Update: The Ashley Treatment

I first talked about The Ashley Treatment back on January 5, 2007. Please check out that post for all the background details. The case took an interesting turn Tuesday. According to the Seattle Post-Intelligencer, the hospital was required to obtain a court order before performing surgery on Ashley.

According to a report released Tuesday by a non-profit advocacy group, Ashley's constitutional and common-law rights were violated when she underwent a hysterectomy as part of her treatment. Washington law requires a court order before sterilizing a developmentally disabled child.

The decision for treatment went before the hospital's board of ethics, which agreed with the decision, but recommended it be reviewed in court.

But an attorney told Ashley's parents in a letter they didn't need a court order for the hysterectomy, said Deborah Dorfman, director of legal advocacy for the Washington Protection and Advocacy System, which conducted the investigation.

Ah ha! I knew there would be some kind of legal angle to this story eventually. So, let me get this straight, after the parents of a child come to a treatment decision with their doctor or doctors, they must ask the state if it's ok? Ridiculous!

The hospital is now in a pretty political pickle now, and in the situation of reparing their damaged credibility, and appeasing their critics.

Children's has agreed to appoint a disability rights advocate to its ethics committee and bring in experts as needed to make decisions about medical care for people with disabilities. It will require a court order for growth-stunting procedures, when it involves a child with a developmental disability. The hospital will also give the Washington Protection and Advocacy System notice of any sterilization or other growth-limiting procedures on persons with disabilities so it can act as a watchdog.

Dorfman said the group won't seek legal action against the hospital, but the Washington Department of Health, which is in charge of licensing hospitals and physicians, is planning to investigate further to see what actions, if any, may be taken against the hospital or physicians, said Steven Saxe, director of facilities and services licensing for the department.

Even if this group won't take legal action, I predict that the political hacks out there across the country will be sharpening their knives and getting ready to dive into this case for political points. According to political calculations, it's still ok to go after doctors and hospitals.

Now, I want to clarify, I'm not defending this hospital. Especially from a legal sense, hospitals have the responsibility to make sure that all the details have been taken care of. Someone on the inside dropped the ball, and they should be given the necessary consequences.

However, from a media standpoint, this story will be energized (I can see this now with the hits on my site), and the hype will begin again for this family - That's the real tragedy here...

Transitions

I'm still in kind of a weird blogging place right now, so bear with me. The self-reflective posts continue (at least for now). I've been feeling like this since I've gotten back.

It's hard to describe where I'm at with things in general right now. I can't quite put into words, but I'll try. I just completed a long fourteen month project which culminated in last week's meeting.

I was on the planning committee, and I had a lot invested in this project - especially from an emotional standpoint. From a professional standpoint, I was kind of putting myself out there on a limb, since I was one of the key contacts/presenters for the meeting.

Being the "go-to" person on site has its ups and downs. While I got most of the complaints from the people that attended, I also received some compliments. I'm a detailed oriented person (imagine that), and there were nights where I couldn't sleep trying to anticipate all the problems of the next day.

When all was said and done, at the end of the last day, I did feel relieved that the entire thing was over. There were no disasters that occurred (at least from what I heard), and for the most part, people got a lot out of the meeting.

Now, I'm not perfect, and I believe I made some mistakes - or, at least, I felt that some things could have been done better. But, at some point during the meeting, I had to surrender and let go of the things that I could not control. I said my serenity prayer, and moved on.

Even when I attend meetings that I do not plan (just an attendee), I go through this "post-conference" let down. And, I guess that's where I'm at this week. Physically and emotionally, I feel drained - even to the point of not blogging how I usually do.

This week really has made me reflect a little bit. Being focused on the day-to-day tasks here at home really has made me forget about just letting my mind go free sometimes - and think about - just about anything. Is life really about completing tasks until you're too tired to stay awake? Probably not.

I begin a new fourteen month project next week. I will give it all of my heart and soul, as I do with all of the projects that I strongly believe in. I'll make my to-do lists and complete the tasks one by one until all of them are completed next summer.

Hopefully, I'll have more weeks like this where I'm not so focused - and maybe a little bit random and scattered. Changing the routine every once in a while is good for the body, mind, and spirit. I really believe that....

Grand Rounds

Grand Rounds 3.33 is now up and running at The Blog That Ate Manhattan. Because of my busy schedule last week, I wasn't able to write anything, and subsequently not able to contribute anything to the festivities this week.

I wouldn't say that there's a GR theme this week, like has happened in other weeks. TBTAM dedicated this week's Grand Rounds to a fallen blogger....

