Tuesday, April 01, 2008

Experts call to end first aid's 'kiss of life'

Once again medical "wisdom" bites the dust when subjected to proper testing

The "kiss of life" may be ditched by rescuers because research shows it doesn't necessarily save lives. In a controversial move, the Australasian College of Emergency Medicine has recommended that mouth-to-mouth ventilation be abolished from national cardiopulmonary resuscitation (CPR) guidelines and replaced with chest compressions only, saying the move would save more people. The recommendation comes after two prestigious overseas studies found patients were more likely to survive without brain damage if CPR was administered without mouth-to-mouth.

But the Australian Resuscitation Council (ARC), the peak body overseeing CPR guidelines, is resisting recommendations despite last year slashing the rate of breaths to compressions and eliminating pulse checks.

Dr Stephen Bernard, of the Australasian College of Emergency Medicine, told The Sunday Telegraph latest research showed compression-only resuscitation was the best way to improve survival. "The evidence is becoming quite convincing, and it makes one think: should it be the standard?" Dr Bernard said. "My view is that it's not something that should wait. Shouldn't we really look at this as a matter of urgency?" Dr Bernard said data showed that if a decision was made now, "a considerable amount of lives are likely to be saved". "I would call on the ARC to make a decision earlier," he said. "If someone collapsed in front of me, I personally wouldn't do mouth-to-mouth for five to 10 minutes; I would do chest compressions."

Hundreds of thousands of resuscitators - including surf lifesavers, lifeguards, doctors, emergency workers, nurses and workplace first-aid officers - would be affected by the proposal to abolish mouth-to-mouth. But ARC chairman Associate Professor Ian Jacobs said he was not convinced by research showing compression-only CPR was better than the breaths-and-compressions combination. "It shows interruptions to chest compressions are bad - and we know that," he said. "The studies raise concerns for us to be aware of, but they haven't reached the point where we feel we need to change."

Professor Jacobs said research on the issue was not of convincing quality or scope, but conceded there would be an argument for introducing lay people to compression-only CPR. The evolution of CPR has sparked international debate in the past couple of years. A study published in the Journal of the American Medical Association this month found patients of emergency workers who delivered compression-only resuscitation were three times as likely to survive.


Are We Really That Ill?

America has reached a point where almost half its population is described as being in some way mentally ill, and nearly a quarter of its citizens - 67.5 million - have taken antidepressants. These statistics have sparked a widespread, sometimes rancorous debate about whether people are taking far more medication than is needed for problems that may not even be mental disorders. Studies indicate that 40% of all patients fall short of the diagnoses that doctors and psychiatrists give them, yet 200 million prescriptions are written annually in America to treat depression and anxiety. Those who defend such widespread use of prescription drugs insist that a significant part of the population is under-treated and, by inference, under-medicated. Those opposed to such rampant use of drugs note that diagnostic rates for bipolar disorder, in particular, have skyrocketed by 4,000% and that overmedication is impossible without over-diagnosis.

To help settle this long-standing dispute, I studied why the number of recognized psychiatric disorders has ballooned so dramatically in recent decades. In 1980, the Diagnostic and Statistical Manual of Mental Disorders added 112 new mental disorders to its third edition, DSM-III. Fifty-eight more disorders appeared in the revised third edition in 1987 and fourth edition in 1994.

With over a million copies in print, the manual is known as the bible of American psychiatry; certainly it is an invoked chapter and verse in schools, prisons, courts, and by mental-health professionals around the world. The addition of even one new diagnostic code has serious practical consequences. What, then, was the rationale for adding so many in 1980?

After several requests to the American Psychiatric Association, I was granted complete access to the hundreds of unpublished memos, letters, and even votes from the period between 1973 and 1979, when the DSM-III task force debated each new and existing disorder. Some of the work was meticulous and commendable. But the overall approval process was more capricious than scientific.

DSM-III grew out of meetings that many participants described as chaotic. One observer later remarked that the small amount of research drawn upon was "really a hodgepodge - scattered, inconsistent, and ambiguous." The interest and expertise of the task force was limited to one branch of psychiatry: neuropsychiatry. That group met for four years before it occurred to members that such one-sidedness might result in bias.

Incredibly, the lists of symptoms for some disorders were knocked out in minutes. The field studies used to justify their inclusion sometimes involved a single patient evaluated by the person advocating the new disease. Experts pressed for the inclusion of illnesses as questionable as "chronic undifferentiated unhappiness disorder" and "chronic complaint disorder," whose traits included moaning about taxes, the weather, and even sports results.

Social phobia, later dubbed "social anxiety disorder," was one of seven new anxiety disorders created in 1980. At first it struck me as a serious condition. By the 1990s experts were calling it "the disorder of the decade," insisting that as many as one in five Americans suffers from it. Yet the complete story turned out to be rather more complicated. For starters, the specialist who in the 1960s originally recognized social anxiety - London-based Isaac Marks, a renowned expert on fear and panic - strongly resisted its inclusion in DSM-III as a separate disease category. The list of common behaviors associated with the disorder gave him pause: fear of eating alone in restaurants, avoidance of public toilets, and concern about trembling hands. By the time a revised task force added dislike of public speaking in 1987, the disorder seemed sufficiently elastic to include virtually everyone on the planet.

To counter the impression that it was turning common fears into treatable conditions, DSM-IV added a clause stipulating that social anxiety behaviors had to be "impairing" before a diagnosis was possible. But who was holding the prescribers to such standards? Doubtless, their understanding of impairment was looser than that of the task force. After all, despite the impairment clause, the anxiety disorder mushroomed; by 2000, it was the third most common psychiatric disorder in America, behind only depression and alcoholism.

Over-medication would affect fewer Americans if we could rein in such clear examples of over-diagnosis. We would have to set the thresholds for psychiatric diagnosis a lot higher, resurrecting the distinction between chronic illness and mild suffering. But there is fierce resistance to this by those who say they are fighting grave mental disorders, for which medication is the only viable treatment. Failure to reform psychiatry will be disastrous for public health. Consider that apathy, excessive shopping, and overuse of the Internet are all serious contenders for inclusion in the next edition of the DSM, due to appear in 2012. If the history of psychiatry is any guide, a new class of medication will soon be touted to treat them. Sanity must prevail: if everyone is mentally ill, then no one is.


1 comment:

Anonymous said...

Semi-Random Hypotheses a Nutrition-Science "Skepticism Skeptic"


(1) Overweight people, once they have a heart attack or kidney failure, have much better survival rates than non-obese patients. This could be because merely walking around with 30–60+ extra pounds on you is just like walking around with a large backpack, so they end up more muscular and more aerobically fit. It could also be due to many other factors. But *avoiding* kidney failure or having a stroke in the first place is much more important. That obese people usually develop diabetes which IS THEN TREATED means they become normal people who just by walking around GET MORE EXERCISE since they are supporting much more weight. Perhaps obese people are MORE AEROBICALLY FIT than normal people exactly and *only* because of this, so us normal people should strap dead pigs to our backs

Yet another observation demands to be recognized: might some obese people, even a significant number, unlike my biased NYC region, be quite content being "fat"? From visiting Middle America often, I'd say they seem QUITE JOLLY indeed (most of them already having had kids helps). Then they would be happier than diet-conscious types, and also experience a periodically tonic dopamine pumped up pleasure of stuffing themselves at chain food restaurants, where meals can easily contain an extra 1000 calories than in normal restaurants? High calorie single-serving meals can act a lot like addictive pleasure drugs. There is also the undeniable fact that their 22 year old daughters have not yet lost a sense of vitality (instead of merely becoming rather, uh, food-focused, they are still "boy crazy" too).

(2) There *is* an obesity, heart disease, and diabetes ('Metabolic Syndrome X') epidemic, which has taken an upturn in the 70s and again in the early 90s. The upturn in the 70s was likely due to the anti-fat campaign which used the Food Pyramid as its major propaganda device, along with general care doctors being told fat was indeed scientifically proven to cause obesity and heart disease, which is not so, yet they passed the advice onto their patients.

(3) Super-skinny people are NOT NATURAL in a world where exercise is not a part of daily living and where not a single day goes by without full-satiation meals. So skinny people either have metabolic disease, or they exercise very often which produces a lot more free radicals that cause both aging effects and artery clogging (due to free radical oxidation of lipids).

(4) Low–carbohydrate diets are the only diets that work long-term, since they do not induce hunger and in fact promote all "comfort foods" except for sweets and pasta, while also excluding grain and sugar filled breakfast or snacks. And since they don't create hunger, they can be maintained for life. This is mainly for those of age 30+ when glands start to age.

