I saw a patient recently for parasites.
I get a sinking feeling when I see that diagnosis on the schedule, as it rarely means a real parasite. The great Pacific NW is mostly parasite free, so either it is a traveler or someone with delusions of parasitism.
The latter comes in two forms: the classic form and Morgellons. Neither are likely to lead to a meaningful patient-doctor interaction, since it usually means conflict between my assessment of the problem and the patients assessment of the problem. There is rarely a middle ground upon which to meet. The most memorable case of delusions of parasitism I have seen was a patient who I saw in clinic who, while we talked, ate a raw garlic clove about every minute.
“Why the garlic?” I asked.
“To keep the parasites at bay,” he told me.
I asked him to describe the parasite. He told me they floated in the air, fell on his skin, and then burrowed in. Then he later plucked them out of his nose.
At this point he took out a large bottle that rattled as he shook it.
“I keep them in here,” he said as he screwed off the lid and dumped about 3 cups with of dried boogers on the exam table.
To my credit I neither screamed nor vomited, although for a year I could not eat garlic. It was during this time I was attacked by a vampire, and joined the ranks of the undead. (more…)
Take up the White Man’s burden–
The savage wars of peace–
Fill full the mouth of Famine
And bid the sickness cease;
And when your goal is nearest
The end for others sought,
Watch CAM and woo Folly
Bring all your hopes to nought.
The White Man’s burden, a bit of racism from the 19th century:
The term “the white man’s burden” has been interpreted as racist, or taken as a metaphor for a condescending view of non-Western national culture and economic traditions, identified as a sense of European ascendancy which has been called “cultural imperialism.” An alternative interpretation is the philanthropic view, common in Kipling’s formative years, that the rich have a moral duty and obligation to help “the poor” “better” themselves whether the poor want the help or not. The term “the white man’s burden” has been interpreted as racist, or taken as a metaphor for a condescending view of non-Western national culture and economic traditions, identified as a sense of European ascendancy which has been called “cultural imperialism.” An alternative interpretation is the philanthropic view, common in Kipling’s formative years, that the rich have a moral duty and obligation to help “the poor” “better” themselves whether the poor want the help or not.
I will let the commentators debate the meaning of the poem. There are places in the world so devastated by poverty, disease and political corruption that it may be beyond the capacity of the local populations to overcome. They need outside help. Certainly, the impulse to help those less fortunate than yourselves is a noble tradition. Haiti, Central America and Uganda are parts of the world that need assistance in overcoming an incredible number of problems to reach even a basic level of material support for its population.
I do a lot of driving as part of my job. I am the sole Infectious Disease doctor at three hospitals and I can spend an hour or two a day in the car, depending on traffic. What prevents me from going crazy sitting in traffic is listening to podcasts and audible books. I especially like reading (and yes, audio books is reading, pedant) multivolume epics. Currently I am reading Steven King’s Dark Tower series, which occurs in a universe “where the world has moved on.” In Mid-world there was once a world with science and beauty and art, but something changed, what I do not know yet (I am only on the third volume; no spoilers in the comments), and the world moved on, leaving behind some artifacts of science and technology, but it appears to be an increasingly primitive world. Being fantasy, there is, unlike the world I live in, magic as well.
I like that phrase: “the world has moved on.” (more…)
There is germaphobia, the fear of germs. Or Germans. One of the two. Oddly, I do not fear most germs, despite my daily reminders as to how destructive these wee beasties can be. I recognize their limits and my immunologic strengths and know I have more to fear from cars or unsaturated fats than E. coli or influenza.
There is also a fear of vaccines, the too many too soon that is said to be at the heart, or maybe the left atrial appendage, of one of the imaginary problems with vaccines. There are, by my counting, 5 live attenuated viruses and 21 different antigens in the vaccine schedule by age 6, for a total of 26 or twice thirteen. Some fear those antigens and viruses, making it a triskaidekaphobia times two (1).
From my perspective the paltry quantity of antigens children receive with the vaccine schedule are, when compared to the enormity of antigens in the environment, a rounding error. We are awash in bacteria, fungi, viruses and an enormous number of environmental organisms. I think of each of us like Pig-Pen, but instead of dirt, we are in a cloud of micro-organisms.
Our immune systems, contrary to the opinions of the unimaginative who direct scorn and derision at Dr. Offit, can cope. As discussed, we have a ability to stave off the phenomenal number of organisms that would just as soon use us as the ultimate supersized meal. Of course, it is not all the immune system that keeps the wee beasties away. Being warmer than ambient temperature helps. Understanding disease epidemiology, hygiene and the prn malum q 24 h also keeps the doctor away. (more…)
There are sources of information I inclined to accept with minimal questioning. I do not have time to examine everything in excruciating detail, and like most people, use intellectual short cuts to get through the day. If it comes from Clinical Infectious Diseases or the NEJM, I am inclined to accept the conclusions without a great deal of analysis, especially for non-infectious disease articles. Infectious disease publications I have to read more closely; its part of passing as an expert.
