drmargaret

First let me post an update. My husband had his other hip replaced and is doing as well as can be expected following six surgeries to the area. The entire last year was rough on him. He’s fortunately of a strong constitution and coping well.

I’ve had asthma all my life. I got a bit better between when I was 14 and when I was 24, and then it returned with a vengeance. Last year I had a lot of problems with breathing. I was tried on about 17 different medications including steroids. Ultimately nothing worked. So all the medications were discontinued and I had a CT scan of my lungs, then an MRI scan. It turns out I have an unusual lung disease called sarcoidosis. I’ve probably had it since I was in my early 20’s when my “asthma” returned. It’s late in the course of the illness and I’ve already tried and failed all of the conventional treatments. I did try an experimental treatment for about 6 months and eventually my doctors conflicted with the research team on the treatment and, in consultation with both sides, I elected to stop treatment. What that means is that eventually my lungs will not be able to adequately supply oxygen to my body. I’ll probably end up with death from a heart attack or complications of infection rather than oxygen deprivation.

So I changed from a treatment model of care to a palliative care model. Treatment models in medicine involve the idea of working towards recuperation, or cure of an illness and a return to a prior baseline level of functioning. A palliative care model involves comfort. The goal is making symptoms tolerable with no goal of recuperation or cure. It’s difficult for physicians to switch from their normal treatment role to a palliative care role. It is the model used for all hospice care and all end of life care in general. It’s been a wonderful transition for me. No longer do I have a drawer full of medications and pill containers to take literally around the clock with alarms being set for every 6 hour intervals, but for the most part I’m on no medications except for those needed temporarily if I need some increased comfort.

I’m familiar with this model of treatment because I used to see people in hospice settings and I’ve had friends who have had terminal illnesses. A psychologist friend of mine with end stage cancer elected to continue chemotherapy and radiation as a last ditch effort, but then stopped all work and “stopped churning money.” The pressure she had put on herself to continue to attempt to manage a practice and run a home was a bit much. Her illness offered her the opportunity to pair down, scale back and only focus on what was most important. I spoke with her a few weeks prior to her death. She was happy. Her family was around. She wasn’t in pain. She was relaxed. I talked with a psychologist who was going blind from a brain tumor. He was just starting to switch from treatment to a palliative care model and was extremely bitter about the fact that there wasn’t anything else that could be done for him. He was trying to elicit sympathy from other people. He ended up driving people away. I lamented to him that it’s a shame that the “Make-A-Wish Foundation” that does such wonderful work with children with life-threatening illnesses doesn’t have the same service for adults. He could ask for some super model to visit, or engage in some fantasy sports camp, or get that one last car, pet, travel experience, life experience thing prior to the end. That seemed to give him a different perspective. He thought of many things he could do with the time he had left and elected to have meaning rather than to be bitter. Other people decide to maintain in treatment mode through to the end of their lives. It lets them think they are “doing something” and for some, it gives them hope.

I have lots of hope for the future. I just don’t want to spend my time chasing down treatments that sap the life out of me and do nothing to reduce my symptoms. So for the time I have left I want meaning. I’m intending to work as long as I’m physically able to. I’m one of those people that on my death bed will say “Gee, I could have spent more time at the office.” My husband is able to come to work with me at times so I see him often. Our dogs are both old and not in good health themselves and we just won’t replace them when their time comes. I’m also not concerned about big issues like politics, or the economy, or other things I won’t conceivably have an impact on in my lifetime. Yes I’ll recycle and won’t waste energy, but a lot of things are just not all that important. They aren’t worth my time. Other things have become more important.

My mother found out she had about a year to live. She had serious, untreatable heart disease. Given the extent of her illness she had a choice: she could try some treatments that would likely have killed her or she could do whatever she wanted with the rest of her life. She elected to discontinue all treatment towards cure and elected a palliative care model. She maintained some medical treatment and decided to spend the remaining few months of her life teaching English in Hunan, China. She sent me email of a regular basis and I heard from the Chinese consulate when she died there. She had a wonderful last year. Probably one of the best in her life.

