Monday, April 02, 2007

The organ of Zuckerkandl, and cursing the darkness.

Hail,
And sitting at home having been sent home with some vague virally thing. I have spent half the day lying in bed whining at the cat and lacking the gumption to study, write or even play my stupid computer game*. I've been trying to read - actually, below is a list of the last however many good books I read.

Spook by Mary Roach
Stiff by Mary Roach
The Ice Museum by Johanna Kavenna
Tough Jews by Rich Cohen
Monkeyluv by Robert Sapolsky
Almost Like A Whale by Steve Jones

That's in between the fascinating excursions into the pharmacology of the genitourinary tract.

Anyway, will endeavour to write something interesting and then get on with study - today I am revising the cardiovascular drugs. Some of it is quite interesting - if your blood pressure goes way up out of control, we sometimes give you a drug called nitroprusside. That works, except as a side effect it forms cyanide in your blood. You can get rid of the cyanide by adding another chemical that normally poisons your haemoglobin, but combines with the cyanide to form a third chemical - it's all rather mind-blowing.

Plus I am one of these people who can't remember stuff unless I understand it, so when I read that a certain medication can cause, say, necrosis of the Organ of Zuckerkandl (a real organ, by the way) , I have to forcibly stop myself from wasting hours finding out why. Inflammation of the organ of Zuckerkandl, by the way, in the old days might have been called Zuckerkandlitis. Now it is the much less evocative para-aortic body inflammation or something.

Been thinking about that horrible Salon article, about various aspects of it. In the areas where I work I see a lot of medicated kids. The youngest was a six year old on olanzapine, which is a powerful antipsychotic with very significant side effects. He had been put on the medication by a specialist, a paediatric psychiatrist, and from one point of view I couldn't say it was the wrong thing to do. Both his parents had schizophrenia (they had met in one of the psych wards, a remarkably common occurence), and the child was certainly much quieter, less distressed and more docile on the medication than off it.

But there were a lot of questions. I don't know that anyone has done the long term studies where we see what antipsychotics do to the six-year old brain. I don't know that they've done the studies that show these things reduce the incidence of psychosis, or the risk of suicide, or the duration of hospitalisations. I don't know that anyone's ever looked at exactly how much obesity these kids get, how much cognitive slowing, how much sooner their diabetes comes on because of the medication.

And that's even with staying away from the diagnosis. Now, I'm not even the aglet on the shoelace of the boot of a paediatric psychiatrist, those people know stuff I don't even know I don't know, but it would seem to me that psychiatric illnesses in kids are difficult things to diagnose. Particularly schizophrenia, maybe less so for the mood disorders. It is difficult sometimes to disentangle the symptoms the patient has from the symptoms you suspect they have, for example, and children's ideas can be remarkably malleable - you can always find what you are looking for if you look forcefully enough. And bizarre beliefs? Intrusive thoughts? Auditory hallucinations?

I was going to give some examples here of weird things I thought and believed as a child, but I just realised that the conclusion "and there's nothing wrong with my mental state!" maybe wouldn't hold a lot of water. But my eldest son wanted to grow up to be a dinosaur.

And I know I'm in danger of the whole romanticising of the mentally ill here, but that's not what I'm trying to say. I'm trying to say that as doctors, we often make mistakes, and the giving of anti-psychotics to kids seems to me to be an area where horrible mistakes could easily be made.
In medical school we were taught that illness is a derangement of the normal functions of various organ systems. That's not the only way of looking at it. I've said before that an illness is whatever a drug company can sell a medication for: shyness, chubbyness, not having double D breasts, getting bored easily.

Well, from another point of view, the point of view that killed Rebecca Riley, illness is whatever society reckons doctors should treat.

I don't quite know how to articulate what I am trying to say. The actual receiving of treatment , the rx, changes the thing being treated. If something, some characteristic, is treated by a doctor there is the assumption that that characteristic is pathological, that that characteristic is not normal, that it is not, say, a quirk of your character or a flaw in your personality or one of the normal slings and arrows of not-actually-that-outrageous fortune that we have all been putting up with for millenia.

And if there is some advantage that will accrue to somebody by some characteristic being treated as a medical condition, then they will try to get that characteristic treated as a medical condition.

And doctors will do it, especially if there's money to be made. The Golden Rule kind of thing - whoever has the gold makes the rules.

And this is a controversial view, and one I haven't thought out, and one I am sure will strike several of my fellows as saying something deeply suspect about myself - but you can't have it both ways. You can't maintain the - I don't know, mana? - of being a doctor, you can't see yourself and have yourself seen as someone somehow involved in an intrinsically noble profession, you can't get whatever respect is left in the profession if all you do is make porn stars' breasts bigger, or sedate kids so their parents can spend more time in front of the telly, or whatever.

Medicine is meant to be about healing the sick. It's only medicine if that's what it does. Otherwise it's shilling.

Anyway, enough of this. Out to hang the washing (under the light of the autumn full moon) and get a grip on the anti-arrhythmics - very unfutile drugs we give when your heart is beating incorrectly that can cause your heart to beat incorrectly.

Thanks for listening,
John

*Civilisation II. Owes me months of my life.

4 Comments:

Blogger Midwife with a Knife said...

Have you tried Civ3 yet? Almost as addictive. One of these days, when I can afford it, I'm going to get a newer, better, faster computer that will allow me to play Civ4. My older brother has it, and I'm actually tempted to go on vacation to his house, just to play Civ4 while he works.

The other thing I am going to need to be able to play is the new game from the guy who created the Sims, called Spore ( http://www.spore.com/ )

So now you know, I'm a total dork with no real life who plays too many videogames. :P

Anyway, I do agree with the point of your post. If you're not practicing a version of medicine that alleviates suffering and treats disease, then you're not practicing medicine, you're doing something else.

10:08 PM  
Anonymous ozma said...

The story of that girl. I cannot stand to think about it. It is beyond tragic.

I have some family members who were on medication for learning disabilities. This has been criticized by many but they needed the medication: They could not learn without it. They learned what they needed to learn, advanced in school and one is now very successful (if still learning disabled in certain ways). They stopped the medication as they got older and more able to cope with their issues. If a mental illness cuts a child off from others emotionally and cognitively, this could be much worse than if it gives her diabetes--as unfortunate as that side effect would be.

One standard might be the capacity to learn, to interact and to move through developmental stages. If that is impaired by mental illness, then medication might be a lesser evil if it enhances that ability in some way. However, it is possible that medication would be a quick fix and might even hamper socialization and interaction.

2:01 PM  
Blogger Camilla said...

That story really got to me as well. How on earth does anyone diagnose something like bipolar disorder in a two year old??? How can that even be possible? Not denying the possibility of mental illness in the very young, but...I don't know, it just sounded to me like those kids got those diagnoses because their parents couldn't be bothered being decent parents and actually spending time on them. Argh, argh and more argh. And that poor little girl :(

Camilla

1:09 AM  
Blogger Foilwoman said...

Despite your video game addiction, I nomindated you for a Thinking Blogger Award. Because you are a thinking blogger who makes me think. Toodle-oo.

11:41 AM  

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