Thursday, January 12, 2017

The Moral Matrix of Wartime Medicine

The following excerpt from a longer work was published in The Intima: A Journal of Narrative Medicine,  (Columbia University School of Graduate Education) Fall 2015

My Arrival

A trim stewardess wearing a powder blue skirt and a pretty smile pushed her food cart down the center aisle. At first glance, this looked like a routine flight. It wasn’t. The passengers were combat-ready troops who were mostly young, mostly somber, and mostly silent. Some chose sleep to escape from troubled thoughts; others anesthetized them with the droning white noise of powerful jet engines. One consequence of our rapid buildup in Vietnam was that soldiers were transported on commercial airlines. Another was that doctors like me had only six weeks of transition from civilian to military life before we shipped out with them. We wore summer weight khaki uniforms but felt like civilians right to the moment that overhead speakers crackled news of our arrival.

It was late August 1966 and monsoon rains would continue for another two months. The strong wind that delayed our landing had just blown by and we walked quickly through thick mist that smelled like wet wool. The sky was gray. Everything else was olive drab splattered with brown mud: boots, gear, vehicles—everything. Like the other military items that were stenciled with descriptors, I was labeled too. Captain’s bars, a caduceus, and a plastic name tag announced what and who I was to anyone who was interested.

The Camp Alpha processing center for incoming troops was located near Saigon (now Ho Chi Minh City). It looked more like a tropical prison than a welcoming area. Heavily armed guards patrolled perimeter fences topped with coiled concertina wire. Screened and sandbagged barracks were separated by narrow rivers of muddy rainwater. Malaria-carrying mosquitoes fed on hot sweating skin. And, if not for a poorly tested vaccine, fleas from indigenous rats could infect us with the same bubonic plague that created medical mayhem during the Middle Ages. I was housed with other junior ranking officers. War noise and jet lag assured a miserable night’s sleep.

At first light, a sergeant appeared. His ethnicity was nondescript, but his bearing was not. He was professional and unambiguously intimidating: straight back, athletic build, and piercing gaze. Somehow, his fatigues were pressed and his boots were shined despite the pouring rain and an absence of rain gear. This was quite remarkable. Either he was secreted away with us overnight or he possessed special powers that repelled mud and water.

“Attention to orders,” he barked.
We paid attention.
"The following orders have been changed...."
I was assigned to the 2nd Battalion, 14th Infantry Regiment.
Other names and orders followed.
There were groans.
One came from me.

I stood tall, stepped forward, and did my impression of an Army officer.
"Sergeant," I said. “I am scheduled to join the 85th Evacuation Hospital in Qui Nohn. I am also classified 3-C because of a well-documented medical problem. This disallows an assignment to a combat unit and I want an explanation for this change of orders.”
Without effort, he assumed the persona of a hotel manager denying a confirmed reservation.
"Sir,” he said with a hint of condescension. “I am so sorry I can’t help you. Your medical file seems to have disappeared in transit. I suggest you discuss these medical issues with the doctor when you get to the two-fourteen in Cu Chi.”
“But you said that I am going to be the doctor at the two-fourteen.”
“That’s correct, Captain. Effective 0600 today, you are the battalion surgeon for the two-fourteen.”

This man had not earned all those stripes for nothing. A few months later I would have responded to this ridiculous Catch 22 dialogue, but at the time, I was speechless. With luck, maybe a higher level of stress hormones would lessen my frequent bouts of asthma. That same afternoon, I was convoyed west to join elements of the “Tropic Lightening” 25th Infantry Division in central Vietnam.  We drove on dirt roads through large areas of denuded landscape that had been sprayed with the herbicide Agent Orange. We were told it harmed only vegetation; human toxicity for those exposed is now measured in parts per billion.

I felt like an imposter wearing a steel helmet, a bulky pre-Kevlar flak jacket, and canvas jungle boots that were reinforced against hidden punji stakes. My accessorized vehicle foreshadowed what would come next: Sand bags to keep land mines from exploding through the floor, a slotted vertical bar to cut sharp wire strung neck-high across the road, and a locking cap to keep local kids from dropping hand grenades into the gas tank.

At Cu Chi, my 30 medics were armed and did not wear Red Cross insignia. Before being embedded with 900 infantry troops as their only doctor, I was issued an M-16 rifle and a .45 caliber pistol. Notwithstanding the Geneva Convention and my lack of weapons training, the Viet Cong were known to target medical personnel.

I was one year out of medical school and only a few weeks earlier worked as a medical intern in a respected teaching hospital. I had not decided on a career path and joined the military to avoid being drafted, but this assignment bore no resemblance to the psychiatric training program I had been promised. Clearly, the person who got me into this mess deserved more than just a simple reprimand. Unfortunately, the culprit was me.

