Econstudentlog

Stuff (and a few personal remarks)

i. Yesterday I had a very bad and prolonged hypoglycemic episode which lasted hours. I was in a semi-conscious state for a long time before realizing there was a problem, and the situation did not improve much even after intake of significant amounts of dextrose. This is by far the closest I’ve been to a hospital admission for more than a year – I had both severe neurological symptoms and GI-tract involvement. I don’t think I’ve ever been admitted without GI-tract involvement, and this tends to worsen outcomes significantly – it’s hard to reverse a disease process the main treatment of which is putting stuff into your stomach and keeping it there if you have severe nausea and vomit up the stuff you eat.

I really hope that if something like this happens again I’ll be smart enough to actually call an ambulance, or at the very least involve other people so that they can help me if things go really bad. I like to tell myself that I am a very self-reliant and independent person in general – the sort of person who don’t like to ask other people for help and so rarely do. And nobody likes to be seen and judged by others when they’re at their weakest. Combine these facts with the inherent difficulty of assessing when a situation such as this one is sufficiently severe to merit involving other people while you’re having neurological symptoms impacting your thought processes and impairing judgment, and you have the perfect recipe for a situation where you end up making bad decisions and running a major risk of things going very wrong by not getting help. I should really become better at reminding myself (to the extent that it’s possible; as mentioned impaired judgment is a symptom here, so this stuff is not completely under my control) that when I’m in a state like this I’m just a very sick person who very well may need other people’s help simply to survive. Type 1 diabetics die from such hypoglycemic episodes all the time.

Here’s a related post from the past.

ii. (Yet) A(nother) medical lecture:

iii. An event that changed the world:

Here’s more.

iv. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.

Abstract

Objectives To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.

Design Systematic review of randomised controlled trials.

Data sources: Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists.

Study selection: Studies showing the effects of using a parachute during free fall.

Main outcome measure Death or major trauma, defined as an injury severity score > 15.

Results We were unable to identify any randomised controlled trials of parachute intervention.

Conclusions As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.”

v. On Being Sane in Insane Places, by David L. Rosenhan.

“At its heart, the question of whether the sane can be distinguished from the insane (and whether degrees of insanity can be distinguished from each other) is a simple matter: Do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environments and contexts in which observers find them? From Bleuler, through Kretchmer, through the formulators of the recently revised Diagnostic and Statistical Manual of the American Psychiatric Association, the belief has been strong that patients present symptoms, that those symptoms can be categorized, and, implicitly, that the sane are distinguishable from the insane. More recently, however, this belief has been questioned. Based in part on theoretical and anthropological considerations, but also on philosophical, legal, and therapeutic ones, the view has grown that psychological categorization of mental illness is useless at best and downright harmful, misleading, and pejorative at worst. Psychiatric diagnoses, in this view, are in the minds of observers and are not valid summaries of characteristics displayed by the observed. [3-5]

Gains can be made in deciding which of these is more nearly accurate by getting normal people (that is, people who do not have, and have never suffered, symptoms of serious psychiatric disorders) admitted to psychiatric hospitals and then determining whether they were discovered to be sane and, if so, how. If the sanity of such pseudopatients were always detected, there would be prima facie evidence that a sane individual can be distinguished from the insane context in which he is found. Normality (and presumably abnormality) is distinct enough that it can be recognized wherever it occurs, for it is carried within the person. If, on the other hand, the sanity of the pseudopatients were never discovered, serious difficulties would arise for those who support traditional modes of psychiatric diagnosis. Given that the hospital staff was not incompetent, that the pseudopatient had been behaving as sanely as he had been out of the hospital, and that it had never been previously suggested that he belonged in a psychiatric hospital, such an unlikely outcome would support the view that psychiatric diagnosis betrays little about the patient but much about the environment in which an observer finds him.

This article describes such an experiment.”

Here’s the wikipedia article about the experiment. Below some more stuff from the paper:

“Eight sane people gained secret admission to 12 different hospitals [6]. […] the pseudopatients were never detected. Admitted, except in one case, with a diagnosis of schizophrenia [10], each was discharged with a diagnosis of schizophrenia “in remission.” The label “in remission” should in no way be dismissed as a formality, for at no time during any hospitalization had any question been raised about any pseudopatient’s simulation. Nor are there any indications in the hospital records that the pseudopatient’s status was suspect. Rather, the evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be “in remission”; but he was not sane, nor, in the institution’s view, had he ever been sane. […] Length of hospitalization ranged from 7 to 52 days, with an average of 19 days.” […]

“Failure to detect sanity during the course of hospitalization may be due to the fact that physicians operate with a strong bias toward what statisticians call the Type 2 error [5]. This is to say that physicians are more inclined to call a healthy person sick (a false positive, Type 2) than a sick person healthy (a false negative, Type 1). The reasons for this are not hard to find: it is clearly more dangerous to misdiagnose illness than health. Better to err on the side of caution, to suspect illness even among the healthy.” […]

“The following experiment was arranged at a research and teaching hospital whose staff had heard these findings but doubted that such an error could occur in their hospital. The staff was informed that at some time during the following three months, one or more pseudopatients would attempt to be admitted into the psychiatric hospital. Each staff member was asked to rate each patient who presented himself at admissions or on the ward according to the likelihood that the patient was a pseudopatient. A 10-point scale was used, with a 1 and 2 reflecting high confidence that the patient was a pseudopatient.