My husband went to the hospital to get his second hip replaced. The surgery went well and he was sent home. Two weeks after the surgery he developed signs of a wound infection. It cultured positive to MRSA-Methicillin Resistant Staphlocaucus Aureus. There are a couple of infections that are worse than MRSA, but only a couple. Fortunately he had the hospital acquired form. The bacteria occurs in hospitals because people get resistant forms of bacteria due to antibiotic use and health care staff are not diligent about sanitary procedures and isolation techniques. His physicians removed his titanium hip and replaced it with a plastic spacer. He underwent three additional surgeries to clean out the infection. The body undergoes several changes as a result of infection. All inflammatory markers elevate. Blood glucose elevates and the risk for heart attack and stroke increase with inflammation, elevation in blood pressure and blood sugar. My husband’s markers showed him to be near death at the time of his admission. Fortunately he survived and did well on IV antibiotics. He lost about a 55 pounds while he was in the hospital.

We had gone to the hospital as an emergency. Leaving the house quickly. Unfortunately we left some soiled bandages on the couch and our two Dalmations shreaded them all over the house. Only a few bacteria are able to transfer from humans to dogs. MRSA is one of those infections. Both dogs ended up contracting the infection. It took weeks of antibiotics, treatment with iodized silver, and eventually antibiotics administered intranasally before the dogs tested negative. My thanks to the Bella Moss Foundation in England for their information and support during that difficult time.

My husband contracted an additional infection from being on IV antibiotics. Clostridium Difficile is a bacteria that invades the GI tract after normal bacterial flora is destroyed or it can occur as a result of ineffective sanitization procedures. The bacteria produce spores that can live on surfaces for up to 70 days. Washing surfaces with alcohol gel is not effective, but soap and hot water is effective in killing the bacteria as is bleach.

Eventually my husband was released home the Friday after Thanksgiving. The VA hospital said he was no longer contagious. I didn’t think he looked well when he arrived home. Fortunately we followed universal precautions. He tested positive for Clostridium difficile on Monday. He has not yet had surgery to eplace the titanium rod in his hip. He still has a spacer. With ongoing infection, he remains at heightened risk for heart attack and stroke.

I’m not writing this to document my personal family difficulties. I’m writing to let other people know what to expect from hospitals and physicians. When you go to a hospital, wash your hands with soap and hot water. Expect the physician and hospital staff to wear gloves or wash their hands prior to examination and following examination. If you do not observe your doctor or medical staff washing their hands request they wear gloves.

Initial signs of infection include elevated or subnormal temperatures (99.1 or higher or 98.1 or lower), elevated blood glucose with readings over 200, and elevated blood pressure with readings over 140/80. It’s possible to have abnormal vital signs and not have an infection. But the changes in vital signs are the earliest signs of infection that can be documented. As infection progresses there will be changes in lab chemistries. Leucocytes will elevate above normal, an inflammatory marker called C-reative protein will elevate (normally it’s less than 1), the sedimentation rate will elevate. Eventually there will be an actual fever with a temperature over 101. As the immune system becomes compromised organs shut down with resulting kidney problems and respiratory difficulties. Death results from cardiac failure, pneumonia, renal failure, or wasting.

There are a couple of infections which require urgent treatment. MRSA, VRSA (Vancomycin resistant Staph Aureus), NF- necrotizing fasciitis, also known as “the flesh eating bug,” are all infections that require urgent treatment. Any of these infections can cause life threatening complications starting in a matter of hours or days. Almost all infections can be prevented by good health care provider hygiene, regular hand washing, and normal cleaning of surfaces that come into contact with potentially contaminated material.

Hopefully in the case of my husband everything will eventually turn out well, he will get a new hip and his recovery from that surgery will go smoothly. My you all have a good 2008.

One of the most stressful things that can happen to someone is to get sick, go to a doctor, and have the doctor not be able to determine what is wrong with you. As the illness continues and worsens the physician can often get overwhelmed followed by multiple referrals to specialists or a referral to a mental health practitioner.

I come from a family with unusual medical conditions. My first atypical illness literally began at birth and resulted in my first adoption being rescinded and a week’s stay in a neonatal intensive care unit. Six months later and weighing a pound less than my birth weight I was pronounced fit for adoption and sent home with an unsuspecting couple.

Over my lifetime I’ve had four illnesses which have gone undiagnosed for months to years. The most recent event started January 13, 2007 and I was finally diagnosed on June 7, 2007 almost six months later.

What I want to talk about in this post is how anyone can cope when faced with this type of situation in themselves or in a loved one. The first thing to do when a disease has no diagnosis after a couple of weeks or so and is not responding to systematic treatment, is to put together a list of all the symptoms of the illness for the doctor. Put this on the left half of a piece of paper and give each symptom a few lines of blank space under it. On the right side note what makes that symptom better or worse. Get copies of every laboratory test done and get a basic medical book such as the Merck Manual and look up every laboratory abnormality noted in the tests. Make a list of every medication tried, the dose of the medication used, and the length of time of the trial. This list should include every single medication prescribed, and foods used as medicine, any herbs, any vitamins, any supplements, and anything you are “borrowing” from friends, family or buying on the street including any illegal drugs, tobacco, beer, wine, hard liquor. To this list add foods such as grapefruit, onion, garlic, ginger, and orange juice. These foods can have an impact on the effectiveness of medication. A food diary, of everything consumed, may also be helpful.

Start with the symptom list. On a fresh piece of paper list every illness you can find that has that symptom associated with it. You can use the computer to search by symptom and disease. Make a list of all diseases associated with the symptoms for all the symptoms.

Move to the medical test abnormalities. On a fresh piece of paper list all the abnormalities and all diseases associated with the symptoms. Do this for all the abnormal test results.

Move to the medications, over-the-counter products and foods. Put down all the side effects known to occur with the products. Most medications come with patient hand-outs to explain side effects. The Physician’s Desk Reference or the Pill Bible, or The Physician’s Desk Reference for Herbs or Supplements can assist.

Since you now have lots of information, start looking for diseases that are repeated in the lists. When I do this with patients I find it helpful to have them get a package of different colored highlighters. Highlight each disease with a specific color when it occurs three times in the list.

When these lists are created there is too much information and most of the information will end up being irrelevant. As more tests are being done or more treatments are being tried, it gets easier to see specific diseases that are either being ruled out or starting to be ruled in by how often they are showing up on the lists.

I usually start this process when I’ve been sick for at least a couple of months or the symptoms are severely worsening. While I’m doing this process I also get involved in either chronic illness chat rooms or psychological support chat rooms. This is an anxiety producing process. People going through this feel very nervous. Inevitably there are fatal illnesses and not treatable illnesses or poorly understood illnesses on the lists. Reading about difficult and painful ways of dying can be depressing. Psychological support can be very helpful during this time. A visit to a professional psychologist may also be able to help.

When you come up with multiple lists that have a specific disease or two, then you would want to ask your treating doctor about testing or treating you for that specific disease or two. You can choose to share your lists with your physician or simply put down all the symptoms, lab tests, medications, foods that lead you to come up with the disease you are interested in investigating further.

Let’s say you have neck pain. It gets worse when you exercise. It gets better when you lie down, but not when you are completely flat, just sort of reclining. The neck pain is accompanied by chest pain or a feeling of discomfort sometimes but not all the time. The first time you saw the doctor, they thought you might have strained a muscle and suggested some over-the counter pain medication. Over time, nothing has improved and the chest pain now is moving more into the center of your back and you need to lie down more often. Lab tests show your blood pressure is elevated, you have elevated cholesterol, you have some problems with inflammation. You have no problems with glucose. The doctor ran a special test to check for arthritis and did an x-ray. Those came back normal. Your list showed that neck, back and chest pain, elevated blood pressure, and elevated cholesterol are all consistent with heart problems. Okay, time to go back to your doctor to ask about testing for heart problems. If those tests show heart problems you can get treatment. If not, you can go back to your lists. Doing this process is likely to come up with a diagnosis eventually in conjunction with your doctor.

Now a word about doctors. There are some doctors who think that they need to manage the illness, treatment, and understanding themselves without patient input. If you have a doctor that will not assist you in helping to get a firm diagnosis, or work with you on developing a treatment plan, you may want to consider getting a different physician.

This strategy is helpful in working with many rare, unusual, or hard to diagnose illnesses.

