Unconventional Wisdom 1

A continuation of Conventional Wisdom posted August 8, 2011.

“Listen up, Julie.  I’m going to teach you that exposure to small amounts of radiation won’t hurt you.  In fact, it may even be good for you, even at the levels used for diagnostic purposes such as computed tomography (CT) scans.  Recent research has shown that living in a radiation-deficient environment stunted the growth of a protozoan.  And living in a radiation background that is several times our present level should improve our health and longevity. (Google Sir Samurai T. D. Luckey.)”

“Get off it, Curmudge!  I’ve been taught since I was a child that all radiation is dangerous.  Old men are supposed to dream dreams (Acts 2:17), but isn’t this one pushing the envelope?  And besides, blogs are too brief to teach anything.  The most they can do is inspire the reader to learn more.”

“Right as usual, Julie.  Our teaching—I mean exposure—to this topic began over a year ago (August 8, 2011) in our posting on Conventional Wisdom.  At that time we still had a sponsor and had to tread softly on controversial topics.”

“Hooray! Vive l’indépendence!  Now we can tackle controversial issues head-on.”

“Whoa, Ms. Enthusiasm.  As I said, we introduced today’s topic, the linear no-threshold (LNT) concept, in 2011. To avoid repeating everything, let’s all go back and read the Conventional Wisdom posting.”

[Blog delayed 10 minutes for Jaded Julie and readers to read old posting.]

“Now I remember, Curmudge.  According to the linear no-threshold theory a plot of cancer occurrence vs. exposure, based on high levels of exposure to radiation, could be extrapolated to the origin, i.e., there was no threshold below which there was no effect.”

“That’s it, all right.  But extensive research has shown the LNT theory to be invalid.  We cited some of it in our earlier posting, and we’ll list more books and papers today.  If our readers study the documents that we cite, most should agree that the LNT theory has become outmoded.  However, there will likely be some who will cling to the LNT dogma.”

“Also in our Conventional Wisdom posting there were references suggesting that exposure to low-level radiation imparted a protective effect against cancer.  Will we discuss that also?”

“We surely will, Julie, but it may require more than a single posting.  There’s so much information on these topics that we’ll only have room in the blog to mention authors and brief summaries.  Complete references are in Hiserodt’s book, discussed below.  And to examine these documents critically, a reader will need to become familiar with the units used to measure radiation, which we don’t have space to cover.”

“But Curmudge, we’ll need to use some numbers, and readers will require a few units to even gain a seat-of-the-pants understanding of our story.”

“Good observation, Julie.  Here are some common abbreviations and units:

Abbreviations: m = milli or 1/1000; c = centi or 1/100.

Rem is effective dose in U.S. units; sievert (Sv) [gray (Gy) is equivalent] is effective dose in international units.  1 Sv = 100 rem.  1 cSv =  1,000 mrem.”

“How about providing a frame of reference?”

“Here are some ballpark values:

Typical background radiation (cosmic, terrestrial, radon, medical) in the U.S. = 300 mrem (0.3 cSv) per year.  Background in Denver = 600 mrem (0.6 cSv).

Maximum permissible exposure for a nuclear worker = 5,000 mrem (5 cSv) per year.

Acute exposure (1-2 days) to cause radiation sickness = 100,000 mrem (100 cSv).”

A single computed tomography (CT) scan = 1,000-5,000 mrem (1-5 cSv).”

“Thanks, Old Guy.  Now we all should be on the same page.  Shall we begin our discussion by mentioning the books on this subject that are available?”

“To easily obtain the most information at a reasonable price ($5.91 from Amazon), I recommend Ed Hiserodt’s Underexposed (subtitled What if radiation is actually good for you?) (2005).  Despite its easy-reading appearance, the scientist or nonscientist will likely agree that much of the story is there, and that it is supported by a comprehensive Amazon review by Jay Lehr.  Books with more detail and a much higher price include Radiation Hormesis by T. D. Luckey (1991) and Radiation Hormesis and the Linear-No-Threshold Assumption by Charles L. Sanders (2009).  These books are well documented with peer-reviewed literature.  Luckey’s two books—an earlier one was published in 1981—contain over 2,00 citations.”

