Lily's Blog

Patrick was home for the weekend and while home he referred me to this article by Atul Gawande, an American doctor and journalist, in the New Yorker magasine. The article is entitled, ‘The Checklist‘ with a sub heading, ‘If something so simple can transform intensive care, what else can it do?’

This simple tool – the checklist, is no new, ground-breaking, expensive medical treatment. This simple tool however can be very powerful as Gawande’s article demonstrates. The full article is very well-worth reading but I have to warn you that it’s long. Here are extracts:

A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions—but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard.
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This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four per cent of those lines become infected. Line infections occur in eighty thousand people a year in the United States, and are fatal between five and twenty-eight per cent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks.
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In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it (checklists as used in flying) a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, … line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary … The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.

Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

Pronovost recruited some more colleagues, and they made some more checklists. One aimed to insure that nurses observe patients for pain at least once every four hours and provide timely pain medication. This reduced the likelihood of a patient’s experiencing untreated pain from forty-one per cent to three per cent. They tested a checklist for patients on mechanical ventilation, making sure that, for instance, the head of each patient’s bed was propped up at least thirty degrees so that oral secretions couldn’t go into the windpipe, and antacid medication was given to prevent stomach ulcers. The proportion of patients who didn’t receive the recommended care dropped from seventy per cent to four per cent; the occurrence of pneumonias fell by a quarter; and twenty-one fewer patients died than in the previous year. The researchers found that simply having the doctors and nurses in the I.C.U. make their own checklists for what they thought should be done each day improved the consistency of care to the point that, within a few weeks, the average length of patient stay in intensive care dropped by half.

The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events … A second effect was to make explicit the minimum, expected steps in complex processes.

Gawande stated that Pronovost is hardly the first person in medicine to use a checklist, but that he was among the first to recognize its power to save lives and take advantage of the breadth of its possibilities.

Gawande then described how Pronovost then took his findings on the road, showing his checklists to doctors, nurses, insurers, employers—anyone who would listen. He spoke in an average of seven cities a month while continuing to work full time in Johns Hopkins’s Hospital. But this time he found few takers.

There were various reasons. Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost’s evidence. So far, he’d shown only that checklists worked in one hospital, Johns Hopkins, where the I.C.U.s have money, plenty of staff, and Peter Pronovost walking the hallways to make sure that the checklists are being used properly. How about in the real world—where I.C.U. nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the idea of filling out yet another piece of paper?

Michigan Health and Hospital Association went ahead adopted Pronovost’s ideas in 2003. The project became known as the Keystone Initiative.

In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U. … cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.

Gawande stated that Pronovost has since had requests to help Rhode Island, New Jersey, and Spain do what Michigan did.

Gawande suggests we consider: there are hundreds, perhaps thousands, of things doctors do that are at least as dangerous and prone to human failure as putting central lines into I.C.U. patients. It’s true of cardiac care, stroke treatment, H.I.V. treatment, and surgery of all kinds. It’s also true of diagnosis, whether one is trying to identify cancer or infection or a heart attack. All have steps that are worth putting on a checklist and testing in routine care. The question—still unanswered—is whether medical culture will embrace the opportunity.
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I (Gawande) called Pronovost recently at Johns Hopkins … I asked him how much it would cost for him to do for the whole country what he did for Michigan. About two million dollars, he said, maybe three …

This is the end of my extracts from the article. In my opinion two million, maybe three for a country the size of the USA seems like petty cash when one observes the results being achieved and in the context of the overall cost of US healthcare.

Can you imagine if we achieved these results here in Ireland!

My final post from Patrick Holford’s latest book, ‘The 10 Secrets of 100% Healthy people’ is to list his diet golden rules. I personally find this list useful because it is so clear. There are sixteen in all:

1 Eat more fresh seeds or nuts (whole or ground)

2 Increase intake of vegetable protein (e.g. beans and lentils)

3 Increase intake of lean animal protein. (Best; oily fish, eggs, chicken/turkey)

4 Eat more fresh fruit (aim for a mix of colours)

5 Eat more wholegrains such as rice, rye, oats, wholewheat or quinoa

6 Eat more vegetables with a variety of colours, including dark green and root vegetables, either raw or lightly cooked

7 Drink more water, diluted fruit juices or herbal or fruit teas. (eg water and non-caffeine drinks e.g., herbal teas, dilute juice or squash, hot water with lemon/ginger/mint)

8 Eat more oily fish or take a fish-oil supplement

9 Avoid refined, white and processed foods.

10 Avoid fried, burned and browned foods and excess animal fat

11 Reduce intake of caffeinated drinks

12 Reduce your alcohol intake (He recommends no more than one alcoholic drink every other day)

13 Reduce your intake of wheat-based foods

14 Reduce your intake of milk-based foods (milk, cheese, yogurt)

15 Avoid sugary foods and drinks

16 Avoid salt

This list is going on the fridge …

In an earlier post, I listed the 10 secrets of 100% healthy people according to Patrick Holford. The fourth was ‘Increase the anti-ageing antioxidants – 20 foods that will add years to your life’.

