Last Dance

This is it. Last night at LGH. 28 years. I have mixed emotions. LGH was more than a job. My family and I were all treated as patients in this hospital. My father-in-law died here. I made friends who have proved tried and true in my times of need. I have worked with and treated generations of people at LGH. The current administration felt that I needed to leave. I will join a list of nurses, techs, aides, and secretaries who were also shown the door. The criteria for hiring and firing people seems to have more to do with personality conflicts than competency. The upside of leaving is a blessed lessening of my stress level. The lack of space and personnel relative to the volume and acuity of our patients, has made this ER a risky place to be a worker or a patient.

There are kind, smart, hard working nurses, doctors, physician assistants, techs, and support staff. They will provide our patients with very good, if slow care. They deserve to be recognized by there leaders for the extraordinary work that they do. Good luck to all my friends.

A special thanks to Sue G, Deb, Sandi, Kristen, Jess, Fo, Donna S, Marie P, Donna B, Jackie, the Rachels, Heidi, Bubba, Lisa B, Leza, Kellie, Dawna T, Mel, Brandy, Tara and all the folks on nights. I will miss my partners. I leave the night shift in the strong hands of my brother, Chris K.

The world's oldest ER doc will continue to blog but at a new lodge of the B.O.N.E.R. docs

Lyme Disease

Time to walk the dog. Hot and humid conditions but I don a long sleeve shirt treated with insect repellent and long white pants. I tuck the cuffs of the pants into heavy white socks. Why? Ticks!

Deer ticks of the genus Ixodes may transmit Lyme disease with a bite. A spirochete (spiral shaped bacterium), Borrelia burgdorferi is the causative organism. The tiny deer tick must be attached for at 36 hours before transmitting the pathogen. In the ER a single dose of antibiotic may be given if the tick bitten patient meets certain criteria. Most important is that the tick is identified as a deer tick and not the more common dog tick. The deer tick must have been attached for at least 36 hours and the antibiotics be given with 72 hours of removing the tick. The preferred antibiotic is doxycycline. For children, women who are pregnant or breast feeding, or those patients allergic to tetracycline, another antibiotic will be used.

Early Lyme disease is characterized by flulike symptoms. The patient often has chills, a low grade fever, headache, muscle aches, tiredness, joint aches, and less frequently nausea and vomiting. These symptoms appear within 30 days of the initial bite. A characteristic rash, erythema migrans (EM), occurs in 80% of Lyme disease patients, on average 7-10 days post bite. It is flat and red and spreads out from the center. 40% of the cases of erythema migrans show clearing of the redness staring in the center and moving to the edges. 20% of patients with EM will have separate lesions, thought to be from spread of the bacteria via the blood stream.

Stage 2 Lyme disease is also referred to early disseminated. Neurological, joint and cardiac manifestations of Lyme disease are present. Cardiac problems occur in less than 10% of stage 2 and 3 Lyme patients. Palpitations, syncope (sudden loss of consciousness) and chest pains are the symptoms of borrelia infection of the heart. Damage to the conducting cells in the heart may lead to dangerously slow heart rates. Infection with inflammation of the heart muscle and/or the membrane covering the heart chest pain from myocarditis or pericarditis respectively.

Joint pains or arthralgias are common in both stage 1 and 2 of Lyme disease. Actual inflammation of the joints, arthritis is more commonly seen in stage 3. Bursitis, myositis, sinovitis, and tendonitis causes pains of muscles, tendons and bursae.

Infection of the cornea or uvea of the eye may lead to eye pain and visual changes in some Lyme patients.

Stage 2 disease occurs weeks to months after the initial bite. The neuropsychiatric symptoms of stage 2 Lyme are varied and mimic other diseases. Decreased concentration, memory disorders, numbness, nerve pains, sleep disorders, paralysis of facial muscles and visual changes have all been reported. 25% of Lyme patients with a facial palsy will have the condition on both sides of the face. Headache and neck pain and stiffness are symptoms of Lyme meningitis.

Other signs of Lyme disease may include an enlarged liver or spleen and enlarged lymph nodes. Blood tests starting with the ELISA for Lyme will be sent. A Western Blot test may be used to confirm the diagnosis. A lumbar puncture will be done if there are signs of meningitis or neurological symptoms of Lyme disease.

Stage 3 Lyme disease, or tertiary Lyme occurs months to years after the initial bite. This may happen because the initial disease wasn't treated at all or inadequately. There is some experimental evidence that the spirochete may persist intracellularly in fibroblasts despite adequate antibiotic treatment. Arthritis of the knees and other large joints is evident in tertiary Lyme. Cardiac symptoms as noted earlier are also occasionally found in stage 3. Fatigue, chronic headaches, memory loss, sleep disorders, abnormal sensitivity to light, confusion, decreased levels of consciousness and numbness and tingling are all neurological signs of tertiary Lyme disease.

