Cultural Awareness in Medicine

A comment I made on an especially poignant Answer in Quora to the Question

*As a nurse, what is the most disturbing "cultural practice" you have ever seen?"

The expected answer would be “female genital mutilation ” from cultural practices of “female circumcision”. That is abhorrent, and a lifetime burden for the young victim. It’s not often seen in North America. There is a more prevalent cultural practice, being seen more often, that can be deadly for more than one victim. That is the “cultural practice” of a wife not being “viewed” by a man other than her husband- even if the “man” is a life-saving doctor.

It was a small, 30-bed hospital in small-town Appalachia, which happened to be not far from I75N. The town was formerly a booming coal mining community, so there were fine mansions in the town, as well as crumbling trailers with McGivered wood stoves for heat on the mountain roads. Most of the businesses had closed in town. The biggest employer was Walmart - which was also the best source of food and clothing. All those folks you see on the “seen at Walmart” sites, live in towns like this one. There was one laundromat, which didn’t always have hot water. There was a decaying public school, and after 6th grade, it was a one-hour bus ride to middle school.

Why is this relevant? A hospital can only attract good staff physicians based on salary and quality-of-life. This town had no “quality-of-life”, so the salary was above the norm. Still, it was hard to attract permanent staff, and the hospital relied on “Locums” - moonlighting doctors looking for extra income. So, especially on weekends, when arriving at this emergency/urgent hospital; one must be grateful a board-certified physician was on call.

It was a blustery snowy night in the mountains of West Virginia. Precariously driving on I75N was a man and wife, who was 36 weeks pregnant. Her water broke, and sudden hard contractions commenced. The husband saw the H hospital- sign and made his way into the sleepy town. The ER recognised the critical imminent delivery, and called the Locum physician; a highly qualified OB/GYN from a major hospital. The OB doc was in-house, so the staff breathed a sigh of relief that all would be well. A stand-by call was made to the nearest NICU (1 ½ hours away) in case the baby needed special care. A helicopter would be dispatched at once.

BUT.

The Locum OB doc was male. The husband absolutely forbade the man to view his unclothed wife. The L&D nurses were female. Anesthesia was female. The husband was in the room, and he physically barricaded the door so that the OB doc could not enter.

The contractions got worse. Too close together, and mom screamed in pain and fear. Anesthesia called out that a C-section was needed NOW! Husband would not let the male OB specialist in the room. The nurses shouted out vital signs, contraction strength and duration, and lack of progress for cervical dilatation. The doc called back orders. Anesthesia called out falling VS. Mom pleaded with her husband to PLEASE let the doctor in to help. The nurses begged. Anesthesia begged. During this screaming session, a call was made to local social services, who arrived within minutes to advocate for the safety of mom and baby. Social Services notified the closest sheriff.

The Husband was adamant and aggressive. 6’2”, 200 lbs, and as aggressively angry as a confronted tiger His honour and his wife’s honour would be forever compromised if this unknown male saw his wife in such a naked and compromised position. It was not going to happen while he was there.

The female staff continued to relay information. The doctor continued to call out instructions. But the nurses, by law, could not perform the manoeuvres or procedures required to deliver the baby. Mom screamed. Cried. Pleaded.

Mom then started to cry and plead only for the baby. Pleaded for her husband’s son. Save your son! Your heir! Each cry was becoming weaker. And weaker. Until there were only gasps. Then the doctor overrode policy, and pushed past the husband guarding the door, and was rewarded with a knock-out punch to the head.

Now the doctor, the ONLY medical doctor within 60 miles able to assist with this complicated delivery, is unconscious on the floor. Mom is losing too much blood. The contractions are too strong, the cervix not dilated; this baby is not coming out.

Mom’s voice grew weaker. The husband demanded a female physician or he would sue. The nurses did as much as they could - but only the doc, out cold on the floor, could do the C-section that would save both mom and baby.

By the time police arrived, mom had died from placental abruption, loss of blood, and shock. The baby died in utero. Husband was screaming about suing the hospital as he was pulled away in handcuffs.

And that, was the most horrific case of “cultural practice” I have ever seen. I pray I never see it again. I might be the one to cold-punch the husband to the floor. Sue me for the lives I’ve saved.

My Comment

I was going to answer this until I read yours. This is absolutely horrific. I'm going to have nightmares tonight.

