In real life (i.e. not on this blog), I'd been pretty critical of John McCain's medical history of melanoma so was pleased when he released his medical records, limited that they were. Back in the early primaries, I was equally critical of Barack Obama's smoking habit (correction: smoking addiction). That issue just faded away. Where is it now? Evidently, Obama may still be smoking. Michael Kinsley of the Washington Post thinks it's okay that he's fibbing about quitting. I'm not so sure I agree with that, but I am sure about it not being okay that the next president smokes. We need some health advocacy groups to jump on that (if it's true).
What have you heard about the next president lighting up?
Showing posts with label Public Health. Show all posts
Showing posts with label Public Health. Show all posts
Thursday, November 20, 2008
Friday, July 25, 2008
Blogging My Needle Stick
Taking my lead from ScienceBloggers Abel, who blogged his vasectomy, Dr. Free-Ride, who blogged her mammogram, or Zuska, who blogged her dilation and curettage, I decided to blog a recent personal medical experience of my own: a dirty needle stick.
Working in the Harborview emergency room is a unique experience. Medical students have the unique opportunity to be 'doctor' for a large number of patients. Yes, we have supervision... but if a case is straight-forward, we are permitted, correction, expected to manage the patients' care from start to finish. Students also see a large number of complex cases. Typical large hospitals may see 4 or 5 traumas roll through the door in a day. Regional trauma centers like Harborview commonly receive 50 medivac, airlift or medic arrivals each day. Medical students only manage the most simple of these cases, and even then, it's under the close eye of two residents and an attending physician.
It was in one of these cases that I incurred my first dirty needle stick.
Before this time, I'd never actually stuck myself with a needle. Five hundred rodent thoracotomies and a year in medical school, and never once had I punctured my skin with a suture or injection needle. My clean streak ended in the Harborview ER.
We received a morning transfer from a hospital in Montana. The announcement had come in over intercom that an intubated young man with a gunshot wound to the face was in transit. Only the basics are conveyed in these announcements, the dispatch only relays information critical to receiving the patient and supporting him. Often, GSWs (as they are referred to on the patient board) come with no warning. Rooms are already equipped to handle victims' emergent needs. By the time that "Airlift is through the door" was announced, I was in the room ready to help with the case.
My extensive (for a medical student) experience with delicate surgeries comes in handy in the trauma bays. I am happy to suture head and hand lacerations for the busy residents, and I take pride in my skillful artistry. (Although, I am careful not to tell patients where I got all of my experience.) By some miracle, the large gage bullet missed the jugular vein and carotid artery. It had destroyed most of the right half of the jaw and torn open the neck below where the angle of the jaw had been. Without major vessel damage, it was clear that some temporary repair would be performed before the patient went to the operating room; I made sure I was in the right place to help. By the time the ear nose and throat (ENT) surgeon came down to the ER, I had washed the wound with five liters of warm sterile saline. The surgeon was a young resident. At the time, I made no notice - owing to my extra-medical education, most of the residents are younger than I am. But this guy might fly in the face of a previous argument I made in the debate over whether it's more dangerous to get sick in July than any other month.
In the hierarchy of medicine, there is one way to make suggestions to superiors that helps get around the delicacy of status. It's the "would you like me to" question. Medical students and residents should always pay attention to the friendly nurse who asks, "would you like me to send this blood for lactate and enzymes, too?" or the physician's assistant who asks "would you like me to sign an order for labetasol? I've had good success turning this into a nice approach to suggest we do something with minimal toe steppage. In this case, I asked:
At my hospital, one employee per day experiences a needle stick. It is so common among health care providers that there are highly standardized approaches to dealing with the experience. The first steps occur in the ER. Fortunately for me, I was already there and everyone I came in contact with worked in an efficient manner. Along with the compassionate first year surgery resident who later that day asked if I wanted to talk about my experience, or the attending who checked in by email several days later, the efficiency of the process counter-balance my building worry with a sense of support. None of them knew that my wife was on vacation out of the country and that I might not have anyone at home to talk about this with. They were just there.
So what is the risk of needle stick injuries in contracting blood-borne diseases? My reading suggests the average risk for HIV transmission after percutaneous exposure to infected blood is low - about 3 per 1,000 injuries. And that is with exposure to infected blood. The other killers to worry about are the hepatitis B and C injuries, and they have much greater transmission rates. Transmission in needle sticks with exposure to the hepatitis B virus is 30% and could be as high as 10% for the hepatitis C virus. Like all health care workers, I am immunized against Hep B. There are a host of other diseases transmissible by blood (see this nice Canadian site for more info), but I was most worried about Hep C and HIV. There are no cures or vaccines for these diseases, but there are decent treatments for them. In particular, immediate use of anti-retroviral drugs have good evidence of reducing transmission from needle sticks. But did I want to take them? This returns me to the specifics of my situation. Much of medicine is paying attention to the history; this case's history is obscured because the patient was intubated and communicating via hand squeezes, and that his family was still en route.
The patient was a young man from rural Montana. Epidemiologically, that cuts his risk of having HIV or Hep C. But why was he shot? The story at the time was that he was snooping around a hermit's shack at 2:00 in the morning. My hunch was that illegal behavior was involved. Fair or not, at the time, this element increased my perceived risk of his being seropositive. In my head, I quickly came to the conclusion that my chances of catching one of the big three were very small, but not non-existent. I made the quick decision to take a dose of Truvada.
