Ebola

I haven't posted on the subject of Ebola virus, but I am getting a lot of questions about it, so here goes.

As a general matter, I think the world at large has been very slow to respond to this outbreak.  On the other hand, I think the initial panic and furor are abating and cooler heads are prevailing.

When I say that the world response has been slow (excepting Medicins Sans Frontieres or MSF, otherwise known as Doctors Without Borders) I  mean it has taken months for the World Health Organization, Centers for Disease Control, National Health Service or European Union to respond in any way.  The above photo appeared in the March 2014 breaking news coverage by the British Broadcasting Company of Ebola in Conakry.  Notice the suburban homes behind the guys in Personal Protective Equipment.  That's suburban, not rural village.  Ebola outbreaks up until now have occurred 2,000 miles from the African coast, and have been in isolated locations.  Given the lack of medical care in these isolated areas, Ebola patients generally didn't survive long enough to get to cities of any size.

Conakry is the capital of Guinea and has 1.7 million people in it, an international airport serving Western Africa and Europe, and a deep-water port.  It's in Wikipedia- you don't have to be CIA to figure it out. I find it hard to imagine not breaking out in a cold sweat realizing Ebola is in a large port city with an airport, especially if you are in government or public health.  It does rather appear that the world-at-large only sat up and took notice when Westerners got Ebola. (warning: satire.)

At this point, Ebola has spread to adjacent countries but the ground response is more effective.  This is largely due to hard-won lessons in nursing care, social networking and community support.  For example, family members can now see and communicated with sick loved ones (by phone or the other side of a window) and can see workers don or remove PPE and can see the dead before their burial.  Think about it: if this was happening here, how would we react to sick family members being taken into a big white tent or building from which  no one ever comes out alive?  And you never, never see them again?  We are once again reminded that nursing care is critically important, and communication and emotional support are a big part of it.  This New Yorker piece is an excellent history of the earlier ground war against the outbreak.

A big question now exists over quarantine.

Some perspective should be applied over general air travel out of the three affected countries. Last year, those three countries comprised under 0.02% of the world's commercial air travel.  The US received 2% of these passengers, coming in 12th place as destinations from these countries.  Projections suggest a total of 2.8 commercial air passengers per month flying out of these countries for the next year.

Also, bear in mind that this is not an airborne illness like a cold or flu.  The current CDC recommendations that open with 21 day monitoring but not forced close quarantine are reasonable in this light.Similarly, the New England Journal of Medicine advises against forced quarantine of returning health care workers.

It is reassuring to consider that the only people in the US who have contracted Ebola did so through very direct contact.  In fact, consider the Liberian patient who died in Texas.  He slept with his fiancee for days before being hospitalized.  She and her family were in mandatory quarantine in that apartment for close to a week before it was de-contaminated.  None of those folks went on to develop Ebola.

I think it is now time to turn to increased global efforts to address the outbreak in the currently affected West African countries.  Certainly, forcing returning symptom-free health care workers into 3 weeks of restricted quarantine is not the opening move here and neither is blockading travel in or out of those countries.

Aside from humanitarian reasons, impeding any effort from developed countries to flood in to combat the infection with money, personnel and resources is foolish in the extreme.  As General MacArthur is famously quoted as saying regarding the Pacific Theater of Operations in World War II "Would you rather fight in Saipan, or in California?".  Doing everything possible to quell the outbreak while it is still confined to Western Africa is to avoid fighting it in Karachi or Mumbai.

The sparks that have flown to the US and Spain have been well contained.  It should not be assumed that sparks landing in large urban centers in developing countries with marginal health care and political infrastructure will fare as well.  As an example, consider that 40% of the world's supply of generic prescription medication is manufactured in India.  If Ebola were allowed to become pandemic in India, the humanitarian suffering would be unimaginable.  Additionally, the rapid loss of generic medications for the world would have immediate impact on the entire world's population.

So, my $0.02? Don't panic, take reasonable precautions for self-protection, and put the resources where the real fight is before it gets out of control.

Myth: 8 glasses of water a day

I still get asked whether one should drink eight full glasses of water a day for reasons of health, and the short answer is "No.".

It's a bit of a mystery where that meme got started, but it has never been the advice of doctors as a matter of general health. It may have gotten its start in the 1940's around the amount of fluids in both solid foods and beverages in the average diet.

At any rate, if you are becoming a bit dehydrated you will feel thirsty.  Feel free to have some water or any  other fluid.  Certainly most of us are going to be better off drinking water than alcohol  or sweetened drinks.  It is simply not necessary to push  fluids beyond this point.

How often are people late for appointments?

This is an interesting post in which a doctor is vexed by how often his patients are late and asking whether this is the norm.

The post does address this and found a study showing that 7.7% (one in thirteen) patients are late for doctor appointments.

However, it also pointed out that another study shows an average patient wait time of 38 minutes for the doctor. Gulp. Mea culpa maxima.

My own experience and perspective?

• We do encourage the first patient of every morning and afternoon to arrive 10-15 minutes early to make it easy to start out on time.  I do often run late because the first patient is late to arrive and I am then already starting off 15 minutes behind.
• I do spend a lot of time with  each  patient.  It's difficult to arrive at an accurate diagnosis without an extensive understanding of the development and nature of symptoms and a physical examination.  This takes time.  There's good medicine and fast medicine, but no good, fast medicine.
• I gotta admit that because of this I rarely ask patients to re-schedule if they happen to be running late!

How understanding why you don't like certain people can be helpful to you

Here's a neat thought.  We all meet people we just don't like.  It's pretty unusual to like everyone you meet, and it's impossible to be all things to all people.

However, maybe it would be good to pause and reflect on why you don't like that person.  What if the reason is that that person has some characteristic we wish we had more of?  What if the things we don't like in others are often the things we dislike in ourselves?

What if meeting someone you don't like not only affords an opportunity to learn ways to accept if not like them, but also a way to examine and  better yourself?

Changes in prescribing and dispensing hydrocodone

The Food  and Drug Adminstration of the federal government (DEA) has changed hydrocodone to a Schedule II agent.  This is effective as of Monday 10/06/14. Scheduled agents are felt to have varying levels of potential for dependency or abuse. 

This is due to concerns that this narcotic pain-killer which is  the active agent in Vicodin, NorCo and Lortab (as well as a number of other brand names) is over-used and/or over-prescribed.  Certainly, the US, which comprises about 4% of the world's population, is using about 99% of the world's Vicodin and NorCo.  It is unlikely that Americans have 99% of the world's physical pain.

What this means is that doctor offices will no longer be able to prescribe or refill these medications by phone or fax.  Like morphine, Dilaudid or Percocet, any  prescriptions or refills of hydrocodone pain killers will require a hard copy.

If we are prescribing this  to you for the first time, you will be given a physical prescription.  No refills can be written on the original prescription.  The  pharmacy cannot fill the prescription without this physical prescription.  They cannot act on faxing or phoning it in ahead of you.

Any refills will also require a physical prescription.  If you need one, please call my office and allow two full business days to have it ready for you to pick up and take to a pharmacy.  A friend or family member can pick up the prescription and/or the medication.  If we feel we need to see you about this, we will make an appointment for you. 

If you are using pain medication or other scheduled agents regularly, we will want to see you regularly in order to evaluate its effectiveness and safety.

Doctors in California are being encouraged to use the state Department of Justice's Physician Drug Monitoring Program which allows doctors to determine whether patients are being prescribed scheduled agents by other doctors or providers.

If you are using hydrocodone or any other scheduled agent and would like to be able to reduce the amount you take, or stop taking them altogether please feel free to see me about this.