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Whack em hard/Whack em once and Stroke

There is no satisfaction in hanging a man who does not object to it.
~ George Bernard Shaw

I work in a 5-hospital system and many of us practice at several hospitals. The residents rotate through at least three of the hospitals and the peripatetic nature of health care allows word of curious cases to percolate through the system.  My current resident mentioned that there was a case of a vertebral artery dissection in a young female shortly after chiropractic neck manipulation.

Man, that’s awful. Is she doing OK?

Evidently there were no permanent neurologic sequelae. She dodged that bullet. Or perhaps that noose, as I once calculated that the force of a neck crack is about 40% that of hanging by the neck and it has the same pathologic changes if it goes wrong. Every time I see a death in the movie where the neck is twisted to break it, I think chiropractic, although some tolerate it better than others.

I have not written on CNS events related to chiropractic since 2008, although the topic has been covered by Dr. Hall.  I still suspect that occasionally there is a perfect storm of bad luck, the forces are perfectly aligned in a susceptible patient and they get an embolic stroke or a vertebral artery tear.
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Posted in: Chiropractic, Clinical Trials

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Animal Therapy

Animal-assisted therapy is a huge topic: almost 1500 hits using those terms alone. There is no way I am going to cover all of them and do them justice. Instead I am going to cherry pick, er, I mean, select references of interest to illustrate issues surrounding animals in the hospital. Sometimes I get the impression that readers of the blog expect encyclopedic knowledge and understanding of a topic whenever we put pixel to screen. That is only true of the other contributors to the blog, not me.

I would like to mention that I do, in fact, like animals, even dogs. I loathe most dog owners, as confirmation bias suggests there is no such thing as a considerate dog owner. But I never have contact with the dogs that don’t bark, that don’t crap on my yard, that don’t run up to me to nip at my legs. I only see the dogs that their owners allow to behave in ways I would never allow a human to behave.

It is no surprise that my kids have grown up mostly animal free. My eldest did wear me down and I bought him a hamster. It promptly bit me, drawing blood. Great, I thought, LCM. Just what I need. Then in the dead of winter it escaped, fell down a heating duct (we were putting in new floor) and electrocuted itself on the heating coils so every time the heat turned on we smelled rotting, roasting hamster. It cost $500 to take the furnace apart and clean it. Good thing it wasn’t a beagle. That was enough pets in the house for me. (more…)

Posted in: Epidemiology, Science and Medicine, Veterinary medicine

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Uneasy Lies the Head That Wears the Flu

Infectious diseases (ID), as those who read my not-so-secret other blog know, is without a doubt the most interesting speciality of medicine. Every interesting disease is infectious in etiology. What is cool about ID is that it has connections into almost every facet of human culture and history.

I note that at some point I have gone from being the young whippersnapper to the Grandpa Simpson at my hospitals and am one of the few who has been around long enough to be a repository of institutional memory. I remember what it was like 20 plus years ago, when no one consistently washed their hands, when all S. aureus (S. aureui?) were sensitive to beta-lactams and we wore an onion on our belt, as was the style of the day. Oh the changes I have seen.

Besides remembering the not so good old days of my professional career, ID keeps me reminded of how the world used to be in the past. Medicine used to be about the epidemics that would routinely sweep across the world. Polio, measles, mumps, scarlet fever, rheumatic fever, tuberculosis and on and on. I occasionally see TB but thanks to modern medicine many of these scourges have mostly faded from medical practice in the US. Not a one, I might add, has faded due to the efforts of alt med practitioners.

Influenza still gives me pause. It is, as infections go, quite the tricky virus and it remains a difficult beast to treat and prevent. Which is a drag as it remains one of the more consistent causes of infectious morbidity and mortality. (more…)

Posted in: Basic Science, Epidemiology, History, Science and Medicine

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Boundaries

Vacation then taxes have consumed my focus the last two weeks, and I have had little time to devote to issues of infectious diseases, much less SBM, so I will instead meander around a more philosophical terrain.  I feel guilty when I do not have a substantive, data driven post evaluating a paper or essay in detail, but some weeks there just is not the time.

