Thursday, December 30, 2010

Excerpt from "Weaning the Vent"

As I slid into an exhausted sleep, memories of the last two and a half years floated past me; the gnawing nervousness I felt during my first ED shift and the amazing girth of my first patient (a woman with mysterious abdominal pain); walking home in bright East Sacramento morning sun after a 12-hour night shift and being ‘chauffeured” to work by Angela for early morning rounds; practicing intubations on surgical patients in the operating room and the horror of chipping a patient’s tooth in the process; a favorite attending teaching me the proper way to place a thumb spica splint and an hour of practicing on Angela at home; taking parents to the quiet room to tell them that their son was dead, a victim of random gun violence, and running after a psychiatric patient who was trying to abscond from the hospital, naked; a patient in the hallway of the ED whose primary complaint was coprophagia (eating shit) while a man with diarrhea raced by, trying, unsuccessfully, to reach the bathroom in time; a frustrated ED attending telling me as I attempted to place a central line catheter, “Ballard, you have bricks for hands,” and a disaffected attending saying “I’ll be napping in my office, call me if anyone is going to die;” cleaning maggots from an old man’s feet and removing scalpels from a young man’s urethra; harassing a crotchety nurse to do her job and being harassed, in turn, regarding my horrific, chicken-scratch handwriting; the glorious feeling of a night off from work and a drunken round of Cranium with friends, and the ache in my stomach before a week-long string of shifts; a wonderful delayed honeymoon to Maui and the simple joy of an overdue vacation with my wife; the feelings of self-doubt and loathing after failing to diagnose cardiac stent occlusion compared to the triumphant feeling of nailing a lumbar puncture on the first try; serving beers and relationship advice to Karl and listening to his panicked phone message the day he misplaced his cell phone; attempting to climb Mount Shasta the day after a night shift and the look of dread on Angela’s face as I slipped and tumbled down a glacier directly past her; the pain of working with a massive bruise and abrasions to my buttocks from my failed mountaineering expedition and the stupidity trying to play basketball the next day; a methamphetamine tweaker strapped to and humping a backboard and a meth cooker whose lab exploded in his face; sick patients of all shapes and sizes and circumstances…

Monday, December 13, 2010

"Donald" from Weaning the Vent

So, it was close to noon by the time we made it to Bed One, where we found a toddler named Donald Merrill. Donald Merrill was, for the moment, my only patient. It was my turn to lead the team. I was fortunate to have inherited a light load of patients, but that would soon change. I was on call that day and night and any kids admitted in the next eighteen hours would be primarily my responsibility. For now, however, Donald was it. I was preoccupied with the morning’s events, namely the disturbing visage of the girl in Bed Seven and Karl’s antics, and so when we arrived at Donald’s bedside I made a rookie mistake.

“Donald Merrill is a three-year-old male admitted from Sutter Delta,” I began “for pneumonia with hypoxia. The patient was brought in by Life Flight with an oxygen sat of seventy percent, but with otherwise stable vital signs. The patient initially presented to Sutter Delta Medical Center with two days of fever and congestion and was found to have a room air sat of ninety-two and an interstitial infiltrate on chest X-ray. He received one gram of Rocephin and was transferred to UC Davis. Overnight, Donald has been on non-invasive ventilatory support with Bi-level positive airway pressure, BIPAP.”

Dr. Connor interrupted me. “Wait, wait.” He gesticulated sideways, as if he might break into the electric slide. “Before you continue, please tell us what Donald’s underlying condition is.” I knew the answer and was about to respond, but someone else beat me to it.

“Ondine’s curse, also known as CCHS, Congenital Central Hypoventilatory Syndrome.” It was Karl. He just couldn’t help himself. “It comes from Greek mythology.”

Dr. Connor coughed loudly, but Karl continued. “The name comes from the tale of the Ondine, a beautiful water nymph. Ondine was wronged by a young lover and in revenge she cursed him. The curse…” Karl appeared ready to launch into a lengthy explanation. Dr. Connor appeared ready to burst a temporal vein.

“Doctor Krumholz,” Dr. Connor cut him off, “let’s allow Doctor Ballard to educate us about Congenital Central Hypoventilation Syndrome.” Karl nodded and flipped his hair again. Dr. Connor grunted, “Doctor Ballard?”

I told the team what I knew about CCHS, which wasn’t much. “CCHS is a rare condition, a genetic disorder,” I stammered, “one that affects automatic respiration.” Later, I would research the condition and its associated mythology. Karl was right, at least mostly right. Ondine was a water nymph, born in 18th-century German, rather than Greek, mythology. She was beautiful, enchanting, and extremely leery of men. Ondine, like other nymphs, could lose her everlasting life under only one circumstance: if she fell in love with a mortal man and bore his children. Despite her caution, Ondine fell in love with handsome young Palemon, who broke off his engagement to a noblewoman to marry her. On their wedding day, Palemon vowed, “My every waking breath shall be my pledge of love and faithfulness to you.” Years later, lovely Ondine bore Palemon a child, a son, and in doing so forfeited her immortality. Immediately, she aged and her transcendent beauty faded. Palemon’s eye wandered and on a fateful afternoon, Ondine heard the familiar sound of her lover’s snore in the stable on their estate. Entering, she found him entangled in a post-coital embrace with his former fiancée. Enraged, Ondine kicked Palemon and uttered a magic curse: “You pledged faithfulness to me with your every waking breath, and I accepted that pledge. So be it. For as long as you are awake, you shall breathe. But should you ever fall into sleep, that breath will desert you.” And so it was that Palemon’s next sleep, preceded by complete exhaustion, was his last. In the 1960s surgeons discovered a condition, following spine surgery, in which patients lost their spontaneous drive to breathe after falling asleep, and it was named after the mythical curse of Ondine. But at the moment, as I boiled with disappointment at Karl’s interruption, I didn’t know any of that.

Since its discovery, a genetic form of Ondine’s Curse had been found – linked in over 90% of cases to mutations to the PHOX2B gene and occurring in one out of 200,000 live births. Most victims died quickly, usually as infants. Donald Merrill was one of only 200 known living patients with CCHS.

Donald had survived to age three for a couple reasons. First, his mother also had CCHS so his family knew, even before he was born, that Donald was at risk. This allowed Donald’s physicians to make the diagnosis before it had fatal ramifications. Secondly, like his mom, Donald had a relatively mild form of the disease. He needed constant respiratory support when sleeping, otherwise his breathing became too shallow. But unlike some (approximately one out of every ten) with Ondine’s Curse, Donald did not need any when he was awake. None, that is, unless his lungs were compromised in some way, such as with an illness like pneumonia.

As we reviewed his situation, Donald was asleep in the room. I knew his family situation was complicated – the note from Sutter Delta mentioned that his mom was in treatment for heroin abuse, so I wasn’t surprised that he was alone. Pale and thin, with flat brown hair pressed onto his forehead, he looked sickly, although not critically ill. He wore an oval-shaped mask over his nose and mouth. When Donald exhaled, the mask clouded with mist. His breathing was even and peaceful. It looked normal, but I had to remind myself that if it were not for the mask, Donald might forget to breathe.

Donald’s care was pretty simple, and conscious of the length of our morning rounds, I summarized concisely. “We will continue antibiotics, await cultures and continue BIPAP at 12/4.”

“Wait, wait,” said Connor. “Doctor Ballard, it is important that you are precise. Imprecision is precisely the cause of most medical errors. What, precisely, are the antibiotics and what rate is the BIPAP set at?”
Yikes, more embarrassment. But he was right; the rate of the BIPAP respiratory support was critically important. Normal BIPAP merely assisted each inspiration and expiration with pressure that helped force air into and out of the lungs. But, this alone would not help Donald. He needed his breaths to be triggered on a regular basis. Thus, his BIPAP was set at a pressure of 12/4 (inspiration/expiration) and a rate of ten breaths a minute. I was about to correct my error, when we were interrupted.

“Bed Seven,” said a weathered nurse in pink scrubs, “she is hypotensive and de-sating. I’m worried about her. You need to look at her now.”

Monday, December 6, 2010

Treat them like family?

MY FATHER, a pediatrician, tells a cautionary tale.

A family physician, the story goes, agrees to work at a lakeside summer camp for boys. Several days and many bandaged bumps, bruises and bee stings into this service, the campers catch and fry up some perch. As it turns out, the fish is rather bony, and four kids come to the doctor complaining of bones stuck in their throats. One by one, the doctor examines the boys and removes the small slivers of calcium until he gets to the fourth boy. Here, he loses his nerve. He can't get the child to properly open his mouth, and he can't find the bone. Finally, he gives up. This child, he declares, must see a doctor in town. The problem is that the boy is his own son.

I recount this story in order to scrutinize the oft-encountered circumstance in which physicians and other health-care professionals provide medical assistance to friends or family. Today, I'm not talking about lighthearted, curiosity-inducing discussions, but rather situations in which good health may be at stake.

Situations like this are stressful for everyone involved, and for health-care professionals there can be the added stress of a unique inner conflict. On the one hand, we have knowledge -- not only medical knowledge, but also insight into how the system works. On the other hand, we often take on an added responsibility when we attempt to treat loved ones.

Medical evaluation and treatment requires a tremendous amount of weighing risks and benefits. Unfortunately, for many physicians, the simple fact that they are now giving advice to a family member may change their usual risk/benefit calculation.

In particular, physicians in this situation may have a diminished tolerance for making an error of omission -- that is, failing to take action. For instance, we may be reluctant to reassure a family member that everything is going to be fine if there's a chance that we'll find out later that it's not.

And while the term "taking action" has a positive connotation for many, in medicine there are real risks associated with doing so.

According to a 2007 report from the Institute of Medicine, more than half of medical treatments in this country are unproven. Meanwhile, most physicians, patients and malpractice juries tend to overvalue treatment over potential harm from side effects (for example, in most situations the potential benefit of taking antibiotics for a sore throat is much less significant than the potential harm caused by an adverse reaction to those antibiotics). Mix in concern about committing an error of omission, and you may have doctors making unnecessary and risky recommendations to their family members when in fact the clinical situation calls for a doctor with the courage to do nothing.

Medical science is just starting to explore the implications of certain personality qualities, such as risk tolerance, on clinical decisions. A recent study by Dr. Jesse M. Pines, director of the Center for Health Care Quality at George Washington University Medical Center, found that emergency physicians' scores on a standardized risk-taking scale (sample question: "I try to avoid situations that have uncertain outcomes") were associated with significant differences in the clinical management of patients with chest pain. Interestingly, scores on both fear-of-malpractice and stress-from-uncertainty scales were not associated with differences in decision-making.

