Saturday, March 26, 2011

Hospital staff showed utmost compassion to dying son | Comment | London Free Press

There has recently been a very end-of-life sad case at Children's Hospital in London that may have left a difficult, uneasy feeling among some people. Based on my family's long experience with this hospital, I believe the hospital and the dedicated staff there have been unfairly portrayed by some.

My son Eddie had been relatively healthy, despite nearly dying the first few months of his life. We were quite involved with the medical community, though, due to his very severe cerebral palsy, and the complications that can often accompany such a disability.

In early 2009, Eddie began monthly admissions into hospital. They would last between a few days and several weeks. With each admission Eddie's symptoms became more complicated to treat.

In September 2009, Eddie commenced Grade 9 at Mother Teresa secondary school in London. On Sept. 28, an ambulance was called to the school to transport Eddie to Children's Hospital. He was again admitted to the same floor to be with the same staff who had come to know him so well.

It became apparent, after a week or so into this admission, that Eddie might not be released from hospital. We as a family had to prepare ourselves for what might happen. A father and mother were soon to lose a son, and a sister was about to lose her only sibling, her twin brother. The doctors and nurses did their utmost to keep Eddie comfortable.

We met with the palliative care specialists who work at the hospital. This team is made up of very experienced staff, including doctors, nurses and social workers who work daily with families and their dying loved ones.

It is a sad fact, but children die every day, and this group of dedicated professionals do their very best to prepare all involved.

After all efforts were exhausted to treat Eddie, we again met with the palliative care team.

Also in attendance was a pediatrician from Children's Hospital who had treated Eddie for a number of years. She had come in on her day off to help us come to terms with what was happening. I repeat, she was not working, but came in on her own time.

We were assured all efforts would be made to keep Eddie comfortable and free of pain. His body was indeed shutting down, and no further treatment was available. It was time for God to take him.

We were set up in a room on Eddie's usual floor. Beds were brought in for us to allow for some sleep, if that were at all possible. We simply did not want to leave Eddie's side.

Over the next few days, Eddie was assigned some exceptional nurses to give him care. They knew, coming into the hospital for their shift, that they would be dealing with a family in pain, and a child who was dying. They showed remarkable compassion and ability. This was difficult not only for us, but also for the caregivers. Every effort was made by the doctors and nurses to prepare us for what would undoubtedly be the worst thing that we had ever experienced.

On Oct. 13, 2009, Eddie died. Doctors and nurses who had cared for Eddie came into the room throughout the next few hours to offer their condolences. Some sat and talked with us for some time, knowing the emptiness we felt was excruciating. We will always be grateful for their support and kindness.

A few days later at the funeral home visitation, several doctors, nurses and therapists from the hospital came to offer their condolences.

We have also received phone calls from some of the nurses we had come to know, inquiring about our family's well-being, since his death.

This indeed shows the concern that Children's Hospital staff have for families dealing with end-of-life circumstances.

Their compassion exhibited a level of morality that is beyond reproach. At times they are not given credit that they so definitely deserve.

Rob Herlick is a London resident.

Friday, March 25, 2011

Frequent churchgoers frequently fatter – The Chart -

Young, religiously active people are more likely than their non-religious counterparts to become obese in middle age, according to new research. In fact, frequent religious involvement appears to almost double the risk of obesity compared with little or no involvement.

What is unclear from the new research is why religion might be associated with overeating.

"Churches pay more attention to obvious vices like smoking or drinking," said Matthew Feinstein, lead author of the research and fourth-year medical student atNorthwestern University Feinberg School of Medicine. "Our best guess about why is that...more frequent participation in church is associated with good works and people may be rewarding themselves with large meals that are more caloric in nature than we would like."

The new research, presented at an American Heart Association conferencededicated to physical activity, metabolism and cardiovascular disease, involved 2,433 people enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study.  The group was tested - at first between 20 and 32 years old - for various cardiovascular disease risk factors such as diabeteshypertension, and smoking.  Those same tests were repeated in the same group over the next 25 years.

The results were mixed for many risk factors for cardiovascular disease, but as researchers analyzed the data, one disparity stood out.  Those who reported attending church weekly, or more often, were significantly more likely to have a higher body mass index than those who attended infrequently, or never.

