A little quiet time

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Adventure Reading

Do you ever feel like Santigo of the Alchemist, needing direction during the daily drudge?  Yearning for more adventure in your life?  Living that low budget resident life?   Outside magazine asked readers what inspired their “athletic, artistic, and environmental feats,”  many highlighting insight which might come in handy in the emergency department. Check out these summer reads, and even more, found at:

https://www.outsideonline.com/2176152/adventurers-books-changed-their-lives?utm_source=facebook&utm_campaign=facebookpost&utm_medium=social&fbclid=IwAR1ew3J5vGF7UXXmi1nVkhbMpu5nMhGkmvwoTMm8nff4UVM4bwMk4cvc4MM.

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‘Willpower: Rediscovering the Greatest Human Strength’ by Roy F. Baumeister

“When distance runner Alexi Pappas was assigned psychologist Baumeister’s book about self-control as summer reading in college, it changed the way she thought about her limits as an athlete. “The book gave me the words to identify some of the things I was feeling,” Pappas says. “It taught me that I have a certain amount of willpower that can be depleted but can also be replenished, which are both such important things to know and realize as an athlete trying to push boundaries and improve yet also have longevity. It also told me that it is okay and super important to sleep.”” (1)

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‘Thinking Fast and Slow’ by Daniel Kahneman

 

“In his job as host of the Dirtbag Diaries podcastFitz Cahall breaks down a lot of the one-dimensional conventions we have about the outdoors, from weekend warriors to environmental activism. The book that Cahall says colored a lot of his thinking, Thinking Fast and Slow, does the same, just on a different scale. “I think for me it basically comes down to this: there are a lot of obvious ways of looking at the world and at people, but they aren’t always the correct ones,” he says. “We are really good at tricking ourselves into following others and our own deep biases. Right now, I think it’s worth examining how we think, how we engage, and how we empathize with others. There are a lot of ideas in that book, but I think what’s important is that questioning our assumptions is more imperative than ever.”

Our Favorite Quote: “Our comforting conviction that the world makes sense rests on a secure foundation: our almost unlimited ability to ignore our ignorance.”” (1)

 

  1. Hansman H. 10 Adventurers on the Books that Changed Their Lives. Outside Online. https://www.outsideonline.com/2176152/adventurers-books-changed-their-lives?utm_source=facebook&utm_campaign=facebookpost&utm_medium=social&fbclid=IwAR1ew3J5vGF7UXXmi1nVkhbMpu5nMhGkmvwoTMm8nff4UVM4bwMk4cvc4MM. Published July 10, 2019. Accessed August 21, 2019.

 

Fall 2019 Selection

The Alchemist by Pablo Coelho

Check out this review, if you’re feeling luke-warm about the selection, this youtuber will get you pscyhed! (1)

Bonus: No joke on the graphic novel version of this book!  https://www.amazon.com/Alchemist-Paulo-Translated-Clarke-Coelho/dp/0007435185

  1. Entertainment MD. This is why you should read the Alchemist! (Review). YouTube. https://www.youtube.com/watch?v=dH0IVh5YOLY. Published September 1, 2014. Accessed July 28, 2019.

Copa Book Club Fall Selections

A Long Way Gone

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A Long Way Gone: Memoirs of a Boy Soldier (2007) is a memoir written by Ishmael Beah, an author from Sierra Leone. The book is a firsthand account of Beah’s time as a child soldier during the civil war in Sierra Leone (1990s).[1] Beah ran away from his village at the age of 12 after it was attacked by rebels, and he became forever separated from his immediate family. He wandered the war-filled country and was forced to join an army unit who brainwashed him into using guns and drugs. By 13, he had perpetrated and witnessed a great deal of violence. At the age of 16, however, UNICEF removed him from the unit and put him into a rehabilitation program. There he was able to find his uncle that would adopt him. With the help of some of the staff he was able to return to a civilian life and get off drugs. He was then given an opportunity to teach others about child soldiers. He traveled the United States recounting his story.”  (1)

 

One Few Over the Cuckoo’s Nest

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“One Flew Over the Cuckoo’s Nest (1962) is a novel written by Ken Kesey. Set in an Oregon psychiatric hospital, the narrative serves as a study of institutional processes and the human mind as well as a critique of behaviorism and a tribute to individualistic principles.[3]  (3)

The Alchemist 

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“Paulo Coelho’s masterpiece tells the magical story of Santiago, an Andalusian shepherd boy who yearns to travel in search of a worldly treasure as extravagant as any ever found.

