December, 2020 | Hank Dunn

Compassionate, informed advice about healthcare decision making

Archive for December, 2020

Friends, Alzheimer’s and My “Profound Hearing Loss”

Posted December 21, 2020 by [email protected]

Sixteen years ago, I remember sitting in a movie, not understanding even half of the dialogue. Of course, my family had been complaining about my hearing or lack thereof. But it was the movie that pushed me to have my hearing checked out.

I remember sitting in the sound-proof booth with headphones on listening for the faint sounds the audiologist sent my way. I was so thankful I could hear the faintest of the sounds. It came as a shock to me when I came out of the booth and the audiologist said, “Mr. Dunn, you have profound hearing loss.” What was a faint sound to me would have been a loud noise to others. I had deceived myself.

Over the years I have gone through two sets of hearing aids. On my birthday in 2014, I got a cochlear implant at Johns Hopkins in Baltimore. These devices are not perfect, but I was heading toward complete deafness.

Here’s the scary part. I found a recent article in JAMA that said, “Individuals with hearing loss had a 55% greater risk of developing dementia compared with those with normal hearing. Furthermore, the risk of dementia increased linearly with the severity of hearing loss.”

Friends are good for our mental health

I once spoke at an Alzheimer’s Association conference where I shared the program with a physician/researcher. He ended his lecture wanting to leave on an upbeat note. We can’t prevent Alzheimer’s, but we can reduce the risk. He then listed three things we can do to reduce the risk of dementia. He said:

Walk one-half hour every day.
Fight depression at all costs.
Have two or three close friends.

Last year, I saw a story on the NBC Nightly News with another list, this time from Rudolph Tanzi, a professor of neurology at Harvard University and the director of neurology at Massachusetts General Hospital. He suggests an approach he calls SHIELD, an acronym for lifestyle factors that appear to help reduce the risk of developing Alzheimer’s. They include:

Developing good sleep habits
Getting a handle on stress
Interacting with friends
Exercising daily
Learning new skills
Eating a healthy diet

Those pesky friends show up again. How do friends help prevent me from losing my mind?

The brain continues to change and friends can help

I got a clue about the friends piece in a recent podcast from Brené Brown with David Eagleman on his book Livewired: The Inside Story of the Ever-Changing Brain. Eagleman is a neuroscientist who is curious about the brain — how it is mysterious, malleable, constantly changing, and up for new challenges. He believes that our brains are “malleable” because they can — and do — change in response to new situations.

Dr. Eagleman also endorses “learning new skills” from Dr. Tanzi’s list above. “Does malleability depend on us trying new things?” he asks. “If you are challenging yourself, you are building new roadways.” He suggests learning new skills from learning a foreign language to brushing your teeth with your other hand.

Where do the friends come in? “Other people is the hardest thing that brains deal with,” he continues. “The degree to which one can maintain an active social life is massively important.” Carrying on a conversation requires that I pay attention. I never really know what the other person is going to say. I build those new roadways in my brain in my response.

He goes on to say that “blind people are generally happier than deaf people because they can communicate.” And this interaction can help ward off dementia.

Social distancing and friendships

So, I’ve adapted. Bluetooth sends the TV audio directly to my brain through the cochlear implant. Headphones make phone calls and Zoom meetings very workable. The most difficult situations are social settings — a crowded party with lively chatter all around or a noisy restaurant. These are exactly the places in non-COVID times where I might meet those friends who are so important to my mental health.

I plan ahead. No more Mr. Nice Guy, “You sit down first, and I’ll just take what is left.” I take the seat at a table where I will be more likely to hear others. I’ll tell people, “I can hear better if I am in this seat” and not have a hint of embarrassment.

Social, or physical, distancing is hard on friendships. I tend to be an introvert who has not developed friendship patterns with a lot of talking and visiting. This year has made me more acutely aware of this missing piece. Turns out my future mental health depends on it.

The Spiritual Side of “Grey’s Anatomy”

Posted December 16, 2020 by [email protected]

“Chaplain Dunn, we need you in the emergency room,” the nurse started her call to me on a Saturday morning. “An eight-day-old baby died at his mother’s breast at home and the family needs your support.” This family had no minister to call. I did what I could for them. It was a sad, sad situation. A few hours later the funeral home called, and the family asked if I could conduct a graveside service for the child.

