Waiting To Call An Ambulance Is Not Much Of Plan

I don't like to write about my own health problem - but it is a ready example and I already have another blog about it so here goes.  I also don't need to worry about violating my own confidentiality.  It involves a personal medical problem called paroxysmal atrial fibrillation.  I have consulted 5 different Cardiologists and the rhythm problem is not due to valvular or coronary artery disease.  It is probably due to excessive exercise - specifically exercise with sustained high heart rates.  After a period of frequent episodes, I started taking a generic brand of flecainide 4 1/2 years ago and have not had an episode since.  During that time I have had two episodes of influenza and 1 episode of acute bronchitis requiring prednisone therapy with no recurrence of atrial fibrillation.

Lately I have been seeing patients and about 40% of them have an upper respiratory virus and the various complications.  I knew it was just a matter of time.  Earlier this week I developed a cough, sneezing, facial burning, and a headache but no additional flu like symptoms.  It is not flu season here, but respiratory viruses abound.  Monday, Tuesday and Wednesday morning - I was awakened at 4 AM with an intense flurry of palpitations.  Taking the pulse showed a pattern of 4 or 5 regular beats followed by what seemed like a pause or dropped beat that I recognize as the early transition (I think) to atrial fibrillation.  In each case I drank a large glass of water, paced for a minute or two and I was back in sinus rhythm - the palpitations resolved.  Initial BP check was about 130/80 with a pulse of 88 rapidly back down to 110/70 with a pulse of 58.  The last readings are my typical baseline and I check them four times a day.  I know how much physical, mental, and emotional exertion affects those readings and I try to stay cool.

When it happened Wednesday, I decided to do the responsible thing and take the day off of work and see my primary care physician.  He did a physical exam, ordered labs and an ECG.  Everything was normal.  That is my ECG from that clinic visit at the top of this post.  It is normal sinus rhythm with a slight bradycardia (less than 60 bpm).  An interesting homage to artificial intelligence is that the ECG machine communicated with the electronic health record (EHR) and determined that there was no appreciable change between this ECG and one I had done 10 months ago.  The cardiologist is out of that loop.  The bottom line is that the tests were all negative and the plan was to see what happened and consider a Holter monitor if it persisted.  A Holter monitor in this clinic is a 48 hour recording of the ECG looking for discrete events that might suggest a cause of the rhythm disturbance.  It also allows the patient to mark any episodes of subjective disturbance on that record.

Yesterday morning I felt a little tachycardic at about 5 AM and got up and checked.  Heart rate was 66 and blood pressure was fine.   This AM, a flurry of palpitations wakes me up.  They are gone in two minutes after pacing and drinking water.  There was no chest pain or lightheadedness.  In fact when I had the initial episode about 10 years ago, I was speedskating and my heart monitor showed a rate of well over 200 bpm.  No chest pain or lightheadedness at that time and I drove to the hospital and told them I was in atrial fibrillation.

Today I respond to my primary care physician's note though the EHR and describe what happened.  I recall that he is not in, so I go back to the EHR,  agree that I can be billed if this is not a problem that I have been seen for in the last 7 days and attempt to cut and past my note to my primary care doctor into a separate email to his team.  The EHR cuts me off because it says that I can only use 255 characters.  It is the Twitter of EHRs.  I edit it down and send it - no response to my request for the Holter monitor.  I call the clinic and get on the phone with a triage nurse.  The conversation goes something like this (not a transcript):

Me: (Relating the history and Holter monitor request).
Triage RN:  "Well what is the emergency here?  It is Friday afternoon, there is no way that we are  going to get a Holter monitor today.  It will be Monday at the earliest. Your doctor can call it in then"
Me (a little steamed): "Maybe you could suggest criteria that I can use to call an ambulance."
Triage RN: "What?"
Me: "You know - when I wake up from a deep sleep with this arrhythmia at 4AM tomorrow morning, what criteria should I use to decide when to call an ambulance?"
Triage RN: "I did not know it was still happening."
Me: "It happened this morning.  That is why I e-mailed and called you.  That is why I stayed home from work."
Triage RN: "Well in that case I will run it by one of the attendings who is here and ask them about what should be done."

After another call back to get more of the usual information about cardiac symptoms, the Triage RN called again and connected me with the Holter Monitor tech.  I can apparently get in next Wednesday.  He told me the entire procedure would take 5 minutes so I would only have to miss a half day of work instead of a full day.  I did not pursue the obvious "Well why can't I just drive down there now and have it put on."  Everyone must be scheduled.  Schedules must be adhered to.

