Tag Archives: immunize

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Release the Kraken!

I chose measly for the Ragtag Daily Prompt because there is a measles outbreak. Great. Another outbreak? Yes. Parents are behind on bringing kids in for Well Child Checks and kids are behind on immunizations, so measles.

Measles is way more infectious than Covid-19 and is spread by coughing and droplets. Per the CDC: “Measles is one of the most contagious diseases. Measles is so contagious that if one person has it, up to 90% of the people close to that person who are not immune will also become infected.” Read here. Immunizations are at 18 months and age 4-6, two shots. That will make the vast majority of children immune but not quite all. No immunization reaches quite 100%. Measles unfortunately can have some awful and serious complications including death. If your child is behind, get them immunized as soon as possible!

If some has the measles, the rash, they are measly. That is one of the definitions of measly.

Measly weasely
You are so teasely
Your heart has a rash
Our friendship is hash
You toss me like trash
Your heart just smashed
You are so measly
Weasely teasely

___________________

I keep wondering if the earth is annoyed at the way people are behaving. Perhaps she has said, “Release the Kraken!” But the most efficient Kraken turns out not to be a giant monster attacking New York City, but Covid-19, influenza, measles and strep A. Invasive strep A is out there too. Having had strep A pneumonia and borderline sepsis twice, I very much do not want invasive strep A.

It’s the little things that get us, right? Viruses, bacteria. Measles is a virus, like influenza and Covid-19. Strep A is a bacteria. I had very bad influenza in 2003 that put me out for two months. I read about influenza and thought, oh, we will have another pandemic and in fact we were overdue. They come about every fifty years. My children heard quite a bit about it. My daughter said she wondered if I was a little nuts until the ebola outbreak and then she decided that I was probably and unfortunately correct. The only surprise for me was that it was a coronavirus instead of influenza. That and that humans behave in very interesting and often dysfunctional ways when they are stressed: and the same ways as in the 1918-1920 influenza pandemic. Logic flies out the window replaced by panic, magical thinking and rumors and people happy to take advantage of others. Selling fake cures, refusing masks, refusing immunizations and denying that it is happening at all.

For the Ragtag Daily Prompt: measly.

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Covid-19: working in healthcare

So, should healthcare workers be required to have Covid-19 vaccines?

Yes.

What is the precedent?

Take tuberculosis, for example. Airborne, very contagious. I was born in a Knoxville, Tennessee tuberculosis sanatorium, because my mother coughed blood a month before she was due and got quarantined for active tuberculosis. Yes, the state could quarantine my mother. I was removed immediately at birth because tuberculosis doesn’t cross the placenta. The antibodies do, but the infection doesn’t. However, newborns usually catch it and die very quickly. I was lucky. My father and grandparents took care of me for 5 months. Then my mother was allowed out (after 6 months total) but was not strong enough to take care of me. So I was taken to my maternal grandparents for the next four months, and did not touch my mother until I was 9 months old.

My mother was taking 36 pills a day at home, because you have to use multiple drugs to kill tuberculosis. It develops drug resistance very very quickly.

Well, so what, you say?

Healthcare workers in the United States are routinely checked with a ppd for tuberculosis. If it is positive, you cannot work until further testing. If you have latent tuberculosis, you are treated. If you have active tuberculosis, the treatment is longer and more complicated, here: https://www.cdc.gov/tb/topic/infectioncontrol/default.htm

My cousin then said, “Well, you don’t have to show the tuberculosis test to go in a restaurant!”

Well, not right NOW, because currently tuberculosis is under more or less reasonable control in the US. Remember that guy who came in to the US with active multi drug resistant tuberculosis and knowingly exposed everyone on that airplane? Great. I remember reading about that and thinking what a selfish jerk he was. And then the group of unimmunized people who went to India and all got measles. The US at that time did not bar anyone from returning, but asked them to finish a 3 week quarentine before returning to the US. One person did not do that. There was a measles outbreak in the midwest which cost the CDC (and therefore you and me because those is tax dollars) millions to trace, quarantine and clean up. So there was discussion at that time about whether the policy should be changed and we should not allow US citizens with known infectious diseases to come in on airplanes. We DON’T allow immigrants in with infectious diseases: they are tested for tuberculosis if coming from countries where it is endemic.

So, if we had a huge outbreak of tuberculosis, we WOULD have quarantines and shut downs.

I have tested a patient for tuberculosis, about two years ago. Her son had been diagnosed with active tuberculosis. We tested her with a blood test and then repeated it in three months. Negative, hooray. In residency I also saw a case of miliary tuberculosis. That is where the tuberculosis is growing so well in the lungs that it looks like little grains of rice in the lungs on imaging. Not a good thing.

My cousin: “You shouldn’t have to put something in your body to work.”

If you have tuberculosis, you do not get to work in healthcare, because you can kill your patients. I think that this is a good thing, to not kill our patients.

I am submitting this to the Ragtag Daily Prompt: starspangled. Keep America Healthy, how about that?

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On covid-19

I am going to post a series of short essays I wrote on another site at the end of 2020. Because we have to work together and these are relevant. I will post one every day or two.

From Tuesday November 24, 2020:

I have just had a call asking for a Covid-19 test.

Not for symptoms.

Nope. Traveled from Washington to California with a buddy and “My sister thinks I should be tested.”

Me: “Oh, does your sister want you tested before you come to Thanksgiving?”

