Saturday, May 26, 2012

Progressive Nature of Alcoholism and Addiction

In meetings of Alcoholics Anonymous people who relapse describe their descent into the abyss of addiction by saying "when I was in the rooms of AA, my disease was in the parking lot doing push ups."  Returning to the struggle with alcohol they went from the plan of 'drinking like a gentleman" or 'drinking like a lady" to the all consuming animalistic life of serving the god of the bottle.
Millions of people come to AA but don't stay, simply using the success of AA to initiate their recovery in some other form.  AA showed the world in the 1930's that Alcoholism and Addiction could be 'cured' through abstinence and 'one drunk helping another'.  The 'self help movement of 12 step programs with the essential spirituality of a 'god of your understanding' ie no longer making yourself and your own desire God but rather joining group and community for a consensus reality, has served countless others with compulsions of wide variety. The recognition was the Aristotelian idea that one couldn't 'think themselves into new action but rather needed to act themselves into new thinking".  The cognitive behavioural therapy of the 12 step program as opposed to the 12 step fellowship showed individuals through action that their belief in the benefits of alcohol were cognitive distortions induced by the insaniety of addiction.
Untreated alcoholism progressed to institutions or death.  Once a person passed a certain point the so called up elevator or down elevator place, the future was either a slow or fast descent depending on how one 'controlled' the drinking, all paths downward being at best 'harm reduction' .  The only cure to date in chemical addictions remains the abstinence which causes so many addicts to say "I don't like AA because......."  Those who themselves achieve abstinence by any means see the value of AA and don't disparage it. Those who don't achieve abstinence will likely condemn all programs which come between them and their drug of choice with the passion which most recognise when we say, "the lady protesteth too much."
A tenet of AA is that once an alcoholic, always an alcoholic.  This is certainly evidenced by scienttfic research which to date has not be able to identify those who won't relapse to previous levels and worse.  Vaillant's research showed that relative to the general population, an alcoholic 5 years sober was 'statistically' no greater risk of drinking dangerously than a person who never drank. This is important in the work place but on an individual basis no one sober knows if he or she could pick up a drink "safely".  A Montreal study of 'controlled drinking' showed that despite 5 years of abstinence of those who returned to drinking 50% within the year drank alcoholically.  I believe it was a Dutch study that showed that 30% of those 15 years abstinent returned to drinking alcoholically.
The research suggests that there is a decreasing risk after 3 years of abstinence of people returning to their previous behaviour but that the risk of this even at 15 years sobriety is that a third risk death or institutions for the sake of a drink.  The World Health Organization designates only 'abstinence' as a cure and requires all other programs be called 'harm reduction".  Further it recommends that 'harm reduction' programs only be used in the context of a stepping stone towards abstinence not as an 'end in themselves' .
This suggests that the insaniety itself persists.  People with simple 'allergies' don't decide I'll try taking something that once caused a horrible rash, again.  Yet people who broke out in police and divorces seem to somehow figure 15 years of good living later that picking up alcohol is again a good thing.
The progressive nature of alcoholism has been the principle reason for people explaining that with relapse a person returns to previous level of abuse much more quickly than the first time. People who drank 'normally' for 20 years then drank abusively for 2 abstain only to relapse and find themselves drinking abusively either immediately or a year or so later.
Personally I remember smoking an occasional pipe or cigar for 10 years before becoming a pack a day cigarette smoker for a year.  Quitting somking on 2 separate occasions with the intent of just having a weekend smoke or at most one or two a day I was back to smoking a pack a day within six months.  Quitting again then I found the next time at six months in the week before I quit I was smoking 2 packs a day, a truly exponential increase. It's almost 15 years since my last smoke and still I occasionally 'romanticize' an 'occasional' cigarette.
Functional MRI studies of gamblers have shown that the addiction is not driven by reward associated with the 'win' but rather by the 'dice' being in the air 'just before the 'decision' of 'win or lose'.  The 'thrill' for the brain is that moment of uncertainty.  Psychoanalytically the addict has been seen as having failure in primary relationships and seeking to re enact that 'moment of abandonment'. Melanie Klein described this as the 'good breast, bad breast' moment for the infant.  The infant wants food and the 'good breast' is the one that delivers it. The 'bad breast' is the breast that doesn't appear 'on time'. The longer the delay in a child having basic needs met, ie the period of neglect, the greater the division between the good breast and bad breast.'  This explains to some extent those who are at greater risk for addiction though to date no one appears to be immune to addiction. As one cocaine researcher said "some of us might not sell our grandmother's for crack in the first week of addiction but all of us would after a few years." Addiction itself causes reversible or permanent brain injury with increasingly loss of the more human motivational structures seen in Maslow's research with the devolution over time to the 'animal' and finally 'lizard' brain of the McLean triune brain model.
All research to date on persons who develop alcoholism or addiction shows them as being inherrently 'immature' psychologically especaily around the issue of  'gratification'.  Despite this the head of the Supreme Court of Canada's alcoholism was a serious concern for the high court only decades past.  No doubt some of the early work of Beverly McLaughlin, present supreme court head of Canada was undoing that 'wreckage of the past'.
The more 'instant' a substance has for providing 'gratification' the greater the risk of addiction. This is shown in the 'addictive' potential of crack which smoked or injected has greater addictive potential than coke which is 'snorted'.  The addictive potential of injected and inhaled substance is greater than that which is ingested. This is one of the distinctions which separate the marihaua or cannibis addict from those who want cannibis for 'medicinal' purposes. The addict must smoke the cannibis whereas the healing benefits of cannibis are equal and more medicinal if taken as a tea.  Those wanting it for medicinal purposes, a highly significant minority, despite the eupheminism of "medical marijuana' the precurser of 'medical prostitution', are therefore not those who insist it only 'works' for them if it is 'smoked'.
Following on this progressive disease of addiction it's been said that the sex addict who has made a life of orgies,   doesn't truly thereafter, want to hold just hands with a nun.
The brain of the addict is demonstrably changed on a whole range of neurochemical measures. Dopamine pathways associated with the nucleus accumbens, the pleasure centre of the brain, are changed and the change persists.  Frontal lobe utilization of sugars, the food of the brain, is altered on MRI studies for 3 months after the last use of cocaine.  Marijuana remains detectable and active in the system for 6 weeks and possibly 3 months.  Alcohol influence on the liver is detectable days and weeks later.  The minimum true test of abstinence and once a diagnostic test of addiction was the abstinence from a substance or behaviour for 4 seasons or one year.  If a person couldn't stop gambling despite negative consequences, or drinking despite dui's, this was pathognomic of inherrent addiction.  Marijuana smokers who say they can go a days or weeks without a 'toke' are akin to alcoholics or  who say they can go a few hours without a drink.
There is permanent organ damage with addiction as well.  Women are much more susceptible to the physical deterioration of addiction which is a kind of poisoning of the system physically and obviously spiritually.  Spirituality is likened to Freud's 'eros' or life drive as opposed to his 'thanatos' or death wish.  The dice in the air or really 'playing with death' seen in the 'adrenaline junkie' and 'compulsive risk taker'.
The definition of addiction is that it is unhealthy and hastens risk of death whereas a behaviour such as AA attendance, normal work or church or sports or any recreation moderately followed is by definition not an 'addiction'.  The term addiction is used for 'unhealthy' substances and endeavours.
The other factor which obviously plays a role in the apparent progressive nature of alocoholism is the aging of the host.  A person will drink to a steady state they may maintain at a younger age but this drinking behaviour is 'hard' on the 'body'.  When a person abstains or takes a break it's a bit like an athlete who leaves and returns to the sport.  The alcoholic now has an older liver, older lungs, and older brain.  Addiction is a burden at the best of times.  A common time for 'relapse' is with early retirement when one has means, loss of life  structure and there's just so much golf one can play. These executives who stopped drinking often 20 years earlier begin to drink excessively in their late 60's. Alcoholism is a principal cause then for the heart disease and illness and death seen specifically in this population.  It's not so much that the 'disease' is 'stronger' it's that the 'host' is older.
The neurochemical explanation for the apparent 'progressive' nature of the disease and the high risk of return to previous level then worse for addiction is that the addiction has established an information 'highway' in the brain.  Not using the highway results in the development of other 'tracks' for neurochemical communication. However the 'highway' remains and can quickly be brought back into use. Much like we say about learning to 'ride a bicycle' .  Once one 'learns to be a drunk or addict' it's like 'riding a bicycle', the learning is always there to return to and build on.
Further if the 'thrill' or 'adrenaline rush' is of the 'dice in the air' then the death wish of addiction is to go further than one's worst last drunk.  So if a person crashed a motorcycle drunk at 70 mph  and lived maybe this time one's unconscious wish would be to 'crash a motorcycle drunker at 80 mph" and see if one lives..
Certainly that's the picture that the sex addicts give in their simply 'pleasure' driven experience so well described in  the snuff movie 9mm starring Nicholas Cage.   Only increasing risk and degradation gives the same 'high' so more and more of a thing is sought in the ancient adage of heroin addiction when one is forever 'chasing the tail of the dragon.'
Thankfully abstinence resolves this issue if the alcoholic or addict can 'surrender' to the notion that this is not their 'war' and there are countless alternatives in life worthy of such intense endeavour.  Addicts and alcoholics not surprisingly when they change their focus from death resulting activities to life enhancing ones commonly go on to great contribution and amazing success and altruism.
 It's well recognised  today that one doesn't need to take the elevator to very bottom of society but rather can get off any at any basement floor.   That then can  become one's'personal bottom' and  the basis for the springboard into a life that has been called for may 'the 4th dimension'.  Peace, bliss,  joy, happiness,  love and meaning  are  far different from the frenzied withdrawal and driven  pleasure lust of addiction.