Whenever there is a dirty needle stick, the potential donor's and the stuck person's blood are sent for testing. This information is used both to treat or reassure the stuck employee and to establish a record of serotype. Usually the patient who's blood contaminated the needle must give consent for the tests, but in the case of an unaccompanied unresponsive patient, this makes matters more difficult. So my blood was sent, and eventually his was. (By the way, this information is divorced from the patient's or my medical record, for both confidentiality and billing purposes.) When the rapid antibody-based HIV test returned negative, I was comforted, but not quite enough to stop taking the anti-retrovirals. Anyone who's taken or given an HIV test should know about the "window period." This is the time it takes for the immune system to seroconvert: it's the interval between infection and a measurable level of antibodies in the blood. For HIV, this is about 6 weeks, but many still use 3 months as a fallback number. The antibody test can therefore only tell you the HIV status of a person three months ago. There's another, more expensive test that measures the virus rather than the human antibody to the virus. It uses genetic amplification to look for viral genetic markers. This can both reveal virus before antibodies are formed and tell physicians how much virus is in the blood (and therefore, more about the patient's symptoms and disease progression). I decided to request this test. After all, if this young man recently took to exploring hermits' shacks, what's to say he hasn't experimented with new drugs or sexual practices?
This argument was barely enough to convince the employee health director to proceed with the genetic test on the patient's blood and required me to take two more days of the one-a-day emtricitabine/tenofovir combo drug. After several conversations opening with my telling her my mother's maiden name, I learned that my serologies and the patient's were all consistent with no infections or infectivity. By then the stress of this experience had faded into just another experience in the Harborview ER. I'll probably be stuck again, and next time, probably won't seek the viral PCR test. But will I take the anti-retroviral immediately after the exposure? You betcha! With no side effects and once a day treatment, the only reservation is cost. I don't know how much one Truvada pill costs because my hospital paid for it. By the time the next stick occurs, the state of diagnosis and prophylaxis for HIV and Hep C may have changed. Perhaps there will even be vaccines.
Perhaps.
Working in the Harborview emergency room is a unique experience. Medical students have the unique opportunity to be 'doctor' for a large number of patients. Yes, we have supervision... but if a case is straight-forward, we are permitted, correction, expected to manage the patients' care from start to finish. Students also see a large number of complex cases. Typical large hospitals may see 4 or 5 traumas roll through the door in a day. Regional trauma centers like Harborview commonly receive 50 medivac, airlift or medic arrivals each day. Medical students only manage the most simple of these cases, and even then, it's under the close eye of two residents and an attending physician.
It was in one of these cases that I incurred my first dirty needle stick.
Before this time, I'd never actually stuck myself with a needle. Five hundred rodent thoracotomies and a year in medical school, and never once had I punctured my skin with a suture or injection needle. My clean streak ended in the Harborview ER.
We received a morning transfer from a hospital in Montana. The announcement had come in over intercom that an intubated young man with a gunshot wound to the face was in transit. Only the basics are conveyed in these announcements, the dispatch only relays information critical to receiving the patient and supporting him. Often, GSWs (as they are referred to on the patient board) come with no warning. Rooms are already equipped to handle victims' emergent needs. By the time that "Airlift is through the door" was announced, I was in the room ready to help with the case.
My extensive (for a medical student) experience with delicate surgeries comes in handy in the trauma bays. I am happy to suture head and hand lacerations for the busy residents, and I take pride in my skillful artistry. (Although, I am careful not to tell patients where I got all of my experience.) By some miracle, the large gage bullet missed the jugular vein and carotid artery. It had destroyed most of the right half of the jaw and torn open the neck below where the angle of the jaw had been. Without major vessel damage, it was clear that some temporary repair would be performed before the patient went to the operating room; I made sure I was in the right place to help. By the time the ear nose and throat (ENT) surgeon came down to the ER, I had washed the wound with five liters of warm sterile saline. The surgeon was a young resident. At the time, I made no notice - owing to my extra-medical education, most of the residents are younger than I am. But this guy might fly in the face of a previous argument I made in the debate over whether it's more dangerous to get sick in July than any other month.
In the hierarchy of medicine, there is one way to make suggestions to superiors that helps get around the delicacy of status. It's the "would you like me to" question. Medical students and residents should always pay attention to the friendly nurse who asks, "would you like me to send this blood for lactate and enzymes, too?" or the physician's assistant who asks "would you like me to sign an order for labetasol? I've had good success turning this into a nice approach to suggest we do something with minimal toe steppage. In this case, I asked:
- Would you like me to make a sterile field around the wound?
- What size gloves do you wear?
- What do you think about clamping this small artery? and
- Would you like me to move the sharps off your field?
At my hospital, one employee per day experiences a needle stick. It is so common among health care providers that there are highly standardized approaches to dealing with the experience. The first steps occur in the ER. Fortunately for me, I was already there and everyone I came in contact with worked in an efficient manner. Along with the compassionate first year surgery resident who later that day asked if I wanted to talk about my experience, or the attending who checked in by email several days later, the efficiency of the process counter-balance my building worry with a sense of support. None of them knew that my wife was on vacation out of the country and that I might not have anyone at home to talk about this with. They were just there.
So what is the risk of needle stick injuries in contracting blood-borne diseases? My reading suggests the average risk for HIV transmission after percutaneous exposure to infected blood is low - about 3 per 1,000 injuries. And that is with exposure to infected blood. The other killers to worry about are the hepatitis B and C injuries, and they have much greater transmission rates. Transmission in needle sticks with exposure to the hepatitis B virus is 30% and could be as high as 10% for the hepatitis C virus. Like all health care workers, I am immunized against Hep B. There are a host of other diseases transmissible by blood (see this nice Canadian site for more info), but I was most worried about Hep C and HIV. There are no cures or vaccines for these diseases, but there are decent treatments for them. In particular, immediate use of anti-retroviral drugs have good evidence of reducing transmission from needle sticks. But did I want to take them? This returns me to the specifics of my situation. Much of medicine is paying attention to the history; this case's history is obscured because the patient was intubated and communicating via hand squeezes, and that his family was still en route.
The patient was a young man from rural Montana. Epidemiologically, that cuts his risk of having HIV or Hep C. But why was he shot? The story at the time was that he was snooping around a hermit's shack at 2:00 in the morning. My hunch was that illegal behavior was involved. Fair or not, at the time, this element increased my perceived risk of his being seropositive. In my head, I quickly came to the conclusion that my chances of catching one of the big three were very small, but not non-existent. I made the quick decision to take a dose of Truvada.
