23 Feb 2007 - Respiration
Change will hopefully soon happen, but based on "new evidence" that delayed
clamping of the umbilical cord is safer, as though clamping the cord immediately at
birth has always been the traditional practice. In fact it has been a tradition for 20
years, or possibly 50 in some hospitals. Virginia Apgar developed her score for the
newborn because at the Sloane Hospital (Columbia University) the cord was cut within
the first minute after birth - to preserve the "sterile field" for suturing, and to give the
infant to a specialist, a neonatologist, for resuscitation if necessary.
According to recent statistics, about six of every 1000 babies will not breathe right
away at birth, and will need assistance. The assistance is ventilation, but what does
ventilation do?
In every organ of the body except the lungs, respiration involves release of oxygen
from the hemoglobin molecule in exchange for carbon dioxide, the end-product of
cellular metabolism. In the lungs oxygen is received and carbon dioxide released by
the hemoglobin molecule. Respiration is a biochemical process mediated by
hemoglobin. Without hemoglobin, respiration cannot take place in the tissues or the
lungs. Ventilation of a newborn infant is useless unless sufficient blood-flow into the
capillary system of the alveoli has been established. Sufficient blood volume is
needed also, because oxygen-rich hemoglobin needs to be circulated to every organ
of the body. One desperate maneuver made by neonatologists is injection of a blood
volume expander to promote circulation in a newborn suffering respiratory distress.
Blood circulating from the placenta to the infant at birth, and back to the placenta, is
respiratory blood. As Erasmus Darwin noted in 1801:
"The placenta is an organ for the purpose of giving due oxygenation
to the blood of the fetus; which is more necessary, or at least more
frequently necessary, than even the supply of food."
Clamping the umbilical cord immediately at birth is a grave medical error. Blood in the
placental circulatory system must be transferred to the capillary system of the alveoli
before respiration can begin in the lungs. Placental blood is not excess blood to be
discarded or collected for cord-blood banking. Even the infant who breathes right
away needs all of it for optimal transition from fetal to neonatal respiration.
24 Feb 2007 - Poster pages (first draft started)
Autism: 2-6 per 1000
Respiratory depression at birth: 5.2-6.2 per 1000
Respiration: Release of oxygen for carbon dioxide
Lungs: Release of carbon dioxide for oxygen
Hemoglobin: Molecular basis of respiration
Blood circulation: needed to/from lungs and organs
Transition at birth: The first breath is taken after placental blood fills the capillaries
around the alveoli.
The first breath: Oxygen replaces carbon dioxide on the hemoglobin molecule.
Circulation: Sufficient blood volume is needed for hemoglobin to reach all organs.
Brain damage: Oxygen deficiency damages the auditory pathway of the brain.
Learning to speak: Language is learned through the auditory sense
--
Damage to the auditory system of the brain should be what makes respiratory
depression at birth important to investigate as an etiology of autism.
In PubMed: autis* & loci yields 125 citations. The oldest is Simon N. Echolalic speech
in childhood autism. Consideration of possible underlying loci of brain damage. Arch
Gen Psychiatry. 1975 Nov;32(11):1439-46.
Adding & brain* yields 23 citations. The rest refer to gene loci on chromosomes. The
locus (or loci) of impairment in the brain need to be the focus of research on autism,
whatever the cause. Oxygen insufficiency at birth results in a plausible site of damage
that can be related to the language disorder for starters.
25 Feb 2007 - Milieu research: Mainstreaming
Another day on my former MHW unit, where I learned the value of just being there, in
the milieu, day after day. They say our patients are not good historians - that is they
are not able to give a coherent, chronological account of their life stories. Milieu
research means being able to gather fragments of a patient's revelations, and piece
them together bit by bit.
Today I was unable to make eye contact with a patient who used to seek me out to
discuss whether he could succeed if he went back to DMH (the Department of Mental
Health state hospital where he was previously hospitalized). This particular state
hospital was closed many years ago, so it would have to be one of the two state
hospitals still in operation, or one of the DMH community units. The focus of treatment
in DMH is to prepare patients for discharge into a community group home. This is
called "mainstreaming," and I'm not sure group homes have led to many success
stories, but I tried to encourage this patient to move on. He has so many strengths,
including the motivation to try to figure out if and how he could manage in the
community.
Our patients' older records are in storage, so information about schooling is not easy
to lookup. I think I could argue for the now dull-eyed patient being on the autism
spectrum, at the high functioning end. Bit by bit I learned a good deal about his past,
and especially about his worries over proposed discharge to DMH. He had clearly
thought about how he might fit-in in a DMH hospital with which he was not familiar, and
beyond - what would it be like living in a group home?
For at least the last ten years, this patient has sabotaged every attempt to enable him
to move on. He appeared quite depressed today, and I see he is now taking an
anti-depressant medication. Depression is the final co-morbid diagnosis for many of
our patients. They understand too well how much they have missed out on in life.
26 Feb 2007 - Milieu research: having a job
White-out snow storm started on my commute to work today, earlier than expected,
and no sanding trucks out there between 5 and 6 this morning. Inside the hospital
yard, the pre-release cadre workers were busy shovelling the snow and sanding the
walkways, so the patients could get to the chow hall between 7:30 and 8. The capacity
of the cadre workers to work and get a job done provides a sharp contrast to the
disabilities of most of our mentally ill patients. In addition to shovelling snow, the cadre
workers perform many other functions, preparation and serving of meals, moving
furniture and equipment, helping with some construction projects, and in the summer
mowing the lawns.
