Category: Clinical Medicine

2/1/2018

As though influenza by itself isn’t bad enough, a new study reported in the New England Journal of Medicine details an increased risk of heart attack in the week following diagnosis of flu. This is but one mechanism that leads to over 30,000 deaths per year, in the US alone, due to flu. This year, a particularly nasty form of influenza is expected to take more than 50,000 American lives. Unfortunately some of those people did get a flu shot–which doesn’t guarantee protection, but is the best chance any of us have to prevent this life altering, and sometimes life-ending infection. There is no question that an annual shot reduces illness and death from flu. Despite my professional career working with the sickest of flu patients, I have not had the flu during the 30+ years I’ve had the shot.

Get your shot. Every year. Since it takes 2-3 weeks for the shot to become effective, and flu season lasts through at least March, it’s still not too late.

December 2017

Happy holidays! ‘Tis the season for family and friends…and coughs and colds, almost all of which are caused by viruses. Unfortunately, the latest research shows too many patients are still receiving antibiotics for treatment of these annoying, but mostly benign, conditions.

Is there anyone on the planet who by now does not realize that antibiotics do not help viral illnesses? I think not, so the problems must lie elsewhere. Let’s explore some myths and facts.

Myths:

1. People know colds/ coughs are caused by viruses, but they think they have a bacterial illness because:

-their mucus is colorful

-their symptoms have lasted too long

-they feel too sick foar a virus

2. People ask for/ demand antibiotics because they:

-erroneously think the illness is bacterial based on one of the above reasons

-know it’s probably viral, but they “can’t afford to be sick right now.” (As though there is special antibiotic effectiveness for those too busy to be sick.)

-know that antibiotics have always worked for them before

-don’t realize the harms of unnecessary antibiotic use

3. Providers give antibiotics because:

– patients demand them

– they think the illness possibly might be bacterial

– they don’t know that mucus color is not indicative of bacterial illness

– they don’t know how long the average viral bronchitis lasts

– they want to make the patient happy

– they are unaware of the extent of antibiotic harms

– it’s faster to order the drug than to explain why the patient doesn’t need it

Facts:

98% of respiratory illnesses (sore throat, cough, cold, ear infections) in otherwise healthy people are due to viruses.

While certain bacteria impart certain colors to colony growth, viral infection regularly causes colorful excretions too. For common colds and coughs, mucus color mostly has to do with how long the goo has been sitting in your body—the longer, the more colorful. First-thing-in-the-morning junk is likely to be green, yellow, brown or even blood-streaked. As you clear out last night’s goo, the color gets paler to clearer as the day goes on. What you are seeing is a heap of your infection-fighting white blood cells clouding the mucus to rid you of the germs.

The average length of bronchitis—that is a cold with a cough—is 3 weeks. Three! That’s the average! Some viral coughs last up to 6 weeks—and I’ve had my share. A typical cold lasts 7-14 days.

According to surveys, most providers who give antibiotics for coughs, colds, non-strep sore throats, and ear infections, do so because the patient demands them.

98% of coughs and colds get better without antibiotics.

 

How to tell if you are in the 2% who may need additional treatment:

–the presence of any chronic disease, like diabetes or COPD, severe heart failure, dementia, kidney failure, or cancer places patient at higher risk for bacterial complications of viral illness—you should see your doctor for advice if you are feeling sick

–temperature > 100 degrees occurring anytime after the first 2-3 days of illness

–feeling suddenly a lot worse after experiencing steady improvement

–sudden pain over one sinus (pressure in all the sinuses is normal with a cold)

–symptoms lasting longer than 2 weeks for a cold, or 3-6 weeks for a cough

 

Of course it doesn’t hurt to see your provider when you’re sick, but be clear you are looking for their opinion on your illness, not demanding an antibiotic. Watch your provider’s jaw drop in surprise and respect when you say, “I don’t want an antibiotic unless I need it.”