Whenever there is a dirty needle stick, the potential donor's and the stuck person's blood are sent for testing. This information is used both to treat or reassure the stuck employee and to establish a record of serotype. Usually the patient who's blood contaminated the needle must give consent for the tests, but in the case of an unaccompanied unresponsive patient, this makes matters more difficult. So my blood was sent, and eventually his was. (By the way, this information is divorced from the patient's or my medical record, for both confidentiality and billing purposes.) When the rapid antibody-based HIV test returned negative, I was comforted, but not quite enough to stop taking the anti-retrovirals. Anyone who's taken or given an HIV test should know about the "window period." This is the time it takes for the immune system to seroconvert: it's the interval between infection and a measurable level of antibodies in the blood. For HIV, this is about 6 weeks, but many still use 3 months as a fallback number. The antibody test can therefore only tell you the HIV status of a person three months ago. There's another, more expensive test that measures the virus rather than the human antibody to the virus. It uses genetic amplification to look for viral genetic markers. This can both reveal virus before antibodies are formed and tell physicians how much virus is in the blood (and therefore, more about the patient's symptoms and disease progression). I decided to request this test. After all, if this young man recently took to exploring hermits' shacks, what's to say he hasn't experimented with new drugs or sexual practices?This argument was barely enough to convince the employee health director to proceed with the genetic test on the patient's blood and required me to take two more days of the one-a-day emtricitabine/tenofovir combo drug. After several conversations opening with my telling her my mother's maiden name, I learned that my serologies and the patient's were all consistent with no infections or infectivity. By then the stress of this experience had faded into just another experience in the Harborview ER. I'll probably be stuck again, and next time, probably won't seek the viral PCR test. But will I take the anti-retroviral immediately after the exposure? You betcha! With no side effects and once a day treatment, the only reservation is cost. I don't know how much one Truvada pill costs because my hospital paid for it. By the time the next stick occurs, the state of diagnosis and prophylaxis for HIV and Hep C may have changed. Perhaps there will even be vaccines.
Perhaps.
Thursday, June 05, 2008
Teenage Sex
In the past 16 hours, I've removed extensive perineal condylomas (laser ablation) from a 14 year old and removed a tubal ectopic pregnancy (laproscopic excision) from an 18 year old. Well, I "assisted" with the procedures... Ectopics occur in 2% of pregnancies, are fatal to the fetus and very dangerous to the mother. They must be removed ASAP - hence the call at 10:30 tonight. Genital warts are far more common. I think every human is infected with at least one of the more than 100 human papillomaviruses (HPV). Some of these viruses cause plantar warts, others are to blame for genital warts, yet others predispose women to cervical cancer. If you have an immune deficiency, the virus can turn you into a tree. HPV ranges from benign to deadly. (GUESS WHAT! There's a vaccine for the HPV's that most often lead to cervical cancer! If you're reading this, you're too old - you've already been exposed. But your 10 year-old-daughters haven't. Give them Gardasil. They'll thank you...)
But this gets me back to the point of this entry. Teenagers are having sex. Remember back in the '90's? There was lots of talk about safe sex, safer sex, harm reduction, and a catchy little phrase, "safe, legal and rare." What was the outcome of such openness? Some say there was hypersexualization of pop culture. Wait a minute... Wasn't it an earlier generation that subscribed to free love? Hmmm... It turns out that a concerted campaign to educate teens of the risks of sex and ways to make it safer ACTUALLY reduced the amount of sex teenagers had. Whoa...
Any scientist who's tried to publish the results from a new knockout mouse knows that showing an effect of the intervention is not enough. You need to also show the 'rescue.' Basically, turn the mouse back to the way it was before the change and see if the outcome reverts. Well, whadaya know? The last 8 years HAVE BEEN JUST THAT! Abstinence only, no talk of condoms, no pregnancy preparation no nothing with public money have all combined to flip the culture from the previous decade. That decline in age of first intercourse and encounter frequency stops. It's been in a holding pattern. Well, at least kids aren't having more sex... yet... Teen pregnancy is up this year (first time in 15 years!) and 1 in 4 teenage girls have an STD.
It doesn't take the chairman of the department of population and family health at Columbia University to point out that "abstinence education spends a good amount of time bashing condoms. So it's not surprising, if that's the message young people are getting, that we're seeing condom use start to decrease." But John Santelli went ahead and stated the obvious in a Washington Post article that got me all riled up after a day of medical treatment of the effects of teen sexuality. Sure, comprehensive sex ed will be blamed. (Hey, Jimmy! we sure learned some swell things in school today - you want to do some homework later?) Oh, and don't forget about R-rated movies. And the internet. And hormones. And those perverts at Planned Parenthood.
Humans cannot divide asexually. If we don't talk about the consequences of our species' tendency to rely on genetic recombination, someone else will. It will be your kids' doctors, delivering their babies or treating them for gonorrhea, HPV or worse.
"Just say no!" didn't work for drugs. It looks like it doesn't work for sex, either.
Let's talk...
But this gets me back to the point of this entry. Teenagers are having sex. Remember back in the '90's? There was lots of talk about safe sex, safer sex, harm reduction, and a catchy little phrase, "safe, legal and rare." What was the outcome of such openness? Some say there was hypersexualization of pop culture. Wait a minute... Wasn't it an earlier generation that subscribed to free love? Hmmm... It turns out that a concerted campaign to educate teens of the risks of sex and ways to make it safer ACTUALLY reduced the amount of sex teenagers had. Whoa...