“Well Curmudge, I can guess which book a very familiar tightwad bought.  Prof. Luckey is revered in Japan, where they accorded him the honorary title of Samurai.  This can be confirmed by ‘googling’ Sir Samurai T. D. Luckey, where many of the teachings of this blog are also supported.  By the way, I noticed that the books by Luckey and Sanders have hormesis in their titles.  Perhaps you can tell us what hormesis means.”

“It’s the protective effect mentioned by Tubiana in Conventional Wisdom.  And more generally, it’s the phenomenon where something that is harmful at high doses is helpful at low doses.  Examples are many trace metals, vitamins, and even water.  So to proceed, in addition to the papers cited in our Conventional Wisdom posting (those by Vaiserman, Tubiana et al., and Scott et al.) the following tend to refute the LNT theory and support the radiation hormesis concept.  We’ll start with the early observations, made mostly by Japanese scientists, on survivors of the atomic bomb attacks on Hiroshima and Nagasaki.”

“Chapter 15 in Hiserodt shows plots of cancer deaths vs. exposure.  Because plots are hard to show in this blog, I trust, Old Guy, that you can describe them.” 

“A ‘hockey stick’ plot of effect vs. exposure (with blade to the left coinciding with data on unexposed controls) would have refuted the LNT theory.  These plots were shaped like field hockey sticks with blades drooping below controls, thus demonstrating radiation hormesis (fewer deaths than controls) below around 10 cGy.”

“Curmudge, with those exciting findings published in Health Physics and seemingly ignored since 1987, let’s take a few days to search the books further and find some more data.  Sayonara.”

Kaizen Curmudgeon                                               

The Ordeal 3--Summary

“Cancer patient, Jay, and his devoted wife, Ann, have begun six days of in-patient chemotherapy in a different hospital.  Hopefully, they will not be subjected to any hospital screw-ups that we’ll want to discuss.”

“So we’re done for the day?  I’m outta’ here.”

“Nicht so schnell, Julie!  We’ve still got work to do.”

“Based on the tone of your voice, Curmudge, I perceive that you just said ’Not so fast’ (in German).”

“Right as usual.  As we promised last week, we’ll summarize what we learned from Jay and Ann’s ordeal.  In addition, we’ll provide some unsolicited suggestions that the original hospital (which will remain anonymous) needs to consider.  Let’s start this way: Julie, if a hospital said that they were providing patient-centered care—and most of them say that—what would you, as a patient, expect?”

“First of all, if I were in severe pain, I would expect the hospital to do everything feasible to alleviate it.  Nothing else matters to one experiencing intractable pain.  If I had nausea or constipation or other physical discomforts, I’d expect help there too.  Also, I would consider a noisy environment to be a physical discomfort.  Finally (but definitely not least), the hospital should minimize the patient’s and family’s emotional stress.  Not knowing, waiting, or poor communication in general would be almost as bad as pain.  Things often not known would include one‘s diagnosis, when the next test will be and when its results will be available, and when one will be able to eat.  If a hospital can’t communicate with its patients, its supporting elements like clinics and pharmacies, and within itself, it might as well be a cottage industry in Kyrgyzstan.”

“Well put, Julie.  And at some point during Jay and Ann’s ordeal, they experienced each of the above.  The biggest issues at the first hospital were emotional stress and communication problems, which started with the computer hang-up in getting Jay admitted.  Then there were the almost non-existent communications between the hospital and pharmacy.”

“I was really concerned about Jay’s having to wait a day—in pain—for a CT scan and then overnight for the result.  CTs are run 24 hours a day in most hospitals, and there are services that read them overnight.  Of course, Jay, Ann, or nurses in the hospital should have stayed abreast of the constipation problem before it became serious.  Most everyone knows that narcotic painkillers cause constipation.”

“On the other side of the ledger, I was impressed by the on-call oncologists who answer the phone at 2:30 a.m.  It’s amazing that they can be alert and give sage advice to someone who might not even be their patient.”

“So, Curmudge, what’s the bottom line?  The original hospital seems to have a peck of systemic problems.”