The only “what if" I can honestly put forward is this: What if the hospital had hired TWO security guards? I think that is the crucial question.

My heart bleeds for everyone, including the husband. But not for the hospital. I've said over and over again that while the overwhelming majority of physicians and nurses are motivated by healing first and money second, hospitals are now guided by three policies (in order): profit, image, and (maybe) healing third, as long as it doesn't interfere with the first two.

Why is this relevant to your account? Because hospitals are more concerned about risking a lawsuit over “cultural insensitivity” and the negative press they create than they are about healing. 

“But Dr. Mangold, why does your heart bleed for hubby, the obvious cause of two deaths and the instigator of assault and battery?” Because he is obviously the victim of his own cultural upbringing.  Where is the cultural awareness here? He didn't create his irrational jealousy on his own. It was learned. Dad taught him through example, education, and probably physical violence. Mom reinforced it. One of Dr. Mangold's Rules is that jealousy is a mental illness. And now his mental disorder has become a legal one. Unless he is a Malignant Narcissist or Sociopath, he has suffered enough. The death of a spouse is terrible. The death of a child? No parent should endure that. There ought to be a law that no kid dies before its parents.

http://bit.ly/2vfHYmM

Fight, Flee, Freeze, or Fawn

A great article from Well.org. This is from my email but there is no link to to an outside site, so I copied and pasted it in its entirety. There are reference links, though.

Attention All “People-Pleasers”: Important Trauma-Healing Info People-pleasing is commonly considered to be an altruistic method of getting along with your neighbor. But according to prominent psychologists, it’s more accurately an acute response to trauma, called “fawning.” We’re all pretty familiar with fight or flight responses… it turns out, there are two others. “Freeze”... And “fawn.” These are our defense structures — and “fawn” is a response characterized by codependence. Meaning you either require too much of others, or others require too much of you. Here are some of the behavioral points common to fawning as a response to conflict, or the threat of conflict… Mirroring opinions Anticipating/appeasing needs Relaxing/ignoring personal boundaries  Absorbing the wants of another party as your own There are many different ways that these can manifest, but generally speaking, the “fawner” doesn’t assert their feelings and experiences as a valid stance (like a “fighter”), or obsessively strives for perfection to avoid conflict (like a “flighter”), or disassociates and becomes as invisible as possible (like a “freezer”). You see, matching your “opponent’s” posture and attitude is a way to blend in and convince the source of conflict that you’re on their side, you’re not the target, you’ll help them to make it better.  It’s usually a trained reaction to trauma or abuse — to get in front of a conflict before it gets in front of you.  The Psychology of Fawning  Therapist and author Pete Walker developed his “fawning” theory as an exploration of the affability of PTSD survivors.  Not only does fawning serve to diffuse conflict, it also creates a false sense of security in relationships by using constructed commonalities as a bond. Basically, it’s the long-con.  But what it all boils down to? Feeling safe. This means that you’ll often find fawners in relationships with people who are: controlling (so that they don’t have to make decisions which could later impact them negatively)  withholding (so that receiving affection feels “earned” and therefore less likely to evaporate)  or in some cases abusive (so that having no boundaries seems justified, since they wouldn’t have been respected anyway) Are you detecting the pattern?  Does This Sound Like You?  People whose trauma response is fawning tend to prefer relationships and situations that are inherently unstable because it feels comfortable, and because their required contribution is clear and familiar: soothe and supplement. If you suspect this might be you… Here are a few more checkpoints. Do you… Go back and forth between bottling up your emotions and unleashing them onto people, usually not the people who need to hear them? Have a really hard time saying “no”, even when you’re completely overwhelmed? Second-guess yourself when you’re angry at someone and end up feeling guilty for possibly misunderstanding the situation? Craft your behavior based on the perceived reactions of the other person involved as though you were responsible for their behavior as well as your own? Bend and mold your values depending on the situation? Those trends are an indication that you respond to conflict by fawning. What Should You Do? This is a personal journey, so everyone’s answer will be different. You could seek out therapy, with a focus on self-preservation through self-worth, and not through external validation that fawning seemingly secures. If you’d like to take matters into your own hands, you could start dismantling your “fawning” reaction by considering which people in your life illicit it the most from you. Who do you go out of your way to please? And who do you ignore as a result?  Noting who you ignore is helpful, because those people are often the people you actually should be spending energy on.  You see, they’re the people that you’re not afraid of — who aren’t mad when you take time for yourself, or who don’t question your feelings when you present them.  It’s likely that you’ve paid less attention to these people because their approval wasn’t conditional, and you weren’t punished for not paying attention. Consider starting there, but if you’d like something a little bit more hands-on… You could try a course in healing emotional trauma, like this one.  Whatever you decide to do, simply understanding when and why you engage in a “fawning” response is absolutely crucial. For full references, please click here.

