Hype

All Irene, all the time. Hype. Snow storm, hurricane, heat wave; local news stations love a good/bad weather story. People are encouraged to prepare for Armageddon. The ER is effected by this hype. Every child with a fever must be checked out before the winds/ snow/ rain arrives. Local media hype medical issues as well.

Years ago I was in my final hour of a busy 10 hour shift. A mother arrived with her school age child and said she wanted her offspring to be checked for meningitis. There had been a recent local case of a teenager dying from bacterial meningitis. This distraught mother's child had not been exposed. Her concern was because the child had vomited once. She pointed out to me that vomiting was one of the signs of meningitis. She had watched the news broadcast the night before. I bit the inside of my cheek to keep from laughing. I asked the child, who was happily sucking on a popsicle, if he had a headache, or any pain, and if he felt nauseous. The answers to all my questions were in the negative. I was finally able to convince the mother that her precious did not need an lumbar puncture. I assured her that we would be ready if junior developed the headache, neck stiffness, fever, and vomiting that might indicate a diagnosis of meningitis.

The recent medical hype concerns the discovery of mosquitoes carrying the West Nile Virus (WNV). Lots of cans of insect repellant will be purchased to protect the citizenry from this disease. Some years, the mosquito-borne disease being hyped is EEE (eastern equine encephalitis).

Lets look at the facts. In 2009 there 720 cases of WNV in the entire US. The incidence of neuroinvasive disease (meningitis/encephalitis) was 0.13 per 100,000 people. The incubation period after exposure from an infected mosquito is 3-6 days. The number of cases of infection is very low compared to the number of people exposed. When someone develops encephalitis/meningitis, the fatality rate is 5-10%. The fatalities are mostly in the elderly. If a patient is in the 90-95% survival group, they usually make a complete recovery.

EEE tends to occur in outbreaks that may last for years. In 2005 Massachusetts and New Hampshire had a combined 11 cases of EEE. The 7 human cases in NH were the first cases in 41 years. Of the 11 patients who were diagnosed with EEE, 4 died. The incubation period for EEE is 5-10 days. There are about 20 cases in the US per year. The case fatality rate is 1:1000 for adults, 1:50 in children, and approaches 1:1 in infants. The overall case fatality rate is 50-75%. Most patients who survive EEE have permanent disability.

The treatment for both WNV and EEE is supportive. There is no specific medication or therapies. How high on one's list of health care problems are these 2 diseases? Next weekend is Labor Day. I predict that more people will die from accidents on the road and waters of Massachusetts than will be diagnosed with WNV and EEE combined.

I am in favor of educating people as to the risks of infectious diseases. Wearing long sleeves and long pants, using DEET containing insect repellants, and avoiding the peak times for mosquito activity are all good practices. When I walk my old pooch in the woods, I wear white scrub pants, and a long sleeve shirt that contains insect repellant. I tuck the pants into my white socks. This outfit serves the additional advantage of reducing my exposure to the deer ticks that carry Lyme disease (please refer to a recent blog on Lyme disease).

My concern is that exposure to the pesticides used to control mosquito populations may in the long run cause more wide spread neurological sequelae. There will always be risk. We must assess the degree of risk. The actions taken to mitigate the risk should be cost effective and not cause excessive damage to the environment or the people and animals in the area. As I have tried to stress in my blogs, be prepared. Read and listen to the media sources. Do your own research into the actual risks. Common sense approaches are your best protection.

Irene is now being downgraded as to wind velocities and rainfall amounts. The local food and home supply purveyors are counting the recent purchases made by the people who believed the hype. My wife and I have lots of snacks ready. We have a generator that runs on the natural gas. The ice/rain storm of December 2008 was not hyped as a severe storm. The power outages were devastating being both widespread and long lasting. Our house flooded because our trusty sump pump runs on electricity. Ready; come on Irene.

Nosce te ipsum

Nosce te ipsum, know thyself. Self-knowledge seems so obvious. Look in the mirror, et voila! We  have all seen people on the beach or in the workplace who made us wonder if they even owned a mirror. Being self-aware is much more complicated than mirror gazing. How do others view us? Coworkers, family, friends may all contribute to the portrait we carry in our mind. Check list: man, middle aged, thin, tall, husband, son, brother, uncle, cousin, friend, ER doc. The shading in my portrait contains experiences, education, books, music, art, travel...life.