The Mercy Killing

My first week in the field was uneventful; the few patients I saw had only minor complaints. On the morning of the eighth day, during my transition from mostly asleep to almost awake, I heard a shout, "Where’s the doctor?” the voice said. I grabbed my gear and came running.

Framed in the center of an empty dirt road, the backlit silhouette of a young soldier walked toward me; awkwardly, as though he was afraid of dropping something fragile. His deuce and a half (2½ ton truck) was parked to the side with its engine still running. Typical for soldiers at that time in Vietnam, he wore a helmet but no body armor, so I could see that his shirt was wet with dark red blood. An M-16 rifle was slung over his left shoulder because his arms were cradling a scraggly, malnourished, mixed-breed dog. Its brown fur was matted from the fine misty rain and it was whimpering in the most pitiful way.

The cause of the dog’s pain was obvious. A two inch shard of whitish bone protruded through the torn flesh of its right hind leg. The soldier tried valiantly to protect the leg from moving but the dog’s cries were evidence of his limited success. Despite holding the dog, he stood mostly at attention and addressed me in the staccato voice used for giving military report. "It was an accident, sir. I never saw him. It was dark, my headlights were dimmed, and there was a thud. I exited the vehicle and this is how I found him." The dog was not wearing tags or a collar. "Does he belong to anyone?" I asked. "I don't think so, sir. He just shows up. We play with him sometimes and feed him scraps but I’ve never seen anyone actually looking after him."

Involuntary tears left tracks on both cheeks. He studied the dog's pained face with the affection reserved for close friends and relatives. I am quite certain that today I would protect my dog’s life with my own, but at the time I had little empathy for the depth of this man’s emotion. His combat platoon received sniper fire a day before. Two members of his squad had been killed, others were seriously wounded, and these tears were shed for a stray dog.

Successful treatment required the skill of a surgeon, a proper medical environment, and prolonged convalescence. These did not pertain to me, the situation, or the dog. Like all doctors assigned to military units, my title "surgeon" was vestigial from battlefields of much earlier wars and not based on meaningful surgical training. The equipment in my aid station was meager, and to make matters worse, we were packing up supplies before moving out the next day.

One of my medics approached from the rear. "I’m sorry,” I said in a calm voice. “There isn’t much we can do except relieve its pain.” The dog was placed on a poncho at a spot that was shielded from the rain. I kneeled in the mud, repositioned the dog, and carefully propped the injured leg to what I thought was a more comfortable position. The dog yelped. I flinched. Without conversation, the medic handed me some ampoules of morphine. An average soldier weighs about six times more than this dog, so I reasoned that half an adult's lethal dose should end its life in a humane (sounds silly) way. Army medics love giving morphine, and for good reason. No matter how severe their patient’s injury, it relieves pain and anxiety quickly. But on the dark side, a large dose can inhibit the brain center that controls breathing and cause death.

I located the vein that runs down the dog’s foreleg, inserted the needle, and administered the first dose intravenously. Injecting it directly into the blood stream increases the drug's potency and protects against erratic absorption. Almost immediately, the dog closed its eyes and seemed at peace. I was relieved; sometimes pain causes more distress for the doctor than it does for the patient. Thankfully, I thought, this will be over soon. It wasn’t. I injected a second larger dose, and then a third …. Nothing much happened. The dog’s breathing slowed a bit, but it was not shallow. I doubled the next two doses ….The dog was still breathing normally and his pulse was strong as ever.

This was not going well. If death was the goal, it seemed nowhere in sight. And now I had wandered outside my comfort zone. I had never used medical knowledge to end a life and I didn’t like the way it made me feel. I wondered if I had miscalculated the dose of morphine or whether my impulsive pragmatic morality was somehow being tested. In the very back of my mind, a third option was much scarier: Was it remotely possible that some spiritual force was telling me it was not time for this dog to die? I held my ground and injected more morphine …. The dog was still breathing …. more morphine …. still breathing …. And then, without warning, the dog was dead. I stopped breathing too and was devoid of thought and air and sound. When I recovered, I refused to tell myself that I put the dog to sleep or out of his misery. It seemed necessary to acknowledge the gravity of what I had just done.

Once again, the soldier slung his rifle over a shoulder and then dropped to one knee. Taking great care to protect the dog’s injured leg, his trembling hands hugged the still warm body to his chest. He paused and stared into my eyes. Plain words captured the complex amalgam of his sadness, betrayal, anger, and resignation. "I feel really miserable, sir," he said.

I did not possess the medical magic that might have saved this dog's life nor the knowledge of how best to comfort this grieving man. I felt the pain that comes from admitting to one’s own lack of competence. I surely hoped that one day I would acquire the requisite skills but at that place and time they were not mine.

I nodded, looked away, and said nothing.