This week's grand rounds is dedicated to our favorite surgery registrar, Barbados Butterfly, whose blog was unceremoniously taken down not too long ago. I will not write here of the circumstances of her leaving the blogosphere, or posit the details thereof. I wish only to celebrate her as the quintessential medical blogger that she was.

Barb's blog was everything a medical blog is supposed to be - well-written, thoughtful, honest, educational, entertaining, heartwarming, humorous, heart wrenching and above all, real. I only hope that I occasionally achieve what Barb did with every post of her blog. She was (and is) the best. Barb, this one's for you.

If you don't know what Grand Rounds is, it is a weekly compilation of the best posts from the medical blogosphere that moves to different sites each week. And, who doesn't like reading about medicine and science?

The location of next week's Grand Rounds has not yet been revealed yet by the Grand Poobah of GR - Nick Genes. In the mean time, check out The Blog That Ate Manhattan - It's Grand Rounds!

The meeting escape

I was at a meeting last week, and that's why I wasn't posting anything. And, actually, I'll be a meeting next week as well. Forgive me if this post is kind of out of sorts. When you don't post for a few days, it's difficult for me to get back into things. And, I've been feeling a little self-reflective lately.

What is it about meetings that makes me think and reflect? Am I in such a rat race at home that I've forgotten how to open my mind? Am I so focused on the next task at home that I cannot see the big picture?

I also have to admit that my blog was causing me a little stress before I left. I was feeling the pressure to post - which I know is ridiculous, but that was where I was at. Absence does make the heart grow fonder (or however that saying goes). I knew blogging was calling me back today. So, here I am.

I have found that I really need to pace myself at meetings. Ten years ago, I could wake up early, go all day, go out to the bars until early in the morning, and then start again the next day.

Now? I have learned that sleep is very important at meetings, particularly if you're presenting a session. And, having one or two drinks the night before a presentation may not be the best choice.

Is anyone still reading this? If you are, thanks, because I'm just rambling. If for anything else, it was nice to get out of town for a few days and to think about something other than work.

I dreaded coming back home, but knew that it was necessary. The good news is that I'll be leaving town again at the end of this week. I haven't taken this much time off in a while. Sorry for the babbling. I'll try again tomorrow for a more cohesive post....

Grand Rounds

Grand Rounds 3.32 is now up and running at the Shrink Rap blog. Their theme is pretty simple: BYOB - Bring Your Own Brain. I love the above picture that they have accompanying their post. Thanks to the shrink rappers for including my post this week:

• Our friend, Dr Anonymous, posts The Baby Emilio Debate, about a 17-month old child who "has a rare genetic disorder which will eventually end his life. An ethical debate is taking place in Texas and around the country having to do with end of life issues and who has the final say in these issues."

If you just cannot get enough of Grand Rounds, there is even a podcast about it this week by My Three Shrinks. Thanks to MTS for including my little audio clip in their podcast (I'm at about 28 minutes). I definitely had a lot of fun making the clip.

I was all set to give them a huge congratulatory comment on all of their hard work. Unfortunately, they have the comment feature turned off for some reason. Anyway, great job with the 50 posts. Sheesh that was a lot! And, there were even two posts about ducks. Imagine that....

If you don't know what Grand Rounds is, it is a weekly compilation of the best posts from the medical blogosphere that moves to different sites each week. And, who doesn't like reading about medicine and science?

Next week, GR moves to The Blog That Ate Manhattan. Great posts recently over there about a road trip to Athens, Georgia including pictures and great storytelling. Check it out.

Stand up for chocolate

I've talked before on this blog about how the federal government is screwing up our lives. Now, they've went too far: They are messing with our chocolate. Chocoholics unite! We need to stop this!

What am I talking about? In Friday's Washington Post, there's an article called, "Chocolate Purists Alarmed by Proposal To Fudge Standards." Food standards are made by the Food and Drug Administration, and in "Appendix C," they stated the following, "use a vegetable fat in place of another vegetable fat named in the standard (e.g., cacao fat)."

Chocolate lovers read that as a direct assault on their palates. That's because the current FDA standard for chocolate says it must contain cacao fat -- a.k.a. cocoa butter -- and this proposal would make it possible to call something chocolate even if it had vegetable oil instead of that defining ingredient. Whoppers malted milk balls, for instance, do not have cocoa butter.

You mean to say that something can be called chocolate but actually not have any chocolate in it? That's ridiculuous. I'm shocked! I'm outraged! Not to worry, according to the Post article, there's already a grassroots campaign out there to stop this.

