Perspective Regarding the Sharon Treatment

There have been an enormous amount of medical details and media hype in Israel regarding Sharon's post-stroke surgeries in recent days. It is important to be clear on the perspective, particularly now that there are a rash of optimistic-sounding headlines on the wires such as Sharon's Brain Scan Shows Improvement and Surgeons Stop Sharon's Cranial Bleeding. Fifteen minutes after the story was first announced, the essential medical condition was clear: the doctors had taken a calculated risk that had failed tragically. Aggressive anticoalgulation combined with brain hemorrage had meant that there was no possibility of meaningful recovery from the moment he arrived at the hospital. Because I had extraordinary confidence in my neurologist source's professional expertise and judgement, I headlined these facts immediately, including that the only question remaining was how long he could be kept alive in a severely debilitated state.

All of the subsequent contradictory reports represented simple medical misunderstanding combined with an element of wishful thinking. The most egregious of them was "Sharon's Physician Says he Expects PM to Emerge from Surgery 'Safely.'" I immediately contradicted this, and later wrote that unless this was a misundertanding of some type (perhaps by "safely" he meant "alive") this was possibly a key to understanding his poor treatment.

The doctor was either woefully ignorant of his patient's condition or spreading disinformation. (Of course there is the possibility that the journalistic simply got the story wrong.) One could make a case that Sharon's physician did not understand his condition because he was not a neurologist, but this is facile. I spent a few minutes talking to a neurologist and came away with a simple principle: the biggest fear with aggressive anticoagulation is brain hemorrhage, which is why everyone involved should have been focused on the intuitive, small list of precautions that I listed here. That should have been made crystal-clear to his circle of medical and non-medical handlers, but there was obviously negligence involved in observing those precautions. After the first stroke, I correctly disputed the "clean bill of health" diagnosis and demonstrated disinformation on the part of his medical team. I also stated that it was clear that the team was focused on preventing the public from understanding the obvious point that I wrote after the first stroke: that his poor and precarious health "is the key to the current election. Ariel Sharon is nearly 78, very much overweight and not likely to change." Sharon's team was maddeningly effective at obfuscating that point. But they apparently frustrated their own understanding of the medical reality as well.

Here is a technical assessment from my neurologist source:

It is still not clear what went wrong. I see two scenarios:

Blood pressure scenario: Sharon's blood pressure rose, possibly due to stress over police leaks that day, and he burst a hole in a blood vessel that did not seal because of anticoagulation.

Clots breaking up scenario: Sharon had blood clots in some part of his vascular system such as his leg veins. The blood clots were beginning to break up with the anticoagulation and a large clot went to his right atrium and from there to his lungs, producing a pulmonary embolism. The pulmonary embolism produced the chest pain and sense of unease. Part of the clot may have crossed the hole to the left atrium and gone on to the brain, causing local damage that resulted in hemorrhage. Alternatively, the pulmonary embolus may have led to a rise in blood pressure that played out as in the blood pressure scenario.

Sharon should have had a doctor nearby, whether by his being in Jerusalem, where there are lots of doctors minutes away, or by having a doctor at his ranch. The ideal doctor would have been one who would have recognized both pulmonary emboli and cerebral hemorrhages, which could be done by any good clinician who knew the serious side effects of his anticoagulant. The reports that we got in December of Sharon's prior health suggested a lack of blood pressure issues in the past so it may not have seemed crucial to monitor his blood pressure, but significant tension over police leaks would raise anyone's blood pressure, whether or not he or his associates did anything wrong.

We would know a lot more if the doctors would discuss whether there was a workup for leg vein clots. Unfortunately, the news conference after Sharon's initial stroke was closed and external doctors such as medical journalists were barred, but I do not recall any such discussion of leg veins. It would not be surprising if leg veins were not mentioned in the closed news conference and no one thought to ask. If the leg vein scenario is correct and Sharon's leg vein clots had gotten the same publicity as did those of Richard Nixon while in office, this tragedy may have been avoided.

Update (10 pm Israel): Obvious medical errors and lack of medical understanding continue to crop up in the coverage. Except for yesterday's report of brain death which my neurologist debunked two hours ahead of anyone else in the MSM, I have not commented much on them given the more constructive elements that needed to be explained. Here is one recent example, however: "Prime Minister Ariel Sharon's vital signs, including cranial pressure, continued to decline Friday, following a third round of emergency brain surgery." This is an inversion of the truth. Declining intracranial pressure is good news in this situation. The ICP rises when the brain swells within the closed space of the skull. As the swelling falls, as is typical a few days after damage, the ICP falls to normal.

Medical news should be published under expert medical supervision.

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