Pssst… a Secret to Good Blood Pressure

One of my patients today was a kindly Hispanic gentleman in his 50’s who took no medications.

His blood pressure was perfect and he was in remarkable health for his age–and especially for his occupation as a truck driver.

So I asked him, what was the secret to his good health.

His face broke into a big weathered smile.

He told me this, as he shrugged his shoulders and grinned:

“No me preocupo.”

Three profound words.

Translated to English:  “I don’t worry.”

Pillar #1 – Psychosocial Balance (managing the stress of life, feeling in harmony with yourself, your family, having a good support system) is the single most important part of health.

It is from this foundation that we are able to find our confidence, to feel free to pay it forward, to feel good about making positive life changes, and to be likely to stick with them.

I simplified this term for a younger audience to Love:  the love of yourself and others–your family, friends, other human beings.  It is the single most difficult of all the pillars to achieve, because we are constantly worried (preoccupied) with events and things, and yet it is key to being able to find the best health for each person.  This is often the root of many illnesses, because it relates to stress, which is certainly a factor that will cause physiological changes including the increase of stress hormones which in turn cause such things as elevation in blood glucose, elevation in blood pressure, difficulty sleeping, cravings for comfort foods, addictive behaviors.

The five pillars of health that I defined are important and relevant, because they represent the things in life that we may have some control over and are not things that are based on the dependence on someone else.  We may never be able to change a deformity we were born with but we can change or end our relationships with others, our perceptions of the world and ourselves, how we sleep, whether or not we drink water, how and what we play, and what we eat.

Rich or poor, we all have things that we struggle with.  The key to being able to overcome obstacles is the ability to shift perspective, to focus on the good and positive things in our lives–even if it is one single thing.

And, truth be told, the more you look, the more you will find things that will make you truly happy, even if they are things deep within yourself.  The greatest adventure in your life may well be the one within your own heart.

Namaste.

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B. Pertussis – If It Coughs Like a Duck….

EVIDENCE BASED MEDICINE – IF IT QUACKS LIKE A DUCK, IT’S PROBABLY A DUCK BUT RIGHT NOW IT DOESN’T EXIST BECAUSE THERE HAVE BEEN NO STUDIES.

courtesy njfamily.com August 2012

(First, to all my English-savvy peeps, I am using “they” rather than he/she, with my doggone poetic license, which I have had much longer than my physician’s license, and, of course, for protection of the innocent). 

This all started the week before Christmas. I had a patient who was having a coughing fit. Cough. Cough-cough-cough, wheeze. And I, attempting to be a Good Physician (GP), nonchalantly asked the patient if they were up to date with their pertussis (whooping cough) vaccine.

When the patient finally caught their breath, they gasped, “Oh, I had whooping cough last year. Turns out I didn’t build good immunity when I got my vaccine. My culture came back negative, but the immunity studies showed that I had it. Could I have it again?”

Cough. Cough-cough-cough-cough. Wheeze. Cough.

“Hmmm….” I said. “Good question.”

I rubbed my chin in good doctorly fashion, and felt my zebra-hunting hackles rising.

After a little data exploration, curbside consulting (that’s when I ask a fellow doc for some tete-a-tete advice), and harrumphing, looking at the length of time the cough was present and how the patient was coughing, and going over my 10-minute patient encounter allotment time, I went with the instinct.

It was a highly suspect case, especially with a history of immunity issues and immunosuppresants.

Unfortunately this clinic, like a lot of other clinics around the country, was not equipped to do the proper nasopharyngeal swab with a special applicator and technique to cultivate the bacteria or get sufficient secretions to do DNA PCR testing. The only thing we had was an MAID blood test for B. pertussis antibodies. According to the big commercial lab, this newer test had good sensitivity and specificity (big science words, meaning that we are pretty sure the results are mostly good—a hat off to Miracle Max).

So we treated the patient to the best of our ability, this probably being late to catch any viable bacteria anyway as the cough had been around for several weeks.

I got a pertussis booster.  I was up-to-date with my TdaP, but it had been a couple of years.  The documentation suggested that it is a good idea in a suspected case of pertussis to be treated with prophylaxis (meaning to take a pill to keep from getting sick–it is not only a reference to condoms). The drug of choice is the Z-pak (azithromycin).

