Recent Brain Death Cases: My Interview With Dr. James Bernat

Earlier this week I published a post regarding the differences between brain death, coma, and vegetative state:

https://sleephelpdesk.com/2014/01/12/the-differences-between-brain-death-coma-and-vegetative-state/

In it I aimed to clarify terms that are often used incorrectly or even casually by the public and the media.  Numerous recent news stories–such as that of the passing of former Israeli Prime Minister Ariel Sharon–have invoked these clinical terms.  Among the most gut-wrenching of these recent stories are the Marlise Muñoz case from Fort Worth, Texas, and the Jahi McMath case from Oakland, California.  I have received a lot of feedback regarding my January 12th post, so I’d like to expand on this important subject further.  In today’s post, I briefly review the background of these two cases and bring in the expertise of a world-renowned medical ethicist to weigh in on how brain death and our understanding of it may affect their courses and outcomes.

The Muñoz case involves a pregnant 33 year-old woman who collapsed following a blood clot in the lungs.  Reportedly Muñoz is now brain-dead, though as of this writing I have been unable to find documentation of a physician or hospital spokesperson officially and publicly announcing that she has been declared brain-dead.  The health status of the fetus is not clear.  Muñoz’s husband, Erick, has requested that mechanical ventilation be terminated, in keeping with what he strongly believes her wishes would be (both he and his wife worked as paramedics, and he states that she had made her wishes very clear to him regarding what she would want in such a clinical setting).  However, the hospital where Muñoz resides has declined to do so, citing a Texas law prohibiting the withholding of “life-sustaining treatment” from a pregnant woman.  As I understand it, this Texas law is intended for pregnant women who are comatose, not brain-dead.  Muñoz’s husband has now filed a lawsuit against the hospital.  The central issues in this case are whether Muñoz is in fact brain-dead, and the degree to which a hospital may or may not have the right to operate against the wishes of the spouse given the pregnancy.

The McMath case involves a 13 year-old girl who underwent nasal and throat surgery–including a tonsillectomy–as surgical management for sleep apnea.  She suffered cardiac arrest post-operatively, and according to hospital spokespeople she subsequently has been declared brain-dead–and therefore clinically dead–by several independently-evaluating physicians.  As such, the hospital released Jahi’s body to the coroner, who then released the body to Jahi’s mother.  At the center of this impassioned debate is the question of whether or not Jahi is dead.  The McMath family’s attorney, Christopher Dolan, reportedly said in an interview that Jahi “has not passed.  Her kidneys function, she regulates her temperature and her body moves now more than ever.  This is a real human being, not a dead body.”  Jahi’s uncle, Omari Sealey, reportedly has told interviewers that he hopes “to have her come back home with 100% full recovery.”

These are heartbreaking situations, clearly, with no simple answers or methods of resolution.  So yesterday I spoke with my former teacher and mentor, Dr. James Bernat, professor of neurology and medicine and the Louis and Ruth Frank Professor of Neuroscience at Dartmouth’s Geisel School of Medicine in Lebanon, New Hampshire.

 

Dr. Bernat is a well-respected clinician with a scholarly interest in ethical and philosophical issues in neurology.  He is extensively published in the discipline of medical ethics; his textbook, Ethical Issues in Neurology, is widely considered a seminal publication in the field.  He has particular expertise in impaired consciousness, including brain death and the vegetative state, and has provided guidance, testimony, and consultation for many organizations regarding these topics over the years.  On a more personal level, Jim is just a great guy, one of the most caring, compassionate instructors I’ve ever had.  It’s an honor to call him my mentor and friend.

(Here’s a grainy old photo of us at an Academy meeting, back in the day.)

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Dr. Bernat was kind enough to provide his thoughts and expertise regarding these two complex cases.

MC:  Jim, do you get a sense that people in general have a firm understanding of what “brain death” really is and what it means?  

JB:  Most people do not understand the concept of brain death. They regard it as a metaphor for severe brain damage causing coma but fail to understand its totality and irreversibility, and particularly do not realize that it represents a medical and legal standard for death determination in the United States.  The public press compounds the confusion when journalists who also do not understand the concept discuss “brain death” incorrectly and confuse it with coma and the vegetative state.

MC:  As a neurologist, my concern is the confusion that may arise when the public hears in the media terms like “life-sustaining treatment” and “life support” when referring to a brain-dead patient receiving mechanical ventilation and medications.  Could you speak to this concern, and are there better, more accurate terms you would suggest the media use?

