Randi Hutter Epstein M.D. M.P.H.

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The Autopsy Business

On October 27, 1883, about a dozen men, armed with spades and shovels, snuck into Mount Olivet Cemetery in Baltimore, hoping to dig up a body. Their efforts were to no avail. The cemetery’s keeper fired shots, startling the vandals, who ran away. An hour later, pistols sent another group running from the very same grave.

There was a thriving business in dead bodies back then. Medical schools relied on body snatchers for a steady supply of cadavers for research and to lure prospective students. As John Harley Warner wrote in Dissection: Photographs of a Rite of Passage in American Medicine 1880—1930, cadavers gave doctors-in-training rare hands-on experience and gave schools an edge over competitors that taught by textbook only. The bodies—supplied through the black market—also helped doctors figure out why things went wrong, perhaps shedding light on how we die—or how we can postpone it.

The autopsy business isn’t what it used to be. For one, the body-snatcher industry has been replaced by a legitimate process that includes, among other things, obtaining permission from family members. And yet, the notion of learning from autopsies is a dying industry. It shouldn’t be.

In this week’s New York Times, Dr. Sandeep Juahar makes a good point. He notes that fifty years ago, autopsies were done on half the people who died in hospitals. Today it’s about one in ten. You may think—as lots of doctors do—that autopsies are no longer necessary, what with all the imaging tools and lab tests available. But they are. Jauhar notes that hospitals that do the most autopsies also make the fewest diagnostic mistakes. It’s not quite cause and effect, but does suggest that we may be learning a thing or two from the autopsies that are preventing further mistakes. “Despite the emphasis on metrics and data in medicine today, we ignore perhaps the most important information of all: what we can see for ourselves,” he writes.

As for that coveted dead body of 1887? That was poor Blanche Gray, a Fat Lady in the circus who died at the young age of 27. Her death was just as much of a show as her life, with hordes of neighbors ogling at the crane that needed to lift all 500 pounds of her from her room in the Freak Show museum all the way to the cemetery.

During those fledgling days of endocrinology, doctors were eager to learn more about the glands that secreted the juices (soon to be named hormones) that control our bodies and behavior. Blanche, well, she stayed dead and buried, never to be exhumed to a Baltimore lab—despite several attempts. But the field of endocrinology would blossom without her.

 

John Warner:

http://www.amazon.com/gp/product/0922233349?keywords=dissection%20john%20harley%20warner&qid=1457120412&ref_=sr_1_1&sr=8-1

 

NYTIMES link:
http://www.nytimes.com/2016/03/03/opinion/bring-back-the-autopsy.html?_r=0

 

Sandeep jauhar

Sandeep Jauhar

Sandeep Jauhar became a contributing opinion writer for The New York Times in March 2015. A practicing cardiologist, he earned a Ph.D. in experimental physics at U.C. Berkeley before going on to study medicine at Washington University in St Louis. He has been writing regularly about medicine for the Times since 1998.

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Thanks to Rosalyn Yalow

Last April the Endocrine Society hosted a meeting in Washington D.C. to discuss, what they considered, is the shoddy state of hormone testing.

I was reading about the hormone-measuring dilemma in the recent issue of Endocrine News (the Endocrine Society’s newsletter) and it got me thinking that it wasn’t too long ago that doctors considered the amount of hormones in the blood too small to quantify at all.

The ability to be measure hormones—that came about in the late 1950s—is in many way thanks to the Nobel Prize-winning Rosalyn Yalow.

Had she lived, Yalow would be celebrating her 95th birthday this week on July 19th. When she graduated from college and told her teachers that she wanted to be a scientist, they suggested she become a secretary for one. Good thing she didn’t listen. She only got into graduate school because so many men were off fighting in World War II, a few spots opened. As she would say later, “They had to have a war so I could get a PhD and a job in physics.”

She had trouble finding work even after graduating tops in her class but landed a position at the Bronx V.A. As legend has it, her first tiny laboratory had been a janitor’s closet.

It was at the V.A., where Yalow joined forces with Dr. Solomon Berson, and developed the radioimmunoassay, or RIA for short. RIA measures hormone concentrations down to the billionth of a gram. As Yalow’s biographer put it, that’s like measuring a teaspoon of salt tossed into the ocean. It’s also used to measure other things in the blood that had been considered unmeasureable, such as viruses and some kinds of drugs. (Berson didn’t get the Nobel because he had already died by the time it was awarded and Nobels are not given posthumously.)

These days we know that RIA works well for hormones that fall into a certain range, but it isn’t as good for hormones that are really scarce. The results also vary according to which brand is used. It’s like scales—we all know that some make us seem thinner than others.

For hormones, it wouldn’t matter so much each if each clinician relied on their own company’s standards for normal. But all too often, there’s one general chart with the window of normal values.