Chocolate purists, of which there are apparently many, have undertaken a grassroots letter-writing campaign to the FDA to inform the agency that such a change to the standards is just not okay with them. More than 225 comments to the petition have been processed so far by the agency, and chocolate bloggers are pressing for more. In the annals of bureaucratic Washington battles, this is a sweet one.

"If this puts a smile on people's faces even though it's a serious matter, that's what chocolate is meant to do," said California chocolate maker and traditionalist Gary Guittard, whose Web site, DontMessWithOurChocolate.com, has led the counterassault.

Jump on the bandwagon today! Forget global warming! THIS is the most important issue for our generation. HA! If chocolate is not sacred, then nothing is. Write the FDA; Write your congress member; Heck, tell Hillary, Barack, and Rudy. Stand up for chocolate - You'll be glad you did....

Post of the Day

I was pleasantly surprised to check my e-mail box to find this message:

Congratulations on your award on The Rising Blogger. It is a brand new site that awards posts, not blogs. Your post from April 24, 2007 "Asians: The New American Villian" won.

Since we award posts, not blogs, you might even win again. We ask winners to nominate a post favorite of a fellow blogger. Call it "paying it forward". It is not a requirement. You have won this award because we truly feel you deserve it. Great post, good job! Thanks, Judd Corizan

I read their opinion regarding my Post of the Day, and found it interesting. What I really found refreshing is that even though they disagreed with my opinion, they still awarded the post.

It is his conclusion that we disagree with, that since Imus was fired, so should they. We are not sure if you disagree with one firing that you should use it as a reason for another. But, as we said this post is a fantastic read. As an Asian American he speaks of the tragedy at Virginia Tech and the face of the murderer.

I definitely concede the point that justifying wrong behavior (the firing of Imus) with more wrong behavior (the firing of these radio personalities) is not the way to solve the problem. I appreciate their fair analysis of this and I am humbled by this award. Thanks so much! I encouage you to check out their blog. It's a great read.

Now, as the message says above, I should nominate a favorite post to "pay it forward." What a great idea! I'll definitely be on the look out next week. If any of you fellow blogaholics have suggestions on really good posts, send them my way, and I'll take a look at it. What I like, I'll send to Mr. Corizan. Get your best posts ready, because I'm coming to check them out!

A Nap to Remember

Out of all the reports I read on this story, Fox News has the best title, which is above. A Nap To Remember -- Good stuff....

Anyway, having a rough time remembering? Well, put down the ginkgo biloba and go to bed, would ya? Really? Yes, really. This is according to a study that will be presented at the American Academy of Neurology meeting next week in Boston.

The researchers -- who included Jeffrey Ellenbogen, MD, a neurologist and fellow in sleep research at Harvard Medical School -- studied 48 healthy adults aged 18 to 30.

The study subjects were split into four groups and they had to remember pairs of words that they just recently memorized. One group was tested at the end of the day. Another group was given the same test the next morning after they slept at home the night before. The group that slept at home had better scores.

"These results provide important insights into how the sleeping brain interacts with memories: It appears to strengthen them," he says. "Perhaps, then, sleep disorders might worsen memory problems seen in dementia."

Clinically, this is interesting in that they are trying to link dementia with sleep disorders. Maybe we have been treating memory loss the wrong way. Or, maybe sleep treatments can be used with current treatments for memory loss. Stay tuned for more developments on this.

Using my own anedotal evidence, I have definitely seen in myself difficulties with memory when I don't feel rested in the morning. Actually, my entire system is out of whack when I don't get enough rest. I know, it's not rocket science to figure that out.

But, getting enough rest, for me, is an ongoing challenge. Of course, late night blogging doesn't help. But, I guess it's better than looking up at the celing for hours on end trying to make myself sleep. What to do -- Hmmmmm..... Have a great weekend!

The Baby Emilio Debate

Emilio Gonzales is a 17 month old with a rare genetic disorder called Leigh's disease. According to WebMD and other sources I've read, this is a neurological disease in which the entire nervous system deteriorates with symptoms showing themselves as early as three months old.

There is no cure for Leigh's disease. As the disease progresses, all of the muscles in the body progressively get weaker, including the respiratory muscles. As breathing becomes more difficult, it requires being put on a ventilator to stay alive. This is the stage that Baby Emilio is at right now.