Z for zebra. I like the Z-pak. Taking an antibiotic once a day was helpful in a helter-skelter world when I had little kids who needed treatment for their infectious issues. Yes, I know it works for bacteria not viruses. But you know, it is awfully hard to look at someone and know for sure if what you are seeing is a virus or not. Probably it is. Probably. Could there be a secondary bacterial infection? Could be. Probably not. Maybe. Yes, there is a world of bacterial resistance out there probably fueled by well-meaning or simply frustrated physicians who just throw the antibiotic book at everything because that’s all you can do in 5 or 10 minutes.

But I was skeptical. I figured this patient was probably not contagious, and I was just trying to be cautious, and I should be thinking horses.

They beat this into us in medical school and residency—hoofbeats = horses, not zebras. Unless, of course, as I like to point out, you are in parts of Africa.

We tried to report everything to the CDC which referred us to more local resources, like the state, and the medical assistants were not able to get anyone on the phone because it was the weekend. Then it was Christmas. Then it was the day after Christmas, and I got the results back, and they were positive!

Of course, all the government (federal, state, local) offices were closed for the extra day off, and of course there was another weekend in-between.

  • INSERT RANT:  Thanks, Obama (in this case, mind you, I can actually say that and mean it).  We can thank both parties for budget north and southbound Zax stubbornness that caused mayhem with the CDC in recent years.  Infectious disease doesn’t take a holiday, politicians. END RANT

I started a nasty cough. My sinuses were running. 6 days after I had seen the coughing patient. Naaahhhh….

And then that day I saw another patient—same exact presentation, more than 3 weeks of coughing getting worse. The patient was with their spouse. Couldn’t remember if they had ever had a TdaP. The spouse was a teacher–not sick. So I told the patient about the test, looked at the records, and they had never been treated with a Z-pak for this—but had been seen a week or so before and finished some amoxicillin (the usual evidence-based choice for sinus, ear, upper respiratory infections).

Just because I had seen it before, and we discussed the possibility of pertussis the patient consented to let me do an MAID test and treat her with a Z-pak.

I filled my Z-pak prescription. I also filled a prescription for my household. I had 4 people at home with asthma who were at high risk for respiratory problems.

None of the 4 ever got sick. They got prophylaxis.

My cough got worse. I had to use an inhaler. I coughed so hard when I was driving home that I had to change and do laundry. I was instructed to suck it up and go to work. If every doc who got sick stayed home, there would be no docs. It couldn’t possibly be pertussis, and even if it was, it’s not a problem in adults and everyone is vaccinated (including me, and multiple times). So I went to work, and I wore a mask and refused to see kids. Patients thanked me for wearing a mask, as they heard me cough.

Then I started a fever along with my nasty cough and got a couple of days off, long enough to finish my Z-pak.

Z-pak can treat bacterial sinusitis, bacterial ear infections, bacterial throat infections, and some bacterial lung infections, and is the treatment of choice for most cases of community-acquired (walking) pneumonia. It is also the treatment of choice for B. pertussis.

One of the local health department guys called to follow up on our reported case. Wondered if maybe something like an Amber alert should go out. I told him I was concerned, but wanted a few more positive tests before I would know for sure to feel comfortable about pressing the panic button. I told him what I was seeing and promised to get back with him.

There was a particular presentation that I started to see with my patients. They all had severe nasal congestion, ear pressure, a scratchy or sore throat with post-nasal drip, red (injected) conjunctiva evident in the lower eyelids, some had dry cough, some had more productive cough, some had a lot of forceful cough with vomiting or urination, some a little, most had a hoarse voice. Lungs were clear. A few people reported diarrhea.  Most had some episodes of low-grade temperature elevations or frank fevers that would come and go if it had been more than a couple of days. Patients with asthma or COPD had to use their rescue inhalers—some for the first time in years, and those folks did wheeze. Most did not know about the pertussis vaccine, were adults, and if they did have one, it was more than 4 or 5 years ago. They were teachers, restaurant workers, grandparents, recently on a cruise, saw someone coughing at the grocery store, moms with coughing kids who were getting over “a cold.”

