. Incidentally, the FDA and
Centers for Medicare and Medicaid Service (CMS) were investigating Theranos around the same time. Earlier this year, the hammer fell. Ms Holmes was been banned by the CMS from operating any lab services for 2 years. The Edison machine was been banned by the FDA. Walgreen pulled out of an agreement with Theranos to open blood testing centers. Ms Holmes is being investigated by the SEC and some lawsuits are in the wings. That $9 billion valuation now looks like a pipe dream.

The practice of all branches of medicine lends to it’s practitioners a certain aura of authority that is the envy of many. Some also erroneously see the profession as a way to fame and fortune. Thus, the profession attracts not only the best and the brightest but also charlatans. These quacks also bleed into the pharmaceutical and medical device industries and can cause as much harm there. We in the profession can only hope and pray that the mechanisms in place can weed out these snake-oil salesmen pitching bad medicine.

The number of myths about anesthesia out there never cease to impress me. Today, I really want to do some myth-busting because every now and then, these myths actually impact patient care and not positively.

1. Regardless of what you may have heard, anesthesia is not always to blame.
A few years ago, a colleague on call was contacted by an irate Obstetrician (OB) . A patient of the OB had developed a headache after delivery and he blamed it on the epidural she had received for labor. He needed her seen stat to fix the situation. My colleague saw her stat. There was a small problem – she never got a labor epidural or a labor anything from the anesthesia department. My colleague ordered a CT-Scan which showed a Sinus Venous thrombosis and that wasn’t caused by anything we did!
Anesthesia is blamed for almost anything that goes awry preoperatively. Think I’m kidding? Ask any OR nurse or surgeon. Even when a surgeon is late, anesthesia gets blamed for not realizing the surgeon will be late!
Anesthesia is surely not responsible for all preoperative complications and any surgeon who tells you otherwise needs to be tarred and feathered. In blaming anesthesia for all, patients are sometimes cheated out of knowing important history.
2. My doctor said I can never be put to sleep. He said if I need anesthesia, I should get a spinal.
If you are a doctor or nurse practitioner and you ever tell a patient this, may you lawn be invaded by giant dandelions every summer till 2092! Seriously! The result of this bad advice is that, the poor patient shows up for a craniotomy and insists on a spinal. Or needs a thoracotomy and wants only a spinal. If you ever tell a patient that, please come with him into the OR to do the spinal and manage the anesthetic.
Please leave anesthetic choices to people who actually provide anesthesia. Irrespective of how sick a patient might be, with the right anesthetic and monitoring, he or she might do just fine. Telling them they will only survive if they get a spinal makes our jobs harder as we have to spend valuable time trying to explain to the patient why you were wrong and we are right. Don’t do it!
3. Epidurals and Spinals paralyze people.
A study in the UK in 2009 showed a risk of 1:20000 – 50000 of getting serious neurologic injury from an epidural or spinal. It is rare. Not that it cannot happen but it is really rare. The very act of the needle entering your back has not paralyzed anyone yet. Now if a patient is on an anticoagulant and gets neuraxial anesthesia, the chances go way up since an epidural hematoma can result. For most patients though, in the hands of a good practitioner (like most procedures in medicine), the risk is really low. So stop listening to the your cousin Bubba who heard from Leroy that Dan’s wife got paralyzed from an “epidermal”.
4. It’s just a small case.
Dear Surgeon, it may be a small case but there is no small anesthetic. None. If anyone ever tells you otherwise, call the FBI. There is no small anesthetic. The minute a patient’s consciousness is altered, the airway is not as protected and hemodynamics may change. The same degree of vigilance is needed as in every other anesthetic. So repeat after me: “IT MAY BE A SMALLL CASE BUT THERE IS NO SMALL ANESTHETIC”.
5. I woke up during my colonoscopy so please make sure I don’t wake up during my colon resection.
For a colonoscopy, most patients are sedated whereas for a colon resection, almost all patients are under general anesthesia. Prior to the widespread use of propofol for colonoscopies, most patients were sedated for colonoscopies with versed and fentanyl. That combination got some patients through the procedure but for many, the combination was woefully inadequate and these patients never were totally comfortable. Hence, they remembered patches of the procedure. A general anesthesia on the other hand is a different animal. You are out. Anesthetized and paralyzed, often with a BIS monitor on to monitor for awareness.
So no, if you woke up during a colonoscopy, it does not count as having a history of awareness.

Above are a few of the many myths that dog us anesthesia providers daily. Even if this post helps to bust only one myth, that will be awesome. All anesthesia providers will be really grateful. Then as the quote goes by Raheel Farooq goes: “Misunderstanding is generally simpler than true understanding, and hence has more potential for popularity.”

Recently a patient asked me if being under general anesthesia was like being asleep. Well, the answer I gave him was not wholly true and for good reason. Let’s explore that.
There are three states of decreased arousal – a coma, sleep and general anesthesia.
A coma is a period of prolonged unconsciousness due to injury to the brain. A comatose patients typically lies still with eyes closed, unresponsive to physical stimuli. At the start of the comatose state, patients may withdraw from painful stimuli or even grimace but as the coma deepens, even these reactions may vanish. EEG (electroencephalogram) shows low frequency, high amplitude waves.
Sleep is a state of very decreased arousal that is controlled by centers in the hypothalamus, brain stem, and forebrain. It is necessary for a human’s well-being. Humans cycle between two phases of sleep – REM (rapid eye movement) sleep and NREM (non-rapid eye movement sleep).
REM sleep last about 90 -120 min and is characterized by dreaming, erections, inability to move and high frequency, low amplitude waveforms on EEG.
NREM sleep has three phases and has low frequency and high amplitude waves on EEG. Restfulness is achieved in this phase of sleep. There are parts there is muscle activity and parts where muscle activity is rather low.
Lastly is general anesthesia. This is a reversible drug-induced state of unconsciousness, amnesia, analgesia, and being motionless. EEG shows low-frequency high amplitude waves. There are four phases of general anesthesia – light, intermediate, deep and profound phases. Surgery is usually performed between the intermediate and deep phases. A profound phase is achieved for procedures where the brain needs to be protected or to stop intractable seizures. As anesthesia deepens, the waves on EEG go from a decrease in number and amplitude to a flatline in the profound state.
So which state is general anesthesia closer to?
You guessed right – a coma.
General anesthesia is a reversible drug-induced coma. The sites in the brain that seem to be affected in a coma are the sites most anesthetics work to effect unconsciousness. For example, propofol induces unconsciousness by it’s effects in the cortex, mid-brain, thalamus and brain-stem. These same areas have been noticed to be affected in comatose patients.
A patient in a coma does not react to pain, just like a patient under general anesthesia, at least when the depth is adequate. Under general anesthesia a limb can be amputated, the appendix removed or even a hip replaced. Now try that in a patient sleeping at night.
Sleep refreshes. General anesthesia does not. Now, pure propofol anesthesia seems to have that refreshing effect. It has been found that propofol can help recover from sleep deprivation.
Sleep also has cycles, something that general anesthesia and the comatose state do not have.
The changes seen on the EEG during sleep differ from those seen the comatose state and under general anesthesia.
So I guess it was understandable that I did not tell the patient the whole truth. Imagine being told before your anesthetic as a lay person that you were going to be placed in a coma! With the kind of patients we see, I bet more than half of them might flee. I’d rather they believe they are going to have a nice, long nap. Ignorance is at times truly bliss.