Any scientist who's tried to publish the results from a new knockout mouse knows that showing an effect of the intervention is not enough. You need to also show the 'rescue.' Basically, turn the mouse back to the way it was before the change and see if the outcome reverts. Well, whadaya know? The last 8 years HAVE BEEN JUST THAT! Abstinence only, no talk of condoms, no pregnancy preparation no nothing with public money have all combined to flip the culture from the previous decade. That decline in age of first intercourse and encounter frequency stops. It's been in a holding pattern. Well, at least kids aren't having more sex... yet... Teen pregnancy is up this year (first time in 15 years!) and 1 in 4 teenage girls have an STD.
It doesn't take the chairman of the department of population and family health at Columbia University to point out that "abstinence education spends a good amount of time bashing condoms. So it's not surprising, if that's the message young people are getting, that we're seeing condom use start to decrease." But John Santelli went ahead and stated the obvious in a Washington Post article that got me all riled up after a day of medical treatment of the effects of teen sexuality. Sure, comprehensive sex ed will be blamed. (Hey, Jimmy! we sure learned some swell things in school today - you want to do some homework later?) Oh, and don't forget about R-rated movies. And the internet. And hormones. And those perverts at Planned Parenthood.
Humans cannot divide asexually. If we don't talk about the consequences of our species' tendency to rely on genetic recombination, someone else will. It will be your kids' doctors, delivering their babies or treating them for gonorrhea, HPV or worse.
"Just say no!" didn't work for drugs. It looks like it doesn't work for sex, either.
Let's talk...
Sunday, April 06, 2008
Heston's Fingers
I think that we can finally pry that gun from his cold, dead fingers.
Unfortunately, gun control is not so much of an issue in the current political environment. I'll still have to learn how to treat gunshot wounds...
Unfortunately, gun control is not so much of an issue in the current political environment. I'll still have to learn how to treat gunshot wounds...
Tuesday, October 16, 2007
Life
How is it that being a third-year medical student can both suck the life out of you and inject you full of it?
Speaking of getting injected full of it, did you get your flu shot yet? You medical types can get it for free, and the last time I checked, my local Safeway had doses for $10. That's $10 that can save your life. In the United States, 36,000 people die every year from influenza, and 200,000 will be admitted to the hospital this season.
Last week in my hospital's virology lab, I saw the first positive viral fluorescent antigen test for influenza A in Seattle (and maybe the state of Washington). It's still a little early for the cases to be rolling in, but what you get today should protect you for the whole season.
Just do it.
Speaking of getting injected full of it, did you get your flu shot yet? You medical types can get it for free, and the last time I checked, my local Safeway had doses for $10. That's $10 that can save your life. In the United States, 36,000 people die every year from influenza, and 200,000 will be admitted to the hospital this season.
Last week in my hospital's virology lab, I saw the first positive viral fluorescent antigen test for influenza A in Seattle (and maybe the state of Washington). It's still a little early for the cases to be rolling in, but what you get today should protect you for the whole season.
Just do it.
Saturday, October 13, 2007
Kill Your Television
Or send it to its room for a timeout.
A recent study found that 32% of 2- to 7-year-olds and 65% of 8- to 18-year-olds have television sets in their bedrooms. The average child in the U.S. watches television an average of 3 hours a day. This figure increases to 6.5 hours a day if other media such as videotapes and video games are included.
Although television may serve as a positive educational medium, several negative associations have been described, including increased violent and aggressive behavior, poor body image, substance use, early sexual activity and obesity. The American Association of Pediatrics recommends limiting children's total media time to no more than 1-2 hours a day of quality programming and removing TVs from children's bedrooms.
Okay - maybe you shouldn't send the TV to its room. Instead, send it out of the room.
Who knew that television was a medical issue!
A recent study found that 32% of 2- to 7-year-olds and 65% of 8- to 18-year-olds have television sets in their bedrooms. The average child in the U.S. watches television an average of 3 hours a day. This figure increases to 6.5 hours a day if other media such as videotapes and video games are included.
Although television may serve as a positive educational medium, several negative associations have been described, including increased violent and aggressive behavior, poor body image, substance use, early sexual activity and obesity. The American Association of Pediatrics recommends limiting children's total media time to no more than 1-2 hours a day of quality programming and removing TVs from children's bedrooms.
Okay - maybe you shouldn't send the TV to its room. Instead, send it out of the room.
Who knew that television was a medical issue!
Thursday, October 11, 2007
The Pox
I was on call today. At my current hospital, this means that I work from 7A to about midnight and take care of some of the new patients that join our team. ("Join our team" has an interesting but not so inappropriate second meaning...Someone remind me to explore that later.) On the bus ride home, I realized my two charges have an interesting connection: Varicella.Varicella is the virus that causes chicken pox. My first patient came in for an inflammatory disease, and because of his parents' beliefs about immunization, had not received any vaccines. He got the chicken pox as a toddler and then a few months later, shingles. Ouch. My second patient was a baby who got the chicken pox from a teenage sibling. The child in between (age 5) had been vaccinated and had no symptoms. My patient is 7 months old - too young for varicella vaccination.
I will refrain from comments about vaccination here, since my impression of the chicken pox is that it's a harmless disease. I will say the chances are good the facts are at odds with my sentimental 'when I was a kid' perspective.
Two kids: one from the northern and western hemispheres; the other from the southern and eastern hemispheres. Both in Seattle. With important chicken pox stories. On the same floor. Three doors down. Under my care.
Whoa.
Sunday, August 05, 2007
Medicine 2.0
Web 2.0 is the name for the user controlled distribution of content on the internet. It's a broad term that includes now-common elements of the web like wikis, blogs, social networking platforms and personal broadcasting (like YouTube and podcasts). A contingent of health care provider bloggers contribute to a regular online conference (called a carnival) to share ideas about how web 2.0 could change health care. Head over to The Health Wisdom Blog for the latest Medicine 2.0 carnival. My contribution features the Who Is Sick service, a site where anyone can self-report symptoms. I ask whether this will help providers and public health folks understand current contagious illnesses, or will it confuse efforts to understand cold season epidemiology? Other entries highlight using the virtual world SecondLife to teach chemistry, and the danger of using the physician's online tool UpToDate too much.