Who should decide whether to remove life sustaining treatment from this infant? The interesting key point about the Baby Emilio case is that the hospital, according to Texas state law, may withdraw life support if medical experts deem it inappropriate. This is even if the parent, in this case, Emilio's mother Catarina Gonzales, wants the treatment continued. (Cnn.com)

The case, and the Texas law, have divided medical ethicists. Art Caplan, an ethicist at the University of Pennsylvania, supports the Texas law giving the hospital the right to make life or death decisions even if the family disagrees. "There are occasions when family members just don't get it right," he said. "No parent should have the right to cause suffering to a kid in a futile situation."

But Dr. Lainie Ross, a pediatrician and medical ethicist at the University of Chicago, says she thinks Emilio's mother, not the doctors, should be able to decide whether Emilio's life is worth living. "Who am I to judge what's a good quality of life?" she said. "If this were my kid, I'd have pulled the ventilator months ago, but this isn't my kid."

The law, signed in 1999 by then-Gov. George W. Bush, gives Texas hospitals the authority to stop treatment if doctors say the treatment is "inappropriate" -- even if the family wants the medical care to continue. The statute was inspired by a growing debate in medical and legal communities over when to declare medical treatment futile.

Issues of medical ethics have always fascinated me. I wrote about The Ashley Treatment back in January, and up to now, that post has generated over 50 comments (that's huge for me) and continues to be one of my most viewed posts on a daily basis. I always feel weird quoting myself, but here's what I wrote back then....

Ethics always lags behind science. When that happens, the legal system and possibly even the government get involved. And, that's where things get ugly. Things get more political. The activists with political agendas get energized. I won't be surprised if this very issue is inserted into the 2008 US Presidental campaign - Remember Terri Schiavo and the end of life debate? Remember Michael J. Fox and the stem cell debate?

The government already got involved before Emilio Gonzales was even born. I certainly hope that the politicians and the activists on both sides will not get involved in this debate. Just to let you know, from the legal point of view, Baby Emilio's case is in the court system with the next hearing to take place in 12 days on May 8th.

Now, people are probably not going to be surprised by this, but I would have to agree with the hospital docs on this one. My disclaimer is that the only information I have is from news reports. Of course, I'm not there and I don't have any first hand knowledge of the medical portion of the case.

Here are questions to ask yourself as you sort out how you feel about The Baby Emilio Debate:

• When it comes to making medical decisions on stopping life support for young children and infants, who should have final say (hospitals or parents)?

• If there is no hope for recovery, how do you know how much suffering you're causing by the life sustaining treatments that are being done? How you know how much benefit you're gaining?

• How do you define quality of life?

• Emilio is on Medicaid, which means that the taxpayers of Texas are paying for his continued treatments. Should ability to pay be a factor in ethical debates like this one?

Drug Rep Rant Revisited

I took a lot of criticism from a number of different fronts following my post called Drug Rep Rant. Docs called me naive. Reps and former reps told me to get a life and be honest if I really wasn't interested in the product.

All good points. That post was written in a fit of emotion and non-logical thinking. I just love all the judgmental people out there who pretend to know all the answers and apply their utopian ideals to my little insignificant post. It was a snapshot in time and what I was feeling, and not necessarily what I usually do.

That being said, those who criticized me had some good points. The marketing tactics that are implemented are cold and calculated - at least according to an article from Reuters called, "Posing as pals, drug reps sway doctors' choices"

"Physicians underestimate their own vulnerability. They think they are smarter ... but they are not trained in recognizing this kind of manipulation," said Adriane Fugh-Berman, a Georgetown University Medical Center researcher and co-author of one of the studies.

"Reps scour a doctor's office for objects -- a tennis racquet, Russian novels, '70s rock music, fashion magazines, travel mementos or cultural or religious symbols -- that can be used to establish a personal connection with the doctor," Fugh-Berman and Ahari wrote.

These studies show what people have been telling me all along. Yes, drug reps have an influence and now there's the more data for people to prove their point. Ok, I get it.

"The remarkable thing is how effective a very brief visit by a drug representative -- most often less than five minutes -- can be in influencing physicians' choices to use a drug for an unapproved indication," Dr. Michael Steinman of the San Francisco Veterans Affairs Medical Center said in a statement.

Besides free drug samples, salespeople often bring gifts, lunch for the doctor or office staff, new pens and coffee mugs. "The doctor feels subtly, even subconsciously, indebted to the representative," Steinman said.

Maybe that's why more and more offices are banning reps from their offices. On one day here, there can be fifteen reps - maybe five from the same company spread throughout the day. That can be a lot of time that could be spent doing other things - like trying to tackle the endless paperwork on my desk.

What's the solution? I don't know. I'll think about it. I am feeling a little bit hungry after all this paperwork. What's for lunch today and who's bringing it?