While this study also did not attempt to judge whether risk-adverse physicians provided better care than risk-tolerant ones, the clear implication is that how physicians perceive risk can affect their decisions. Thus, it stands to reason that physicians giving advice to family members will have an altered risk-taking score -- they are, after all, taking on a new complex level of risk.

Doubt this conclusion? Then ask yourself these questions: "I try to avoid situations that have an uncertain outcome for my patient" and "I try to avoid situations that have an uncertain outcome for my mother."

During my medical training, I was told to treat patients as if they were family. This "grandmother test" was often invoked when considering a treatment or procedure. "Young Dr. Ballard, would you recommend the procedure to your own grandmother?" The assumption was that such an association would lead to better, more-compassionate decisions. Now, I wonder if that's always true.

Do physicians provide better advice to family and friends than to their patients? On the contrary, I believe that in many circumstances the closeness of the situation may cloud our judgment. A number of physicians I asked about this shared my concern.

For example, one said: "I find myself giving so many 'if/then'-type statements and covering every eventuality it really leads to a breakdown in the decisiveness I have when dealing with a patient. Throw in the often odd family dynamics, and you have some pretty crappy advice."

When I contacted Pines, he agreed that medical advice given to family members is often different but asserted that the quality of this counsel depends on the situation.

"The advice might be better in situations where they are very familiar with the family member's medical history," he says. "But the advice could be worse in cases where the doctor may not feel comfortable asking particular questions (like history of sexual partners) and in certain instances feel less comfortable doing a physical exam."

Valid qualifying points, but nonetheless, I wonder if we should reconsider the maxim, "Treat patients as if they were family"? How about we change it to, "When they are sick, treat your family as if they were patients"? Or, better yet, like the camp doctor of yore, leave the treatment to someone with less emotional investment.

Saturday, November 20, 2010

First Page of "Weaning the Vent"

The girl was bloated with fluid and her skin was so white that it was nearly transparent. Plastic tubes, secured with grainy tape, invaded her mouth and nose. Prone and lifeless, she looked like a drowning victim washed facedown on a beach. But she wasn’t at the beach and she wasn’t lifeless – at least not yet. She was in Bed Seven of the Pediatric Intensive Care Unit (PICU) at UC Davis Medical Center, being kept alive by a machine. Her room reverberated with the sound of a mechanical ventilator – also known as “the vent” – doot-doot-doot-doot-doot-doot-doot-doot. The rapid beat was maddening, like Chinese water torture on over-drive. This frenzied rhythm was her lifeline, the music of a high-speed oscillator vent delivering oxygen to her lungs. Doot-doot-doot-doot-doot-doot-doot-doot. Each puff of air was so fast, and so small that the girl’s chest didn’t move.

Or perhaps it did, but her body was too swollen for me to notice. If she’d been on a traditional ventilator, there would have been no question of if and when breaths were being delivered. Now in my third year of residency training in emergency medicine (EM), I was comfortable with operating traditional ventilators. They made sense to me. Just like with my favorite remote control, I knew where the important buttons were and when to use them. Traditional vents calmly and predictably delivered breaths, and there were only a handful of variables (namely the percentage of oxygen and the frequency and volume of air delivery) that I needed to consider. Traditional ventilators were reassuring, in a morbid sense; no matter how sick or sedated a patient was, the sight of inhalation and exhalation was comforting. Breath in, breath out. Not so with high-speed oscillators, which dispensed tiny puffs of air ten times each second. Doot-doot-doot-doot-doot-doot-doot-doot. I knew the percussive rate aimed to keep the girl’s lungs from collapsing under the weight of the fluid in and around her chest, but this didn’t change the fact that the body in Bed Seven looked more like a horrible science experiment than a living child.

As I listened to a manicured blonde resident named Lesley present the case, I averted my eyes out the 7th-floor window. It was a grey February morning and mist had settled into the skeletons of the sycamore and maple trees. The streets were wet and lawns brown with winterized turf. I could almost smell the muddy grass and taste the soggy air; it was an excellent day to be on a couch, or at a movie, or in a hot tub. And, I supposed, since I had no choice about it, it was a fitting day to start a month-long rotation in the PICU with a 30-hour on-call shift. As I meditated on the dull day, I felt eyes on me. I glanced towards the chairs by the window – they were squeezed into a corner among boxes of ventilator tubing, blankets and other clutter. The girl’s mother, professional dressed with reddish-blond hair that rested on her shoulders, met my gaze. Her soft hazel eyes held a look of bewilderment mixed with exhaustion. Ashamed, I turned back to the girl, but her barely human form was no less awful. In my two and a half years of residency, I’d seen hundreds of awful things: gruesome injuries, grotesque infections and the blank stares of the newly dead. This was the worst.

Is it bad to crack your knuckles? (Marin IJ)

For many of us, the body is like an old car. It’s always surprising us with its new sounds, sensations, and unexpected breakdowns. And it’s constantly providing material for investigation. Yes, the human body is a fascinating, unpredictable machine. At the same time, medicine is a fickle art and an imperfect science. For answers to medical questions, there’s always WebMD and “Doctor” Google, and an abundance – perhaps over abundance - of other online health information and advice. But when it comes right down to it, most of us still prefer the face-to-face interaction and in-person opinion of a health professional. Typically we think this interaction occurs in the sterile environment of a physician’s exam room, or perhaps on the phone with an advice nurse. But often, medical opinions are garnered in very unusual places – at dinner parties, the gym, and via Facebook messages.

Health professionals are accustomed to fielding medical questions from family, friends and acquaintances. I certainly am and I’m often intrigued by the curiosities these questions unearth. Have any of the following questions occurred to you? (The answers are adapted from my favorite cocktail party reference, Why Do Men Have Nipples by Mark Leyner and Billy Goldberg, M.D.).

“Is it bad to crack your knuckles?” (Not in moderation, and it sure is satisfying.)
“Can hot tubs make you infertile? (Probably not, and wouldn’t they still be worth it?)
“Should you put steak on a black eye?” (An ice pack is just as good unless you are really set on attracting attention from turkey vultures.)
“Can you swallow your tongue?” (No, you’d have to chop it out first.)

These types of questions are nearly universally interesting (the fact that Nipples was a best seller is sufficient evidence of this) and usually harmless banter. But, if you’re searching for real medical advice from that doctor friend you bump into at Whole Foods, here are some helpful guidelines for inquiry.

1) Know her specialty. A urologist is very different from a neurologist, even though the names sound quite similar (just ask any hospital operator). Thus, you should try to avoid asking a neurologist about a flaccidity issue that is better suited for the talents of a urologist.

2) Know the limits. Lighthearted questions are fine, and most physicians don’t mind them. Many of us enjoy telling our war stories in return. I certainly do. By the way, did I ever tell you about the time that…But, unless you truly think you are in danger, it is best not to casually invoke certain words or phrases. “Heh doc, it sorta feels like there is a big ol’ elephant on my chest,” and “You know, this really is by far the worst headache of my life,” are statements that may cause your physician friend to have a major change in sphincter tone.

3) Know when to stop. If M.D.-in-line-at-the-post-office says “You should really talk to your doctor about that,” what she’s really saying is either [A] that sounds serious and I don’t want to be responsible for you not getting it checked out in a formal medical setting or [B] That is totally out of my realm of expertise, I have no idea what you are talking about, and I’d much rather talk about Buster Posey.

Can you curl your tongue? Does your daughter seem to have bionic hearing? Will your cousin’s eleventh toe be genetically passed on to his offspring? Are you convinced 99-year-old Aunt Mabel is still ticking because she drinks a thimble of scotch with breakfast? These are interesting, fun conversations that physicians often like to engage in. But a party is not the best place to talk about potentially serious medical issues. That said, I look forward to seeing you at the neighborhood holiday cookie exchange. Then I can tell you about that time…

What does the term “palliative care” mean to you? (Marin IJ)

What does the term “palliative care” mean to you? Do you think about metastatic cancer, depression and Death Panels? About funerals and estate planning? Most likely, you don’t think about palliative care at all, or would very much prefer not to. But chances are, at some point, you’ll be faced with a decision related to palliative care, for either yourself or a family member.
The term “palliative care” is derived from the Latin palliare, which means, “to cloak,” and refers to treatment aimed at relieving symptoms and pain rather than effecting a cure. Hospice (perhaps a more familiar term to many) is a type of palliative care that is usually reserved for people in the end stages of terminal illness. Palliative care, on the other hand, may be offered to anyone who has a serious illness —regardless of life expectancy. The basic philosophy behind them both is the same. My wife Angela, a volunteer for Hospice By The Bay, described it this way.
“When everything important to a person is being stripped away by illness, it’s vital to give them the chance to hold onto dignity and autonomy, to receive compassion, to be comfortable, to be home, and to have as much quality of life as possible.”
I agree with my wife (imagine the trouble I would get into if I didn’t); this is a humane way to deal with serious illness. But I also recognize why many people choose to fight end-stage illness, no matter what the cost in terms of side effects and suffering. It’s a very personal calculation, but new evidence is suggesting that it need not be a stark “either-or” choice. This is because new data indicates that some patients with terminal illness may live longer with palliative care than with more aggressive treatment.
Consider the study by Dr. Jennifer S. Temel and colleagues published this past August in The New England Journal of Medicine. The authors compared two randomly assigned groups of patients with metastatic lung cancer – an aggressive care group (defined by no or late referral to palliative care and/or chemotherapy within the last 2 weeks of life) and a palliative care group (early palliative care integrated with standard oncology care). As expected, they found that those who received early palliative care had higher quality of life scores and lower levels of depressive symptoms. The goal of palliative care is, after all, to improve or maintain quality of life. Surprisingly, however, they also found that the palliative care group lived longer – more that 30% longer (11.6 months versus 8.9 months). Even when we keep in mind that this study examined patients with only one, specific subset of lung cancer, the ramifications are striking; palliative care may offer a chance to live longer and live better.
Other research supports this concept – Dr. Stephen R. Connor and colleagues have reported that patients with congestive heart failure and advanced cancer live longer with hospice care (remember, hospice is palliative care given to a certain segment of terminally ill patients) than without it. Recent journal articles have also reported on the successful integration of palliative care into both the oncology and intensive care environments. And, there are the anecdotal stories. Art Buchwald, former Washington Post columnist, wrote a book (Too Soon to Say Goodbye) chronicling one such story. Buchwald, on hospice for end-stage kidney failure, was expected to die within weeks, but instead survived nearly a year, becoming known at hospice as “The Man Who Would Not Die.”
So, knowing this, perhaps we need to re-define and re-frame the concept of palliative care. Dr. Robert J. Lavaysse, Director of Inpatient Palliative Care at Kaiser-Permanente San Rafael offered me one such description.
"Palliative care is about bringing the patient and their families' values and goals to the fore as the driver for medical decision-making. It is also about alleviating symptoms. We are understanding that these conversations need to happen upstream and not in the last few days, weeks or months of life." And this is an important point – palliative care is more than just narcotics for those on the brink of death – it is about providing support in illness – relieving pain and suffering, bringing family together, provide psychological support, and thinking about living wills and estates.
Hopefully the term palliative care is one that will keep its distance from your life, but should it encroach on you or your loved ones, I hope this column has helped you to understand it benefits – both those that are long established and those that we are just now unearthing.

