publix

So, I got a piece of mail today. Publix thought enough to spend money on a piece of mail that would inform me of their new policy of free antibiotics. Purely on their own initiative, Publix has decided to provide the free world with needed antibiotics. I should be happy. Obviously as a physician, I should be ecstatic. I must routinely prescribe antibiotics for sick individuals with a bacterial infection that require antibiotics but can not afford them.

Then why does it tick me off???

Because Wal Mart came out with a plan 6 months ago to provide low cost generic drugs to the population for $4? Or because now people will expect antibiotics to rain from the heavens as water.

I'm a physician. As such, I have pursued a craft that allows me to follow my internal calling. My calling is to help as many people as possible. Now I will have the poor as advantaged as the more insured to request and demand antibiotics for every viral infection that occurs.

First off, how many people that really required antibiotics have not been able to afford them?? I have worked at Grady in Atlanta, and in South Central Los Angeles. If you need antibiotics for a life threatening infection, you will receive them no matter your ability to pay.

So who is this appealing to? The new initiative is appealing to people who want antibiotics for any infection that may occur. Instead of requiring a sacrifice and an attention to health, antitbiotics are now free. I do not mean to isolate the poor, who will now have free antibiotics, I mean to isolate all who do not see antibiotics as a VERY expensive treatment. Anyone with a viral infection (cold, cough, sniffles) has the right to symptomatic treatment. They do not have the right to an antibiotic. In contrast, people who are quite well off do not have the right for an antibiotic, no matter how much they can pay. If you have a viral infection, you do not need antibiotics!

But I still have patients that demand them. Why do I refuse? Why do I continue to educate, knowing that I'll just get a poor evaluation on whatever JHACO score of the minute exists? I know they'll go across the street, so why do I waste my time? Because I know that antibiotics that are unnecessary lead to resistance. I know that a patient that requires a z-pack 3-4 times a year for their "sinus infection" will at some point actually need antibiotics, and will therefore be unresponsive to a Z pack. Amoxil is already a moot point thanks to enough parents that want to cover any eventuality. How many more will remove from our arsenal as people demand them? Luckily now, at least they may be free.

Panacea and Hygeia

In ancient Greece, Asklepios was the god of healing. In fact, the classic symbol of medicine is a staff around which is wound one snake, the staff of Asklepios. Asklepios had two daughters, Hygeia and Panacea. Hygeia was the guardian of health and champion of common sense practices as the basis of wellness. Panacea, greek for "all healing" was primarily responsible for the use if interventions such as surgery and the use of chemicals with curative properties.

Today there is the continued dichotomy of Hygeia and Panacea. As a physician, I am more likely to be a hand of Panacea. Public Health is the acting arm of Hygeia. I see many patients each day, and I would like to think I have a benefit in lives. Hygeia is at an entirely different level. No matter the amount of work I do, the number of lives I save will never be equal to that saved by simple practices such as mosquito spraying, water filtration or appropriate garbage treatment. Hygeia has the possibility of saving untold numbers of lives. Imagine being at the forefront of the discovery of the link between fleas and the bubonic plague, or contaminated water and cholera.

Unfortunately, the relative importance of Hygeia versus Panacea has never been reflected monetarily. Treating individual patients is more lucrative. A surgeon that removes one tumor or a physician that prescribed one round of chemotherapy is rewarded much more than the number cruncher that connects bladder cancer with analine dyes and then increases the protection of those that work with the dyes, possibly saving thousands of lives.

The most pressing problem with Public Health is that it is designed to self-combust. With each new disease outbreak, the populace presses for an answer. The tireless soldiers of public health may isolate the contagion and then work endlessly to inform the public and reinforce preventive measures. If their work is successful, they are put out of business. The disease in question decreases in prevelence, public worry decreases, and funds dry up.

Such is the case in Winston-Salem. The pathogenesis of syphilis is treponema pallidum, and treatments have been available since 1908. We know how the disease is spread. By all accounts, syphilis should have gone the way of smallpox by now, almost 100 years after the definitive organism was found and a treatment made available. Unfortunately, syphilis is an STD, and as such, will always have a stigma. Not allowed in popular conversation, syphilis is a disease that must not be advertised. In addition, it is a disease that most people assume has been eradicated and so they do not seek medical care for the treatment of what is seen as a disease of an old world. Combine this with HIV, and syphilis is on the rise. In Winston-Salem and 9 other N.C. towns, syphilis rates have been 10-20 times the national average.

With the high rate of syphilis against national averages, the public health threat was noticed. Money was funneled into syphilis education and an education campaign was instituted to inform the population of these affected areas. As you can see from the graph, in 1998, money began to be funneled into educating the public in Winston-Salem about syphilis. The results were remarkable. The rates of syphilis dropped to less than 1 case in 100,000.

What was the reward???

Money spent towards education about syphilis has been moved elsewhere. As such, the rates will begin to rise. Money spent towards Public Health was successful, so much so that it will now be removed, to the detriment of this area.

