A Woman Who Needed to Be Upside-Down (2012) | Hacker News Reader

A Woman Who Needed to Be Upside-Down (2012)

discovermagazine.com

288 pointsColinWright97 comments

Slightly tangential, but in Brave New World they trained future embryos to be rocket-plane engineers altering oxygen levels based on their vertical orientation.

> The first of a batch of two hundred and fifty embyronic rocket-place engineers was just passing the eleven hundred metre mark on Rack 3. A special mechanism kept their containers in constant rotation. "To improve their sense of balance," Mr. Foster explained. "Doing repairs on the outside of a rocket in mid-air is a ticklish job. We slacken off the circulation when they're right way up, so that they're half starved, and double the flow of surrogate when they're upside down. They learn to associate topsy-turvydom with well-being; in fact, they're only truly happy when they're standing on their heads."

Reading this article makes one appreciate just how much expertise doctors have. As soon as the doctor was presented with a few symptoms, he was able to begin running through a checklist of problems related to this specific issue and arrived relatively quickly at the solution.

Many doctors are able to routinely do this for dozens of ailments under intense pressure, making them even more impressive.

And unfortunately some doctors cannot make a proper diagnostic even after visiting them several times, and having a rather uncommon, but not rare, condition. First hand experience.

Well that's life.

I'm not surprised by that. There is an exhausting amount of information that they have to digest & recall. It makes sense that they would assume that the most common conditions are likely to be the cause of your ailment. Maybe AI or automated diagnosis could help in the future, by suggesting rare conditions that fit the symptoms as well as the common ones.

How can I rapidly ascertain (within the first minutes of meeting for the first time) if I'm talking to such a doctor, vs someone who's going to complacently sit around and pontificate about what's possible without actually actioning anything?

I’ve not found a way yet, other than being around when they handle some kind of crisis, seen that a few times while working in a hospital. Wandering though on my way to/from lunch break was very occasionally surprising. It’s quite a surprise the first time you see a hospital bed roll past as a doctor on top is doing cpr compressions then literally hops off, while a second doctor hops, mid-run, to resume the compressions... like trick horse riding or something. Only ever saw it once but damn it was something.

It makes me appreciate how much expertise these doctors have. Generalizing it to all doctors is going one step too far.

The pattern matching could easily be automated. It's basically a game of 21 questions. Doctors sometimes fail here by getting too fixated on prior probabilities ("this condition is very uncommon so you don't have it").

The expertise, and IME this is rare, is in turning vague descriptions into matchable patterns, prompting for more detail when needed, and explaining things at the appropriate level (which for some patients might be quite high, others quite low).

In theory sure, in practice nobody had built a general system that works well yet.

I think the point was that the difficulty for machines is not the differential diagnosis, but in coaxing out the right details of patient history to feed into that algorithm. I don’t know if differential diagnosis is automatable but machines definitely suck at the latter issue.

"While in theory there is no difference between theory and practice, in practice there is."

Maybe the patterns change and that is what makes humans good at it and automated things not.

If you enjoyed this article, you might also enjoy The Man Who Mistook His Wife for a Hat and Other Clinical Tales by Oliver Sacks. It’s a book of essays about brain function and disorders, but each begins with an individual who exhibits particularly unusual symptoms. They don’t have tidy resolutions like this article, but the book is well-written and engaging—-as are the rest of Dr. Sack’s writings.

Just started reading this. It's really sucked me in, but it also fills me with a sort of biological dread. Something goes wrong with your brain-meat and suddenly you find yourself teleported 40 years into the future every time you look in the mirror, or become an unstuck, powerless spirit inside your own body.

I cringed at the part where they're yelling about epinephrine and IVs, and Jason has to barge in and put her upside down again.

I think it is illustrative of how important it is to have someone who cares about you and knows you around when dealing with doctors.

An incredibly tiny percentage of cases presenting to the ER are unique and necessitate a friend or family's help in diagnosis - let alone treatment.

I know multiple stories from just my family of people who only got adequate help through persistence of their family member or significant other.

Though I am from Poland and I don't consider Poland to have adequate medical system.