Tuesday, July 31, 2007
Dead Crows
Lately, my walks to and from bus stops or around campus have included a little foraging for berries, flowers, coyote scat and other cool stuff. A consequence of this is that I notice (more than usual) animal carcasses. Since I am on the lookout for an intact crow's head for a Wunderkammern project I am working on, there are a few health issues I need to pay close attention to. Namely, West Nile Virus. If you see a dead crow and live in a region where WNV has been detected, there's a good chance your county has a reporting system in place. In King County, you can call 206-205-4394 M-F 8a-5p, or go to the easy web-based form I just used to report two crow roadkills I saw on Saturday.
Sunday, July 29, 2007
Meddling With Public Health
Today's Washington Post revealed the specific machinations behind the Bush administration's gagging of former Surgeon General Richard Carmona. Carmona testified to congress earlier this month about the obfuscation and silencing of reports from the SG's office. There are no surprises here, except for perhaps the extent of nepotism and good-'ole-boyness in government right now.
The individual responsible for carrying out the long arm of the Bush/Cheney law is William Steiger. Heres some background:
There it is! The chief qualification for being a Bush appointee: Never cautious about giving your boss an "Atta Boy!" Steiger had it. Carmona didn't. Carmona's out. Steiger's in. Let's tell him what he's won: Steiger is now awaiting a Senate vote on his nomination as Bush's ambassador to Mozambique. Send your senator an email. Ask him or her to vote no for Steiger. Tell the Senate you've had enough of Bush's patsies. For his political meddling with public health reports, Steiger gets a thumbs down from me on scientific integrity. From Bush et al., he gets an ambassadorship? Just say no!
The individual responsible for carrying out the long arm of the Bush/Cheney law is William Steiger. Heres some background:
Steiger, 37, is a godson of former president George H.W. Bush and the son of a moderate Republican who represented Wisconsin in the House and hired a young Dick Cheney as an intern. The elder Bush appointed Steiger's mother to the Federal Trade Commission in 1989. Steiger's parents, now deceased, were "lifelong friends" of the Rumsfelds and the Bushes.In reference to a report on global health, Carmona said that a senior Bush aide (now known to be Steiger) told him "this will be a political document, or it will not be released." The Post reports that
Steiger said that "political considerations" did not delay the report; "sloppy work, poor analysis, and lack of scientific rigor did." Asked about the report's handling, an HHS spokeswoman said Friday that it is still "under development."This all comes from a man without any public health or scientific experience or credentials. So what are his credentials, apart from being born into the right family? A Department of Health and Human Services spokesman invites us
"to look at his skills as an executive leader in spite of the fact that he doesn't have a medical degree or a public health degree."I am not buying that. How about this insight from a different career HHS employee:
"Steiger always had his political hat on," he said. "I don't think public health was what his vision was. What he was looking for, and in general what he was always looking for, was, 'How do we promote the policies and the programs of the administration?'"
There it is! The chief qualification for being a Bush appointee: Never cautious about giving your boss an "Atta Boy!" Steiger had it. Carmona didn't. Carmona's out. Steiger's in. Let's tell him what he's won: Steiger is now awaiting a Senate vote on his nomination as Bush's ambassador to Mozambique. Send your senator an email. Ask him or her to vote no for Steiger. Tell the Senate you've had enough of Bush's patsies. For his political meddling with public health reports, Steiger gets a thumbs down from me on scientific integrity. From Bush et al., he gets an ambassadorship? Just say no!
Wednesday, July 18, 2007
Canada Declares War on Pittsburgh
Following the revelation that federal and county officials rounded up and exterminated 272 Canada geese in Allegheny County's North Park, Canadian Parliament moved to honor a long-standing treaty with GeesePeace by declaring war on Pittsburgh, Pennsylvania. The Canucks are in for a tough battle, however. County parks director Andy Baechle reports that
they had two people out on the lake in canoes and a guy on land with a laserrounding up the geese. The geese were collected in cages and shipped to a meat processing plant in Latrobe, PA. No word yet on whether the plant is in any way connected with Rolling Rock beer. The Pittsburgh populace has little to fear. Unlike some countries, in Canada, 'declaring war' is synonymous with 'pursuing diplomacy.'
Tuesday, July 10, 2007
America's Next Top Doctor
The confirmation hearings for America's Next Top Doctor are in a couple of days, so hopefully you will start to hear something about that in the media. The first big story I came across came by way of a House Oversight and Government Reform Committee hearing where the former Surgeon General spoke. From what I can gather, Dr. Richard Carmona, a Bush appointee, was interested in applying scientific evidence to the practice of medicine and public health. He was most notably silenced on his perspectives concerning human embryonic stem cell research, and a commitment to comprehensive sex education.
Update 7/13/07: Yesterday, Dr. Holsinger testified for the first time. Of note was this statement referring to an anti-gay position paper he wrote for the Methodist Church in the early '90s:
Carmoma's prepared remarks to the committee are available here.
A nice NPR review of Holsinger's testimony is here.
Carmona reported that his Surgeon General predecessors - Republican and Democratic appointees - told him, "We have never seen it as partisan, as malicious, as vindictive, as mean-spirited as it is today, and you clearly have it worse than anyone's had."It is sad how familiar this refrain has become. From his prepared comments (I recommend listening to these words from his own mouth in an online NPR segment):
"The reality is that the nation’s doctor has been marginalized and relegated to a position with no independent budget, and with supervisors who are political appointees with partisan agendas. Anything that doesn’t fit into the political appointees’ ideological, theological, or political agenda is ignored, marginalized, or simply buried."For respecting the principle that public health should be based in sound science rather than a political agenda, Carmona's term was not renewed. Let's see if Dr. James Holsinger, the next appointee in line for this will be able to toe the Administration's line. If he does, he deserves to be sacked in 2008. If he doesn't, good for him. Holsinger might be facing an uphill battle; comments denigrating homosexuality have already earned him two 'no' votes on the Senate Committee on Health, Education, Labor and Pensions, who will be holding the confirmation hearings this week.