Why the existential angst? The new job and my place in the medical community. What is an ER doc? The American College of Emergency Physicians would define an ER doc as one who has completed an approved residency in Emergency Medicine, been board certified by passing the written and oral parts of the American Board of Emergency Medicine examination, and who works in an Emergency Department. Paying your yearly dues is also important to ACEP.

I have met the above criteria and have recertified every 10 years to maintain my status with the ABEM. When I worked at LGH, I never questioned my professional self as an ER doc. I saw lots of patients from neonates to the very elderly. I treated patients in labor, having heart attacks, in respiratory failure, with traumatic injuries, suicidal depression, psychosis, and life-threatening infection at both extremes of age. I supervised PA's, taught PA students, mentored young ER docs, and tried to impart some of my thirty years of ER experience to the nurses, EMT's and paramedics who worked on the patients in the ER. Arriving at 2030 hrs for my 2100 hours start time, I would scan the lists of 20-30 patients waiting up to 5 hours for treatment. After a ten (shortened to 8 just before my forced exit from LGH) hour slog, the waiting room would be close to empty.

Tonight I will leave my house at 2230 for my 2300 hour start time. There may be a few patients waiting. I will see an average of 5-6 patients during my 8 hour shift. In the month since I began working at NMC, I have treated few children and very few infants as NMC has no in-patient pediatric beds. I have seen so major trauma patients. Pregnant patients do not use NMC as there is no obstetrical services. NMC is a small community hospital in a somewhat isolated location.

Am I still an ER doc? The nurses, secretaries, (lab, radiology, and respiratory) technicians and other physicians in the ER, the hospital and in the community are smart, hard working and dedicated to providing great patient care. I have been welcomed with friendship and respect. My patients look to me as an ER doc. They wish relief from their pain and answers to their questions. The slower pace and lower acuity allow me to spend more time talking with and examining my patients. Maybe I am still an ER doc.

Whether in a 9,000 per year ER in a small town or a 250,000 visit per year ER in a large city, if you provide care to ER patients, you are an ER doc. Listen, empathize, comfort and use all your self knowledge to be the best ER doc you can be.

Adjusting

I have worked two doubles, a triple and a quadruple at my new job. At LGH I had stopped working 4 nights when I turned 55. By the fourth night I would be physically,and  mentally spent and rather cranky. Not so at NVMC. Average night shift census is about 6 patients. Although I have not been sleeping any better between shifts, I am not STRESSED as before. I do miss my friends and coworkers at LGH. I received a call from Robin, my trustworthy PA today and my sense of loss was palpable. Don't we all feel that we are irreplacable? The staffing of the ER at LGH has been difficult since my forced departure. The remaining docs have had to go back to longer shifts. I like to soothe my ego, by thinking that the powers-that-be regret their active or passive complicity in my termination.

My daily routine has been adapted to my new circumstances. I have a snack and my coffee before I leave the house. My wife and I now have some quality time together even on my work nights. The drive is a pleasant 10.3 miles of countrified roads with a single traffic signal. Leaving the house at 10:25 PM allows me to listen to jazz on WGBH-FM on the ride into work. There is a fair amount of time to pass during the 8 hour shift. My newish 4G phone has been packed with 2 versions of "Angry Birds", "Bejeweled", "Scrabble", Mah-jong tiles, poker, backgammon, multiple solitaire variations, newspapers, magazines, etc.

The patient population is quite different from LGH. I have yet to use the translation phone. In three weeks, I have only treated one child under the age of 2. There is little trauma. The patients have been as pleasant as any at LGH but I am able to spend much more time with the patients and their families. If NVMC uses Press-Ganey surveys, I feel that I will consistently be in the top percentile. The fact that my patients are not waiting 2-5 hours before being evaluated by a physician, makes them much less cranky.

The nurse and secretaries have been most welcoming and are very good at their jobs. Last night the nursing supervisor brought in a cake to celebrate the birthday of one of the ER night nurses. I have made friends with the security guards, night housekeeper, and the sargeant of the local town police department on the overnight shift.

After the last 2 weeks of financial shock to my retirement funds, I will be working for the next 8 years. Is NVMC my final destination? Only time will tell. For now, I will improve my gaming skills, enjoy spending time with my patients, and be a relatively stress free "world's oldest ER doc". Thanks to my friend Wendell for his sage wisdom, when he told me that would be life after LGH.

Skin deep

There are only a few true dermatological emergencies, but skin problems are a common cause of ER visits. Red, scaly, itchy, painful, blistered are all part of the skin game.

