Monday, August 22, 2011

Everyone is terminal.

A few months ago I was diagnosed with a dilated cardiomyopathy having an ejection fraction of 20-25%. I weigh about 270 and at the time I went into the hospital. I was bloated with water because of congestive heart failure. I had been on Flurosimide for about six weeks and I had dropped about 30 pounds of water so far, but, I was still pretty squishy.

I was talking to the doctor about what was causing the CHF, congestive heart failure, and he started talking about eating better. I stood up with all the monitor crap and started pounding on my stomach.

Back in my early twenties I had once done 300 sit-ups using a roman chair, 6 sets of 50. You lay back flat with your hands crossed over your chest and come up to about a 45 degree angle. This works the hell out of your abs and it isn't as hard on your back as normal sit-ups. Back in April of 2010 I was working out in a hotel exercise room and some guy who was pretty well ripped was smirking at me as he did roman chair sit-ups. He did 25 or 30 so I knocked out 50. He did another 25 and I did another 50. It was the most I had worked my abs for years and they hurt for days, but, he wasn't smirking any more.

I have great quads, calves and abs. My leg-biceps, my lower back and my upper body are no where near as well developed. My best bench is 315. I worked my way back up to that back in 2006 and 2007, but, then I had to sell my weights so my workouts were limited to my recumbent bike and some dumb bells. I wasn't regular about it and then I tore my rotator cuff so for about a year I just did the recumbent, 30 to 45 minutes a day, moderate workout burning about 300 calories according to the computer.

While I was working at Oak Ridge National Laboratory they had a great employee gym. My bench was 3 sets of 10 using 160. I used the gym until December when I started feeling sick and fatigued. By February I had advanced CHF and that takes us to April when I was standing in the ER pounding my ab muscles telling the doctor that what we thought was a big gut was actually distended abdominal muscles combined with some visceral fat, but, not as much as they probably thought. I have about a 1/4” of fat over my upper abs and a pretty normal roll around my middle. When the doctor figured out I was in a lot better shape than he thought I was he ordered some other tests. Bingo, idiopathic dilated cardiomyopathy with an ejection fraction of 20-25%.

Treatment for that? Heart transplant. They can put in a pace maker. They can give you drugs. I can't do 30 minutes on an exercise bike any more. Ten minutes is about the most I can do and I can walk for a couple of hours if I get some resting in.

Median survival for someone with a pacemaker is about 8 years. They install pacemakers at below about 40% EF. Typical survival after a heart transplant is about 6 years. They do heart transplants for people with about 20% EF. Sixty percent of people with a cardiomyopathy having 20-25% EF without a transplant live longer than a year.

So right now my chances for survival beyond 5 years, with or without a pacemaker or transplant are pretty poor.

Http:// Intelligent Analysis of Long-Term Patient Survival after Pacemaker Implantation Poor survival of patients with idiopathic cardiomyopathy considered too well for transplantation.

If you want to review the chances for survival restrict the google search using the site:*.edu or site:*.gov so you get reliable data instead of all the new age mysticism BS out there.

As usual I don't plan on things working they way people tell me they should. After 30 years in manufacturing and engineering, 15 years in advanced situations where I am typically accomplishing something people tell me is impossible. I figure this is a similar situation, someone tells me what is possible and impossible and then I ignore them and make the impossible happen.

I couldn't count the number of times people with doctorates have argued really dumb positions. The older I get the less respect I have for formal education. All education is self education, the literacy rate of college graduates establishes this beyond a shadow of a doubt.

So what is causing my cardiomyopathy?

There isn't any specific diagnosis concerning the cause. This is typical and they have a name for it, idiopathic. It means the doctor knows the symptoms but does not know what the root cause is. Sometimes the doctor makes assumptions like the idiots who looked at my distended abdominals and bloated water retention deciding that my diet must be merde because I'm fat. Idiots, but, what can you do. Everyone stereotypes and makes stupid bigoted decisions based on their stereotypes. In medicne there are more stereotyped guesses than you would imagine.

If you want to know if a person is “profiling” or stereotyping ask about the standard deviation. A “profile” is a statistical analysis indicating probability. If someone does not know the numbers behind the probability they do not understand the probability and they are just stereotyping. For example, if someone tells you most drug dealers are young blacks ask them what percentage and what the standard deviation is. If they don't know the numbers they are spouting stereotypes, not profiling. Most young blacks are not drug dealers even if most drug dealers are young blacks. Get the idea?

Doctors depend a lot on test results because “patients lie”, or as Greg House explains it, “everyone lies”.

Lets look at a study about obese cardiomyopathy: Obesity cardiomyopathy: is it a reality? An ultrasonic tissue characterization study.

We'll look at a a couple of numbers and the mean because the abstract does not give us median or curve modality. With a normal curve the mode, mean and median are all about the same number. “A slightly reduced LV diastolic function was demonstrated in obese patients (transmitral early to late peak diastolic transmitral flow velocities ratio = 1.1 +/- 0.7) as compared with control subjects (1.5 +/- 0.5, P < .02)”

So the range for obese patients is 0.4 to 1.8 with a mean of 1.1 and the range for control subjects is 1.0 to 2.0. The interesting thing here is that we can estimate the standard deviation from these numbers and the standard deviation is higher in obese patients.