(5) ATTITUDE has been shown to be THE major determinate of overall mortality, but this does not show up in biochemical studies. Optimism about life in general makes you live longer. Chronic stress (possibly caused in many cases by a pessimistic outlook) is EXTREMELY bad for you. Evolutionarily, being of low social status ranking has been a source of chronic stress, but so too are people unhappy in their romantic or professional situations. The hostility component of "Type A personality" is quite unhealthy, likely due to how it too creates chronic stress. Chronic stress hormones cause digestion to slow down and blood pressure to go up, chronically. Period stress, on the other hand, especially extreme physical bursts of energy as embodied in HIIT (high intensity interval training) or low repetition weight lifting, has been shown to be quite tonic, and lowers chronic stress hormone levels.

(6) "Health food" fanatics suffer from malnutrition, period, end of story. Humans did not evolve to not eat meat, fish or eggs. Vegetarianism is extremely unnatural diet. It is very well known that vegetarians, besides having a pale anemic look have, on average, shall we say, complaining, "antagonistic" attitudes and are in general not fun to hang out with.

(7) There is a true homeopathic effect, but not that of "infinite dilution" snake oil, yet by the same theory, *actual* trace amounts of toxins such as oxidants or mutagens (same thing really except oxidants also cause sugars to randomly attach to proteins) can have a tonic effect, since the body then triggers various emergency repair systems that it normally does not activate.

(8) Aging and eventual life-span limits have evolved, due to group/group selection in which a good number of old people were very useful, especially in human groups, due to their ability to act as libraries of knowledge as well as to help with child rearing. However, too many old people would hinder a group.

(9) Fossil records indicate that early hunter-gatherers lived quite healthy lives, since, like sleek tigers, our bodies evolved for maximum health based on the diet we had access too during this major major epoch humans lived under. Though agriculture allowed many humans to at times live longer, since life was literally less tooth and claw in nature, they also, in older age, became less healthy since they had not had time to evolve to a radically new diet based on carbohydrates. However, humans happen to be one of the fastest evolving species ever known, so the idea that we are purely the same as hunter gatherers is speculative, and perhaps incorrect. Modern hunter gatherers are not a good model of those we evolved from, any more than are chimpanzees, since we are city-state humans, not hunter-gatherers, who evolved neither from existing hunter gatherers nor from existing chimpanzees, but represent a different branch on the genetic tree. Evolution *can* happen in sudden jumps, especially if one or two mutated individuals appear who are healthier than others eating carbohydrates; cities also increased the population of humans enormously, making this more likely. Also, a warrior class existed, as did a hunting class, both of which at a lot of meat which was trivially preserved by turning it into dried jerky using sunlight. Other classes relied more on carbohydrate diets. Attention Deficit "Disorder" has been theoretically linked to those individuals who, like hunter-gatherers, at a lot of meat and had psychological temperaments which abhorred the routine manual labor work in the fields, in favor of the ability to wait for game or enemies to appear and then suddenly spring into violent action.

(10) Being 20-30 pounds overweight is healthy, and often times healthier than being of youthfully athletic build, it's not very fun and doesn't feel sexy, more so in men than women, except in the last few decades in which the advertising industry has made women stop enjoying the sexual attractiveness of having "curves." However, campaigns of "fat is fine" are not the elixir ladder-climbing city dwellers will ever accept. Thus the safest way to look good at the beach should be the goal of medical science to offer answers to, which so far it has not done so. Much evidence indicates that a Banting/Atkins diet, along with the right types of exercise as an option, do indeed, unlike all other diets which involve "going hungry" or exercising in the extreme (which also makes you hungry!), are nearly 100% ineffective, long-term, and in fact not only prime the body to become heavier in the future, but also, especially in women, cause stretch marks and loss of geometrically attractive breast form, especially loss of nipple definition, not to mention the horrendous scaring disfigurement that results from breast reduction surgery. People *want* to have youthful LOOKING (athletic) bodies into their 30s and 40s when women are in husband-hunting mode in modern cities. In our modern culture, fat people, especially fat men, but also insecure fat women are simply considered UGLY, if not directly so, then by social pressure alone. WOMEN simply prefer tall, rich athletic (square instead of effeminate jaws) men and MEN prefer hourglass figures, clear skin, careless vitality, and bright flirty eyes.

(11) Contradictory scientific evidence exists, about diet versus health versus obesity. Massive political and funding-bias exists in the field of nutrition science. Harvard's nutrion science building, along with much of its funding owes a large piece of its pie to the Sugar Industry (General Foods etc.). Yet most dogma has been debunked, leaving a vacuum of real information useful to those who spend their mandatory month a year trying to figure out "health issues." Popular books do as much harm as good. This means that even trained scientists cannot come to solid conclusions without a healthy dose of both skepticism AND skepticism *of* skepticism!