When you are really bad you may not be able to explain to medical staff what is going on. There are cases in life threatening condition that are misdiagnosed as drunk. You need a family member to tell the medical staff that no, they are absolutely positively sure you are not drunk.

Surprised they can't smell the difference.

I call bullshit. I have more children than average and during every single labor & delivery I've caught paperwork problems and mistakes in communication while my wife was too distracted to pay attention to such things herself. All minor, but given the option I would always want an advocate on my wide who is purely there for my own benefit and who isn't experiencing a major medical problem at the time.

Just someone being there will cause staff to pay more attention to a patient.

I doubt it. My son would very likely have had permanent damage to some of his internal organs while in the NICU had I not insisted on a second look at a diagnosis after the physician ruled it based on a checklist cross-indexed with age because "it's impossible."

And that was just one instance among many where me and my wife were the best--and most accurate--advocates for our son's care.

It's not that doctor's are dumb or uncaring: they're simply stretched thin and feel they have to play by restrictive rules put in place to help prevent lawsuits.

It is absolutely crucial, in my opinion, to have someone who truly cares about you accompany you if you must go into a hospital for any reason.

That kinda talk is exactly why the parent holds that sentiment. I get that to a doctor you're being evaluated against a statistic, but as a patient I'm obviously invested in my particular circumstances.

Not blaming anyone, but nobody feels reassured being treated that way.

It depends on the situation. If the patient can talk and answer to questions it's usually enough. If they can't then having someone else play that part instead usually helps. 99% of the cases though patients think they are special in their problem but they are not.

I think you're ignoring a huge gap between "can talk" and "can adequately explain situation and advocate for self and how they are feeling to a relatively dispassionate listener".

I'm not saying that doctors are dispassionate, but that doctor will be spending at most half an hour with the patient, if you're lucky, while your family will be with you the whole time, listening attentively.

Doesn't need to be super precise. We are trained to work with uncooperative patients. Of course it helps though.

With all due respect, I've personally been witness to two different occasions when having a family member around asking questions literally saved someone's life by drawing the doctor's attention to something they had not noticed previously.

Then it's the doctor's fault for not noticing it.

Well, that's the whole fucking point I'm making, isn't it?

All doctors, even the best, are busy, tired, and overworked, and no matter how much they want to give you all the attention you need, they're not able to, in part because how our medical system set up, and in part because that's just... reality.

And they're going to not notice something all the time, even the best doctors in the best hospitals.

And if the best doctors are fucking up, what about the ones who are not so good?

If you want a good outcome, you need your own advocate, be responsible and inquisitive, and you can't just leave it to the doctors.

Well, this is the point...

> 99% of the cases though patients think they are special in their problem but they are not.

It is this attitude that is the problem, in my opinion.

Every patient is special and unique, and "modern" medicine just fails to admit it and treats everyone like a fucking steam engine.

Pardon the profanity, but I've seen too much of this shit my limited experience with the medical system to know better that doctors are best treated as powerful and dangerous tools, and not sentient beings, until proven otherwise.

It doesn't mean doctors will catch on or accept outside theories.

That's quite a claim to make without any evidence to back it up. I don't think you have any idea what you're talking about.

If you had ever accompanied someone with a serious condition, you would probably think differently.

I don't have that much experience in this area, yet I've personally witnessed several occasions when family advocating for a patient saved their life.

And, sadly, vice versa as well.

This is in the U.S, in major cities, in hospitals that were recommended as being above average by those in the know (medical professionals and other patients.)

Do you have a source for this?

From my experiences, healthcare advice is designed for the most likely scenario given an imaginary average person- and it is incredibly important to take an active role in conversations with medical professionals (I suppose unless you happen to be perfectly average in every way and experiencing the most likely ailment given your description).

From people I know in healthcare it is very common for people to catch healthcare provider mistakes ranging from troubling to terrifying.

It absolutely needs to be a collaboration whenever possible.

Right after the couple explained the pattern, predicted the consequence of placing her on the bed, and how to solve it!

Seems like "Thinking, Fast and Slow" territory. They were fed new info but the intuitive part of the brain just went straight to the routine even though they had evidence this was not routine.

Definitely - they just reacted exactly as they have been trained to do.