For more on Palliative Care

Thursday, October 21, 2010

Pumpkin in the Paunch (Marin IJ)

The devilish debauchery is done. Candy wrappers litter the living room and cobwebs cover the corridors. Pumpkins seeds party in the green bin and ghoulish mascara smears the face. It is late Halloween night and if you are like me, there is hell to be paid. If history is any indication, post-Halloween will mean a trick-or-tummy – a pop-pop, fiz-fiz, oh what an abdominal pain it is. I do indeed have an avid sweet tooth and hence many Halloweens past have left me feeling like I have a Jack O’Lantern in the innards. There are surely many others out there who have experienced something similar. Ostensibly, Halloween candy is for children, but in reality many adults take liberties. In fact, according to the National Confectioners Association, an estimated 90% of parents “sneak” some goodies from their children’s treat bags. And, even if you can avoid the sneak attack on the candy bag, there are way too many adult-oriented treats to resist! Consider this entry on…

“On Halloween I invited friends to ‘stop by.’ Not knowing how many would come and how much they would want to eat, I had way too much food to finish. All by myself. I had pigs in a blanket, shrimp, jalapeno poppers, taco dip, wings, chips and dip, cheese and crackers. Then there was pumpkin pie and pumpkin cookies. Not to mention obscene amounts of Halloween candy. I ate and ate until my tummy was aching and then I ate some more. The result was one huge monster tummy with an ache to match.”

Sounds familiar? If it hasn’t happened at Halloween, maybe it has been post-Thanksgiving or a Super Bowl celebration gone a-gorging. There are many variations on this post-feast malaise, with a number of medical terms to match; dyspepsia, abdominal colic and borborygmos (this is my personal favorite and refers to audible gurgling in the bowel). Regardless of the terminology, those whose eyes are bigger than their stomachs are often desperate for treatment. Acknowledging the obvious (that prudent prevention is the best medicine), the following are some recommendations, based on the degree of discomfort.

One Groan. Ouch, the candy corn blew up in your gut. Here are some simple steps towards relief; sipping warm water with lemon or ginger mixed in. Or try honey and cinnamon, perhaps blended with yogurt. A brisk walk around the block might help (but skip the trick or treating this time). If the walk doesn’t work, try a heating pad or a gentle clockwise belly massage.

Two Groans. That caramel apple is on fire! Now might be a good time to consider medicating. There are numerous over-the-counter options and your choice will depend on your symptoms. For a sour stomach, try Tums, Maalox and/or famotidine (Pepcid). For excessive gassiness, try simethicone (Gas-X). For looseness from below, loperamide (Imodium) is worth a shot. And finally, for a repeated pattern of reflux, talk to your doctor about starting a course of omeprazole (Prilosec).

Three groans. This is getting severe. At this point, it is time to consider whether something more serious is going. Heart attacks sometimes present as upset stomachs without chest pain, and there are plenty of potentially life-threatening abdominal conditions that are associated with bloating and cramping. Some clues that the post-feast beast in the gut needs medical evaluation include; fever, dizziness, chest or neck pain, repeated vomiting, bloody or black stool, a hard or rigid belly, or one that is tender in a particular spot. Don’t follow the stoic example of Harry Houdini, who ignored an ache in his right lower abdomen for several days before seeing the doctor. He died from a ruptured appendix on October 31st, 1926.

Most belly pain gets better on its own, and the chances are pretty good that the pumpkin in your paunch will soon pass. But, take this opportunity to make a resolution for the next holiday. Think smaller portions, less booze and some exercise. For the kiddos (and for parents who can’t fight temptation), consider Halloween toys rather than candy. Believe it or not, this choice has been scientifically studied, and kids choose small toys just as often as they choose chocolate. The same, however, is not necessarily true for adults, so it is best to have some ginger ready to go.

Follow the Herd (Marin IJ - Dr. Goel)

This week, our guest columnist is back – discussing “herd immunity.” This important public health concept is often mentioned in the media, but it’s rarely explained in depth. So, here to remedy this situation is Anju Goel, MD, MPH, the Deputy Public Health Officer for the Marin County Department of Health and Human Services…

You’ve probably seen the advertisements on public buses and in movie theatres in Marin: “Herd Immunity…Join the Herd! Build Community Immunity!” The ads encourage you to get immunized as a double whammy against disease: 1) to protect you, the individual, and 2) to protect the community.

It’s the protecting the community part that can be confusing. How can a vaccine, given to individuals, have a far-reaching effect across the county and beyond? Herd immunity is like a firewall that prevents a contagious disease from taking hold in a community. Immune people don’t become sick from the disease and thus cannot pass it on to others either. The higher the proportion of immune individuals, the lower the likelihood that a susceptible person will come into contact with an infectious person and become ill. As long as that number of non-immune individuals remains low, the disease cannot easily spread.

Most commonly, protection is the result of having been vaccinated. Having previously had a disease also plays a role since we build immunity to many infections that we experience. The duration of immunity, whether via immunization or illness, varies from a few months to lifelong. The level of immunity needed to achieve community protection varies by disease and depends on how easily an organism is transmitted between people. The greater the transmissibility, the higher the immunity threshold required to keep most of us safe. For measles and pertussis, 94% of the population must be immune to protect the 6% that are not. The figure is around 85% for rubella and diphtheria. Below these critical thresholds, diseases will spread more easily.

Herd immunity is vital to people who cannot get a vaccine because of age or medical conditions. It also helps those with impaired immune systems who receive a vaccine but don’t build a sufficient immune response to it. In short, herd immunity protects everyone who is not immune, including those who choose not to vaccinate for personal belief reasons.

Here’s a concrete example of just how important herd immunity is, especially to families with young children. In the last 14 years, nearly every person (except one) in California who died due to pertussis was less than 3 months old. Why are infants so susceptible to severe pertussis? Children receive their first pertussis vaccine at 2 months and their last at 4 to 6 years of age, excluding the booster. So infants under 3 months of age have only partial to no immunity. To protect them, family members and caregivers must be vaccinated. These vaccinations form a cocoon, or circle of protection, around the infant.

Lack of herd immunity and breaks in the circle, then, are partly responsible for the current pertussis outbreak. Though most Marin children have received their primary vaccine series, many pre-teens, teens and adults have not received the booster shot. They serve as a reservoir for the disease. California is one of only 11 states that does not require the pertussis booster for middle school students. Now that Assembly Bill 354 has passed, this will change in the 2011-12 school year and boosters will be required for 7th through 12th graders.

Once we achieve herd immunity, we have to keep immunizing to maintain it. If we were to stop immunizing, we would see resurgence in disease. As the CDC describes on their website, the situation is much like bailing out a boat with a slow leak. When we started bailing (immunizing) the boat was filled with water (the community had rampant disease). But we have been bailing fast and hard, and now it is almost dry and disease is almost gone. We could say, "Good. The boat is dry now, so we can throw away the bucket and relax." But the leak hasn't stopped. Before long we'd notice a little water seeping in, and soon it might be back up to the same level as when we started. Until we can "stop the leak" (eliminate the disease), it is important to keep immunizing.

This risk of disease resurgence is more than theoretical. There are numerous recent examples. Some, such as the resurgence of measles in Europe, have been well publicized. When an (intentionally) unvaccinated American child visited Switzerland in 2008, he returned home with measles and consequently San Diego experienced it largest measles outbreak since 1991. The child exposed 839 people. Eleven of them, all unvaccinated children, became seriously ill including an infant who needed to be hospitalized. All as a result of a potentially deadly disease that is vaccine preventable.

Vaccines are one of the most significant public health advancements in the last century. They save literally millions of lives each year. They’re most effective when a substantial portion of the population is vaccinated. Choosing to vaccinate means choosing to contribute to community immunity. The majority that does vaccinate provides protection to the few who do not.

So give it some thought, and if you haven’t done so already, I hope you decide to join the herd and immunize. Do it for yourself and for your family. Do it for your community.

Monday, September 27, 2010

Embrace your Autonomy (Marin IJ)

Earlier this season on AMC’s popular drama Mad Men (a series set in the 1960s), a character named Anna is diagnosed with terminal cancer. When viewers see her, the disease has invaded and fractured her leg and, we’re told, she has only a few months left to live. Anna, however, is blissfully unaware of her condition – she believes that in a few weeks she will be dancing again. How can an independent middle-aged woman be diagnosed with cancer and not be aware of it? In this instance, it’s because her sister and doctors have agreed that it is in Anna’s best interest not to know.

When series lead Don Draper learns of the situation, he is, at first, furious. “I'm here now,“ he tells Anna’s sister, “she's going to see some real doctors, and she's not going to live in the dark."

"You have no say in the affairs of this family," the sister replies. "You're just a man in a room with a checkbook." Ultimately, Draper decides to honor her request to "do the decent thing" and leave before he reveals the diagnosis.

Pretty shocking, isn’t it? Could you envision this “decent thing” happening to you? I should hope not. Most readers would agree that it is intrinsically wrong for a physician or family member to decide what personal health information is “good” for an independent adult to know. But, just fifty years ago, withholding health information was standard practice. What has changed? Respect for patient autonomy.

Patient autonomy is one of the four core principles of medical ethics – famously articulated by Justice Benjamin Cardozo in 1914. “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.” But, as accurately portrayed in Mad Men, this basic principle was not widely accepted until the last half century. Before then, there existed a quaint and persuasive notion that doctors were best equipped to make decisions about what information was healthy for their patients and what was not – just as a parent would do with diet choices for a young child. The transformation from a paternalistic, “we know what is best” approach to an autonomous approach was spurred not just by the words of Justice Cardozo, but also by revelations about unethical medical studies (including the “research” atrocities committed in Nazi Germany and the infamous Tuskegee (Alabama) syphilis studies in which infected African-Americans were neither told their diagnosis nor offered treatment.) These abuses made the critical weakness of paternalistic medicine – the potential for abuse in the name of another’s best interests – unmistakable and unacceptable. Nowadays, a competent patient cannot receive a medical intervention or participate in a research trial without autonomously giving “informed consent.”

