One of our national pimples is coming to a head, and it’s pitting those that understand medicine against those that don’t. The former group understands that there’s never a free lunch; that you don’t get something for nothing; that everything in medicine is a trade-off between risks and benefits. The latter group expects a perfect pill for every disease (or even just a pill for every disease).

An attending that I’ve really come to respect over the past weeks made a similar comment out of the frustration with Mexican immigrant family. The boy in the family wasn’t taking his anti-seizure medication regularly (which is important, both because it prevents seizures, which can be dangerous to the patient, and because it’s dangerous to quit an anti-seizure medication cold turkey). My attending, himself an immigrant, said “there was a cultural problem,” but I now think I see what he means.

Until we develop the perfect pills and vaccines and surgeries without any risks, side effects, or complications, everyone must understand this simple fact: everything in medicine is a trade-off between risks and benefits. We do our best to minimize these risks and maximize these benefits as physicians–by doing research to discover which drugs work better and which operations are safer, but even we cannot prognosticate. Leave that to the groundhogs. We can tell you with X percent certainty that a drug will work, or that Y percent of patients will have an infection after surgery, but right now, we don’t know which people are which, in most cases.

That’s the tough part about medicine: we do all this research and publish all this crap to do our best to predict the future; we’re the ultimate in control freaks. We want a good outcome for our patients, so we study and crunch numbers to try to have more control over the outcome, but nothing’s for certain. Life’s precious and fragile. We’re doctors, not miracle workers.

Now, this is no blame-free mantra. As physicians, we must make sure patients understand the above simple fact. But we must also provide them with as much information as possible, in as easy to understand format as possible. And, as we have learned from the Vioxx disaster, we must not allow any possible risks that are known to be hidden. I’ve spoken with several patients in chronic pain with stomach problems (the only group Vioxx should have been targeting) who say that they’re very upset Vioxx was taken off the market: it was the only drug that helped them. They said they were willing to take the risks of Vioxx; it should be each person’s choice.

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The cure for canker sores in two paragraphs, but first, a little education: I’m talking about canker sores, also known as apthous ulcers, found inside your mouth. I’m not talking about herpes sores, which are usually found around the lips or on the genitals, or syphillis chancres, or chancroid, yet another similar-sounding STD. Canker sores probably have an unknown viral or bacterial cause from what I’ve read, and are not STDs, for the damn record.

If you get canker sores recurrently like I do (mine are generally from stress), you’ve probably tried every possible cure. I’ve tried vitamins, amino acids, yogurt bacterial cultures that you have to keep in the refridgerator, mouthwashes, toothpastes, numbing agents, and anti-viral drugs, with absolutely zero success. When I was in high school, I had 17 in my mouth at one time. I’m not kidding. (Thankfully I’ve learned to de-stress since then.)

But I’ve finally found a cure (for me at least), thanks to the doctor at the student health service: triamcinolone paste (it’s a corticosteroid). The stuff works wonders. Spread the gospel, please. Dry off the canker sore, put the paste on the canker sore just before bed, fall asleep, repeat for a couple days, and it’ll hurt less and heal much faster. Your doctor can easily prescribe it, and it’s a generic, so it’s cheap.

Please appreciate this advice, I’m probably sacrificing my kissing-attractiveness by posting this one.

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Okay, I’m probably sacrificing my overall attractiveness with this one, too, but it’s all in the name of patient care and relieving suffering, which I hope are valiant and attractive enough to outweigh the too-much-information-eww-gross-disgusting part.

I used to make fun of my college friend Sam for doing this, because it really is pretty gross, and he did it in the public bathroom, but I’m sorry, Sam. You were right.

I’ll just lay it out there now: suck warm salt water up your nose.

If you feel a sore throat or cold coming on, get a mug of warm salt water, and suck it up each nostril. I have absolutely no evidence to support this, as I’m just not in the mood to search PubMed, but I’ve had good results.

And for you post-nasal drip sore-throaters like me, this will most likely cure your sore throat. It flushes the mucous off your soft palate that’s collected during the night. Gross? I guess. But if it saves one person a sore throat, I’m okay with that.