We need oxygen to release the energy from food. To paraphrase Holford … Oxygen is chemically reactive and highly dangerous; in normal biochemical reactions oxygen can become unstable and capable of ‘oxidising’ neighbouring molecules. This can lead to cellular damage which triggers cancer, inflamation, arterial damage and ageing. Known as free oxidising radicals, these free radicals (also known as oxidants) need to be removed. As well as in normal body processes, free radicals are also formed in; smoking, the burning of petrol to create exhaust fumes, radiation, sunlight, pollution, fried, barbecued and burnt food. Chemicals capable of disarming free radicals are called antioxidants.

Some antioxidants are known essential nutrients, like vitamin A and beta-carotene, and vitamins C and E. Others like bioflavonoids, anthocyanidins etc found in common foods, are not.

Oxidation and a lack of antioxidants is the main underlying mechanism of ageing. The balance between your intake of antioxidants and exposure to free radicals is critical. Simple changes in diet can tip the balance in your favour. Studies have shown that one can extend a healthy lifespan by eating a low-calorie diet, rich in antioxidant nutrients.

The following is Holford’s list of 20 foods, high in antioxidants, that can easily be incorporated into a daily diet:

Ground Cinnamon
Dried Oregano
Ground Turmeric
Mustard
Blueberries
Pear, grapefruit, plum
Blackcurrants, blackberries, raspberries, strawberries
Cherries
Orange or apple
Dark chocolate (70% cocoa solids)
Walnuts
Pecans
Pistachio nuts
Lentils
Kidney beans
Avocado
Red Cabbage
Broccoli
Artichoke or Asparagus
Red Wine

As a rule of thumb, to again paraphrase Holford … where you find the most colour and flavour you will also find the highest antioxidant levels. Basically aim for five to ten servings daily of a range of fruits and vegetables to keep your intake of antioxidants high. Since heating destroys antioxidants, it’s best to eat most fruit and vegetables raw or lightly cooked.

Holford also recommends taking supplements. Up to now, I have rarely taken supplements, having tended to rely on trying to eat well.

I went back to my earlier post to check what Pollan, author of ‘In Defence of Food’ had to say on this subject. Whilst he said Be the kind of person who takes supplements, he added our bodies’ need for and ability to absorb antioxidants from food declines as we get older. I might look into supplements now.

Further reading here.

I’ve always been interested in health and healthy eating. That’s why the discussion on the radio the other day caught my ear. Patrick Holford, the British nutritionist was being interviewed. Having heard the interview I decided to buy his latest book, ‘The 10 Secrets of 100% Healthy People’. I have read some of his previous books.

I believe in healthy eating and try to eat well, but don’t always succeed. I find it helps at least if I’ve a clear picture of what healthy eating actually is. I also believe it’s what you eat everyday that’s important, occasional treats are fine.

The discussion at the beginning of the book as to what 100% health actually is, was interesting. From responses to a major health survey, Holford and his team found that the top health scorers don’t smoke, take at least five supplements daily, have a low ‘glycemic load’ (GL)* diet, eat fish at least three times a week and much less meat, as well as exercising for three or more hours a week, half doing something like yoga. They have good relationships, are happy, feel fulfilled and are clear on their purpose in life. Most consider themselves spiritual people.

(*Glycemic load considers the quality and the quantity of carbohydrate content of foods. Glycemic index takes into account the quality of the carbohydrate in a food and ignores its quantity.)

His ideas in this latest book though not radically new, were nonetheless interesting. I don’t think one should slavishly follow any health ‘guru’. Holford’s work has its admirers but also its critics. I’m also a little careful of gurus who have developed a large commercial enterprise around their ideas, as Holford has. Having said that, I do think reading such books is useful though in prompting us into taking a healthy interest … in our health.

From his body of work, Holford proposes the following ten secrets to 100% health:

1 Perfect your digestion – Discover your best and worse foods

2 Balance your blood sugar – The key to gaining energy and losing weight

3 Get connected – How to sharpen your mind, improve your mood and keep your body’s chemistry in tune

4 Increase the anti-ageing antioxidants – 20 foods that will add years to your life (I’ll write more on these in a further post)

5 Eat essential fats – Keep your mind and body well-oiled

6 Keep yourself hydrated – Water is your most vital nutrient

7 Keep fit, strong and supple

8 Generate vital energy – The Chi factor

9 Get your past out of your present – Let go and learn from the past

10 Finding your purpose – Becoming clear on the bigger picture

I’ll also write a further post on his diet golden rules. I’m just using this book to kick start a more healthy lifestyle. ‘Better half’ wants it too. Unfortunately it sounds like the gorgeous Roly’s white yeast bread, I’ve just discovered, will be off the menu for a while.