The story of the treasures Santiago finds along the way teaches us, as only a few stories can, about the essential wisdom of listening to our hearts, learning to read the omens strewn along life’s path, and, above all, following our dreams.” (2)

 

  1. A Long Way Gone. Wikipedia. https://en.wikipedia.org/wiki/A_Long_Way_Gone. Published March 6, 2019. Accessed July 22, 2019.
  2. Coelho P. The Alchemist. Amazon. https://www.amazon.com/Alchemist-Paulo-Coelho/dp/0061122416. Published April 25, 2006. Accessed July 22, 2019
  3.  One Flew Over the Cuckoo’s Nest (novel). Wikipedia. https://en.wikipedia.org/wiki/One_Flew_Over_the_Cuckoo’s_Nest_(novel). Published June 22, 2019. Accessed July 22, 2019.

Dream Land, Summarized

We hope you can make it to the July 23rd Summer Edition Copa book club. A quick summary for reference from Book Rags.

“Working as a crime reporter with a focus on Mexican drug trafficking, Sam Quinones found himself at the nexus of Ohio’s Rust Belt and Appalachian Kentucky, investigating how heroin from a small village from a small state in Mexico found its way to the eastern United States in alarming numbers. “I grew consumed by this story,” he admits the book’s introduction, “it was a story about America and Mexico, about addiction and marketing, about wealth and poverty, about happiness and how to achieve it” (8). The story, which he retells in the pages of Dreamland, follows the progression of opiate abuse and dependence throughout history with a hyper-critical lens on the years leading up the current opiate epidemic. Combining his investigative and storytelling prowess, Quinones paints a dynamic and moving picture of the opiate epidemic from every possible perspective, from dealers and addicts, to doctors and clinicians, to football players and wrestlers. With a swiftly-moving structure, dramatic flair, and a genuinely insatiable appetite for his subject matter, Quinones manages to maintain several fluent narratives within his rapid pace; the product is an equally captivating and informative investigation into one of the largest social issues of the modern United States – opiate addiction.

Quinones begins by investigating the roots of pain and pain management, a history plagued at every turn by the morphine molecule. Though the “Holy Grail” of modern medicine, a non-addictive opiate painkiller, continues to elude researchers, pain remains a far-reaching and serious problem (76). Combined with Americans’ proclivity for fast and convenient fixes, those suffering from pain and the doctors ethically bound to treat them initiated what Quinones calls the pain revolution, a hugely successful campaign to destigmatize the use of opiates for a wide array of pain patients. On this newly destigmatized turf, pharmaceutical behemoth Purdue introduced OxyContin with a direct and aggressive marketing campaign driven by profit as opposed to pain management. Alongside his story of the pain revolution and the spread of OxyContin use and abuse, Quinones weaves in the narrative of the book’s primary cast of characters: a vast but loosely connected network of Mexican heroin traffickers called the Xalisco Boys. The Boys’ efficiency, scope, their humble roots from the same small state of sugarcane farmers, and their reluctance to engage in territorial violence and drug use like most trafficking networks intrigued Quinones and law enforcement alike. Within the pages of Dreamland, Quinones details these two powerful waves of opiate abuse, one stemming from prescription pads and the other from Mexican black tar heroin, and their convergence to create the opiate epidemic.

In studying the convergence of these two waves, Quinones found himself at the same frustrating and confusing crossroads as the parents of overdose victims: how can someone grow addicted to doctor-prescribed drugs? Why did black tar heroin ravage middle class suburbia? Why wasn’t rehab enough? By the end of his investigation, he realized that “the history of heroin was best told by addicts,” as their relatable stories of human suffering and failed attempts at redemption re-painted them as humans affected by a disease rather than desolate junkies (71). In this light, Quinones works to humanize addicts by offering their stories in their own words as well as the stories of family members who have lost a loved one to addiction. Support groups and activist organizations run by parents of young overdose victims offer a beacon of hope that a “drug scourge so ably abetted by silence” may be defeated by speaking out (289). While most of his text is dedicated to the investigation of the roots and progression of the opiate epidemic, Quinones naturally finds himself searching for the same answers as those in the throes of the epidemic. Instead of wallowing in these difficult questions, however, Quinones looks to the future to find hope; “perhaps heroin is the most important force for positive change in our country today,” because, as he believes “more strongly than ever,” “the antidote to heroin is community”” (1)