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Dear Google and Karen Wickre,

I loved your story “We Get Letters (2)” about new parents finding information to help prevent a blood transfusion of their newborn, but it’s inaccurate that the blood transfusion would be “extremely dangerous,” as the parents report. Blood transfusions are generally *extremely safe*, and the “danger” is a myth medical professionals have to dispel all the time. It’d be great if you noted this in your entries.

From Nelson’s Pediatrics:

“a current estimate for risk of transfusion-associated HIV is 1/1 million donor exposures, with estimates ranging from 1/800,000 to 1/2 million donor exposures. Similarly, the risk of viral hepatitis C is 1/1 million donor exposures. Transfusion-associated cytomegalovirus can be nearly eliminated by transfusing leukocyte-reduced cellular blood products or by selecting blood from donors seronegative for antibody to cytomegalovirus.”

Sincerely,
Me.

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Rachel Gets Fruity is a sexually clever ad to encourage men to perform regular testicular self-examinations to help prevent testicular cancer.

Unfortunately, The US Preventative Screening Task Force doesn’t think testicular screening will be all that helpful; Rachel’s ad would have been better served encouraging screening for colorectal cancer, but we all know that putting something up your butt automatically turns you gay. I guess if that happened, Rachel’s ad wouldn’t be as effective anymore.

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… is up at Sneezing Po. Go read this week’s best in medical weblogging.

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I’ve always thought that one way to tell if you’re truly fluent in another language is if you can make a joke in the language–humor requires not just meaning and proper grammar, but a level of comfort with the language and a good sense of comic timing. It’s totally true for the medical languages, too.

Case in point: at the beginning of this month’s rotation, I attended a weekly neuroradiology conference where the attendings kept making these only-funny-to-neurologist jokes about patient’s MRI scans, and I didn’t get a single one. They all went right over my head, but everyone else in the room was just cracking up.

Yesterday in clinic, I found myself making an only-funny-to-neurologist joke while evaluating a teenager with chronic daily headaches. As I sat down to present to the attending, I said, “Looks like a pretty classic case of giant cell arteritis,” and I got a good laugh from her.

Giant cell arteritis is a headache disease, but only presents in people over the age of 55. Ha! Err… ha. Sigh. Soooo lame.

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That’s right, folks. Starbucks now spends more on health insurance for its workers than it does for the primary product it sells: coffee. We’re in trouble, folks:

Howard Schultz, chairman of Starbucks, announces his plans to spend more on health insurance for its employees this year than on raw materials needed to brew its coffee.
According to Schultz, the Seattle-based company has had double-digit increases in insurance costs for the last four years.
Schultz made the announcement at a Washington, D.C. meeting with lawmakers from his home state – one of several organized by Schultz to address “a growing health care crisis.”
Shultz said he hopes congressional leaders will put the issue “at the front of their agenda.”

It’s similar to the American car manufacturers; they spend more on health insurance than on the steel to build their cars.

Something’s got to change, but mark my words–if it hasn’t changed by the time the avian flu hits (if the epidemiology predictions are right), it’ll definitely change after.

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(This is the first in what will be a series of practical tips I’ve learned on my clerkships that are applicable to everyone, not just medical professionals.)

There are many types of seizures, not just the classical shaking ones you see on television. If someone should have one of these seizures, however, or another one where they fall down or lose consciousness, there’s some basic first aid guidelines, and also some myths that need to be dispelled. Use your common sense, keep the person safe, and reailze that in most cases, the seizure will end on its own. If it lasts more than 5 minutes, then you should call 911. From epilepsy.com, one of the best medical websites I’ve found for a specific disorder

1. Stay calm. You’re probably more scared than the person having the seizure; they’re unconscious (for shaking seizures, know as generalized tonic-clonic seizures, as well as many others).
2. Prevent injury. Make sure the person isn’t going to hit a piece of furniture with their body, knock over a glass and get cut, or grab a cord and pull an object onto themselves, etc.
3. Pay attention to the length of the seizure.
4. Make the person as comfortable as possible.
5. Keep onlookers away.
6. Do not hold the person down. You don’t need to restrain them.
7. Do not put anything in the person’s mouth. There’s a big misconception that you should stick a spoon or something into a person’s mouth. They’re not going to swallow their tongue, but they may bite it.
8. Do not give the person water, pills, or food until fully alert.
9. If the seizure continues for longer than five minutes, call 911
10. Be sensitive and supportive, and ask others to do the same.
11. The person may become incontinent (soil themselves with urine or stool). This is normal.
12. The person may bite their tongue or cheek, so they may have a little bloody saliva coming out of their mouths. This can look very scary, but is probably normal.

