It’s Not Just a Ritual

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“It has been over 10 years- we can give you your tetanus booster before you leave today,” my medical assistant cheerfully remarked as she recorded the vital signs.

“Um, okay, I guess so…  if I’m due. Sure,” my patient awkwardly replied.  Not sure if it was an extra bonus to the visit or an unwelcome surprise, my patient considered the scene unfolding and thought, “I’m here because I have a cough-  I didn’t realize I would be getting a shot in the arm today.”

Since getting a tetanus booster is given every ten years to protect against an uncommmon disease, getting the shot may seem almost as if it is a ritual.  Yet most people somehow know that tetanus is a disease worth preventing, and tetanus boosters are often readily accepted by patients. Staying up to date on your tetanus booster is a wise decision:

1.  The vaccine provides immunity to the toxin, but not the bacteria.  Clostridium tetani, the bacteria that makes the tetanus toxin, is just as prevalent in our world today as it was in 1938 when the tetanus vaccine first became available. In fact, the bacteria is present in 30% of American soil samples, while up to 40% of American livestock have the bacteria present in their stool. There’s a good chance that throughout your life you have been- or will be- exposed to the tetanus bacteria.  But thanks to the vaccine, the bacteria’s toxin will not harm you. 

2.  The tetanus toxin, which is called “tetanospasmin,” is one of the most potent toxins on a weight basis known to humans. The tiny amount of 2.5 nanograms per kilogram, is enough to cause death.  To give perspective, the weight of a nanogram is equal to one billionth of a gram.

3. Preventing tetanus is well worth the effort because the disease is truly devastating. The toxin causes muscles to become painfully rigid, in which legs straighten, arms become flexed, and the face becomes contorted. A person with tetanus becomes unable to breath as the muscles that move the lungs become paralyzed. The mind is unaffected while one’s body stiffens out of control.

4.  The highest risk of infection and succumbing to tetanus is in individuals whose tetanus boosters have gone overdue, most commonly older adults. Don’t let this happen to you.

5. Finally, getting a tetanus booster is a two for one bonus package; the tetanus booster also includes protection from diphtheria. A tetanus booster is “Td”, tetanus and diphtheria. The diphtheria bacteria causes a severe airway infection, and like the tetanus vaccine, the diphtheria vaccine provides immunity to the bacteria’s toxin but not the bacteria itself.

Preventing tetanus and diphtheria requires ongoing maintenance because immunity wanes after about ten years. These diseases are rare in the United States today thanks to an outstanding vaccine, but can occur if boosters are neglected. 

The next time you see your healthcare provider and a tetanus booster is recommended, here’s what to say: 

“That’s great- let’s do it!”

Loving Big In Kittitas County

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1529106390704Cancer turns life upside down; for individuals and their loved ones, life becomes overwhelmed with medical care. Instead of working, socializing, and enjoying daily routines, days are suddenly filled with doctor appointments, tests, surgical procedures, and treatments. Even simple appointments or medical tests can swallow up a day. In addition, the lives of spouses, friends, and family- the patient’s support group- are disrupted. Whether it is offering emotional support, attempting to understand insurance coverage, or coordinating appointments and navigating the medical system, providing support is practically a full time job!

To top it off we live in Kittitas County, which means that for virtually any cancer related medical care, patients must drive to Yakima or Seattle. For chemotherapy, radiation therapy or other treatments given at regular intervals, the necessary travel time can be a heavy burden on individuals and families. People with cancer – and those who support them- need help. They need time, monetary support, and importantly, emotional support.

The silver lining is that we live in Kittitas County, a place where people are exceptional at caring for one another. There is a generosity of spirit here that is unique, and it is from this sense of caring and generosity that a grass-roots organization called “The Gretchen Weller Foundation” was formed in 2015. Gretchen Weller is a mother of three who was diagnosed with breast cancer while still breast feeding her youngest child. She and her family have responded to cancer by choosing to “live life intentionally,” which she describes as “loving big”: living and loving the best she can, every day.

Inspired by Gretchen, Cathie Day and a group of dedicated individuals created The Gretchen Weller Foundation, whose mission is to support patients and families during their journey with cancer: “When one family member has cancer, everyone in the household becomes affected by that struggle. Besides medical expenses, cancer is costly in many ways. Families need transportation, meals out, car maintenance and a host of other expenses. The Gretchen Weller Foundation helps to bridge some of these gaps.”