 

Potential harms of antibiotics—even when used appropriately:

–diarrhea

–tendon rupture

–kidney compromise

–allergic reactions

–heart electrical disturbances

–increased resistance of germs in current and future infections, both for individual patient and society

–some of the approximately 8 pounds of “good” bacteria we all carry inside and outside are killed by the antibiotic (we are only just beginning to realize the importance of our 8 pounds of good bacteria to maintaining health—including asthma, obesity, immune system malfunction, mental health)

–higher risk of intestinal infection with C. difficile—currently the most common health-care related infection in the US—and some forms are now resistant to all antibiotics

 

I can’t remember the last time I used an antibiotic. And it’s not because I don’t get sick. Antibiotics are life-saving for serious bacterial conditions. I’d like to keep them that way, just in case you or I really need one.

 

 

June 1, 2017

Headed to San Juan Island in July, for a 3 month stint of traditional family medicine. Outpatient and inpatient duties, and (without actually wishing injury on anyone), I can hardly wait to do some stitches again! I’m very excited to work with the providers in Friday Harbor, and to explore the beautiful Pacific Northwest in my time off.

Denver
April 24, 2015

Flu season is almost over for us humans, so if your flu shot kept you healthy this year, be grateful.

Unfortunately 7 million birds in the US haven’t been that lucky. That’s the number of dead or killed poultry due to bird flu on Midwest farms since March. This is not the same H5N1 virus that’s been responsible for bird flu outbreaks in Asia for the past decade. This is H5N2, a new combination spun off by the roulette wheel of Mother Nature as 15 “H” proteins and 9 “N” filter through the living systems of a multitude of birds and other susceptible creatures. Like, hmmm, us.

This particular virus has caused no human cases in the US. There is little imminent risk to humans as it will take significant changes of the viral particle for it to cause disease in us, however the fact is we have no idea when one of these bird flu iterations will make that leap into the human pool. What is clear is that all flu viruses that do infect humans—the ones we prudent citizens get vaccines against each year—start in birds. The largest flu pandemic ever recorded was the 1918 “Spanish” flu which likely began in the United States and took the lives of 50-100 million people around the world over the ensuing 3 years.

What can we do about it?

CDC has already collected “seed” viruses from this epidemic as potential stock for future vaccine. Considering how much the virus would still have to change to infect humans, it would be a colossal waste of money to manufacture a human vaccine at this point. Much like our flu shot this year missed the strain on one of the three components, flu vaccines only work when they’re very accurately targeted. So human prevention by vaccine is not an option for bird flu at this time, like it is for regular flu.

The dept of agriculture and CDC are on high alert with Midwest farmers to track and control the avian outbreaks through culling—mandatory killing—of infected or exposed poultry, and through stepped up efforts on sanitation. Despite these measures, the virus has continued to spread. No one yet knows how, but there can be no doubt that the extreme crowding of factory farming is ideal for transmission of this disease.

From experience in Asia we know that wild birds often carry avian flu over wide areas, spreading it through tiny rural farms as well as large urban areas. We also know that all types of flu are spread by close contact. Both of these vectors are likely responsible for the recent arrival of this strain.

We need to be doing research into better vaccine production methods. Current processes haven’t changed since they were invented and rely on the slow and unpredictable means of growing the organisms, which are then inactivated or killed prior to being made into vaccine. This method takes several months for each batch. It would take years to manufacture enough vaccine for a new flu. By then the number of worldwide deaths would dwarf the 1918 tragedy.

Pharmaceutical companies are not likely to take up this challenge; there is no money in it, at least not until there is a pandemic, and by then it will be too late. Government entities like NIH and CDC excel at research, but our less-is-less Congress has been parsimonious with funding.

While I am no fan of factory farming, even if we stopped totally today we still have the wild birds to contend with. But reducing or eliminating the close confines of livestock will slow the spread, and everything we can do to buy the birds more time, buys us more time to develop prevention and cure.

For the first time in history we are watching the gestation of the next virus likely to cause a pandemic. The virus must continue to alter itself through generations of folding and unfolding and rearranging those “H” and “N” proteins to be infectious and lethal to humans. We don’t know if that will take 1 year or 5, 20 or 50, but we do know it will come.

We must fund work on real-time vaccine technology, but we probably won’t. At least not until bird flu starts killing us. And when it does, we shouldn’t be surprised.