After the seizure, the person should be placed on her left side, in the recovery position. There’s a small risk of post-seizure vomiting, before the person is fully alert. The left side is better than the right because the left side has a sharper angle of the lungs, so there’s probably a slightly smaller risk of vomit going into the lungs. Therefore, the person’s head should be turned so that any vomit will drain out of the mouth without being inhaled. After the seizure, the person enters the postictal state, which is just medical lingo for post-seizure. People can be very sleepy or confused at this time, so stay with the person until she recovers (5 to 20 minutes).

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There’s a number of types of seizures, but here’s a short list of the most common with common descriptions (every person is unique!), in case you’re concerned in a child, friend, or loved one. Seizures are divided into partial and generalized. Partial means they affect only part of the brain, whereas generalized affect the entire brain. There are usually medications that can treat these seizures.

• Simple Partial: It’s simple because you don’t lose consciousness. They can be motor (have muscle movements of a limb, for example), sensory (see weird things, have weird smells), autonomic (heart rate or breathing rate changes) or psychic (feeling deja vu).
• Complex Partial, aka Partial Complex, aka Temporal Lobe Epilepsy: They’re complex, because the person loses consciousness. People will blank out, maybe smack their lips, fumble with their hands, pick at their clothing, or blink their eyes sometimes. These can “secondarily generalize,” which means they can start with this seizure type, and then have a full shaking seizure. Complex partial seizures often have auras–the person can tell they’re about to have a seizure by seeing something in their vision, having a muscle tightness, a feeling of stomach fullness, weird smell, or almost anything else.
• Absence Seizures, aka Petit Mal: These start in kids. This is the kid in class that, out of nowhere, will just stare blankly into space, like they’re daydreaming, and then snap out of it in less than a minute. Many times they’re diagnosed with attention problems, when they’re actually having seizures. They lose consciousness, but immediately go back to whatever they’re doing, and don’t even necessarily realize they’ve had a seizure. (They’ll just pick up their conversation where they stopped, for instance.)
• Generalized Tonic-Clonic Seizures, aka Grand Mal: Your classic Hollywood seizure. Starts with the tonic portion (increased tone), where the person arches their back, straightens their arms out, and is very rigid. Then the clonic part starts–more medical speak for the rhythmic jerking of the muscles.
• Febrile Seizures: These are like the above GTC seizures, but only in kids 6 months to 5 years old, and associated with a fever. Two-thirds of kids with one febrile seizure won’t have another, so neurologists usually don’t treat unless the child has more than one. (Once you have more than one, you have a pretty good chance you’ll have more.)

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Often those that oppose national health care schemes like to claim that innovation and research suffer under the budgetting schemes of countries like Canada and the UK, but this year’s Lasker Medical Awards, “widely considered the United States’ most prestigious medical prizes,” went to two British and two Canadian researchers:

The research award for stem cell work is going to Drs. Ernest A. McCulloch and James E. Till, emeritus professors at the University of Toronto and the Ontario Cancer Institute.

…

Sir Edwin Southern of the University of Oxford and Sir Alec J. Jeffreys of the University of Leicester in England received the Lasker Award for developing two powerful technologies, Southern blotting and DNA fingerprinting, that, the foundation said, “together revolutionized human genetics and forensic diagnostics.”

The initial CT and MRI scanner creation also partially came out of Britain as well.

(thanks quote of the day!)

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My plans for world domination continue with a fluff piece of the prevalence of PDAs in medicine. The writer had it easy; he used my email message as pretty much verbatim to fill his story.

In other news, I’m slow to post as I’m working on a top-secret new web application to do nothing all that exciting. Should be ready for comments this coming week. Over and out.

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