The Mine Field

Most troops greeted me with “Doc, let me show you something.” It is impossible to maintain decent hygiene living in the jungle or wading through rice paddy water, so the "something" was usually skin that was lacerated, abraded, ulcerated, blistered, weeping, or infected with bacteria and fungi. And since there are no private body parts in this setting, I did get to know these guys pretty well in relatively short order.

Our battalion was conducting search and destroy operations in Tay Ninh province near the Cambodian border. My new home was a small sandbagged tent that doubled as the forward medical aid station. It was located less than 100 yards from the perimeter machine guns which meant we could be under fire while treating casualties. The triage and treatment area consisted of two canvas stretchers called litters that rested on metal racks. If necessary, we could expand its capacity by laying ponchos over the mud. There was no suction, no oxygen, no blood products—none of the medical stuff I had previously taken for granted. Changes in military tactics and helicopter evacuation of the wounded from point of injury had mostly relegated us to the role of highly-trained medics. So, over time, our job was phased out and most combat doctors were eventually transferred to better equipped medical facilities. The higher command finally learned what we already knew—the added danger could not be justified.

Shortly after arriving, I embarrassed my novice-self by leading my medics on a frantic search for burn dressings. I heard there was a firefight and imagined that soldiers were using flame throwers. I didn’t know that a “firefight” is an exchange of small arms fire. About five weeks later, that same inexperience compelled me to join two of my medics who were treating a critically wounded soldier. He had wandered into a well-marked minefield and they were having trouble keeping him alive. This area was adjacent to our operations center and had been seeded with “Bouncing Betty” landmines that contained a smaller first charge that lifted the second waist high before exploding. They inflicted terrible damage and an unfortunate misstep had mangled this man so badly that there were no obvious places to apply tourniquets. Not helping my medics did not seem like an option. And, like a mother running into traffic to save her child, I entered the minefield thinking of the danger as abstract, as though the mines did not pertain to me.

Our patient’s bleeding had slowed because he was already in shock. I injected him with morphine, applied pressure dressings, managed to start IV fluids, and we placed him on a litter. Then, we exchanged glances, shrugged to acknowledge the frailty of our existence and without speaking – simply walked out. We were so close to each other that detonating a single mine would injure us all. This loss of control was a humbling experience. Our survival was solely dependent on a sequence of random near misses. If a boot struck the ground here, we were okay. If it struck there, we would most likely die.

We were covered with blood. The wounds were extensive and almost certainly lethal but the outcome was finalized while we waited for the Medevac team to arrive. He began copious vomiting, then gasped, and then breathed the vomit deep into his lungs. A well-intentioned soldier added to our frustration by pleading "Do something! Do something!"  But with no suction available, we knew our attempts at resuscitation and clearing his airway were futile. The reality was, there wasn’t much we could do except watch him struggle to breathe, suffocate, and die.

I don’t know the name of the man who was injured, or the names of the brave medics who assisted me, or the name of the anxious soldier who had been annoying me. Unfortunately, it is his voice that I remember most. None of us spoke about this incident again; the next day would be just another day.


The sterile, almost clichéd term, “post-traumatic stress,” belies the impact its symptoms have on those who are afflicted.  Mild symptoms create bursts of emotional and physical complaints. But for some patients, they become so severe and pervasive that they disorder their lives. Anxiety, hypervigilance, self-doubt and depression are expected, but it is time disorientation that makes precipitant events seem contemporary and part of the present-day self.

Older folks like me are always surprised when they become symptomatic long after the trauma has occurred: Aging veterans are more vulnerable physically, psychologically and financially, and they have more time for reflection. When I told a Veterans Affairs psychologist that I did not think my late-in-life symptoms were related to my Vietnam experience, he smiled. “If you really believe that you were not affected by running into a minefield, disarming a disturbed soldier while he was threatening to shoot you, and watching your patients die while you treated them in the mud and under fire – you are an idiot.” I reluctantly admitted that maybe his diagnosis was correct. “Do you have a DSM code for this?” I asked.

Combat medical personnel who served years and sometimes decades earlier often describe their experiences as if they just happened. I believed that fear of personal injury would be the principal trigger for anxiety but their recollections were similar to mine: "Professional terror” was far worse than worry about physical harm. Given our less than optimal equipment and training, we rarely felt competent to fulfill professional responsibilities. Our psychological survival required a decision to make do with what we had – not what we wished they had, and having the ability to redefine what was an acceptable outcome and level of performance.

