Ok - I'm up to date: the H1N1 flu shot is worth it!

A little more research (between my daughter’s volleyball tournament games) has revealed some reassuring referenced statements about Thimerosal.

The official CDC statement is here:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4843a4.htm

And the official Canadian Statement is here:
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/07pdf/acs33-06.pdf

WHO’s official statement on Squalene is here:
http://www.who.int/vaccine_safety/topics/adjuvants/squalene/Jun_2006/en/index.html

A REALLY good and well referenced review of Squalene appears to be this one:
http://www.mdpi.com/1420-3049/14/9/3286/pdf


Bottom line is that it was a good exercise to go through: being asked by a patient to do a mini-lit review on this subject – with additional online discussion through a Physician's newsgroup list. Accepting the popular opinion just isn’t enough....going through the exercise of finding/evaluating/reading well referenced material has been invaluable.

The components of the H1N1 vaccine that are causing concern are the Thimerosal (Mercury) and the Squalene (the stuff blamed on "Gulf War Syndrome". The articles detailed above are very well written, researched and referenced. The bottom line is that - while it is probably preferable to not have these things in the vaccine, having them present in the H1N1 vaccine is not sufficient to exclude the vaccine from your "to do" list.

This is really a question about "RELATIVE RISK". After everything is said - your risk of morbidity or death is higher WITHOUT the H1N1 vaccine than it is WITH it!

I am now a lot more confident in recommending the H1N1 flu shot. At least now, I’ll be able to have a lot more familiarity with the increasing onslaught of questions I’ve been getting about the safety of these components of this vaccine.

This has been a great exercise!

JF

Ps. The Tom Baines Boas got Silver!

The safety of the H1N1 Swine Flu Vaccine - We can always trust the Government, right?

Patients have been emailing me about the safety of the H1N1 vaccine. The concern is that it is the first vaccine made for the civilian population to contain an adjuvant called "Squaline".

There is not a lot of information on the effect of Squaline on OVID - but the "independent" research appears to be quite chilling.

As a result - I am not comfortable recommending the H1N1 vaccine until this issue is more fully answered.

Does anybody out there have any additional wisdom to add? Read on:

Because there is no listing on the safety or efficacy of squaline on OVID, I have conducted an online literature review on the subject - which is surprisingly interesting. The bottom line is that the Swine Flu vaccine is the first to have Squaline included as an ingredient. Only three other vaccines for civilian use have been developed that contain this molecule - and two of them did not earn FDA approval in the U.S.

If you need to get immunized against the Swine Flu, it is possible that a better alternative will be the vaccination with the AstraZeneca nasal vaccine "MedImmune" - which more closely mimics a natural "real life" inoculation that does not use squaline.

Bottom line is that this is, I believe, the first time a vaccine has been allowed to escape proper FDA approval processes. It is interesting to note that "official published studies in prestigious medical journals have revealed that Squaline is safe in humans". The "studies", however, were published by the "makers" of the vaccine - a new conglomerate of Novartis and Chiron. This is in DIRECT contrast to "profound and lasting autoimmune effects" of Squaline found by independent researchers.

Experience has revealed in abundance that Drug Companies do not necessarily provide unbiased data to the public and to Doctors (remember Viox, Baycol, Naprosyn, Tequin, etc., etc.).

That being the case - I don't believe that I can recommend the H1N1 vaccine to anybody until a repository of reliable information has become available. The Cochrane review people are great resource that does exactly that - and they haven't entirely caught up to the safety of H1N1 vaccine yet. Their official statement about H1N1 flu vaccination is in the following:

Some public-health officials have described flu vaccines as “highly effective,” but the internationally recognized Cochrane Collaboration (which accepts no money from the pharmaceutical industry) did a systematic review of all high-quality randomized trials (25 in all) studying influenza vaccination. They concluded that “the evidence does not support universal immunization of healthy adults.” Period.

An interesting and reasonably referenced article without special interest ties is listed here:

http://www.foodconsumer.org/newsite/Opinion/Comments/180720090846_squalene_the_swine_flu_vaccine_s_dirty_little_secre.html

and here:

http://www.newsmax.com/health/vaccine_swine_flu/2009/07/07/232717.html

Hope this helps somebody.....