If you know of a friend or family member with cancer, help ease their burden by connecting them with The Gretchen Weller Foundation. In addition, donating to the Gretchen Weller Foundation is a great way to support fellow residents of Kittitas County in their journey with cancer. One hundred percent of donations go directly to Kittitas County patients. To learn more, visit their website at https://gretchenwellerfoundation.com/, or listen to an inspiring interview with Gretchen and Cathie Day at https://soundcloud.com/eburgradio-org/dr-john-36-gretchen-weller-foundation?in=eburgradio-org/sets/dr-johns-radio-show.

PechaKucha

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Twenty images and for each image twenty seconds to say what you want to say, for a total of 6 minutes and 40 seconds of sharing.  PechaKucha, which in Japanese means “chit-chat,” first began in 2003, and has spread around the world as a way to share ideas in a concise and creative format. Our own Gallery One in Ellensburg has been hosting PechaKucha evenings every four months since 2014. If you have the opportunity to attend a PechaKucha evening, I highly recommend it- it is fun, stimulating, and a great way to connect with your community.

Each Pecha Kucha has a theme, and in March the theme was “on being human.” I was invited to do a presentation, and I would like to share it with you:

https://www.pechakucha.org/cities/ellensburg/presentations/on-being-human-perspectives-as-a-doctor-and-as-a-patient

 

Hope you enjoy it!

Spread The News

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Not on the news today-
a child got to play. No,
not on radio, TV or social media feed-
a garden, a kid planting a seed.

2017
first time ever
deaths from Measles worldwide dipped below 100,000.

You won’t see it on a president’s tweet-
little kids played on the street. No,
no juicy gossip, headlines and politicians taking heat-
look around and see, less wheelchairs on the street.

2017
all time low
15 people in this world afflicted with Polio.

A tribute to science,
a gift to humanity:
Vaccines lessen death and disability.

Spread the news.

 

Chickenpox Is Not A Party

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Sick child with chickenpox, sad girl looking back.

Kids love parties and play-dates, and parents enjoy both organizing them as well as socializing with each other as their child is joyfully engaged with friends. After a high energy afternoon of play and socializing, parents and children return home to recover and begin the next day anew. It is a story repeated every day across America- a happy story.

I would like to address a different kind of party, the “chickenpox party,” where parents bring their children together in order to expose them to chickenpox, an infectious disease caused by the varicella virus. While the party begins the same with the theme of happy kids and socializing parents, it has a different ending in which children return home to later develop chickenpox.

The rationale behind a chickenpox party is that by experiencing the natural disease, a child develops natural immunity to the virus, which some feel is better than immunity from the vaccine. While this reasoning may seem appealing, please consider how the decision to join a chickenpox party can impact the health of your child as well as others in your community.

  1. When a child- or a person of any age for that matter- has active chickenpox, they experience a disease. Chickenpox can sometimes be mild, but is typically a moderate illness that lasts one to two weeks and is characterized by fever, headache, fatigue, and a rash of blisters that covers the body. Most children who have the infection miss 5-6 days of school or daycare. When a child receives the vaccine, they do not suffer from the disease.
  2. Complications of chickenpox can be serious. The most common complication of chickenpox is a bacterial skin infection, which at a minimum requires antibiotics. When the bacteria enter the body through one of the many ruptured blisters to cause a bloodstream infection, children need hospitalization for treatment. Meanwhile, the leading cause of death from chickenpox is pneumonia and a brain infection called encephalitis. Before the advent of the vaccine in 1995, 10,000-12,000 children were hospitalized and 100-150 children died every year in the United States from chickenpox.
  3. There are people in every community who are vulnerable to serious complications from chickenpox, such as babies, pregnant women and people with a suppressed immune system. Infants less than a year old are at an increased risk of severe disease, and since children are not routinely vaccinated until a year old they are vulnerable during this first year of life. In addition, varicella infection during pregnancy can be devastating to the developing fetus, causing birth defects and miscarriage. And lastly, a person with a suppressed immune system is at high risk of severe disease or death from varicella infection. Immunosuppression is increasingly common in medical care these days as people receive immunosuppressive medications for cancer, Rheumatoid Arthritis, or Crohn’s Disease for example.
  4. The varicella vaccine is 90% effective in preventing chickenpox, and immunity (protection) is typically long lasting. While it is possible to get chickenpox despite having received the vaccine, when this happens the infection is very mild. Of profound significance, the varicella vaccine is 100% effective in preventing serious complications and death from chickenpox.
  5. The natural course of varicella infection is such that following the initial infection, the virus lays dormant throughout one’s life. If the varicella virus reactivates in adulthood it causes “shingles,” which is a localized, painful blistering rash. A third of adults experience shingles during their lifetime. Almost as a special bonus to receiving the vaccine, research has shown that those vaccinated with the varicella vaccine tend to experience a milder case of shingles in adulthood compared to those who have had the “natural” infection.