JB:  In the context of the brain-dead patient, the use of the term “life support” to refer to tracheal positive-pressure mechanical ventilation is seriously misleading and further confounds the question of whether such patients are alive or dead.  The medical and legal standard of brain death means that the patient is dead so the ventilator or other treatments should not be referred to as means of “life support.”  I prefer the term “physiological support” or simply that the dead patient’s respiration is being provided entirely by a machine which thereby permits their heartbeat and circulation to continue.

MC:  Every American state has its laws defining death.  As I understand it every American state defines death as either complete and irreversible cessation of cardiac and breathing functions or complete and irreversible cessation of brain and brainstem function.  Therefore, state law defines brain death as equivalent to the actual death of an individual.  What can be done and recommended in situations in which one’s individual opinions or religion differ from state law?

JB:  Your understanding of state law is correct.  Each country adopts a unique perspective to this problem.  In the United States, where our traditions emphasize respect for religious beliefs, enforce the rights of the individual, and promote the value of a pluralistic society, we allow states to amend their death statutes or their department of health administrative regulations to provide a religious exemption to declaring brain death.  Currently, New Jersey and New York have chosen this route.  In these states, in the presence of a qualifying religious exception, physicians must use the circulatory-respiratory tests for death.  Some scholars have advocated even more personal choice over the standards for death determination but I fear that this proposal would yield chaos in hospitals.

MC:  The news reports pertaining to these two tragic cases often refer to state law and hospital policies.  If you could communicate directly with state officials and physicians caring directly for these two individuals, what clarification would you ask for to assist in a better public understanding of their situations?

JB:  Hospitals are constrained about how much specific patient medical data they release to the public by HIPAA regulations and by their internal risk management-legal advice.  The dearth of specific information complicates the role of commentators because they lack a clear and complete understanding of the facts of the case.  Additionally, when hospitals’ every decision or statement is exposed to public scrutiny by an interested press, it is understandable that they become cautious in their decisions and public statements.  Despite these constraints, the public relations aspects of the cases require optimal management to provide sufficient facts and clarity for commentators and the public to understand the reason for their actions.  These facts include the diagnosis, how the diagnosis was made, whether brain death was formally determined, and the reasons for the hospital’s actions in each case.

MC:  What else can be done to ease the suffering of the families of these two unfortunate people?

JB:  These are both tragic cases of young people who died from massive brain damage.  As a parent, I cannot imagine the extent of suffering that these tragedies caused to their loving families.  In addition to taking every measure to inform and comfort such families, I strongly recommend offering the opportunity for organ donation.  Although some may criticize this approach as a predatory action, organ donation offers transcendent meaning to the families of brain dead patients.  Numerous studies have demonstrated that families later emphasize how important and meaningful they found the donation process because it helped mitigate their suffering by creating good for the organ recipients from an otherwise senseless tragedy.

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Football and Bridgegate: People Losing Sleep in the News

 

Last week we were bombarded by the media over the controversy surrounding New Jersey Governor Chris Christie‘s staff and “Bridgegate.”  During his recent press conference regarding this matter, Christie indicated at 2:27 in this video clip below, “I haven’t had a lot of sleep the last two nights, and I’ve been doing a lot of soul-searching.”

I want to make clear this is not in any way a political post, and is not intended to defend or criticize Christie or anyone else.  I present this here simply to illustrate one generally well-understood point, which is that emotionally significant life events–whether they be good or bad–commonly cause difficulties sleeping.

There are several potential reasons for this.  First, problematic life events–such as Christie’s–are often accompanied or followed by mood problems and anxiety, both of which can cause difficulties falling and staying asleep.  Depression is commonly associated with insomnia–in particular a phenomenon called “early morning awakening,” in which the depressed person tends to awaken spontaneously several hours earlier than the normal or desired time, with very substantial problems returning to sleep.  Second, anything that you think about in bed that is of emotional value can cause difficulties sleeping, because those thoughts have a stimulating effect which makes you more awake and alert.  The more intense the emotions or concerns (I suppose that would include “soul-searching”), the more psychologically and physically stimulated you can get (an extreme example might be the feeling of sweating and heart-pounding upon hearing devastating news), and this stimulation can cause your insomnia to snowball.