Toxic epidermal necrolysis is a life threatening skin problem. It is seen in Steven-Johnson syndrome, a hypersenitivity reaction that may be caused by many commonly used medications. The skin and mucous membranes are effected and the treatment is similar to that for severe burns. Scalded skin syndrome, caused by certain staphylococcal infections is characterized by fluid filled blisters as the outer layer of skin separates from the deeper layers. This separation with only slight pressure is referred to as Nikolsky's sign. This condition is also treated in a burn center.Pemphigous is an autoimmune disease that also presents with painful blisters. It may be associated with certain cancers.

Skin infections are often seen in the ER. Fungal infections of the skin are caused by dermatophytes. Ringworm, athlete's foot, and jock itch are all common names for fungal skin infections. Tinea versicolor presents with patches of of skin that are a different color than the normal surrounding skin. Tinea pedis, pubis and capitis refer to fungal infection from the bottom, middle and top of the body. While not life-threatening, the ER docs and PA's can initiate treatment for these conditions.

Viral skin infections are potentially more serious. Herpes infections caused by herpes simplex either types 1 or 2 are painful eruptions of small blisters (vesicles) around the mouth or genitals. Occasionally a herpetic whitlow presents as painful vessicles on a finger tip from the patient contaminating his or hers finger from touching/scratching vesicles around the mouth or genitals. Shingles is caused by the herpes zoster virus. This virus is also the cause of varicella (chicken pox). Many species of herpes virus have the ability to "hide" in ones body and recur years after the initial infection. Shingles describes a recurrence along the distribution area of a nerve. It is almost always unilateral and looks like a patch or swath of vesicles on a red base. The incidence of shingles increases as we age. It is a very painful condition and the pain often persists even after the rash clears. Fortunately there a booster vaccination for patients older than 60 that has been shown to decrease the incidence of shingles and to both shorten the course and the postherpetic neuralgia (nerve pain) if shingles does occur.

Many diseases have distinctive rashes as part of the illness. Measles, chicken pox, rubella, Rocky Mountain spotted fever, Lyme disease and many other viral and bacterial infections will have rashes as part of the signs of the illness.

Bacterial skin infections are common and need urgent treatment. Erysipelas is a painful skin eruption caused by strep. pyogenes. Impetigo is a common childhood skin infection caused when scratching by the patient, breaks the surface of the skin and strep or staph bacteria are inoculated into the skin. Impetigo is often seen in sports where skin to skin contact occurs, such as wrestling. Cellulitis presents as a localized red, warm and tender skin. The margin of the cellulitis is often elevated above the normal skin. Staph and strep bacteria are the most common organisms. Impaired immunity because of medications or diabetes increases the incidence and severity of cellulitis.

By far the most common dermatological conditions seen in the ER are those caused by inflammation. Contact dermatitis by irritants such as solvents, alkalies, latex and plants presents with area of small vesicles, sometimes "weeping". Allergic dermatitis looks similar and is most often seen with exposure to poison ivy, oak, sumac and metals such as nickel. That gold or silver jewelry you are wearing may contain nickel as a hardener. Photodermatitis occurs when an irritant or allergen is on the skin or has been ingested (many medications) and the ultraviolet light from sun exposure triggers a reaction.

Eczema is a chronic form of dermatitis that may present with some combination of redness, itching, dryness, crusting, flaking, blistering, cracking, oozing or bleeding. Eczema like contact dermatitis is treated with topically applied or orally administered corticosteroids.

Psoriasis is a chronic immune mediated skin disease. Thick flaky patches may occur anywhere on the body. Topical steroids may help with an acute flair up. PUVA (psoralens and ultraviolet A phototherapy) and immune modulators such as methotrexate or cyclosporin are used to treat this chronic condition.

Patients with sunburns are frequently seen in the ER at this time of the year. Moisturizers, pain medications and occasionally corticosteroids are prescribed. Prevention by limiting ones exposure, and using sunblock are the preferred method of not getting burned. Apply copious amounts of at least SPF 30 sun block, twenty minutes before sun exposure. Reapply every 2 hours or more frequently if swimming or sweating. As I found out on while snorkeling on the island of Anguilla, remember to protect ones bald spot.

World's oldest ER doc update: I have begun the next phase of my ER career. I am now working at a low volume/ low acuity community hospital. Although this move was forced on me by the adminstration of my former hospital, the slower pace and reduced stress will allow me to reach my goal of 40 years as an ER doc.

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.