Doctors, nurses, medics and corpsmen also struggled with constant conflicts between the need to fulfill their unit’s medical objectives and our obligations to individual patients. The military required us to keep troops healthy enough to fight, but we worried that treating patients to make them combat-ready might be writing them a prescription for death. These decisions made us weary because we viewed ourselves and the troops viewed us as their protectors – similar to the way that doctors interact their own families. The night before a dangerous mission, a soldier who complains of a severe headache relies on our intuition to determine whether to keep him safe on sick call. We both know there is no objective way to know how incapacitated he might become and whether his absence or a debilitated presence would be more harmful to his squad. Then, the very next day, we might decide whether the correct triage decision was to risk a medevac crew’s lives by insisting on a night-time landing or whether we should wait until morning and risk losing a critically ill patient. There were no “right” answers to these choices and the consequences would not always be easy to live with.

I did not realize that the intimacy of just being present when a patient died would create an existential bond that would always be remembered. But I did naively believe that keeping patients alive at all costs was an uncomplicated goal until I was confronted with permanent brain injuries combined with the loss of multiple body parts. Is it “more” morally correct to preserve this life because we can or to not burden this man and his family for many years after his return? Even worse, we did not know what these soldiers would choose for themselves or what their families would decide if given the opportunity. Later, as a pediatrician searching for a way to accept the loss of so many young lives, I reasoned that those who died were not really cheated out of a longer life. By definition, a lifetime is the time from a person’s birth to the time of his death. Its essence is not quantitative. Whether its existence is measured in minutes, days or years, it is always complete; it cannot be missing something that never was or would ever be.

Our matrix for morality was once painted in the clarity of primary colors. Now it was a kaleidoscopic jumble of moving parts. Medical personnel were issued weapons because they were targeted by the enemy. Women and children unexpectedly became dangerous assassins. Enemy soldiers placed innocent civilians at risk by not wearing uniforms and hiding in places of worship. Everything in our daily routine was potentially booby trapped and could literally explode at any time. The rules for war seemed to be wishful thinking and after our return, a hostile public betrayed and abandoned us by not distinguishing between an unpopular war and the warriors who were fighting it.

There is a great difference between being in a dangerous place where you might die and one where others actively try to kill you. The likelihood of making errors that would result in friendly casualties or harm innocent civilians was so great that it was accepted as inevitable. It was also likely that some decisions made using an in-the-moment survival mentality would breach our own deeply held moral beliefs.  And when we revisit them absent the drama and without the support of like-minded individuals, we know there can be no do-overs – only the do-laters that will become our challenges for the future. If we allow ourselves to carefully examine the events and decisions that injured our moral-selves and ask, “What kind of person am I?”  the answer will be very complicated.

Youth is not wasted on the young.
If we were wise during our youthful years,
We would not make the mistakes
And feel the pain that is
Required for learning life’s lessons.
And if we could regain youth during our later years,
Its exuberance would overwhelm us
So we could no longer see the world
Through wise eyes.      – JLB

Jeffrey Brown teaches as a Clinical Professor at New York Medical College and at Weill Cornell. He has written three published book titles and many papers, articles, and book chapters. Before residency training, he served in Vietnam as a combat Army doctor where he was awarded a Bronze Star for Valor. Caring for sick and injured children in local villages resulted in his eventual career choice to become a pediatrician.  Brown recently retired after forty years of full-time practice in Westchester County NY and has been active in improving the healthcare that veterans receive from community physicians. He also lectures on how moral injuries from wartime experiences affect soldiers following their return to civilian life.

Tuesday, January 10, 2017

The Need for Revision: Traditional History and Physical “Write-up” Provides Inadequate Context for Sharing Patient Information

Brown JL. Communication pitfalls associated with traditional history and physical write-up documentation. Adv Med Ed Pract 2016; 2017(8): 37-41 DOI

The decades-old traditional “write-up” outline used for documenting patient encounters and giving oral presentations provides inadequate context for sharing clinical information: The examiner’s observations made at the start of a patient encounter are described out of sequence ­― after the patient’s history and chief concerns have already been presented.

An experienced clinician correctly understands that diagnosis and treatment begin when patients enter the examination room. The examiner’s early perceptions about the patient's demeanor, severity of illness, level of distress, and obvious abnormalities can affect patient-clinician interaction, triage, content and accuracy of the history, and clinical reasoning: Patients reporting the same chief concern of “chest pain” are likely to be asked different questions with different focus and interpretation of responses when the examiner perceives the patient to be well, in severe pain, dyspneic, toxic, or clinically depressed. Together with background information that includes age, gender, cultural identification, and occupation, these observations are used to place concerns and history in the context of the patient as a person rather than as an intellectual challenge. (“It is more important to know what sort of person has a disease than to know what sort of disease a person has.” – Hippocrates.)

It has been traditional but not entirely reasonable to categorize the patient's "general appearance" in physical findings because they are as pertinent to the history-taking process as they are to conducting a proper examination. To enable others to interpret the history using the same mindset and context as the examiner, it is necessary for early perceptions to be shared before rather than after the chief concerns and history have already been presented.