Kenneth F. Ferraro, author of similar studies linking obesity with religion, suggested that marriage may have played a role in the weight gain.

"The time period studied is when many Americans get married," said Ferraro, director of the Center on Aging and the Life Course at Purdue University.  "We know that weight gain is common after marriage and that marriage is highly valued in most religious groups.  Thus, one wonders if the results could be partially due to religious people being more likely to get married earlier and then gaining weight."

Those church potlucks probably don't help either.

"There's certainly a church culture around eating," said Erik Christensen, a pastor at St. Luke's Lutheran Church of Logan Square in Chicago, Illinois. "What I see among congregants in their 20s and 30s is they are very fit and what I see among congregants in their 50s and 60s is disproportionate obesity."

Christensen suggested that the virtual disappearance of church-sponsored baseball and basketball leagues may be part of the problem.  He added that the decision to attend church is sometimes made at the expense of being involved in athletic or recreational activities.

But he kept coming back to that culture of eating.

"What's ironic to me is that in my congregation we are working on a childhood obesity initiative and spend a lot of time thinking about weight and food," said Christensen.  "We sit and have a potluck and talk about obesity."

Yet another irony is the number of studies suggesting that religion and faith are actually beneficial for health.  Recent studies suggest that a "relaxation response" in the brain among people who pray, meditate, or engage in otherwise relaxing activities may alleviate anxiety and stress. Stress is implicated in many illnesses.  Other studies suggest an association between church-going and longevity.

"On the whole being religious has been shown by many studies to be associated with better mental health, lower smoking rates, lower mortality rates and better overall health status," said Feinstein.  "There are a whole lot of things religious people are doing right, but it's just this specific area where there appears to be room for improvement."

The upshot of the new research, said Feinstein, is that knowing there may be an obesity problem among church-goers provides a captive audience for intervention.

"The real value of the study is not understanding why," said Feinstein.  "What this study does is highlights a group that could potentially benefit from targeted anti-obesity initiatives. That's exciting because there is a lot of infrastructure already in place in religious communities."

Thursday, March 24, 2011

Doctor and Patient: Interns at the Operating Table -

Doctor and Patient: Interns at the Operating Table -

One afternoon in clinic, a patient’s wife stopped me in the hallway. I had just finished describing an operation to her and her husband, obtaining his consent and answering their questions, but I wasn’t surprised that the woman was still worried. Despite her easy smile and infectious throaty laugh, she had appeared anxious throughout the visit, the corners of her mouth twitching and her hands flitting from her hair to her face to her pocketbook and back to her hair again.

In the hall, she opened her mouth to speak but stopped abruptly when one of the residents, a doctor-in-training, passed by. Once the resident was out of earshot, she cleared her throat. “Please don’t bring any students into the operating room,” she said, looking toward where the resident was standing. “It’s not that I don’t like these young doctors. I just don’t want one practicing on my husband.”

I hear that request often regarding doctors-in-training, whether they are in their first year of training after medical school as interns, or are in the middle of their training or about to finish as residents or chief residents. But I’ve never developed an adequate response. A part of me understands these concerns. As talented and as earnest as residents can be, it’s true that they are still learning to operate. At the same time, I’m also fully aware that I am the doctor I am because other patients once allowed me to participate in their operations and care.

That afternoon a comment about the training process or my residency experiences would not have directly addressed the concerns of my patient’s wife. Or, frankly, my own disquietude. While my colleagues and I might have believed that our supervision of residents in the operating room ensured patient safety and quality of care, none of us really knew that for sure.

Now we do.

This month The Journal of the American College of Surgeons published the results of a study on how well patients come through when a surgeon-in-training is involved in the operation. Analyzing the results of more than 600,000 operations at more than 225 hospitals across the country, researchers found that while resident involvement was indeed associated with slightly higher complication rates and longer operating times, those patients who had trainees participating in their operations also experienced decreased mortality rates.

In other words, having a resident scrub in on your operation is not only safe but might also offer a bit of protection against death.

“Patients have the right to have whomever they want in the operating room,” said Dr. Mehul V. Raval, the lead author, a senior surgical resident at the Northwestern University Feinberg School of Medicine in Chicago. “But on an individual level, it’s hard to prove that there’s any significant difference in safety or quality of care when there are no residents involved.”

