Countdown.

5 signs it’s time for a vacation.

  1. You’d rather sleep in than go for a run.
  2. You have no idea what day of the week it is and don’t care to find out.
  3. Listening to your patient with a laundry list of complaints causes you to start daydreaming of the lake.
  4. You stop caring. Period.
  5. You start marking an ‘X’ on every calendar you see until the day it’s time to leave for vacation.

muskoka-cottage-rentals

An Unexpected Gesture

I have several families in my practice who have delayed vaccinating their children.  (Don’t get me started!)

One such family came in today for the final vaccination of the childhood series.  The little boy is 4 years old and he was receiving his second dose of MMR and varicella (conveniently packaged in a single dose vaccine called MMRV).  He was a little scared, of course and asked me a question as I was preparing the vaccine.

“Can you put it right here?”

I turned to look at him as he pointed to the inside aspect of his forearm.

“Well, the needle has to go in the fatty bit of your arm and there isn’t enough fat there.  How about we put it up higher on the back of your arm?”

He agreed with a nod of his head.

I cleaned the back of his arm with a swab of alcohol and gave him the needle. There was not a whimper.  He took it like a man.

As I was back at the desk, finishing up the clinical note and completing his immunization record he walked over to me and said “Thank you, Doctor” and gave me a hug.

A hug! For giving him a vaccine.

Well, I’ll be damned.  He just made my day.

Life Imitates Art.

I have always been a sucker for disaster movies.  If I’m laid up on the couch sick with the flu, or just need a go-to movie to watch, my husband always knows which film to put on.  Hollywood doesn’t disappoint – there are many to choose from, be it in the form of natural disasters like comets and asteroids threatening the Earth, or solar flares, or climate change causing another ice age – I have my pick of movies that I can watch over and over and over again.

There’s a certain suspension of reality from the movies I’ve listed below – how likely is it that we will see another ice age? I mean, really.  How likely is it that a comet or asteroid is suddenly going to be discovered that will hit us in just the right way to cause an extinction level event?  I always joked that if such a thing were to ever happen, I would want a front seat to watch it.  A giant asteroid hurtles towards the Earth and will destroy the planet?  Yes! Sign me up for a front row seat to watch it enter the atmosphere!

 

 

 

 

 

 

 

 

 

 

 

But then there’s the other kind of disaster movie.  The movie about a virus, spreading throughout a population.  There’s only been a few that I can think of, probably because it hits a little too close to home for most people.  You know the movies.  You’ve seen them.

These movies are a little harder to watch, especially Contagion.  Why?  I think that’s pretty much self-explanatory.  The likelihood of a virus causing illness and spreading quickly, infecting and potentially killing people, is well documented in human history.

The Black Death (aka the Second Plague) killed an estimated 75-200 million people in the 14th century.  It was caused by a bacterium called Yersinia pestis and was carried by rats.  Also known as the Plague, it ravaged most of Europe, and took almost 150 years for Europe’s population to recover.  The Plague recurred on and off for the next 500 years, causing smaller outbreaks in Spain, France, Sweden and Russia.

 

Smaller pandemics of cholera, typhus, measles and smallpox have been reported throughout the past 1,000 years:

  • The Italian Plague killed 280,000 people in the 1600s
  • In Southern New England, 30-90% of the population of the Wampanoag people died of leptospirosis
  • In the 17th century, the Great Plague of London killed an estimated 100,000 people
  • In Asia/Europe, in the early 1800s – the first cholera pandemic killed over 100,000 people
  • The second cholera pandemic, in the mid 1800s, killed another 100,000+ people in Asia, North America and Europe
  • In 1838, over 100,000 people died in the smallpox epidemic of the Great Plains
  • The third cholera pandemic affected Russia killed 1,000,000 people in the span of 8 years, between 1852-1860
  • 20,000+ people died of a typhus epidemic in Canada, in 1 year in 1848
  • In 1875, 40,000 people died of measles in Fiji
  • Worldwide, in 1889, 1,000,000 people died of a flu pandemic

The 20th century alone saw some of the world’s worst pandemics.