Perpetuating use of the unofficial but widely-used write-up outline deemphasizes the importance of creating context when formulating diagnoses and sharing clinical information. Suggestions to improve documentation and oral presentations include placing greater emphasis on teaching contextual methodology and modifying the outline sequence to conform to clinical practice. This modification can be incorporated into most electronic health records by adding early observations to the background information or the chief concerns. Objective and subjective components can still be identified by qualifying them with appropriate language: "This acutely-ill appearing Hispanic male states that he has been having headaches for the past two weeks,"

These needed changes have the potential to decrease miscommunication and clinical error. They also teach the importance of context as a basic principle of clinical reasoning


Tuesday, March 31, 2015

Unnecessary Driving Restrictions After Surgery

A recent WSJ article reviewed new protocols to speed #post-operative-recovery. Patients bounce back faster from surgery with hospitals’ new recovery protocols. ( via @WSJ) The instruction to not drive for two weeks following surgery is a left-over from the days when lack of power steering,power brakes and automatic transmissions required physical work to drive a car. Unless patients are sedated with anti-anxiety or pain meds, in most cases, there should be no contraindication to driving a car. In many cases, the driver was more debilitated from the illness before surgery than afterward. It is time to reevaluate this unnecessary instruction. The morbidity from lack of independence can actually hinder post-operative recovery and lead to depression. Time to rethink #driving-restrictions.

Thursday, March 12, 2015

Curing Hatred Without Granting Forgiveness

Does Hatred Have a Simple Cure?

“Hatred, which could destroy so much, never failed to destroy the man who hated, and this was an immutable law.”   ― James Baldwin,  The Fire Next Time

     I have counselled many families through times of marital discord.  When a breakup occurred because of infidelity or betrayal of common goals, the person who felt wronged described feelings of disbelief, sadness, anger, and hurt.  These patients often appeared ill. They slept poorly; they looked anxious and depressed; and they had multiple somatic complaints. When anger morphed into toxic hatred of a partner, their clinical condition deteriorated further. The advice I offered them was traditional and pragmatic: “Hating someone harms you more than it hurts them. It serves no useful purpose and anchors you to the past. It interferes with your ability to make sound decisions and it keeps you from enjoying pleasures that might replace those that were lost. It is in your best interest to put these hostile feelings aside so you can focus on improving the future.”  I was very aware that the preferred solution would be to suggest forgiving the perceived wrong, but I rarely made this recommendation.  I had already observed that individuals who are consumed by hate for any reason are irrational and think this advice reflects naiveté; some even become hostile at its mention.  Even worse, if forgiveness is believed to be an unattainable goal ("I will never forgive him for this despicable behavior"), it might convince them that their only choice is to keep on hating. My intent was to facilitate functionality. Philosophical discussions about forgiveness would have to wait.
     To address this issue properly, we must first distinguish between hatred that is a transient emotion and hatred that is consuming and pervasive.  Perhaps we should refer to the latter as a “hatred disorder” when it becomes so severe that it interferes with a person’s ability to function normally.  The hater experiences visceral pain that can be so intense it becomes immobilizing and it can be accompanied by a dangerous mistaken belief that only retribution will bring relief.  In our personal lives, this animosity might be directed toward a person who is blamed for our suffering. In a more abstract setting, it can target any group whose values present an existential threat to our own. In both cases, just being alive seems reason enough to hate these individuals.
     The process of hating generates instant reward by using spiritual magic to punish the villain - the equivalent of piercing a voodoo doll.  On the other hand, the delayed gratification that might occur from granting forgiveness requires mental agility because the culprit remains conceptually unpunished.  In addition, when we are told that we must learn how to forgive [1]it implies that this is an acquired rather than innate skill.  So, except for those few individuals whose generosity of spirit allows them to forgive because it is the ™right™ thing to do, forgiving is not forgiveness at all. It is a pragmatic choice to suppress hatred to achieve a longer-term goal.
     I was frustrated by my inability to help these patients and it seemed clear that a different strategy was needed: “Forgive, Forget (Ignore), and Move On” did not seem to be the best answer. A viable solution became apparent once I realized that similar to the act of loving, the act of hating is also a very strong emotional attractant. Both extremes on the spectrum of human interactions constantly draw us toward the other person as reassurance that the intensity of emotion has not changed. In this case, we are attracted to the object of loathing in order to be certain that we still hate it.  And when hatred is used as a psychic weapon, the attraction becomes even stronger: The more we obsess over the person, the more we hate him. And the more we hate him, the more punishment we are inflicting. 
     Trial and error confirmed that if we substitute for hatred equally intense but different emotions that repel rather than attract, we can create an alternate plan that does not require forgiveness. Disgust and repulsion are excellent choices. Voila!  When we think of the hated person as disgusting and repulsive, it pushes their image away and out of our consciousness. As a bonus, the more the individual was hated, the more repulsive and distant he becomes. What difference does it make what this disgusting person did - or is doing - or will do in the future? Why would anyone care why he did it? Repulsive individuals do despicable things; no other explanation is necessary. The desire for retribution suddenly evaporates because exposing this person’s vile nature is satisfaction enough. Aversion has created distance from toxic thoughts and made room for recovery that hopefully will return us to our pre-injured state. And yes – we now have the ability to move on.
     This entire process seemed counter-intuitive. I had to put aside my personal and professional hesitation to prescribe the use of negative thoughts directed toward others. But my reservations were balanced against the effectiveness of this strategy and the knowledge that the patient’s decision is not irrevocable. Circumstances and perceptions can change with healing and time. And if they do, forgiveness remains an open option that can be considered in the future.