  1. Dreamland: The True Tale of America’s Opiate Epidemic Summary & Study Guide. http://www.bookrags.com/studyguide-dreamland-the-true-tale-of-americas-opiate-epidemic/#gsc.tab=0. Accessed July 22, 2019.

Glial Cells Hijacking Pain

Maybe you’ve had a patient who’s response to pain is out of proportion to their medical illness.  Outside of pain of proportion being a harbinger for badness in a few rare conditions, could severe pain be a mis-wiring, a mal-interpretation of otherwise appropriate stimuli?

Consider the approach of Elliot Krane in addressing chronic pain featured on NPR’s TED Radio hour:

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https://www.npr.org/2017/02/10/514142569/is-pain-a-symptom-or-a-disease

Soul Pain

I was introduced to the term “soul pain” by an attending this week, and I can’t help but share.  I think we as emergency department personnel come in contact with an awful frustrating feeling that we fall short of addressing the pain that patients bring to our practice.  It occurred to me that maybe we are failing to acknowledge the very real “soul pain” that we see on a regular basis.

I actually came across an “academic piece” — a paper written with academic leanings –that investigated the effects of “soul pain” on providers working with victims of trauma.

“Soul pain, a term first used by one of the women I interviewed, refers to a deep, gut-wrenching ache that pierces the core of one’s being. It is a spiritual pain, a sorrow born of seeing the cruelty that human beings inflict on one another and of feeling powerless to stop it. This finding is important not only because it expands on our current understanding of the occupational hazards of the helping professions, but also because it reveals a hitherto unexamined dimension—that of the soul or spirit—that is affected by one’s activities in the workplace.” (1)

Maybe it seems like a matter of semantics, but consider what the material costs of working with victims of violence.

“Similarly, researchers have found that counselors working with survivors of violence experience significant changes in their beliefs about the goodness of other people (Schauben & Frazier, 1995), as well as disruptions within their own interpersonal relationships (Robinson-Keilig, 2014).” (1)

Next time you see that 4th patient of the night with vague abdominal pain, seemingly ongoing for multiple years,  think of soul pain.  Acknowledging that utter frustration might be more meaningful than you think.

 

  1. Jirek SL. Soul Pain: The Hidden Toll of Working With Survivors of Physical and Sexual Violence – Sarah L. Jirek, 2015. SAGE Journals. https://journals.sagepub.com/doi/10.1177/2158244015597905. Published July 23, 2015. Accessed July 10, 2019.

Isolation and Addiction

Rachel Wurzman is a neurobiologist interested in the interactions between addictions, society and behavior.  She gives a TED talk that winds it way to focus on addiction and isolation.  I’ve included some of my favorite quotes as well as a link for the talk below.  Wurzman does not offer a solution, but she does leave me wondering how medicine could adopt loneliness and isolation as a health problem and what tools we might use to solve this puzzling problem.

“Think of it like this: when you’re at your hungriest, pretty much any food tastes amazing, right? So similarly, loneliness creates a hunger in the brain which neurochemically hypersensitizes our reward system. And social isolation acts through receptors for these naturally occurring opioids and other social neurotransmitters to leave the striatum in a state where its response to things that signal reward and pleasure is completely, completely over the top. And in this state of hypersensitivity, our brains signal deep dissatisfaction. We become restless, irritable and impulsive.”

  1. Wurzman R. Transcript of “How isolation fuels opioid addiction”. TED. https://www.ted.com/talks/rachel_wurzman_how_isolation_fuels_opioid_addiction/transcript#t-486877. Published October 2017. Accessed June 28, 2019.

Who’s Role was it to Get Me Off This Medication?

You see it not infrequently these days, our ‘solutions’ that now need more ‘solutions.’ We created the miracle of plastic, and now it’s micro-particles clogs our water supply.  We create amazing long lasting drugs to address horrible pain and yet do not consider how patients may come to live without pain medication.