Update 7/13/07: Yesterday, Dr. Holsinger testified for the first time. Of note was this statement referring to an anti-gay position paper he wrote for the Methodist Church in the early '90s:
"First of all, the paper does not represent where I am today. It does not represent who I am today," Holsinger replied. He said he was not anti-gay, and that he wrote the paper in response to a request from religious scholars who wanted him to summarize the medical literature.Which scientist among us has never changed his or her mind in the face of evidence that contradicts previous assumptions or hypotheses? Isn't the point of bringing science and/or rationality into the political process so that people will change their minds to adopt a truer course of action. Somehow this always gets mixed up in that political character flaw known as flip-flop.
Carmoma's prepared remarks to the committee are available here.
A nice NPR review of Holsinger's testimony is here.
Saturday, June 23, 2007
Who Is Sick?
Are you ever sick but not enough to bother with a visit to the doc? Do you wonder if you've just caught the bug that is going around? Thanks to an interesting new site, you can now dial up a snapshot of illness over the past two months in your zip code.
Who Is Sick? is a new website where users self-report their symptoms and can see if others have the same thing. I have some sniffles today, so took a first-hand tour of the system. Call up your zip code and you'll see a map with a bunch of little trivial pursuit game pieces. Averages of the reported symptoms and a bar graph of total illness reports in the past two months is also visible.
The default mode is for posting an illness. Users fill in their pies, but instead of Science, Arts or Sports & Leisure, they choose wedges like Fever, Stomach Ache or Cough. I clicked the Runny Nose box, filling in a red wedge. Select your age and gender before reporting more details. I entered, "General malcontent with sniffles. Could be allergies and/or stress & fatigue."
One 40 year old woman claims to have picked up her "Runny Nose, Stuffy Nose, Sneeze, Cough Sore Throat, Fever, Chills, Muscle Ache, Body Ache, Tired" illness "from a child at the KEXP's annual Father's Day dance party."
The site is inspired by other simple Web 2.0 functions like Craig's List and real estate mapping programs. It is easy to use and has a clever interface. I might use it again, but probably will not stake any personal medical decisions on it. As a future physician, I am not sure if I would rely on hearsay from other providers about what is "going around" more or less than a site like this. If it produced generalized reports for a city, I might give it the benefit of the doubt. Public health experts from Seattle give it mixed reviews.
This site would improve its utility if users were forced to report a date of symptom onset. Also, the bar graph indicating "# of sicknesses over the last 8 weeks" will be unreliable until some steady state usage is achieved. Right now, it doesn't seem to me that nearly enough people are reporting for there to be a reasonable chance of discovering someone with the same illness. This begs a question: How many different upper respiratory illnesses, stomach flues, influenzas, head colds and other contagious goodies are there out there at any time? Can we really identify a preponderance of particular causative agents based on symptom reports?
And who are the folks registering symptoms? I am going to guess there is a tendency for self-reporters to be slightly more hypochondriac than most. This or any similar skewing of the data is a data collection problem public health officials call reporting bias. I picked from one list at least ten other types of bias. If this data were to be used in any sort of study or health recommendations, it would have a number of problems. The website authors clearly indicate it is not their intent to use this for public health assessments. From their website,
Instead of tracking stomach aches and head colds, maybe someone should think about reducing the hassle of medicine!
Who Is Sick? is a new website where users self-report their symptoms and can see if others have the same thing. I have some sniffles today, so took a first-hand tour of the system. Call up your zip code and you'll see a map with a bunch of little trivial pursuit game pieces. Averages of the reported symptoms and a bar graph of total illness reports in the past two months is also visible.
The default mode is for posting an illness. Users fill in their pies, but instead of Science, Arts or Sports & Leisure, they choose wedges like Fever, Stomach Ache or Cough. I clicked the Runny Nose box, filling in a red wedge. Select your age and gender before reporting more details. I entered, "General malcontent with sniffles. Could be allergies and/or stress & fatigue."
One 40 year old woman claims to have picked up her "Runny Nose, Stuffy Nose, Sneeze, Cough Sore Throat, Fever, Chills, Muscle Ache, Body Ache, Tired" illness "from a child at the KEXP's annual Father's Day dance party."
The site is inspired by other simple Web 2.0 functions like Craig's List and real estate mapping programs. It is easy to use and has a clever interface. I might use it again, but probably will not stake any personal medical decisions on it. As a future physician, I am not sure if I would rely on hearsay from other providers about what is "going around" more or less than a site like this. If it produced generalized reports for a city, I might give it the benefit of the doubt. Public health experts from Seattle give it mixed reviews.
This site would improve its utility if users were forced to report a date of symptom onset. Also, the bar graph indicating "# of sicknesses over the last 8 weeks" will be unreliable until some steady state usage is achieved. Right now, it doesn't seem to me that nearly enough people are reporting for there to be a reasonable chance of discovering someone with the same illness. This begs a question: How many different upper respiratory illnesses, stomach flues, influenzas, head colds and other contagious goodies are there out there at any time? Can we really identify a preponderance of particular causative agents based on symptom reports?
And who are the folks registering symptoms? I am going to guess there is a tendency for self-reporters to be slightly more hypochondriac than most. This or any similar skewing of the data is a data collection problem public health officials call reporting bias. I picked from one list at least ten other types of bias. If this data were to be used in any sort of study or health recommendations, it would have a number of problems. The website authors clearly indicate it is not their intent to use this for public health assessments. From their website,
Who Is Sick was started in 2006 with a mission to provide current and local sickness information to the public - without the hassle of dealing with hospitals or doctors.There you have it. The motivation behind this site was the hassle of dealing with hospitals or doctors. Ouch!
Instead of tracking stomach aches and head colds, maybe someone should think about reducing the hassle of medicine!