Previous research has been limited to the experiences of a single hospital or to broad comparisons in a geographic region or among Veterans Affairs hospitals. This study, however, looked at figures from the American College of Surgeons National Surgical Quality Improvement Program, a national database of information gathered directly from hospital charts or from phone calls and letters with patients, rather than from administrative or insurance claims reports.

“There’s an old adage about research and data: ‘garbage in, garbage out,’ ” said Dr. Clifford Y. Ko, senior author and a professor of surgery and health services at the David Geffen School of Medicine at the University of California, Los Angeles. “This study definitively answers the question of whether or not it makes a difference to have a resident involved in surgery because it is based on the best data currently available.”

That data revealed that while patients who had residents participating in surgery did develop more complications, those complications were not necessarily serious. And once one complication occurred, those patients with residents involved in their care were more likely to recover and less likely to fall prey to the so-called domino effect of complications, where one leads to another and ultimately to death. “It may be the fact of having a whole team of surgeons rather than just one that ‘rescues’ patients from these complications and even death,” Dr. Ko observed.

For example, for every 1,000 people who underwent colon surgery with trainees present, 30 patients experienced complications who wouldn’t have if they had undergone the same operation without residents. But five patients who would have died ended up surviving because trainees were involved in their surgery and care. “The question might then become,” Dr. Raval added, “‘Would you accept the risk of a urinary tract infection that required an antibiotic for several days if you knew it might save your life?’”

Researchers acknowledge that in the end, the most important factor for patients and their families is not the quality of the available data or the results of any study. It’s the relationship they have with their surgeon. “After all of this over-the-top statistical analysis to prove or not prove something, patients still have to be able to trust their surgeon.” Dr. Raval said. “They have to trust that their surgeon will take responsibility for their care and won’t give it to a resident or to anyone else.”

But they can also relax if they see a young doctor following their gurney into the operating room. She or he is really there to help, and the data proves it.

Wednesday, March 23, 2011

Grown-Up, but Still Irresponsible -

They have sex with friends, acquaintances and people they're casually dating. Many have never been tested for H.I.V. or any other sexually transmitted disease, but they rarely use condoms. Who are they?

The irresponsible scoundrels are not teenagers but 50-something singles, according to the National Survey of Sexual Health and Behavior, one of the most comprehensive national sex studies in almost 20 years, carried out at the Center for Sexual Health Promotion at Indiana University.

It turns out that "friends with benefits" — a sexual partner who is "just a friend," and neither a soulmate nor a romantic interest — isn't just for teenagers and college students anymore, and maybe it never was. Young adults may have given the practice a new name, but it probably started during the '60s sexual revolution, when the middle-aged Americans of today were young themselves.

Most men over 50 do have sex with a partner. But almost 23 percent said their most recent sex was with a "friend" or a "new acquaintance."

Among women 50 and over, that figure was more than 13 percent. Those numbers don't surprise the experts.

" 'Friends with benefits' are uniquely suited to two groups of people — the young, who want to delay starting their life, and older people, who don't want to complicate it," said Pepper Schwartz, a sociology professor at theUniversity of Washington in Seattle who serves on the sexual health advisory council of Church & Dwight, which manufactures Trojan condoms and financed the sex survey. "People in the middle are building families and building a life — they need more than a friend, they need lifetime partners."

For older people who are casually having sex, "it's warm, it's nice, they care about each other, but no one is under the illusion this is a grand love," Dr. Schwartz said.

For middle-aged heterosexual women, limited expectations of a sexual relationship may be a function of demographics: Since women outlive men, there are simply fewer older men around, said Debby Herbenick, one of the study's authors and associate director of the Center for Sexual Health Promotion.

Young teenagers are far more responsible than older adults about using condoms, and they are not nearly as sexually active as many people think they are, the study found. Most past studies have estimated that half of all adolescents are sexually active, but those figures included 18- and 19-year-olds. Among those 14 to 17 years old, the new study found, fewer than one in four had ever had vaginal intercourse, and sexual activity increased gradually as they matured.