A party to spread an infectious disease that could otherwise be prevented by a safe and effective vaccine is not my kind of party. Instead, my suggestion for a chickenpox party is to have a party to celebrate the vaccine and good health. Bring your vaccinated kids, have a great time, and go home without disease and suffering. Share happiness and health with each other rather than a viral infection. This is the type of happy story medical practitioners hope to see within our communities, as well as across America.

 

Flu Season Fence Sitting

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Winter comes every year, and so does influenza. The influenza virus causes a predictable epidemic every year that sweeps through our country and takes the lives of 12,000-56,000 people. Many people are surprised to learn that influenza is consistently within the top ten causes of deaths in our country each year. Doctors have little to offer in effective treatments to combat the virus- preventing the disease with vaccination is our best defense.

Fortunately, when I recommend the influenza vaccine most of my patients receive it, and in doing so reduce their risk of severe illness. However, every year there are a number of patients who turn down the vaccine, patients that readily get other vaccines without a second thought. While they may see the benefit of vaccines in general, they sit on the fence when it comes to the flu shot. From my perspective, patients turn down the vaccine because of personal experiences, emotions, or the influence of social media. Unfortunately, science does not factor into the decision.

With this in mind, for those who are uncertain about the influenza vaccine for whatever reason or source of information, please consider these common situations and hear out my science-based response. Mull it over for the next time the influenza vaccine is encouraged for you.

“I have never had the flu. I don’t need it.”

For most years, any one individual is not likely to get ill with influenza. However, all it takes is one severe influenza infection to result in hospitalization or death. I like to think about this as I think about the use of seatbelts. Almost everyone puts on a seatbelt when they climb into a car to drive on the interstate freeway, and yet it is rare to be involved in a serious accident. We wear seatbelts to save our life in the unlikely event we are in a serious car crash. The same is true for influenza and the influenza vaccine: most of the time you won’t get influenza, but if you do, the vaccine could save your life.

“My relative/friend/someone-I-know got the flu shot and was sick all winter.”

The flu shot does not protect us from the many common cold viruses that circulate every winter. Most illnesses that occur after the flu shot – whether it is the next day or a month later- have nothing to do with vaccination. The influenza vaccine is not a live virus and cannot cause disease. The influenza vaccine should not be your scapegoat.

“I heard on the news that the vaccine is only 40% effective. I don’t want to bother getting it if it won’t help.”

Within this comment is a very important notion to discuss and clarify. It is true the influenza vaccine is not as effective as most of the other vaccines we have available. For example, the Measles vaccine is 97% effective in preventing Measles while the influenza vaccine is only about 40% effective most years. The very important concept to share is that protection from the flu vaccine is not an all-or-nothing, back-or-white situation. The vaccine almost always provides some level of protection. A better way to think about immunity from the influenza vaccine is in degrees or shades of color. For example, the vaccine may not prevent you from getting sick with influenza, but it may make the difference between missing work and spending a week in the hospital. Similarly, it may make the difference between becoming hospitalized verses respiratory failure and death. In other words, although the vaccine is not as good as we would like, it can still make a critical difference to save yours or your loved ones life.

If you are on the fence about the flu shot, think it over. The influenza virus comes every year without fail and causes thousands of deaths. The vaccine is our best defense and may save your life. Sitting on the fence won’t help you fight influenza, but the vaccine will.