I did the most reading I have ever done on B. pertussis. It is one of the major causes of mortality in the world. Half of the children under the age of 1 who get it in the US end up in the hospital, reasoned due to incomplete DtaP vaccination series and swelling of the nasopharynx that in the very young with soft tender throats lead to an inspiratory whoop (stridor), with difficulty breathing in, and in older kids and adults may sound more like a hoarse voice or laryngitis (which is also similar to the presentation of croup and parainfluenza).

  1. Sound of Infant whooping
  2. Sounds of different severities of pertussis in kids, one without whooping
  3. Adults may not make a whooping noise

The vaccine used in the US, the aP in TdaP and DtaP, stands for acellular pertussis and replaced the old vaccine which was a “whole cell” vaccine (the old TDP and DTP). To confirm pertussis for epidemiology (the health department), a patient should be coughing for a couple of weeks (the only way to truly differentiate from the similar early presentation in various colds and influenza types) and have a postitive culture. The culture is rarely ever done, because although the B. pertussis organism is virulent (easy to spread to others) it is very very difficult to collect on a swab without killing it and to grow in a petri dish and thus PROVE that it is there (or was there—Kilroy was here!—usually by the time the bad cough starts, the bacteria is gone).   Newer tests find the DNA of the pertussis organism. And even newer tests, like the MAID, check for the presence of elevated antibodies that when raised beyond a certain lab-determined level indicate a PROBABLE exposure to B. pertussis. In addition there are variants of B. pertussis like parapertussis out there (good luck getting that one diagnosed). The vaccine IS ALSO NOT A GUARANTEE THAT YOU WON’T GET PERTUSSIS. B. pertussis goes in 14 day phases where a nasty cough settles in after 2 weeks. It is known as the “100 day cough.” As I sit down to write this, I have been coughing for 4 weeks.

AND the aP vaccine is only good for about 4 years… at 5 years the protection goes down to the 30% range. BUT there are no recommendations to do boosters every 5 years. Because (drum roll here) the CDC stated it was not cost-effective.

Not cost effective. Major cause of mortality in the world. Or is it really? How do we know, because IT IS VERY HARD TO CULTURE AND NOBODY DOES IT!

And, it seems to have a fairly benign progress in adults—like a cold with an annoying cough.

So back to the duck analogy…. If it quacks like a duck, you would think….

I have seen a lot of quacking and I started doing a lot of blood tests—I chose patients carefully on both presentation of the signs and symptoms I mentioned AND a link to kids under the age of one, to the public, or to others in the family who might have an immune-compromised state. All of these patients received a Z-pak prescription from me. And I wrote them for the families. For others without the child link, I had a low threshold to prescribe a Z-pak.

Some patients were resistant and threw the Mayo Clinc book at me for evidence and cultures. I had to sum up the new evidence, and patients agreed. In fact, I encouraged them to follow up with their regular doctors and get that culture—‘cause I couldn’t.

And here’s the shocker: Ninety percent of the patients that I tested came back with PROBABLE exposure to pertussis. I had MORE positive results on pertussis than I had on influenza.

After I started getting a handful of positive cases, I tried to recontact the health department person but had no luck in getting the message through.

I wrote to the CDC—“Hey, is there an outbreak of Pertussis in Houston? I have these tests and I can’t get a hold of the Texas Department of Health.” They wrote back—“Contact your local health department, we can’t help you, it’s not our job.” I wrote back, “What if this was Ebola? This is a contagious reportable disease! I can’t get a hold of the Texas Health Department, and I need your help! Little babies are at risk!” They relented and wrote back that they passed the word along.

I got a call from the Pertussis expert in Houston the next morning who spoke with me and approved of what I was doing. He begged for cultures, but couldn’t say for sure if there was an outbreak because they needed the cultures to make it definitive enough to report.

The other doctors I was working with were giving out a lot of amoxicillin and Tamiflu, neither of which would or did do anything for this syndrome, although with time, I knew this would get better on its own. Lots of time. Weeks. Maybe months.