Wednesday, May 23, 2012

Methadone Maintenance Therapy - missed dosage

Because methadone requires time to build up in the system, if a person misses dosages they may need to return to a lower level. 
As a rule of thumb I've learned that if a person misses three days of methadone and is on 100 mg the dosage is halved, ie 50 and 25% added, roughly 70 mg.  If a person misses 4 days then they probably will have to start back at the 20 to 40 mg dosage that is used as a starting dosage. A person who has an unknown tolerance for methadone may be started at 15 to 25 mg a day to be safe. Overdose deaths have occurred with dosages as low at 50 mg in non tolerant individuals.  When one misses dosages for more they lose their tolerance for methadone.
Methadone routinely is increased by 5-10 mg a week, no more frequently than every 3-5 days.  Therefore a person missing dosages may have this set back where once again they have to build up to the most effective dosage for them.
The maximum dosages for starting a new person, which a person off methadone for 4 days essentially, becomes is 40 mg.

Prisoner's Dilemma

Prisoner's dilemna is a game that is used to study cooperative and non cooperative behaviour.  In the out come analysis there are 4 possibilities:
1) You win, I lose
2) You lose, I win
3) We lose
4) We win.

When I first studied this a quarter century ago I was struck by the finding that most people are unable to achieve the we win solution because they must forfeit the I win you loose option to achieve we win. Hence more commonly people end up in the 'we lose' scenario.

The game is described as follows:

Two men are arrested, but the police do not possess enough information for a conviction.
The men are separated.
Police offer both a similiar deal.
- if one testifies against the partner (defects/betrays) and the other remains silent (cooperates/assists), the betrayer goes free and the cooperator receives the full one year sentence.
If both remain silent, both are sentence to only one month in jail for a minor charge.
If each 'rats out' the other, each receives a thre month sentence.
Each prisoner must choose either to betray or remain silent; the decision of each is kept quiet.
What should they do?

Trolley Car Moral Dilemnas

One of the tools used to question morality and ethical behaviour is the trolley car thought experiment.

Imagine that a trolly car is headed down the tracks towards 5 people.
Imagine a bystander who can switch the trolly car from the path to another?
Imagine that the other tracks have only one person.

Is it morally required for the person to switch the trolley car to the second track?
Is it morally permitted for the person to switch the trolly car to the second track?
Is it morally prohibited for the person to switch the trolly car to the second track?

What if the bystander was himself standing on the second track alone?

Would it be permitted, required, or prohibitted to switch the trolly car to this second track now?

What if you could push a fat man in front of the trolly car and that would make the car safely switch from track one to track two, albeit killing the fat man?

The answers that you make to these questions defines to some degree the basis one uses for making decisions.

The Confession John Grisham

John Grisham is a captivating writer whose knowledge of law is impressive. His story of the condemned man on death row with all it's uncertainty and ambiguity is a trying story.  Falsely accused or not the drama unfolds with police and woods and race riots.  In the midst of this are governors and pr and media ratings. All the while a young man waits and a lawyer fights for his case.  Families huddle and sometimes cry. There's not much laughter in the serious business of life taking but that's just what Grisham in this novel is bringing forward to the reader's attention.  It's all about the death penalty.  Should the state be in this business and what about the mistakes in the justice system, or rather given all the mistakes in the justice system.  What is Christian and what is American and what is finally Texan? Who would have known that the cost of killing was greater than the cost of living? A good novel and very thought provoking read if only for the actions taken. There is little wonder why John Grisham is a New York Best Seller.

Mysteries of the Middle Ages Thomas Cahill

Mysteries of the Middle Ages and the Beginnings of the Modern World by Thomas Cahill is as much a joy to read as his previous works in this Hinges of History series. I was captivated by the first, "How the Irish Saved Civilization". The "Gifts of the Jews" and "Desire of the Everlasting Hills" were especially fascinating as a result of the most erudite research presented in a most appealling after dinner story way.  Thomas Cahill is a remarkable scholar but his real gift is as a story teller.  I loved reading most this time the extraordinary women of these times, the political giant and epoch maker, Eleanor, and Hildegaard of Bingen.  I actually think I can make sense of the various crusades thanks to this book and even more appreciate the art and architecture of the day.  Sometimes thought of as a dull time before the rennaissance Cahill makes it clear that the middle ages were anything but.  Thank you Thomas Cahill for taking me on another overland journey, as compared with your earlier work,  Sailing the Wine Dark Sea .

Cosmetic Green Karey Shinn

Karey Shinn's latest fashion production celebrates nature in dance and theatre on the anniversary of Rachel Carson's classic ecological work,  Silent Spring.  Karey's previous fashion works have included clothing for activists in extreme conditions..  Concerned about the far reaching effects of pesticides, she is ever  protecting the purity of the water supply. Her fashion is always 'wearable', allowing one to dance and run,  if only because she as a truly creative artist she knows  'one step ahead of the crowd makes you a leader whereas two steps ahead can make you a martyr."   Karey's show opened in Toronto   Moving forward from Andy Warhol she brings consciousness to the catwalk  When another Canadian Marshall McLuhan said the "medium is the message' obviously Karey was listening.  Cosmetic Green is eye candy for the heart and brain.

Use me, Sweet Jesus

Use me, Sweet Jesus
Help me to know the wonder of knowing you
As I go through this day that too often feels a burden
Because you are not on my mind ever and always
Help me to serve you in my dealings with people
Always remembering how you spoke to the thief on the cross
When you might otherwise be distracted
Use me, my eyes, my ears, my legs and hands
In this day, and all days,
Live in me that I might live in you
Awaken in me the sacred
And use me.