That means that a hormone test may suggest you are deficient in a hormone when you’re really not. And then you’ll be taking unnecessary treatment. And vice versa. You could think you have enough of a hormone when you could benefit from therapy.

For now, the Endocrine Society has gathered experts and formed PATH, which stands for Partnership for the Accurate Testing of Hormones. Their goal, as they put it, is to “advance the development of standardized hormone assays and advocate for the universal adoption of these assays in medical practice and research.” Which sounds like a sound idea.

I don’t think they intentionally announced their aims around Yalow’s birthday, but it seems to be good karma. A good time to remember a woman who fought against the odds to break down the all-male barriers—and at the same time revolutionize the field of endocrinology. I often loathe the overused word “revolutionize” when it comes to scientific achievements, but Yalow’s really was.

When she received her Nobel Prize in 1977, the committee said, “We are witnessing the birth of a new era of endocrinology, one that started with Yalow.”

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How to Survive a Chemo Haircut

How to Survive a Chemo Haircut

After my girlfriend, Tracy, had her first bout of chemotherapy and after she got her appetite back, we indulged in a really decadent lunch. That’s when we decided we would eat our way through her ovarian cancer, splurging during her chemo holidays and when she was feeling good enough to enjoy a meal. (BTW, chemo holiday is the term her doctors’ used for the almost-normal days post-bouts of being drugged up and suffering the aftershock and pre-your next round.)

When we went for lunch, we talked kids, careers, books, and movies. We didn’t avoid the cancer talk. But we didn’t dwell either.

The other day on the way to the dry-cleaners, I ran into Tracy and she asked me to join her that afternoon for her head shave and wig fitting. How could I refuse?

And yet, I worried I’d sob the whole time and not be the support system she needed. Watching a friend have her hair removed is watching her parade into cancerland. Up until now, she may have been marching through hell but I was loitering in deep denial. We met outside her apartment at noon.

All morning, I had tried to image what a hair stylist majoring in chemotherapy cuts and cancer wigs would be like—particularly one on the tony upper east side of Manhattan. Tracy’s aunt was paying for her to get a top-of-the-line wig.

I imagined it would be spacious and white and pink. White for sanitary/medical. Pink for girls. Then I visualized the hairdressers. I pictured either (a) overly perky and saccharine-sweet chattering away in cheerleader diction to distract from the whole cancer theme (yuck!) or (b) overly soothing and sympathetic with airy yoga-teacher voices to make peace with all the bad stuff going on (equally yuck).

What we got was anything but cheerleader or yoga. And there wasn’t anything close to a slick paint job. We entered a drab apartment on the first floor of skinny walk-up. I’m talking no décor whatsoever. Pine-wood cabinets and tables with lots of wigs each one fitted on a head-shaped form. There were wigs on the table and wigs on the book shelves and rows of wig shampoo in the cabinet above the kitchen sink.

We were greeted immediately by the hairdresser. Again, nothing like I expected. Think Catskill comedian meets Italian Jersey shore. He said “Fahgettaboutit” and “you-know-what-I’m-saying” more often than someone doing a bad impression of how often New Yorkers say “Fagettabout” and “you-know-what-I’m-saying.” He bellowed when he spoke and put his face really close to yours.

In the old days, he said, when he was doing wigs “for like regular, crazy people,” the hairdressers really looked down on the wigmakers. “I mean it’s like putting a gay in the same room as Rick Santorum. Fahgettaboutit. You know what I’m saying?”

“Rita,” he hollered, “you can buzz her.”

His utter lack of sympathetic clichés made him all the more caring. He was loud and blunt and matter-of-fact and somehow that made the whole process a lot easier to digest.

Tracy winced when he started to cut her already short hair and she didn’t expect so much scalp pain. It hurt putting her head on a pillow, something her doctors never told her. That’s typical the first few days after chemo, her stylist said. (He knows. After all, he’s dealt with cancer patients for decades.)

But not to worry, he added. “Yeah, I think once your body gets used to, the uh, you know the tingling sensation, it’s like putting up with a tooth ache. After a couple days, you don’t even remember what it feels like not to have it.”

Well, that’s reassuring.

“When do you go for the next chemo?,” he asked.

“Tuesday,” said Tracy.

“So you’ll feel really sick on Friday. It’s mathematical.”

And, indeed, he spoke as if Tracy’s future was as predictable and straightforward as addition and subtraction.

I asked why he had a mirror in front of the chair. Did clients really want to watch as he buzzes? He said he swings the chair backwards for a lot of women but Tracy, he could tell was “well adjusted. You know what I’m saying?”

He doesn’t even have a barber chair, just a regular wooden desk chair with a swivel that makes him lean over so much it must hurt his back. Did he ever think of getting a chair that most hairdressers have that go up and down?

“Too Luciano,” he said.