About 33% of obese patients will have an LV diastolic function flow velocity between about 1.1 and 1.3. About 17% of non-obese patients will range between 1.0 and 1.35.

Hmmmm, so if someone has a flow velocity of 1.25 are they suffering from obesity related cardiomyopathy? About 20% of obese patients and about 20% of non-obese patients will test at this point. So the doctor looks at the person's weight and appearance and decides if the person is obese.

So what is the standard deviation and probability curve relating to weight? Yep, you guessed it the vast majority of doctors have no clue. What is the calorie requirement based on age, weight and height? Yep, you guessed it most doctors couldn't even tell you that there are two different formulas for this calculation and they really couldn't tell you what the standard deviation for caloric intake is.

Pretty scary since we all depend on these people to analyze probabilities as they pertain to ourselves as individuals and give us medical advice.

In reality doctors are not using probabilities, they are using stereotypes with minimal factual basis in probability.

You have to hope you have a good guesser, like “Greg House” and lets face it the probability is that your doctor is an average guesser. 66% of doctors will be average guessers. About 4% will be exceptional guessers. 4% will suck at guessing. About 13% will be above average guessers and 13% will be below average guessers. So you have about a 2/3 chance of having an average to good guesser who will guess right X% of the time, on average.

Now here is one of the issues, there are not a lot of real doctor guessing statistics, but, what there is indicates that the probability of incorrect guessing increases with the severity of the illness.

Yeah, I don't buy that. I figure that people are caught making bad guesses in serious situations more often then they are caught making bad guesses in non-serious situations.

Now there are a bunch of really bad numbers out there on diagnosis, some saying that 98.6% of doctors guessing is correct. This is using numbers similar to those we just reviewed where there is about a 20% overlap between normal and obese patients.

98.6% would mean subjective decisions made by doctors are more accurate than objective decisions made using a standardized test.

Yeah, I'll buy that for a dollar. If you have to ask what that means, don't bother.

In reality, after reviewing the data available I would guess the reported mean for average guessing is between 80% at the high and 70% at the low with a range of about plus or minus 20%. If we guess 75% then most doctors get 3 out of 4 right, which is actually pretty good for subjective interpretation. If stock brokers did this well we would all be billionaires.

So what is the probability those numbers are correct? What are the chances doctors are better at subjective analysis based on reviewing factual reports of objective statistical data than stock brokers? Interesting question. I would guess that the numbers are actually pretty close and the best stock brokers only guess right about 30% of the time (those numbers are easier to come by and objective since bad stock choices are objectively analyzed).

So, looking at the available data I figure the subjective analysis by a doctor is probably correct closer to about 1/3 of the time. In fact, subjective analysis by almost everyone is probably correct about 1/3 of the time. The most of the best are probably right about 45% of the time and guys like me (and I have tracked my subjective analysis stats) are correct about 60% of the time at my best in my area of expertise, between about 45 and 50 years old.

Okay, so doctors probably become better guessers as they age and have more experience and at the best are probably correct around 60% of the time. Statistics including all doctors are probably closer to 30% with, I would guess, a standard deviation of about 10% and these statistics can probably be further refined based on age, medical school and other variables.

Trouble is, we will never know if my analysis is accurate because medicine is no where near an objective science at this time which is why predictability on patient prognosis has so many anecdotal miracle and disaster stories. The prognosis stories are a result of the lack of objectivity and the over lapping data ranges in diagnosis.

Medicine will get better as research develops and data becomes more objective. For example, doctors may eventually have a method of objectively and easily measuring fat and muscle ratio. Maybe an office level scanner that reports muscle tone, water and fat percentages. Maybe brain computer interfaces will develop and doctors will have more confidence in the patients witness concerning their eating and exercise habits.

No way any doctor believed I once did 300 roman chair sit-ups in 6 sets of 50 until I began pounding on my abdominals. I can't blame them, I don't exactly walk around looking at fat guys and saying “I bet that guy has really solid abs”.

It's fun screwing with people though, like the time I was at REI and let the guy running the rock wall talk me into climbing because he thought it would be funny to watch me. After I hooked up he bent down to check his belay and I was already at the rafters. My wife laughed her butt off at the look on the guy's face. I swung over to an overhang and didn't do very well at that and that made the sales man feel better. It had been 15 years since I had done any rock climbing so I didn't feel bad and I didn't try very hard at the overhang. Overhangs were never a strong point for me because of my relative upper body strength. My strength is mostly in my lower body.

So I hope you take the knowledge that doctors are no better at guessing than anyone else is, when people are guessing in their area of expertise. Remember doctors go through a fairly difficult vetting procedure to determine if they are good guessers. Really bad guessers are weeded out and there could be a curve skewed to the above average guessing based on the vetting procedure. Of course charismatic people can be poor guessers and make it through the subjective vetting procedure and people who are un-charismatic and good guessers can be kicked out.

In the end you can only be the “best” person you can be for as long as you are around. In the end everyone is terminal, everyone dies, everyone mourns, everyone loves and everyone leaves love behind. Those of us who are religious have a lot of love to look forward to.

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