However, the issue is not as cut and dry as it may seem. Yes, the disease is now on the rise, but the money is now being spent in other areas of the country where it will begin to decrease. In addition, continuously reminding a population with advertising of a disease will begin to have less of an effect as time goes by. Would this increase in syphilis (and thus the activities responsible for same) have occurred anyway, just as a corollary of our brains' tendency to focus on that which is new? Are we destined to always play with prey in the microbe predator-prey relationship? Does Panacea exist to save the individuals that fall in the cracks of Hygeia?

Torture from the Experts

Say what you may about the AMA, but the organization has gone on record against docs participating in torture in this war on terror. The APA, however, has not been so steadfast. Salon has uncovered psychologists that have been working to develop new and improved torture methods. These methods include waterboarding that simulates drowning, and a dog box designed to foster "learned helplessness." Many of these studies have been variants of experiments used in the past to help protect American soldiers from torture. Vanity Fair and the New Yorker have corraborated the story.

While the AMA has an explicit policy against participating in torture, the APA does not. This topic will likely be a popular one at the APA's annual meeting August 10th. President Koch has selected 10 psychologists to draft a statement, however 6 of these psychologists have direct ties to the military and 4 had been involved with detainees at Abu Ghraib or Guantenamo. It remains to be seen if the new policy will prohibit members from participating in torture.

A central tenet of medicine (psychology included) is "First, Do no Harm." Any participation in developing or implementing torture goes against this most basic of ideas.

Ether

In 1842, Crawford Long became the first physician to use ether as anesthesia. He used the medication to remove a tumor from a patient's neck. Crawford Long was born in Danielsville, Georgia, shared a room in college with Alexander Stephens, and his cousin was Doc Holliday.

In his early twenties, Dr. Long was a single partier. He noticed at many of the ether parties he attended that most participants would bang themselves up quite a bit. Despite developing large bruises, the partiers felt no pain during these frolics. From this recreational use of the drug, he wondered if similar benefit could be found medically. The rest is history.

SNAKES!!

The other day we had a guy come in after being bitten by a copperhead on his hand. The pain and swelling were spreading rapidly, making him a candidate for antivenin. I had never realized it, but that is an amazing expense. Consider that the average dose is 6-20 vials, at a cost of approximately $1000/vial. So, consider: you are out mowing the grass and are bitten by a snake. Next thing you know, it's a 20,000 bill just in CroFab. Of course, in my instance, practically seeing a snake may lead to an MI, so my costs may vary.

bovie

The Bovie electrocautery tool was developed by William T Bovie between 1914 and 1927. Dr. Bovie was an inventor with a doctorate in plant physiology. Dr. Bovie worked closely with Dr. Harvey Cushing at Harvard University to develop this tool used to pass high frequency electrical currents in to tissue. The first use of the Bovie knife was in 1927 by Dr. Cushing and was initially used on previously inoperable brain tumors. Most physicians today have been exposed to the Bovie, however Dr. Bovie himself did not benefit. He sold the patent on his machine for $1 and was not granted tenure at Harvard.

Unusual Presentations

A 45 year old hispanic female reports to the ER complaining of right sided abdominal pain. This is her third visit to the ER. The first visit was by ambulance one month previously, and she was discharged after observation and treatment for nausea and constipation. Labs were insignificant except for a UDS of methamphetamines and opiates. The second visit occurred two days later, with treatment of nausea and discharge. This is her third visit, she reports nausea, constipation and abdominal pain. Physical exam shows minimally distended abdomen that was tender to palpation. Labs were ordered, as was an abdominal CT. Labs were essentially negative, including the HCG. However, patient did have cholelithiasis and nephrolithiasis. At this time, patient is discharged with pain medicine and follow up.
Now she is in your ER the next day complaining of right sided abdominal pain. She has a history of diabetes and hypertension. She has had one laparotomy and an appendectomy. She denies taking any medication but the pain medication given. Vital signs are stable. Abdomen is diffusely tender, worse over the right lower and upper quadrant. What do you do?

Patient was discharged with follow-up, and returned the next day. At this time, she was admitted for pain control then discharged. She returned once more and expired.

I'm sure most people have heard the story of Edith Rodriguez and King-Harbor. I present this, not to discuss the many socio-economic factors involved, but to highlight the medical pathology. The autopsy report is at: http://www.latimes.com/media/acrobat/2007-06/30524153.PDF
According to the autopsy, the patient's death was caused by a ruptured colonic diverticulis. This is an interesting presentation, considering the patient seemed to only complain of right sided pain, and most cases of diverticulits result in left sided pain. Also, the case is a classic example of not "marrying a diagnosis." The patient did have another cause for her pain- multiple gallstones. The CT, a major tool for evaluating the abdomen, also seemed to be otherwise negative from the report, so how should further evaluation proceed? On ER visits and during the admission, should she be expectantly managed with serial exams, or would an ex lap have been appropriate? Assuming the exam did not show an acute abdomen, would surgery have been recommended, or would medical management with pain medicine and a surgical follow up have been more appropriate. Did the patient continue to not exhibit a classic acute abdomen? Were there signs of infection that we would have expected with diverticulitis?

We do not have information other than the autopsy and news reports, and cases are easier to examine in hindsight. However, often in medicine, the way to learn is from your mistakes. Right sided pain due to diverticulitis is an unusual presentation, and it is also wise to note that diverticulitis can lead to bowel perforations and can be fatal.