Zombies Wanted, But Are They Dead or Alive?

One of my favorite lines in the Wizard of Oz goes like this:  “As Coroner I must aver, I thoroughly examined her, and she's not only merely dead, she's really most sincerely dead.”  It has a measure of decisiveness and finality. If someone is dead, we’d like assurances that they’re really and truly dead.

In order to determine the relative deadness of a person, there are two different criteria that may be used.  There’s the always popular clinically dead, the medical term for when the heart stops pumping and the lungs stop breathing. Then there’s brain dead, based on neurological criteria, that allows for a beating heart and working lungs (many times artificially maintained by a ventilator or respirator), but a nonfunctioning brain. Brain death determination looks at cessation of cerebral and brainstem functions and demonstration that the changes are irreversible.

Some definitions of death include all three markers, meaning death is defined as the cessation of all vital functions of the body including the heartbeat, brain activity (including the brain stem) and breathing.

And that makes me think of zombies.

Unfortunately, most definitions of zombies include some reference to the supernatural or witchcraft. The Centers for Disease Control Preparedness 101 Zombie Apocalypse home page states: “Although its meaning has changed slightly over the years, it refers to a human corpse mysteriously reanimated to serve the undead.” New theories support the notion that zombies are merely humans infected with a parasite that spreads through saliva. No matter what definition is chosen, a zombie is a human form that has lost the ability to reason and is no longer reliant on a heartbeat or breathing to survive. He or she retains the ability to move, but their movements are slow and awkward (unless one believes in zoombies).  Zombies have brain function, and that is the trait that causes most of us to fear the Zombocalypse.  Luckily their brain function is very limited. Enough for them to stagger around. Enough for them to capture people. Enough to remember that brains are their choice of food. Mobility, lack of brain function, and a hunger for brains is a terrifying combination.

But traditionally zombies are not considered alive or undead.  They are categorized as dead, and though they fit the criteria because of their lack of breathing and circulation, what about their brain function?

Dr. Steven C. Schlozman, an assistant profession of psychiatry at Harvard Medical School, postulates that zombies suffer from Ataxic Neurodegenerative Satiety Deficiency Syndrome or ANSD. He contends that zombie brains have some function, as well as dysfunction, in their cerebellar and basal ganglia. He likens the amount of brain function in zombies to that of a crocodile. Their unpleasant behaviors, including their insatiable appetites, derive from the lack of activity in the parts of the brain that modulate behavior.  But does this make them dead?

Since, at this point in time, medical technology has not created a need for zombie organ donation, devising new definitions of dead are not at the forefront of medical science. If, in the future, a method to safely use zombie organs is developed, I have no doubt that a new definition will arise and it will include the presence of limited brain function in the absence of respiration and circulation. The process will follow the same path to definition and acceptable use that occurred when human organ transplantation became viable. Prior to the need of organs, one definition of death, absence of heart beat and breathing, sufficed. After organ transplantation, a new definition of death, brain death, arose. When the need for zombie organs is great enough, medical science will become interested in ensuring that the answer to the question, are zombies dead or alive,  will become “really most sincerely dead.”

Interested in reading more about zombies? Check out:

http://www.cdc.gov/phpr/zombies.htm

http://io9.com/5286145/a-harvard-psychiatrist-explains-zombie-neurobiology

Defining Death

The first dead person I saw was my grandfather.  At first, I didn’t know he was dead. Lying on the hospital bed that filled the living room of his single wide, he looked the same. Cancer had turned him into an insubstantial man, gaunt and translucent. His eyes had sunk into his face and closed themselves off from the world. His mouth was open, like a baby bird begging for food, and his breathing ragged. Suddenly my sister gestured me to her side and said I think grandpa’s dead.  

I waited to hear him breathe, for his chest to rise, but nothing happened. I finally did the only thing I could think of, I went to the bathroom and found a small mirror. I carried it to his bedside, half hidden behind me, then held the mirror up to his mouth. No moisture appeared to indicate he was breathing.

