Israeli Medical Team: Ethical Dilemmas in Haiti Disaster

The New England Journal of Medicine featured an article by the Israeli medical team that set up a field hospital less than 48 hours after a major earthquake hit Haiti. When there is so much suffering, whom do you help first?

Under normal circumstances, triage involves setting priorities among patients with conditions of various degrees of clinical urgency, to determine the order in which care will be delivered, presuming that it will ultimately be delivered to all. After the Haitian earthquake, however, it was impossible to treat everyone who needed care, and thus the first triage decision we often had to make was which patients we would accept and which would be denied treatment. We were forced to recognize that persons with the most urgent need for care are often the same ones who require the greatest expenditure of resources. Therefore, we first had to determine whether these patients’ lives could be saved.

Our triage algorithm consisted of three questions: How urgent is this patient’s condition? Do we have adequate resources to meet this patient’s needs? And assuming we admit this patient and provide the level of care required, can the patient’s life be saved?

In the first days of our deployment, most of the patients we saw had recently been removed from the rubble. The majority had limbs that were compromised by open, infected wounds. Untreated, open fractures meant infection, gas gangrene, and ultimately death. Clearly, the sooner after injury the patient received medical attention, the better his or her chances of survival. Late-arriving patients who already had sepsis had a poor chance of survival. But there was no clear cutoff time beyond which patients could not be saved; each case had to be evaluated individually.

Read the full article here: The Israeli Field Hospital in Haiti— Ethical Dilemmas in Early Disaster Response.

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Child Put in Foster Care When Parents Refused to Offer Junk Food

This is for the many parents of children who do not grow according to charts, and have been told over the years to feed formula instead of breastfeeding or to give a child cornflour, Bamba or other high-calorie, low-nutrient food so he will gain weight.

The Daily Mail reports on a child put into foster care because his parents refused to follow a doctor’s instructions to give the slow-gaining child crisps, chocolates, and cakes.

Zak is now putting on some weight, but his eating problems were not cured by his time in the care of ‘experts’ and, much to the annoyance of his parents, he has acquired a taste for junk food.

Mrs Hessey, of Bolsover, near Chesterfield, said: ‘I thought I was doing the right thing going to the best people for advice when Zak began to lose weight.

‘Instead they basically accused me of neglecting him and implied it was all my fault. I have four other children and they are perfectly healthy, it was just that Zak was refusing food for some reason. They said I should just feed Zak chocolate, cakes and junk food just to get calories into him. But I objected, saying that was only a short-term answer and not a proper solution.

‘The Government and doctors are always drumming into parents the importance of healthy eating – yet they were telling us to feed Zak all the wrong things.

‘That is obviously what they were doing when he was in foster care so now it is hard to get him to eat anything else.

Follow-up post: Toddlers and Weight Gain

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Israel Conference on Breastfeeding

The breastfeeding support organization La Leche League (LLL) and Tel Hashomer/Sheba Medical Center Nursing School are co-sponsoring a conference Monday, June 1, 2009 at Tel Hashomer. The conference is open to health care professionals, nursing mothers, and the general public.

The conference will include lectures by physicians and lactation experts on breastfeeding premature babies, milk supply issues, natural fertility, breastpumps, and introduction of complementary foods (solids) .

You can get a registration form from La Leche League Israel’s website. Space limited.

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Breastfeeding and Introduction of Solid Foods: New Guidelines from Israel Health Ministry

This week the Israel health ministry issued new guidelines on introduction of complementary foods (solids) to breastfeeding babies. Unfortunately, the media got hold of the information early and published misleading information.

There is nothing especially new or radical in the guidelines, which are based on information from the World Health Organization.

The main difference is in the statement that the first taste of complementary foods may begin at four months instead of six. In other words, exclusive breastfeeding should begin from birth and continue for at least four to six months. Mothers can give tastes of solids, including meat, fruits, vegetables, and grains containing gluten, before six months. Quantities should be limited to two tablespoons a day from the mother’s finger. After six months quantities can be gradually increased but breastfeeding should continue for at least a year. Solids given before six months may have a developmental, but not a nutritional, benefit.

There are several reasons for the change:

1. Recent studies have shown that the increase in celiac disease—sensitivity to gluten as found in wheat, barley, and oats—is related to too-early or too-late  introduction of gluten in the baby’s diet. For lowest risk, babies should be exposed to gluten between 4 and 7 months.
2. Research on celiac disease also shows lowered risk to babies exposed to gluten while their mothers are still breastfeeding. Since more mothers are nursing at four months than at six, the guidelines may ensure that more babies will be exposed to gluten during the breastfeeding stage.
3. Research on allergies has not shown a benefit to delaying solids for longer than four months, even in children with a family history of allergies. Relatively early exposure may actually reduce risk.
4. Introduction of large quantities of solids at an early age can negatively affect breastfeeding and lead to lower weight gain, but small quantities (1 to 2 tablespoons after four months) do not harm babies developmentally nor do they impact long-term breastfeeding.
5. This was not in the report, but there is concern that formula-fed babies could also benefit from earlier introduction of solid foods. Several years ago, three Israeli babies died and many were brain-damaged because of lack of Vitamin B1 in one type of Remedia brand soy formula. Since then the health ministry is concerned about the lack of variety in the diets of formula-fed babies. The babies on the Remedia formula that received even one dose of Vitamin B1 from another source, whether it was nursing or Bamba, survived.

It is not necessary or required to start solids before six months, but according to new research it may not be wise to delay much longer than six or seven months. I know many babies are not interested until long after that age, and if that is the case with your baby I would not be overly concerned. We are talking about statistical lowering of risk, and genetic components are more significant.