Probably the doctor has no readily accessible way to hang a patient upside down and wouldn't want the legal liability of doing so anyway.

Except for the "giant" who brought the patient in.

> Or her blood pressure could be so low that blood reached the brain only when she was upside down. Blood pressure that low could have been triggered by an allergic reaction, anaphylactic shock, or severe dehydration.

So, if this is a generic thing about low blood-pressure, including—potentially—low blood-pressure from shock... then could inverting someone who's going into shock in the field (where an ambulance is not yet arrived), be neuroprotective—ensuring they keep some oxygenated blood near their blood-brain barrier to feed their brain, long enough to stave off brain damage until EMTs can arrive and get a saline+steroid IV into them? Would it work for all types of shock? Toxic shock, for example?

I know that in the case of the article, the cause turned out to be a malfunction of the pacemaker itself, but is the doctor's original line of thinking still valid?

Interesting point, as this is actually the topic of some debate.

The position you're referring to is known as the Trendelenburg Position. The benefits were thought to lie not so much with increasing perfusion to the brain, but bringing more blood back to the heart (known as preload), thereby increasing cardiac output and increasing blood flow to vital organs. If you're interested in this, there's some neat physiology called the Frank-Starling law [0].

However, it turns out that in practice, cardiac output doesn't actually improve. In fact, this position also increases the risk of fluid build up in the lungs (pulmonary oedema) and can worsen cerebral perfusion [1]. Therefore, it's falling out of favour in the context of shock. A compromise might be to elevate solely the legs, but its efficacy is also being questioned.

This illustrates a recurring theme in modern medicine; the human body & disease is so complex and poorly modelled, that it's often not possible to translate intuition or first principles of physiology into treatment. Instead, one relies on real world studies like those reviewed in [1] - AKA 'evidence-based medicine'.

[0] https://en.wikipedia.org/wiki/Frank%E2%80%93Starling_law

[1] https://www.cambridge.org/core/services/aop-cambridge-core/c...

This is why they have, no joke, inflatable pants [0] more commonly known as "Military Anti Shock Trousers(MAST)".

I am not a dr (IANAD?) but the idea is that you inflate the pants around a patient's legs which helps both push and keep blood out of the lower limbs and closer to the hear and brain. In principle, you could do the same by tying a tourniquet around each leg but the MASTs probably cause less tissue damage and are more adjustable.

[0] - https://en.wikipedia.org/wiki/Military_anti-shock_trousers

I've been out of EMS for a few years now, but these have (or had at least) fallen massively out of favor.

Effectively, you could artificially keep the patient alive by using MAST pants, but they inevitably crash when they were removed. My old service had a few pairs tucked back in a closest, but none on any of the rigs. I'm quite certain they aren't in allowable by protocol in most places at this point.

A pretty wild device, nonetheless!

EDIT: Quick edit to throw in that I have heard tales from the old heads of using them to stabilize pelvic fractures, too.

Even if they crash, couldn't MAST pants be useful in ambulances in order to deliver patients alive to the OR? Or did it somehow make them less likely to survive than not using them at all?

At least the more mild version of raising their legs is definitely recommended for people in shock. Probably something as aggressive as completely flipping them upside down will depend on why they're in shock in the first place.

> Passive leg raise, also known as shock position, is a treatment for shock...

https://en.wikipedia.org/wiki/Passive_leg_raise

What I learned in Boy Scouts four or five decades ago, that when I recently checked (sorry, no source readily at hand) was still valid:

"If the face is red, raise the head. If the face is pale, raise the tail."

I can't be the only one that called it as soon as I read the word "pacemaker". Nice to see that the hospital still went through the troubleshooting flow chart though.

Do you have a background in cardiology? It may be more likely that the pacemaker would jump out to you as the cause because you're not familiar with the other possible causes.

Purely binary performance, it's either working or it's not, is common for digital electronics and rare for body parts. Body parts tend to work less and less well and there's a threshold where it starts causing problems down the line. Body parts also don't tend to have intermittent failures where they can toggle between "working fine" and "not at all" rapidly whereas electronics do.

Once they stated that she had electronics in her that became obvious as a likely source of the problem.