Health studies are of limited value versus role-models and online forums who are chock full of those who have permanently taken control of their fitness and weight and have thus also become much happier with their lives. JohnStoneFitness.com is a good example. Being aerobically fit and somewhat muscular can vastly improve both the performance and the satisfaction of one's sex life, assuming one's sex life is not a mere spectator sport. Being fit, in general, is desired, for being fit affords greater vitality in general, both physically and mentally. So what is needed is good information on how to avoid increasing one's risk of chronic (fatigue, diabetes, etc.) or acute (heart attacks, cancer) disease in the process of increasing one's vitality.

When one has gotten a bit less energetic and less sexy looking in middle age, it's simply FUN to spend the tiny amount of time a day it takes to impress your doctor and ex-girlfriend with your lower blood pressure and younger girlfriend (since the younger they come, the more freaked out they are about dating much older guys unless they LOOK young too).

(12) That obesity or heart disease etc. can be "shown to be X% genetic" implies genetic determinism, and may be true for those eating a modern diet that *most* people are maladapted to, but such genetic studies may in fact only mean that some people will have a lot harder time becoming sexy looking than others, once the most healthy and effective route to doing so is found.

(13) Much of 'Metabolic Syndrome X' is hormonal, not just calories in/out, since different types of calories (protein, carbs, fats, alcohol, fructose as a carb, etc.) effect satiation, hunger and eventual insulin system problems in different ways.

(14) Alcohol has been shown to literally thin the blood, and in doing so, slows down heart disease. However, only 1–2 drinks a day are usually found to be idea, whereas more than that again becomes unhealthy. This does *not* control for other lifestyle factors, mainly the fact that most heavy drinkers are solid alcoholics who suffer from major malnutrition. That neither AA nor doctors suggest a harm reduction vitamin/mineral supplement for such heavy drinkers amounts to a puritanical outlook, much analogous to "conservative" opposition to clean needles or free condoms in high schools. With merely a (folate and possibly Milk Thistle) supplement, most chronic alcoholics would live longer lives, many of them productive ones. The pharmaceutical industry could create a safer inebriant, one that does not kill tens of thousands of people due to auto accidents, meaning one that merely decreases social inhibitions while not also causing a lack of response time.

(15) The Glycemic Index (more useful as the Glycemic Load) which measures blood sugar spikes for various types of food, taken as a SINGLE, LONE food, is great stuff for DIABETICS, but is of limited use for the vast majority of people for whom a carbohydrate is a carbohydrate. It is also tainted by the fact that FRUCTOSE does not cause insulin spikes. As weight-loss diet theory, it is best seen as a curiosity. That Asians eat one of the worst offenders, rice, as their staple food, yet have been historically neither fat nor prone to heart disease is *not* adequately explained that "white rice" is a relatively new staple food. Yet certain spices, namely cinnamon and curry, have been shown to have massive hormonal effects on the insulin system, cinnamon itself being a practical cure for insulin insensitivity. Classically, intense spice has been a form of ridding the gut of worms. My lover is Korean. I've learned to like Kimchee. There is also the Japanese tradition to stop eating at the FIRST sign of satiety, and the fact that they make a ritual of most everything, thus slowing it down.
That's an attitude factor.

(16) Humans who do not exercise via weight training (either by being obese or by lifting iron weights), lose 1% of muscle mass a year, so from age 20 to 40 lose 40% of their muscular metabolic rate during the day when they are not doing much but sitting around. Re-gaining this muscle mass means middle age people can become less sensitive to an extra bite or two of dinner each day. Aerobic exercise (jogging, treadmill, cycling) is not very effective in losing weight since one must run very far to burn off even a single can of cola.

(17) That both the skinniest and fattest of people have the lowest longevity compared to normal somewhat flabby people may be explained by many separate effects. First, super sninny people, if you just look around, are usually FRAIL, not stocky looking, meaning they are just basically unhealthy, period. That we have not evolved, via sexual selection, to spot unhealthy people is preposterous. Second, highly fit, health-aware athletic people have a lot of very high muscle weight in their body, so their body mass index will include them in the "flabby" category, which is just not good science. Finally, truly "fat" people are both insulin intolerant, often have extremely malnutritious diets, tend to have a history of traumatic binging/dieting, and most important of all, since chronic stress hormones are the most unhealthy condition imaginable, their usual LOW SOCIAL STATUS in modern society makes them stressed out. It's no fun to date even a slightly "super-curvy" woman, since it's too hard to find one who feels sexy about herself instead of CHRONICALLY low self-esteem, often verging on man-hating wrath (since they can usually seduce men, but find it hard to find actual long-term boyfriends).