OK, I will add just one brief, slightly political point here.  I wish people in the media would stop calling Christie fat and teasing him for it.  I NEVER use this term in my clinic or socially to refer to one’s weight.  Plus, he’s lost a substantial amount of weight following his gastric lap band surgery last year.  I’ve heard several Christie “fat jokes” on national radio and television programs in the past week.  Really?  Come on, folks, let’s at least be civil, yeah?

Anyhow, in a completely different matter, Pete Carroll, head coach of the Seattle Seahawks, said in a television interview last week that he hasn’t been sleeping much lately either, but that’s probably because of how crazy his schedule must be right now in addition to the excitement of prepping his team for the playoffs and, now, Sunday’s NFC championship game!  There must be some anticipatory anxiety, for sure, and this kind of emotion certainly can lead to sleepless nights as well, though for reasons quite different from (and in many ways the opposite of) Christie’s.  And hopefully–understand, I live in Seattle–he won’t have any sleepless nights due to game losses in the next several weeks!

Finally, continuing with the football theme, I will leave you today with this recent video clip of ESPN analyst and former Chicago Bears coach Mike Ditka dozing while on air during ESPN’s Sunday NFL Countdown Show.  Keyshawn Johnson had to nudge him awake!  Glad Coach was behind a desk and not behind the wheel at the time.

I have no idea what the circumstances were that led to Ditka’s on-air snooze.  Maybe he was watching George Wendt‘s State Farm commercials over and over late the previous night.

Enjoy the playoffs, everyone, no matter who you’re rootin’ for!

 

The Differences Between Brain Death, Coma, and Vegetative State

You may have noticed over the past week several major news stories of brain dead or comatose people, their loved ones, and their unfortunate circumstances.  For many years neurologists have been concerned about the substantial confusion that exists regarding what is meant by certain terms that are utilized by the media pertaining to types of impaired consciousness.  Brain death, coma, and vegetative state are in fact very specific terms in clinical medicine, and there are volumes of medical literature describing and discussing all of them.  So today I will take off my sleep medicine hat, put on my neurology hat, and do my best to define these terms and distinguish them from each other for you, as briefly and succinctly as possible.

 

These 3 terms all refer to altered states of consciousness.  They are distinctly different from conventional sleep, which is a normalpredictable, temporary, diurnal and readily reversible state of unconsciousness necessary in and common to virtually all animal species.  All 3 of these states are generally bad–that is, with very few exceptions (such as drug-induced coma to prevent prolonged and life-threatening seizures, for example)–but neurologically speaking they are associated with varying levels of badness, not only in terms of unawareness of the patient’s environment but also in terms of prognosis for eventual “meaningful” neurologic recovery (i.e., return of consciousness with abilities to function independently, engage in basic activities of daily living, and enjoy the process of life).

Coma refers to deep sustained unconsciousness.  The patient is alive, but there is no sign of conscious or behavioral movement, vocalization, or voluntary eye opening.  The patient cannot be awakened; he or she does not respond to verbal commands or other conventional stimuli.  However, physical examination may demonstrate basic neurologic reflexes and variable (usually primitive or abnormal) responses to painful (“noxious”) stimuli.  There are a great many potential causes, including stroke, brain hemorrhage, severe closed head injury, medications, hypothermia, drug overdose, and prolonged deprivation of oxygen (such as from drowning or cardiac arrest).  The chances of someone regaining consciousness and substantial neurologic function depend on a variety of factors, including the nature, duration and severity (and potential reversibility) of the underlying cause(s), the duration of the coma, and how severe the coma is based on a thorough physical neurologic examination conducted by physicians.  In general, however, if the cause is severe and irreversible, and if the patient remains comatose for a long time (such as several weeks) following an injury, the likelihood of meaningful neurologic recovery is unfortunately small, even if he or she remains technically alive.

Vegetative state is a term is so deeply entrenched in the medical and popular literature that it is still utilized clinically.  In this form of impaired consciousness, the patient episodically appears awake but does not demonstrate evidence of awareness of self or environment; some refer to this as a state of “wakeful unconsciousness.”  The patient may appear awake upon casual observation, open and move the eyes, and exhibit sleep-wake cycles.  However, voluntary movements or vocalizations and purposeful behavioral responses to conventional stimuli are not observed.  It is usually associated with severe injury to the brain and it is prolonged in duration.  Basic brainstem functions are preserved, allowing the patient the possibility of many years of life in this fashion.  Unfortunately, this neurologic condition can be confusing (and often agonizingly so) for family members and clinicians, because signs on neurologic examination, the “depth” of neurologic impairment, causes and outcomes can all be so highly variable, and because the patient appears awake, though signs of awareness remain absent.