Monday, May 21, 2012

Burnaby Victoria Day journal

I'm here in my motorhome with Laura and Gilbert. We'd planned to go away hunting and fishing but because of a minor financial shortfall with taxes and high overhead I didn't feel up to spending money on travel. We'd planned to go to Clinton and frankly I didn't feel much like driving up the canyon towing the motorhome.  It's serious scarey business.  People die on roads.  Towing means all the concentration of driving my Harley without the sense of freedom. I feel like a water buffalo in the truck towing my RV whereas on the Harley I feel like a free spirited stallion.  I just have to concentrate a whole lot more.  The Mazda Miata is a gelding compared to the Harley but much more responsive to the touch and a joy to drive.  I don't have to worry about Gilbert beside me whereas when he's behind me on the Harley I always worry if he's okay.  Laura loves the Miata and the motorhome.
I love Burnaby.  Came here circa 1970 after the Strawberry Mountain Peace and Love Festival in the Colorado mountain.  True hippy ecological peace and love event where you had to back pack up the mountain and there was only acoustic guitars, gorgeous girls, tents and hugs. After that we hitchhiked to San Francisco wearing flowers in our hair, marching through the streets by the 10 thousands and dancing.
 Then we came to Vancouver for a European songfest. Thousands of voices singing of peace and unity.  Most had been written between the wars, after the War to end all Wars before Hitler then Stalin tore up the world with megalomaniacal dreams.  We were all afraid Vietnam was the beginning of WWIII and a nuclear holocaust.  Easy to think back now and see that things didn't turn out that way.  I like to think the peace movement had its influence on the industrial war complex.  Caused them to rethink war.  Okay to keep blowing up foreigners but had to figure out a way to kill less of one's own.  After Vietnam the world needed popular wars.
But Stalin had enslaved most of the world then and it wasn't even possible to think of the Berlin Wall just coming down.  Later that year we'd be in London with IRA bombings and all the talk would be about Carlos and terrorism. We never envisioned 9-11.  The terrorists just scared us and made us thankful for our own laws and order. Government by suicide bomber.  Later I'd learn all the ammunitions, studying physics and chemistry with an appreciation I'd not have had were I to stay in a suburb, go to a university and not ever encounter the Europe of the 70's when such skills seemed necessary as we all might have to fight terrorists with  their own tools.
I was raised by cowboys.  Long gone were the days of honor and men fighting one on one.  It was a dark world of shady deals and gangs on one.  No heros.  Just survival.
Burnaby at the time was the house of a family friend with all the loveliness of my mother's home. Quilting and embroidery and gardens and family and fine meals.  I loved the greenery outside the window. It rained the whole weekend that I recalled. But it was lovely rain.  Like the rain today.
There's something special about rain when all around there's grass and trees and bushes.  In Vancouver downtown the rain is an irritation because there's just concrete and parking lots. The city doesn't need bike lanes. It's needs boulevards and more sky trains.  I love Stanley Park but it's out of the way.  I don't get over there enough.  Maybe I should get an apartment off Denman so I can use the park. I did when my sailboart was moored near there in  Coal Harbour. Every day I'd walk around the lagoon. Stuart loved the walks in the park and I loved taking pictures of the ducks. The swans laid eggs that year.  The year before vandals had destroyed them. What kind of people destroy the eggs of swans.  It's always a reminder that port city hide trolls and psychopaths.  It's why Vancouver and New Westminister have so much drug traffic whereas Burnaby is relatively free of such sordid insaniety.
I've just come from swimming in the pool. Earlier today I walked Gilbert for an hour along the Brunette River.  Yesterday I spent hours researching medical legal topics, reviewing the literature regarding patients cases, trying to stay up to date this year, 2012, when only last month I read the report of a rich administrative doctor who'd not cracked a clinical text in 30 years or more by his recommendations, yet he was still practicing and telling others how to practice. It's all the rage to get MBA's instead of specialties.  Money is more important that learning yet I want my patients to get better and maybe there's something new I can learn. Always learning. Always driven to study and go to lectures, go to conferences, search the internet.  I miss working overseas when I could read for an afternoon and be available for the hospital at the same time. I was on so many physician discussion sites back then.
These days its hard to keep up again.  I feel behind and know it's at most only months.  There's no money in knowing the latest or doing the best.  All the riches go to the businessmen not the clinicians.  There's no bafflegab in the life and death questions.  And I realized that I haven't done what I set out to do when I entered medicine. I wanted to lazarus and be like Jesus, heal by touch and raise the dead.  Now I'm a cog in a wheel.  Anyone who actually questions the system is called a 'disruptive person'.  Anyone who wants to cure cancer really is called 'grandiose' and delusional. There's such negativity and heavy weight in the overly beaurocratized system of non believers and pay cheque seekers.
And I'm not much better. I'm older now.  I sometimes find myself working for weekends. After a year or two of being caught up with morons, psychopaths and criminals in the system I'm only happy seeing patients and trying to figure how to save just one.  What can I do for this person. Mostly it's just band aids now.  So little time, no resources and a deluge of sick and dying, the aging, like me.  Too many of the people I thought were heros too have retired and I don't know the young who are smarter into 9-5 and overtime.  I never was paid for over time.  Millions lost in service when she told me "it's just a job'.  The doctors call them clients today and even customers.  I gave my pound of flesh.
There's nothing in self righteousness or self pity.  Both are dirty urinals.  I have to raise my eyes.  Climb another mountain. My friend still does the Grouse Grind.  I wonder if my knee could do it. Its been several years since I could climb stairs without pain.  I always feel better in the desert. Loved being in Arizona and Texas.  The rain is beautiful today but it's hard on the joints.  Something about barometric pressure.  The joints love celebrex but the stomach doesn't
I'll go back to my book. It's about India and terrorists.  I just learned 70,000 Indians died in WWI and 9-13 was the Mumbai equivalent of 9-11.  Hundreds killed by terrorist bombers.  One character commented on the Pakistan Indian War.  Another talked about the War of Independence. They're trying to protect athletes in the games from terrorist bombs.  Canadians aren't described as good sports.  Helicopters and Chinese near Kashmir.   So many of my patients or their parents are immigrants. I read histories of the areas where they come from.  So many have been tortured or jailed, some from refugee camps, boys who sold themselves, a woman raped dozens of times by roaming gangs.  I see the soldiers who have nightmare about what they can't forget but would like to forget.
Just had some Murchies Golden Jubilee Tea - Queen E II 1952 to 2002.  Laura says her diamond jubilee is coming up.  Today is Victoria Day.  British empire and the queen who said, "we are not amused'.  I  listened to the CBC podcast Divine Blake and read some William Blake poetry after listening to Bob Smiley the hilarious Christian comedian.  We ate elk curry I made a couple of days ago and put away for a rainy day in the freezer. Laura's daughter just got some baby goats. We pray each day for the baby that is coming too.
God the rain is beautiful with all the green around. Thank you Lord for this day and for this life. Thank you for the challenge and prividge of medicine and healing.  Help me through another week and help me pay the taxes and not regret all the nights and days and weekends I worked for free.  Instead God make the monetary system a 'calling' and let them work for free for a change.  I'd rather that than think the materialists are all headed for hell and I'm going to be in heaven with saints and me a sinner knowing even Jesus supped with tax collectors while Paul was as much a beaurocrat as a tent maker.  Let me be less critical of groups and focus on the individuals who make Darwin's Awards so appealing to even Christians who otherwise have no use for such religion.
It's a short work week and I'm already worrying about all that needs to be done and how little time there is to do all that others say you must so they can be idle.  Lord let there be more Indians and fewer chiefs.
I talked to Dad today.  That was good too. Thank you Jesus for caring for him.  I read my brother's blog and enjoyed his pictures. Thank you for family Lord.   It was sunny there.  Dad was glad to hear of Gilbert and his always wanting to play ball.

Saturday, May 19, 2012

St. James Anglican Church - Mother's Day

Laura and I enjoyed church mother's day.  We'd once been in another church on mother's day and the minister hadn't even acknowledged the day. Laura and I both talk still of our mothers who have passed but still remain an influence on so much of our day to day life. I can't say I think often "What would Jesus do?" but I still find myself thinking "What would my mother say?"  As I've grown older this is more a positive thought than when I was much younger.
Rev. Robbins-Greenaway made it clear that we don't 'worship' Mary at St. James but it's equally clear that she is celebrated as the Mother of God.  It was fitting therefore that on this day Mother Alexis Saunders gave the sermon.. I was delighted after by the children being called forward for the blessing of the flowers for our lady.  I had to restrain Gilbert as he would gladly have run along with the little boys and girls as they streamed forward to the altar. This was followed by a procession to the intimate  blessed sacrament chapel behind the main altar.  Vandals had damaged the painting there of the annunciation which parisioners had taken upon themselves to restore.  Together we prayed there before the concluding of the service.
As usual leaving the church the light was brighter and I felt freer.  Gilbert was glad to get out so he could pee on more trees. Together we drove to our favourite Sunny Cafe on Main for brunch, a new Christian week begun.

Ballet BC -Bliss

IMG 1132
Laura and I enjoyed the Ballet BC performance Bliss. It was a world premiere by Montreal Choreographer Jose Navas. It was a neo classical peice with Mozart music, girls on endless point and robust men making flying leaps across the stages.  So unique in it's mixture of old and new styles it was almost baroque.  True genius in conception with the dancers performing brilliantly.
It was still light out when we arrived.  I was surprised at the spring 'skin' with ladies no longer wearing stockings, sandals and bare legs for all. We looked a pale lot rain tanned by Vancouver winter and only now breaking out in light cottons and spring frocks.  We found it hard to leave the outdoor deck chairs  this Saturday night.  The Ballet BC has a loyal following with seats packed despite no doubt drawing tonight's crowd from barbecues and beeches.
This was a grand and timely season finale. I look forward to next year's offering already having my Ballet BC season tickets.  I can't imagine how anyone survives Vancouver winters without Ballet BC.  The dancers always lighten the darkness and celebrate the body electric.