My Quora Answer to: Why do so many people have allergies today? Because we are born into, are raised up in, and work in sterilized environments.

Early and constant exposure to bacteria common in nature but not so much in cities builds our immune systems in many ways. Think about it. Who gets more exposure to allegens such as pollen and fungi?

I wrote about this a few years ago on my blog titled, “Eat Dirt.” That article was specifically aimed at a genus of bacteria called “Nitrosomas,” but could very well apply to other genera and fungi. Nitrisomas species live off of the form of nitrogen found in urine, urea. Believe it or not, they can live on your skin too, like under armpits. Nature's original deodarant.

Other ingested and inhaled allergens directly affect your internal immune system. For one, chronic low-level exposure stimutes the formation of Immunoglobulins G and M which “overpower” the release and activity of IgE. The IgE molecule (if unopposed) attaches to mast cells in your blood, causing the release of histamine, which is the chemical responsible for all those nasty and even deadly allergic reactions.

According to this 2013 study, rural bacteria also affect natural killer T-cells in the lungs of mice. I haven't read the science behind the article but assume it's valid:

https://www.livescience.com/36217-early-bacterial-exposure-immunity.html

Very good question, BTW.

Nanobes and Coronary Artery Disease

Something I Discovered En Route to Looking Up Other Things

I got my chest CT results and an incidental finding is that I have "severe coronary calcification." So, I started looking up ways to decrease it and found a great article on outpatient chelation therapy. The researchers used a combination of plant powders and tetracycline orally, and EDTA suppositories per rectum. 

But why the antibiotic? The article sites nanobacteria (nanobes) as a causative factor in coronary artery disease and the tetracycline kills them off. 

This is the first time I've heard about nanobes, sooo...

https://serc.carleton.edu/microbelife/topics/nanobes/index.html

Polyphenols

Polyphenols are chemicals found abundantly in many types of foods, especially brightly colored fruits and veggies, but also teas, coffee, chocolate, and herbs/spices. Red wines are a rich source, too.

Of the top 5 polyphenol-containing foods, four are from berries. In order:

1. Wild Blueberries
2. Blackberries
3. Pomegranate
4. Cranberries
5. Blueberries

You can add strawberries and raspberries as close contenders.

Try to include at least 2 cups per day of these fruits in your diet.

Citrus Fruits and Kidney Stones "...lemonade therapy appears to be a reasonable alternative for patients with hypocitraturia who cannot tolerate first line therapy."

Although a terribly small study, let's hope it's a springboard to greater things. One other issue I have with this study is that they don't reveal how much real lemon juice is in their lemonade. 

Permit me to help translate some of the medspeak:

"Citrauric" simply means the amount of citric acid in your urine.

"Nephrolithiasis" is the term for kidney stone formation. 'Nephro' means kidney, as like the medical specialty Nephrology. 'Lith' means stone. Think of 'monolith,' or a large monument carved from a single (mono) rock.

"Hypocitraturia" is a chronically low (below normal) level of citrate in your urine.

Here are excerpts from the study. The full link is found at the end.

"Purpose: Citrus fruits and juices are a known natural source of dietary citrate. Of all the citrus juices, lemon juice appears to have the highest concentration of citrate. Therefore, lemonade therapy has been proposed as a potential treatment for patients with hypocitraturia. We retrospectively evaluated the impact of long-term lemonade therapy on urinary metabolic parameters and stone formation in patients with hypocitraturic nephrolithiasis."

"Conclusions: Due to its significant citraturic effect, lemonade therapy appears to be a reasonable nn.alternative for patients with hypocitraturia who cannot tolerate first line therapy. Future study in the form of a prospective, randomized trial is needed to validate these findings."

https://www.ncbi.nlm.nih.gov/pubmed/17382731