I saw patient after patient with the same presentation. Some were in for physicals and were “getting over a cold.” Yeah, everyone in the family has been really sick, ran a fever for a while, but I’m getting better now. Hack. Hack. Cough.   Clear lungs. Congestion. Red eyes. Retracted ear drums.  Teachers reported that they have been seeing kids who never miss school who are out for several days sick.

Did I say 90%?

So the other day, a colleague came up to me and asked me why I was doing all these tests. The doc didn’t really trust or understand the significance of the labs. This doc did not believe it was possible that so many people could have pertussis because this doc had been practicing for 20 years and never came across it. “Really? Congestion and a sore throat? Come on…. WE WOULD HAVE SEEN IT BROADCAST FROM THE HEALTH DEPARTMENT.”

The doc was absolutely right…. you would think it would be broadcast by now.

(English majors, am I allowed to call this irony? I am not sure what that word means any more, thank you, Alanis Morissette.)

I took it to heart, and that zebra throw started to look a little worn. “It must be me. What am I thinking? Okay, I won’t test.” I was so conflicted.

Did I say 90%?

I was off the next day, and I called the local health department. Am I nuts? What am I seeing? I have many probable cases—so many that I now have an exact idea of who has this and who does not based on the clinical presentation alone.

I spoke to the Pertussis expert again, and he was still in agreement of what I was doing. He said that the elevations from the labs are indeed considered probable exposure, and that they have been working with the same lab as well. The hard part is getting a proper culture–usually the outbreaks are in a specific area or school, rather than widespread, but that the criteria of waiting for the long term cough is still part of the profile, so it takes some time to get all the data. It’s not uncommon to have pertussis outbreaks. (The last data I saw was about 2410 cases in the entire state of Texas, and I have seen a lot in the past month!).  The PDF letter dated 2013 from the Texas Department of health (below) listed 1935 cases reported to the CDC as the highest number in 50 years.  We are now quite a bit above that.

Pertussis-HealthAlert-09032013

NOBODY tests for this thing. And should we? And who pays for it?

But…. We are in the middle of an outbreak and there is a way to head it off at the pass, BEFORE it spreads more.

It is this pre-diagnostic tender time that the Z-pak makes a difference, before it has a full-on presentation with more evidence for diagnosis.

I, rookie that I am, can spot this presentation within a couple of days of symptoms, even before the fever, especially as I know this is the bug-du-jour that is palling around with influenza (everybody knows about influenza).

He said, if we can identify a particular school or area and get a culture, that would be ideal, although from a public health perspective, what I am doing with the blood tests and presumptive treatment is in the best interest of the patients and their families, including giving out Z-pak prescriptions to other family members.

So?

Most of the docs will still be doing amoxicillin and tamiflu. They are following the evidence.

Nowhere on the public websites is there note that in this city of millions of people there is a PROBABLE spread of a disease that is potentially fatal to kids under the age of one.

EPILOGUE:

These are the things that I wonder:

  • How do we ever communicate with other health workers on potential outbreaks? There’s no comment forum or thread on the CDC or on state or local health department websites for docs to post a, “Hey, guys, I found these cases of PROBABLE pertussis with this presentation, you might want to be on the lookout! Schools and hospitals might want to know.”
  • We aren’t even sure who we are supposed to report to other than to be as local as possible so that the chain of health departments can push the data along to the right places. There are city health departments, county health departments, state, CDC, and if you don’t pick the right one and that agency doesn’t work with the right agency, your report might just end up lost in the bureacracy—unless somebody dies or starts a lawsuit, of course. And then the fingerpointing starts. Plus neither medical assistants nor doctors have the (literal) 2-hour hold time to wait to speak with someone.
  • How do we notify the safety chain to get the word out quickly. Heads up?
  • Is the vaccine even effective? You can get the vaccine and still get ill. Perhaps the acellular version just isn’t that good. I saw three young children, all with updated vaccines, all coughing with history of fever and earache and mom that had elevated pertussis antibodies and no recent vaccine. She had PROBABLE pertussis, and that means her kids did, too, despite their vaccines.
  • Is it really that bad of an illness, and if it isn’t, why does the CDC and the state and local health departments fuss about it when nobody is doing anything to be proactive other than a dubious vaccine?
  • It’s treatable—why are we not treating it?
  • How about parapertussis? Is something else going around?
  • Who is doing the cultures, how do we get one, and who is gonna pay for it?
  • Will someone please beat the dust out of my zebra rug? NOW. PLEASE.