  • The Spanish flu decimated the world’s population after WWI, killing an estimated 75,000,000 (75 millon) people, in 2 years!
  • In 1957, the Asian flu killed  2,000,000 people worldwide.
  • 1 million people died in 1968 of the Hong Kong flu.
  • 15,000 people died in India, in 1974, of cholera
  • More than 30,000,000 people have died of HIV/AIDS since 1981

The 21st century is almost a decade and a half old.  We have seen our fair share of outbreaks. Nothing as devastating as in the past, thanks mostly to sanitation, vaccination, antibiotic and antiviral medication, but outbreaks nonetheless.  One might argue that the world is due for one.

  • In 2003, SARS killed 775 people, mostly from China, Hong Kong and Canada; it spread to 37 countries from China
  • The 2009 flu pandemic (H1N1) killed about 15,000 people worldwide.

And this brings me to the real reason for this post.

For months now, news of the Ebola epidemic in West Africa has filtered through my Twitter and Facebook feeds.  The numbers of infected are astounding. I’ve seen estimates that by January 2015, over 1 million people will be infected, half of whom will die.  Ebola, historically, has had 90% death rate.  During this recent epidemic, about half of people infected are dying.  But that is still 50% case fatality rate.

So, what is Ebola? And why is it so deadly? Well, Ebola is a virus.  It’s actually quite pretty, I think.

My knowledge of virology is limited to a few hours of lectures on viruses from medical school.  It has an RNA-genome and it is kind of long for a virus.  Like most viruses, Ebola enters a cell by attached to that cell’s protein coat and fusing with it.  Once fusion of the two occurs, the virus empties it’s contents in the cell and the RNA attaches to the host cell’s RNA and takes over. Instead of the cell making its own proteins, it now has instructions from the viral RNA and starts making copies of the virus.  Once those copies are made the virus attaches to the cell’s outer coat, buds with it and leaves the cell.  By this time, the cell usually cannot function anymore, and so it dies.  The new virus copies get into the bloodstream where they are free to infect other cells and the cycle starts again.  The host immune system cannot keep up with this invader.  The virus makes special proteins that interfere with the hosts’ defenses and leaves the host vulnerable.

The Ebola virus especially likes the cells that line the blood vessels, as well as certain cells of the immune system and the liver.   After infecting these cells, it damages the integrity of the vessels, leaves the immune system’s defenders weakened, and damages the liver’s ability to form clotting factors.  The host then starts to bleed internally, hence the reason Ebola virus infection is also known as hemorrhagic fever.  The host bleeds internally, eventually causing death.

By the grace of God, if you so believe, Ebola virus is not airborne.  This means that it’s not present in the air and cannot be transmitted from being coughed on, sneezed on, or breathed upon.  Infection with Ebola occurs when bodily fluids (blood, feces, urine, emesis) from an infected host are mixed with a healthy host.  Most of the people who have gotten sick in Africa were family members and health care workers caring for the sick, and sadly, the dead.  The WHO recommends avoiding contact with the sick whenever possible, regular hand washing with soap and hot water, and discourages traditional funeral rites of washing and embalming the bodies of the dead.  The virus can be killed with heat (heating for 30 to 60 minutes at 60°C or boiling for 5 minutes).  Quarantine remains an effective method of controlling the disease.

I’ve often joked with friends and family that the world is due for a pandemic.  It’s been almost a hundred years since the Spanish flu pandemic.  The seasonal flu is nothing to joke about – the very young and the very old, still die every year from regular, joe-schmoe influenza.  There is a vaccine developed every year against the strains that most likely will be in circulation.  Since 2009, the vaccine now protects again H1N1 as well. Our office is getting ready for our annual fall classic – the Flu shots are arriving tomorrow and we are starting “flu shot” clinics next week.