Patient: “Uh, I think so.”

Me: “First of all, the priority is for people who have symptoms or have been exposed. Secondly I am not ordering a test for someone who has no symptoms, chose to travel and then thinks it’s ok to go to a Thanksgiving dinner in another household if they get a negative. It’s not ok. You can test negative one day and be shedding virus the next. The quarantine after exposure is 14 days. The medical advice from the CDC, from the surgeon general and from me is STAY HOME.”

Others are asking for antibody tests. We don’t know if the antibodies mean you aren’t infectious. We don’t know how long they last. Typically with other covid viruses they don’t last long. In contrast, chicken pox virus gives lifelong immunity. We don’t know if a person can get Covid-19 again, though there have already been some cases. No, I won’t do an antibody test because the person “Just wants to know.”

STAY HOME STAY HOME STAY HOME.

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Headache without words

When I was in residency, a staff member brought a young man to see me.

The young man couldn’t talk. He could make some sounds. His head was a funny shape, asymmetric. His mother had rubella during her pregnancy: German measles.

“His head hurts.” said the group home staff member.

“How do you know?” I asked.

“He isn’t acting right. There is something wrong. He’s different.”

“How long?”

“About a week or ten days.”

“Did he fall?”

“We’ve talked about that but we don’t think so.”

I tell the young man what I am going to do before each part of the exam. I look in his ears carefully. His ear canals are odd too and I can’t see well. His exam is basically pretty normal for him. He is not running a fever. He doesn’t have a stiff neck. He doesn’t seem to have nasal congestion.

“If he hit his head, he could have a subdural, a bleed pressing on his brain.”

The staff member shakes their head.

“Ok. I can treat him for an ear infection, though I can’t see that well. If that doesn’t work, we will have to image his head. Would he stay still in a CT scanner?”

“No.” says the staff member.

“Then I would have to set it up with anesthesia. Which is difficult.”

So we treated him for an ear infection. No improvement. He returned. Exam unchanged. The staff was still sure his head hurt. I had never seen him before the initial visit, so I couldn’t tell.

I set up the CT scan with anesthesia. Twice, because they mucked it up the first time and it wasn’t coordinated right. I had to explain to multiple people on both anesthesia and radiology what and why I was doing it. “His head hurts and he can’t talk?” I argued until they gave in.

The ENT chief resident called me with the results. Not radiology. “What?” I said.

“It’s the biggest pseudocyst we’ve ever seen!” said the ENT chief. Surgeon. “He needs surgery!” His voice said “Cool!”

In residency I’d noticed a striking difference between family practice and other residency folks: internal medicine, surgery, neurology, all the subspecialties. They got excited when there was something rare or weird. I always thought, oh, shit, my poor patient.

“What is a pseudocyst?” I actually didn’t ask, because they knew I was just a lowly family practice resident and would probably not have heard of a pseudocyst. A cyst like structure can form of snot in the sinuses and can cause headaches. It can erode through the bone into the brain. His hadn’t, thank goodness, because that can be bad. Bad as in lethal.

Because of the measles, he had some of the largest sinuses ENT had seen ever, and the largest pseudocyst. ENT happily took him off to surgery. Great case.

I got to see him in follow up. He was his normal self. His group home staff member was delighted. “He’s back to normal! Thank you so much!”

But it’s the group home staff that noticed and cared and brought him in. “Thank you for bringing him in,” I said, “I would not have noticed. And some people wouldn’t have cared.”

Differentiating pseudocysts and other things: http://www.oapublishinglondon.com/article/1266

More on pseudocysts: http://www.ncbi.nlm.nih.gov/pubmed/6595617

Pseudocyst images: https://www.google.com/search?q=maxillary+sinus+pseudocyst&biw=1366&bih=634&source=lnms&tbm=isch&sa=X&ved=0CAcQ_AUoAWoVChMIoZzWwv_QyAIVUJuICh248gGC

Rubella in pregnancy: http://www.marchofdimes.org/complications/rubella-and-pregnancy.aspx

Rubella, aka German measles: http://www.mayoclinic.org/diseases-conditions/rubella/basics/definition/con-20020067

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Influenza alert!

My small clinic has only been open again with our wonderful Megan Bailey, PAC, for a month, but we’ve already seen two people with influenza. And that is seeing less then ten people daily.

Please get your influenza shot. Yes, it doesn’t cover all of the strains, but most years it covers 80%. And initially Washington was seeing influenza B but now it’s influenza A and that has better coverage.

Remember that the vaccine takes up to two weeks to provide immunity. Consider wearing a mask if you have to go on an airplane — our second patient with influenza had gotten off an airplane that day. If you get a cold within one or weeks of getting the influenza vaccine, that is not caused by the vaccine. You are still at risk for influenza as well, especially the first two weeks.

If you have influenza, stay home and try not to expose other people. If you have frail or elderly or sick family, or very young children in the family, make sure that you get to the doctor early and see if prophylactic treatment is needed for household members who are exposed. If you are in the doctor’s office with any upper respiratory symptoms, put on a mask. That way you will not infect and potentially kill other patients.

Here is the CDC weekly influenza surveillance map: http://www.cdc.gov/flu/weekly/usmap.htm

You can watch it change color as the influenza crosses the country from east to west.

Please take care and Happy New Year!

The picture is the Solstice sunrise outside my house…