So that is where it stands tonight.  All of the bullshit that passes in the press for medical news does not apply.  There is no IBM Watson computer out there that knows more than I know about this condition or how to treat it.  There is no personalized medicine.  I have not encountered a single cardiologist interested in the genetics of atrial fibrillation or why I might have it.  Most  physicians assume I have neglected hypertension or have done something wrong with regard to my self care and therefore deserve it.  I still encounter physicians who doubt that I have never smoked a single cigarette in my life - even though it is true.  Hard to believe that somebody could bring this on by excessive exercise.  Isn't exercise supposed to be good for you?

I am probably being overly dramatic.  This is most likely a benign atrial arrhythmia.  On the other hand - why am I so certain if my physician wants another Holter?  I did a Holter and a longer event monitor 5 years ago.  I run a heart rate of 130 bpm during 4 hours of exercise per week and have tolerated a sustained heart rate of 140 bpm from a medication side effect - calmly pacing and taking incremental amounts of beta blockers to slow it down.  The final instructions from the triage nurse were to get to a hospital if a sustained heart rate of 120 bpm or greater and call an ambulance if chest pain.

Personalized medicine in the early 21st century is in many ways inferior to medicine the way it was practiced in the 20th century.  In those days, there may have been an interested physician who said: "Spend a night on telemetry and we will see if we can capture the beats and figure out what to do about it."  I saw those people being admitted when I was a medical student and an intern.  That was before you had to be dying to get into a hospital and the admission rules were dictated by case managers.  In those days personalized meant a long term personal relationship with a real physician who  could make things happen.

Now like me - those people are sitting at home waiting for something to happen and guessing about when they should call an ambulance.


George Dawson, MD, DFAPA




Disclaimer:

Don't try any of this at home.  This is not medical advice.  Only your personal physicians and consultants can give you that advice.

JAMA Psychiatry Suicide Article, Statistics and AI

Suicide Rates - Selected OECD Countries

Suicide is a very important problem for psychiatrists.  Even though it is a rare event, it seems like most of our time is focused on preventing suicide.  There are many days where many high risk patients and patients with chronic suicidal ideation are seen in clinics and hospitals.  Most of them are treated in outpatient settings and very few are treated on an involuntary basis in hospital settings.  Since suicide is diametrically opposed to self preservation it is assumed that any rational person would want to get help with those thoughts and impulses.  Like most things in psychiatric practice it is almost never than simple.  Psychiatrists encounter a wide range of of reasons for suicidal thinking.  At times, the suicidal thinking was not obvious until it was declared after a suicide attempt.  Many people decide to see psychiatrists after a first suicide attempt.  Even at that point it is common to find a person who is disappointed that they did not succeed.  It is more common to find a person greatly relieved that they survived but even then that does not assure the cooperation necessary to prevent another attempt.

The standard of practice for assessing suicidal thinking or ideation and potential risk is risk factor analysis.  This has been the standard of practice for as long as I have practiced over the past 30 years.  To do this analysis, it requires making a diagnosis or a series of diagnoses and looking at associated factors and how the patient describes his/her mental state at the time.  Major psychiatric diagnoses like major depression, schizophrenia, bipolar disorder, panic disorder, borderline personality disorder and chronic substance use disorders all have significant lifetime prevalences of suicide varying from 3 to 15%.  Psychological autopsies of series of suicides find that nearly all of the patients who have suicided in these studies had a significant psychiatric disorder.  There are also studies done from a social science perspective that emphasize the social risk factors for suicide including sex, martial and relationship status, economic factors and loss.

Suicide is a widely misunderstood problem sometimes even for the patients who are experiencing the thoughts.  It is common for example to encounter people with suicidal thinking who say that their only deterrent to suicide is that they don't "have the guts" to do it.  An associated worry might be that it is "too painful."  They feel a need to explain why they cannot carry out an irrational act.  I take this to mean that at some point in time, the suicidal person's conscious state has changed.  They are no longer a rational person and that is why they must explain away the fact that they cannot carry out an irrational act.  Another common observation that speaks to the conscious state is that many people will say "I never understood how a person could be suicidal until I finally felt that way."  That suggests that the altered conscious state is associated with a mood state of depression or many times a mixture of depression, anger, and anxiety resulting in an agitated state that led to the understanding about suicidal thoughts.  A final observation is one of the most stressful parts of psychiatric practice and that is:  "Can I believe this person when they tell me they are not going to kill themselves?"  Much of acute care psychiatry hinges on that ultimate question.  The risk factor analysis is essentially nullified if the patient is in an emergency department and their diagnosis and past suicide attempts are known.  The only thing left to go on are the standard questions about current state of mind, deterrents, safety plans and whether the person seems reliable and says they will not kill themselves.   It is widely known that people kill themselves after leaving emergency departments and hospitals.  People have killed themselves in hospitals while under direct observation.