# # #

[1] "If we really want to love we must learn how to forgive."
     –Mother Teresa

Less Is More When Discussing Death with Children

When a child asks, "What happens when someone dies?" there is no need for parents to stumble over answers. Many feel insecure because (1) Few of us really know what happens; we accept our concept based on faith not fact. (2) They don't want to frighten their child. (3) They aren't certain if they should be truthful - or if they should use a "feel good" explanation, whether they believe it or not..  A common error is to over-explain the concept of death and dying - which makes it less likely your child will understand  or be reassured by it.

This should not be complicated. All of these concerns are met by saying,  “No one knows for sure what happens when someone dies, but the people in our family or religion or cultural group believe that …” and then say what you really believe. This answer is honest and protects against confusion if another trusted person says something different,  Your child can make her own decisions when she gets older.

Dying is as natural as being born and both can occur at unexpected or inconvenient times.. Discussions should be concise, age appropriate, and accommodate your child's personality. When discussing the loss of a loved one, expressing sadness but not fear is appropriate. It may also be important to stress that you and your child are safe.When a death was unexpected or occurred under tragic circumstances, discuss the concept of death and this occurrence separately.

Honesty is important.  Most of us accept a variant of three basic themes: Biological: “Wherever I was before I was born is where I will be after I die.” Reward and punishment afterlife: “Good people go to heaven; bad people go to hell” And a forgiving afterlife: “God takes us all to a pleasant place where we will be at peace forever.”  Any of these will be understood my all but the youngest children.

Explaining the process of dying is a bit trickier. Guard against equating death with age or illness. You don't want your child to conclude that everyone who is old or sick is about to die. “Life” is an abstract concept that is difficult to put into words. Yes, your brain and heart stop working and you might look like you are in a deep sleep. But life represents a form of energy (physical or spiritual),which provides an opportunity to use an example your child can easily understand: “Many of your toys have batteries that make them run. When the battery wears out, the toy stops working. The same thing happens to people except that the battery can’t be replaced. Luckily most of us have batteries that last for a very very long time.”

Should your child attend a funeral? The answer depends on age, maturity, and custom. A good rule of thumb is that if you would allow your child to attend a happy event that requires similar demeanor (like a wedding), the child can attend a funeral unless there is strong family objection. In many cases. young children can provide a welcome distraction for those who are grieving. Children are more likely to be curious than frightened and it sets a valuable precedent that your family shares both happy and sad occasions together. Not everything in life is fun. And a healthy exposure to happy and sad creates realistic expectations for the future. I was very resentful when I was away at summer camp and my parents did not tell me that my grandfather died because they didn't want to" spoil my summer.” I held a grudge for many years because I thought it was disrespectful to me and to my grandfather. Don’t make a similar mistake.

Friday, February 27, 2015

Parents' Intuition: It Can Harm As Well As Help

    After my children were born I was very surprised by the degree to which emotional rather than rational thinking influenced our parenting decisions. Even simple choices seemed complicated: Should we wake the baby to feed or allow her to sleep? Was the injury risk from contact sports greater than the benefits of team play? Should the kids stay home when they have a cold but miss their math test? Were we setting boundaries that were too strict or not strict enough? The list was endless and intuition quickly earned a prominent place in our parenting tool kit. We came to realize that there was simply no other practical way to make these choices.
     The concept of intuition is quite mysterious. We understand that it is not rational and use vague descriptive terms like “gut feeling” and “sixth sense” but we don’t quite understand how intuitive feelings get into our heads in the first place.  Even more disquieting is the notion that we have to use intuition to know when to trust our intuition. Intuitive thoughts allow us to make predictions that might seem to be based on absolutely nothing, but the most valuable intuitions occur when we unconsciously compare past experience to what is happening in the present. They can warn us away from serious danger, “I don’t want my daughter travelling in that boy’s car,” and they can address the more trivial concerns of a mother who asks through the bathroom door, “Are you okay in there?” Despite its limitations, most of us agree that a parent’s intuition has real value and it is easy to recall situations where potentially terrible mistakes were prevented by responding to a seemingly unexplained anxiety. It is quite possible, however, that we exaggerate its accuracy and minimize its failures because we are more likely to remember those times when we discovered a toddler about to drink furniture polish than when we rushed to the kitchen and found our child happy and safe. 