The vast majority of the sexually active boys — 80 percent of those aged 14 to 17 — indicated that they had used condoms the last time they had sex. "Teens have gotten a bad rap," said Dr. J. Dennis Fortenberry, a professor ofpediatrics at Indiana University School of Medicine and one of the authors.

Perhaps they can counsel their older counterparts. Only 25 percent of those 50 and over who were single or had a new sex partner or more than one partner in a year said they had used a condom the last time they had sex, the study found. Almost 40 percent had never been tested for H.I.V., and a significant number didn't know the sexual history of their partners.

Experts say many reasons could account for this behavior. Many older singles have spent much of their adult lives in long-term committed relationships, and may think of H.I.V. and AIDS as a concern of young people. They haven't been targeted by public health messages urging condom use, and there's no parental figure handing out condoms along with the car keys on a Saturday night. Older men may also worry that condoms cause erectile problems, Dr. Herbenick said.

And they may just have gotten out of the habit, Dr. Herbenick said. "They may just be thinking, 'Gosh, it's been 20 years since I used a condom, I'm not going to start again.' "

Think Like a Doctor (The Contest) -

The Challenge: Can you solve a medical mystery involving a healthy child who is losing her hair?

For the past nine years, the Diagnosis column in The New York Times Magazine has presented hard-to-crack cases that were eventually resolved. Many readers have told me that they figured out the diagnoses before the answers were revealed. Often, these sleuths aren't doctors, but just folks who simply enjoy a good mystery.

Now I'm going to try something new, giving all you medical detectives a chance to think through a difficult case and solve the diagnostic dilemma yourselves. Below you'll find a summary of the case. Over the course of the day, I will try to answer any questions that come up, and I may even offer a few hints along the way. The first reader to figure out this very tough case gets a signed copy of my book, "Every Patient Tells a Story," along with the deep satisfaction of solving a real mystery.

So get ready to channel your inner "House," and let's get started.

The Presenting Problem: A 10-year-old girl is losing her hair.

The Patient's Story:

A healthy 10-year-old girl noticed that she was losing a lot of hair every time she showered. She mentioned this to her mother several times over a few months. The mother didn't see any change in her daughter's hair until one morning when she was putting her child's long blond hair into a ponytail, and saw for herself how much hair remained on her hands after this simple procedure. Watching her child get on the school bus later that morning, the mother noted that her daughter's hair seemed much thinner. Worried, she made a doctor's appointment for later that day.

The Doctor's Exam:

Dr. Kathryn Italia, a pediatrician in Exton, a suburb of Philadelphia, had been the child's doctor for several years. The girl's chart showed that she was rarely ill. After hearing the mother and daughter's story, Dr. Italia asked about other symptoms. Had she had any fever or chills? Had her appetite changed? Did she have pain anywhere? Any rashes or skin changes? No, the mother responded, though she thought her daughter might have been a little more tired lately.

Dr. Italia examined the child. She appeared healthy. Her hair was fine but didn't seem exceptionally thin. There were no bare patches on the scalp. The rest of the exam was likewise unremarkable. Dr. Italia felt that it was important to get some studies to further evaluate this unusual complaint.

Possible Diagnoses:

Thyroid disease: Disorders of the thyroid frequently cause hair loss. Order a test to measure T.S.H., a thyroid hormone.

Lupus: Lupus or another immune-system disorder in which the body wrongly attacks its own tissues can sometimes cause hair loss. Order a test measuring sedimentation rate (which looks for signs of an overactive immune system) as well as a blood count to look for anemia or abnormal white-cell counts.

A metabolic disorder: Disruptions of any of the multiple processes the body uses to get energy from food could be responsible for hair loss. Order a test to check blood chemistry, liver function and kidney function. Any metabolic disorder is likely to show up as a disturbance of one of these basic body functions.

Lab Results:

You can view some of the patient's laboratory test results here: the complete blood count with differential (which quantifies the number of red and white blood cells and platelets in a sample) as well as the liver enzymes. All the tests were unremarkable except for two liver enzymes (called A.L.T. and A.S.T.) usually seen after an injury to the liver. Both were four times higher than normal.