(18) Unlike Middle America, New York City, for reasons unknown to me except the idea that a combination of tonically periodic stress of city life, along with the competitiveness ladder-climbing here (along with Central Park to exercise in), and much more frequent dining out at non-chain-owned restaurants somehow combine to make us healthier. Few here own cars, also, so actually do a lot more actual walking than those who live in the vast spaces of Middle America. Also, I note, there are very many quite healthy looking and quite vital retired people here who are not at all apple-shaped, compared to Middle America. None, and I mean none, are WADDLINGLY obese in the way you see in the airports of the rest of America. Blacks can be an exception, but just as often their fat is in the hips, not the torso. We also, actually, unlike most large cities, do not have a lot of pollution (as indicated by smog days, for instance), but we do have raised carbon monoxide, which forces us sea level mammals to increase our oxygen using capacity, since carbon monoxide is a suicide inhibitor of hemoglogin. I dub this the "New York Paradox." The only exception are the "New Age" types who do yoga and worship crystals. They look very pale and are unabashedly loud hypochondriacs whose favorite word is "healing."

(19) Most of what I've written is probably wrong. A computer model of physiology is needed, one that includes genetics, medication, malnutrition, temperamental type (use Myers-Briggs to start with, adding "neurosis" as a fifth axis), etc. etc. etc. Unlike climate modeling, it would not make politically socialist predictions 100 years in the future, but merely see if it can match that existing data sets. There are currently just too many "yeah but" issues for a sane, scientifically trained skeptic like myself to figure out. Smoking causes a majority of lung cancer, and the one-step mechanism is known. Fine. Alcohol causes a majority of traffic accidents, and the one-step mechanism is known. Fine. But obesity and diet are not as simple. Hunger is regulated by hormones, for instance, and "will power" is over-rated, in fact inversely rated, since resistance to eat when hungry oft ends in binging. Many mildly depressed people become obese, as well, and being depressed screws up your health a LOT.

One model type should include only correlations. Another type could include actual physiological and stress/insulin hormone etc. models.

Individual studies are merely starting to contradict one another. This of course calls for more funding, and vastly increases the sickness of the population, which makes a hell of a lot of people very rich by treating the symptoms instead of preventing them in the first place.

(20) Stress hormones (linked to temperamental attitude and social status dynamics over time) explain all of the results I've ever heard. That stress is around 50% genetic, merely means that 50% should learn to mellow out, having a beer or two and stop fussing, be they too fat or too skinny. Being fat, pre-diabetic, with high blood pressure, not very popular socially, and being yelled at by a doctor who scribbles in latin for pills to fix you, is stressful, if and only if you actually *go* to the doctor. That so few people who are overweight end up in intensive care units might have a bit to do with the fact that they never TEST their fitness, since they RECLINE ALL DAY watching TV...an average of 4-7 hours a day, living no life at all, meaning they are undead zombies in the literal sense of having no life. That's why when they retire, they move to awful places like humid Florida: there being even summer season excuses to never go outside, and they never have to shovel snow, which is when most heart attacks occur in Middle America. To BUNCH calories, nutrition and psychological vitality indeed can produce "Paradoxical Results". In other words, people who don't LIVE life in an active, engaged, at times heroic sense, don't die very often either.

(21) Witness pot-bellied John Ray, reclining 12 hours a day to blog, social recluse, his thunder stolen by the multimillion dollar author of Liberal Fascism, paying top-dollar for laser treatments as he waits for his chronic skin cancer to invade the rest of his retirement-age body. Witness also, folk hero (and for me, father figure and surrogate academic advisor combined) creating the most extensive blog network ever created. Notice the youthfulness edginess of his attitude, his sense of pride (in himself, his sexual conquests, and in his son who he has been blogging about from puberty until advanced college). Witness, that he is not a zombie, but indeed Shakes his Spear, daily, the keyboard being mightier than the smart bomb. He is pessimistic about nothing, and is indeed a fighter, and not in a shock-jock sense either. He's still in denial about Conservative Fascism, but let an old man have his Reagan era romanticism, eh?