I'm between a rock and a hard place. If I recommend the H1N1 vaccine - I could be sentencing patients to significant morbidity as a result of potential dangers from Squaline. If I don't recommend the vaccine, I could be sentencing people to morbidity or mortality from H1N1 infection. This is a tough position to be in - and the old Hippocratic oath of "Doing no Harm" is a seemingly impossible challenge in the absence of good and reliable information.

Do I believe, so called, "Officials"? I know that my Professional knowledge of the issues with this vaccine vastly surpasses that of most "Officials". Also - as a Professional, I've learned to trust my caution when it comes to advice from "Officials". I still remember Tequin, Vioxx and Baycol being bandied about in my office by a small army of Drug Reps that assured me (with less than half of my education and knowledge on the subjects) that all of these drugs were effective, safe and "properly studied".

None of that turned out to be the case.....but then if we had applied the same amount of rigorous concern to ASA - it never would have won FDA approval! The wisdom of the ages has taught us how to handle and recommend the use of ASA. It certainly has its risks and benefits.....but the information gleaned from dozens of years of experience with the H1N1 vaccine is simply not available to us.

So - we are left with inadequate and suspect data.....and patients literally entrust their lives and well beings to my advice!

So - for now, I'm saying "no" to H1N1 vaccinations until I can get better and better referenced, unbiased and properly questioned information.

ps: another good synopsis is at: http://www.digitaljournal.com/article/280927

Bottom line: Wait for unadjuvinated H1N1 vaccine that is devoid of Thioresal (Mercury).

The challenges of practicing Family Medicine

I am certainly maturing in my ability to treat patients - and I'm probably more up-to-date, skilled, energetic and enthusiastic than I have ever been in my life. I'm pleased to say that I've been able to help patients through some of the toughest times of their lives, discover deadly diseases early while they are curable and provide support for devastating physical, social and interpersonal traumas.

I go to work smiling every day....but this is only because I know that I will eventually prevail in my ongoing struggles with Alberta Health.

It appears that for a Family Doc, there is always an assault upon you. Whether it is patients with boundary issues, Insurance Companies not paying you, staffing and business challenges, government and regulatory College intrusion into your daily operations - it seems as if some person or entity is always trying to stab you in the back.

Add all of this on top of operations costs that exceed your capability to earn money, and a culture engineered by Alberta Health to make Physicians feel like criminals if they earn more than a 7-11 employee.....and it is no wonder that out of over 36 Physicians in my "Medical Building" just 3 years ago - there are now only 6 left. Once the leases mature in 2 years, there will be only 4 Physicians left in my building.

90% of all my stress and concerns of operating as a Family Physician would disappear if I simply chose to stop participating in government insured medicine. But then I would only really be able to treat rich people that don't mind paying personally to see me, and I don't want to abandon my patients.

For example - somewhere in Northern Alberta a couple of years ago, it was found that a few nurses were using the same needle to mix up medications. No patients were contaminated and it should not have been a great big deal. But the government went nuts due to misperceived public pressure - and threatened the College into an unreasonable action.

Physicians in Alberta now have to follow this new "Infection Prevention Standards Protocol". To implement to new protocols, each Physician's clinic will need to invest at least $10,000 in capital costs, never mind staffing costs - which would easily double that figure.

For example - to simply remove sutures, a Physician has to use sterile tweezers. No problem, right? Seems simple. The problem is that the tweezers now have to be sterilized using both biological and chemical indicators ($10 each for a test and control), quarantined for 24hr before use (means you need at least 3 sets of tweezers) and you have to go through a very meticulous audit system to sterilize a simple set of tweezers.

According to the law in Alberta - you cannot charge the patients the cost of the tray....you are supposed to personally take the loss as the Physician.

Physicians have been taking out sutures in Alberta for over a century without any problems - but the now the College (ie. "Government") is telling us how to do it better.

Only the cost was never considered.

How foolish!

To sterilize a simple set of tweezers now costs the Physician about $60 (probably more). An office visit earns a Physician about $30. Therefore, the Physician has to pay about $30 out of their pocket to take a patient's sutures out.