The Follow-Up:

Dr. Italia ordered an ultrasound of the liver and a repeat of the liver-function test after two weeks. (A mild viral infection can frequently cause a transient elevation in these enzymes that resolves on its own.) Additional tests were ordered to look for other common infections and diseases that cause abnormal liver enzymes in children: Epstein-Barr virus (the infectious cause of mononucleosis) and viral hepatitis; evidence of immune-system diseases, including autoimmune hepatitis, a rare condition in which the white blood cells mistakenly attack the liver; and the presence of celiac disease, a more common disease in which the immune system attacks the small intestine in response to a food component known as gluten.
You can view more of the patient's laboratory test results here: the test for celiac disease and a viral hepatitis test.

Additional Test Results:

The tests showed that her blood count was completely normal, without any anemia, and that she didn't have either viral or autoimmune hepatitis or celiac disease. All of the other tests were unremarkable, except for the liver function tests, which still showed the same elevated enzymes. Dr. Italia referred the girl to Dr. Elizabeth Rand, a doctor at the Children's Hospital in Philadelphia who specializes in pediatric liver disease.

Meeting With the Specialist:

When the mother and child met with Dr. Rand, the doctor was struck by how healthy the child appeared. She did not look like someone with chronic liver disease. Was she able to keep up with her friends? asked Dr. Rand. "No problem," the girl answered promptly. But her father added that she wasn't that active. "Some kids play soccer; some play music," he said, noting that his daughter played the violin. There were no new symptoms to report, the parents told Dr. Rand — just the ongoing hair loss and the elevated liver enzymes. On exam, the doctor could find no evidence of liver disease.

The Specialist's List of Possible Diagnoses:

Wilson's disease: An inherited metabolic disease that causes an inability to get rid of excess dietary copper, which builds up in the body and causes damage primarily to the liver and brain. Order a test for ceruloplasmin, the enzyme missing in those with Wilson's disease.

Alpha-1-antitrypsin deficiency: A condition in which the body does not make enough of a protein that protects the lungs and liver from damage. Order a test to measure the protein.

Muscle disease: Damaged muscle can also produce the elevated enzymes seen in this patient. Order a test of C.P.K., another enzyme that rises when muscle is injured. If the C.P.K. was also elevated, it would suggest that the problem was not a damaged liver but damaged muscle.

The Results:

The C.P.K. was elevated — four times the upper limit of normal. The tests for Wilson's disease and alpha-1-antitrypsin deficiency were both negative.

The Challenge: Can you figure out what's going on with this 10-year-old girl with abnormal liver enzymes, abnormal muscle enzymes and hair loss?

Tuesday, March 22, 2011

When Optimism is Unrealistic -

As a medical student and later during my residency, I trained for some time in a medical center known for its research and clinical trials. Every week, patients with rare diseases and cancers that had not responded to standard therapy arrived from all over the country, eager to try something new, even if the efficacy of the treatments had not yet been proven.

One of the patients was a woman in her late 30s, a mother of three. Known for her cheery disposition — she reminded the doctors and nurses of a brunette Cathy Rigby — she had melanoma that had spread through her body despite efforts to halt its growth. By the time I met her, she was already the veteran of two clinical trials at the center. Her tumor had responded slightly during one of those studies, but slowing the pace of its growth had come at a significant price. She had endured countless hospitalizations, serious bloating, a punctured lung, overwhelming fatigue and two nearly intractable infections.

Nonetheless, when her cancer began growing again, she eagerly applied for a third study. This time she would participate in one of the earliest studies of a brand-new drug, a Phase I clinical trial, and would have to undergo major surgery before taking the experimental drug.

On the evening before her operation, she joked with the surgical team and shook her head when we asked if she had any more questions. "Haven't we talked about this enough?" she said smiling and nodding gamely as the head surgeon explained once more that because this was an early-phase trial, it would benefit research but was not likely to be of any therapeutic help to her. Like other such trials, it would test only for toxicity and the maximum safe doses of the experimental drug; generally fewer than 5 percent of patients ever benefit from such early trials.

The woman nodded and waved her hand for the consent form. "I've been through this before," she said to us as she signed the papers. "I know what I am getting into."

Then, voice lowered, she added: "I'm a mother. I would do anything for a little extra time with my children."