     There is usually a complimentary relationship between intuitive and rational thought.  But when there isn’t, bad things can happen.:When rational thinking tells us one thing and intuition another, parents can become so immobilized that they can't make any decisions at all. And there are times when parents were absolutely certain that something is true but intuition tells them to ignore it anyway. It is counterintuitive, but very confident parents who believe that “no one knows my child better than I do,” are at extra risk for making mistakes because they are so certain they know what will happen next.
     Group intuition can also lead us astray.  Most recently, it is playing a role in vaccine refusal. Vaccinating against infectious disease is one of the few times a parent can knowingly lessen their child’s chance of developing permanent brain damage and even death. But the strong power of negative intuition might cause a parent to delay or miss this opportunity - especially when it is reinforced by like-minded friends, relatives and pundits. The statistical evidence is very clear that the risk of developing brain inflammation from measles illness is one thousand times greater than from the vaccine: One per thousand vs one per million. Even when we exclude parents whose religious beliefs don’t allow vaccination and those who think that vaccination is a conspiratorial plot, we might reasonably wonder why an informed parent would hesitate to vaccinate against this disease. The answer is that a fairly large group (including some parents who did vaccinate their children) have a strong intuitive feeling that it is the wrong thing to do. They are aware of the benefits and the risks to their child and others, but it just doesn't feel right. Some have understandable but irrational concerns about giving too many shots, tinkering with the immune system, injecting a "foreign" substance, or the discredited association between vaccines and autism. Often, they will not or cannot articulate why they are so wary. But once this feeling of dread has been planted in their heads, a rational discussion with the doctor is unlikely to make it go away. Unfortunately, we pediatricians can be part of the problem. We often tell parents to trust their intuition but then we don’t address their non-rational fears in a respectful or meaningful way. 
We can and should  agree with parents that their iintuition is a very powerful tool ,but then we can offer them some additional advice: First, be certain that the information you are relying on is current and comes from a reliable source. Be especially wary of “junk science,” anecdotes, and unsubstantiated claims that are found on the internet. Next, try to keep rational thinking and intuitive thinking separate. Don't try to rationalize one in terms of the other; we will make better decisions once we can say, “I know that the evidence says this, but my intuition tells me that…,”  Third, get another opinion – preferably from the child’s other parent. In the vaccine example, I was surprised to learn how often parents in stable relationships have never discussed this issue with each other.  (That is why I frequently made both parents sign our refusal to vaccinate form; it is not legally necessary but it forces both parents to have a conversation.). And last, suggest that they give more weight to the best available information and rational thinking when making those decisions that are most important; vaccination is one of them. Life events are unpredictable, but over time, we are more likely to guess right by playing known odds than by betting on a hunch.

A Search for the Perfect Haircut

The plight of a regular guy who just wants a regular haircut has been neglected by mainstream media because of two erroneous presumptions:  An average-looking fellow should have no difficulty obtaining a medium length hair that is parted on the side and any discussion about it will be boring. Neither is true. Appearance can and does affect the weay we feel about ourselves and how we are perceived by others. And since hair style is integral to the way we present ourselves, it is not surprising that there is a regular flow of opinion pieces that describe ways in which hairstyles can give insight into the wearer's personality, make fashion statements, create practical dilemmas, and impact budget. Even the traditionally male-dominated military has been so concerned about ways that hair can impact female members' morale that new regulations were written to allow ponytails that fall fewer than three inches below the collar, corn-rows of specified length and geometric design, and buns that are less wide than the wearer's head. 

To create proper context, it is necessary to revert to my childhood. My mother’s hairstyle was chosen by a caucus of my mother's mother, sister, and first-cousin.  I was inadvertently drawn into this process when I was left to fend for myself in the "beauty parlor" (now hair salon) waiting room. It took the better part of a wasted afternoon for this trio to have their hair washed, cut, colored, and "permed." Most intriguing was the row of shiny hair-drying hoods that looked like props from a low-budget science fiction movie. To combat boredom, I studied the lady clients as they came and went.  Even as a child, it was obvious that the term beauty in beauty parlor was being used rather loosely: “Looking better” parlor might have been more accurate. 