Wednesday, May 16, 2012

Cipralex - Escitalopram

I've been prescribing Lundbeck Pharmaceutical's, Cipralex, (Escitalopram) since it first became available in the last few years.  Finally it's covered by our provincial formulary.
Prozac or fluoxetine, the first of the SSRI, Serotonin Specific Reuptake Inhibitors,  was truly a break through in pharmaceutical therapeutics. Prior to it's introduction the tricyclics, such as Amitriptylline,  were all that was available. I remember the horrors of seeing acutely suicidal patients and beginning them on one of the tricyclics knowing that the medications had unpleasant side effects. They would have to be titrated upwards slowly because of toxicity and would take at least 6 weeks to become psychoactive. The tricyclics further had a narrow window of benefit versus danger. A small amount of medication, usually less than a week or twos supply was all that was necessary to cause cardiac arrest if taken as an overdose. If the patient didn't die they had to be admitted to an intensive care units for days to protect against lethal arrythmias.
Having faced all of those risks as a clinician I was thankful for the SSRI"s.  The first generation brought rapid onset of action, with patients experiencing benefits in as little as 2 weeks though the full benefits of the medication could still take 1-2 months.  The side effects were far less and each generation has resulted in a medication with fewer and fewer side effects.  Finally the risk of suicide by overdose is very little and much less with later generations of SSRI.
Cipralex is the latest of the SSRI generations. It's advantage over the previous SSRI"s is it's short action. Prozac could accumulated in the system because of it's long half life, half life being the length of time it took to remove half of a compound from the system.  Cipralex clears out of the system in a day or two. This is important in case there are any reactions to the medication by itself or in combination with others. In comparison consider that alcohol clears in less time and marijuana is psychoactive for 6 weeks or sometimes more.
The second generation of SSRI"s included two I found very useful and beneficial.  Zoloft or sertraline was specifically used for PTSD whereas Paxil or Paroxetine was an amazing anti anxiety medication for generalized anxiety disorders and panic attacks.  Zoloft continues to be used extensive as does Prozac.  The difficulty with paxil was that it was most likely to cause sexual side effects, delayed ejaculation, decreased desire and erectile failure in as many as 40 per cent of patients at higher dosages. This could be counteracted first with ginkgo biloba and secondly with viagra or cialis.
Trazadone anothe second generation SSRI still tends to be used more for an interesting side effect. It's extremely good for keeping people asleep so that it can be combined with most of the other antidepressants in those people who have difficulty with insomnia, a common sympton in depression.
Celexa , or citalopram, a third generation SSRI, was extremely useful in the elderly and in treatment of patients who had other medical conditions especially a history of myocardial infarction or cardiac concerns in general.  It was a surprisingly safe medication with a very 'clean' profile in its being least likely to interact negatively with medications used in other specialities. It commonly was beneficial for patients with major medical illness and post surgical depressions without having any signficant down side. Celexa is essentially the closest precurser of Cipralex.
Cipralex in contrast to Celexa, while retaining it's benefits, had specific superiority in the treatment of anxious depression, anxiety disorders with panic attacks and interestingly Obsessive Compulsive Disorder.
Clomipramine the tricyclic antidepressant was shown before Prozac to be almost essential to the treatment of OCD.  High dosage of medication was commonly needed too. Whereas a person with depression or general anxiety might benefit from 10 mg of prozac , the ocd patient would often need more than 60 mg to get the full benefit.  Cipralex appears almost equally beneficial for OCD but again at higher dosage that presently recommended.
Both Celexa and Cipralex have another interesting clinical significance. Of all the antidepressants I've used treating head injured patients, patient with traumatic brain injury it's been these two and wellbutrin or buproprion that my patients have literally sworn by.  I think it's interesting that these cipralex has benefit in brain injured patients and OCD because these are considered more 'biological' than what can be described as the more psychological depressions that tend to respond to a wide variety of therapies.  That the patients and their families see the benefit so significantly is what is most exciting.
Cipralex is a good antidepressant and really shines as a long term anti anxiety medication.  It's beneficial in TBI and in OCD. It's also beneficial in patients who have mood disorder but the diagnosis is Bipolar.  Because of the safety and cleaness of it's pharmaceutical proflie and relatively short half life it's also one of the safest medication that can be used with patients who use drugs or alcohol but may well not be open about this with the doctor. It's been well tried in a street clinic I work at with much benefit and no serious side effects of concern.  Safety is appreciated and the pharmaceutical companies are most concerned that their medications are safe simply because they pay the costs when things go wrong.
Prozac is the only antidepressant that is said to be acceptable for the treatment of childhood depression in Canada.  The research on patients whose mother was on an SSRI when they were intrauterine is now in 30 year follow up with one of the safest profiles in the history of pharmaceutical treatment.
Depression is a life threatening disease. Anxiety is a horror to live with. It's not just something that goes away. OCD is wholly disabling for some patients.  Suicide is a major cause of death and medications like Cipralex are truly beneficial adjuncts to the armentarium of ways we successfully and effectively treat cases mild to severe to save patients from hospitalization.
I thank Dr. Tsung, a colleague for 'picking my brain' and causing me to think of the thousands of prescriptions I've written over the years for SSRI and how I chose which medications. I do choose the latest medication which usually is the best in the way that the newest of cars incorporates the latest science and technology in those who have not responded or only had a partial response to previously available treatments. Further I will use the latest medication in those who are well off and can afford it and have moderate to severe symptons.  I was very thankful when cipralex became part of the formulary, which means it was available to all patients on disability or pensions or even welfare.  It's a recognition by the decision makers of the benefit of the medication and a testimony to the pharmaceutical company to bring in a new and very beneficial product at a price where most people can afford it and governments can see the benefit of providing coverage. It makes it that much easier for clinicians.

Tuesday, May 15, 2012

Third Day - Langley 1099IMG 1090
 I first heard the band Third Day at the West Coast Biker Church. I couldn't believe how much the music moved me.  It was the very best of rock and roll with as hard hitting a Christian a message as the drums and rythm section delivered the soul.  Mac Powell's voice  was simply pure and true to me.  I left the church on my Harley Davidson Roadster that night. Laura remembers me buying my first album within days at the first Christian music store I came across.
Next I'd be sailing across the Pacific Ocean with my friend Tom. We'd break the mast on my forty foot sailboat a thousand miles from land.  With a jury rigged mast  we continued our trip. At night in storms I'd be listening to Third Day's , "There's a Light at the End of the Tunnel".  When it was darkest and I was worrying most we'd not make it through in the wee hours, that song would come on and I'd know God was standing watch beside me.  We'd be okay.
When I returned I wrote a letter to the band, probably the only time I've done something like that, thanking them for helping me in through the dark night of the soul.
When I bought my Harley Davidson Electraglide I had a sound system that came with it. Of course I had all of Third Day's albums by now and was always listening to them as I roared along. There's a lot of scripture in these songs. I loved the Creed.  I loved the old time Blessed Assurance. I loved all their songs but most of all I loved "There's a light at the end of the tunnel."
Then I heard they were coming to the West coast on their Wave tour. I couldn't see any Canadian sites online but saw they'd be stopping in Washington.  Work and so much else took up my time so I simply forgot.
Then Ryan came in one day, and knowing I loved Third Day music,  said, "Third Day is coming to Langley".
It was three days before the concert.  I had my secretary book us tickets.  Laura and I had the ballet that night but  we changed that till Saturday.
Third Day was coming to Canada. That was something I wasn't going to mis..
I worked later than I expected. Laura was waiting. I drove my new Mazda Miata with the roof down and Third Day playing on the radio. There was construction and I confess I worried we'd not be there in time. But we were and I even had time to buy tshirts before my size sold out.  Then Laura and I both loved Trevor Morgan and Matt Maher. We got the three cd set with Third Day, Matt Maher and Trevor Morgan for $25.
I already had the Third Day, Move album so now had a second.  The Langley Events Centre was packed.
In person Third Day was  simply awesome   Laura loved them. "They're such beautiful people, inside and out."  I liked that their minister travelled with them. I like the message too.  Revival.  They came down onto the floor and played some acoustic numbers before returning to the main stage.
When they were finished we were all standing applauding,  though we'd mostly be standing all along.  They came back for the encore.
And that's when they sang "There's a light at the end of the tunnel."  I cry now to think of it. I was crying there hearing it.  A bit of serendipidity and whole lot of remembering those lonely nights on watch.
Later that night Laura and I  drove back to Vancouver  feeling good through and through.  The Third Day Wave album was  playing loud on the radio.
Thank you Jesus.
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Dr. Tamar Gendler and Open Learning Yale University

I downloaded the applications iTunesU for my iphone.  The selection of choices for the app in itunes was slim except for this truly remarkable presentation "Philosophy and Science of Human Nature" by philosopher Tamar Gendler.  Philosophy can be dry but Dr. Gendler enlivens it with present day relevance.  She uses the stories of Vietnam war politically decided 'point' soldier experiences to explore morality as discussed by Plato and Aristotle. She describes Milgram's experiments on decision making exploring the horrors of Nazi Germany with Aristotles learning of habits.  Happiness and pleasure are compared while in the midst of these discussions she gives delightful comments about her husband's experience at MIT, a bar mitzvah event or the education of her own children in comparison with the teaching of male philosophers who implicitly are not mothers.
For the last 2 weeks I've had the true pleasure of hearing a Dr. Gendler lecture each morning on the way to work in my car or returning home.
I am very thankful to Dr. Gendler for her erudition and exciting teaching capacity and itunes and Yale for enlivening my commute.  Thank you.