So, what do you, as a patient or a potential patient, need to know about protecting your autonomy and giving informed consent? Well, let’s consider an example; a common operation like an appendectomy. Before your surgeons can proceed, they must explain to you the procedure’s risks (bleeding/infection), benefits (avoiding appendix rupture), and alternatives (wait-and-see approach). Then, they will have you sign a document to prove that you have been informed and given your consent. What they won’t necessarily do is ensure that you have understood all the details. Studies have demonstrated that, in general, patients’ understanding of consent information is spotty at best – a survey of people involved in a clinical trial of a cholesterol-lowering medication found that only 31% could name the main side effect of the treatment. How informed is your consent if you don’t know what side effects to look out for?

The burden of understanding your medical care does, I’m afraid, fall primarily on you, the patient. And a critical component of this understanding is considering what information is of particular importance to you. The legal standard for disclosure of information is based on what a “reasonable” patient would want to know. But I suggest that your personal standard be your response to a friend’s query, “What the heck is it they want to do to you?” When it comes to an appendectomy, there may not be much variance in how people respond. That may not, however, be the case for other medical tests or interventions.

What about a blood test that could determine if you’re at risk for developing dementia at a young age? This type of test doesn’t exist, but if it did, would you take it? How important would its accuracy be to you and what percentage of “false positives” could you live with? Of course you’d want to know if there were risks involved. But also consider the ramifications of being told that your productive life will be cut short by twenty or so years. Making a choice about whether to know that or not is a very personal calculation. Is this information you would want to know, or is this a case where ignorance is bliss? In this day and age, your doctors cannot withhold a diagnosis of cancer from you, but they may someday be able to offer you a test that predicts your risk of cancer. How much would you want to know? Even if you are young and healthy, it’s never too early to think about what you’d do – or want done. Medical ethics can be sticky, informed consent can seem esoteric, but it’s your consent regarding your health. Embrace your autonomy.

Wednesday, September 22, 2010

Is Smelling Like a Fish Still Worth It? (Marin IJ)

Fish oil has become a popular dietary supplement – one endorsed by cardiologists, Consumer Reports and this column. It contains marine omega-3 fatty acids, known to biochemists as docosahexanoic acid (DHA) and eicosapentaenoic acid (EPA) that are thought to have beneficial anti-inflammatory and anti-clotting properties. But over the last six months, the safety and effectiveness of fish oil has been questioned, leading some to wonder… has the era of fishy burps come to an end? Could it be that the purported benefits of mackerel are actually baloney?

This past March, a group of plaintiffs, including the Mateel Environmental Justice Foundation, filed suit against five manufacturers of fish oil supplements – contending that the products contain levels of polychlorinated biphenyl (PCB) that are above California’s “safe harbor” limit. PCBs (for those, like me, who have a hard time keeping their environmental toxins straight) are industrial chemicals that take an extremely long time to degrade in the environment. Although they used to be widely used, PCBs are now banned. They’ve been linked to cancer (in rats) and to a number of other health conditions. The plaintiffs based their complaint on tests they’d performed themselves – by puncturing fish oil capsules and studying their contents. Their suit alleges wide ranges in PCB concentrations – with some products being well above the reportable level (90 nanograms a day). "The people buying these fish oil supplements,” attorney (and plaintiff) David Roe said “are not being told the PCBs are there." This legal announcement, and the accompanying press coverage, scared the fish oil right on out of some folks.

Then, just last month, The New England Journal of Medicine published the results of a Dutch study (the Alpha Omega Trial) that followed patients who’d previously had heart attacks and who were taking omega-3s (in the form of margarine fortified with marine and/or plant fatty acids). The study subjects (all on standard heart medications such as aspirin) were given small tubs of margarine – with or without different formulations of omega-3 fatty acids – and their intake was tracked by measuring the amount of unused margarine at 12-week intervals. The study followed nearly 5,000 patients for forty months and found no difference in “major cardiovascular events” (such as repeat heart attack or stroke) or in death rates between those who were and those who were not taking omega-3s of any type.

For fish oil advocates, this seems discouraging. And, if you factor in environmental concerns about over-fishing, perhaps it is time to re-consider fish oil. But wait, before you toss out those omega-3 soft gels and discontinue fresh fish Friday dinners, consider some additional perspective.

First, regarding PCBs, there are several reasons not to get too freaked out.

1) No one really knows how dangerous PCBs truly are. Numerous studies have failed to link PCBs to cancer in humans (rats are a different story). And while there is no good data on what a safe level of PCB exposure is, the California reporting limit is far below federal levels.

2) Previous, more comprehensive, studies of fish oil supplements have found limited contamination with heavy metals or PCBs. This is not to say that there aren’t outliers, but the vast majority of fish oil supplements likely contain less PCB than fresh fish or meat.

3) The brands with high PCB levels named in the recent lawsuit are predominantly cod and shark liver oil products. The liver, as you probably know, processes chemicals, meaning that oil from the liver is more likely to contain detectable levels of PCB. Perhaps, and I stress perhaps, it is better to avoid fish liver products.

In my opinion, recall the maxim “the dose makes the poison” and don’t be majorly concerned about PCB toxicity in your fish oil. But, what if, as the Alpha Omega Trial suggests, marine omega-3s offer no beneficial health effects? Well, that would be a different story. There are several reasons, however, to doubt this conclusion;

1) The Alpha Omega Trial, despite being a well-designed prospective study, has some weaknesses. These include the forty-month follow-up time – which does not give us a good sense of long-term events. Second, this study focused on a group of patients already on state-of-the-art cardiac treatment. Third, there is the choice of omega-3 delivery. Dr. Alan S. Go, a senior cardiovascular researcher at Kaiser-Permanente, told me “The choice of putting these agents into margarine was rather curious, especially given that the trans fatty acids in margarine are cardiotoxic and perhaps could have blocked any potential beneficial effects.”

2) Multiple previous studies have suggested an array of protective effects from omega-3s – particularly marine omega-3s. These benefits are not restricted to those people who have already had a heart attack – and it may be those at risk are more likely to benefit.

Where then, does this leave us? Well, as is often said in science, further study is necessary. But, Dr. Go and others are still on board the omega-3 boat; “the overall preponderance of evidence supports the efficacy of marine omega-3 fatty acids for reducing cardiovascular events and arrhythmic events - in selected populations - and the benefits of eating more fish with higher omega-3 levels likely outweigh the risks from contaminants (at least currently)."

This doesn’t mean I recommend fishy omega-3s for everyone, but those at risk should consider them (either via diet or supplements). If in doubt, talk to your doctor. I, for one, am not giving up Kirkland Signature soft gels just yet. Given my family history of heart problems and hypertension, I am willing to risk a few nanograms of PCB for a potentially healthier heart; I just hope my wife is willing to risk the olfactory offense of an occasional fishy burp.

A Contested Illness (Marin IJ)

Some years ago, a sinewy chap sought my help for an aggravating condition. This young man was convinced that microscopic bugs were crawling over and under his skin. You can imagine how horrible this creeping sensation would be and it had driven this guy to a frenzy of restlessness. His arms and legs were covered with excoriated sores and fingernail-induced streaks of scarlet. I inspected him from head to toe and couldn’t find evidence of insects or parasites. Then, as I silently puzzled the situation, he handed me a smudged envelope and asked me to carefully look inside. I removed a half dozen pieces of scotch tape, each holding a spattering of blackish specks. These specks, he declared, were the bugs that were tormenting him. I was doubtful, but nonetheless took a close look under a microscope. And while I didn't see signs of movement or anatomic structure, I wasn’t sure what the specks were or where they’d come from. After several minutes of debate, during which my patient wanted answers and I challenged his theory but failed to offer an alternative explanation, I noticed something. His fingernails were crusty. Along the nail bed and under the nail tips I noticed a blackish substance that looked like..."Are you a painter?" I asked him. Well, indeed he was, and it seemed clear to me that he was mistaking paint chips for parasites. But, he remained dubious. I thought he probably had a psychiatric condition called "delusional parasitosis;" he was certain that he had a treatable infestation.

Years later, I wonder whether this patient and I were meeting at the intersection of a contested illness known (to some) as Morgellons syndrome. You may have heard of Morgellons before; it received some media attention around the time that the Centers for Disease Control and Prevention (CDC) announced they were partnering with Kaiser Permanente to study the syndrome. But more on that later. First, what exactly is a “contested illness”?

To define “contested illness,” let’s start with the concept of “medicalization” – the process by which aspects of the human situation are described and treated as medical conditions or illnesses. For example, bad breath is diagnosed as “halitosis”, and excessive sweating transforms into “hyperhidrosis.” Writes Dr. H. Gilbert Welch in an LA Times editorial: “Everyday experiences get turned into diseases, the definitions of what (and who) is normal get narrowed…we doctors feel increasingly compelled to look hard for things to be wrong in those who feel well.” Lately, the medicalization of society has been driven forward by several dynamics. These include the insatiable market and marketing of personal health and beauty products, and the Internet-enabled organizing capability of condition-specific support groups. When advocacy groups (arguing that they are suffering from a treatable medical condition) collide with skeptics within conventional medical institutions, the result is a “contested illness” such as Morgellons.

Nearly ten years ago, biologist Mary Leitao’s s two-year-old son developed a strange skin condition. He scratched at himself incessantly, creating sores that, upon close inspection, contained bundles of multi-colored fibers. The physicians Leitao consulted were either baffled or skeptical. Frustrated, Leitao set out to educate herself and, in the process, discovered that her son’s symptoms had been described before, as far back as the 1500s. In fact, she found a name for the problem in Thomas Browne's A Letter to a Friend (1690). The letter described a "distemper of children... called the Morgellons, wherein they critically break out with harsh hairs on their backs." Determined to help her son and others like him, Leitao created the Morgellons Research Foundation and its website to disseminate information about the condition. She was surprised when thousands of strangers with similar symptoms contacted her. Pretty soon, Mary Leitao’s frustration had transformed into an advocacy movement. But, experts in dermatology and psychiatry were not convinced – the overwhelming opinion from the medical community was that Morgellons was a variant of delusional parasitosis – a well-described psychiatric condition. According to dermatologist Norman Levine (quoted by Brian Fair in his recent article in Sociology of Health & Illness), “[Morgellons] is not a mysterious disease…If you polled 10,000 dermatologists, everyone would agree [that Morgellons is Delusional Parasitosis].”