As a counter-point to these dreaded outings, every third or fourth Saturday morning my dad and I visited the local barbershop. It was dingy, narrow and sparsely furnished. There were a few chipped-paint mirrored-cabinets mounted above old-fashioned sinks that were never used. Three barber chairs sat in front of speckled grey linoleum that had been worn bare where the barber stood.  And five barely padded waiting chairs sat in front of a plate glass window with a blind opened just enough to let sunlight enter the room. These chairs always had at least two bored-looking occupants who would be seen before us regardless of our time of arrival. Despite the gradual morphing of beauty parlors into luxurious hair salons and a growth-industry,  this pragmatic simplicity has not changed much over the years. According to industry statistics, salons now outnumber barbershops by more than twenty to one. 

My father was a no nonsense kind of guy, and I came to appreciate the predictability of each barbershop visit. No appointment is needed and I expect a total weight time of about 20 minutes. I am not good with names, but regardless of which shop I visit, I only have to remember Richie, Tony, Frank (a.k.a. Frankie), and Vinnie. When these same barbers “style” hair in an upscale salon, their clients will know them as Richard, Anthony, Francis, and Vincenzo.

My haircut ritual does not vary much from one visit to the next.
“Hey Richie, how are things going?”
“Don’t cut my hair too short. I want it a little on the long side”

The haircut takes less than ten minutes and my barber always cuts it too short. Then, he uses three brushes in the same sequence: A soft brush that applies lavender-scented sneeze-inducing talcum powder to my neck; a stiff bristled brush that rids me of itchy hair remnants, and a push broom that moves hair from the floor to some secret location.  When he is finished sweeping, I say, “Thanks. It looks nice.” I give him a tip and I am on my way. There are no surprises. this is not true for hair salons. They have lots surprises. During the middle ages, barbers cut hair but they also did blood-letting, tooth pulling, and minor surgery. (The red stripe on the barber’s pole is said to have originated from bloody rags draped over the pole.) Modern salons generate twenty billion dollars a year by offering a list of ancillary services that include poking cuticles with sharp objects, applying hot wax to yank out unwanted hair at the root, and rubbing mud on facial skin with the promise that it will glow and look more youthful.

With the admonition that I needed to spruce up my appearance, my wife sent me to a well-known hair salon. Danielle took me right on schedule ‒ which was disappointing because I like reading outdated magazines and reflecting on absolutely nothing. She covered me with a pink nylon smock instead of the familiar white and blue cotton variety.  I said, “Don’t make it too short.” She said. “Okay,” and began washing my hair. This was humiliating. I had washed my hair when I showered that morning and I was probably six years old the last time someone washed my hair for me. There was no chance of escape. The pink gown was like wearing prison orange and prevented me from rushing out into the street. As a peace offering for my “Is this really necessary?” she handed me a cup of coffee garnished with little hair clippings that moved aimlessly about its surface like tiny amoebae. Her animated monologue made me extremely nervous, not because of content, but because her pointed scissors were being waved dangerously close to my right eye. I learned the names of her three most recent boyfriends, which of them were cute, and why she did or did not like them.  My wife had prepped her that I was a physician, so she thought it reasonable to share that she was suffering from cramps and diarrhea. I hadn't said much, but now I was speechless: Tony or Vinnie would have required I.V. fluids and an ambulance before they would admit to having diarrhea.  When she finished, my new best friend (and patient) held up a mirror to show me parts of my head I had never seen before. And when I nodded acceptance, she sprayed it with enough shellac to keep it neat if I decided to walk through a wind tunnel.  Maybe the hair washing was needed to remove any foreign matter that might have been permanently plastered to my skull.  I smiled and said, “The haircut looks very nice.” Then I gave her a generous tip to go with the pricier bill, and I left.

Not admitting defeat, my wife vetted the next establishment more carefully. This time I was sent to a unisex “spa” where an unsmiling Asian woman bowed and offered me steaming lemon-scented towels for which I could find no useful purpose. I unfolded them, squeezed them into a ball, and put them back on the metal tray. As expected, there was no waiting, my hair was washed before it was cut, and this time I drank from a cup filled with bitter-tasting green tea. So far, everything was okay – except for the music. A real barber has a radio sitting on a shelf  plays upbeat 1960’s oldies; the barber' favorite opera favorite opera. or the third inning of a Yankee's game. Instead, I was listening to tinkling noises filtered through the sound of waves crashing on a stormy beach. Maybe this music was chosen because my shirt was soaked from a mishap that occurred during the hair-washing part of my haircut.  There was endless combing and snipping, snipping and combing, until the operator announced that we were almost finished. I skillfully eluded the hair spray but I was unprepared for what came next.  I closed my eyes when she began to gently massage my neck. I opened them wide when she began using her knuckles to “loosen tight muscles” that were probably caused by the stress from the haircut. When she held up a mirror so I could examine the back of my head , I was almost too distracted by the red welts to notice that now my hair was too long. It looked exactly as it did before it was cut. I told her that “It looked nice,” gave her a generous tip, and walked down the block to wait in line at Richie’s barbershop.             # # #