Many of these assessments become adversarial.  By the time a psychiatrist sees a patient in a hospital, a lot has already happened. In all of the hospitals where I have practiced, crisis teams, paramedics, and the police have assessed the person in the community and brought them in to the hospital.  Very few people were under psychiatric care at the time of that intervention.  Friends and family members of the patient were the people who called the first responders.  The patient is usually there out of some concern for their welfare that they may not be aware of.  The psychiatrist comes around sometime in the next 24 hours and the interaction unfolds.  Very few people seem interested in the fact that they might kill themselves.  Getting out of the hospital may be the priority.  Their approach might be one of non-disclosure or denial: "I really did not say I was suicidal." or "I did not mean it",  or "I was drunk or high at the time".  Even those responses can vary from very unlikely (as in a patient with a serious self inflicted gunshot wound) to unlikely (a patient with delusional depression stopped in the midst or a suicide attempt) to possible (the intoxication history with no suicidal ideation while sober).  The interview dynamic is also quite variable.  A person may be sullen, irritated, and not wanting to discuss much information.  They may express concerns about self incrimination: "I know what I can and cannot say to psychiatrists.  I know if I say the wrong thing you will lock me up and throw away the key."  They may blame their problems on the psychiatrist: "Look - I know you don't care about me.  The only thing you care about is covering your ass.  You are going to do whatever you want to do."  They may be more hostile and sarcastic: "Look if I was really going to kill myself I wouldn't be sitting here talking to you.  I'd be dead.  I wouldn't be talking about it."

All of these statements ignore the fact that the person is sitting in front of the psychiatrist as the result of the actions of several other people including persons affiliated with them and having their best interests at heart.  That situation is so intense and uncomfortable that it prevents physicians from going into psychiatry.  I  have had many physicians tell me they could not go into psychiatry because:  "Guessing about whether or not a person will kill themselves is too stressful."  There are many ways to reduce the guesswork involved but the point I am trying to make here is that all of these behaviors are consistent with the patient having undergone a change in their conscious state.  They are no longer acting like a person interested in self preservation, but they are now a person who is contemplating self destruction and taking active measures to hide that thought pattern.  That is the main reason why psychiatrists can't predict suicide over long periods of time with any degree of certainty.  When a person's conscious state changes that completely, their actions are less predictable even to the point that they may be potentially self destructive and want to cover it up.

That is also why risk factor analysis is so imperfect.  In the case of the diagnosis, a lot of clinicians are under the impression that if a person satisfies some written criteria for a diagnosis that provides a lot of critical information about the potential for suicide.  Many clinicians seem to miss the point that a patient can have the exact same written criteria for major depression with psychotic features and the same chronic markers on a suicide risk assessment and suddenly be much more likely to attempt suicide.  The only thing that has changed has been the patient's conscious state and their awareness that suicide is an unwanted state.  The evidence that this happens is clinical and ample.  Patients will report back to their psychiatrists that they were in this conscious state and the psychiatrist did or did not miss it.  Either way, there is no clinician in this situation who could make the correct call.  Without any clear markers, there is no way to figure out if this change in conscious state has occurred.  The patient usually recognizes it only in retrospect.

This clinical information on the assessment of suicide is what makes this JAMA Psychiatry article interesting.  In this article the authors attempt to determine predictors of suicide by soldiers in the year following psychiatric hospitalization within the Veteran's Administration hospital system over a 6 year period.  That was a total of 40,820 hospitalizations or 0.9% of the total Army personnel in any 12 month period.  During that time there were a total of 68 deaths by suicide.  That is number is 12% of all US Army suicides.  The authors consider a long list of potential risk factors that are largely demographic in nature to determine concentration of risk of suicide.  That list includes a law enforcement data base that clinicians do not have access to.  Their overall goal was to determine of it was practical identify high risk patients for post hospitalization intervention and whether that might be a cost effective way to prevent suicide.  They were able to identify the highest risk group - the 5% of hospitalizations in which 52.9% of the suicides occurred.  Like many similar studies the authors also comment on  how their "actuarial" methods usually trump clinicians making the same predictions.  I found very limited commentary on that fact that it is generally possible to illustrate what you want with enough variables or as we used to say "a large enough spreadsheet".  In this case they looked at a large number of variables to come up with 421 predictors for further analysis.  I have reviewed hospital records consisting of the printout of the electronic health record where there were scarcely 421 words and it was usually impossible to determine an admission or discharge date.  Any information on even a short term assessment of suicide risk is scant and it frequently says basically that the patient told us he or she was not going to make a suicide attempt.  In some cases a rating scale approach like the Columbia is used.  Clinicians using these scales are often surprised about how few variables change after the initial rating and how the numerical risk does not necessarily reflect an inpatient versus and outpatient population.