Being involved with SBM has been, like all intellectual endeavors, a process rather than result. I keep experimenting with conceptual frameworks with which I can understand the differences between a SBM approach and a SCAM (supplements, complementary and alternative medicine) approach. Nothing clarifies thoughts quite like writing them down. Or maybe not.

The motto of the blog is “exploring the relationships between science and medicine” but it is often more about non-overlapping boundaries* than relationships. We are often separated more by Berlin walls than Venn diagrams.

There are perhaps four boundaries that separate science-based medicine from those who prefer SCAMs. More if you are a splitter; I am a lumper by nature. At work I am an Occam kind of guy. (more…)

Posted in: Science and Medicine, Uncategorized

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Comprehending the Incomprehensible

Medicine is impossible. Really. The amount of information that flows out the interwebs is amazing and the time to absorb it is comparatively tiny.

If you work, sleep and have a family, once those responsibilities are complete there is remarkably little time to keep up with the primary literature. I have made two of my hobbies (blogging and podcasting) dovetail with my professional need to keep up to date, but most health care providers lack the DSM-4 diagnoses to consistently keep up.

So we all rely on short cuts. People rely on me to put new infectious disease information into context and there are those I rely upon to help me understand information both in my specialty and in fields that are unrelated to ID.

Up and down the medical hierarchies we trust that others are doing their best to understand the too numerous to count aspects of medicine that no single person could ever comprehend.

If I want to know about the state of the art on the treatment of atypical mycobacterium or how best to treat Waldenströms or who knows the most about diagnosing sarcoid, there is always someone who can distill their expertise on a topic to the benefit of the patient and my knowledge.

Trusting others is the biggest shortcut we routinely take in medicine to wade through the Brogdignagian amounts of information that flood into medical practice. We have to trust other clinicians, the researchers and the journals that all the information is gathered and interpreted honestly and accurately. (more…)

Posted in: Basic Science

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Acupuncture and Allergic Rhinitis: Another Opportunity for Intellectual Sterility

You need to keep an open mind.

A common suggestion offered to naysayers of nonsense.

The usual retort concerns not letting one’s brain fall out.

Evaluating SCAM’s is less about having an open mind and more about having standards, a conceptual framework that is used to interpret and analyze new information. One of the benefits of writing and reading topics covered by science-based medicine (SBM) is it has clarified and sharpened the ideas by which I understand the world. Those concepts were nicely summed up by Steve Novella at Neurologica, and I reproduce them here, slightly modified. They should be on stone tablets, not quite commandants, but strong suggestions. The 8 strong suggestions somehow doesn’t cut it however. (more…)

Posted in: Acupuncture, Clinical Trials, Science and Medicine

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Warts

As this is published I am finishing the last day of a 12 day stretch covering my partner while he is off trying to get MDRTB and typhoid fever.  He is in India. I may have to autoclave him when he returns before I let him in the hospital.  Double the work means double the fun, but free time goes down by the power.  Same thing happens with the kids.  If you have two kids, the work squares, three kids, the work cubes.  A linear change in one domain leads to exponential change in other domains.  I am sure that phenomena has a name that one of our readers will know.

I lack the mad typing skills of other contributors and it usually takes me at least a week to carefully construct the spelling errors and grammatical faux paux for which I am justly famous.  And then I have to come up with content to surround the faulty English.  This week I have little time and so a ‘fun’ post.

When I make rounds it is not unusual for people to ask questions about their health and their family.  I learned long ago to ask why they want an answer to a particular question so I do not inadvertently offend a colleague.  When I offend I like to be advertent.  Years ago I was asked what I thought of hyperbaric oxygen, and I replied that it is great for the bends but otherwise mostly serves to enrich the hyperbaric doctors.  Why do you ask?  I am the new director of the hyperbaric program, was the reply.  Open mouth and insert foot.