Chronic Lyme disease is reported by some patients. This may represent an autoimmune phenomenon. Molecular mimicry occurs when one's immune system attacks one's body because of similarity to molecular components of the Borrelia spirochete. Some physician treat chronic Lyme patients with antibiotics for many months to years. There is no experimental proof that this treatment is effective.

As with many of life's unpleasant diseases, prevention is the best weapon. Risks of exposure to deer ticks are gardening, hiking, hunting, walking in high grass and pet ownership. My bizarre attire when dog walking is just what is recommended. Long sleeves and pants. Insect repellent sprays. Light colored clothes to more easily spot the tiny ticks. Use of tick and flea treatments for outdoor pets is also a good idea. There is a veterinary vaccine for Lyme but its effectiveness is questionable. Have a great summer.

E Coli

Scary stories about E coli outbreaks appear in the news regularly. The most recent occurrence in Germany is worrisome because of the deaths of younger healthier women and the lack of an obvious source.

E coli is a resident bacteria of the human GI tract. One's personal inhabiting specie rarely causes problems. The proximity of the rectum and vagina in women make E coli a common cause of urinary tract infections. E coli may infrequentlt cause pneumonia and meningitis in neonates, long-term care residents and hospitalized patients. The bacteria may infect diabetic and decubitus (pressure sores) ulcers and causes up to 10% of bacterial bone infections in the vertebrae. The newsworthy danger arises when one is exposed to a strain of the bug that produces toxins that cause harm to the human host.

The most familiar of these toxin producing strains of E coli is the enterotoxigenic variety. Euphemisms such as traveler's diarrhea or Montezuma's revenge make the illness seem trivial. Bouts of watery diarrhea are no fun. Treatment however is relatively simple; rehydrate with fluids and Pepto Bismol in large quantities.

STEC/EHEC refers to strains of coliforms that produce a Shiga toxin. Shigella bacteria are another cause of gastrointestinal infection. The shiga toxin invades the lining of the intestinal tract and enters the blood stream. Unrelated species of bacteria may "share" genetic material by exchanging plasmids. Plasmids are packages of genes that may encode for resistance to antibiotics or production of a toxic protein.

Shiga toxin targets the endothelial cells that line blood vessels. The resulting damage is referred to as microangiopathy. The red blood cells and platelets (clotting cells) are injured as they pass through the damaged blood vessels. Hemolytic anemia (low RBC's from lysis or rupture) and TTP (low platelet counts from consumption of the platelets in clotting) cause the life-threatening consequences of HUS, hemolytic uremic syndrome.

The kidneys main function is filtering out toxic products from metabolism. They are highly vascular. In the kidney cells, the Shiga toxin inhibits protein synthesis, eventually leading to apoptosis (cell death). The lysis of RBC's, the direct damage to renal blood vessels and renal cell apoptosis may lead to kidney failure, i.e. HUS. If recognized early, intravenous fluids may prevent renal failure. Once established, renal failure is treated with hemodialysis until the kidneys recover. The kidney failure may be permanent and lead to a life of thrice weekly dialysis while awaiting a kidney transplant.

The early symptoms of STEC/EHEC are bloody stools, fever, lethargy, vomiting and weakness. Diarrhea, vomiting and increased irritability may be the only early symptoms in babies. Later in the course of the illness, patients may have bruising, decreased level of consciousness, low or no urine output, pallor, petechiae (small red or purple skin lesions) and jaundice. HUS is most common at the extremes of age. The very young and the elderly are usually most at risk.

In the USA, outbreaks of HUS from enteroinvasive strains of E coli have come from contaminated meat (especially hamburger) and vegetables contaminated by irrigation water that had been fouled by animal waste. Thoroughly cooking meat eliminates the risk but washing vegetables does not. There have been proposals to irradiate food products to kill the bacteria in and on the food. Irradiation does not make the food radioactive but it may alter the taste or texture of the food.

The most useful thing that we can all do to prevent the spread of food borne illnesses is good hand washing. Fecal-oral spread sounds gross but is all too frequently the source of both viral and bacterial gastroenteritis. Reminding children to wash their hands after going to the bathroom is a must. I have been tempted to expose people that I have seen leaving public bathrooms without washing their hands.

Use warm water, soap, and scrub for at least a minute, use paper towels to dry your hands and also to shut off the water and open the door. Any ground meat must be cooked completely. A hamburger with a red center is a "crap" shoot.