Brain death is the ultimate badness, referring to the complete and irreversible absence of all neurologic activity in the brain.    Physical examination demonstrates an absolute lack of response to stimuli; there are no movements or reflexes.  Diagnostic tests, such as electroencephalography (EEG), demonstrate an absence of brain and brainstem electrical activity.  The patient does not breathe without the assistance of a mechanical ventilator; when the ventilator is stopped, there is sustained apnea.  If other potentially reversible “mimics” of brain death (such as barbiturate intoxication and hypothermia) are ruled out, and if brain death is certain, there is no coming back from this; there is no chance of return of neurologic function or meaningful neurologic recovery.  Though historically people have thought of death as the permanent cessation of heart function and breathing, many people and most clinicians consider brain death consistent with clinical death, even if mechanical ventilation can keep vital organs of a brain-dead person functioning for long periods of time.  The Uniform Determination of Death Act (UDDA) is a draft state law approved for the United States in 1981 and has been adopted by most states.  It defines death as “either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem,” the determination of which is made “in accordance with accepted medical standards.”

There are several important issues to bring up briefly here.  First, it’s important to recognize that these terms may be confused with each other in the media, and sometimes even used interchangeably; be very careful of what you read and hear, and be prepared to challenge terms that are used.  Second, the clinical condition and neurologic status of the comatose or vegetative patient can change and evolve over time, and sometimes highly improbable or unexpected outcomes have been reported to occur without explanation or warning, such as spontaneous neurologic improvement following sustained coma for example; as one of my mentors once told me during my residency, “patients don’t read the textbooks.”  Finally, and importantly, there is an ongoing debate regarding the ethics of what these decreased levels of consciousness may mean for the patient, how loved ones should make decisions on behalf of the patient, and how society defines or views the concepts of death and a meaningful life over time.  These are all obviously very complex issues, affected and influenced by individual, ethnic, generational, and religious differences.  But we all–particularly those in the media–should at least strive to keep our terms and definitions as accurate and appropriately descriptive as possible, for the sake of ourselves and our loved ones.

“Why is My Mouth So Dry With CPAP Use?”

I must have struck a chord with yesterday’s post on dry mouth, given the responses I’ve received.  Dry mouth is a very common symptom associated with sleep.  So let’s continue this topic, but with a little twist.  Do you awaken with your mouth feeling dry during a night of CPAP use?

As mentioned briefly yesterday, obstructive sleep apnea (OSA) is a sleep disorder of breathing associated with episodic collapse of your upper airway while you are sleeping; sleep disruption, gasping sensations at night, witnessed breathing pauses during sleep, substantial snoring, and daytime sleepiness are common clinical features of this very prevalent but under-recognized medical illness.  CPAP (continuous positive airway pressure) is a primary form of treatment for OSA.  CPAP is an electronic device which pressurizes room air and gently sends it down the throat via a mask to keep the airway open all night.  If properly used, CPAP stops the snoring and breathing pauses, deepens your sleep dramatically, and therefore makes you feel much better and more awake and alert during the day.

 

Some still think of CPAP use as a primitive, invasive, or unavoidably uncomfortable medical therapy based on what they’ve seen or heard a decade or more ago; this is unfortunate, in part because many people end up foregoing medical evaluation and treatment for their sleep apnea for many years based on an erroneous perception of what their treatment may be like.  There are now dozens of mask interfaces available, each with different sizes; the CPAP devices themselves are much smaller and quieter than they used to be, with lots of bells and whistles to make them more comfortable and easier to use.  If used properly and if you are willing to use it, CPAP can be an absolute game-changer; untreated sleep apnea can wreck your life, and proper treatment can dramatically turn things around.

Having said that, though, there are lots of potential ways for CPAP use to go wrong, causing people to have difficulties using it or to stop using it altogether.  I will write about these problems more in later posts, but one problem some CPAP users may have is dry mouth.  The majority of CPAP users don’t have substantial problems with this, but if this is relevant to you or someone you know, read on.