But something in the news recently has me a bit worried. Earlier this week, it was reported that a traveller from West Africa boarded a plane in Liberia and landed in Dallas, Texas.  Asymptomatic at the time, he passed through whatever checkpoints were in place and entered U.S. soil.  A few days later, he started getting sick and presented himself to the local ER.  He told the triage desk his travel history, was seen by a doctor, given a script for antibiotics and was sent home.  He returned to the hospital 4 days later, very ill, and was diagnosed with Ebola virus.

Yes, folks. Ebola virus is now in North America.

I have one question.

How the FUCK did this happen?!?!?

Why are planes from West Africa being allowed to land?  If such a plane does land, why aren’t those travellers being immediately quarantined and monitored for symptoms?  Have we learned nothing from SARS and H1N1?

I wouldn’t want to be that triage nurse in Texas who took the travel history information from the Ebola patient and failed to forward it along to the attending physician.  I’d like to think that physician, had he known his patient had recently been in Liberia where there is an Ebola outbreak occurring, would have immediately notified the Centers for Disease Control and Prevention (CDC), and locked down his hospital. But no, that physician apparently didn’t know of the travel history, the patient didn’t bother to mention it again, and he was sent along his merry way to infect his family and God-knows who else.

Apparently, the man went back to the apartment complex where his family lived, started getting progressively more sick, was actually seen vomiting outside the building before being taken back to the ER where he was eventually diagnosed.  Does this not alarm anyone?  When I read the news report to my husband, he made an interesting observation. One that actually is a bit frightening.

Who cleaned up the vomit which likely was teeming with Ebola virus?

Did a dog come by and lick the vomit? Did that dog go back to his owners?  Is the dog sick? What will Ebola do in a new host species? Has the virus mutated? Can it become airborne?

According to that report yesterday, 18 people have been identified as being in contact with this individual.

Today? The Texas health departmentt said there were 100 potential contacts.  “Dallas County officials said more than 80 had direct or indirect contact with the patient.”

Well, which is it?  Indirect contact shouldn’t be a concern with Ebola, right?  Only direct contact, like family members cleaning up vomit or feces, or wiping the face of their sickened family member; or the maintenance worker of the apartment complex told by his bosses to clean up the vomit outside the building?

Today it’s 100.  Tomorrow it could be 1000.

Is this the beginning of next pandemic I joked earlier I thought we are due for?

In those two movies I love to watch, Outbreak and Contagion, the CDC takes control of local health departments and gets the epidemic under control.  Is life about to imitate art?

For all of our sakes, I certainly hope not.

 

 

 

 

 

 

 

 

 

Higgledy Piggledy

Higgledy piggledy
Wiggledy wump,
I met a man
Who caught a mump:
With his left cheek lumpy
And his right cheek bumpy –
Higgledy piggledy
Wiggledy wump.

Higgledy piggledy
Sniggledy sneezle,
I met a man
Who caught a measle:
With his chest all dots
And his face all spots –
Higgledgy piggledy
Sniggledy sneezle.
– Alligator Pie, Dennis Lee, 1939

I read this book to the kids the other night.  My daughter loves the illustrations and this one in particular.  She asked me what a mump and measle was.  I explained that they were illnesses caused by germs (viruses) but that most of us don’t get them anymore because of vaccines. She kind of understands what vaccines are, I explained how it’s a needle that she gets that protects her from illnesses like the one described in the story.  She seemed satisfied with that, so we continued reading the book.

But my mind stayed on Higgledy Piggledy, primarily because of the news recently.  There have been outbreaks of measles in a few Canadian cities, mostly in communities where the vaccination rates are frighteningly low.  In the nation’s capital, Ottawa, a young boy contracted measles after returning from the Philippines, a trip he took with his parents.  The child wasn’t vaccinated.  Upon returning home, he became ill and went to not one, not two, but three different walk-in clinics (including an emergency room) before getting diagnosed. Meanwhile, the child was infecting his classmates at school, not to mention a potentially vulnerable population in the ER.  Within a few weeks, another four cases were confirmed.  Another outbreak is also happening in British Columbia.

I’ve written a lot about vaccines.  I’m not going to belabor the point, I believe vaccines work and I believe they are safe.  I don’t believe they cause autism and I believe that, in the end, after all is said and done, vaccines save lives.