Saturday, May 12, 2012

Suboxone and Dr. Patrick Fay

Even the offer of a splendid dinner in one of Vancouver's finest restaurants, the Market, in the Shangri la Hotel, isn't likely to get me out for an evening of learning after a normal grueling 10 hour work day so common to Canadian physicians.  As an addiction psychiatrist having family physician, specialist, subspecialist and more subspecialist certification, and an even unhealthier proclivity for extensive self learning,  I am usually finding in my own practice that the rate limitting steps in health care management are the stupidity and hostility of overpaid, under educated,  beaurocratic thugs with position authority and purse strings.  My rich patients can get the health care they need here or overseas but increasingly those most in need are targetted alongside their care givers for chronic abuse.
That said, Dr. Patrick Fay of Orchard Treatment Centre is not only a leading authority in addiction medicine but one of the most respected clinicians I personally know. Having had the honour of treating patients who have known him I've had the privilege to hear of his empathy and compassion as a human from those patients  as well as see the genius in his medical management with patients who frankly were most unlikely to make it. Dr. Gary Horvath another leader in the treatment of opiate dependent patients encouraged me to come out if only to have the pleasure of bantering with my addiction medicine specialist colleagues,  Dr. David Tsung and Dr. Leszek Kalinowski.  In addition to these two racanteurs I was delighted to finally meet  Dr. (George) Djordges Kljacic, a most highly regarded clinician and the author of The Art and Wisdom of Healthy Living. Across the table I saw Allison, Olive and Sean, the administrative and counselling staff of Doc Side Medical Clinic,  also present.
Sarah Hardy, the representative of Reckitt Benckiser Pharmaceuticals was a surprise.  I thought she was a Vogue model and shocked to have her speak to me till my mind overrode my eyes and accepted that this must truly be one of those unfortunate women of brains whose beauty confuses the average male, not that I was such a human.  She welcomed me and immediately began talking science, mu receptors, k receptors and partial agonists till my mind  was spinning. When the waitress offered me a glass of wine I gladly took a cup of coffee instead.

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Dr. Patrick Fay's presentation on Suboxone was excellent, not just for the more academic overview of addiction and the place of buprenorphine in the treatment of opioid dependent patients but also for his extensive clinical experience.  Buprenorphone is the active opiate ingredient in Suboxone. Compared with the full agonist methadone which is also used for the treatment of opioid dependent patients, buprenophone is a partial agonist so has 'ceiling effect',  a decided limit to it's potential for abuse.  The genius of Suboxone is that it is coupled in a 4:1 ratio with Naloxone, the opioid antagonist.  Suboxone is taken sublingually which allows buprenorphine to be released without naloxone. However if it is injected the naloxone counteracts the effects, making the medication even safer from being abused IV.
Dr. Patrick Fay had excellent slides showing the 'disease' of addictiton. He distinguished addiction by the classic 3 'c's, loss of control, continuance despite negative consequence, and a compulsion to persist despite this. He briefly discussed the  MRI studies showing impairment in glucose utilization in the frontal lobes, associated with higher reasoning, and delaying gratification,  as well as discussing the impairment of the nuclear accumbens, the emotional reward centre of the brain. (
Where he shone though was in detailing carefully for us clinicians how he himself began patients on suboxone.  He described the use of the COWS, Clinical Opiate Withdrawal Scale (,
Then he went on to say that though the guidelines suggest a number of 10 before starting he himself tended to prefer a number of 12. He began by giving the patient 2 mg then tended to give 8 or even more mg through that first day. He saw the patient usually three times  that first day and told the patients they needed to have that day off and a friend available to be with them.  He admitted that headache was a side effect that he'd seen but in the large numbers of patients he'd treated he'd only had one  stop because of persisting headache. He'd also had to stop one patient from going onto buprenorphine maintenance because they developed a variety of odd pains. Withdrawal syndrome was the principal concern because buprenorphine has such strong affinity to the mu opioid receptor that it displaces other opiates. When transfering a methadone maintenance patient to suboxone he reduces the methadone to roughly 30 mg a day before making the switch.
He had used suboxone extensively in young people 18 to 25 and preferred to include the parents in the care if the patients were living at home.  He found that this family approach to addiction therapy resulted in even better results. While some of his patients have been switched in the detox and treatment facilities he has at the Orchard Treatment Centre on Bowen Island the majority of his patients have been started on suboxone in the community. He himself has a clinic where he does just this on Commercial Avenue in Vancouver.  As well as young people he found those who appeared to most benefit from suboxone were those who were snorting opioids, those using opioids such as morphine or oxycontins as opposed to heroin, and those whose methadone usage was under 100 mg a day. He said that there was a belief in the community that it was easier to get off buprenorphine but that he himself had found that it was still difficult for patients to stop that last 2 mg a day.  Suboxone maintenance patients were commonly able to take their medications weekly and were seen monthly relieving them the need of daily visits to a pharmacy for witnessed injestion.  He used suboxone for detox and for maintenance of patients with very good patient report and success long term.
Overall he found that he had the best results with patients who recognised that  addiction was more than just the drug abuse but that it affected, sometimes prominently while other times subtly, their thinking and relationships as well. Addiction specialist, Rabbi Dr. Twerski has written an superb book, called "Addictive Thinking",  detailing this essentially neurological disease process.   Follow up in groups such as AA, NA, Smart Recovery,  and Cognitive Behavioural Therapy  were all associated with better long term protection from relapse. He quoted Dr. Marc Gallanter's ( research on the efficacy of 12 step programs in long term recovery.
Dr. Fay concluded his presentation with his own complex case studies of patients who really were truly extraordinary for their successful long term recovery from what was clearly a life threatening illness with near death experiences.
Dr. Fay was very optimistic about suboxone and it's benefits but certainly didn't see it as a replacement for methadone. He was clear in the need to combine the right patient with the right treatment in what has traditionally been the most successful approach to all medical treatements to date. He was insistent that addiction patients be treated fairly and with the dignity that anyone suffering a chronic disease deserves.
His presentation was excellent and well worth the time.  To prescribe suboxone now in British Columbia the physician must already have been certified as a methadone prescribing doctor and in addition complete  online educational modules at  I did this when I worked in the United States and remember the process as reasonable and relatively straight forward. Sarah told me that it usually takes about 6 hours total.  There is now also public funding for suboxone for selected patients for whom methadone is contraindicated. is a great resource.  Dr. Patrick Fay's presentation was well worth the effort, even after a long day.

Canadian Author's Association - West Coast Branch Meeting - May 2012 and Arlene Prunkl

Author and President Robert Mackay opened the meeting only to have author Ben Nuttall Smith (Secrets Kept, Secret's Told)  announce that Bob's  novel, Soldier of the Horse, had won the North American Independent Publishers (Ippy) Gold medal for historical fiction. The following is from Bob's blog,


Soldier of the Horse Wins Gold Medal

I am very excited to report that "Soldier of the Horse" has won a gold medal in the military/wartime fiction category at the 2012 Independent Publisher Book (IPPY) Awards. The IPPY's are a North America-wide contest, with entries from all over the globe.
One of my aims in writing "Soldier" was to tell Canadians about the Canadian Cavalry Brigade, whose activities in the Great War are known to few. And--the gold medal will look good on any subsequent printings!

Then Bob announced me as the night's  poet.  Courage is not fearlessness but rather doing the next  right thing in spite of fear.  I took the stage and recited 4 poems from my book of poetry.  Hell's Angels had come by earlier and explained that as I too drove a Harley there was expectation that the audience would applaud suitably.    The poems  were "Acute Pain and Chronic Pain", "I've Been Burnt Out for So Long", "Sloth", and "My New Year".   This was followed by applause after which I paid those individuals I'd seeded the audience with in case the Hell's Angel help had met ethical resistance.