Friday, May 18, 2007
Science News is Slipping
I was pleased to encounter a science news story today about a research group that I know. The Seattle Post-Intelligencer published an AP story about the University of Pittsburgh's Human Movement and Balance Laboratory. It happens that the lab's director, Mark Redfern, was a professor when I attended Pitt, and taught a couple of my classes. I was even a research subject for some of their experiments.
In all, this story was a good presentation of scientific research. It included a personality profile, the implication that human subject volunteers are needed for experiments, a reference to a famous person (Kurt Vonnegut) affected by the condition (falls) being studied, some stats about the importance of falls, and an interesting question for which there is no certain answer. This last part is where the science comes in handy!
But since I know the professor featured, I sent off an email to him to find out how it was that his research made it into my local newspaper. If he responds, I will post the answers here. Any of you out there want to venture a guess about how a story from the Three Rivers made it to the Emerald City? Both funny and cynical comments will be appreciated.
---Update 5/18/07; 1900 hrs PDT---
Dr. Redfern just emailed me this description:
Hi Tom,
This is how this came about:
The School of Engineering had a two day educational program a couple of years ago for some reporters. At that time, a number of different investigators talked to them about the kinds of work we were doing. Our lab was one of those presentations. About two months ago (now two years after the presentations), I was contacted by one of the reporters, who asked what progress we had made. He decided to come out to Pitt to do an interview and write a story on the work. Nice guy and fairly sharp.
Cheers!
I will still accept comments about how this got from Pittsburgh to Seattle! Usually you only read stories from the local university...
In all, this story was a good presentation of scientific research. It included a personality profile, the implication that human subject volunteers are needed for experiments, a reference to a famous person (Kurt Vonnegut) affected by the condition (falls) being studied, some stats about the importance of falls, and an interesting question for which there is no certain answer. This last part is where the science comes in handy!
But since I know the professor featured, I sent off an email to him to find out how it was that his research made it into my local newspaper. If he responds, I will post the answers here. Any of you out there want to venture a guess about how a story from the Three Rivers made it to the Emerald City? Both funny and cynical comments will be appreciated.
---Update 5/18/07; 1900 hrs PDT---
Dr. Redfern just emailed me this description:
Hi Tom,
This is how this came about:
The School of Engineering had a two day educational program a couple of years ago for some reporters. At that time, a number of different investigators talked to them about the kinds of work we were doing. Our lab was one of those presentations. About two months ago (now two years after the presentations), I was contacted by one of the reporters, who asked what progress we had made. He decided to come out to Pitt to do an interview and write a story on the work. Nice guy and fairly sharp.
Cheers!
I will still accept comments about how this got from Pittsburgh to Seattle! Usually you only read stories from the local university...
Friday, February 16, 2007
Would You Like Peanut Butter With your Spinach?
I recall my mom preparing lightly steamed spinach salad cooked with a small dollop of chunky peanut butter. I find it ironic that the two most recent reports of food-borne illness refer to ingredients from the same fond culinary memory.
But seriously, what's the deal with these outbreaks?
How is it that a peanut plant in Georgia causes illness in Washington state, spinach from California gets recalled in Massachusetts and the lucrative carrot juice market takes a hit everywhere?
A Centers for Disease Control spokesman (Robert Tauxe, chief of the CDC's Foodborne and Diarrheal Diseases Branch) recently said, "Nature's been throwing us curve balls. We've had seven major product outbreaks in the last five months, and three have been in brand-new foods — botulism in carrot juice, E. coli in spinach, and now this."
Excuse me: NATURE's been throwing us curve balls?
Each of these contaminations were in food processed at large manufacturing centers or distribution points. Perhaps if we relied less on the global industrial complex for our food and more on in-season produce and local meat, we really would be more healthy! You won't catch me in the aisles of Whole Foods quite yet, though. I have to make more than a graduate student's salary to be found there doing anything more than collecting some delicious free samples on the way to work.
In case any of you have Peter Pan or Wal-Mart 'Great Value' brand peanut butter with the numbers 2111 on the lid, you can avoid an interaction with the CDC's Diarrheal Diseases Branch by throwing that container away. If you need other reasons to avoid Wal-Mart, I could connect you with more resources on that front.
But seriously, what's the deal with these outbreaks?
How is it that a peanut plant in Georgia causes illness in Washington state, spinach from California gets recalled in Massachusetts and the lucrative carrot juice market takes a hit everywhere?
A Centers for Disease Control spokesman (Robert Tauxe, chief of the CDC's Foodborne and Diarrheal Diseases Branch) recently said, "Nature's been throwing us curve balls. We've had seven major product outbreaks in the last five months, and three have been in brand-new foods — botulism in carrot juice, E. coli in spinach, and now this."
Excuse me: NATURE's been throwing us curve balls?
Each of these contaminations were in food processed at large manufacturing centers or distribution points. Perhaps if we relied less on the global industrial complex for our food and more on in-season produce and local meat, we really would be more healthy! You won't catch me in the aisles of Whole Foods quite yet, though. I have to make more than a graduate student's salary to be found there doing anything more than collecting some delicious free samples on the way to work.
In case any of you have Peter Pan or Wal-Mart 'Great Value' brand peanut butter with the numbers 2111 on the lid, you can avoid an interaction with the CDC's Diarrheal Diseases Branch by throwing that container away. If you need other reasons to avoid Wal-Mart, I could connect you with more resources on that front.
Wednesday, May 10, 2006
Update
Note: This is the concluding entry in a series of posts related to my experiences in quarantine. Remember the mumps outbreak? King County Public Health was concerned that I was a vector, but...
The PCR was negative,
So I am back at the lab.
Instructed to keep a distance,
And avoid crowded spaces.
They drew some more blood yesterday.
Called "convalescent serum."
What? Convalescent? I feel fine!
Parotid stone passed Monday.
So much for mumps quarantine poems.