I’d recommend this book.

I’ve written a post before about Thalidomide in Ireland

Thirty-two people living with the consequences of Thalidomide in Ireland.

Thalidomide, a drug which caused birth deformities, sold to pregnant women between 1958 and 1961.

The story of Thalidomide in Ireland is devastating; a delay in banning its sale after it was known to cause birth defects, to this day paltry compensation and broken promises for the small number of people, the thirty-two people, living with its consequences.

On Tuesday, Carmel Daly McDonnell described very eloquently her struggle.

My mother took just two teaspoons of thalidomide when she was pregnant with me.

She took it once. Someone had recommended it for morning sickness. She would have taken more except it made her so ill.

When I was born with no arms and no legs she never thought of the drug which she had bought over the counter.

By the time she took it, doctors had already been advised not to prescribe it any more, but of course she did not know that. I was born in July 1962. I think the Government’s culpability is even worse in cases like mine because they knew, they had warned doctors, but they didn’t ban it and thalidomide was still sold in chemist shops over the counter.
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My parents and brothers did everything to help me have as normal a childhood as possible. I have spent my whole life trying to be positive. And in many ways I succeeded. I have a great husband, two lovely sons.

But I am tired now. My health is getting worse and I am terrified. And I am angry that we are not getting what the Government promised our parents so long ago. If we were, my quality of life would be so much better. And things would be much easier for my family, my husband and my children.
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Now my husband has to be with me 24/7. He cannot work or play golf. He cannot go for a pint with his friends in case I need to go to the toilet. My dignity is gone. I cannot do anything for myself. My husband has to lift me in and out of the shower. I did apply for a toilet which I could use on my own and which would cost about €4,000. I was refused point blank.

If I drop the key when I am trying to put it in the front door, then I am stuck there until someone comes along.
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I cannot fight any more. I am too old, too tired. I cannot think about what will happen if my wheelchair breaks because I know how long I would have to wait for another one or for it to be repaired. I cannot spend all my time worrying about the future, about what happens if my husband is gone. I am worried all the time.

The full text of Carmel’s story is here.

Yesterday Thalidomide victims handed in a letter to the Taoiseach demanding a State apology for the 32 remaining Irish victims.

Finola Cassidy, spokeswoman for Irish Thalidomide Association (ITA) said the move followed two years of “stagnant” talks with Minister for Health Mary Harney … She said the Government predicted they would all be dead by now and there is no provision for middle age as mobility decreases and pain increases. Some of their members are on as little as €16 per day …

I feel very strongly for the people suffering because of Thalidomide. I am a mother of a boy with Cerebral Palsy (CP). There was nothing I could have done to prevent my son having CP, though I still feel guilty about it.

There was something the Irish government could have done to prevent at least some of the Thalidomide cases.

These 32 people deserve justice. Justice our government is denying them.

Our government – yours and mine.

It’s 50 years since the drug Thalidomide was first prescribed in Ireland.

The drug which was manufactured by the German pharmaceutical company Grünenthal, was used to treat morning sickness in pregnant women with devastating consequences for their unborn child. Some 10,000 affected babies were born worldwide before the drug was withdrawn. It was found that thalidomide crossed the placental wall and impeded the normal growth of the foetus.

There are 32 people living with the consequences of Thalidomide in Ireland.

Thalidomide caused severe foetal damage. We were born without limbs, with limbs foreshortened, with impairments of hearing and vision, as well as injury to internal organs. This caused pain and suffering, not only to ourselves, but also to our parents, siblings and to our own children and partners …
A description of the condition from the homepage of the Irish Thalidomide Association.

An unpublished study entitled “What Has Happened to Them 50 Years On? A Review of Disability in People Affected by Thalidomide” showed that just over a third were no longer working due to their disability. Many found that their disability had worsened. Pain management was found to be a significant problem, with more than half reporting regular pain.
(Source; Irish Thalidomide Association, Irish Times)

One of the authors of the study, a Dublin based GP, has thalidomide.

The Irish Thalidomide Association are in talks with the Department of Health and Children to try to improve the provisions made in 1975 for those affected by thalidomide. That settlement comprised a lump sum and a monthly pension for life, supplementing compensation from the German government, which eventually accepted liability. The Irish government has never accepted liability, the Department of Health being the regulatory authority for drugs at the time. Parents of those affected by thalidomide fought hard for a settlement. The lump sum agreed in 1975, when those affected were only children, was a few thousand euro. Depending on the level of disability, the pension now ranges from €16-€35 per day.