ARTICLES IN THE NEWS:

PERTUSSIS BOOSTER VACCINES MAY NOT FIGHT DISEASE RESURGENCE – MEDSCAPE – JANUARY 22, 2015

TOPEKA, KS – THREE CASES OF PERTUSSIS CONFIRMED IN LYON COUNTY – JANUARY 29, 2015

LOCAL MOTHER ENCOURAGES VACCINATIONS AFTER HER BABY DIES OF PERTUSSIS – JANUARY 29, 2015

Zebras

Secrets to Good Health from DOT drivers.

Kenworth_W900_semi_in_red

The US Dept. of Transportation recently changed their requirements for healthcare providers to take a course and pass a test in order to be able to do physicals for these important workers who keep our society and industry rolling.

As a rule, doctors complain about this sort of thing.  More regulations, more finger-pointing.  And the truckers and other drivers, like those who drive trains or busses, are also beseiged by regulations.

The DOT is strict about blood pressure, sleep apnea, vision, hearing, diabetes, seizures and other issues, and reasonably so, because DOT drivers have a 30% higher risk than the general population of having health problems.

WHY?

This is 5 pillar stuff–all of it.

  1. Pillar # 1:  Drivers are often on the road for a long time.  They are away from their families, many have financial concerns and are the breadwinners.  Many rely on their driving for their livelihood and the potential for disability is devastating.
  2. Pillar #2:  They often don’t sleep enough or don’t sleep well, as they are on the road a long time and may smoke to keep awake or pass the time.
  3. Pillar #3:  They drink everything except water, often also to keep awake or pass the time, and they don’t like to make pit stops.
  4. Pillar #4:  Rest and relaxation may be a couple of beers or a glass of whiskey before bed–see Pillar # 2.  The hours and places are not conducive to regular schedules and workouts.
  5. Pillar #5:  The highways and byways are littered with fast food, full of salt, fat, sugar, caffeine, nicotine, hot greasy and tasty stuff that is quickly satisfying, but a quick ticket on the heart-disease train.

I am a certified DOT medical examiner.  I am always sad when I have to disqualify someone, and I have frank discussions about the rules, about the things they can do to get their certification back, and I always tell them that FIRST I am a physician, which means that my first duty is to the patient, and that I am committed to giving them good advice and guidance, because I got into this profession because I care about people and their health.  And everybody and everything else comes after that, whether it is the company I work for or the DOT.

I have sent people to get treated for their sleep apnea, their heart arrythmia, their terrible blood pressure, and their vision before they can get their certificate.  It is hardest when people are older and heading for retirement, struck by something that holds them back from being able to work.  But you know, my patients understand this.

I sit down and have a frank discussion and I tell them that the most important thing is their good health, and the reason they need to go get things checked is not just because the DOT says so, but because I would be a bad physician if I did not pay attention to the things that could really hurt them, not to mention the other folks on the road.  I don’t want my patients to drop over from a sudden heart-attack or a stroke that might have been prevented.  I don’t want them miss a road sign and get hurt because their vision wasn’t good.  I want them to get to retirement!  And you know, for all their toughness (and they are tough men and women by all means), they are good about it.  They understand, even though they don’t want to, and they will make the haul for themselves when all is said and done.

But you know, we often focus on the folks with the problems.

  • INSERT RANT:  Things seem dire, and we as physicians don’t even look you in the eye while muttering the usual “diet-and-exercise,” from between clenched teeth, which is, I must say, the most trite and meaningless thing that doctors and other health professionals tell people whom they secretly (or not so secretly) disdain.  I think it is the worst possible thing that any doctor or medical professional can say to anybody.  I think it should be stricken from medical-speak.  It is the pinnacle of doctor and patient condescension and reflects the hopelessness in our medical system.  Truthfully, 95% of “diet and exercise” fails.  Don’t believe me?  Go check the statistics.  Not good odds for advice or a prescription.  Why wish that on anybody?  EXIT RANT.