The appointment lasted probably twice as long as we needed to be there, because there were so many stories. We heard about his visits to clients in their fancy Park Avenue apartments. Another woman, he said has trouble adjusting her wig. “And she went to Harvard. You know what I’m saying?”

“You know why she can’t adjust her wig,” he asked us (or really asked himself to lead into the next story) “Because she can’t cook. They order in all the time. If you can’t cook, you can’t fiddle with a wig. I don’t know an Italian man who would stand for that. My kids expect my wife to cook a three or four course meal every night. You know what I’m saying? Faghettagboutit.”

Tracy added that she’s worried about getting the wig on right and she’s a Harvard grad, too. But he wasn’t listening to us. He was busy with his own stories.

Then he pulled out her wig—a gorgeous, long, reddish piece with wispy front layers. He put it on but said he would need an hour, at least, to cut it down and fix the front. He suggested we go for lunch.

Before we left, I took a snapshot of Tracy with her pre-styled luscious red hairdo emailed the pictures to her boyfriend and relatives. She looked fabulous. Thanks to her hairdresser, I didn’t cry at all and then, as will be our usual, we went for another fancy lunch.

P.S: Later that afternoon, when I got home, I did two things:

  1. I did some online research to see if we know precisely what happens to hair shafts to make your hair fall out in clumps and if anyone is doing anything to prevent it. We’ve known for years that cancer drugs target cells that multiply fast—like your cancer cells and your hair cells, making your hair ridiculously breakable. But we still don’t know precisely—at the molecular level that is—what happens inside the hair. One scientist noted that his team is studying the impact to devise drugs to block hair loss. The problem, wrote Dr. Vladimir Botchkarev, in a 2003 article in The Society for Investigative Dermatology, is that “due to ethical problems in obtaining scalp biopsies from patients treated with chemotherapy, little is known about mechanisms.”

Let’s face it, after cancer surgery, cancer drugs, the devastating side effects, the hours and hours waiting around for treatment—not to mention the emotional upheaval of becoming a cancer patient—many women probably aren’t volunteering for a trial that requires scalping. A few drugs, he noted, seemed to prevent hair loss in newborn rats, but the same drugs were useless in older mice or human scalps.

  1. I got inspired to grow my hair long to donate to places that supply wigs for children with cancer. There are several organizations, many of them outlines in this New York Times piece. http://www.nytimes.com/2007/09/06/fashion/06locks.html?emc=eta1

 

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My Dad, My Dog: The Humanity of Dying

When my dog deteriorated to the same level as my father (not able to move or eat on his own and appeared to have little cognitive functioning), I knew it was time to put Dexter, our 13-and-a-half year German Shepherd down.
Dexter hadn’t walked the length of a block in about six months despite twice daily painkillers and a host of other pills to get him moving.

When I arrived at the hospital to end it all, two technicians lifted Dexter onto a gurney and into an examining room. As I wrapped my arms around him—wishing he would close his eyes—the vet, held the syringe of euthanol, and asked:    “Are you sure you are ready?”

That was probably the toughest moment of all.

Then she injected him. One huge syringe of a milky-white powerful sedative followed by another syringe filled with phenobarbital that stopped his heart. There was no last cry or yelp. He just dropped his head and peacefully left.

Right away, my dog’s life flashed before my eyes. I pictured him as an 8-week-old puppy with huge floppy ears and then as a rambunctious hulking 5-year-old. That’s when I knew, hard as it was, that we made the right decision.

Then, oddly enough, my dad’s life flashed before my eyes. The man he was before Alzheimer’s struck. When he was chairing a world-renowned pathology department, editing a prominent cancer journal, leading the American Cancer Society, running miles every day, lifting weights, and so on.

My dad was always a good listener and a great decision-maker. I could tell him anything and he seemed to simplify the process, ask key questions that allowed me to come up with “my own” solution. Even now, when I visit him in the Alzheimer’s ward of the assisted living home, I tell him things just the way I used to. Sometimes it’s the teenage me, asking for life advice about whether I should do this or that. Sometimes, it’s kindergarten me, “hey, dad. Look. I wrote a book!” Often it’s proud-mom me, “the boys are playing football, just like you did.” And somehow, I just know what he’d say. I’ve even learned to predict those key questions guiding my decision-making process. And I know that if he could talk even for a moment, he’d beg us to end it all.

For years, I’ve been a huge proponent of death with dignity, insisting that surely, we must “do something” for dad. I’m proud New Jersey, where I grew up, may become the third state to allow near-death patients to self-administer life-ending medication. Still, I think for all my talk, I’m just going to have to wait this one out. I really wish we could respect my father’s wishes. We’ve agreed that we will not be reaching for lifesaving remedies should he take a turn for the worse. And yet, if my father’s doctor asked, the way my dog’s vet had: “Are you sure you are ready now?”

I’m not sure what I’d say.

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