Can you guess what is happening?

That's right - Physicians are sending patients to the E.R. to wait 20 hours to get their sutures taken out. Others are saying "screw the College - they've totally lost their minds and I no longer respect their decrees" and are doing what they've always done.

More disturbing, however, is that lots of Docs are going back to the 1700's and are resorting to trying to pick up the ends of sutures with their fingernails and using a handheld disposable scalpel to take out sutures.

Patients are returning to my office weeks after sutures were supposed to be taken out - with retained sutures that have to be surgically debrided. And no, as a Physician you will not be paid to do the surgical debridement (which needs another tray).

So what is a Physician to do?

Moronically implemented governmental and collegiate policy appears to have cast one aspect of medicine in Alberta backwards in time by over 300 years.

Many Family Physicians in Alberta are doing the only thing they CAN do - they are closing shop and leaving. It is increasingly hard to find a Family Doc in Alberta that will take you on and will be there for you for the next few decades.

But I still go to work smiling because of something that should be obvious to Alberta Physicians........

Each one of us has thousands of people supporting us that would much rather get rid of a bad Government than a Good Doctor!

Leadership review of the current Government happens in November....will be interesting!

;-)

A reminder about Humility.....

It has been a long time since I blogged! In truth, I had forgotten about it. I have been very busy!

We have totally renovated our office! It is now a place of modern, tranquil beauty - with Italian Slate flooring, Brazilian Granite Countertops, a merrily gurgling slate wall fountain and an updated Electronic Medical Record System.

A few days ago, I - for various reasons - careened off a 6 ft high retaining wall while chasing a helicopter when the lights went out momentarily due to a power failure. I managed to somersault at the last second to save my head...but I based it anyways on the concrete. My left shoulder took most of the energy of the fall, however, as was evidenced by a complete dislocation. I probably had a mild concussion as well - but I seem to remember things just fine.

The pain was indescribable.....after what seemed to be a long while, I ended up in the E.R. and was assessed very quickly, thanks to a very kind and understanding E.R. Doc that I called while en route to the hospital.

While I was completely opiate naive - I have never even taken a tylenol #3 - I had 10 mg of i.v. morphine - and that didn't even touch the pain. What it DID do, however, is make me goofy enough that I called everybody I knew on my cell phone - even the Orthopedic Surgeon on call!

I should not have been surprised, therefore, to note that pretty much everybody I knew ended up coming to the E.R. to see me! I was touched - and I understand that I was very much a source of entertainment for these fine people with my morphine-induced goofyness.

The E.R. Doc was very good and appropriately gave me crap when I called the Orthopedic Surgeon (for some reason, I believed that I had a bad fracture - which I didn't). He was a good Doc and put my shoulder back together very competently. The dislocation was inferior/anterior...and I could feel the head of my humerus grinding into the underside of the glenoid of my scapula. It was absolutely horrible!

I have reduced many shoulders over the years and now I have a much better understanding of the subjective experience of the process!

Today, I did an operation on a very pleasant mentally retarded 30 year old man. His intellect was about the same as a 6 year old, a fact of which he was very much aware. He had a job mowing lawns for Seniors and was flabbergasted that so many seniors treated him so poorly. Last week, he asked his aid worker to attend his job with him - just to see how badly he was treated, and she was able to verify that several of his clients were abusive towards him. She struck them from the register of Seniors that were getting subsidized lawn serviced - leaving him feeling slightly vindicated.

He and I chatted while I removed the mass from his left posterior hemithorax that had been growing against a pain sensory nerve that had kept him up at night for the past few months in unrelenting pain.

His perspectives of the world were very honest, simple and uncomplicated. He still looked at the world through rose colored glasses, and was full of wonder and awe at the beauty and mystery of everything he experienced on a daily basis. I had to explain to him what I was doing literally every minute during the operation - and I was pleased to do so.

Though he was retarded - he was uniquely able to enjoy the wonderful gift of the ongoing appreciation of beauty, wonder and mystery that we as adults and busy "important" professionals seem to have lost some time over the course of our becoming "important adult professionals".