For some, this is their only source of income. It’s really unfortunate that the change in our economic circumstances, coincides with these talks.

In addition, the fact that the level of their disability is increasing with increasing age, was not, nor could not really have been fully foreseen, when the 1975 settlement was agreed.

We are only talking about 32 people!

In writing this piece, I contacted the Irish Thalidomide Association to check a number of facts, including the actual number of people in Ireland with thalidomide, as I had read conflicting numbers. I had a long conversation with a woman who herself has thalidomide and campaigns relentlessly for her fellow sufferers. After a long telephone conversation, I was in awe of her sheer determination, enthusiasm, and eloquence. The Irish Thalidomide Association have a great spokesperson.

Another example of altruism has to be the doctor with thalidomide referred to above, who himself has huge difficulty walking. He did a fund raising cycle in July of this year. His professional work has been with the homeless. The funds were for a mobile outreach clinic for healthcare professionals working on a voluntary basis with the homeless, and women involved in prostitution. Report here

He could teach our government a little … about altruism.

It’s 50 years since the drug Thalidomide was first prescribed in Ireland.

The same time as my mother was pregnant with me and my siblings.

A chronic condition is challenging.

Challenging because it is just that – chronic.

Having a chronic condition has meant that since birth almost, youngest mouse has been attending medical professionals. Last week he and I were in the US for a review at the hospital where he had surgery five years ago. This was our second visit back since then.

There’s something about being away, which makes one take stock, so to speak.

Over the years, we have gotten to know a fair few medical professionals. Both sides of the pond.

Neither the health system in Ireland nor America is perfect. Both health systems are flawed, flawed in different ways. Obama has a challenge ahead of him as he tries to tackle the US health system.

Flawed health systems don’t stop some amazing professionals doing amazing work.

We have been fortunate, over the years, to come across some amazing professionals. Heroes in the health system.

So having time to take stock,

To those heroes, we have met, both sides of the pond,

A big thank you.

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The real wealth we possess is our health. Our real poverty is lack of health.

I like Patrick Holford’s discussion of health at the beginning of his book ‘The Optimum Nutrition Bible’

‘ Positive health … can be measured in three ways:
1 Performance – how you perform physically and mentally
2 Absence of ill-health – disease sign and symptoms
3 Longevity – healthy lifespan

… a profound sense of well-being … is characterised by a consistent, clear, high level of energy, emotional balance, a sharp mind, a desire to maintain physical fitness and a direct awareness of what suits our bodies, what enhances our health, and what our needs are in any given moment. This state of health includes resistence to infectious diseases and protection from the major killer diseases such as heart disease and cancer. As a result the ageing process is slowed down and we can live a long and healthy life.’

A close family friend had cancer last year, fought and won a brave battle against this invader. She went into hospital for surgery and was due out after 10 days. She finally emerged from hospital 17 weeks later. During this period I observed at close range this mighty battle while visiting her almost every day. Through observing this mighty battle being fought, I learned a lot of life lessons.

I learned how easily health can be lost.
I learned how much we take our health for granted.
I learned how important it is to have ‘fight’ in us

Longevity in in my genes. My father died at 93. My mother was killed prematurely at 71 in a car accident. Both came from big families who lived long lives. I intend beating my father. I will be reasonably happy to depart at 100, having received my 100 Euro or whatever from the President. As someone said recently, they plan on their last cheque bouncing! I thought what a great aim. In the next 50 years I intend living not existing. I have lots of changes to make before then. I want to do a PhD but don’t have time at the moment. There’s lots of time yet.

To really enjoy the next 50 years and to get the most out of them though, I have to remain healthy. That’s why I read books such as above. I don’t intend slowing down.

But whose health is it anyway? I believe we are responsible 100% for our own health. We cannot sub-contract this responsibility. We can go to professionals but we remain the owner. It is our 100% responsibility to look after our health.

To get the most out of a car, it has to have regular maintenance. Do people go for maintenance checks on their bodies in the same way as they do their cars?

I feel if we don’t play our part then we have less of a ‘leg to stand on’ in criticising the health system in Ireland. I remember a friend with a lung condition questioning if the consultant they were under was the best, as she smoked yet another cigarette. I had to bite my tongue.

I don’t know if people have seen the transparent kid toy engines. One can see the inner workings. If we could actually see our arteries clogging, would we be more aware and do more to prevent? I’m all for transparent bodies!

I loved the Bodies exhibition and would highly recommend it to all. It gave a great insight into our bodily systems.

Our health is our responsibility.
Our health is our wealth.

I think I can get down off my soap box now!