Back in 1939, Dennis Lee was born. Decades later he wrote a poem about mumps and measles.  He likely had the illnesses as a child.  He probably recovered.  Not everyone he knew would have been that lucky.

Please vaccinate your children.

Too Close For Comfort

Day 21. National Blog Posting Month.

Every now and then, I get an email from my son’s preschool about an outbreak of Hand, Foot and Mouth disease, or Fifth’s disease.  These are viral infections that are generally self-limiting and not a whole lot to worry about.  Except if you’re a pregnant woman exposed to Fifth’s disease.  In that case, there is an increased risk of miscarriage if exposure occurs in the first trimester and if exposed after 20 weeks there are certain biological effects to the fetus, in particular a life-threatening form of anemia.

Last night, around 1am, while I was nursing the baby, I decided to check my email.  In my Inbox is a note from the preschool announcing that there has been one confirmed case of Chicken Pox.

And so it begins ….

At this point, my son has already been exposed and has likely exposed all of us, including the baby.  Thankfully, both my husband and I have had the infection in childhood, our daughter was immunized and got a booster last year, and the toddler was immunized at 15 months.  My first thought was to get my son his second dose immediately, if for any other reason than to protect the baby.

Where I live, children are given one dose of the Varicella vaccine at 15 months of age and again at age 4.  According to the CDC, one dose of the vaccine is “85% effective against any form of varicella and close to 100% effective against severe varicella.” However, two doses of the vaccine is 88%-98% effective at preventing all varicella disease.

Don’t get me wrong, 85% effectiveness is pretty darn good, but is it good enough for me?  Especially having a 2 month old in the house?  My instinct as I mentioned was to bring my son (the toddler) to his pediatrician today for the booster.  Instead, rational heads prevailed and I called instead.  Our pediatrician assured me that my son’s immunity should still be strong enough to protect not only himself, but his little brother as well.

Phew.

Still, I can’t help but be pretty pissed off at those parents.  Given the type of preschool my son attends (okay, it’s a Montessori school in an affluent area of the city and quite frankly, not cheap), I have to assume these parents are well-educated and probably know that a vaccine against Chicken Pox exists.  But, I’m also quite sure they’ve heard all the “horror stories” on the Internet or from Ms. McCarthy herself and decided it was best for their child to skip the vaccine.  Right.  

Ugh.  I’m sorry if this offends any of my readers, but these kinds of parents are putting other children at risk.  As a mother, I’m not okay with that, but there is zero I can do about it.

As a doctor?  Well, you know where I stand on that.

End rant.

 

A Frightening Trend.

Day 12. This is actually a lot easier than I thought it would be, writing a post everyday.  I actually look forward to it!

And, yes, I’m back, despite my little rant yesterday, which in case you missed it, you can read here.

What’s on my mind today?  Vaccines.  I know, I know, it’s a volatile topic and I’ve discussed it before, but you see, the baby is 8 weeks old today (my goodness, when did that happen?) and he will be going for his first set of vaccinations next week. For me, it’s a no-brainer that he will be vaccinated.  All of my kids were vaccinated.  I didn’t even give it a second thought.  Now, that’s probably because I am a physician and a rational, logical human being.  Okay, that last part was a bit of a dig.  I am just so sick and tired of parents thinking that just because they’ve done their “research” on vaccines (ie. have read about Wakefield, everything that Jenny McCarthy has to say on the subject, and discussed it with their “friends” on countless message boards), does not mean that they understand the science and study behind creating a vaccine.  These parents haven’t seen the devastation that Polio caused, they haven’t seen what congenital Rubella syndrome looks like, nor have they had to tell their son that they may never be able to father children because the Mumps caused orchitis and has the potential to limit his fertility. And let’s not forget the risks of meningitis from certain strains of pneumococcal pneumonia, Measles, and rarely, chicken pox.