In many ways, over the hour-long procedure, this delightful retarded man was able to remind me of lessons of long ago that I had forgotten - but now have more need than ever to remember!

It was a great privilege to be able to end this fellow's chronic pain, and an even great privilege to learn something from him.

My new motto: There is NO EXCUSE for not enjoying yourself!

Adding an Electronic Medical Record (EMR)

I've decided to computerize my office and to get rid of all the paper that is now threatening to consume all of my time, energy and resources.

I've searched high and low and have decided that I don't want to go with a private vendor.  They just go out of business and then hold your data hostage.  They also charge you and arm and a leg and provide poor customer service for their software that doesn't really work all that well anyways.

And on top of all that, their software usually has to run on (gasp!) WINDOWS!  Everybody KNOWS that you just can't use Windows for mission critical work.  It is too unreliable and crashes to frequently, and the viruses attacking it are too numerous - to the point that over half of your computer's power has to be devoted to virus defense!

So I've decided to go with a LINUX system that is open source, free and developed and maintained by a wonderful group of Physicians and computer professionals that are devoted to only one thing:  the perpetuation of top notch free software for the betterment of people.

So, I'm reading my first 1000 page book of a set of three books to learn about Linux, and I am configuring and building a server to run this thing.  Some very nice people in the Linux community have decided to help me out for free, and I'm taking them up on it.

This system will also allow my patients to log in to view summaries of their medical charts for travel/emergency reasons.  I'll be able to better interface with Pharmacies and other diagnostic testing and imaging facilities.

The future is really exciting beyond this new frontier - and it is especially exciting with respect to this new free EMR from McMaster University (OSCAR).

All I have to do now is to build an economic support structure for this new EMR idea and I think that it'll start to grow exponentially to take over EMR's in Alberta!

Just have to climb this very steep learning curve......

Treating a patient on a plane

While on a plane from Calgary to Phoenix with my Family yesterday, the stewards asked for medical personnel for help.

A 74 year old female complained of nausea, light-headedness and shortness of breath. The Stewardesses had already appropriately given her oxygen, but she did not improve.

On assessment, I discovered that the patient's pulse was weak and thready and that her heart rate was regular, but zipping along somewhere close to 200! Her pressure was normal and she was otherwise well with no comorbidities or cardiac history.

It was apparent that this lady was in PSVT and getting increasingly anxious and not maintaining pressure. After listening to her neck, I decided to do a rather firm carotid sinus massage while having the poor lady (a retired trauma nurse) valsalva (bear down) at the same time (There didn't appear to be any bruit (turbulence) in her carotids).

Thankfully, she converted right away....and this lasted about 10 minutes until her next episode.....so the valsalva was repeated again with some success (and ice water).....and seemed to stabilize after the 3rd "conversion".

The captain asked me a couple of times whether or not he needed to divert the plane....but she seemed stable and had calmed down. A diversion would only have made about a 15-20 min difference in any case.

A peds ICU nurse that helped along opened the "medical pouch" on the plane, and it appeared that all there was, was ASA, Tylenol and some old Sublingual nitro tabs. I gave the ASA as a precaution (no allergies or asthma), and held back on the nitro (no chest pain or variant angina)

I wanted to keep her calm and relaxed, so we had a nice long chat while doing breathing exercises for an hour or so - and learned that she was the widow of a fighter pilot, she snowbirded in Phoenix, had 2 daughters (one in Philly where she was en route and one that was a Pediatrician in Calgary).....it was very interesting to learn about her life experiences and her travels throughout the world and the wars with her fighter pilot husband....in fact, listening to her about her life was more interesting than any novel or in flight movie I could have busied myself with!

Eventually, the firemen arrived and I filled them I on a synopsis of "successfully converted PSVT in probable need of a long-term beta blocker".....but they didn't seem that interested in the details (the Medics were waiting off the plane).....their job was to assess and manage overall risk.

I then returned to my seat amidst some kind but rather embarrassing applause from the other passengers.

The whole experience - although far from a serene and relaxing flight, was overall a positive experience for me....I'm not sure why there are grumblings in the odd newspaper stories about Dr.'s on flights being "forced to work" when called upon on airline flights.

