Flu and more…

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.

Antibiotics

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:

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

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

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.

San Juan Islands #2

9/14/2017

Tippy the Adventure Dog

A story in pictures

July 1, 2017. We’re going on an adventure. That’s a new word for me. When MJ said it, she sounded excited, like it was a treat! or a walk! I’m dubious. I’m pretty sure it involves getting inside that red thing, which she’s been trying to tempt me into for weeks. I’m not buying it.

This is more like it, finally, after spending all day wedged under the seat in that red abomination. Ugh. MJ says everybody’s stuffed into airplanes these days, so I shouldn’t take it personally. But now I’m sitting up high on a seaplane! An I-can-see-plane! Seattle! The water! The islands! YES! That’s the pilot on the left—he’s a good guy. We were best buds from the moment he said, “No dogs in crates,” for the hop from Seattle to Friday Harbor. He was petting me and flying the plane–at the same time! I could tell MJ was a little tense when he kept turning around, but I thought he was great! The other guy—the not-co-pilot on the right—started drinking at the airport. I don’t think he likes to fly.

We’re here! Yay! And Rob’s already sitting. Why is he sitting? We’ve been sitting for hours. I want to go for a walk. New smells!

Things to do on San Juan Island:

4th of July parade. There were boats. And bagpipes. And giant fish. I can tell we’re not in Ohio anymore.

Fireworks are very loud. I already knew this. They should have left me home and texted a photo.

Here I am taking Rob on a ferry ride while MJ is at work. He likes to look at the water and all the islands. Sometimes there are even whales.

Lots of walks!

Rob and I walk down to the harbor nearly every morning and watch the people and the boats. It’s a very busy place.

Here we are on top of the world! It’s a long way for my little legs!

I love go to the farmer’s market, but they won’t let me in. If they did, I’d go straight for the paella.

Here we are strolling through a field of lavender. My people liked it, but if you ask me, it all smelled the same. BTW, nice hair.

A walk onto the pier. I don’t know what this is, and I’ll never figure it out if I can’t smell it. Where is its bum?

All that walking makes me…sleepy. And, did I mention, I like pillows?

A fundraiser for the local animal shelter. This guy was supposed to jump in the water to retrieve the winning lottery ball. He stood there and stood there making like he was gonna go. Yeah. No. Yeah. No. No. Ummm. No. Whose idea was this anyway?

Now I leave you to your own adventures. May the Force be with you!

San Juan Islands #1

9/2/2017

Ten Weeks

One of the ferries docked at Friday Harbor Marina.

The yawning mouth of the ferry as it approaches San Juan Island is apparent even from a distance. It rounds the bend from Shaw Island and glides as smoothly as a swan on the most placid lake, magisterial in size, yet dwarfed by the magnificence of Mt. Baker behind it, looming over the still snow-capped Cascades. The foghorn croons one long, low tone announcing its arrival into the port of Friday Harbor, and the echo courses once, twice, three times, off the bluffs of surrounding islands, fading into oblivion like a stone skipping over the water.

Thus begins this Saturday morning, the start of my tenth week on San Juan Island.

I am on a working assignment at the one and only hospital/ outpatient facility in the San Juans, an archipelago off the coast of Washington. I waken each morning, my head on the pillow of a bed whose mattress is raised, literally, to the height of breasts (young breasts, not old ones). There are 2 stairs to climb up onto this Olympian plateau, which I eschew because I am fearful of breaking a toe on them during a nighttime expedition. Instead, I have pushed the stairs under the bed (plenty of room there for a yoga class), and each night opt for a vault, in pike position with full one-and-a-half twist to attain nosebleed height. This degree of physicality is not a great prelude to sleep, so I have to read a while to calm my heart rate, which is a good problem to have. These days I get more than 3 paragraphs in before I recover from the gymnastics. Yay.

Morning 1 from condo featuring “great view”. Hm.

But the point is, it became apparent to me after about a week, when the smoke and haze from wildfires in British Columbia and Washington cleared, exactly why the bed had been ordered in giant-size: without moving my head from the pillow I can see no fewer than 3 islands and the mainland, with the water rolling out like a pink, orange, blue or gray carpet, depending on the weather, to the magnificent edifice of Mt. Baker. Then, I get to get up and sip coffee while I leisurely read the morning news, and alternately go stupid watching the sunrise, and the swirling currents of the tides, and the sailboats take wing. I no longer have to set an alarm to wake up—the sun does that for me, and my eagerness to see just what colors the dawn has in store that day. But I do still set my alarm—for the last possible second for when I have to start getting ready for work, because the view is so intoxicating, demanding attention, time, day after day.

809594B2-3249-453B-AE6D-29830E42297B — The weather and smoke are clearing.

Work is a delightful experience, difficult to call, actually, work. I can hear a sigh of wonder erupting from my recent colleagues as they read those words and know, because they are still in the soup and I so recently escaped, just how marvelous this is. I am seeing 12– 15 out-patients per day—just as promised by the client. In addition, I share hospital rounds and overnight calls with 2 other doctors. Our average hospital census is 0.7 patients per day. (I have worked this out to torso, 2 arms and a leg.) I have enough time to spend with each patient on my schedule, most of whom are delightful. They are educated to taking care of themselves. They are genuinely thrilled when I tell them they don’t need an antibiotic. They’ve heard of viral illnesses. Antibiotic resistance. The importance of microbiomes. My first day, when I asked one woman if she smoked, she said, “It’s 2017. Who still smokes?” I almost fell over. Most of my patients back in Ohio.

Wow. Note the dense fogbank in the distance. That's Mt. Baker just beginning to show itself. — Wow. Note the dense fogbank in the distance. That’s Mt. Baker just beginning to show itself.

I do have a few obese patients, not many. Everyone exercises. There is alcoholism here, and heroin abuse. Depression and suicide, and the dying. But there is also community among the 2000+ year-round residents who know one another intimately and support those in all manner of need. There remain the difficult conversations necessary around the country, the world. And because I am filling in for only 3 months while this site searches for a permanent doc, they have not given me the difficult long-term non-compliant diabetics to manage, so part of the la-la land I am in is due to my transience. I am grateful for all of it. In fact it feels like I have died and must have gone to heaven, despite my numerous and serious shortcomings.

Of course, while my colleagues here are so kind, missing from my heaven are the kisses and hugs of family and friends, the eye contact not possible even with face time. Technology only goes so far; I miss just being in the same room with my people. My tribes. Rob was here, and our love child (Tippy, the Adventure Dog) for the first 7 weeks, which was wonderful. Then my sister came for a few days during which we cavorted like the old people we are, which is to say we ate well, celebrated happy hour, laughed a lot, and went to bed early. But everyone is back home now, and I am left here for 3 more weeks. Despite the sadness nibbling around the edges, being here, now, is the best problem in the world to have. Ah, life!

Next up: Tippy, the Adventure Dog