For twenty years, for one week each quarter, I volunteered as the on-call chaplain at the Loudoun Hospital Center in Virginia. During normal business hours, there was a full-time chaplain ready to handle emergencies. I almost always got a few calls each week I was on duty. Often, it was for deaths in the ER. Sometimes, it was for stillbirths or neonatal deaths. The staff knew they needed to provide spiritual support in times of crisis. Who could they call after hours?

The mysterious absence of chaplains

As I wrote in my last blog, we have been binge-watching Grey’s Anatomy during the pandemic. In the over 300 episodes of Grey’s Anatomy I have watched, I can’t recall a time when a chaplain was on camera. Isn’t that curious? Like all medical dramas, the show is filled with crises and death. Where are the chaplains? Full disclosure here: I am a chaplain and could be protecting my turf.

One past TV medical drama, M*A*S*H (1972-83), cast a chaplain in a significant role. The Mobile Army Surgical Hospital amid the Korean War might make the presence of a chaplain seem more acceptable. After all, it was the Army in the middle of a war. The chaplain, Father Mulcahy (a Catholic priest), was one of only four characters who appeared in all eleven seasons of the hit show — along with “Hawkeye,” “Hot Lips” Houlihan, and the crossdressing Klinger.

There was one Grey’s episode when two doctors talked about needing to get a chaplain. A patient was asking for forgiveness. He was the landlord of an apartment building that had collapsed resulting in multiple injuries and some deaths. He said he was trying to save up the money to make repairs to the structural damage the building had suffered in an earthquake. Now, people had died because of his procrastination and he wanted to be forgiven.

Dr. Ben Warren said, “The chaplain is M.I.A. and I heard there was a rabbi in geriatrics.”

Dr. Leah Murphy encouraged Ben to go see the patient and act as chaplain, “All you have to do is listen and nod your head.”

Dr. Warren did see the patient and told him he was not a priest. The guilt-ridden landlord said, “I just need someone to listen.”

The spiritual side of Grey’s Anatomy

Just because the show is absent chaplains or other clergy does not mean it does not tackle some very important spiritual and religious topics. More than once did a child need life-saving medical treatment when one parent wanted to trust the doctors and the other wanted to take the child home and trust God only. Similarly, a Jehovah’s Witness patient refused to accept a blood transfusion that could have saved his life but would violate his strongly held religious belief. A new intern felt compelled to use her hijab to stop the bleeding in a patient. It was later was returned to her, cleaned, by a fellow physician who knew the spiritual importance of the head covering.

Rabbi Eli, a dying patient, comforts Dr. April Kepner

For nine seasons of Grey’s most of the “spiritual teaching,” centers around the character, Dr. April Kepner. She starts out on the show as a conservative Christian and something of a prude. Gradually, life seems to interrupt her strongly held beliefs and morals. She loses her virginity and then recommits to a chaste life in an effort to “re-virginize.” She gets married, has a child die soon after birth, gets a divorce, and has another child as a single mother. Her own painful life story and the random tragic stories of her patients causes a crisis of faith in Dr. Kepner.

The journey we’re all on

Kepner’s breakthrough to a more mature faith is helped by a dying patient, Rabbi Eli. He is dying because of a mistake made by Dr. Miranda Bailey. Kepner views Eli’s case as just more evidence that God does not care for us. She wants a guarantee that if you are faithful good things will come your way.

The rabbi will have none of the guarantee talk. He recites a long list of faithful biblical characters who were tragic victims. Eli says it’s also in “the sequel” (by which he means the New Testament). He argues that if only good things happened in these stories, the bible would not have been a best-seller.

Rabbi Eli helps Dr. Kepner through her crisis of faith

“Who are you to know why some people live and some people die?” the dying man tells Dr. Kepner. “God’s not indifferent to our pain…the world is full of brokenness and it’s our job to put it back together again.” He asks her to tell Dr. Bailey he forgives her for her mistake. He dies confusing Dr. Kepner with his wife who is out of town. Get out the tissues.

Occasionally, the hectic scenes in Grey’s O.R. and E.R. shift to the quiet of the chapel. Doctors pray, light candles, or just sit silently. Here, Kepner walks in on a distraught Dr. Bailey who is lighting a candle and seeking solace.