We all fell silent when she said those words. She seemed to understand the study, and it was hard not to be in awe of her courage and selflessness. But we were also hesitant to probe any further. None of us wanted to deflate her sense of hope. And knowing what we did about the extent of her disease, it was hard not to convince ourselves that optimism, even if based on somewhat false hopes, had to be helpful for someone in her position.

I remembered her words a little over a year later when I heard she had died. Her tumor never responded to the experimental treatment.

For almost four decades, researchers and patient advocates have debated the ethics of informed consent in early-phase clinical trials, studies that test only toxicity and dosing and offer little, if any, therapeutic benefit to those enrolled. A major part of the debate has focused on the motivations of patients who participate. Some research on patient motivations has had disturbing ethical implications, indicating that patients may never fully understand the purpose of trials, despite explanations by the researchers. Others have been more reassuring, noting that patients are driven by a sense of altruism and a desire to help others who may one day suffer from the same disease.

More recently, a few studies have offered what appears to be the happiest of hypotheses. Patients may simply be optimistic and have strong needs to express hope. And because optimism has long been considered an effective coping mechanism for patients with terminal diseases, other researchers have also then assumed that optimism in this context poses few ethical issues.

Now one group of ethicists has just published a study challenging that assumption. It turns out that when it comes to being hopeful, not all optimism is created equal.

The ethicists surveyed 70 patients enrolled in several early-phase cancer trials and asked them about their expectations and understanding of their respective trials. A solid majority understood that the trials' purpose was to advance research, not to treat them. But despite clearly understanding the purpose, and limits, of early-phase trials, the patients were also blinded by what researchers called an "unrealistic optimism," or an optimistic bias, when it came to applying that knowledge to their own particular situations. A majority of patients assumed that the experimental drugs would control their cancer and that they would experience benefits but not complications.

In essence, they believed they would fare better than the average patient enrolled in the same trial.

"It's the Lake Wobegon effect, " said Dr. Daniel P. Sulmasy, senior author and a professor of medicine and ethics at the University of Chicago. "If you have more than 50 percent of patients saying their chances are better than average of avoiding some harm or obtaining some benefit, they are being unrealistically optimistic because you can't say that most people are above average."

Such unrealistic optimism differs from so-called dispositional optimism, or a general optimistic outlook. "This is not about trying to quash hope in dying patients," said Lynn A. Jansen, lead author and an associate director at the Center for Ethics in Health Care at Oregon Health and Science University in Portland. "It's about distinguishing between the different kinds of optimism."

Social psychologists point to smokers who underestimate their chances of getting cancer or gamblers who believe they will beat the odds as classic examples of unrealistic optimism. But unrealistic optimism can be present in anyone, regardless of whether they have a generally optimistic outlook. "No one is immune to this kind of bias," Dr. Jansen said. "Optimistic biases are part of human psychology."

But placed in the context of early-phase clinical cancer trials, unrealistic optimism results in a perfect ethical storm. "You have oncology, a field of medicine that is strongly evidence-based and research-intensive, and you have a population of patients who are experiencing an immediate threat to their lives," said Dr. Neal J. Meropol, a researcher who has done extensive work on the ethics of early-phase cancer trials and chief of the division of hematology and oncology at University Hospitals Case Medical Center and Case Western Reserve University in Cleveland. "Patients almost invariably take part in early-phase clinical trials because they believe they will personally benefit."

While the study represents a breakthrough in understanding how different types of optimism affect the informed consent process, doing something about these biases presents a whole different issue. Unrealistic optimism is notoriously difficult to recognize because most individuals are completely unaware that it even exists. "We would probably be able to walk away from these types of biases," Dr. Jansen said, "if we realized when we were operating under them."

Dr. Jansen and her colleagues are hoping next to delineate the factors involved in evoking this biased response in patients. By gaining a deeper appreciation of how unrealistic optimism develops, they believe they may be able to help patients and cancer researchers more easily recognize those optimistic biases that impair a patient's autonomy and compromise the ethics of clinical trials.

"We all need to care about this kind of research," Dr. Jansen said. "It's how we advance knowledge and cure disease."

She added: "We just need to realize that not all optimism is ethically benign."