I was a resident in family medicine working on the Pediatric ward when a 15 month old girl was admitted with seizures.  She had been diagnosed with pneumonia 2 days earlier.  Blood cultures revealed a particular strain of bacterial pneumonia.  This strain is one that is covered by a vaccination available here, called Prevnar-13.  A review of this child’s medical records showed that her parents declined all vaccinations.  The seizures were eventually controlled, she was diagnosed with encephalitis and a few weeks later was found to be completely deaf.  Totally preventable had she only been vaccinated as an infant.

At least once every few weeks I see a news article about an outbreak of a vaccine-preventable illness.

It’s becoming so common these days, it’s actually starting to scare me a little bit.  If we continue down this path of non-vaccination, herd immunity is going to fail.  We will see the resurgence of illnesses we haven’t seen in twenty or thirty years.  I have never seen a case of measles but I’m sure one day, at this rate, I will.

What’s next?  A North American outbreak of Polio?

-18C and I’m happy.

That cold snap I’ve been wanting to happen has finally happened.  And funnily enough, my household has been well for the past 3 weeks.  Coincidence?  I think not!!

I won’t belabor the point, but it’s been a brutal fall for cold viruses and Influenza.  See my previous posts.  I have been inundated the last few weeks with patients coming in for their flu vaccines.  Better late than never, I say.

It’s a refreshing change not to have to deal with the constant running noses, running around to find the thermometers, running out of baby Tylenol for the umpteenth time.   The house is healthy.  Yay!

So, you won’t hear any bitching about the deep freeze we are having.  I welcome it.  Take that, viruses!!

The Autumn Classic In Doctor Land.

Ah … Fall.

Some people mark the beginning of fall by the calendar date, the changing of the leaves, others by the start of the World Series.  Me?  Fall begins when the shipment of flu vaccine arrives in the office.

Fall came last Friday in a pretty package containing 160 doses of flu vaccine.

Influenza.  The Flu.  Most people use the term “flu” synonymously with “cold”.  The two are very different.

I’ll never forget the first (and only) time I had Influenza.  It was January, 2000.  I was heading back to medical school after the Christmas holidays.  While on the train, I started getting a scratchy, sore throat.  I woke up the next morning, feeling like I got hit by a truck. Within 6 hours, I had a fever of 39.8C (103.5F), my entire body was wracked with rigors, my head felt like it was going to explode.  My friends watched me deteriorate in class, apparently I looked weaker and paler by the minute and someone took pity on me and drove me home.  That night, I slept on the couch and watched re-runs of “The X-Files”.   I had to change clothes at least once very 2 hours due to drenching sweats.  My roommate called her mother who was a family physician and offered me an anti-viral, but I was pretty incoherent from the fever and declined.  In retrospect, I probably should have taken it.  The next day was no better, and there was no way I could go to class, so I basically lived on that couch for a few days.  Tylenol, Advil and Gatorade were my friends.  By the end of the week, the fever had broken, the muscle aches were gone, but I was left with a horrible cough which lasted about 4 weeks.  (Turns out I also got bronchitis after that).

Did I mention that was the first year I’d gotten the flu shot?

Riight, so it was also the year that I had influenza, bronchitis and laryngitis, pretty much back to back.  It was also the first year I trekked back and forth inside a hospital to get to my classes.  Such a glamorous life that was.  (I secretly loved it). I had never been that sick for that long.  It’s interesting to note that I haven’t been that sick since!  Obviously, I contracted a different viral strain which the flu shot didn’t protect me from.  It happens.  I was young (hey, still am!) so was able to fight the virus.  The extremes of age often aren’t so lucky when it comes to influenza.

It wasn’t always the case though.  The great flu pandemic of 1918 wiped out close to 50 million people.  The Spanish Flu decimated the world’s population (then, 1.36 billion) in a little over a year.  Most victims were healthy young adults, in contrast to most influenza outbreaks, which predominantly affect juvenile, elderly, or weakened patients (from Wikipedia).  Its been said that the Spanish Flu was deadlier than the Black Death and in fact, this flu killed more people in 24 weeks than AIDS has killed in 24 years, more in a year than the Black Death killed in a century!

Remember H1N1?  Much ado about nothing, in my opinion.  Not to be nihilistic, but we ain’t seen nothing yet.  The big one is coming.  I don’t know when, I don’t know how, but we’re due for a real pandemic again.

So, I got my flu shot again.

I kinda hate the Internet.

Warning – somewhat of a vent ahead, again.  Remember this post?  I’m kinda coming back to it.

The last thing I want to do is offend my readers, but this is my blog and I should be allowed to say what I want, when I want to, right?  Now, I know that my being a physician can be a bit tricky.  While I strive not to provide overt medical advice, I can’t help sometimes to want to talk about medical issues from a personal perspective.  Does that make any sense?

So here’s the thing – despite me using the Internet for my own selfish purpose (ie this blog), I am actually kinda hate it.  I am sick watching (ie reading) strangers discussing their medical issues or their children’s medical issues and vilifying the doctors that care for them.  I used to frequent a few message forums, mostly for entertainment purposes, but constantly found myself drawn to the “health/medical” posts.  Most of the time, I can remember shaking my head at my computer, wondering how some people can be so daft, or shocked that someone would ask a message forum for medical advice about whether they thought their kid should see a doctor.  (If you’re asking the question, the answer is probably yes!)  I made the mistake on a few occasions to post a response.  Big mistake!  I’m not actually seen as an expert by these people.  I am just a GP who can’t possibly know everything.  Yet, the “research” the parent has done over the course of a few days or a few weeks, is far more inclusive than anything I’ve learned in my years of training.  Gee, thanks.

I know what you’re thinking – why bother to visit these sites?  My answer – because I want to know what kind of (mis)information is out there, so I’m prepared to fight it in the office.  I have already made leaps and bounds in my knowledge around the “MMR causes Autism” controversy.  Having read books like, “The Panic Virus” and “Autism’s False Prophets“, I am now armed for those parents who refuse the vaccination.  Unfortunately, it doesn’t seem to matter to most of them, which is quite shocking to me actually.  They would rather believe the stories on the Internet than sound scientific results.  They would rather believe the pseudoscience than tried and tested science.   They really don’t seem to care that they are putting other children at risk by not vaccinating their child.  Their reliance on herd immunity is misguided, because in point of fact, herd immunity is waning.

The vaccine debate is just one of hundreds of discussion points, but it’s the one that comes up the most often in my office.  I would say that about 2-3/10 parents are refusing or delaying their child’s vaccination. That frightens me!   Last year, there was news of a pediatrician refusing to care for children whose parents didn’t vaccinate.  I totally get it.  Sure, it’s an extreme reaction on the part of the physician, but this particular physician felt that parents were not trusting in her expert opinion.  How can she care for their child if there is a fundamental lack of trust?

Medicine has come a long way in the last 100 years. Science continues to advance and yes, maybe in 10-15 years, we might learn that A+B does not equal C like we thought it did.  Case in point: hormone replacement therapy once touted as the savior for post-menopausal women was actually found (via the Women’s Health Initiative in 2003) to cause more harm than good.  This is the nature of the scientific method. Develop a hypothesis, design a study to test it and wait for the results.

I’ve never experienced it myself, but I often wonder what it was like for the older doctors whose opinion was respected for what it was.  Paternalism aside, patients and the public looked up to physicians.  There isn’t much of that going on these days.  Patients are showing up for appointments already having diagnosed themselves.  Patients are not afraid to question their diagnoses, and in fact feel quite entitled to do so.  Now, don’t get me wrong, I have no problem with discussing my findings with patients, and explaining to them my rationale behind said diagnosis.   It’s the attitude that I find offensive.  It’s the sense of entitlement from these patients that I have a problem with.   I didn’t spend an extra 12 years in post-secondary education to be put down by someone who thinks they know better because they read about it on the Internet.  It’s insulting.  I wouldn’t dare tell a mechanic how to fix my car.

I’m not a perfect physician – I never claimed to be.  But I would like to be respected for the years I put in to my training and for the continued self-education I engage in on a daily basis.

Is that too much to ask?