A case for simplicity

Case 1. Bev

Bev is a jolly 63yo farmer who came in to the hospital after suffering a minor stroke. One quiet afternoon when I spot our medical student looking a bit out of place (well, even more so than usually) I take him to see Bev for a neurological exam practice. Bev looks flattered and obediently sits back in her bed, being the perfect patient. I remind the student that we start with a general observation of the patient,the side of bed assessment. He dutifully recites “alert, comfortable and in no respiratory distress”. I gently nudge him to describe the patient’s body habitus, the student gets instantly embarrassed and looks lost. How do you tell a patient she is fat? I explain while looking at Bev that her central obesity is an important risk factor which may be pertinent to diagnosis at hand. Bev chuckles good-naturedly: “I love me food, I’ve always been a good baker!”.

Most medical students hate the neuro exam: it’s tedious, long, complicated and seemingly impossible to make smooth. I don’t rush him and Bev seems happy with the attention. The student correctly identifies the weakness on the left side of Bev’s face. He asks Bev to blow up her cheeks, Bev makes a valiant attempt but ends up making a noise like letting out air of a balloon and promptly laughs. I hear laughs from the other side of the curtain: evidently this has been a source of amusement to other patients as well. Bev’s limb weakness is improving and we take her for a gait assessment. With her tiny feet, narrow shoulders, perfectly rotund middle and a wide crooked smile, she looks almost comically cute. The student summarises the findings of his examination and correctly identifies that Bev has likely suffered an ischaemic stroke in the area of a middle cerebral artery in the right brain hemisphere. I thank Bev for being the perfect model for us, she wisely nods:
– They all gotta learn somehow, don’t they? So you think it’s gonna get better for me, doc?
I point out that she already has made marked progress and then ask her how she feels about the future.
– Oh I know. I gotta watch that cholesterol, don’t I? No more fish’n’chips for this chickie! (laughs)
I tell her I’ll come back to chat to her about diet before her discharge, thinking I’ll get to her before she gets fed some pseudo-nutritional rubbish.

Two days later, on my day off, Bev suffered a major stroke. The nurse found her in the morning, stiff in her bed, unable to move, call out or ring the bell. The stroke affected the other side of her brain and left her completely paralysed on what just 2 days ago was her “good side”. I never got to see her again because she was transferred to another hospital to a dedicated stroke unit.

Case 2. John

I only find out about John at morning rounds as he was admitted last night. I barely have enough time to register “64yo male transferred post BKA” on my handover sheet as we enter his room. BKA stands for Below Knee Amputation. John has just had his second one. As I stand in the room while the consultant chats to John about his surgery my eyes keep drifting to an empty space below John’s knees. No matter how many times I have seen it, this sight still unnerves me.

I distinctly recollect one of my most distressing experiences in operating theatres when I was assisting in a BKA. My job was to stand at the bottom of the table and stabilise (a.k.a hold tightly) the foot and calf of the leg being amputated. I still remember own visceral startle when the toes suddenly started to move, as if in a mute protest, when the surgeon was severing the tendons at the knee. At some point through the cut the lower leg stopped being a part of the human being and became an object. As the last thread connecting it to the breathing body was dissected I was left holding that object in my hands, temporarily stunned, until the nurse offered a big bucket to deposit it in.

John is looking defiant. The consultant has just finished drawing a pretty bleak picture and suggesting a nursing home placement. I feel the hot wave of indignation at this seemingly cruel crushing of a patient’s determination to maintain independence and mobility. John repeats mulishly that he wants to have double prosthesis, he wants to walk again. Later that day I find out that my anger was misplaced. While his raging diabetes destroyed the small vessels in his feet and opened him up to ugly ulcers and gangrenous infections, John’s dementia caused him irretrievable short term memory loss and, consequently, an inability to learn new skills required for amputation rehab. He has been on insulin for years but has been steadily forgetting to inject himself in the evenings when he gets most confused.