“Julie, my one-word answer is the same as it has been for the past six years.  Lean! The hospital needs a Lean transformation.  Anyone who is not acquainted with Lean can start with the first Kaizen Curmudgeon posting in May of 2007 and read the next 240.  In a nutshell, the hospital needs to empower the employees to map their processes, find the root causes of problems, and then use plan, do, study, act cycles to implement continuous improvements.  They need to find the waste and inefficiencies in their systems and get rid of them.  And finally, the hospital must do this with the full support and leadership of management at every level.  If Jay and Ann’s first hospital has already started a Lean journey, it needs more attention.”

“That was a pretty concise rant, Curmudge.  If a hospital can get its systems in order, they should be well on their way to providing patient-centered care.  So what kind of problem will we illuminate—but not resolve—next?”

 

“We’ll take a break for a couple of weeks, read some books, and then present some stuff about a little-known issue that a few readers might not believe.”

“Sounds interesting.  I’m with you, Old Guy.”

Kaizen Curmudgeon

The Ordeal 2

Another tough week, but are screw-ups subsiding?

“Curmudge, a newby who just surfed into this posting would have no idea what we are talking about.”

“That’s the way it is in blogs and in life, Julie.  It’s difficult to put today into context without knowing what went on yesterday, or last week.  But we can’t wait for stragglers.  Time to proceed onward.”

“I understand, Old Guy, that Ann became a ‘frequent flyer’ at the local pharmacy.  Quoted below are some of her comments:

‘Needed several new medications. Local pharmacies do not carry some of the specialized ones; they have to be ordered.  One special one to prevent infection would have cost $3,200!  We did not get it filled.  It had to be ordered from somewhere.  I called the clinic early this afternoon to learn if there is an alternative but have not heard back yet.  Having to run to the pharmacy daily is frustrating—especially with back orders, meds not in stock, or unusual drugs.  Wish there were a better system for cancer patients. The clinic does not stock samples of drugs.  Some days it's multiple trips to the same pharmacy.’

‘Jay had a strong drug reaction that lasted an hour during an outpatient chemo infusion that took 8 hrs last Thursday, and a Neulasta injection that produced severe flu-like aching—very painful. Plus other painful side effects: mouth sores, bad stinging and pain in jaws and throat. Incredible fatigue.’

‘I asked the pharmacy to call as soon as they got the Vicodin order (for pain), and they called us back to say it was ready. Then they also texted Jay's phone.  Nice.  I made friends with the pharmacist today; told them all I'd be a "frequent flier" and that Jay was enduring aggressive chemo. I think they will be ready-on-the-spot now since they know we need help. They were great about the Vicodin—usually that one can't be called in.’ “

“The situation at the pharmacy end of the system seems better, Julie, but things are still messed up at the hospital end.  This is what Ann wrote:

‘Any e-filing or phoning of prescriptions from the hospital side to our pharmacy has not worked.  I asked where the disconnect is occurring, but I’m not sure I got an answer.  I called the clinic to get a prescription, and they said I had to talk to the hospital medical unit.  After four phone calls to the hospital last Friday afternoon, the clinic finally just did the Rx—and phoned it in. The hospital never did do it in spite of three calls from me to the 3rd floor medical unit (they promised it was done, each time I called) and two calls from the clinic to the medical floor!  The clinic staff told me the staff on the hospital floors don’t like to phone in prescriptions.  Nice, huh?  Then why don't they just hand me a written script then?’ “

“Wow, Curmudge!  As in the Book of Job, it seems that trouble keeps coming:  

‘It’s 6 a.m. and Jay was up all night throwing up.  At 2:30 am I called the on-call doc. She said to come right into the clinic at 8 a.m. What a long night.  No sleep again for Jay. It may be a bowel obstruction.’

‘It’s 11:30 am, and he still feels crappy; blocked up. The x-ray showed a mass in Jay’s abdomen. He must have a CAT scan for a better view.  Jay will be an inpatient for the day and tonight.’

‘The CAT scan—where is it?  It was ordered at 11:30 am.  Jay is not able to have any food or water due to the blockage, and he's extremely uncomfortable with nausea. The RNs gave him meds that helped. But the doctor still doesn't know what the problem is.’

‘Jay waited all afternoon; but by 5 pm, still no scan.  Where's the CAT scan? Then we will have to wait for a radiologist to read it.  Now the business day is over, and Jay has a serious blockage that hasn’t been identified.’