As Morgellons became more contested, the CDC, at the behest of some members of Congress, got involved. The CDC chose a middle ground in nomenclature – calling the condition “unexplained dermopathy,” and partnered with Kaiser Permanente to enroll and study patients suffering from “…symptoms including crawling, biting and stinging sensations; granules, threads or black speck-like materials on or beneath the skin; and/or skin lesions…”

And so here we are, several years later, waiting for the results and a peer-reviewed publication. The CDC website states that data collection for the study (which included skin samples from affected patients) is complete and under review by an expert panel. A press officer at the CDC confirmed this status (an inquiry to the Morgellons Research Foundation was not answered).

Whatever the CDC reports, in my opinion the Morgellons story illuminates two distinct points. First, patients’ symptoms should always be taken seriously and symptomatic treatment offered if available. In the case of Morgellons-type symptoms, this means a thorough exam to look for an explanation and (at a minimum) recommendations to alleviate symptoms (such as hydrocolloid dressings, low-dose steroid creams and anti-itching medications). Second, the medicalization of the human condition contributes to the development of contested illnesses and this is not healthy. Is Morgellons the medicalization of a psychiatric condition or is it an unexplained illness? We don’t know. But while it is clear that those with an “unexplained dermopathy” do not feel well, it is also very unclear whether modern medicine is capable of a definitive solution to their problem.

Whatever the answer to the mystery of Morgellons, the dynamics that have made it a contested illness are not going away. I have a feeling that those dynamics will be bugging us for some time.

**Dr. Ballard is not a part of the Kaiser Permanente team involved with Morgellons research.

Saturday, August 7, 2010

Excerpt from "Weaning the Vent"

For Savannah Jones, it was not a great night for sleeping, far from it in fact. Savannah sat up straight in her bed in the Pediatric Intensive Care Unit, breathing fast and shallow like a frightened rabbit. She opened her eyes as I entered the room and looked at me wearily. Mist filled the mask over her mouth and nose and billowed with each breath; she was breathing at least forty times a minute, twice the normal rate. Her lungs sounded even worse than before – wheeze, wheeze, crackle, wheeze, crackle – and although her pulse oximetry reading held steady in the mid 90s, I feared it might not stay there for long.

“Crap,” I thought as she hurried out of the room, “this girl needs to be intubated, and soon.” I hustled to the nursing station and paged Dr. Connor. As I waited for the return call, I reviewed, as I had dozens and dozens of times before, the procedural steps of an intubation. Intubation, the technical name for placing a breathing tube in the windpipe, is without a doubt the most crucial hands-on skill that a novice emergency physician must learn. Since the first day of my residency, I had been taught that my job was to “own the airway.” When I first heard this phrase, “own the airway,” I thought it presumptuous – how could a physician “own” a patient’s airway as if it was a commodity? Surely, a person’s trachea was more innately his or her own than a moped or a surfboard? With time, however, I came to appreciate the phrase because it captured the mentality necessary to learn a critical skill. Training in emergency medicine emphasizes, above all else, the skill of airway management and with good reason; when a patient ceases to breathe immediate action is required. Bodily organs deprived of oxygen fare poorly and basic functions, such as the heartbeat, rapidly lose their verve. Depending on factors such as patient age and health, there might be minutes to spare, or maybe only seconds. And this is why the intubation process fills even a seasoned emergency physician with trepidation; because while the procedure is usually straightforward, if things go wrong, they can go very wrong.

“Ballard, I am on my way in,” Connor bellowed over the phone. “Get the airway equipment and drugs at the bedside and call the respiratory tech. Talk to Savannah’s mother, make sure she knows what we are up to. If Savannah crashes, you know what to do.”
“Yep,” I replied, surprised. I hadn’t told him a word about the situation. He just knew that this was going to happen. Obviously, he had been doing this for a lot longer than me, but experience alone didn’t allow an average physician to reliably predict future events. Connor was special.

Savannah’s mother nodded sadly. “Doctor, as I said before, do what you need to do. I trust you.”
She inhaled deeply. “How long? How long do you think she will need the breathing tube?”
“I don’t know. I am sorry, but your daughter’s infection is very serious. It could be a long road.”
“I see,” she muttered softly.
“We will get you as soon as the tube is in.” For a moment, Savannah mother’s worry weighed heavily on my soul, but I didn’t have the time to linger. Savannah’s respiratory rate was nearing 50.

“Okay,” I said to Savannah’s nurse, “we need to get this done now. Push the etomidate, eight
Milligrams. Follow that with the succ sixty milligrams.” I ran through my mental checklist one more time – tube with stylet, suction, syringe, bag and valve, color change detector.

Just after the medications had been pushed and Savannah’s eyes closed with a slight shudder, Connor strode into the room. He looked at me.
“Looks like we are doing this. Ballard, I hope your technique is cleaner than your hair-do.”
I chuckled. I hadn’t even considered my bed head. I was pretty legendary among my peers in my ability, in a short period of time, to get significant bed head. Just 15 minutes of lying in a bed could reliably cause a large puff of my hair to stand straight up. Thirty minutes in bed was guaranteed to leave pillow lines across my forehead. Usually, after I’d been paged in the middle of a nap, I would take a brief swing by a mirror and attempt to temper the follicular uprising. But, in this case, the urgency in Savannah’s nurse’s voice had caused me to skip the mirror. I was thankful that Savannah’s mother had focused her trust on my words and not on my appearance. Connor’s comment calmed my nerves and I focused on my task. We lowered the back of the bed so that Savannah was lying flat and I gently pushed the top of her head down, which popped her chin up slightly. I opened her mouth with my right hand and inserted the L-shaped blade at an angle with my left. I pushed her tongue to the side and the tip slid into the valleculla. I pushed up and out, at a steeper angle than normal, because of where I expected her young vocal cords to lie. And there they were, glistening and outlining the tunnel to a successful intubation.

“Tube,” I said.

I felt it in my right hand. “Steady now,” said Connor. “Keep your eyes on the pearly gates.”
The tube slid in smoothly, and although I didn’t see it pass the cords, I knew it was in.
Connor pushed the plunger on the syringe, filling the balloon. The respiratory tech connected a color detector and a respiratory bag, after a large squeeze, the detector glowed yellow. I listened to the breath sounds – still wheezing and crackling, but present. I listened over the abdomen to be sure and was reassured because I didn’t hear the hollow sound of air blowing into Savannah’s stomach. The respiratory tech began to tape the tube into place and connect Savannah to the ventilator. The nurse prepared to slip a tube into her nose down to her stomach. I looked at the monitor, Savannah’s pulse oximetry was creeping back up, now in the mid 90s.

“Good job, Ballard.” Connor gave me a slap on the shoulder. “Now, let’s find you a comb.”
I laughed in relief and headed towards the call room and then stopped.
“How did you know?” I asked Connor. He smiled. “Simple really, you weren’t the only one who got a call from Savannah’s nurse. We don’t let you rookies have too much latitude. C’mon, let’s get some rest.”

Brain Shield! (Marin IJ)

Have you heard about the latest medical breakthrough? It’s a miracle cure that reduces the risk of brain cancer by 52.737%! Brain Shield was recently unveiled at the Meeting of those Concerned with Brain Cancer with stunning success. But don’t take my word for it. Annie from Lodi says “What a godsend. This treatment changed my life.” Annie has been using Brain Shield for 13 months and guess what, no brain cancer. Brain (CT) scans have confirmed that Annie is cancer-free. Interested in reducing your risk of cancer? Call 1-878-4-SHIELD.

Sound suspicious? Well, it should, because it’s completely bogus. I’m certain most of you weren’t fooled. But, did you pick up on the specific clues that Brain Shield story is full of bull#$%*? There are a number of them. By discussing each red flag, I hope to provide some tips for cutting through the hype in the medical media. Your health is of the ultimate importance and the quality of the medical news you heed (or ignore) is critical. So, here’s how to discern the valid from the bull #$&*. I thank the Association of Health Care Journalists (AHCJ) for providing the basic principles to work from.

Red Flag #1: Language. Be wary of health reporting that utilizes sensationalistic language. I am not sure that “miracle cures” actually exist, but if they do, they are rare. Antibiotics might qualify. A (hypothetical) treatment to reduce the risk of brain cancer by 53% certainly does not. The vast majority of “breakthrough” treatments and “dramatic” findings are nothing of the sort. Similarly, phrases like “deadly diseases” and “sweeping epidemics” are used to sell media, not to properly inform.

Red Flag #2: The anecdote. Testimonials may be useful in painting a vivid and personal picture of a disease or treatment but anyone who extrapolates the experiences of a handful of people to larger groups is taking a leap of faith. The AHCJ cautions health journalists to avoid the “tyranny of the anecdote,” particularly when the anecdote contradicts the sum of available evidence. An excellent example is the long hyped (and many times disproven) link between vaccines and autism. Causality is difficult to establish and a series of heart-breaking stories about children who developed autism not long after receiving immunizations does not establish a link and absolutely contradicts the vast evidence exonerating vaccines as a causal agent. Similarly, absent more information, readers should not be impressed by the “remarkable story” of Annie from Lodi.

Red Flag #3: Lack of peer review. The peer-review process in the scientific community is far from perfect, and plenty of junk slips through its cracks and into the medical literature. Andrew Wakefield’s seminal publication about the MMR vaccine and autism has become a classic example. But nonetheless, peer-review is a rigorous process – and one that (mostly) discourages researchers from publishing poorly conceived or managed research. Thus, you should put far more trust in medical evidence presented in a peer-reviewed journal (such as the New England Journal of Medicine) than preliminary results that appear in the mass media or at a scientific conference. Research presentations at conferences have not been vetted in the same manner as studies that make it to print in journals. The Meeting of those Concerned with Brain Cancer sounds like a worthwhile gathering, but should not be taken as the definitive source for information about preventing brain tumors.

Red Flag #4: Lack of perspective. There is a lot of nuance involved in interpreting the numerical significance of medical research. A 52.737% reduction in the risk of brain cancer sounds fantastic until you consider that brain cancer is an extremely rare condition (about 6 cases per 100,000 people). Think about it in terms of the value of your home – a 53% reduction in value is profound if the starting value is high. But what if your house isn’t worth squat (let’s say $100) to begin with? Then a 53% difference is no longer a big deal. Similarly, a 53% reduction in the number of cases of a common medical condition is big news, but a 53% reduction in cases of a rare condition is less newsworthy. Journalists can put this into perspective by giving data about statistical significance (the benchmark as to whether an observation is likely to have occurred randomly or is likely related to an exposure) or – for medical therapies – the number-needed-to-treat. For example, our hypothetical Brain Shield would need to be used in nearly 200,000 people in order to prevent a single brain cancer. When you consider this, you also realize the use of extra decimal points (52.737%) is another red flag. Those extra decimal points are purely for show – a means of making the results seem more robust than they actually are. Genuine data does not require three decimal places – none or one is usually sufficient. Watch out for numbers with drawn out decimals.