The fact is, that being a Doctor is a rare and special privilege. Should we be expected to always help out in an urgent situation? Absolutely......but to do so at a personal or professional cost should not be assumed by the airline or cruise industry.

A Physician's urgent actions on an airplane or other similar situation (I once put a chest tube in an old man with a pneumothorax on a cruise ship) is ONLY between the Physician and the person/people that they treat. Cruise ships and Airlines are external to that relationship......although one would think that a note or acknowledgment of appreciation from the airline or cruise ship would just be good form.....

ps.  the stethoscopes, blood pressure cuffs and meds kits they carry on airplanes are woefully outdated, and inadequate of quality or quantity.  They really should address this.  From now on, I'm going to carry my own equipment and emergency meds!

JF

Mental illness can hit anyone

A nice young lady was booked to see me last Friday; for an excision of a large epidermal inclusion cyst on her scalp.

This lady worked as a consultant archaeologist, but seemed to be abnormally bothered by her Epidermal inclusion cysts - a thing I noted on her initial consultation several weeks ago.

On Friday, she called my nurse while she was driving to her surgical appointment at my office - she was about 10 minutes late, and was extremely agitated and crying while driving.  My nurse gently talked her in to the parking lot of my office, and then ushered her into the surgical suite.

I then met her and talked her into a state of calm - all while noticing the fact that the left side of her head seemed to be missing a lot of hair, and that her scalp was terribly excoriated.  One of the cysts that I was supposed to excise was missing and the area over top of it was excoriated.

We chatted for a while during the surgery to remove the larger of the scalp cysts, and what I discovered was that this poor, gainfully employed professional had been suffering from severe Trichotillomania (A compulsion to pick at one's skin or hair) since her University years.  Prior to that, she had been suffering from a lifelong generalized anxiety disorder.  She had a normal, happy childhood with normal relationships and normal parents.

She stated that she had been treated initially by a Physician with Luvox, but that the efficacy of the medication wore off years ago.  When her Physician left, she saw various Docs at walk-in clinics that would variably refer her to a Psychiatrist with a years-long waiting list.

She then lost faith in walk-in clinics, and continued to suffer and just "live with her illness" for a number of years.  The Doc that referred her to me knew nothing about her illness and did not appear to have made any commentary about her trichotillomania on the referral note.

It was interesting that while technically, I was performing a surgical procedure on her (elliptical incision, cystectomy, rotation advancement flap) - what I was really doing was taking a proper psychiatric history....a medical procedure that would make a far larger difference to this lady's life than the surgery I was performing on her.

Ironically, I was being paid much more to do the surgery than I would have been for the Psychiatric history and diagnosis.

But at length, the surgery was complete and I was able to determine that the lady suffered from Trichotillomania as a compensatory response to a severe ongoing somatic generalized anxiety disorder.

I am not a Psychiatrist.  I would have really liked to send this person to a Psychiatrist.  But a referral to a Psychiatrist that will see her for an ongoing therapeutic relationship, takes at least 2-3 years in Calgary - if the referral will be accepted at all.  

So while I lament that I will be unable to see this patient again (my Family Practice is closed) for the ongoing Psychotherapy that I know she will need, I was able to start her on the Effexor that I think will make a significant positive difference to her life.

I have to see her in two weeks to remove her sutures - and at that time, I will hopefully find out whether or not she is covered for a private Psychologist.  If she is covered, I will refer her on to one of the very fine Psychologists that I have been referring to for a number of years.

This case just highlights the suffering of people that fall through the cracks as Family Physicians abandon working in their traditional areas of expertise that depend upon long term Physician Patient relationships.  

While walk-in clinics serve a vital and valuable role, I believe that society is slipping slowly but surely into another kinds of "dark ages" of medical care when we accept the limited services that they  and the Emergency Rooms can provide as our highest standard of ongoing care.

I would like to teach students to do what I do - and to show them how to thrive financially while they do it...but I've learned that each student costs me a fortune/day to keep in my office (we don't get paid to teach students).  The $5000 at least per month a student would cost me would be far better spent on a savings plan for my kids' education as well as my retirement plan.......

So for now...we'll make change one patient at at time.....

Cheers!