‘My patience is wearing thin with delays at the hospital.  Jay has been through hell. The clinic staff and on-call folks have been wonderful—responsive, caring, and attentive, but there seem to be snags at the hospital diagnostic level again.  Where's the urgency with a cancer patient?’

‘Jay just sent a text: He just got back from the CAT scan at 5:45 pm.—6 hours late. He said the CT folks were swamped with ER cases today.  As expected, results will not be available until tomorrow.’

‘Next day: The CAT scan showed that the mass is severe constipation from the GI system’s shutting down due to electrolytes being out of balance.  Electrolytes via IV are starting to wake up Jay’s GI system.’ “

“Curmudge, might some of those ‘urgent’ scans in the CT backlog have been defensive medicine?  And I’m surprised that there wasn’t a radiologist on call.”

“With a name like yours, Jaded Julie, I would not be shocked by your having suspicions.”

“So where do we go from here, Professor?”

“It depends, chère étudiante.  If delays and screw-ups have really subsided, next week we’ll summarize what we’ve learned.  And you and I, who probably aren’t qualified to make recommendations, might make some anyway.”

Kaizen Curmudgeon

The Ordeal 1

The First Week—Further Diagnosis and Follow-Up

“Prepare, Jaded Julie, to be dismayed, disgusted, and disheartened by today’s discussion.  Every cancer patient’s experience is an ordeal; some are quite tolerable, but some are horrible.  We are going to discuss one that started out in the horrible category.”

“Curmudge, I sense that you are in a black mood that can only be assuaged by feeding it to the computer, pressing the ‘save’ button, and ultimately posting it on our Kaizen Curmudgeon blog (http://kaizencurmudgeon.blogspot.com).  So how are you and I going to tackle this?”

“To maintain our focus on Lean management systems in health care, we will pluck the organization’s systemic problems from the patient’s experience.  Most of these first- and second-order ‘screw-ups’ will be described by quoting the patient’s spouse.”

“Screw-ups, Curmudge!  Those are harsh words coming from an ancient but dignified professor.  We know that hospitals work hard to avoid ‘never’ events, wrong site surgeries, surgical site infections, and medication errors, but it’s the seemingly minor and more frequent screw-ups, as you describe them, that make life miserable for patients and their families.”

“Patient-focused care doesn’t always happen, Julie.  Here’s the story.  My close friend, Jay (not his real name), was diagnosed with Burkitts lymphoma quite recently.  In fact, the full extent of the disease has not yet been determined.  In any case, it will be treated quite aggressively beginning with a week as an inpatient in a hospital outside the immediate Fox Valley.  Jay’s wife, Ann (not her name either), has been providing daily updates to friends and family.  Quoted below with her permission (and with some editing) is how she described Friday:       

‘Jay is finally an inpatient after a snafu that took all day.  The morning began with a PET scan.  Then at noon we got lots of our questions answered at the oncology clinic.  The PET scan results were not what we hoped.  There is mall lymph involvement in Jay’s chest—only 1 cm more than normal but still there in two little places.  The spinal test still has to come back.’

‘We then walked over to Inpatient, but there were no orders, not even an order for food. Poor starving Jay; he has had nothing to eat since yesterday.  Our hope was to get a jump-start on treatment today.  The orders got lost between the oncology clinic and the hospital, which incidentally are in the same building!  Orders had to be re-done—followed by lots of apologies.  Apparently the problem was the staff’s unfamiliarity with their new computer system.  But we still lost a day of treatment.   Jay is just now getting settled in at 7 p.m.  We were there all day!’ “

“Now I understand your blue funk, Curmudge.  What a horrible way to treat the patient and his family who are already under a level of stress that neither of us can fully appreciate.  It was unconscionable!  So how might a hospital avoid these situations?”

“Every hospital knows its own system best, and some may have their screw-ups under control.  Those that do not will need a person or persons with strength to walk through the hospital’s silo walls and the stature to be heard when he or she speaks.  It’s critical that these problems be nipped in the bud, so patients will need to know whom to contact when things appear to be going awry.”

“So what do you foresee in Ann’s next report, Curmudge?”

“It’s time for some good news, Julie, so I remain hopeful.  Many years ago Jay and Ann and I hiked together in the Rockies, and I want to do it again.”

Kaizen Curmudgeon