Some of our patients can't even be given a rag and taught to wipe off tables in the
chow hall. There are some jobs patients do in the kitchen and chow hall, and on the
units, and some are quite competent. One of our Asperger patients has the job of
making sure the water and juice pitchers are full on the dining tables. He also
supervises three or four other helpers. He is very particular about how the pitchers
are stored on carts, with all the handles lined up in the same direction, and he has
trained his helpers to keep the pitchers compactly ordered on the cart in the same
way. I'm not sure I can picture him shovelling snow, mowing grass, or especially doing
a job like helping move a vending machine up the stairs from the basement.
Having work to do though is good for self esteem, even a dirty job like dumping the
remains of meals off the dinner trays, and loading up the dishwashing machine. Some
patients take care of trash, and sweeping, mopping, and waxing floors. The more work
they are given to do, the better they get at it. I am told in the past, the state hospital
was a working farm, and produced milk and vegetables. Are our patients less
competent now, or do we just expect too little of them? This may have been a
negative result of the patients' rights movement a few years back.
If "mainstreaming" and living in the community are goals for rehabilitation, then training
for doing some kind of work should be a priority focus of patient treatment plans.
27 Feb 2007 - Oral surgery
My first-born son, Ralf, had a difficult birth, and had a cephalhematoma prominent on
the right side of his head noticeable for at least most of his first year of life. At my
grandmother's insistence, I took him at 20 months of age to be evaluated by a child
neurologist at Children's Hospital in Boston. He was seen by Dr. Charles Barlow, who
was a professor of neurology at Harvard Medical School. I am grateful for Dr. Barlow's
straight answers. Instead of all the chiding I had been given by pediatricians, who told
me not to worry, "Boys are slower," etc., Dr. Barlow told me Ralf had a "mild" form of
cerebral palsy. The adjective "mild" should, however, never be used to describe any
impairment of neurological function. When I asked further what "mild cerebral palsy"
meant, Dr. Barlow told me, "He will never be quite the person he would have been."
Those words have echoed in my ears forever more, and, indeed, they were far more
accurate than any explanation modified with the adjective "mild."
Ralf lives in a group home now. We went through periods of high hope for him, which
always ended in disappointment. He did better than expected all the way through
school, but didn't quite finish high school. He has attended GED classes, but has yet
to try the test. Helping him get a GED is now a priority for me, against everyone else's
better judgement it seems - more on this sore point in another blog entry.
The community group home system stinks. There are dedicated people working in
these houses, but high staff turnover, and reliance on "relief staff" leave a lot to be
desired. Ralf spent nearly ten years in Westborough State Hospital, where the staff
are long-term state employees, with all the benefits that go with working for the state.
Medical and dental exams were regularly done every three or four months. According
to the manager of Ralf's group home, he refused dental checkups. According to Ralf,
no one ever asked him if he would like to go to the dentist. I came home from vacation
last summer, and saw that Ralf/s right lower jaw was quite swollen. When I asked
about this, he told me he had been having some tooth pain. When I asked if he was
seeing a dentist, he told me, "I'm thinking about it." The problem is that he never
speaks up and asks for anything. This is part of what makes him not quite the person
he would have been.
I was able to get him seen at the Boston University Dental School clinic, where the
abscessed tooth had to be pulled on an emergency basis. He needed more work
done, which it was decided should be scheduled to be done under general anesthesia,
which finally happened today - an interesting experience in that Ralf recounted to the
anesthesiologist and nurses having seen the very first NOVA program on the
discovery of anesthesia. More later on this islet of intelligence in a person regarded
by many as hopelessly impaired. More later on his most interesting comments on this
experience. For now he seems to be doing well, and coping with the aftermath of
anesthesia, root canals, and more extractions.
28 Feb 2007 - Milieu research: sixteen hours in the infirmary
I stayed with Ralf on Tuesday until I was sure he was feeling well enough to cope with
house routines etc. When I got home, I had a message from work asking if I could
come in Wednesday - no message had been left on my cell phone ( someone new is
doing the scheduling). I called to ask if I were still needed, and the joyful response
was a request for me to come in for the infirmary, which I accepted. My job is
interesting, and right now the money for dental work and other expenses is most
useful. I am semi-retired, and work now only per diem on an as-needed and
where-needed basis. As often happens, I got "forced" to stay on for second shift.
Patients today were (1) a man with severe liver degeneration (cirrhosis), and now
many other complications, (2) a chronic case of Korsakoff's dementia due to
alcoholism, especially tragic because he was a school teacher and most proud of it,
(3) a 23-year-old paraplegic, paralyzed at age 20 by a gunshot wound through his
lower spine, and he has a horrible deep tunneling lesion in his right buttock, treated
with a new kind of iodine saturated gauze packing/dressing material that costs $18 per
two-by-four sheet, (4) a man with severe weakness of unknown origin, possibly a
recent stroke, or possibly medication side effects, and he has been started on a
different new psych med, (5) a man the same age as my son Ralf, also with Asperger
syndrome, admitted to follow the pre-procedure prep for colonoscopy, which he is
following with meticulous care.
More on these, and other more chronic patients, when I have more time.