So recently a nurse asked me if duct tape would remove warts.  Wary, I asked why, and she showed me a huge wart on her hand.  I have used duct tape for many purposes; few home repairs cannot be (temporarily) accomplished with duct tape. But treating warts?  Do you use the tape as a way to yank the wart out by its roots?  Got me.  I gave my best Gallic shrug and went looking for information. (more…)

Posted in: Clinical Trials, Naturopathy

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Honey Boo Boo

My son has been coughing for several weeks, and the cough will probably persist for another 2 or 3 weeks. Coughs last a long time. Patients think a cough will go away in less than a week but in reality they are likely to last several weeks.

Coughs are a pain for the patient and an annoyance for the people around them. You never really know if the cougher in the row behind you has asthma,  a post infectious cough or  is actively spewing TB or influenza all over the airplane.  I learned from Clinton the importance of not inhaling, especially on airplanes.

I tend to leave most symptoms alone if the they are not life threatening or otherwise unbearable for the patient. Codeine is the only really good cough suppressant and none of the over the counter cough medications are effective.  I assume that coughing with infection, like diarrhea, is beneficial. Key to treating all infections is to physically remove it. Undrained pus doesn’t heal, and a good cough is the most efficient way I know to remove potential pathogens from the lungs.

If there are benefits to suppressing the cough associated with acute respiratory infections I can’t find any and we have all seen people who, because of inability to cough secondary to rib fractures, develop severe pneumonia.  As a resident I had an elderly male die of just such a series of unfortunate events.

I suffer from a mild form the the naturalistic fallacy. I tend to let normal physiologic processes run their course unimpeded as long as they pose no harm to the patient.  So I do not treat infectious coughs, in part because medications are not effective, in part there is no benefit  and in part because the medications that are effective, and those that are not, have side effects.  (more…)

Posted in: Clinical Trials, Herbs & Supplements, Science and Medicine

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One Flu Into the Cuckoo’s Nest*

“I don’t seem able to get it straight in my mind….”
― Ken Kesey, One Flew Over the Cuckoo’s Nest

Influenza is going gangbusters at the moment. I like going to Google Flu trends as well as the CDC flu site to see what flu is doing. Using Google searches as a surrogate for infections is an interesting technique that public health officials have tried with less success in other illnesses but is not without utility. Behaviors of populations can presage a problem, my favorite example is the first hint of the 1993 massive Cryptosporidia diarrhea outbreak in Milwaukee was a sudden shortage of Kaopectate and Peptobismol. It appears there are more patients with flu like symptoms this year than  at the height of the H1N1 epidemic of 2009. We have lots of flu like illness, and per the CDC there are buckets of confirmed influenzaflu, but so far the season, while probably having more cases than 2009, the outbreak is clinically not the same.

Compare and contrast, the two words that defined undergraduate liberal arts essay assignments. Get out your blue books and compare and contrast influenza outbreaks from 2009 and 2013. You have one hour. (more…)

Posted in: Clinical Trials, Epidemiology, Public Health, Science and Medicine, Science and the Media, Vaccines

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SCAMlandia

I quite like Portlandia. I find it funny and it captures a part of Portland. I recognize large swaths of the city’s culture in the show. Other representations of the city I recognize less. Sunset publishes beautiful photographs of the NW, but when I look at the photos I think, that section of the city never looks that good. It is quite wonderful how Photoshop can improve on reality.

Like most major cities, Portland has a monthly magazine, Portland Monthly. The city represented in that magazine is mostly alien to me. I look at the advertisement, the articles, the photographs, and wonder when did Portland become a city with an average 7 figure income? The Portland in which I grew up and currently live is rarely found in the pages of Portland Monthly. If you are extremely well to do, I suppose you are in the demographic Portland Monthly. But when I flip through the pages of the magazine, I see little I recognize, but I have never completely abandoned the hippie/grunge aesthetic of my younger days.

Every January they have the best Doctors issue* and this year, for the first time, they offer The Portland Alternative Medicine Guide. Well, less a guide and more an extended infomercial filled with ‘facts’ that deserve the quotes. (more…)

Posted in: Acupuncture, Chiropractic, Dentistry, Energy Medicine, Homeopathy, Legal, Naturopathy, Politics and Regulation, Science and Medicine, Traditional Chinese Medicine

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