We called the doctor. He came over to the house, briefly placed his stethoscope on my grandfather’s chest, and made the news official. He was dead. I remember the puzzled look on the doctor’s face when I asked, are you sure? You hardly listened. But he was sure. And I wondered what knowledge he had that I didn’t. How did my grandfather, who looked the same as he did when I first entered his house, go from live to dead with no fanfare and no striking change that signaled, dead guy here. Humans have no equivalent of a chicken’s pop up timer to show when their time is up.

The second dead person I saw was as a new nurse. At report I was told he didn’t have long to live. The wife was in the room with him and my job was to check in every once in a while, make sure they were comfortable, and give them privacy. Around two a.m. I went in and saw the man’s chest wasn’t rising. Walking quietly across the polished floor, I placed a stethoscope over his heart. I listened, and listened, and listened, but I couldn’t hear the reassuring thump of a heartbeat. Creeping silently back out of the room, I prayed the wife wouldn’t wake up and question me. I thought her spouse was dead, but I wasn’t 100% sure. Certainly not enough to break the news to anyone, let alone the wife. I found my preceptor and the two of us snuck back into the room. She placed her stethoscope on his chest and shook her head at me. He was dead. Back out into the hall we went and she coached me on how to wake the wife and break the news.

I remember shaking the wife softly, then harder, almost panicking wondering if she was dead, too, until she opened her eyes and peered at me in the dimly lit room. He’s dead, I told her.

I was ready for tears, for sounds of anguish, for cries to God. Instead she sat up, pulled her husband’s arm away from his body, and stuck her hand into his armpit. He’s still warm, she said, he hasn’t been dead very long. I didn’t know what to do with her reaction. Did it make a difference? Was it better to know right away rather than spending the night lying against a cold, dead corpse? Perhaps instead of a pop up timer, it would be preferable to have an actual timer that announced and marked the exact moment of death.

My third death was a lovely woman with heart failure and a host of other medical problems I have long forgotten. On the second day of her hospitalization, she decided she didn’t want any more heroic measures. She was ready to die.

Too bad death wasn’t ready for her. 

On the fourth day, struggling to breathe through the fluid that backed up into her lungs and slowly suffocated her, she looked in my eyes and said I never knew it would be so hard to die.

I wish I could say that at her death the pain and fear in her eyes was replaced with an expression of bliss, but the tortured look on her face never went away. The only change was the silence when the moist sound of her panicked breathing finally ended and her heart stopped.

All three deaths had something in common. Death was defined as the absence of a heartbeat. I don’t know if they continued to have thoughts or sensations. I don’t know if their soul leapt out of their bodies and went to wherever souls go when someone dies. All I knew was they no longer had a heartbeat. Therefore, they were dead.

Since then I've pondered the subject of declaring someone dead. For me, the bottom line is that I’m still the girl at my grandfather’s bedside asking the doctor, are you sure? As medical science develops different definitions of death in an effort to use the latest technology and interventions, I ask that question and find myself dissatisfied with the answer.

Name and date of birth please

A few months ago, I received a notice in the mail that a referral to a specialist had been generated in my name and my insurance company had authorized three visits. The letter was disturbing for two reasons:  the doctor that referred me wasn’t my primary care doctor (and never had been) and the diagnosis prompting the specialist visit wasn’t anything I had. My first, panicked thought was that someone was using my identity to get medical care.

When I called the clinic to follow up, I discovered it wasn’t a case of medical identity theft, rather poor patient identification. My account was pulled up in the electronic health record in error and the documentation and need for a referral belonged to someone else. I wondered how many people had been involved in this mistake, how much documentation was incorrectly entered in my medical chart, and why no one caught it prior to the letter being sent out. I mean, I had to be registered in the system in order for someone to bring me up in their schedule and I needed to have a note in my chart in order for the referral people and specialists to judge how quickly I needed to be seen. At one point in the process you’d think someone would have checked a name and date of birth, a simple task which could have resulted in the right patient getting the referral.

