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.
Saturday, November 20, 2010
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…
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
www.getpalliativecare.org
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
www.getpalliativecare.org
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 stomachachecafe.com…
“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.
“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.
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.
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.
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.
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