Check out MJ's comment on "the role of quarantine." It makes good points about the differences between H5N1 and SARS in terms of incubation time and the usefulness of quarantine. With mumps' 12-25 day period, I suppose it is more like SARS than bird flu!
It looks like public health is overcoming the mumps outbreak in Iowa:
Check this Chicago Tribune article.
The PCR was negative,
So I am back at the lab.
Instructed to keep a distance,
And avoid crowded spaces.
They drew some more blood yesterday.
Called "convalescent serum."
What? Convalescent? I feel fine!
Parotid stone passed Monday.
So much for mumps quarantine poems.
Check out MJ's comment on "the role of quarantine." It makes good points about the differences between H5N1 and SARS in terms of incubation time and the usefulness of quarantine. With mumps' 12-25 day period, I suppose it is more like SARS than bird flu!
It looks like public health is overcoming the mumps outbreak in Iowa:
Check this Chicago Tribune article.
Sunday, May 07, 2006
Deconstructing Pandora's Quarantine
The myth of Pandora seems to me a useful metaphor for understanding the kinds of issues I hope to discuss on this blog. My current experience with quarantine is a good first exercise. Using the Pandora's Box story as a guide, I will try to name the evil spirits of a given situation and identify the hope that can reconcile them. Why not just call them plusses and minuses? I guess that just doesn't seem as interesting to me.
Quarantine
Evil
Hope
Quarantine
Evil
- Endangered Individual Liberties
- Lost Productivity
- Economic Hardship
Hope
- Public Safety
- Time to Recover from Illness
- Increased Personal Time
Day 3 (Economics)
Day three of the waiting game feels much as the first. The weekend is not sush a bad time to be forced apart from society. My wife and I typically spend the time with each other, and if we leave the house, it is for a hike or such. We each typically go into lab for a good chunk of one day, and that is where she is right now. Now facing Monday, I have realized the challenge this will be if this goes on for another week (the nine day period expires Friday.)
This brings me to another point: economic productivity. I wonder what the effects of a widespread quarantine for H5N1 avian flu would have on the economy. I'm no economist, but I would imagine that any effects from lost work would hit the poor first and hardest. Do employers make any allowance for workers on quarantine? Is that something the government is prepared for in the reports recently issued about the possible pandemic? Who's responsibility is it to keep food on the table when the breadwinner is quarantined?
This brings me to another point: economic productivity. I wonder what the effects of a widespread quarantine for H5N1 avian flu would have on the economy. I'm no economist, but I would imagine that any effects from lost work would hit the poor first and hardest. Do employers make any allowance for workers on quarantine? Is that something the government is prepared for in the reports recently issued about the possible pandemic? Who's responsibility is it to keep food on the table when the breadwinner is quarantined?
Friday, May 05, 2006
The Role of Quarantine
So I'm Quarantined...
Institute of Medicine member Marty Cetron opens a published discussion about quarantine as follows: "By utilizing quarantine and isolation as public health tools we are in many ways battling twenty-first century pathogens with a fourteenth century toolbox." The public control of disease is not new. A sizeable number of empirical prescriptions exist in the book of Leviticus that control and reduce the spread of disease. Individual and community health still play a very important role in contemporary Jewish culture. Quarantine as first applied in bubonic plague infested Europe referred to a forty day isolation period.
Having been under quarantine for about 24 hours of an expected 9 day period, I am glad that the Washington and King County health boards no longer stick to that duration. I am already feeling the tension between individual liberty and the public good. This manifests in its own disease: cabin fever. I have repeated to many that, "I believe in public health," and still stand by that statement. In my opinion, public health departments should have even greater reign over the health risks that we confront daily. I would like to see some public authority take more control of school food, for example. (Hooray for the curb on sweet drinks at school!) My condition however falls within the imminent threat category of public health. Perhaps it will help me better think about the real and potential quarantines issued in response to SARS or H5N1 bird flu.
Let me clarify my situation with mumps, in case any of you are worried about me or about yourselves! The public health officials I have spoken with report that a significant number of the mumps cases in Iowa occurred in individuals who had received two MMR vaccines. The MMR vaccine is not without controversy. A report by Dr. Andrew Wakefield published in Lancet in 1998 documented increased numbers of kids with Crohn's disease and autism. Even though this article was retracted, numerous parents - particularly in Great Britain - refused to immunize their children with MMR. This episode is a particularly good one illustrating a dysfunctional relationship between biomedical science and the public, but that is for another entry... Regarding the vaccine's efficiency, the common report is that the MMR is 90-95% effective at producing protective antibodies. Let's say I received 2 MMRs as a child (the standard regimen, confirmed by my mom), a booster shot before high school at age 13, and a booster at age 22 before medical school. By my calculations, that would put my chances of seroconversion between 99.99% and 99.9994%. This is not even close to the risk of infection we would see with a SARS or bird flu outbreak. That puts my experience in quarantine in a different category than its infectious colleagues, but does not refute the legitimacy of my experience.
I believe I am serving what is called a voluntary quarantine. I do not believe I am under any legal obligation to stay home. My doctor says it is okay to go jogging and biking, as long as I do not engage in close contact with others. My wife has already been exposed, so it is okay for me to live in the same place as her – thank goodness! From the statistical data above, I am very inclined to believe that I neither infected or infectious. I wonder what percentage of quarantined individuals in a SARS or H5N1 will actually be sick, and how many will endure the quarantine unaffected (& bored). Another aspect of an epidemic outbreak would be fear of infection. Perhaps if I was really afraid of getting sick, I would not mind as much a forced absence from work and play. If I could telecommute to do experiments, I guess this situation would be very different. Until I figure that out, I will have to put off my studies for a week.
For members of the academic community, see the full transcript of the discussion these quotes are extracted from in the Journal of Law, Medicine & Ethics, Winter 2004 v32 i4 pS83(4). This proceedings includes a number of important topics ranging from the need for quarantine, how it should be enforced, and the mechanism by which state legislators put quarantine laws in place.
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