Dr. Kepner comforts Dr. Bailey, who made the medical mistake that led to Rabbi Eli’s death

Dr. Kepner tells her, “Eli forgave you. Some things just happen, and we don’t get to know why.” She came to a point of acceptance and was able to comfort a fellow traveler in this seemingly unfair world. Is this not the journey we are all on?

“Grey’s Anatomy” and CPR on Television

Posted December 9, 2020 by [email protected]

True confession: I have joined my 22-year-old daughter in binge-watching Grey’s Anatomy during the pandemic. Over 300 episodes viewed and counting. I now know about “10-blade,” “clear!” and the importance of declaring “time of death.” Also, I never knew there was so much romance and sex going on in hospital supply closets and on-call sleeping rooms. Now I know.

Grey’s Anatomy (currently in its seventeenth season) follows Dr. Meredith Grey and her fellow surgeons at a Seattle teaching hospital. She started out as a young, single intern and is now a widowed mother of three small children as well as the chief of general surgery. The show is very engaging, depicting extremely dedicated and hard-working doctors. Most are compassionate, empathetic and caring.

CPR is on TV…but it is not realistic

A staple of medical dramas is the “code.” A heart monitor starts beeping loudly, a doctor starts chest compressions, another grabs the paddles of a defibrillator and yells, “Clear!” Sometimes the first shock gets the heart back in rhythm but most often it takes a couple.

While it seems like all of the cardiac arrests on Grey’s are with a “shockable rhythm.” In real life only about 10% of cardiac arrests are shockable. Medical journals have exposed the unrealistic depiction of CPR on medical dramas.

Why dedicate medical research to the topic? The general public develops a distorted view of the success of the procedure. In 1996, the New England Journal of Medicine looked at CPR on Rescue 911, Chicago Hope and E.R. and found survival rates vastly higher than the actual 17%. On Rescue 911, 100% of those receiving CPR survived.

In 2015 the journal Resuscitation calculated the CPR survival-to-discharge success rate at 50% for House and Grey’s Anatomy. That doesn’t happen in real life. But if 83% of the CPR patients died on TV, not many people would watch it and the sponsors would probably complain.

I have written before about the futility of CPR for large categories of patients. In the years between the fifth (2009) and sixth (2016) editions of Hard Choices for Loving People, the survival rate inched up from 15% to 17%. It is not that the procedure has gotten better. The clinicians are getting better at advising patients and families about who will NOT benefit from CPR. Survival rates have improved because we are doing LESS CPR.

DNR is a big deal

Occasionally on Grey’s, the characters discuss “code status” — whether a patient should have a Do Not Resuscitate (DNR) order. (See my blog on my preference for AND — Allow Natural Death.)

On the show, it’s the patient who is often ready for the docs to write the order so they can have a peaceful death. The family — or even the physicians — sometimes resist. In my experience, this is very realistic. Real-life patients usually come to the conclusion that they are dying before their families or doctors. Their own bodies tell them it is time. This is information others do not have.

The DNR is a big deal. It serves as a sign that it is time to prepare for a comfortable and dignified death. And, on this, I do give Grey’s credit for getting it right.

Drain the Swamp! — I Think Not

Posted December 2, 2020 by [email protected]

Drain the swamp! …I take personal offense at the idea.

Drain the swamp! …But they are some of Creation’s greatest achievements!

Drain the swamp? …Some of my best friends are swamps.

How did such a place of beauty and life and light come to have such negative connotation? Perhaps it was John Bunyan’s “Slough of Despond” in Pilgrim’s Progress (1678) that shaped our view of the swamp as a place of evil. He wrote:

Hank and his sister, Janice, Half Moon Lake, Florida, in front of “the slough”

“This miry Slough is such a place as cannot be mended; it is the descent whither the scum and filth that attends conviction for sin doth continually run, and therefore is it called the Slough of Despond: for still as the sinner is awakened about his lost condition, there ariseth in his soul many fears, and doubts, and discouraging apprehensions, which all of them get together, and settle in this place; and this is the reason of the badness of this ground.”

My first encounter with the swamp was when I was a child. Our family bought ten acres of lake property outside of Tampa right after WWII. After clearing much of the land and building a house, they put in a large lawn that stretched from the house to the lake. Just beyond the lawn there was a swamp in a thicket of underbrush and cypress trees. This was — for me and my sister — a place where you never ventured. Coincidently with Bunyan’s allegory, we called it “the slough” and it appeared only in the background of family photos.