I was followed by the main speaker who I, being paranoid as usual, felt personally was chosen for this night by friends who having read my blog on occasion had noticed a significant editorial deficiency.  They may well have also heard me bemoan my missing the editor from the Medical Post who had on more than one occasion when I was writing for them more frequently, kept me out of jail, by his editorial suggestions.
Arlene Prunkl of Penultimate Editorial Services,, was a very pretty four eyes, slim, blond, articulate and intelligent.  An excellent speaker whose words indicated years of diplomatic training working with authors. She has editted hundreds of fiction and non fiction books.  With great tact she has avoided cement boots to date.
She began by saying, "I know these are your babies" and yet she went on to imply that babies often benefit from an editor's refinements.
The first part of her talk was "Seven Reasons Writers Need Editors".
"Perfection is impossible," she said, while admitting she herself was a perfectionist. Still, a writer needs "a professional set of eyes because writers are too close to their work."  She made a strong point of distinction between a professional editor and the former grade school or college English teacher, or the family member.  "Half of my authors have graduate degrees and some of them in English".
Having done some work in editting myself I so appreciated hearing her admit "editors have a gift or talent for 'hearing the work'' which certainly sums up why I know something  I read isn't right. What I was impressed with in Arlene was that in contrast to me she didn't say things like "any moron would know that's how it's supposed to be written, get your dunce cap on and sit in the corner."  She showed no evidence of rapid mood swings while reading bad writing and clearly had no history of chasing a poor "would be" writer with a knife on behalf of protecting the English language.  She was a picture of patience by comparison.
There was a lot of laughter from the audience when she said, "an editor will be passionate about their work and be perfectionist - not good traits in life, but good in an editor."
"Don't be afraid that your baby will be criticized."
"A good editor is an ally and wants to help you with the business of writing.'
She encouraged self publication but described what she meant by self publishing.
"Just because you're self publishing doesn't mean you can't be the best."
"As the publisher you contract out - decide which tasks you're best at - do those things, writing, and marketting for instance, or cover design, but hire a pro for those things you aren' those things you do best....hire someone to finesse the work, and best someone with years of experience."
She was all in favour of ebooks as they saved money on lay out, design and printing but she said that too often because of the errors of not having an editor, reviewers will see only the errors and jump on them.  "An editor is money well spent.'
"The cost is the greatest argument against editting but people rarely write bad reviews because of the cover art."
"Mistakes jar the reader out of the fictional world you have created, not just copywriting errors but plot and point of view errors. Point of view has deep subtleties editors can help a writer with to their and the reader's mutual benefit."
Given the cost of editting she offered the suggestion that writers, submitting work to publishers,  consider having their cover letter and first three chapters editted before sending them to publishers. This is what publishers would appreciate and is a likely way of avoiding one's work getting a quick passage to the dustbin
As her seventh point she explained that working with an editor was a means to becoming a better writer.  "It's like hundreds of dollars of personal education in writing - all the notes about your own work."  "All my writers have thanked me for what they have learned."
In questions from the audience she discussed the differences between editting non fiction and fiction, working with genres, poetry and writing for children.
She described how she used "Track Changes" in "Word" and how her work today is principally with digital copy though she has done some manuscripts for older people where it's been in paper.
In response to specific questions about cost she explained that she charged $45 an hour while the editting rate was usually $30 to $55.  She is a member of the professional editor societies in Canada and clearly there was merit in hiring those who were so accreditted if only in relation to the cost. She explained that professional editors decide their project cost always on "word count".  The usual policy is to have a 1000 pages of writing given to the editor who then reads it to decide the cost per work. "Everything depends on your writing and the quality of writing."  The better the quality of writing the less editting required, the faster the rate of reading which could vary per individual as much as 2 words an hour to 12 words an hour.  Then the number of pages is factored in, a thousand page novel costing decidedly more than a 100 page children's book. She described children's books as the least expensive to edit because they are commonly shorter works.
She adds another 10 to 15% to the over all cost for administrative time, discussion, research, etc.  "Most editors work out a project rate. Everything is about word count and quality'.
In the second part of her talk she focused on editting itself.
"95% of fiction is about character," she said.  "The Hero, the primary struggler, should revolve around a character flaw. This is then broken into mini struggles, each building to the next - there must be enough qualities in the characters for the reader to have empathy."
"Readers enjoy character driven novels, plot is important, but character drives. Make the characters more real and even give the villain some redeeming qualities of character where possible."
"Readers should have moments of recognition.'"
Arlene spoke in more depth about Point of View.  "Don't do head hopping in the same paragraph."
"Deep point of view allows a deep connection with the protagonist'.
Regarding plot she said, "Understand that plot isn't just a series of events. Plot is about a character with a problem often internal and emotional, having conflict, tension and struggle. Complications arise from the conflict. There is crisis, climax and resolution.
"Don't forget scene building.  A novel breaks down into parts, chapters and scenes.  Each chapter should have a mini plot and contain the same elements of 'problem, struggle, tension, crisis,and partial resolution.'  It's a method of writing that works and you want all the structural elements."
"Avoid poorly written or unnatural dialogue",
"Don't overuse dialogue tags".
"Use action sentences to assist dialogue."
"Beware of 'ly' adverbs.  Show don't tell. Showing always takes more words than telling.'
"Use contractions in dialogue. Contractions are used in speaking".
"All dialogue should advance the plot."
"Balance dialogue with plot".
"Don't back story dump - layer the back story through the overall work'.
"Don't info dump - don't tell the reader all you know about something in the next 10 pages."
"Exposition is exposing facts."
"Beware that narrative or narration can slow a story down.'
"One of the most common errors is not cutting to the chase....get to the inciting incident early....a reader shouldn't have to wait for the action to begin.  Get to the incident that started the protagonists change early'
"Another common writing error is 'weak and sagging middle sections".
"It is your job to engage the reader at every spot - are they showing character growth or advancing the plot".
"Too much plot and not enough character can be a problem too."  "I've read battle scenes that go on for so long I don't know whose sword is sticking who".
"Even in an action scene you can inject a paragraph showing what is going on in the protagonists head. Readers want to be in the head".
"Avoid predictability and cliches'.
"Beware of metaphors and similes. They should be original and should reflect the plot and character'.
"Don't have a lousy ending....especially one that just peters out....the conclusion should do more than a wrap up....not every lose end needs to be wrapped up but the ending must be satisfying."
In the following question time Arlene spoke to ethical editting, plagarisms and discussed the merits or lack there of  various on line 'self publishing' companies.
Concluding she received  a round of applause before being swarmed and tackled  by the audience members having a zillion questions about pros and cons of baby diapers and what suckies work best.
As so often happens on nights like these the evening ends.  Our parking meter was up and Gilbert was waiting for a pee walk back home.  I talked with Ben about the excellent sales of his historical novel Blood Feathers and Holy Men and his publisher Libros Libertad.  Ben has a book of poetry in the works so had some helpful insights to share on how best to go ahead with my most recent book of poetry. Poet Jean Kay, must have been roughed up bad by the bikers because she shared with me that she actually liked my poetry.  I've loved hers now for years and was delighted when I learned that she makes it a point to write a poem a day whether she needs to or not.  Marvellous discipline.
On the way home Laura 'opined' that she had learned so much from Arlene Prunkl. It really was a fine evening.


Thursday, May 10, 2012

Pathophysiology of Brain Injury and Dr. Cheryl Wellington

The University of British Columbia Department of Psychiatry hosts one of the best learning experiences in the city weekly. These are the Neuropsychiatry Rounds in the Deitweiller Pavillion.  They are telebroadcast around the city, province and even to other provinces given the demand for them.  I have attended many over the years with the utmost appreciation for the excellence of presentation and the integrity of the researchers.  Unfortunately being in private clinical practice, it often costs a couple of hours of time getting to the university through city traffic on Wednesday morning at 11 am when I have dual addiction medicine and psychiatry clinic obligations.
This week it was a must to hear Dr. Cheryl Wellington present on the Pathophysiology of Brain Injury.  She is a professor in the Department of Pathology and Laboratory Medicine at UBC, having done her phd in Microbiology there before doing her post graduate training at Harvard Medical School.  Dr. Wellington's research investigates lipid and lipoprotein metabolism in the brain and her group has made key contributions to the understanding of Alzheimer's Disease and Traumatic Brain Injury.
A dynamic presenter she began with an overview of the risk of the field, discussing clinical matters before honing into the underlying pathology.  "Traumatic Brain Injury is the leading cause of death in persons under 40 in the developed world," she said.  Motor Vehicle Accidents were the principal cause. In the elderly though falls became the principal cause instead.
Brain Injuries have been considered as mild, moderate and severe based on Glasgow Scores. However she quoted a colleague who questioned this nomenclature by saying, "Can you imagine us describing cancer as mild, moderate or severe.'  Certainly those who have had brain injuries and know their potential  devastation would appreciate that concern.  Dr. Cheryl Wellington demonstrated her sensitivity and empathy throughout her presentation something much appreciated from someone working principally in the academic laboratory research world. It was so apparent she appreciated patients as people first.
Much of her talk was focused on the Mild Traumatic Brain Injury which has a Glasgow score of 13 to15, often as not, normally according to this rather gross scale originally developed with an emphasis on the acutely severest of cases.
MTBI accounted for 80% of presentations and could be sub categorized as 'Concussive', "Subconcussive" and "Repetitive" as well as "Focal", "Diffuse"and "Mixed".
Discussing Concussions she emphasized the range of symptons that patients presented with including headaches and neck pain that didn't resolve', 'slowness in thinking', 'confusion', 'aggressiveness or irritability', and even olfactory and sensory deficits.
When brains of patients who have died after concussions have been studied they have showned 'Diffuse axonal damage".  Axons are the electrical chords of the brains neuroelectrochemical communication and storage system.  Synapses are like the 'connectors' in the system by comparison.
What has been of significance in the news recently has been the sports injuries and those athletes who have died especially by suicide after once being so celebrated for their performances. Now this concern has been directed specifically to children and adolescences where the risks and consequences of early concussions are being recognised as having more serious potential for long term negative consequence than previously understood.  Indeed Dr. Wellington's team are doing life saving research in this area of community concern.
The term for this specific condition has been "Chronic Traumatic Encephalopathy".  It was previously recognised in boxers who having had multiple knockouts in the ring developed a condition once term "Dementia pugilistica".
Chronic Traumatic Encephalopathy is the consequence of long term repeated trauma.  It's significant in that there is memory impairment, emotional lability, aggression and gait abnormalities. Indeed the picture suggests a process of dementia similiar in ways to Alzheimers coupled with a movement disorder in a way like Parkinson's.  There is this triad of cognitive, personality and movement pathology clinically.
Autopsies have shown the following structures are involved - cerebrum, medial temporal lobe, thalamus, mammillary bodies, and brainstem. The ventricles are dilated as well.
In CTE (Chronic Traumatic Encephalopathy) there is a pattern of tau pathology  and amyloid disorder that is distinct from Alzheimers. In alzheimers the distribution of tau and amyloid is distinct in that with CTE there is significantly more tau.   Further Perivascular tau pathololgy, suggesting vessel trauma, occurrs early. CTE pathology is more in the frontal and temporal lobes where as Alzheimer's begins in the entorrhins and spreads to the limbic system and later the cortex.
An amyloid precurser protein is increased after atonal damage and interstitial ab level correlatess with neurological status
Significant for clinical medicine is the recognition that edema is the major concern and that anything that helps clear away the debris will likely help recover. Thanks to the learning from pathology this is the direction that present clinical research is taking.
Dr. Cheryl Wellington went on to discuss bio markers and the potential for development of neuropsychological scales that might clinically measure the changes caused by tau post injury.  She had some very innovative ideas to share indeed.
To hear more about this we were all invited to the July 12, 2012 UBC Conference on "Pathophysiology of TBI".  She described the work of some of the world's leading researchers and contributors who would be coming to that conference and celebrated their achievements.  It will be worth it just to hear more from Dr. Wellington's and her group.  