Presuming that your dry mouth isn’t caused by one of the problems I wrote about in yesterday’s post, and if the dry mouth started or became much worse after having started CPAP, most likely this symptom is caused by oral leak or oral breathing.  Your jaw muscles naturally tend to relax when you fall asleep.  In some cases, the lower jaw (mandible) may then drop slightly due to gravitational forces.  If you are using a nasal mask (i.e., a mask that covers your nose but NOT your mouth) or nasal pillows (i.e., soft prongs which are placed gently at the entrance of your nostrils), and if the mouth opens a little, then air from the CPAP device may then divert and escape out of your mouth.  This is obviously a problem.  The air dries your saliva, first of all, causing you to awaken more from sleep with that uncomfortable, parched, “Sahara desert” feeling in your mouth.  Just as importantly, though, if air is leaking out of your mouth and escaping into the open space instead of going down your throat the way it should be, then you aren’t being adequately treated because your airway may again be predisposed to collapse due to insufficient air pressure.  So due to sleep disruption and inadequate treatment, oral leak can lead to a perception that CPAP doesn’t work because you may still feel sleepy during the day despite CPAP use.

Oral leak is a very fixable problem.  Don’t turn your CPAP device into a very expensive doorstop because of it.  Before reading how to repair oral leak below, though, make sure you’ve determined where the dryness is; this is particularly important because people often don’t actually feel the air coming out of their mouths, because the leak happens while they’re asleep (when you awaken your muscles abruptly regain their tone and the mouth usually closes).  If the sensation of uncomfortable dryness is in the nasal passages and/or the back of the throat, but NOT in the mouth, oral leak is probably NOT the problem; I would suggest increasing the heated humidity in your CPAP device if this is the case.  However, if the dryness is clearly localized to the mouth chamber–with a pasty sensation in the mouth, for example, a feeling of having to “peel” your tongue from the roof of your mouth, dryness of the lips and teeth–oral leak is then likely the cause.

1.  If you’re using a nasal mask or nasal pillows and you like your current setup, a chinstrap is usually effective.  When wrapped gently around the head, it mechanically keeps your mouth gently closed.  It does not need to placed tightly; it should be just secure enough to be effective, but not so tight it’s uncomfortable.  People usually become accustomed to chinstrap use pretty quickly.  Many straps are made of thin neoprene.  However, particularly for my patients who are more heavyset or who have larger neck circumferences, I prefer a “deluxe” or “heavy-duty” chinstrap, which is wider and made of less stretchy material and therefore more likely to be effective.  An added bonus:  in some cases chinstrap use can be temporary; over time you may find that tendency toward oral leak has stopped after having discontinued the use of the strap.

2.  Another way of addressing oral leak is with the use of a full face mask, which covers both the nose and the mouth.  There are now many different full face masks available on the market.  Potential issues with full face masks, however:  since they’re larger masks, they may be more prone to leak than smaller masks; also, they don’t keep the mouth from opening, so you can still have some dry mouth if air continues to go in and out of your mouth (though usually substantially better).  Try increasing the heated humidity (which usually comes standard) in your CPAP device should this be the case.  But if you’re already using a nasal mask or nasal pillows and you’re comfortable with your current setup, a chinstrap usually does the trick with relative ease.

3.  Finally, as mentioned in yesterday’s post, addressing problems causing decreased airflow through the nose (such as seasonal allergies, hay fever, sinusitis, or anatomic nasal disorders) may well reduce the tendency to open the mouth during sleep.  Consider a visit to your primary care physician or an ear, nose, and throat doctor should you have symptoms that suggest such problems.

Sleep well tonight, everyone, and stay warm!

“Why is My Mouth So Dry at Night?”

Many of us have experienced this problem at one point or another during our lives:  awakening with that nasty sensation of uncomfortable dryness in the morning.  Your saliva–or what’s left of it–feels like paste; there’s that funky, faintly cheesy taste in your mouth that you’re sure doesn’t smell good either.

 

Dry mouth, or xerostomia, can be a particular problem at night.  Saliva is necessary to protect and lubricate the structures of the mouth and throat, as well as their fragile mucosal linings, from friction, foreign particles (food), and virulent organisms (viruses and bateria).  While sleeping, your salivary glands naturally and normally slow down production of this saliva, and so in some respects it may be natural to awaken feeling like your mouth is a little dry.  In some, however, dry mouth at night or in the early morning can be a substantial problem and a source of genuine discomfort; the words “Sahara desert” and “bone dry” are often used by my patients, for example, to describe this unpleasant sensation.