As I read through the article, I was also impressed with the amount of alien statistics and fairly esoteric statistical terms.  If JAMA Psychiatry wants to include these methods, I think an example of the calculations and a bibliography of additional reading would be a minimal requirement.  The addition of statistical reviewers' comments or an independent statistical discussion of the pros and cons of these methods would only enhance the quality of the discussion.  One of my concerns is that as the statistical methods get more abstract and vague notions about big data are more accepted, clinical complexity and wisdom are completely diluted down and out.  I saw a headline the other day that Internet sellers know more about your "personality" than your spouse.  It should be fairly obvious from all of the healthcare research done that is based on HEDIS (The Healthcare Effectiveness Data and Information Set) information, that demographic variables and product choices are not the same thing as clinical assessment and treatment.

If the headlines about artificial intelligence replacing doctors ever comes true, it will only happen if the machine can implement the required knowledge.  The performance of computers sifting through text based findings and diagnostic criteria has been know for 20 years (reference 3).   Those data points were generally far superior to demographics.  I owned 2 of those programs and they don't bother to sell them anymore.  In terms of the assessment and treatment of suicide a knowledge base included in the Harvard  Medical School Guide To Suicide Assessment and Intervention might be a step in the right direction.  A lot of that knowledge depends on the skill of a particular clinician and that includes the personality factors of clinicians who continue to do this impossible job day after day.      

Trying to predict suicide and prevent it can't currently be done with an algorithm.  If I see an algorithm I will consider why the high risk people aren't being seen in follow up from the hospital rather than who should get an intervention.   And I would not mind errors on the false positive side.


George Dawson, MD, DFAPA

1:  Kessler RC, Warner CH, Ivany C, Petukhova MV, Rose S, Bromet EJ, Brown M 3rd, Cai T, Colpe LJ, Cox KL, Fullerton CS, Gilman SE, Gruber MJ, Heeringa SG, Lewandowski-Romps L, Li J, Millikan-Bell AM, Naifeh JA, Nock MK, Rosellini AJ, Sampson NA, Schoenbaum M, Stein MB, Wessely S, Zaslavsky AM, Ursano RJ; Army STARRS Collaborators. Predicting Suicides After Psychiatric Hospitalization in US Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2015 Jan 1;72(1):49-57. doi: 10.1001/jamapsychiatry.2014.1754. PubMed PMID: 25390793.

2:  Douglas G. Jacobs, editor.  Harvard  Medical School Guide To Suicide Assessment and Intervention.  Jossey-Bass Inc., San Francisco, CA, 1998.

3:  Berner ES, Webster GD, Shugerman AA, Jackson JR, Algina J, Baker AL, Ball EV,Cobbs CG, Dennis VW, Frenkel EP, et al. Performance of four computer-based diagnostic systems. N Engl J Med. 1994 Jun 23;330(25):1792-6. PubMed PMID: 8190157.

Will The AI Apocalypse Be Worse Than Customer Service?

I am a survivalist and make no excuses for it.  I have posted my experiences in the cold weather and nearly freezing to death.  I am sure that is part of what makes a survivalist.  That combined with an early recognition that men often don't make rational decisions.   They are capable of making irrational decisions on a grand scale.  I was in grade school during the Cuban Missile Crisis.  Being in a small town, we escaped all of the duck and cover exercises that kids in the big city went through.  But paranoia about the Russians, nuclear war, and radioactive fallout was always there.  I worked for the town library in the 1970s and found out it had been the local nuclear fallout shelter.  I spent days clearing out steel 30 gallon drums that were supposed to double as water and waste containers in a fallout emergency.  In those days before atmospheric nuclear tests were banned, I can still recall a radioactive cloud passing over our town.  Experts from the state university were on television talking about Strontium-90 in the fallout and how that could end up in milk products.  My grandfather picked up on that and referred to it as "Strawberry-90".  He was somewhat of a radical, predicting that there was going to be a "revolution" at some point as the ultimate solution to a corrupt government.  Survivalism may have genetic determinants.