Red Flag #5: Too good to be true. No medical treatment is without risk. This is even true of treatments involving basic life substrates such as oxygen, water and salt. Too much of any of these things can be harmful. Thus, any discussion of a medical treatment must mention its risks. The very rough estimate of lifetime risk of cancer caused by a CT scan of the head is one in 2000 – thus Annie from Lodi has actually increased her brain cancer risk by attempting to confirm that her anti-brain cancer treatment is working. Silly Annie.

So, next time you read “stunning” health headlines or stay up for the 11 o’clock news to learn about the latest epidemic sweeping the area, keep these red flags in mind. If you encounter any, tune out, go to bed, and find a different (better) source in the morning. Or if you’re not sure, you can follow the advice of my buddy (and frequent contributor) Dr. Clark Hinderleider and “investigate the reliability of the outlet from which the content is received by using a 'fact-check' source such as" Whatever you do, I wouldn’t rely on Annie’s advice.

Can you handle the hype? (Marin IJ)

Flesh-eating bacteria, super-viruses, killer E-coli...Bird flu, swine flu, equine flu… Toxic mold, toxic shock, toxic toys, toxic Tylenol…Salmonella in your peanut butter, heavy metals in your salmon…Cancer from phthalates, tumors from your phone…Autism and vaccines, pertussis and vaccines (lack thereof). The media spits out an endless series of scary health stories, many sensationalized for effect. You’re all familiar with these pieces. I feel downright accosted by some of the headlines: “The toxic mold and the hidden room: a homeowner's nightmare,” (, or “The deadly ‘superbug’ that's spreading fast across the country,” ( and “Talk & die syndrome more common that you think” (

With the frenetic heat of media hyperbole, it’s hard to know which health hazards to be concerned about and which to put on the back burner of the worry stove. Not surprisingly, the public is often confused about health matters, and I really believe the media bears a heavy burden of responsibility for this. Medical reporting suffers from a number of ailments, including outbreaks of misinformation, deficits in understanding and context, and, often, a rush to pronounce conclusions.

Take, for example, two stories that sparked a substantial panic this past year. One was the unfortunate death of Natasha Richardson from a seemingly minor head injury and the other was the Food and Drug Administration’s (FDA’s) warning about liver damage due to excessive doses of acetaminophen (Tylenol).
Richardson’s tragic death from an epidural hematoma (bleeding on and around the brain) after falling on a beginner ski slope received widespread media attention, including in this column. The scope of the reporting was varied and from a public health perspective had some beneficial impact. The story reinforced the importance of wearing a helmet during high-risk sports such as biking, skateboarding, and (at least for beginners) skiing. On the flip side, some reports were alarmist and others were dangerously inaccurate. For example, I read an on-line article claiming that clot-busting drugs could have successfully treated Richardson’s brain injury. In actual fact, giving clot-busters to Richardson would almost certainly have hastened her death. Another report recommended that people with head injuries visit their nearest trauma center – which is a good idea for someone who has taken a header off the roof – but not necessary for most minor head impacts. And finally, a rather hysterical blog advised that all patients with head trauma be screened with a CT scan of the head. These and other alarmist stories, such as a Good Morning America feature on a young girl who sustained an epidural hematoma after she was struck with a softball, sent thousands of people to EDs to be checked out for trivial head injuries.
Dr. Brian Walsh from Morristown, New Jersey and colleagues quantified this effect by comparing the number of ED visits for head injury related complaints before and after Natasha Richardson’s death. They discovered that the total number of visits in the ten days after the actress’ death was 73% higher than the number of visits in the ten days prior, while the sum of serious injuries was unchanged. In other words, there was a huge surge in patients with minor head bonks who visited the ED to get checked out. This, of course, is what emergency departments are for, but nonetheless the media let these people down by failing to adequately stress the (well-established) warning signs of serious head injury (such as severe headache and repeated vomiting) and the potential risk of obtaining an unnecessary CT (radiation exposure that is thought to increase lifetime risks for cancer, especially in children). This failure to paint an accurate picture of risks and benefits is one of the five health media deficiencies identified by the American Council on Science and Health (ACSH), an advocacy group dedicated to providing sound health information to consumers.
A second deficiency, recognized by the ACSH and others, is the media’s tendency to gloss over the importance of dose, often altogether ignoring the maxim "the dose makes the poison." An excellent example of this is the media coverage after an FDA advisory panel warned that excessive doses of acetaminophen (Tylenol) could cause liver damage and failure. This statement was intended to raise awareness of the danger of cumulative doses of Tylenol. Truly, it can be hard to keep track of the amount of acetaminophen you’re taking, as it is commonly used as a cocktail ingredient in over-the-counter cold and flu preparations as well as in prescription painkillers such as Vicodin and Percocet. Hence the warning: people taking large doses of these medications, with or without additional Tylenol, are at risk for liver damage. Increased awareness of this risk, as well as changes in physician prescribing patterns (e.g., away from combination medications like Vicodin and towards single drug prescriptions) is desirable. Unfortunately, the message that many patients received, and I heard this many times in the ED, was that Tylenol is a dangerous medication. This could not be farther from the truth – Tylenol is one of the safest pain medications at our disposal and, if used at recommended doses, has far fewer harmful side effects than alternatives such as ibuprofen or naproxen. So please remember – the dose makes the poison. Remember this in regards to Tylenol, lead in children’s toys, mercury in fish, and phthalates in milk. With most environmental or dietary exposures, “everything in moderation” should keep you healthy.
There’s more to write about on the topic of the media and health, and three more ACSH identified deficiencies to cover. But since this column is running out of space and I do not want to violate any principles of responsible health reporting, I will pick up the topic in a couple weeks. In that column, I’ll give tips on how you can become a discerning reader of health news so you can decide for yourself which “scares” to freak out about and which to just forget.

Have you done your neurobics today? (Marin IJ)

There’s a woman at my gym who walks on the treadmill. Backwards. Why the heck does she do that? Not because the view is better and not in protest of the television that sits atop the machinery. Not to keep the wear on her sneakers even or to draw attention to herself (although she accomplishes both.) No, she walks backwards for the neurobic benefit. That’s right, neurobics – aerobics for the brain. And while walking backwards on a treadmill may not be a particularly safe exercise, the basic concept behind it is interesting.
The term “neurobics” was first introduced by neurobiologist Lawrence C. Katz about ten years ago along with the hypothesis that mental exercises, especially those that tax the brain in novel ways, can stimulate the growth of new dendrites and neurons. The theory is that most people perform many actions by routine – the processes are hard-wired by repetition into the brain’s mainframe. Routines like how you tie your shoes or answer the phone or walk on the treadmill are performed with little conscious thought. By switching things up and challenging your brain to orchestrate tasks or thoughts in different ways, you may be able to improve the cognitive (aka thinking) function of your brain.
Intrigued? You’re in luck. Dr. Katz, in collaboration with Manning Rubin, has written Keep Your Brain Alive – a book describing 83 neurobic maneuvers (“cross-training for the brain”) for people over the age of forty. The drills, which are designed to fit into your daily routine, include writing or brushing your teeth with your non-dominant hand and starting the ignition of your car with eyes closed (please remember to open them before you start driving). These are simple changes, not the New York Times crossword or advanced Sudoku, but Katz and others are convinced there is a benefit. But you probably don’t need a new book to teach you neurobics – how about using nothing but facial expressions to communicate during dinner, typing an e-mail without looking at the keyboard, or walking backwards on the treadmill?
Is there any solid evidence that neurobics help cognition? When I recently perused the medical literature I didn’t find much evidence supporting the specific practice of neurobics. This doesn’t mean, of course, that neurobics aren’t valuable; it just means that they haven’t been adequately studied.

Research has shown, however, that “cognitive engagement,” such as regular reading, learning a musical instrument or playing card games, is associated with decreased risk of cognitive decline and Alzheimer’s dementia. (This from an exhaustive NIH review prepared by scientists at the Duke Evidence-based Practice Center.) Physical activity also seems to have a benefit. A recent article in Clinics in Geriatric Medicine reviewed dozens of studies on the topic, many of which enrolled thousands of participants. The bottom line, according to the authors: “Increasing evidence suggests than an active life has a protective effect on brain functioning in the elderly population,” however no quality study to date “has shown that regular physical activity prevents dementia.”

With the U.S. population aging – over 70 million Americans will turn 65 in the next two decades – brain health is sure to become a major priority for physician and scientists. If we can keep this population active and productive well past the age of Social Security, there will be major benefits for individuals and society.
I asked a neurologist friend what he thought about improving brain health. Neurobics – well, he’d never heard of them. Physical activity and plenty of Vitamin D – good ideas for anyone of any age. Antioxidants in the diet to neutralize free radicals? Absolutely. “Tell your readers,” he told me “to eat blueberries.” A tasty thought, but I wouldn’t suggest eating them while walking backwards on a treadmill.

Flop-Roll-and-Face-itis (Marin IJ)

For the last few weeks, each dawn has awakened with the planet’s greatest team competition on television with vuvuzela horns as a brain-buzzing soundtrack.
As a fan, this World Cup has been thrilling to watch. As a physician, however, I’ve found it puzzling. Each morning, I witness an epidemic of a peculiar type of injury. Soccer players, some of the fittest of all athletes, fall to the ground after the slightest hint of contact – and proceed to roll around, hands clamped to their faces as is they’re mourning the death of a loved one. These men are stricken, horribly, for seconds to minutes at a time, and then bounce back to their feet as if nothing has happened. It’s odd actually, and I must admit that my Emergency Department (ED) experience hasn’t given me a clue as to what this mysterious soccer affliction (shall we call it “flop-roll-and-face-itis”) might be.

People with kidney stones will often rock back and forth in misery, unable to find a comfortable position. Patients with migraines frequently hold their hands to their faces, to shield their eyes from the light. Narcotic abusers may shift dramatically from a pose of comfort to one of excruciating distress when they realize they are being watched. But, in terms of traumatic injury, these soccer-induced spells are original. Take the Brazil-Portugal game, a defensive struggle that ended in a 0-0 tie. In this game, between two elite teams, there were more stricken players then quality shots on goal. For example… a Portuguese player feels a soft hand to his back and is launched onto the ground, arms splayed, emulating Dicaprio in The Titanic. His head rests on the ground for a moment and then he rolls to his back, his hands go to his face, he flexes his knees and rotates back and forth on the turf. What is hurt? Is it his head? Is it his Achilles tendon? The referee runs in with a yellow card for the Brazilian who touched him, and suddenly the Portuguese player is cured. He pops up, ready for another run on goal. Later, a Brazilian takes cleats to the heel and falls to the ground, clenching both ankles with his hands, and rolls, 1, 2, 3, 4, 5 times! What an odd injury this is! The announcer, a Brit, dryly takes note; “If you roll around a lot you are not as hurt as if you are lying still, in real pain.”