Case 3. Pat

Pat is a 47 year old Indigenous woman who presented to our Emergency Department with chest pain. The ECG and cardiac markers do not show any signs of heart muscle damage but she is at high risk for coronary artery disease as she is a former heavy smoker and a diabetic. Routine nursing observations show that her average blood sugar has been between 25-30 mmol/L (450-540 mg/dL) over the last day. She normally takes metformin but it’s clearly not doing very much. Like many Indigenous patients she doesn’t look grossly overweight, with her skinny arms and legs sticking out of her hospital gown. The gown cannot fully hide her round belly though, and I have to double check the notes that she is not pregnant. No, she is not. I try to be gentle when I tell Pat that she is likely going to need “the needles”. Sometimes the mere mention of injecting insulin serves as a good wake up call and a good opener to the lifestyle modification conversation. Pat doesn’t seem phased: “Ok doc”. I feel a hint of frustration: the conversation is not going the way I planned. I try to bring it back to the diet, saying that stopping junk food may be an easier solution than injecting yourself every day. “I don’t eat junk food, doc! I didn’t have Maccas for yonks!” – she protests. I note a half empty 2 L apple juice bottle on her bedside table: “And what’s this? You can’t have that with your sugars!” She looks confused. I take a breath and start to rant about soft drinks and sugar but she has already turned off and when her mobile phone rings she picks it up leaving me with my mouth open mid-sentence. As she starts to chat, I walk away taking the juice bottle off her table and pouring it out into the nearest sink.

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My other life, on this blog, as a part of Whole9, on social media, is like another world. Highly motivated people sharing their success stories, intelligent eyes watching our Whole9 South Pacific presentation, challenging questions being asked – I find my enthusiasm recharged and renewed. Although recently I see more and more splinters appear in the community.

Recently a video made rounds in “Paleosphere”. Some bloggers that I respect and follow found it offensive in its simplicity. I won’t comment on the video itself, I have a few minor quibbles with it myself, although I wouldn’t hesitate for a moment to show it to my average patient. I want to comment on the “It’s not that simple” critique. Maybe it’s not that the message is too simple, maybe we are trying to make it too complicated. We dissect this diet thing to its smallest constituents, calories vs grams vs ratios vs micronutrients vs cytokines vs endocannabinoids. Critical scientific discussion is enormously valuable and discourse should only be viewed as the way forward. But somehow discourse all too quickly¬† turns into a personal attack, a spiteful tweet or a post from the safety of a computer screen. And, sadly, some who used to offer valuable contribution to the body of knowledge now seem to offer nothing but negativity. Are we turning into the equivalent of elderly cranky academics arguing about the best fire-fighting methods while the room is engulfed in flames?

What about your average reader who has just googled Paleo or primal or ancestral health? Are we causing “paralysis by analysis” by not making it crystal clear what we actually all agree on? Even those firmly indoctrinated in beef broth/bacon/kale seem occasionally lost. Sometimes getting lost is easy if you are given a way out – maybe Lustig is wrong and sugar is ok? Maybe Taubes is delusional and it’s time to count calories again? Oh no, this thing is not simple at all! Let’s browse through some blogs, maybe we can catch the author out, find an error in the archives and pronounce the final judgment. It’s not exactly helpful for own health problems but sure is satisfying.

I did not choose the three cases for their dramatic value, I chose them because they are average. I see between 20 and 30 Bevs, Johns and Pats daily. Sure, I love reading the latest research papers in a search for truth but for these guys I want SIMPLE. I need a heuristic. If your goals are getting to a single percentage body fat, running a marathon or continue setting PBs by doing smashfit 5 days a week (hopefully not all at the same time!) you may need more tweaking but you are not exactly your Average Joe, are you? My favourite Internet testimonial this year is a 71 yo lady on a social security budget who reduced her HbA1C, came off insulin and halved her blood pressure medications, probably without giving a second thought to the latest blogosphere drama.

We are onto something good here. It’s real and, let me tell you, it may better than any expensive medication I can offer my patients. SIMPLE will get most people most of the way there. Here is my heuristic:

– eat meat/fish/eggs + vegetables (tubers, greens) three times a day to satiety and activity levels

– prioritise your sleep

– move in a way you enjoy

Do this every day for 3 months. Without dissecting, or philosophising, or looking for a loophole. This may just be enough to see change.