Outside of medicine, I am predisposed to accepting at face value many of the articles in Skeptic and Skeptical Inquirer. They are trusted sources. Some topics, like haunted house or Big Foot investigations, I barely skim. After all these years, I doubt there will be any new insights into the subject. Other topics, depending on my interest, I may read more carefully.
I often read longer articles many times. First a quick skim to see if it offers anything of interest. If it does, then I may read it carefully.
This months Skeptical Inquirer had an article called Seven Deadly Medical Hypotheses by Reynold Spector. Just seeing the title and knowing the magazine, I was primed to accept the content at face value. I enjoy a well reasoned, thoughtful rant. I relish a clever diatribe, even if I do not agree with the topic. So I gave it a quick skim. I was discomfited. My first gut check was ick. But I was uncertain why. So I read it slowly and carefully, and still ick. But why? (more…)
I was interviewed for Birmingham Skeptics and you can hear the result at
It is bad enough listening to myself as I correct my podcasts, so I have no idea how good the interview is; it was fun at the time. And the picture makes me look fatter than I am. Oh well.
For those who are new to the blog, I am nobody from nowhere. I am a clinician, taking care of patients with infectious diseases at several hospitals in the Portland area. I am not part of an academic center (although we are affiliated with OHSU and have a medicine residency program). I have not done any research since I was a fellow, 20 years ago. I was an excellent example of the Peter Principal; there was no bench experiment that I could not screw up.
My principal weapon in patient care is the medical literature, accessed throughout the day thanks to Google and PubMed. The medical literature is enormous. There are more than 21,000,000 articles referenced on Pubmed, over a million if the search term ‘infection’ is used, with 45,000 last year.
I probably read as much of the ID literature as any specialist. Preparing for my Puscast podcast, I skim several hundred titles every two weeks, usually select around 80 references of interest and read most of them with varying degrees of depth. Yet I am still sipping at a fire hose of information
The old definition of a specialist is someone who knows more and more about less and less until they everything about nothing. I often feel I know less and less about more and more until someday I will know nothing about everything. Yet I am considered knowledgeable by the American Board of Internal Medicine (ABIM), who wasted huge amounts of my time, a serious chunk of my cash, and who have declared, after years of testing, that I am recertified in my specialty. I am still Board Certified, but the nearly pointless exercise has left me certified bored. But I can rant for hours on Bored Certification and how out of touch with the practice of medicine the ABIM is.
It always somewhat surprises me how some interventions never seem to die. Theophylline seems to have disappeared in the medical pantheon, but what comes around, goes around. I predict a resurgence of theophylline this century. Despite the recent study that shows, yet again, echinacea has no effect on colds, I predict the study will neither decrease the sales of echinacea nor prevent further funds being spent on clinical trials on its efficacy. Hear that JREF? I made predictions. I will await my million dollar check. Make it out to Mark Crislip.
Another therapy that refuses to be put to rest, or even to be clarified, is the use of cranberry juice for urinary tract infections. Pubmed references go back to 1962, and there are over 100 references. Firm conclusions are still lacking.
There is a reasonable, but incomplete, basic science behind the use of the cranberry juice for urinary tract infections. (more…)
I have been in Infectious Diseases for almost 25 years. I have two major jobs: I see inpatient consults and I chair the Infection Control program. I have been involved in quality improvement, especially as it relates to hospital acquired infections, for my entire career. It has been an interesting quarter century. Year after year we have driven down infection rates and other kinds of mortality and morbidity in hospitalized patients. Everyone recognizes that medicine is difficult and dangerous and its biggest problem is medicine is practiced by humans, who, I would venture to observe, are prone to mistakes and any number of cognitive errors.
It has not been a easy journey. People hate change and there has not always been certainty as to the best options to choose to solve a problem, a problem that continues today. For example, how best to treat a patient with potential methicillin resistant Staphylococcus aureus colonization (MRSA). Should we screen everyone? Screen high risk patients? Surgical patients? Do we decolonize, with the long term consequence of accelerating antibiotic resistance? Do we place everyone with MRSA in isolation, with the known decrease in care that patients in isolation may have? Everything we do has potential downsides and unintended consequences. No good deed ever goes unpunished.
I gave a lecture last fall on The Vaccine Pseudocontrovery for Oregonians for Science and Reason. There are evidently Oregonians against Science and Reason, hence the title. My Dad went and said it was a good talk. You going to argue with Dad? I think not.
Someone with a handheld camera recorded it, edited it, and put it up on the YouTubes in four parts. The first part is here:
It was also Quackcast #45 as well, so you may have heard it all before.
If you can’t be self-aggrandizing, what’s the point of having a blog?