Binary states aren't super rare in biological processes. All the causes the doctor outlines are plausible. My first thought was orthostatic hypotension (it's not at all uncommon for people to pass out almost instantly when they go from supine to standing), or some sort of obstructive shock (with cardiac tamponade being the most likely). Both of those conditions are massively more likely than the pacemaker being intermittently connected, so it make sense to rule out the higher probability options first.

What I'm not sure about is why they started doing diagnostic tests (especially ones where the patient was quite clear on what the outcome was going to be) without an IV in place...

The way I saw is it like doing a commit bisect. While there were other problems before, this particular problem started after the pacemaker operation, the other problems had stopped. It is like a one bug is fixed and another was created. Either the operation or the device itself was the most likely cause of the change in such a short time frame?

In software dev a bug being created as side effect solving another usually means QC missed it, perhaps here too?

I don't know if surgeons do checklists or some else normally verifies post op on the procedure( peer review?), and are there ways to verify the device before and after insertion , if it was software dev that's what I would recommend . While surgeries and medical practice has lot of regulations and it cannot be changed easily, the principles are sound, and other fields like airline pilots do similar things.

I totally get where you're coming from. I'm a full time developer, and part-time paramedic. There are definitely a lot of similarities between debugging a program and debugging a person.

The doctor in the post was also working off the base assumption that this was a bug that got shipped in the last release (surgical complication leading to interval bleeding, leading to hypotension; surgical complication leading to cardiac tamponade; etc). My original point was just that the answer that was obvious to the commenter was actually pretty low on the probability list, and it only seemed obvious because they had an incomplete mental model of the system as a whole (something that happens in software debugging as well). As it turns out, it was the correct answer, but the correct approach (on average) would still put "failure of the pacing leads" pretty low on the list of likely causes.

There are a lot of checklists used in surgery. For instance, immediately before any procedure, there is a "time out" to make sure everyone is on the same page with the right patient, right procedure, and right location. I'm not aware of any checklists specific to pacer leads, but I don't spend much time in the OR these days.

Same here, but then again, that article is from 2012 and I am sure I've read it before and connected the dots immediately.

I didn't call it, but I did guess some sort of electrical disconnect.

I bet they used a micro usb cable. Sometimes those things can be so janky my phone won't charge unless you kinda fold them and rest the phone on it a certain way.

Micro USB is great. My first smartphone had Mini USB which was way worse.

That happens with lightning cables too sadly.

The contacts on the lightning cable can be cleaned, which is often my problem. But because they're exposed they have to be cleaned.

Pocket lint in the socket also keeps it from seating. Digging that out is like playing Operation. The bits you can break are on the sides, so you have to push straight in to scrape out the lint.

I really should learn to put my phone in my pocket wrong way up so it doesn't catch all that crap...

Don't scrape it out, use air duster!

If I were forward thinking enough I wouldn't have to do that. But you cram the lint in like you're loading a musket every time you plug a cable into the port.

While reading this I thought it sounded familiar, and realized this is exactly what happens in the Grey's anatomy episode "Love Turns You Upside Down". Interesting that it was based on a real life situation, it seems like a lot of episodes are.

Going to the hospital must've been interesting. I wonder if she, in her mid-60s, was seated upside down in the car, or if the man carried her upside down through public transport.

I really miss the Discover Magazine medical diagnosis podcasts about stuff like this. I don't work in medicine at all but I loved the mystery/problem solving aspect - reminded me of being on call for platform services, without the human life aspect of course.

I cant't help feeling so happy that this poor woman has such an amazing husband. Best wishes to this couple.

Now we know Diana Ross's inspiration.

Upside down

Boy, you turn me

Inside out

And round and round

>“You’re hurting her,” a woman yelled.

What should we do with people like this?

Forgive them for misinterpreting a very unusual situation?

Perhaps. On the other hand, she played a role in escalating the situation. It took a doctor stepping in to find out why the woman was being held upside down.

Context should be an important factor when deciding to intervene and how to intervene. If I encountered such a situation in a hospital, I would have interpreted it as unusual and beyond my comprehension, but it would not have struck me as an intent to cause harm. People tend to go to a hospital for help. Those who hurt others in a hospital would likely do so through violence.