Wednesday, May 9, 2012

Morality for Appearances and the Ring of Gyges

In Plato, Republic Book II, the Ring of Gyges is a mythical artefact that allows the wearer to be invisible.  With invisibility granted by this ringer the wearer acted in an immoral way.  This was an example for the argument that people act morality not for an intrinsic morality but rather the appearance of morality as it instrumentally served them.
Psychologist Daniel Batson of University of Kansas did a series of empirical studies showing that students would 80% of the time be self serving and rate their morality in such cases as 4 on a scale of 1-10.  However if they were allowed to flip a coin and then do a self serving deed, this appearance of being 'reasonable' ie flipping a coin, resulted still in them acting selfishly 80% of the time but because they had taken the time to flip a coin, even though they ignored the results, this resulted in them seeing themselves as acting reasonably and justly, and rating themselves 6-9 out of 10 on the scale.
If a simple action such as putting a mirror facing them on in another experiment putting a pair of eyes was introduced people act less selfishly and more fairly.  The evidence is that most people act morally out of fear of shame.
I'm interested in the 20% who indeed appear to act morally from some more deeply seated sense.
However this speaks to the need for transparency in the courts and certainly supports the idea of television cameras in the court room at least for the masses.  We do this in parliament and despite back room deals this openess probably promotes greater morality.

Monday, May 7, 2012

Stereotyping Lawyers, Beurocrats, Poor and Rich

I know a whole lot of really fine lawyers. They're friends, colleagues and teachers. Yet when I'm unhappy I sometimes actually blame my unhappiness on "lawyers'.  It's the same with women.  My mother is my greatest heroine. I've had women friends who are the finest people I've known. Most women I have known have been truly remarkable.  I hired a psychopath once. She happened to be female.  I knew a real scumbag and he happened to be a lawyer.  My friend growing up was Jewish and I've had so many Jewish friends in university and work.  One was a legitimate sociopath.  My First Nations friends are tremendous. We've hunted and fished and hung out together many a weekend. Yet I know a native man who is so lazy and complains all the time that no one will take care of him. I'm a Christian and yet I know some milk toast mealy mouthed Christians that literally give Christianity a bad name. I've a lot of immigrant friends and my grandfather was one of Canada's greatest immigrant yet I sometimes think I'm unhappy because the 'immigrants' are taking too much.  Same with the prisoners. I've known people who were unfairly imprisoned. I've worked in the jails myself and known 'there but for the Grace of God' go I but sometimes I think that the jails and prisoners are the reason I'm unhappy. It usually occurs that I'm thinking about some of these 'groups' as 'bad' when I don't feel I've got enough money for something I'm doing. Beaurocrats are another one of my bug bears.  When I'm down it's almost certain some beaurocrat is the problem. If it's not the beauorocrat then it's got to be the politicians.  Once it a while too it's the people on social assistance. If they weren't around I'd be doing better, for sure.  Otherwise it's the bankers though my own bankers are really fine people who I know and like and can't truly find fault with individually.  But it might be the rich then. However the truly rich people I know personally came by their wealth through hard work and intelligence and deserve the merits they've earned.  Generally it's administrators and overall usually any authority figure randomly picked on any day. It may as well be the weather man for all it's worth at times.
It seems that predjudice is tied in with 'self pity'.  Whenever I'm feeling self pity I like to blame it on someone.  Probably it's just because the sun isn't shining that day or I've got gas but I somehow like to link my discomfort with some external group in a kind of paranoid ecstatic revelation.  Aha, I say and of course it's these people.
The trouble is, it's rarely the folk I know. It's some 'thosepeople' as E.E. Cummings said.  The lawyers, politicians, beauocrats, women, immigrants, wealthy, poor, Christians or other, all are at fault even though this is logically impossible.
That's why in the end if it's not God it's the aliens that are undermining my personal existence.  And I have to tell you about it.  I have a clear argument in my journalistic brain that makes this clear.  Sometimes it's individually so true but when I speak in groups and 'thosepeople' I'm to be suspected. Not all Canadians are idiots at times like I am, just some of us. And the same goes for others too.

Sunday, May 6, 2012

Brunette River Walk - Birds

The wood ducks were in fine form. The Canada geese had goslings and the mallard ducks had ducklings. There were scaups.  Caribou Damn was just the way it was last year.  Looking very efficient and well cared for.  I think one bird whose picture I took was a Hermit Thrush. The brown headed cowbird was alone, it's mate having probably laid her eggs in a robbin's nest who was now raising cowbirds without knowing. The walk was well populated but not crowded. Others were walking their dogs too. It was great that cyclists were banned in Burnaby Park.  They've got downtown Vancouver to themselves now.    On the Rotarian Spit dogs weren't allowed so Laura kept Gilbert while I went on to take bird pictures.  That's where children were watching the dozens of goslings up close.  Lots of bird photographers were out.  Even the Squirrels were posing.  Everyone 's plummage looked good on this lovely sunny day in May..  DSC 0447DSC 0450DSC 0482DSC 0427DSC 0443DSC 0458DSC 0425DSC 0426DSC 0435DSC 0461DSC 0465DSC 0489DSC 0473DSC 0471DSC 0499DSC 0500

Burnaby Park - Spring Flowers

Laura, Gilbert and I enjoyed a wonderful walk along the Brunnette River looking at spring flowers and birds. I was staying at the Burnaby Cariboo RV Park a year ago and we reminisced about another perfect day like this a year ago. DSC 0515DSC 0415DSC 0517DSC 0408DSC 0509DSC 0424DSC 0420DSC 0421DSC 0414DSC 0413

100 Saints You Should Know

Kate Fodor's play, 100 Saints You Should Know, opened Friday night at Pacific Theatre.  Just a story of people's lives, three generations, about love and death, finding oneself and finding God, or meaning.  I was moved,  I was accompanied by three beautiful women and the two grandmothers nearly ran out of kleenex. Meanwhile I loved the humor.  The writing has a shining brilliance of wit and charm that so highlights the human condition in all it's awkwardness and panache.  I loved every moment of it, drawn into the story by the superb acting.  Rebecca Deboer, Katherine Gauthier, Chris Lam, Kerri Norris and Joel Sephanson.  Anthony F. Ingram was the director.  What a beautiful play done so well by beautiful people.

