Billy Mays and epidural hematomas

This is an unfortunate week to be a celebrity: Michael Jackson, Farrah Fawcett and no Billy Mays.



Billy Mays, the Pitchman, died at the age of 50 yesterday at his home in Tampa, FL. Apparently he was on an exceptionally bumpy airplane ride the day before his death -- the front tires blew out on landing and the impact of the plane on the runway caused carry-on bags to fall from overhead.



Despite being hit in the head, Billy seemed to be doing well, until the evening, when he stated that he wasn't feeling well. The next morning he was found dead in his bed.





His death is similar to Michael Jackson's in several ways:



1. They were both 50.

2. The cause is yet unknown.



These are two important points:



1. Men often neglect their own health issues -- many of their potential health problems could be prevented through simple steps, such as:

- Quitting smoking (reducing the risk for cancer and heart disease/stroke).

- Exercising regularly (reducing the risk of most health problems).

- Eating a healthy diet (once again to reduce the risk factors for bad health).

and

- Seeing a doctor regularly for physical checkups (this can be especially useful in early detection of prostate cancer).



2. There is nothing special about these deaths, as opposed to everyone else who dies and every family and loved one who suffers. It is akin to the H1N1 Flu scare -- no more people died from this flu than from any other typical flu, yet most of us don't think about how many people die from the flu every year, until it hits the news networks.



So, what did Billy Mays die from. It is possible that he sustained a traumatic blow to his head, which caused tearing of the arteries (usually of the middle meningeal artery or its dural branches). After an injury, there may be a lucent period, followed by a neurological downturn.



It is difficult to say whether this is what happened or not (and so he will be having an autopsy), but it does highlight the central importance of good clinical history taking in neurological evaluations.



The untimely death of these celebrities should help raise our attention to potential health problems that may (at times) be avoidable. Most Americans die from heart disease and stroke; more public attention should be focused on reducing risk factors and ensuring that, at the earliest sign, people seek medical attention immediately.



--
Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique

Michael Jackson, Voodoo death and Neurology

Michael Jackson and Neurology?

While these may seem to be strange bedfellows, there are actually a lot of neurological issues involved in his life and death.

He certainly was the King of Pop and we know that entertainment may lead to sleep disorders. Common reasons for insomnia (even in patients with neurological diagnoses), include poor sleep hygiene and obstructive sleep apnea (OSA). Thriller certainly leads to fright, and while it changed the face of music videos (MTV), it's gruesome depiction of zombie-like characters is reminiscent of people with lobotomies and frontal lobe dysfunction. It could be argued that Michal Jackson, himself, sufferred from executive dysfunction.

Another aspect of our recent loss is the outpouring of grieving over his death. Grief is a natural step in all of our lives, and is split into five sequential stages by Elisabeth Kubler-Ross (1959): Denial, Anger, Bargaining, Depression, and Acceptance.

Being diagnosed with a lifetime (not lifelong) neurological diagnosis (not disease) often leads to these stages of grief. It is important for the patient and loved ones to work through these stages in conjunction with their primary care physician, neurologist and psychologist/psychiatrist. For those who are religious, priests, pastors, imams and rabbis may play an important role in this process.


But now the heart of the neurological connection between Michael Jackson's untimely death and neurology: "Voodoo" death.

While normally the heart and other organs work on their own (think about heart cells in a petri dish), we all know that the brain is central to all that we do as human beings (brain death is considered death). This means that sometimes the nervous system reacts to an extreme stressor and cause irregularities, such as cardiac irregularities ("cerebral" T waves and contraction band necrosis).

We now suspect that the insula (http://upload.wikimedia.org/wikipedia/commons/2/20/Gray717.png) plays an important role in regulating the heart (coined the "cardunculus," like the homunculus). Patients with left insular strokes, as opposed to non-insular had a worse outcome in the article by Laowattana et al. (S. Laowattana, S. L. Zeger, J.A.C. Lima, et al. Left insular stroke is associated with adverse cardiac outcome Neurology 2006;66:477-483).

Dr. Marty Samuels, Chairman, Department of Neurology Brigham and Women's Hospital and I have discussed the deaths after the Red Socks defeated the Yankees in the 2004 World Series, where super fans had said things like "I will be able to die once the Red Socks win the World Series." Once the Red Socks did finally break the Curse of the Bambino, people actually died of extreme emotion.

Death also occurs after extreme stress or fright -- see: http://www.boston.com/news/globe/magazine/articles/2006/08/06/scared_to_death/


So what does this have to do with Jacko?

He was about to (hopefully) end many of his financial woes through a three-year plan with AEG worth $400 million (the UK economy was also going to be bailed-out, to the tune of $1 billion, with the stimulus by his concerts -- perhaps there is a hidden lesson for Bernacke, Geithner and Obama). For a frail international icon, these financial boosts were clearly a source of extreme emotion, and may have led to his death.

With such a turbulent and controversial life, may he rest in peace.


--
Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique

M*STAR, individuality and evidence based medicine

M*STAR is the Multiple Sclerosis Team Approach Rule.

While the concept is simple, straightforward and, you would think obvious, unfortunately in today's healthcare environment, the individual person (not patient) is marginalized, while doctors are forced to see more and more patient in less and less time.

[In a National Healthcare plan, this is going to get even worse -- we are going to set government standards on stripping each of us of our individuality, and instead we will all be numbers in the mega-healthcare risk pool -- remind anyone of the cogs in 1984 or a Brave New World?]

The recentering of the patient as the center of the health (not illness) team flies in the face of some of the recent trends in modern medicine. As we focus more and more of our energies on evidence-based medicine, we forget that clinical trials, analysis, post-hoc analysis and meta-analysis are all great tools, but they are only tools.

Patients are people and clinical trials are important, but they only hint at the potential effects of a given intervention (in neurology, that intervention is usually a medication). The results of these trials do not predict how an individual patient will respond to that medication. So, a positive trial (where the results are as we had hoped), does not necessarily mean that each individual will respond to the therapy -- it only gives a hint to the average response in the population in that specific trial. So too, a negative trial (where the results are disappointingly not what we had hoped), does not mean that no one will respond to the medication.

So, there may be great interventions for individuals, but unfortunately these individuals will be denied access to these medications because of the negative trials. This is a problem now, and it will become an even bigger problem as we enter the next phase of healthcare reform.


--
Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique

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--
Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique