Diarrhea!

This topic has been running through my mind quite a bit lately. Infectious diarrhea is one of the world’s most vicious killers, but is susceptible to basic public health measures such as clean water and good sanitation, which is why cholera-ridden Americans aren’t dropping dead in pools of their own feces. (Citizens of other countries aren’t quite so lucky.)

There are many causes to this common problem—various bacteria, viruses, parasites, and a host of non-infectious causes. Even in here in the U.S., public health measures sometimes fail us, as seen in the ongoing Salmonella outbreak.

But diarrhea isn’t just a load of crap. Let me explain.
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How do you say it?

I am often the bearer of bad news. I don’t think I’ve ever been formally taught how to deliver bad news, but I’ve developed a style over the years, and I’m pretty good at it.

I work with medical residents every day in their outpatient clinics. Most of them have never had to deliver bad news. Some people are natural communicators, and some aren’t. Often, one of my residents just “gets it”—they have a great deal of empathy, can “read” the patient from moment to moment, and without any help from me, they can successfully give the news.

What does it mean to give bad news “successfully”?

In medicine, it means giving complex information in a short period of time, with proper emotional content, and in such a way that the patient takes it seriously, but doesn’t become so frightened that they forget the entire discussion. Once the word “cancer” comes out, little after that is retained. Over and over, I hear people say, “what was that thing you said I have?”

There is no substitute for young doctors giving bad news to their own patients, but it’s good to model behaviors and to pass along tips.

For example, if I have to tell someone they have HIV, I usually make sure to shake their hand, put a hand on their shoulder, sit near them, and keep my arms uncrossed. These signals set the tone for how they will view their illness. If you, as a doctor, seem physically distant, the patient will sense that, and may end up feeling stigmatized, isolated, and more afraid. Also, they may disappear out of fear, delaying further treatment.

Giving bad news has to be a flexible skill. All patients are different, and need to hear news differently. For example, I had a patient with a breast lump. She is a bright and straight-forward person, so I asked her, “Do you prefer a good surgeon who is warm and fuzzy and will hold your hand, or who will just get the job done?” She chose the latter.

I can only hope that my skills keep improving and that my residents keep learning. Unfortunately, there will always be people to give the news to.

Ah, the credulity!

Yesterday, it was the Times with “Experts Revive Debate Over Cellphones and Cancer”. Today, it’s the Journal with “Do Fuel-Saving Gadgets Take You for a Ride?”, which includes this little gem from a gadget maker:

The EPA and FTC “only test the ones that don’t work,” says Louis H. Elwell III, chairman and president of Vortex Fluid Optimizer Corp. The Hattiesburg, Miss., company makes the Vortex Fuel Saver, a system that uses magnets to affect the fuel, air and coolant entering an engine. He says the Vortex uses technology that boosts fuel economy by at least 10%.

Yes, Louis, that’s right, the government only tests the ones that don’t work, because the government wants you to waste fuel, and because it is against magnetism. You see, everyone in science, the EPA, and the FTC is actually in cahoots with Exxon-Mobil to sell more gas. Here at UC-Berkeley, we got $500M from BP, and you know what, all I do now is figure out ways to get people to waste gas. Brilliant!

How does this stuff get into important newspapers?

Open letter to Jenny McCarthy

Dear Jenny,

Jenny, Jenny, Jenny. Oh, Jenny. Look, I realize I might have been somewhat less than kind in the past, but I’m hoping you haven’t written me off. I’ve been told you catch a lot more flies with honey than with vinegar, so please take this letter in the spirit it was intended—corrective, constructive, and condescending.

I have it on good authority that you are planning on leading a “March on Washington” tomorrow. That’s a really interesting idea. Many groups have marched on Washington—the Bonus Army, Dr. Martin Luther King, anti-abortion groups, pro-choice groups, a Million Black Men—all to help bring attention to their causes. It is only natural (or should I say “green”) that you would wish to do the same. Other groups that have made the march have had pretty clear goals, whether they be veterans’ benefits, racial equality, or other political causes. I was wondering precisely what your goal is?

According to the website, the goal is “to give everyone who loves a child with Autism (sic) a day for their voices to be heard.” That being sufficiently vague, the website also states that you wish to:

…[d]emand [that] Congress take action to Green Our Vaccine Supply (sic) while reassessing our current vaccine schedule. Ask Congress to reenact legislation that would eliminate mercury and other toxins from our children’s vaccines, study the instance of Autism (sic) and other neurological disorders in vaccinated versus unvaccinated children, and to extend the statute of limitations to allow all children affected by vaccine induced Autism (sic) to file in the National Vaccine Injury Compensation Program (NVICP).

I can understand racial equality and other socio-political causes, but I’m a little confused about your goals. The whole “giving a voice” thing seems rather devoid of actual content, so lets move on to your other statement.

[d]emand [that] Congress take action to Green Our Vaccine Supply (sic) while reassessing our current vaccine schedule.

First, I’m not sure what Congress has to do with this. Leaving that aside, what does it mean to “green our vaccine supply”? Do you wish them to be more verdant, like the Chicago River on St. Patrick’s Day? I suspect not. Perhaps you could clarify?

Ask Congress to reenact legislation that would eliminate mercury and other toxins from our children’s vaccines…

I’m sorry, Jenny, but that doesn’t make a whole lot of sense. You already made us stop using mercury compounds, despite the overwhelming evidence of safety, and yet autism rates haven’t dropped. What “toxins” do you mean? I’m sure you couldn’t mean that list of “chemicals” in some of your literature—since everything is “chemicals”, I’m not sure which ones are “greener” (except copper—that can get pretty green, but it’s not in vaccines—yet). You mention “anti-freeze”, and yet there isn’t any in vaccines. Some have a compound with a similar name (polyethylene glycol vs. ethylene glycol—that “poly” makes a big difference, but it’s kind of “science-y” so I’ll leave it out for now). You mention “formaldehyde”, which is used to inactivate the viruses in some vaccines, but it’s present is such small amounts, that common environmental exposures are much more significant. In some flight of fancy, you also mentioned “aborted human fetus cells”. That’s truly bizarre. A cell culture line has existed for over 40 years whose ancestor cells came from human fetal tissue. To call these culture “human fetal tissue” is, well, wrong.

Oh, wait, here’s one of my favorites: “chick embryos”. Jenny, that’s a synonym (that means “means the same as”) “egg”. Eggs (yes, the same kind we eat) are used to make flu vaccines. It’s too bad, because people who are allergic to eggs will have to wait until we find a new way to make the vaccine in order to benefit from the shot.

I hope you have good weather, and at least check out some of the museums. Even better, you might want to drive a short way out of town and visit the NIH. They do science there. That means the test hypotheses, keeping the good ones and discarding the bad.

Jenny, you’ve been fed a disproved hypothesis (that means “you’re wrong”). It’s time for you to give up your degree from Google University and go back to being a mom and actress. You’re probably good at at least one of those.

I hate being sick

In the interest of blog synergy, I’m reposting this from my old blog.

I’m actually quite lucky. Despite being surrounded by infectious diseases for sixty hours a week, I don’t get sick all that much (OK, maybe more than most, but I don’t have data). I actually called in sick for part of the day, something I rarely do. And that got me thinking…

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West Nile season begins

West Nile season is starting up, with the first few case reports trickling in.

Back in the summer of 2002, I was introduced to West Nile fever. This mosquito-borne viral illness had a minimal presence in North America in the preceding three years, but made its real American debut that summer. It may have hitchhiked over on boats or in an infected traveler, but either way, it’s here to stay.

That summer, as I took over rounding on an inpatient medical service, I was suddenly faced with a relatively large number of very ill patients. They were usually elderly, and would be brought to the ER with fevers, headaches, low sodium levels, and confusion. More often than not, they developed weakness, often severe enough to land them in the ICU on a ventilator. Recovery was variable, with some people doing fine after rehabilitation, and others dying.

I went hiking in the woods that summer (with plenty of DEET solution) and saw a number of dead crows and blue jays, who also serve as unfortunate hosts to the virus.

There is no specific treatment for West Nile, but prevention involves mosquito control and avoidance.

There hasn’t been another summer like ’02. My state had over 600 cases in 2002, including 51 fatalities. Last year saw fewer than 20 cases. I’ve seen plenty of living blue jays so far.

Some of our success is due to vector control, but much is due to immunity. When the virus landed, very few Americans had been exposed. Now, many of us have, and our immune systems have been reasonably effective at mitigating the effects of this now wide-spread disease.

I still view mosquitoes differently. They never really bothered me, but after seeing so many horribly ill people, I think about those little pests before I go out in the evening.

West Nile is a beautiful model for emerging infectious diseases. I wonder what we’ll see next?

Attack of the child zombies!

I was glancing at the Huffington Post today when I ran into yet another piece of what I wish was absurdist health reporting. Unfortunately, it’s meant to be taken seriously.

What’s even worse is that there is a real problem hidden in the hyperbole, but the author’s over-the-top rant does more to obscure than expose the issue.

In this country, we’ve never known how to deal with psychiatric disease. From the mass institutionalization present for much of our history, to the massive de-institutionalization of the mid-1960’s, from forced lobotomies and sterilizations, to the development of helpful medications and their use, and perhaps overuse, we have lived with a chaotic mental health care system. This system is somehow divorced from the rest of the health care system, despite the fact that the brains is an organ like any other. Mental health care is expensive and spotty, and compared to health care involving every other organ, is nearly completely uncovered by insurance.
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