Could it be that these players are faking their injuries? I asked Dr. Joseph Centeno, an orthopedic surgeon and sports medicine specialist at Kaiser-Permanente. "Let's put it this way,” he replied, “I've never had to operate on a flopper." Next, I talked to my brother, Chris Ballard, a writer for Sports Illustrated who covers the NBA. Had he ever seen this type of injury in the sport of basketball? “Only on rare occasions,” he said, “and strangely enough it seems to only afflict European or South American players such as Vlade Divac or Manu Ginobili.”

But, all ridiculous theater aside, I should note that serious injuries do occur in the game of soccer. Many stars, including Ballack of Germany, Essien of Ghana, and Beckham of England, are sitting out the World Cup with physical ailments. And here in the U.S., as soccer gains greater popularity as a youth sport, thousands of kids are suffering knee, ankle, face, and head injuries. Each year, approximately 75,000 children ages five to 14 are treated in EDs for soccer-related injuries – more than the number of visits due to gymnastics, ice hockey and skiing injuries combined. Of these, many are knee injuries, particularly anterior cruciate ligament (ACL) tears. The ACL tear is a serious impairment that usually requires surgery and extended rehab, so it is worth taking note that the risk of this injury can be minimized by reducing the yearly load of play (in other words, taking some time off) and employing structured warm-up before play.

Of greater concern, however, are soccer-related head injuries – as even minor ones can have cumulative consequences. Head trauma, of course, is a problem in many sports, but soccer players are exposed in a rather unique manner because they are trained to repeatedly strike a rapidly moving ball with their unhelmeted craniums. A Canadian study, recently published in the journal Injury, found that 15% of soccer-related ED visits were for head injuries, of which 11% (of these) were concussions. Another Canadian study found that a disturbingly high number of youngsters (age 12-17) playing team soccer had evidence of concussion (over 50%) and that this percentage was significantly lower in those wearing protective headgear. A third study, published in the journal Neurosurgery, found decreased neuropsychological scores and reaction times in professional soccer players who had suffered a head injury the day before – even when these players claimed they did not feel any ill effects.

So, does any of this help explain the puzzling frequency of dramatic injuries at this year’s World Cup? I think it does. Some of these players, it seems, are damaged by years of forceful headers and contested corners. And thus, they have developed the deluded judgment that turf flopping is an acceptable strategic play (and one that the referee and the public won’t notice). From a purely clinical standpoint, they are wrong. The intent of flop-roll-and-face-itis may be difficult for a referee to recognize in real time, but with a remote control and a little clinical perspective, it’s a remarkably easy diagnosis.

Tuesday, May 11, 2010

Wear Insoles (Marin IJ)

My Sunday hoops game is a testament to the limitations of the human body – athletic tape is more plentiful than cartilage in this crowd. But it’s also a testament to perseverance – why else would these blacktop veterans continue to play a game that takes such a toll on the body? Some of my fellow weekend warriors have asked for advice on how to prevent and recover from sports injuries. Well fellas, in the spirit of graduation season, here goes...The following commencement address on recreation-related trauma is shamelessly modeled after an old Chicago Tribune column popularly known as “Wear Sunscreen.” My aim is to provide some flecks of wisdom for readers who, like me, are graduates of their competitive prime and fully cognizant of their performance decline.
Fellow aging athletes, if I could offer you only one tip for your athletic future, a pair of shoe insoles would be it. The benefits of insoles are self-evident; well, at the very least the benefit of having feet is self-evident. And if you are going to have feet and use them for activities that make them hurt, you should try insoles. They just might help.
Now, like insoles, the rest of my advice to weekend warriors and middle-aged rec league contestants has an inconsistent basis in medical science, and is to a large degree a product of my own experience…
Enjoy the pain and hardship of your sport. Actually, that’s bull – you cannot possibly appreciate how much the pain and hardship of your sport pounds your joints into submission. But trust me, twenty years from now you will look back with an ache of nostalgia at the way you used to move.
Warm up before the game. Hopefully your P.E. teacher taught you that. And realize that stretching alone doesn’t count; calisthenics in the sauna most definitely do.
Stop and collect your gear. Sometimes you need the knee brace. Sometimes you need the ankle wrap. The risk of re-injury is always there, so in the end you might as well wear both.
Cross-train or cross-fit. Even if you prefer not to. The best way to limit the repetitive strain of the tennis court is to balance it with time on the yoga mat. And if you succeed in doing this, please tell me how.
Swim – it is good for you – so long as the lapping of monotony against your head doesn’t drive you crazy.
Try running barefoot. But not all the time, and definitely not on gravel. If you need convincing, pick up a copy of Born To Run.
Don’t be reckless with recovery time. Middle-aged athletes are like leftovers from the Olive Garden – not so good on the third consecutive day.
Don’t worry about taking supplements – most of them won’t help, unless they are steroids, epo or HGH, and I’m not going there. Do worry about taking over-the-counter pain-killers – they do help, at least temporarily. But realize that taking too much ibuprofen is about as good for your stomach as pounding a pint of bleach. The real troubles, though, will come from the nagging pains that you ignore, like the twinge in your calf that warns that your Achilles tendon is about to snap.
Try acetaminophen first, but please don’t exceed recommended doses – a liver is a good thing to keep. Teeth are also nice to have, so if you play a contact sport, wear a mouthguard. If you knew how much a dental implant costs (I speak from experience) you wouldn’t ignore this accessory – it is clinically proven to decrease visits to the oral surgeon.
Pay attention to your diet. Especially before and after strength work-outs. Lowfat chocolate milk is probably just as good as a protein shake, and tastes better too.
Understand that many therapies – massage therapy, hydrotherapy, even aromatherapy – may be pleasant and relieve pain but do not improve performance. If you find one that does, hold on to it, for it is precious.
Take it slow with new sports – they will make your muscles ache. Similar to facing your property tax bill, the best way to limit shock to the system is by giving yourself time to adapt.
Most lower back pain will eventually get better and, for pain alone, surgery probably won’t help. Weight loss, core muscle strength and physical therapy probably will. I like to prescribe myself daily back-rubs from my honey.
Don’t feel guilty about not wanting to move on. So what if you are playing hoops against men half your age? Some of the greatest days on the court are those when you unexpectedly feel young.
Know when to ice it (right away), know when to heat it (a couple days later), and know when to walk away (if you need to, consult Brett Favre on this one).
Maybe you run the quadruple Dipsea for kicks, maybe you power walk a few laps on the weekends. Maybe you ride Camp Tamarancho on a unicycle, or perhaps you stick to the straight and flat. Maybe you can surf Ocean Beach in tsunami, or perhaps you wait for a two-foot swell at Bolinas; whatever your passion and your skill, take care of your body and get plenty of sleep too.
Accept certain inalienable truths: All athletes will get injured and the older you are the longer the recovery. You too, will one day retire. And when you do, you may fantasize that you were as springy as Lebron or as shifty as Pele. I know I will.
Be careful with the advice you heed. But be patient with those who supply it. And realize that some physicians may be better at giving advice than following their own.

But trust me on the insoles. Occasionally, I’ll even wear them myself.

Friday, May 7, 2010

On Labeling (Marin IJ)

On a recent trip to Safeway, I decided to pay attention to what was in my shopping cart. Standing in the checkout line, I scanned the nutritional labels on the items I’d selected. What I found was shocking; an eight-ounce package of sliced ham is infused with over two grams of sodium (nearly a full day’s supply). A small glass of Cran-Raspberry juice drink is loaded with 28 grams of carbs. A mouthful (one ounce) of Colby-Jack cheese contains six grams of saturated fat – 30% of your fat budget for the day. And, a single serving (one cup) of the frozen potpie I’d picked out for lunch has a whopping 501 calories and 26 milligrams of cholesterol. Well, I had to put that pie into the send-back pot. While making adjustments to my cart, I decided that although nutritional labels can seem scary, they are actually quite useful.

Once home, I did some research and discovered that food labels are indeed effective. They’ve been shown to benefit public health by encouraging suppliers to offer healthier choices and by encouraging consumers to choose them. What then should we think of other health-focused labels? Labeling lead levels in children’s toys – most of us can agree that this is a good idea. Nutritional content of chain restaurant food – I know that this information might change my choices at the drive-thru. Parts per million of hemp in my t-shirt – that, is probably over-kill. And how about labeling the radiation emissions of cellular phones? Well, that depends. One of my colleagues recently told me that she wasn’t too concerned about cellphones causing brain tumors because they seemed so innocuous. I agree, cellphones seem harmless (unless they are tempting you to text and drive) and they sure are convenient, but the fact is that we don’t know what the long-term risks of heavy use really are.

As I discussed in a column last year, there is some evidence that long-standing use of cellphones increases the risk of certain types of brain cancer. Most concerning is that the impact of cellphone use on the brains of children and teenagers has not been adequately studied. Could it be that cellphone use, much like drinking anti-freeze, seems innocuous at first but turns deadly later? I, for one, am not at all sure, but have advised others to limit direct held-to-the ear cellphone use as much as possible.

Given how little we know about the long-term danger (or safety) of cellphones, it seems reasonable for consumers to ask for easy access to information about the radiation (defined as the specific absorption rate or SAR) of individual phones. This is what State Senator Mark Leno’s new bill, SB 1212, would require at the point of sale (via labeling on exterior packaging). This bill, which is similar to one endorsed by Mayor Newsom in San Francisco, is set for debate in the Environmental Quality committee on April 19th. From a discussion with Senator Leno, I learned that the rationale for labeling is twofold. First, the labeling would address the fact that there is a significant and not necessarily intuitive disparity (over four-fold) between the SARs of different cellphone brands. The Environmental Working Group (EWG) has published a list of radiation levels for over 1,000 phones on their website ( and if you check it out you will notice that there is a considerable difference between the lowest SAR phone (Sanyo Katani II: 0.22-0.55 watts/kg) and the highest ones (Blackberry 8820 and others: greater than 1.5 watts/kg). Second, the labeling would help to raise consumer awareness of the potential risks of what is a very common and yet modifiable exposure. Says Renée Sharp, Director of the California Office of the EWG; “We see this as a very nominal, basic step so that people can make informed choices. If people are more aware of the radiation coming out of their phone, they may be more likely to buy a low radiation phone or buy a headset or use speakerphone.” The headset, explains Lloyd Morgan of the Central Brain Tumor Registry of the United States, is the preferred risk-mitigation strategy; “Because the radiation decreases as the square of the distance from the cellphone increases (100 squared is 10,000), the difference between the lowest SAR phone and the highest SAR phone is inconsequential compared to keeping the cellphone away from your head or body.”