The current standard for identification of patients is to ask people to state their date of birth and full name at every stage of the process: when an appointment is booked, when the patient checks in, when the patient is put in a room, when the doctor sees the patient, and before any injections or treatment. A lot of work, right? But clearly, when the process isn’t followed, mistakes occur.  

In the world of electronic health records, multiple electronic charts can be open on a desktop at one time and it’s easy to err and document in the wrong one. Some of these errors are annoying, like my referral, some of them catastrophic, like the deaths of patients who received blood transfusions not meant for them.

How does this happen in a world where patient identification is mandated by accrediting agencies and where hospital inpatients wear identifying wristbands?  Wristbands can have incorrect information or fall off.  Hurried staff members may verify patient information by stating the patient’s name and date of birth and asking if it is correct. In looking at errors in patient identification, there are myriad ways in which people are misidentified in a busy work environment.  As a nurse, I’ve been in more than one situation where the patient in the room isn’t the patient I expected.

Even in patient simulation exercises (where healthcare workers are aware their actions are being filmed and scrutinized) patient identification errors persist. One study involved three simulated patients, two with patient identification data that matched the task paperwork and one that had a discrepancy in the date of birth and medical record between the patient identification data and the task paperwork. Thirty-nine percent of the healthcare workers performed the assigned task on the incorrectly identified, wrong patient (http://www.ncbi.nlm.nih.gov/pubmed/20031263.  It’s probably a safe bet that the percentage would be higher in the high pressure atmosphere of daily practice.

The solution?  There isn’t an easy one to this complex issue. Healthcare can’t force people to do their job correctly (at least they haven’t been able to so far). Electronic health records offer many benefits, but also more opportunity for error. Involving patients in their care is key, but anxiety, physical limitations such as dementia or hearing loss, and the persistent belief that “the doctor is always right” prevent many patients from asking questions about their medical treatment.

Instead of depending on an overburdened, mistake prone healthcare system to do the right thing, patients have to actively engage in keeping themselves safe. You’d argue with a mechanic who told you he planned to fix the brakes on your car when you came in for a new windshield wipers. Don’t be afraid to question the people who deliver your healthcare. It could save your life.

It isn't brain surgery

Daily life requires some attention to detail. When I drive my car, I’m expected to stay on the right side of the road. Doesn’t make a difference if I spent a month in Ireland driving on the wrong side or if the road isn’t clearly marked as to what side is the correct one. Once I get behind the wheel of a car I’m expected to follow this minimum expectation.  If not, well, best case scenario I’ll get a ticket, worst case a head on crash. Details do matter.

That’s why it’s puzzling that healthcare professionals have such a difficult time making sure they operate on the right side of someone. Cutting off the wrong leg, “fixing” the wrong hand, or operating on the wrong side of the brain is considered a “never” event by the Centers for Medicare and Medicaid Services (CMS) as in “this should never happen.”  Amazingly, a study published in the April 2006 issue of the journal Archives of Surgery estimates that wrong-side surgeries occur between 1,300 and 2,700 times a year in the United States (3-7 a day).

Horrified? You should be. The problem is not a new one.

A quick Google search shows in 1995 a Florida hospital had two cases of wrong side surgery. In one case the surgeon amputated the wrong leg, another surgeon operated on the wrong knee. In 1996 a surgeon removed the wrong kidney from a patient. In 2007 a California hospital performed three wrong side surgeries in the space of 14 months. In December 2010, a Boston hospital reported three wrong-site spinal surgeries in a two-month period.

Scary stuff.