Drain THAT swamp?—It can’t be drained

Platform for camping in the Okefenokee Swamp, Georgia

As an adult, I grew to love the swamp.

I once paddled thirty-one miles with ten teenage boys across the width of the Okefenokee Swamp. For two nights we slept on platforms one foot above the water. We paddled part of the way through the swamp in a canal next to what once was a railroad.

At the beginning of the last century they logged the trees and hoped to drain the water to make room for agricultural land. Didn’t work. It wouldn’t be drained.

The Okefenokee actually has a natural outlet — The Suwanee River. I paddled that river for ten days and camped out ten nights starting in the swamp and ending more than halfway to the Gulf of Mexico — 166 miles downstream from where I put in. The first night out, I was

The Everglades

still in the swamp and found just enough ground a few inches above the water to sleep under my tarp in the rain.

Drain the swamp?—Lose some drinking water

I also slept on the ground while backpacking in the vast Everglades. I dragged my then grade-school-aged children along — sometimes walking in thigh-deep water. Sadly, this swamp has been mostly drained, although governments and NGOs are trying to restore some of what has been lost.

Swamps take runoffs and river overflows. They filter the water, leaching out the contaminants as it percolates into the caverns below. Turns out, all of those condos on Miami Beach depend on the water in the aquifer below the ‘Glades.

Drain the swamp?—A home for wildlife

I share my temporary homes in the swamps with other creatures. Many a night, I have slept on the ground at the edge of a swamp on Cumberland Island, Georgia. A favorite pastime at night was to stand in the darkness with a flashlight pointing toward the water, trees, and grass. If the eyes shining back were low, it was a ‘gator — if they were high, it was most likely a raccoon.

Limpkin in the headwaters of the Loxahatchee River, Florida

Of course, when you think “swamp,” you think alligators. These guys have been around at least for 37 million years, 125 times longer than we have. Who gets first dibs on the swamps?

Also fishing the shallow waters are many graceful birds; the egrets, herons, limpkins, ibises, and anhingas.

I remember walking on a dirt road cut through the swamp next to my campsite on Cumberland Island one sunny, cool March morning and stepping around four cottonmouth moccasins. One time paddling under low-hanging trees in the swampy headwaters of the Hillsborough River near Tampa, I looked up to see one of these very poisonous snakes sunning just above my head.

My swamp adventures continue…

Speaking of swampy headwaters, Florida rivers often start in wet woodlands. Paddling Fisheating Creek on the western edge of the Everglades and the Loxahatchee River on the eastern, both presented problems in pathfinding amidst the cypress and other dense growth.

I’ve also paddled into The Great Dismal Swamp in southeastern Virginia. Up until the Civil War, this once inaccessible land, for generations, was home to “maroons,” whole communities of formerly enslaved people. It has been said that these communities were so isolated that some of their inhabitants had never seen a White person. (Drain that swamp and people lose their freedom.)

Dawn in the Chakchiuma Swamp, Mississippi

Now, living in Mississippi, I have been on a quest to find new swampy waters. A birding friend suggested I look west where there was one of the last sightings of the now thought-to-be extinct ivory-billed woodpecker. The White River National Wildlife Refuge, just over the Mississippi River in Arkansas, has been calling my name and I have heeded the call. The earth where I lay down here is under six feet of water much of the year. When the waters recede, lakes and swamps appear. Priceless.

Closer to home, within the city limits of Grenada, Mississippi, one half-mile from the town square and its Confederate statue (now wrapped in tarps) and not far from the gravesite Mississippi John Hurt, is the Chakchiuma Swamp — three hundred acres of cypress wetlands in connected oxbow lakes cut off from the nearby Yalobusha River. I have timed my visits there to put in just as the sun is rising.

Drain the swamp?—I don’t think so

Sunrise in the swampy waters of the White River National Wildlife Refuge, Arkansas

A swamp at dawn is a moment of serenity to behold. The birds are awakening at first light. Fish are rising and gently break the water’s surface. A turtle’s head occasionally peaks out only to quickly disappear upon seeing an intruder. Even the expanse of the Okefenokee Swamp has a special beauty at sunrise. Light and sky and trees and fog and water and wildlife and the organic ooze at the bottom of it all. Yes.

Drain the swamp? I don’t think so. To connect the worst of Washington insiders to these majestic creations of nature is an insult to swamps.