Friday, May 4, 2012

Lawyers, Doctors and Life and Death

It is possible to get a law degree on line or by mail order.  There is no limitation to the size of a class for lawyers.  The only limit to the classroom size is sound system.  Lawyers could be trained in stadiums and shopping malls. There is further no direct correlations between the well being and health of a community and number of lawyers.  Law is an arts degree, albeit applied arts.  .  
There are distinct limits to the number of doctors a community can produce because the process of learning medicine is hands on. It's a science and an art. Students must have A grades in both arts and science.  The learning of medicine involves dissecting bodies, touching abscesses and talking to dying people with contagious disease while worrying if you are getting the disease the dying person already has.  It's distinctly smelly and nauseating to be a doctor.
Lawyers avoid disease.  Their contact with disease is less that a check out girl's.
Doctors are trained in scientific reality.  There is gravity in their discussion.  Lawyers are trained in argument and are notorious for the 'emperor has new clothes'.  A good lawyer can convince you a serial pedophic murderer is not a bad guy and just didn't get enough cuddling and breast milk.
There is a surplus of lawyers and laws.  There is a shortage of doctors. There is a direct correlation between the health of a community and presence or absence of doctors.  Less than one doctor per 500 people there's a greater burden of disease in the community.
There is no correlation between lawyers and health and there is even further no correlation between lawyers and crime or justice in a community.
I like lawyers. I think they take amazing risks financially and rarely personally.
Who best to decide whether a person is dead.  Hands down a doctor.
Add a lawyer to the equation and there will be delay, increased cost and increased argument. Lawyers make the best critics and are by far the most litigious, political and argumentative.  Lawyers are wonderful where there are no limits on the overall costs of health care.  Lawyers are happiest to make the most money in any context.  They are even better where  time isn't  a factor (I was just in a court where the judge was trying a matter that had occurred over a decade ago when dinosaurs by scientific time sense had ruled the world).
Note, doctors live in a real world of biology and chemistry where seconds and nano seconds in decision making affect life and death. They're like the soldiers in the front lines whereas lawyers are more like the historians who discuss battlefields on Monday morning.
Right now in Ontario there is a tribunal for resolving death.  They leave it to doctors in most cases but now doctors have the burden of everyone looking over their shoulders so when they want  to they step in and discuss death.  It's a doctor, lawyer, layperson committee. I'm always suspicious of the lay persons. Who are these people and what political favour got them in these truly cudo positions.
If a person is dead a doctor wants to stop taking care of them. If there was no limit to resources and infinite funding for medical resources a lawyer would gladly maintain a dead person as they are like 'dead files' in the legal sense.  "Cold cases' in the police sense.  But doctors are devoted to the living and if anything would rather the dead cases be transfered as quickly as possible to the pathologist or mortuarian.
Is a person alive?  A doctor knows betters hands down over a lawyer.  To a lawyer life and death is more like the Monty Python joke about the 'Dead Parrot."  "It's a pretty parrot. Are you sure it's dead." "Yes, it's dead, you sold me a dead parrot."  "N o, it's just sleeping."
In all aspects of my medical care i make decisions about life and death.  I've done amputations and discarded dead babies and pronounced dozens of people dead.
Today a lawyer wants me to discuss these decisons with him.  For that to occur there needs to be another room in the hospital with a bed and 24 hour 7 day week call schedule and lawyers will have to be on call in the hospital even though they'd like to do 'call' from their homes over the phone maybe with skype or television camera.  "Yes, doctor, he looks dead to me over this android iphone . "  The cost of a parallel lawyer on call system will ensure that thousands of babies next year will die because there will not be a surgical unit as theres now another law office in the hospital. There already are law offices in the hospital and administration offices. There's just no room for doctors or patients.
Decisions happen when there's a dead person and doctors have to move the dead person out of the room to let in the live person. It's called triage.
CBC had a freak show sexist person on the radio this morning saying the days are gone when doctors make 'paternalistic' decisions.  What is this 'paternalistic" decisions business anyway.  A leading doctor in the American Civil War was a woman who pronounced dead thousands of soldiers. In 1930 30% of medical school classes were female. Half my class were female.  My teachers were female doctors.  I was called before the College of Physicians and Surgeons over the politically incorrect though clinically correct life saving care of a female child and was judged by 6 women doctors, not a man among them.  They were all extremely parental but not a single maternalistic one among them was paternalistic.  The judges are historically paternalistic but it's still truly frightening when the national  media has this level of sexism front and centre in Canada a supposedly civilized modern or post modern society.  CBC Freak show.
Yet the law would call me offensive if I were to speak disparagingly of the worst evils of maternalistic medical care as it endeavours to deny the dead life saving measures
To the best of my knowledge everyone wants to cherry pick. Right now that's what is happening in the life and death debate.  Doctors are doing it and doing it extremely well and have for centuries. Now lawyers want in on the action, not pro bono, but for a remarkable fee, and doctors would gladly include them. All I ask is that doctors be assured that they get paid equal to lawyers and given the same amount of time in the decision making process about life and death because last I looked the law was principally about money.
Medicine is about life and death.
That said I really admire all my lawyer colleagues who do work pro bono. They exist and are a grand bunch of men and women. Many in their profession frown on them as much as doctors are frowned on who by others standards 'give it away for free'.
All manner of folk don't want to believe their loved one is dead.  All manner of folk want miracles.  Everyone feels good as the gift giver.  No one likes to give bad news.  I confess I'm a little miffed to think that others want the cream and get in on the high profile and cherry picked cases and 'special cases' where they get to say "lets keep your loved one, dead as they may be, a while longer on the life support equipment that someone else is paying for."  I want to be a patient 'advocate'. That's what a doctor by definition was but now the word 'advocate' is restricted to the lawyer.  And soon there will need to be two lawyers because being of two minds about all things they always travel in pairs.
My friends are great lawyers and I love their company so I really appreciated hearing that US doctors are now having lawyers accompany them 24/7 like bodyguards. The amount of money I miss billing for in the public health system because I 'm so distracted by trying to keep people alive would likely pay for a similiar service.  The last hospital I worked at I used to coffee clutch every other day with the hospital lawyer.  But the hard decisions were always in the wee hours of the night when you needed a lawyer at your side to tell you what to do and then for that same lawyer to go to jail with you when you made the wrong decision.  I want someone to have my back and if it's going to double or triple or quadruple the cost of health care, so be it.
Every dead person, not just the pretty or rich ones, should have the same benefit and given an MRI or a lawyer I'm sure dead people would want the lawyer. They certainly don't care for another MRI after they're dead but lawyers who have comforted me in trying times could well comfort the dead.
Now the decision about life and death is going to the Supreme Court of Canada. This is the same group that is pro abortion and said babies were dead and could be killed even better when they were in fact alive. There's one lovely lady who was aborted and chucked in the waste only to live and go on today to give talks about life and death.  Everyone who decides life and death decisions should know her.
The Supreme Court of Canada are all lawyers.  The question is whether dead people need lawyers when we cut away the chaff and just as I saw doctors need lawyers and as lawyers go in pairs and hence need lawyers, the judges will likely say the dead need lawyers.
I am indeed looking forward to being asked by the Supreme Court of Canada to teach the new law students about death. I'm looking forward to showing them where to touch dead people, how neck vessels aren't often as useful as groin vessels for getting pulses. Further it's a particular smell that one needs to become intimitately aware of .So I want to take the lawyers and those lay persons out to smell floaters first. Then I'm going to go round the morgues and get the nostrils of lawyers really geared up for the more pungent death smells.  Gangrene is particularly memorable. Dissecting dead eyes so I gained a real appreciation of the dead gaze and would think dissecting dead people's eye should be part of the curriculum for sure.  I really enjoyed that. Studying the urine and feces and any genital discharge from the body was alwasy helpful.  I haven't noted genital discharge  so it's not been part of my observation but it's said to occur.  I've not needed it for decision making but using a stethescope and listening to chests and also know how to know when EKG machines are unplugged or malfunctioning was important.    I've found that looking at the  feces and urine and smelling sweat helped my decision. There's a whole lot more to the decision making too and frankly I've never met a lawyer to date who is certified qualified or capable of reliably knowing death. I further expect that my training of lawyers will require them to do at least one more year of law school to accomplish what is the bare minimum of knowledge about life and death in a scientific world.  I could teach a farmer a whole faster that a city slicker lawyer but that's a whole other kettle of fish.
I've not made a mistake yet pronouncing people dead.   All my dead have stayed dead but a few of my colleagues, those who worked more with the dead,  who were way better than me at telling death, had their pateints miraculously come a live.
I'd think therefore a religious leader and a lawyer should be present and trained in the decision making about life or death.  I'd be glad to do a year of life and death scientific training for religious leaders and extend their educational requirements in terms of cost and time as well. So now I've got a lawyer, a religious leader, and a lay person and because of that sexist CBC attitude I'd like some representatives from various gender groups.  Transexuals, homosexuals and lesbians shouldn't be excluded.  As well, a random assortment of cultural groups or perhaps the whole United Nations could be present. .  Finally I knew when my grandmother was dead as a child. Most likely by luck. But I've known children who knew things were alive which old folk didn't. So I'd say we should have a child making rounds everyday with me.  It's a committee then and government loves a committee because then no one is accountable and everyone can pass the buck.  Of course the expansion of hospitals will cost billions so that my entourage will be able to go from room to room in the hospital. Probably twenty or thirty lanes will reduce likelihood of foot traffic jams between wards.
But I'm a private person and when I die the last thing I'd want is a committee about.  At most I'd like a doctor and a family member and if I don't have a family member I'd take a friend, a religious leader or a lawyer.  Hell, a cowboy or fireman would be good too but then I'm not fussy.
What I really think is that we should all accept that we need a living will and when we go for our driver's lesson we should have a box to check off.  When you're dead do you want to be dead and stay dead or do you want to come back to life.  Only some of the people I resuscitated thanked me. The others hated me till they died.  I'd prefer the lawyers take the ones who hated me for resuscitating them while I'll be glad to continue to care for the ones who are grateful that I saved their lives.