So I try to spend some time focusing on the DOT drivers who come through with healthy blood pressure, weight, and few if any health issues.  Many have quit smoking.  These folks have beat the odds, and they are doing something that other people may not be doing.

So I say to them (and for that matter to any patients whom I see who are very healthy in any context), “I am really impressed that you have managed to quit smoking!  How did you do it?”  Or, “You beat the odds, your blood pressure is great!  How do you keep so healthy?”  And I will clarify, “the reason I am asking is so that I can help other drivers and other patients who are struggling.”

And this is where I learn some really great stuff.  I am a listener.  I am a networker.  I am happiest when I can draw a picture, connect the dots, and be a bridge for others.  This makes for a very positive patient encounter.  And patients are glad to oblige.

  • Driver #1:  My blood pressure is good because I never go to bed angry.  I don’t let things get to me.  My family and my faith are important to me and help to guide me.  It is not worth being angry because all that does is hurt me.  I have a good sense of humor.
  • Driver #2:  Now that Subway is at so many of the gas stations, like Loves, I find that it isn’t so hard to eat there instead of eating burgers and fries.  It helps.  My whole family is diabetic, but I am not.
  • Driver #3:  I’ve become a pescatarian.  I was scared about becoming diabetic and I had gained a lot of weight, so I lost it by switching to this diet.
  • Driver #4:  You know I have made my health a priority.  I TRY to eat well.  I don’t always do it, but I try to think about good choices and make them.  I make some time to exercise.  I go for a walk with my dog.  Again I try to follow a schedule and I don’t always do it, but I try.  I know my family depends on me, so I try to be as healthy as I can.
  • Driver #5:  I quit smoking cold turkey.  I just decided to do it.

Doctor’s note:  This is the one that surprises me the most.  Most of the folks I know who have remained smoke free for a long time have quit cold turkey.  I think it is the hardest way to do it because of the side-effects–crabbiness, anxiety, mood swings, but it seems to work.  These folks don’t pick up another cigarette again.

  • Driver #6:  I had a gastric sleeve procedure and lost 150 lbs.  I watch what I eat now.
  • Patient (over 100 years old):  The secret to a long life?  I like to kid around.  I eat all sorts of things, everything–vegetables, meat, bread, and I love the ladies.  I just got married to a younger woman.  She is in her 80’s.  I keep active as much as I can.
  • Couple married over 50 years:  The secret to a good long marriage?  Humor.  Never go to bed angry.  Be able to laugh at yourself.

I don’t forget these folks.  They stay in my mind and in my heart, and when I see someone struggling, I reach into my Mary Poppins carpet bag, and I pull out these words of advice.

You know, it makes for a very satisfying and interesting patient encounter when one actually has a conversation with the patient!

I know my my encounter is done to my satisfaction, when my patient leaves smiling, even though things may not have worked out the way they planned.

The best of health,

Doc Bea

Declaration of Health Independence

PREAMBLE TO YOUR CONSTITUTION

The World Health Organization definition of Health:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

The correct bibliographic citation for the definition is:

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

The Definition has not been amended since 1948.

THE DECLARATION OF HEALTH INDEPENDENCE

(by Doc Bea)

We hold these health truths to be self-evident ….

  • that all people are NOT created equal.
  • That we are born with different families who have different races, backgrounds, traditions, lifestyles, challenges, and health problems, and we each have new needs as our ages and health conditions change.
  • That we are males, females, infants, children, adults, older adults, and sometimes in-between.
  • That we are different sizes: tall, short, broad, slender.
  • That although we are all human beings with similar needs, each of us has a unique body, a unique life experience, and unique needs.
  • That we all have the right to a quality of life, to self-acceptance, and to the best health that we can work towards, in constructive partnership with our families, our communities, our physicians, and most-importantly, ourselves.
  • That we will all die someday, as the leading cause of death and disease is life itself, but we shall strive to live to the best of our ability and knowledge with physical, mental, and social well-being.