So, let’s think this through; is it reasonable to conjecture that a consumer who buys a high SAR phone may also buy a headset? Yes. Is it realistic to assume that some informed consumers might choose a lower SAR phone over an equivalent higher SAR phone? Seems to be. Are these actions likely to have a measurable effect on brain cancer rates? Who knows, but the answer could be yes, and if it is, requiring cellphone makers to make SAR values clearly evident seems an innocuous step with significant public health benefits. Realize also, that the Federal Communications Commission (FCC) already requires that manufacturers calculate the SARs, but that most bury the information deep in the phone’s manual. Putting the information front-and-center would give consumers the choice to pay attention, or not – and to change their behavior, or not. And much like me at the supermarket, some folks might be surprised how information can affect simple choices.

Spring Fever Can Hurt (Marin IJ)

Each spring, something stirs. Spring fever it’s called; sunshine, birds singing, an itch for exploration, and a sense of romance in the air. But in your local emergency room, spring’s stirring mean something quite different. In the ER, spring fever is hay fever and instead of bird songs we hear sniffling and wheezing. The itch is poison oak and that “sense” is an embedded tick being pulled from your skin.
With the brilliance of spring comes a myriad of outdoor opportunities, but also some hazards. If you spend a lot of time outdoors, you’re aware of these annoyances, but nonetheless the season calls for a review. So here are ways to avoid the three Ps of springtime – poison, parasites and pollen.

Thanks to El Niño’s rain, poison oak is growing like crazy and causing agony for careless outdoorsmen. With poison oak, prevention is key. So, please heed these four tips. 1) Know what poison oak looks like (shiny with leaves of three) and do not treat it like a decorative shrub – as a family friend did when she transplanted a bush from her backyard to the planter box. 2) Remember that poison oak’s oil (urushiol) is what causes the rash and that the oil stubbornly sticks to clothing – so do not follow the example of one ER patient who thanked her husband for clearing poison oak by greeting him with a naked embrace. 3) Be careful about slipping into the woods to relieve yourself in the bushes – several days later this convenience may cause prickly discomfort in the danger zone. 4) Finally, do not fall for the myth that drinking poison oak tea makes you immune – it doesn’t, in fact quite the opposite – a poison oak tea party leaves guests with painful swelling of the mouth and throat.
If, despite your best efforts, you fall victim to poison oak exposure, act quickly and you still may be okay. Wash off, as thoroughly and as soon as possible. Scrub with Technu or Fels-Naptha soap and get all your clothes into the laundry. If a rash occurs, (usually two to three days after exposure due to a delayed immune reaction) focus on alleviation. Don’t worry, you can’t “spread” the rash by touching it at this point, although you should definitely avoid scratching at it. Aveeno and oatmeal baths may help calm the symptoms, but severe cases will need steroids (such as prednisone) – sometimes for a two week course of treatment.

Ticks are disgusting creatures. These pests are both parasitic and sneaky; they slowly crawl under clothing and discover tucked-away folds of flesh. To top it off, ticks can transmit infectious disease (such as Rocky Mountain spotted fever and Lyme disease) and in some instances inject a toxin that produces full-body paralysis. Luckily, these complications are rare, and although Lyme disease does occur on the West coast (transmitted by the nymph form of the deer tick, the Ixodes pacificus) it is much less common than on the East coast. It’s thought that we have our backyard friend and tick host, the blue-belly lizard, to thank for this –the lizard’s cold blood kills the bacterium that causes Lyme. Most of the time, ticks are merely esthetic hazards – and stubborn ones at that. There are a lot of myths about how to remove a tick: flame its bottom, smother it with Vaseline, or douse it with gasoline. These tactics might have worked for someone at some time but, really, the safest and most effective way to remove a tick is to patiently exert brute force. Using forceps or tweezers, grab the tick’s head as close to the skin as possible and gently pull until the tick releases. Once successful, do a celebration dance and flush the littler sucker down the toilet. Don’t be concerned if there is redness around the area of assaulted skin – this is a normal inflammatory reaction. If there’s a bull’s-eye appearance to the rash, however, that is more sinister and it’s time to think about Lyme disease treatment and prevention. The Centers for Disease Control and Prevention (CDC) recommend preventive treatment for Lyme disease if, and only if, all of the following criteria are met: the tick is likely to be of the Ixodes (deer tick) species, has been attached to the skin for at least 36 hours and treatment can be started within three days of removal. The treatment itself is simple: 200 milligrams of Doxycyline (this shouldn’t be given to children under the age of 8), but somewhat controversial in this area of the country (given the low rates of Lyme disease). The best way to avoid unnecessary medication is to give you and your family a thorough post-hike preening for ticks – and don’t’ forget to look in the tucked-away places – pulling an attached tick out of your belly button is not a pleasant proposition.

Has your spring been a sniffly, wheezy, watery-eyed one? If so, you’re not alone – so far it’s been a banner year for seasonal allergies. Fortunately, you can manage the discomfort of seasonal allergies by monitoring pollen counts in your neighborhood (check out and talking to your doctor about seasonal treatments (which include inhalers and over-the-counter drugs such as loratadine). Truly miserable sufferers may need immunotherapy (allergy shots). Allergy sufferers, be advised that now is not a good time to stop and smell the flowers.
“Spring,” former Marin resident Robin Williams once remarked “is nature's way of saying, ‘Let's party!’” Particularly in this county, spring is a party not to be missed. And with a watchful eye and prudent prevention, you won’t be left with a three P hangover.

Monday, March 29, 2010

Not Vaccinating Puts All at Risk (Marin IJ)

Anarchists contend that government is unnecessary and that an ideal society is an unregulated one. While certain formulations of anarchy may seem conceptually attractive, most of us recognize that government plays a useful role in our lives. We understand that while freedom from regulation is appealing, that appeal exists within the confines of a secure existence. Get rid of government and its associated “intrusions” (annoying things like roads, meat inspections, national defense, and national parks) and the state doesn’t seem so unnecessary anymore. I think most people in Marin would agree with this logic. Which is why it is surprising that many of our local residents do not vaccinate their children.

Vaccination efforts during the past century have made certain childhood diseases so rare that they seem like remnants of an uncivilized past. Few of us have actually seen a new case of polio or measles, so it’s easy to be lulled into thinking that these ailments are so antiquated they couldn’t possibly cause trouble again. Unfortunately, this is just not true. The diseases that we vaccinate against are not extinct; they are lurking, waiting for enough people to drop their guard. If you think that I am an alarmist, consider these recent outbreaks: polio in Nigeria, measles in Britain, and whooping cough in Marin County.

So far this year, we’ve seen three cases of whooping cough (also known as pertussis) at a Marin elementary school and four cases of measles in the Bay Area. Fortunately, no one was seriously ill and the Marin children have completed treatment and are back at school. “It was a small and contained outbreak,” says Marin County public health officer, Dr. Fred Schwarz. Nonetheless, these cases should remind us that we aren’t as safe from vaccine preventable diseases as we may think. Pertussis, for instance, is a highly contagious lung infection that can affect both children and adults and classically causes a “whoop” after coughing. In the days before DTP (diptheria-tetanus-pertussis) immunization, pertussis killed thousands of infants every year. Thankfully, with the advent of widespread vaccination, the number of infections declined 99% between the 1930s and the 1980s and the death rate plummeted to single digits by the 1990s. In the last ten years, however, we’ve seen a resurgence of this infant-killer. Nationwide in 2005, there were over 25,000 cases of pertussis reported to the CDC; 21 of these were in Marin County. There are several explanations for pertussis’ comeback, but mostly it can be blamed on under-immunization. The protection afforded by the pertussis vaccine tends to wear off three to five years after vaccination, thus even children who have received the recommended DTaP series (five shots between the ages of 2 months and 6 years) are at risk for contracting the disease later. Because of herd immunity (immunity that occurs when the vaccination of part of the community – or herd – provides protection to unvaccinated individuals) many parents think that their children are protected against pertussis (and other diseases) even if they are not fully vaccinated. Unfortunately, the more parents who believe this and exercise the (personal belief) exemption to mandatory vaccination, the more likely it is that herd immunity will fail. This is why a group of pediatricians in Philadelphia have published a manifesto to those who “absolutely” refuse to immunize: “by not vaccinating your child you are taking selfish advantage of thousands of others who do vaccinate their children ... We feel such an attitude to be self-centered and unacceptable.” These pediatricians would be appalled with vaccination rates in Marin – according to the California Department of Public Health, the Marin County kindergarten immunization rate is 84.7%, significantly below the state rate of 92.1%. And while we have long suspected that un-immunized children are at greater risk of disease, we now have solid evidence of this. Two papers published last year by a team of researchers from Colorado document significantly increased risk of pertussis (twenty-three fold risk) and varicella (nine-fold) in children whose parents refuse these immunizations.

So, what can we do to ward off a further surge in preventable infectious disease? First, we can acknowledge that although autism is a big problem, there is absolutely no evidence that it is caused by vaccines. As you may have heard, the only previous evidence of such a link, a 1998 study published in The Lancet has been retracted by the journal and thoroughly discredited. Says Dr. Clark Hinderleider, of the Marin Immunization Coalition: "A substantial minority of parents—reported as high as 1 in 5—still believe, quite erroneously, that there is a link between vaccines or the preservative thimerosal and autism. This becomes a significant public health problem when this bad information is translated into refusal of childhood immunizations for vaccine-preventable diseases."

Second, parents should realize that by passing on immunizations, they are not getting a free pass for their children – their kids are more likely to get infected with dangerous diseases. Third, we can all (kids and adults) make sure we have our pertussis booster on board. Kids should get a Tdap booster at age 11 to 12 and adults 64 and under can get the same shot in lieu of a tetanus booster.

And finally, we can give thanks to vaccines for making us safer and healthier than we used to be – and realize that like an anarchist who rants against government while sitting in his federally-subsidized apartment, vaccine critics operate within comfortable confines made possible by the very entity they deride.

For more information, visit the Marin Immunization Coalition web site at or email Dr. Hinderleider directly

Disclosure: I have no financial interest in childhood immunizations.