There are a number of potential causes for substantial dry mouth.  Aging into your 70’s and 80’s, for example, often further slows down saliva production.  Dehydration and metabolic imbalances may cause dry mouth as well.  Certain medical disorders, such as Sjögren’s Syndrome and lupus, often are associated with dry mouth, as are a variety of different medications, such as antihistamines, certain blood pressure lowering drugs, diuretics (“water pills”), and anti-depressants.

Another important thing to think about is whether your mouth is open while you are sleeping.  For many open-mouth breathers, the lower jaw (mandible) may naturally fall a little due to a combination of gravitational effects and jaw muscle slackening while asleep; some may be predisposed to this tendency more than others, and other factors–like body weight, neck circumference, and body position(s) of sleep–may influence mouth opening during sleep as well.  However, it’s important to know if there are other problems that may cause chronic mouth opening during sleep as well, in particular things that can cause nasal congestion or other decreases in airflow through the nasal passages–such as chronic allergies, a substantially deviated nasal septum, and sinus infections.  It stands to reason that if you can’t breathe properly through your nose, your mouth may be more likely to open during sleep to maintain proper airflow.

Another problem is that obstructive sleep apnea (a breathing disorder in which the airway collapses during sleep) is commonly associated with open-mouth breathing and, hence, mouth dryness and throat and oral irritation at night or in the morning.  People with sleep apnea often snore loudly.  Now keep in mind that you can snore with your mouth or closed (try simulating snoring with your mouth open and then with your mouth closed; you’ll see what I mean), but the snoring is generally louder with your mouth open.  As a result, sleep apnea can be more noticeable to a bed partner, because the snoring is more bothersome and the loudness of the snoring provides a greater sound contrast when you sound like you stop your breathing during sleep (which is what the sleep apnea does, due to blockage of the upper airway).  So as a clinician, I actually look at the open-mouth breathing as, in a paradoxical way, a good thing:  it makes the sleep apnea more bothersome to both the patient and the bed partner, thus making it more likely to be brought to the attention of a physician (studies demonstrate that in the United States, about 85% of sleep apnea cases are still not yet diagnosed!).

So here are my first take-home points of 2014!  I recommend that you consider these possibilities if you frequently awaken with xerostomia.  Bring symptoms consistent with reduced airflow through your nose to the attention of your doctor when you speak with him/her about the dry mouth.  If your oral symptoms are accompanied by a history of substantial snoring, and certainly is someone is telling you that you sound like you’re also stopping your breathing during your sleep, I strongly urge you to discuss these important issues with your doctor and consider an evaluation by a person like me, a physician who specializes in sleep medicine.

Have a great week, everyone!

 

Sleep Help Desk’s Top 10 Songs of 2013!

Happy New Year, one and all!  2013 was one wild ride for me, both professionally and personally.  Kids growing up, all the uncertainty of the future of health care, Miley Cyrus’s foam finger–sometimes it’s all just too much for a guy to take.  So today, this first day of 2014, I’m going to relax before a friend’s New Year’s party and list for you my favorite tunes from last year.  There were a lot of great songs released in 2013, so I will list some great “honorable mentions” as well.  I wish everyone a happy, musical 2014!  Enjoy these songs below.

10.  Stay at Home Mother — Sheryl Crow.  I’ve never been a full-time professional musician, but I’ve played many more gigs in my life than I can count.  More importantly, however, I understand fully what it feels like to wonder how your work, work hours, and ambition are impacting your little ones.  This acoustic song, tear-jerkingly honest, heart-breaking, and hopeful, encapsulates that struggle beautifully and plaintively.  Though my boys are maturing faster than I prefer, they still ask me not to leave if I have to leave for an evening meeting or other such thing.  I appreciate and cherish that, and I hope that for the rest of my life my children will want me and my wife to “stay at home.”

9.  Hey Pretty Girl — Kip Moore.  I love songs that summarize a person’s entire life in three minutes.  This song tells the story of one man’s history with his wife, front to finish.  The guy in the song just wants what most of us want, I think–someone to love, someone with which to share the simple joys of life.  I’m drawn to the slightly off-kilter rhythm (which is unusual in country radio), the vocal melodies, the believable lyrics.  Plus, this is the first song I played after bringing my very first bass guitar home five months ago.