I came across a compelling TED talk during which a patient describes his journey tapering opioids. The story is both shocking for its vivid description of withdrawal but also its call to action.  Withdrawal is sometimes difficult to measure with vital signs or lab tests and it is exquisitely easy to underestimate.  Addressing the problem can be equally hopeless and frustrating.  Who in the house of medicine owns this problem? Do we refer to pain management or rehab and call it a day?  What is our role in demanding that treatment, including the use of both medications and therapy, be part of our purview?

“The early stages of withdrawal feel a lot like a bad case of the flu. I became nauseated, lost my appetite, I ached everywhere, had increased pain in my rather mangled foot; I developed trouble sleeping due to a general feeling of restlessness.” (1)

“At the beginning of week two, my life got much worse. As the symptoms dialed up in intensity, my internal thermostat seemed to go haywire. I would sweat profusely almost constantly, and yet if I managed to get myself out into the hot August sun, I might look down and find myself covered in goosebumps. The restlessness that had made sleep difficult during that first week now turned into what I came to think of as the withdrawal feeling. It was a deep sense of jitters that would keep me twitching. It made sleep nearly impossible. But perhaps the most disturbing was the crying. I would find myself with tears coming on for seemingly no reason and with no warning. At the time they felt like a neural misfire, similar to the goosebumps.” (1)

“At the beginning of week three, my world got very dark. I basically stopped eating, and I barely slept at all thanks to the jitters that would keep me writhing all night. But the worst — the worst was the depression. The tears that had felt like a misfire before now felt meaningful. Several times a day I would get that welling in my chest where you know the tears are coming, but I couldn’t stop them and with them came desperation and hopelessness.” (1)

“ Well, after I initially published my story in an academic journal, someone from the CDC sent me their pocket guide for tapering opioids. This is a four-page document, and most of it’s pictures. In it, they teach physicians how to taper opioids in the easier cases, and one of the their recommendations is that you never start at more than a 10 percent dose reduction per week.” (1)

“After being turned away from a rehab facility, I finally admitted defeat. I was broken and beaten, and I couldn’t do it anymore. So I told Sadiye that I was going back on the medication. I would start with the lowest dose possible, and I would take only as much as I absolutely needed to escape the most crippling effects of the withdrawal. So that night she helped me up the stairs and for the first time in weeks I actually went to bed. I took the little orange prescription bottle, I set it on my nightstand … and then I didn’t touch it. I fell asleep, I slept through the night and when I woke up, the most severe symptoms had abated dramatically. I’d made it out. ”  (1)

Below is a link to the CDC pocket guide mentioned in the talk:

https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf

  1. Rieder T. Transcript of “The agony of opioid withdrawal — and what doctors should tell patients about it”. TED. https://www.ted.com/talks/travis_rieder_the_agony_of_opioid_withdrawal_and_what_doctors_should_tell_patients_about_it/transcript#t-86107. Published October 2017. Accessed June 28, 2019.

 

 

 

 

 

 

Science Vs: How a Nation Got Hooked

Science Vs. a podcast produced by Gimlet media, highlighted the making of the opioid epidemic in their March 22nd cast.  They feature the perspectives of a chemist/professor from Wisconsin (whoot!), a pain specialist from Washington as well as an emergency physician from Philadelphia. The podcast largely echos the sentiment from our most recent read, so consider adding it to your commute or work out play list.  Lastly a quick shout out to the podcast show notes with EXTENSIVE use of citations to call out scientific literature. Don’t miss this entertaining format delivering you the evidence right to your ear buds!

More people in the U.S. died from opioids in 2016 than the peak year of the AIDS epidemic. So how did we get here? We speak to Prof. June Dahl, pain specialist Dr. David Tauben, and emergency physician Dr. Jeanmarie Perrone.” (1)

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https://gimletmedia.com/shows/science-vs/6nh3lg/opioids-how-america-got-hooked?utm_source=gimletPlayer&utm_medium=copyShare&utm_campaign=gimletPlayer

  1. Science Vs. Opioids: How America Got Hooked | Science Vs. Gimlet. https://gimletmedia.com/shows/science-vs/6nh3lg. Published April 15, 2019. Accessed June 13, 2019.