You’d think a hospital would learn after the first never event and develop methods to ensure there isn’t a repeat. Wrong. In 2007 a Rhode Island Hospital reported three cases of wrong side brain surgery. If you expect the surgeons involved developed practices to prevent a repeat, you’d be wrong too. Rhode Island neurosurgeon J. Frederick Harrington had already performed a wrong-sided brain surgery in 2006 at another hospital. He repeated his mistake in 2007, even when someone in the operating room questioned whether he was on the right side.

Now, I’m not discounting the universally held, incorrect belief that “it won’t happen to me.” I am sure most surgeons and operating room personnel believe their superior skill, knowledge, and intelligence prevents them from making stupid mistakes. But after the first mistake, do they think lightning can’t strike twice?  No use changing the way things are done because it will never happen again? The statistics don’t support that notion.
Because this is an international problem, the World Health Organization (WHO) developed a surgical checklist, also known as a time out. A time for everyone in the operating room, including the patient, to agree on several key things, including the operative side. If properly followed, the checklist would catch errors before they happened and stop wrong site/side surgery for once and all. Unfortunately putting a policy in place, affixing some posters to the locker room, and filling out a checklist gives the illusion of patient safety, but the reality is, even in hospitals with the checklist and time out, wrong side surgery occurs.
Why? Studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout. Unfortunately, instead of expecting accountability from physicians, hospital strategies to prevent wrong side surgeries include assigning operating room monitors, installing video cameras, and telling the operating room nurse not to hand a knife to the surgeon until the time out is completed.  
Wouldn’t it be better if physicians complied because it is a minimum expectation that they operate on the right side of a patient? We can do it on the highway, it's worth the extra effort in the operating room.

Panhandling in Cyberspace

For a brief period during my teenage years, my family vacationed at Hampton Beach. After long, glorious days of lying on the beach, listening to the radio reminders to “turn before you burn,” and applying copious amounts of baby oil (yes, before anyone worried about skin cancer), my friends and I would spend our nights panhandling on the boardwalk.

The long promenade teemed with people on those hot summer nights. The smell of fried dough, saltwater taffy, and cigarette smoke filled the air. We’d move slowly through the crowd, searching for a place where we wouldn’t block the sidewalk traffic, where people naturally slowed down. Once settled, we’d smile at people as they passed, look them in the eye, and ask, “Do you have any spare change?”

 We didn’t need the money, not like the runaway teenagers or homeless men who lived on the fringes of our vacation experience. At the end of the night, we’d take our loot and give it away to the first person who asked us for spare change.  The thrill was in the boldness of asking strangers for cash, in looking people in the eye and asking the question.

Now there’s a new type of panhandler. One no longer has to fake cancer for handouts or stand on a street corner. Sites like gofundme.com and kickstarter.com provide a painless way to ask for cash. Got a book you want to self-publish? Why dip into your own savings account when you can put the touch on your cyber friends though Twitter. Want to spend a year in Europe? Saving money for your trip is a time-consuming drag when you can put out a plea to your Facebook friends to pay the cost.  The best part of cyberbegging is you don’t have to look anyone in the eye. Just hit send and wait for the bucks to flow in. Hey, we’re friends, aren’t we?

When I deal with real panhandlers, as opposed to virtual ones, I have choices. I can cross the street, avert my eyes, ignore them totally, or toss them a coin. Virtual beggars are harder to ignore. They send emails that evade my spam filter and clog up my social media feeds.  They use peer pressure in an attempt to pry cash out of my pocket and have an arsenal of guilt inducing tools at their disposal. Whether they list contributors on the site, giving everyone the opportunity to see who has, and hasn’t, ponied up, send personal emails, or use their Facebook or Twitter feed to individually thank those who have contributed and keep the begging project front and center (sort of like a panhandler that follows you down the street), it makes those who don’t contribute feel singled out.

But, what is the etiquette for those of us who don’t want to give? And what is the social cost for ignoring the beg? Do you owe someone an explanation for not contributing?

I say treat them like the panhandlers they are. Donate, tolerate it silently, or remove yourself from the situation. Remember we’ve opened our cyber doors to these people, we can shut the same door in their face.