I was surprised when Stephen Hawking came out earlier this year and said that artificial intelligence (AI) represented a threat to humans.  I have seen all of the Terminator films and the Sarah Connor Chronicles.  As expected, any tales of a band of zealots surviving against all odds appeals to me.  But then it seemed that this was more than a cultural and artistic effort.  One of the arguments by Bostrom suggests that the survival of all of the animals on the planet depends on the animal with the highest intelligence - homo sapiens.  If a machine intelligence was developed one day that surpassed human intelligence it would follow that the fate of humans would depend on that machine intelligence.  There are competing arguments out there that suggest a model where the AI interests and human interests would compete politically.  Can you imagine how humans would fare in our current political systems?  A lot of the experts suggest that we won't have to imagine battling robots in human form and that makes sense.  It is clear that there are thousands of cyber attacks against our infrastructure every day.  Imagine what a concentrated AI presence unencumbered by sociopathy or patriotism could do?

Imagining the battlefield of the future scenes from any Terminator film or same-themed video game, I decided this morning that you don't need a high tech approach to wreak havoc among the populace and drain their resources.  You only need Customer Service.  The concept needs to be refined to modern customer service.  Even in the early days of the Internet, you could talk to a fellow human and they would hang in there with you until the problem was solved.  I can recall calling Gateway Computers for an out-of-the-box problem back in the 1990s.   The technical assistance rep and I completely disassembled and reassembled my PC over the next 2 hours.  And the end result was that it worked perfectly for the next 5 years.  I doubt that anything remotely that heroic happens today.

Twenty one days ago I downloaded graphics software from Amazon.   I am an Amazon Prime customer and order just about everything from them.  I am not a stockholder and my only interest is in getting things that nobody else stocks as soon as possible.  I had previously downloaded software from them and everything went well.  This time, I got an activation code and no serial number.  I complained to customer service and got an e-mail saying we will give you your money back but for the serial number problem you need to contact the manufacturer.  To back up a minute, I have no idea how I got that e-mail through to Amazon and could not replicate what I did in a hundred tries.  The obstructionist beauty that underlies all telephone queues and Internet sites is that it is very clear that they are not really designed to get you through to anyone.  It is a maze of dead ends and non answers.  At many of the dead ends you are polled: "Was this page helpful?".  So far I have not found a single page that was.

The dead ends at the computer graphics software site were even more formidable.  In order to contact customer service I had to set up an account.  After doing that I needed a serial number.   Of course that was my question in the first place.  How can I ask about getting a serial number when I need a serial number to ask the question?  It seemed like the ultimate dead end.  Amazon did send me a customer service number for the software company.  This number was not available on the company's web site.  In calling the number, their queue provided 4 options none of which applied to me.  It gave options for order numbers that started with different numbers and I had an Amazon number that did not fit any of the choices.  Just like my previous adventure in medical diagnostic queues - I picked one.  A scratchy recording of bad electronic music started playing.  It was interrupted every minute by a worse electronic voice telling me how important my call was and how I would be forwarded to a customer service rep.  That went on for half an hour and then the voice said:  "We are sorry but there is no one here to take your call.  Please leave a message with your number and we will get back to you?"

That was hours ago.  Given the attitude projected by this company, I am not holding my breath on the return call.  I have 1 week left to try to activate software that I paid over $400 for.  There is no solution in sight and it does not appear anyone is even interested in solving the problem, except me.  I can get my money back - but the whole point of this is that I really want to work with that software.

Implications for the AI Apocalypse?  It doesn't take much to defeat Internet dependent humans and deplete their resources.  I have actually taken PTO to try to accomplish this.

I don't think there will be a shot fired in the AI Apocalypse of the future.  No intense battles between humans and cyborgs.  No Doomsday Weapon.

 Just a low tech endless loop of customer service dead ends.


George Dawson, MD, DFAPA

Supplementary 1:   Photo credit here is FEMA.  It is an open access copyright free photo per their web site.

Supplementary 2:  My customer service problem was resolved today (on Tuesday November 25, 2014).  The final solution was given by Amazon and they deserve the credit for resolving this problem.  I don't think that detracts from noting the overall trend of decreasing support and what that implies for IT in healthcare and the culture in general.