I'm not suggesting that she should not have intervened, but she (and the security guard) should have understood the situation first.

We used to ignore them. I still do.

I legitimately don't understand these types of reactions.

At most, this should have prompted is "Well thats different"

You have read the title and know the woman is not being harmed. You probably don't have to deal on a daily basis with drugged and mentally unstable people, unlike someone who works in an emergency room.

Dunno, give them a gun and hire them for community police work? /s

"Eschew flamebait. Don't introduce flamewar topics unless you have something genuinely new to say. Avoid unrelated controversies and generic tangents."

https://news.ycombinator.com/newsguidelines.html

I don't live in an area with any BLM protests. Instead our boring town has started to freak out about mythical child nappers. Cars have been searched and people have been beaten up by there over reactive types. Different politics, same attitudes.

This makes me think of that X-files episode about the couple that were compelled to travel west to avoid physical discomfort: https://en.wikipedia.org/wiki/Drive_%28The_X-Files%29

Ahh, the episode with Bryan Cranston. I really need to try watching X-Files again.

Factoid for the day: Cranston's work on that episode won him the Breaking Bad role later. AMC wasn't convinced he could pull it off (seeing him as a sitcom comedy actor) until Gillian showed them his work in that episode and he was cast.

And written by Vince Gilligan! He also wrote my single favorite X-Files episode "Bad Blood"

Is that also the one where swear words are sort of censored in English by the narrator?

Another favorite was the Cops spoof. OH -- Also a Vince Gilligan!

"Upside down" - my first thought was 2015 George McFly in Back to the Future 2.

Who was played by a Crispin Glover doppleganger. In fact, they made him hang upside down to hide the fact that Crispin Glover wasn't in the movie. This was a subject of a lawsuit in which Crispin Glover won.

I sometimes remember then end of that episode when they drive to the coast, out of the blue for no reason. I mustn't have been very old when I saw it. That one and the volcano one, and the hilbilly mother under the bed one.

> and the hilbilly mother under the bed one

I saw it exactly once, when it first aired on October 11 1996. I was 13 years old and it left enough of an impression that I still remember that moment vividly to this day.

If one appreciates, as I do, when media can make them experience feelings strongly, regardless of the pleasantness of those feelings, then one must admit it is was a great achievement.

It’s funny, the episode is set about an hour out of Pittsburgh, and having grown up also about an hour out of Pittsburgh (although south instead of East) I really recognized it. Of course the episode was over the top but still you saw crazy things out there.

Not too long ago I saw this news article https://www.wtae.com/article/pennsylvania-attorney-general-s... for example and this town is quite close to where I grew up.

That reminds me of this story on Bali's mentally ill being kept in cages and chains by their families. https://www.youtube.com/watch?v=zdUrrlRgMFw

Sometimes I feel this way due to timezones.

I think there are definitely people who have a circadian rhythm that would compel them to move west due to feeling more “in-tune” with the west and continually chasing that feeling.

This read like a call to Car Talk. “Doesn’t anybody screen these calls?!”

Non-American here, I can't be the only one to find the use of "coughing spell" (especially "spell") on a medical setting... Weird. Maybe it's my understanding of the English language and how I perceive that word.

See "(Entry 4 of 5)", the second noun definition of spell [1]. "an indeterminate period of time" or "a stretch of a specified type of weather" as in, "we've had a long dry spell; I hope it rains soon".

It does not sound particularly strange or unscientific to me.

[1] https://www.merriam-webster.com/dictionary/spell

“A fainting spell” also comes to mind. It seems a bit archaic but I think it’s clear and unambiguous.

A perfect reply. Thank you.

(unrelated, obligatory ad rant)

They really make it hard to resist ad blockers. I cannot concentrate on the text with everything blinking and new ads loaded in constantly. Such a death spiral to try to compensate for low ad revenue by making sure to get extreme amounts of ad views from the few suckers that are exposed to them.

Reader mode to the rescue!

Is there a name for these kinds of articles? Serious matters of importance wrapped into Harry-Potteresque story lines

Should we call such articles Harry-Potter journalism?

There's also related style of articles, very popular in NYTimes, that could safely be called Ulysses journalism.

Reply on news.ycombinator.com