Judgments were obtained on 193 patients who were admitted for psychiatric treatment. All staff who had had sustained contact with or primary responsibility for the patient — attendants, nurses, psychiatrists, physicians, and psychologists — were asked to make judgments. Forty-one patients were alleged, with high confidence, to be pseudopatients by at least one member of the staff. Twenty-three were considered suspect by at least one psychiatrist. Nineteen were suspected by one psychiatrist and one other staff member. Actually, no genuine pseudopatient (at least from my group) presented himself during this period.

The experiment is instructive. It indicates that the tendency to designate sane people as insane can be reversed when the stakes (in this case, prestige and diagnostic acumen) are high. But what can be said of the 19 people who were suspected of being “sane” by one psychiatrist and another staff member? Were these people truly “sane” or was it rather the case that in the course of avoiding the Type 2 error the staff tended to make more errors of the first sort — calling the crazy “sane”? There is no way of knowing. But one thing is certain: any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one. […]

It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meaning of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment — the powerlessness, depersonalization, segregation, mortification, and self-labeling — seem undoubtedly counter-therapeutic.”

September 21, 2013 - Posted by | diabetes, Lectures, medicine, papers, personal, Psychology

2 Comments »

  1. Konsekvenser af at søge hjælp en gang for meget: en smule såret stolthed for dig, en smule besvær for andre.

    Konsekvenser af at søge hjælp en gang for lidt … Jeg har ikke lyst at skrive det.

    Selv hvis oddsene er meget store for, at man kommer til at søge hjælp en gang for meget, vil det være vinderstrategien.

    Comment by info2 | September 21, 2013 | Reply

    • At undlade at søge hjælp er en risiko at løbe, ja, og jeg er selv efterhånden kommet til den konklusion at jeg burde være mere tilbageholdende med at løbe sådanne risici – som jeg også indikerer i posten.

      Relateret til din ‘Jeg har ikke lyst at skrive det’-bemærkning har jeg tilføjet nogle få kommentarer herunder som jeg føler fortjener at blive sagt nu, hvor vi er ved dette emne.

      Først vil jeg sige, at vi skal alle dø, og en død som følge af hypoglykæmisk koma ville være en god død – jeg har været ret tæt på, så jeg burde vide det. Det ville gå relativt stærkt, og det ville ikke være smertefuldt. I sådan en situation ville det værste scenarium ikke være at jeg døde, men derimod forskellige varianter, hvor jeg ikke gjorde det. Permanent hjerneskade er ikke et usandsynligt udfald i sådanne scenarier. Forestil dig hvilket liv et menneske som mig ville have tilbage, hvis min IQ blev halveret og/eller jeg helt eller delvist mistede mit sprog.

      Dernæst vil jeg bemærke, at en indbygger i Athen omkring Platons tid eller en romer under Cæsar kunne forvente ved fødslen at leve omtrent lige så længe som jeg allerede har gjort. Fra et vist perspektiv har jeg allerede levet et langt liv. Jeg har levet mere end 25 år længere end jeg ville have gjort, hvis jeg var født et århundrede tidligere. Mange af mine forfædre levede meget kortere liv end jeg har gjort.

      Jeg har levet længe, men jeg har ikke levet et særligt godt liv. Jeg håber, jeg har nogle årtier i mig endnu, men hvis det af en eller anden årsag skulle vise sig ikke at være tilfældet, vil det ikke være noget, jeg på det tidspunkt, hvor jeg døde, ville ønske andre mennesker skulle blive nedtrykte over. Ingen grund til at græde over spildt mælk. Læs en Pratchett roman i stedet hvis den situation opstår.

      Det bør nævnes, at hvis jeg skulle være helt ærlig med mig selv er jeg ikke sikker på, at situationen jeg gennemgik i fredags ville være opstået for et årti siden. Jeg tror ikke, det er forkert at antage, at jeg implicit tager større risici på dette område, end jeg har gjort. Hvis det er korrekt kunne en forklaring være, at jeg har større viden om følgesygdommene og ved mere om, hvor vigtig stram blodsukkerkontrol er når det drejer sig om at forhindre senkomplikationer. En anden og måske noget mere ubehagelig forklaring kunne være, at jeg har mindre at leve for nu, end jeg havde dengang, så risikoen for at dø spiller en mindre rolle i forhold til mine handlinger nu, end den gjorde før i tiden. Sidstnævnte ide er en lille smule skræmmende, men på sin vis er den også naturlig nok.

      Comment by US | September 22, 2013 | Reply


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: