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Ebola in America: Measured Concern, Not Panic

Schematic of Ebola ecology and transmission cycle (From the Centers for Disease Control)

Schematic of Ebola ecology and transmission cycle (From the Centers for Disease Control)

The 2014 Ebola outbreak in Africa – the most extensive and deadly since the disease was first described in 1976 – has been making headlines around the world.  Now, the first known cases of Ebola infection are coming to U.S. soil – on purpose.  One American – Dr. Kent Brantly – is in a special containment unit at Atlanta’s Emory University Hospital, and another is soon to follow. Here’s why we should not be overly worried about this development.

The Method of Transmission

Ebola is a serious and scary disease; it is highly infectious, has no cure, and has a mortality rate of up to 90%.  And there is no vaccine (yet).  However, it is not as easily transmitted as the flu or the common cold.  One must be clinically ill to transmit the disease.  It is possible for an infected person to arrive in the U.S. or another country before showing symptoms, and then become sick after arriving. But before they actually became sick, they would not pass on the infection.   This would hardly be a trivial event; but health professionals would promptly suspect Ebola and institute a quarantine of both the index case and all contacts while experts confirmed the diagnosis.

Infection Control and Containment Standards

Unlike a hot open-air unit in Africa, where workers swelter in their protective gear, the isolation units in Atlanta and similar facilities would certainly have a far lower chance of accidental transmission to caregivers – let alone to outsiders.  In fact, the chance of an outside spread is close to zero.  The patients will also be kept isolated beyond their apparent recovery, and be confirmed as virus-free before release.  They will be closely monitored after release.

Better Supportive Care

This infection causes damage in several ways, including dehydration from fluid loss and coagulopathy.  Although there is no specific cure for the infection itself, its effects can be treated.

Supportive care with fluid replacement, correction of electrolyte problems, and management of organ failure will be provided at the standards of a top-level American intensive care unit, and this can substantially improve the mortality rate (still estimated at 30% or more).

Potential for Better Care in Future Outbreaks

The current outbreak may take a long time to be contained.  The patients in Atlanta will be studied and monitored with great attention to detail.  With these patients under the direct care of American infectious-disease experts, it is possible that improved treatment methods can be developed and applied to other patients in Africa, and in future outbreak episodes.  We don’t know if an Ebola reservoir species will ever become established outside of Africa, or if future cases will arrive here.  But in any case, what is learned from treating these two Americans will help manage future outbreaks of this disease.

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Streptococcal Sepsis: Rare But Dangerous

The tragic story of Rory Staunton received national attention, as well as scrutiny on physician-only discussion boards.  To recap, this otherwise healthy 12 yr-old suffered a seemingly innocent arm scrape playing basketball.  He soon felt ill and was seen the next day by his pediatrician, who referred him to the ED.  There he was rehydrated and discharged.  He did not improve.  When he returned, now gravely ill, he was hospitalized but succumbed to sepsis.

This is a tragic and unsettling story for several reasons.  Simply put, we live in a world of bacteria.  Any time a small injury occurs; there is a very small but real chance of a serious infection developing, should the body’s initial immune-system defenders fail in their job.

The bacteria at issue here were once far more feared.  In the pre-antibiotic era, this infection was very often lethal.  It was staphylococcal sepsis that in 1924 killed Calvin Coolidge Jr., son of the then-President.  Today in otherwise healthy people, it is very treatable, except in unusual circumstances.

As a disclaimer, Monday morning quarterbacking is not science.  Any commentary by those who did not directly participate in the events is speculative and based only upon whatever information is publicly available.

From the coverage and board discussion of the events, it appeared that when the child presented to the pediatrician, he was felt to have dehydration and gastrointestinal distress.  That seems a reasonable initial impression.  After all, hoofbeats usually mean a horse, and not a zebra.  Referral to the ED made sense if he was felt to require significant rehydration.

Diagnosing streptococcal sepsis at this stage would have been hard, and the far more likely diagnosis was presumed.  But, the appearance of the arm was suspicious.  Usually, people with such wounds are covered with antibiotics if the wounds require suturing, or if not sutured, coverage might be prescribed if any redness or surrounding cellulitis is seen.

In cases such as this, it usually takes more than one missed opportunity to have the outcome turn tragic.

At the ED, reports describe difficulty standing and walking, fever, and a pulse of 140.  That sounds fairly ill to me.  On the discussion boards, Emergency specialists sparred with surgeons over whether this is a typical appearance commonly seen with dehydrated kids.  I have to side with my surgeon-colleagues who said that it should have been apparent that something was really wrong with the young man.

The most concerning thing about the ED visit was the discharge without checking the blood work.  Rory had a significantly elevated white count with a major left shift.  That strongly suggests a systemic infection.  It is this point for me that is the most concerning, and one that deserves more scrutiny.  Were the labs forgotten?  Was it presumed that they were probably normal and therefore not an issue? Did someone read the wrong lab report?

The public expects a medical system incapable of error or untoward outcome.   But before blame is assigned, questions need to be answered.

Was this a system problem or an individual problem?  How busy was the pediatrician’s office?  Were they distracted by the non-medical minutiae required to practice medicine today?  Was the ED awash in non-emergent cases and understaffed?  Did the report get lost or mislabeled?

Cases such as this tend to result in calls for more rules, more scripted procedures, and more ways to try to perfect an imperfect system.  But sometimes the answer is not to add complexity to the process of undertaking a clinical encounter, but to simplify it.  In this case, just be sure to take a look at the big picture, and don’t forget to check the labs.

And sometimes the hoofbeats really are from a zebra.

Junk in the Trunk: Amateur Buttock Enhancements can Kill

The arrest of a Florida man for allegedly performing buttock injections with a variety of home-improvement products may seem shocking to outside observers.  Not so in South Florida.   We see a few a month.   Some are not happy with the results; it’s lumpy, uneven, or otherwise abnormal.  Those are just some of the patients.  To see the others, we’d have to make rounds at the cemetery.

Amateur buttock enhancers are fairly prominent in the region, where there is higher than average demand for all sorts of cosmetic procedures.  Buttock shaping is a popular procedure, and is fun and fairly straightforward to do.  Properly selected patients tend to do well and satisfaction rates are high.

Perhaps due to the economy, or to ignorance, some people allow lay-practitioners (some may be partially medically trained) to inject substances into their buttocks, hoping to get the same effect as a proper cosmetic surgery.  There are two things to keep in mind regarding this concept:

  1. There are only two medically legitimate ways (in this country) to reliably augment the buttocks:  with silicone implants or with fat grafting.

    Silicone implants are less commonly done since there are generally higher rates of complications than with fat grafting.  They can be appropriate for thin patients who do not have enough donor area fat.  But in general, fat grafting is the preferred procedure and makes up the majority of buttock enhancing procedures.

  2. Home-improvement substances such as caulk, silicone, Fix-a-Flat and cement (to  name a few) are not supposed to be put in your body.

    Though this should be obvious, not everyone realizes it.  These substances are not designed for medical use, and can have all sorts of complications.  There can be infection, hardening or destruction of tissue, and embolization (stuff entering blood vessels and clogging up the lungs or other organs).  Any of these events can lead to irreparable tissue problems, disability, or death.

Some victims may believe that they are under the care of real medical professionals, (though I don’t know too many colleagues who perform procedures in basements or hotels).  Others may not think these substances are harmful, or believe they are legitimate in other countries but not in the U.S. (they’re not).

Here is a brief list of similar incidents:

Miami, June 2008

Miami, September 2010

Las Vegas, April 2011

Top 5 Winter Health Hazards

Single-stage Simplicity snow thrower in use on...

With 2 months or so left to go before escaping into spring, its worthwhile to run down a list of five winter weather health hazards.

1.       Frostbite:  When you are exposed to cold for too long, certain parts of the body begin to hurt.  Then, they stop hurting.  Once the hurt stops, things go from bad to worse.  Frostbite is treated similar to burn injuries, and can be just as significant.  Mild cases may leave only a blister.  Serious ones result in loss of appendages.

2.      Icy roads/walkways:  Sloppy conditions lead to cars sliding all over the place, causing anything from fender-benders to major crashes.  Slipping on iced-over steps and walkways can cause injuries ranging from minor to fatal.

3.      Snowblower injuries:  Although probably not part of high-school physics classes, schools in winter areas should review the potential energy remaining in a snowblower when it gets jammed with snow/ice.  Though the machine seems calm, once the clog is loosened that blade moves, fast.  Every hand surgeon covering ER call in a winter area has probably operated on the result, some several times in a season.  Unless you are Superman, you can’t possibly move your hand fast enough.  (And anyhow, Superman would have done the driveway using his heat vision)

4.      Falling off roofs:  The weight of rooftop snow can be a serious problem.  It is not as serious as what happens when one slides off the roof or the ladder collapses.  If you are worried about the roof coming in, do your local trauma room a favor and call a professional to clear it off.

5.      Shoveling snow:  Wet, heavy snow (the common Northeast variety) is about 20.8 lbs per cubic foot.  So for a 50’x20’ driveway, six inches deep with snow, you (and your back) are lugging over five tons of material if done by hand.  Everything from strained muscles to heart attacks can result.

Did I forget any?  If so drop a line.  And if you are tired of winter weather, click here for a more permanent solution.