Storm Clouds Parting

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Wrapped in three blankets, beads of sweat on her forehead, she shivered, sat up, laid down, and rolled over in a futile attempt to find comfort. An emesis bag in her shaking hand, she looked up from her sunken eyes and said in a soft voice, “I can’t go on living like this…. I need to do this for my kids.” A year ago this young woman had an operation and was prescribed oxycodone; her postoperative recovery was complicated which resulted in more pain medications. Then she had dental work done- more pain pills. Meanwhile, the oxycodone helped numb difficult feelings from stressful life events. She soon found if she did not take them, she felt terrible. When doctors became reluctant to prescribe the medications, she bought them on the street. The pills were expensive- heroin was cheaper. She never intended to become addicted; she never thought it could happen to her, but it did.

My patient is not alone: America is in the midst of an opioid epidemic. Addiction to prescription opioid drugs (oxycodone and hydrocodone, for example) and heroin is at a record high and continues to increase. There are currently 2 million Americans addicted to pain medications and 500,000 addicted to heroin. Every day 90 to 100 people in our country die from overdose. The number of people addicted to opioids each year continues to rise, and there does not seem to be an end to the epidemic in sight. It is as if there is a dark storm cloud over the country, a cloud we all wish would just go away so we can see the sun again.

To add to this gloomy predicament, the majority of those addicted to opioids are young, typically in their 20s and 30s, and there is often no cure for this disease. Addiction to opioids is a chronic disease, characterized by remissions and relapses over a lifespan.

Just as there is no simple cure for opioid addiction, there is no one solution to reverse the current epidemic. Solutions to our opioid epidemic will take time, persistence, and a variety of interventions over many years. We need the help of the companies who make the medications,  healthcare providers who prescribe them, and you, a potential recipient of pain medications. Here are a few ways in which we can all work towards ending this epidemic:

1. Pharmaceutical companies should stop heavily marketing the symptom of “pain” and their prescription pain pills. Historically the pharmaceutical industry has successfully popularized medical problems through advertising when there is a drug to sell, be it for insomnia, erectile dysfunction, or low testosterone, for example. The stakes are too high to push treatment of pain with opioids.
2.  Doctors, physician assistants, and nurse practitioners have to reduce the number of prescriptions they write for opioid medications. Since 2010, the number of opioid medication prescriptions written in America has steadily declined, which is terrific news. Despite this trend however, healthcare providers in America currently prescribe four times as many opioid medications as doctors in Europe. Having more pain pills in circulation enables more people to become addicted to them.
3.  Patients who receive prescription opioid medications need to be more careful with these powerful medications. Research has shown that 57% of people who become addicted to opioids begin their path of addiction after having first received opioid medications from family or friends. If you are prescribed pain pills by your doctor, do not share them with others. In addition, store unused medications where they cannot be stolen, or better yet, dispose of them.
4.  Communities need to de-stigmatize opioid addiction. Addiction is a disease, not a moral failing. Like the young woman I have described, people who become addicted are our neighbors and our friends’ children. It is important to acknowledge that anyone can become troubled by opioid addiction and that everyone needs our support.
5. If you or someone you know becomes addicted to opioid medications or heroin, there is help in the form of “medication assisted treatment.” Buprenorphine, or “suboxone,” is a medication that doctors can prescribe in an outpatient clinic setting that enables a person to live a normal, addiction free life. These medications help but can be expensive; tell your representatives in government to support policies that fund opioid addiction treatment. In addition, to be allowed by the FDA to prescribe Suboxone, physicians must complete an eight hour trianing course that can be done at a live conference or online. Encourage your healthcare provider to pursue training in order to prescribe this life changing medication.

Ending America’s opioid epidemic will take time and action in a variety of ways. Reversing the epidemic will require efforts from pharmaceutical companies, our government, healthcare professionals, as well as individuals such as you. It will truly take a concerted effort. We are all in this together.

My patient received her first dose of Suboxone that day. An hour later she was no longer shivering, perspiring or vomiting. She looked exhausted, but relaxed. “You look a lot better, I commented.” She looked up at me and wearily replied, “At least I don’t feel like I’m dying anymore.”

The following day she returned to the clinic for follow up. I entered the room to see a happy and extremely grateful young woman; she smiled and said, “I feel normal now.” Her skin had a rosy color and was bright with light. While my patient will need continued treatment with Suboxone for many years, or even her entire life, the dark cloud of addiction had departed in the exam room that afternoon. The sun was shining bright.