There is a risk that mothers will misunderstand, like the press did, and think that nursing after four months isn’t important. On the other hand, exclusive breastfeeding for four months instead of six may be easier for some mothers to “swallow,” especially since most mothers return to work at around four months. It may seem like a more attainable goal. Relaxing the restrictions on complementary foods reduces pressure on working and pumping mothers, who can relax knowing that the babysitter can give some solids if there isn’t enough pumped milk available. It also gives mothers less reason to supplement with bottles of formula, which is more likely to lead to early weaning.

At any rate, the ministry should be more concerned with the bottles given to 70% of the babies in the hospital (They do address this in the guidelines, but not strongly enough.) Most babies in Israel have been exposed to formula long before they reach four months of age.

Click to read more posts on breastfeeding at A Mother in Israel.

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Heart Attacks: Are Men from Mars and Women from Venus? Guest Post by Dr. Roy Schwartz

A few weeks ago my friend went to the doctor because of transient pain and shortness of breath. She was hospitalized for a few days, and thank God, all tests came back normal. The doctors explained that they are extra cautious with women because their symptoms of heart disease are atypical.

I met Dr. Roy Schwartz, a medical intern, on Twitter (@diseaseaday) through my obsession with interest in swine flu. On his blog, A Disease A Day, he describes symptoms and treatments of common ailments. Because many readers are approaching the critical age I invited him to write a guest post about women and heart attacks.

Heart Attacks – Are Men from Mars and Women from Venus?                    Guest Post by Dr. Roy Schwartz

The answer: YES. We are not only different in the way we look, the way we behave and all the rest. We are also different in the way we experience heart attacks.

Heart disease is a leading killer for both sexes. But what are the differences and why do they exist? We’ll cover some of the major ones here.

1. Risk age
   The facts: Men start to be more prone to heart attacks when they are 45, women at 55.
   The reason: Menopause. After menopause levels of HDL cholesterol (“good” cholesterol) fall and levels of LDL cholesterol (the “bad” one) rise, increasing women’s risk.
   Will hormone replacement therapy (HRT) reduce your risk of heart attack? Unfortunately, no. Studies have found that HRT actually INCREASES the risk of heart attacks, stroke and breast cancer.
2. Symptoms
   The facts: Women experience heart attacks differently. Heart attacks begin with angina pectoris, the chest pain caused by clogged arteries in the heart. While in men this pain is more “typical” (in the center of the chest; radiating to the neck, jaw or arm; occurring after exertion), in women it may appear in different locations and not be related to any activity. The pain of angina in women may come and go over days, weeks, or months. It may be seasonal— becoming more frequent in the winter in temperate climates. It may not appear as pain at all, but as difficulty breathing, nausea, fatigue or abdominal pain.
   All of these differences make the diagnosis of heart attacks in women more problematic, sometimes causing a delay in diagnosis.
   The reason: No one really knows.
3. Attitude
   The facts: Women tend to avoid or delay seeking medical care when they face heart attacks or angina.
   The reason: This might be partly due to denial or lack of awareness, and partly because, as stated above, symptoms tend to be “atypical.” [MiI: My friend resisted going to the hospital because she had "too many things to do."]
4. Tests
   The facts: Some diagnostic tests and procedures may not be as accurate in women as they are in men, so physicians may not order them. This can lead to later detection of the disease.
   The reason: Again, unknown.
5. Research
   Fact: In the past, most research studies in this area were conducted on men. This has led to a poorer understanding of the differences between men and women (and hence the “unknowns” above).

Thanks to Dr. Schwartz for taking the time to write up this informative post. You can learn more at his blog, A Disease A Day and in his series explaining heart attacks.

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Agel Pyramid Scheme Exposed

Jameel at the Muqata writes about the multi-level “pyramid” scheme used to market Agel, an overpriced and unproven vitamin supplement. The highest-level marketers have made a lot of money, but hundreds at the bottom will lose their investment unless they can convince enough others to invest and market as well. Most large “Anglo” communities in Israel have several Agel representatives.  (Agel hasn’t discovered mine yet. Please stay away.)

According to a comment on Jameel’s post by an Agel representative, a month’s supply of one type of supplement costs NIS 1000, or about $250.

In related news, Haaretz reports that an Israeli woman who used and marketed Herbalife products is suing the company over  damage to her liver.

An Israeli woman filed a NIS 2.5 million lawsuit yesterday against Herbalife Israel, claiming that the companies’ products had caused her chronic liver disease, with the risk of future liver failure necessitating a transplant.

In her suit, submitted to district court, Mali Nir, 54, alleged that products marketed by the California-based nutritional-supplements and weight-control company and its Israel affiliate as natural and promoting “health for life” destroyed her health.

The suit claims that she “was never advised that consuming the companies’ products could cause irreversible liver damage, and that they could even be poisonous to the body.”

Nir said she began taking Herbalife supplements in 1998 and even signed on as an Herbalife distributor. She says that the first sign of a problem surfaced in 2001, when she began to experience fatigue and weakness. She then discovered that she had serious liver damage.

When she stopped taking the supplements, her liver function reportedly returned to normal, but with indications of cirrhosis of the liver, along with problems that included pain, chronic fatigue, weakness and insomnia.

Attached to the suit was a medical opinion from Hadassah Hospital internist Dr. Mayer Brezis. In it Brezis stated that research literature from as far back as the 1990s reported the risk of liver damage from herbal products, and that there was a high probability that the Herbalife products caused Nir’s liver problems.

The suit also alleges that Israeli researchers documented 12 cases of severe liver damage similar to Nir’s in patients who used Herbalife products like the ones she took.

Not everything advertised as natural is truly natural.  And not everything natural is good for you. No matter how convincing the pitch, companies and stores that market “health” products are usually more interested in selling than in protecting your health.

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