8.  This is What It Feels Like — Armin van Buuren, featuring Trevor Guthrie.  My boys are completely obsessed with pop music.  They demand it in the car, play it the moment they get home from school, dance to it with wild abandon at their school socials.  Accordingly, a tsunami of modern pop has been forced upon me in 2013.  Understand, pop when I was their age was “Undercover Angel” by Alan O’Day, “Beth” by Kiss, and “Chevy Van” by Sammy Johns, so what is popular now to young people sounds radically different from the music on the radio when I was coming of age.  But my curmudgeonly self must admit that there are some pretty good songs in my boys’s playlists, and here is one of them.  Like “Hey Pretty Girl” the baseline rhythm is a little atypical, but it’s very danceable nonetheless, as I’ve witnessed firsthand.

7.  I Hold On — Dierks Bentley.  This song slays me.  I identify completely with the idea of appreciating what you have and valuing the things and people that have stuck with you for years.  As time goes on your modern life becomes increasingly deluged by garish and obnoxious distractions–technology, hassles, vulture-like people–that in the end don’t hold near the meaning of a small circle of simple, rock-solid things and people that continue to have your back.  Like Dierks, “I hold on.”

6.  Anywhere With You — Jake Owen.  This song speaks to the travel abandon button I wish I could push more frequently.  You know the feeling you get when you thumb through Travel + Leisure or Islands, that wish that you could scratch your itch to travel immediately–like get on a plane right now–but you can’t because you’re looking at the magazines on the treadmill in your gym before going to work?  We love a good trip, and I’m looking forward to more exploration in the near future.

5.  Odds Are — Barenaked Ladies.  BNL still rule, after all these years, despite the departure of Steven Page.  Using their trademark humor (check out the video!) they speak deceptively simple truths.  I hold up this song as a beacon of hope for me and my fellow physicians in 2014.  I sincerely hope that, despite my cynicism regarding what so many different people and organizations are thrusting upon us in health care, “the odds are that we will probably be all right.”

4.  Sunny and 75 — Joe Nichols.  I guess this shows you where my head’s at, considering this song along with my #6 pick.  Here in Seattle in the summer it’s sunny and 75, one of the best places on the planet to spend the summer, but at the moment it’s grey and considerably cooler than 75, and there’s not a beach chair in sight.  I’ve been singing this song in the car all year, though.

3.  Elevate — The Winery Dogs.  My friend, bass master Billy Sheehan, combined with Richie Kotzen and Mike Portnoy to create this explosive supergroup, whose debut album is in my opinion easily the greatest hard rock release of the year.  There are too many great songs to choose from in the album; the relentless “Time Machine” and the sublime, bluesy “Regret” in particular were real contenders for this list.  Ultimately, however, I chose “Elevate” for its awe-inspiring riffs, technical precision, great vocals, and of course Billy’s absolutely sick bass skills.  I strongly urge you to see this trio in concert should they roll through your area in 2014.  A Winery Dogs show is a game-changer.

2.  Alma de Guerreiro — Seu Jorge.  This is Brazilian funk at its finest, chugging over a deeply embedded foundation of ijexa.  I came to know this song from performing it at a Carnaval concert last spring.  The riff is inescapable, and it’s impossible not to move under its spell.  Salve Jorge!

1.  I See Fire — Ed Sheeran.  Put Peter Jackson, Malcolm Gladwell’s David and Goliath, and the traditional Celtic song “The Parting Glass” in a blender and you have this powerful piece, which sings of a fool’s hope in the face of relentless malice and terrible odds.  It’s hard for me not to draw parallels between the song and what is happening on this planet at the moment, but I’m choosing simply to enjoy this apocalyptic track for its dark acoustic brilliance.

Here are some honorable mentions from 2013.

Brainwash — La Luz.  Seattle all-female surf rock quartet.  Great stuff.

Tippin’ Point — Dallas Smith.  Modern Canadian country at its finest.

Wake Me Up — Avicii.  Another impossibly catchy song introduced to me by my pop-lovin’ sons.

Follow Your Arrow — Casey Musgraves.  She has some stones to sing about what she sings about.  More power to her for speaking the truth.

Whatever She’s Got — David Nail.  This was an ear worm all autumn long.

Opiates — Throwing Muses.  Kristin Hersh is a genius.

Didn’t Mean to Fall in Love — Boston.  It is great to hear Brad Delp’s voice again.

Happy 2014!