Friends, if you want to beg, look me in the eyes and ask me once. I’ll appreciate your boldness.

Healthcare's Dirty Little Secret

Having a medical procedure should be safer than getting a tattoo.

My home state of New Hampshire was recently rocked by the news that 31 patients at a NH hospital had been infected with hepatitis while undergoing cardiac catheterization, an invasive procedure used to identify heart disease and defects. Specifically, they tested positive for Hepatitis C, a viral infection transmitted through blood that results in liver inflammation and can result in ongoing health issues. The threat of hepatitis transmission is used to discourage people from getting a tattoo or using intravenous drugs.  It’s not something that’s expected as a result of a hospital procedure. 

When I first heard this, I theorized the problem was due to inadequately sterilized equipment.   It’s no secret to those in healthcare that many invasive medical instruments are re-used and cleaned between patients.  Improper instrument cleaning was blamed in March 2009 when the Veterans Affair department confirmed that ten patients tested positive for hepatitis following colonoscopies. Even supposedly sterile, one-time use equipment has been implicated in disease transmission in the healthcare setting.  Infections from the use of urinary catheters, central lines, and mechanical ventilators occur with enough frequency that healthcare facilities enact policies and procedures designed to lessen the risk. In New Hampshire, hospitals self-report and post data on health care associated infections.  Yes, being the recipient of health care is a dangerous business. 

Though improper cleaning can be attributed to the pace of healthcare (decreased numbers of staff with less training and an increased workload) or financial constraints (doing things right costs money, doing them quickly, not so much), the cause of the Exeter Hospital hepatitis outbreak isn’t substandard cleaning,  rather it’s drug diversion. The theory being that a healthcare worker with an addiction to narcotics took the opportunity presented by multiuse vials and/or medication syringes that are filled but not given immediately, to inject a little for him or herself.  In the process, the infectged addict spread the hepatitis virus and now 31 people have a chronic liver disease.  This shouldn’t come as a huge surprise to anyone.  It’s not as if spreading disease through reused syringes and supplies is new. 

In 2009 at Rose Medical Center in Colorado at least 18 people contracted hepatitis when a drug addicted scrub tech switched out her used saline-filled syringes with drug-filled ones prepared for surgical patients.  An outpatient clinic radiology tech in Florida infected five patients while diverting fentanyl (a potent narcotic) for his/her own use.  Like any other crime, the ones who get caught are only the tip of the iceberg.

The Centers for Disease Control (CDC) report from 2008-2011 (http://www.cdc.gov/hepatitis/statistics/healthcareoutbreaktable.htm) attributes outbreaks of hepatitis at outpatient clinics to the use of contaminated syringes to re- enter single use and multi-dose vials, the use of single use vials for multiple patients, and drug diversion by healthcare workers infected with hepatitis.  Obviously in today’s healthcare environment the patient can’t depend on their healthcare worker doing the right thing (follow strict infection practices) or the facility doing the right thing (random drug testing, especially of hospital staff that handle medications in areas known to be associated with diversion).  Seems like the concept of do no harm doesn’t apply to hepatitis prevention. 

If the victims of Exeter Hospital went to the CDC FAQ on Hepatitis C they’d see their risk factor for contracting hepatitis as “sharing needles, syringes, or other equipment to inject drugs.”  Unfortunately, the victims didn’t make the choice to share, the healthcare worker did. The site also cautions: “A few major research studies have not shown Hepatitis C to be spread through licensed, commercial tattooing facilities. However, transmission of Hepatitis C (and other infectious diseases) is possible when poor infection-control practices are used during tattooing or piercing.”   

Perhaps it’s time to add “transmission of Hepatitis C (and other infectious disease) is possible when poor infection-control and drug control practices are used in hospitals and other healthcare settings.” 

Until healthcare deals with this dirty little problem, it may be safer to get a tattoo than a medical procedure.