Article: Aftershock: The Blast That Shook Psycho Platoon : ProPublica

MINOT, ND -- At 8:20 p.m. on Sept. 21, 2010, Iraq veteran Brock Savelkoul decided it was time to die. He lurched from his black Tacoma pickup truck, gripping a 9-mm pistol. In front of him, a half dozen law enforcement officers crouched behind patrol cars with their weapons drawn. They had surrounded him on a muddy red road after an hour-long chase that reached speeds of 105 miles per hour. Savelkoul stared at the ring of men and women before ducking into the cab of his truck. He cranked up the radio. A country song about whiskey and cigarettes wafted out across an endless sprawl of North Dakota farmland, stubbled from the recent harvest. Sleet was falling, chilling the air. Savelkoul, 29, walked slowly toward the officers. He gestured wildly with his gun. "Go ahead, shoot me! ... Please, shoot me," he yelled, his face illuminated in a chiaroscuro of blazing spotlights and the deepening darkness. "Do it. Pull it. Do I have to point my gun at you to ... do it?"

Twenty feet away, the officers shifted nervously. Some placed their fingers on the triggers of their shotguns and took aim at Savelkoul's chest. They were exhausted, on edge after the chase and long standoff. They knew only the sketchiest of details about the man in front of them, his blond hair short, his face twisted in grief and anger. Dispatchers had told them that Savelkoul had been diagnosed with post-traumatic stress disorder. They warned that he might have been drinking. Family members told police that Savelkoul had fled his home with six weapons, including a semiautomatic assault rifle and several hundred rounds of hollow point ammunition. To Megan Christopher, a trooper with the North Dakota Highway Patrol, Savelkoul's intentions seemed obvious. "Suicide by cop," she thought. "He wants to go out in a blaze of glory."

As it happened, Savelkoul's state of mind was of interest not only to the cops, but to some of the nation's top military officers and medical researchers.

More than 2 million troops have deployed to Iraq and Afghanistan since 2001. Tens of thousands have returned with a bedeviling mix of psychological and cognitive problems. For decades, doctors have recognized that soldiers can suffer lasting wounds from the sheer terror of combat, a condition referred to today as post-traumatic stress disorder. They also have come to know that blows to the head from roadside bombs -- the signature weapon in Iraq and Afghanistan -- can result in mild traumatic injuries to the brain, or concussions, that can leave soldiers unable to remember, to follow orders, to think normally.

Now it is becoming clear that soldiers like Savelkoul are coming home afflicted with both conditions, in numbers never seen before. Studies have estimated that about 20 percent of soldiers returning from Iraq and Afghanistan have suffered a mild traumatic brain injury while deployed. Of those, anywhere between 5 percent to nearly 50 percent may suffer both PTSD and lingering problems from traumatic brain injuries. It is an epidemic so new that doctors aren't even sure what to call it, let alone how best to diagnose and treat it.

Savelkoul and four of his comrades landed on the front lines of this confounding new conflict over the minds of America's soldiers when an Iraqi rocket exploded near their trailer in January 2009. By chance, a senior Army neuropsychologist was in Iraq at the time to conduct a study on the military's tools for diagnosing concussions. After learning of the attack, he persuaded Savelkoul and the others to enroll. The men became the first fully documented victims of "pure blast" concussions -- that is, mild traumatic brain injuries caused by the force of an explosion, rather than a secondary effect, such as slamming into a Humvee wall after a roadside bomb.

The concussions marked only the beginning of the men's problems. Aftershocks from the blast would ripple through each of their lives differently, mirroring the spectrum of psychic and physical outcomes that doctors have begun to catalog. Of the five men injured that night, three remain in the Army and are currently deployed to overseas war zones. One recovered quickly, though he continues to suffer occasional severe headaches. Two recuperated more gradually but complain of forgetfulness and problems concentrating. A fourth left the military, tired of the violence and still grappling with concussion symptoms.

Savelkoul struggled the most to return to the person he had been before. On that night last September, his troubles transformed from academic data point to terrifyingly real confrontation. All the Army's men, all its research, all its treatments, had failed to prevent the desperate showdown that would unfold on a deserted stretch of highway just south of the pinched hills of the Dakota badlands. Now the outcome depended on one distraught man and a half-dozen nerve-wracked police officers, trying to negotiate a battlefield of the mind that none of them -- no one in the world, really -- understood.