As for me, my condition should improve with treatment and may resolve completely. My condition is unusual for someone my age, or my ethnic background so it hadn’t been considered by my doctor. The symptoms clearly pointed to a diagnosis. It was just a matter of ruling out most of the common place things I was more likely to have, then moving on to the weird but possible illnesses. It was then that the illness showed in tests. The research I did also allowed me to understand possible treatments. I brought in 12 pages of treatment protocol for my doctor and he thought that treatment might prove very effective. I started treatment last week.

Medical doctors used to evaluate patients by using clinical medicine not laboratory medicine. They looked at people. They touched people. They asked them questions. They went to their homes. They talked to their family members. Moreover they lived in their communities and saw them on a day to day basis. Things were not sophisticated. The equipment was simple. There was a simple black bag that held most supplies. It could be taken from one house to another and back to the office.

Pharmaceutical drugs were created primarily from plants, and molds. They were also not sophisticated. There were a few medicines being worked on by creating small inert batches of bateria to stimulate the immune system to create antibodies to the infections. There were some other medicines being created by combining chemicals or compounding to form liquids or pastes.

This wasn’t so long ago. It was within my lifetime. I’m going to be 50 this year. I’m talking about this because it’s important to remember these practices. These are valuable and shouldn’t be lost over time.

I’ve worked with internists as a psychologist in my professional life. Few of the internists are trained in clinical medicine anymore. When I started in practice all were. My adoptive father was trained in compounding pharmacy and materia medica (the creation of medicine from plants) few are trained in that now, it’s a subspecialty in pharmacy. So over the years I’ve picked up clinical medicine information and information on plants used as medicine. I understand how medications are used and how they are to be used. I understand pharmacy labels. I can use this information to explain things to my patients and to the people I evaluate.

A young adult came into my office. Illness is written all over the body. It’s written on the face and hands. It shows up in the movements. It impacts psychological functioning. It impacts people differently if they are young or old. It impacts women differently if they are men or women. It impcts them differently if they are of different ethnicities. Science is just beginning to understand this, but clinical medicine has know this for decades.

This young adult was an African American woman. She was morbidly obese. She had problems sitting in the chair because it had arms. She has a bad diet. I don’t need her to tell me that I just need to look at her skin, hair, hands and finger nails. They all tell me. She has malnutrition and probable diabetes. She is 19. Her skin is pale at the lips, the eye lids and her gums are red. She has cuts in the corners of her mouth. Her nails have longitudinal beading like candle wax. Although she is overweight, she is starving of nutrients. She has massive signs of vitamin B complex deficiencies, signs of anemia, and signs of diabetes. She has had these for months if not years. Vegetables in her diet would improve these problems. She isn’t eating them or she has a substantial stomach problem. So I ask her what her medical problems are. She tells me she has diabetes. She is tired all the time. She is depressed. She can’t focus or concentrate. No one has diagnosed malnutrition. Her blood sugar is 250 on medication.

I’m not allowed to treat or advise when I evaluate. So I can only do it here. There are basic concepts of eating food and drinking water. Drinking water means consuming 6 to 8 glasses of fluid per day. To drink less means the body becomes dehydrated. The bowel and the kidneys do not work right. The body works harder. The heart pumps against a load causing a higher level of distolic pressure (the low blood pressure number when the heart rests between beats). Toxins build up and constipation can develop as a result of lack of fluid in the bowel. The skin becomes dry, cracks and infection can set in. Eyes become dry and vision blurs. Urine concentrates providing a haven for bacteria in the bladder and kidneys. The lungs become dry and fail to have adequate secretions increasing the risk of infection and pneumonia. Asthma or COPD, if present, worsens. As fluid continues to decrease the cells in the body dry out from fluids and clinical dehydration sets in. Subtle changes in mental status start to show up. Personality changes with increasing irritability, lethargy, hyperreflexia, progressing to seizures and eventually coma. Impaired thirst is often noted by people as they become increasingly dehydrated. Temperature may increase prior to seizures. Mortality can be quite high. It’s worsened by pharmaceuticals that add to dehydration or increase urinary output. In mildly dehydrated individuals (those drinking 2 to 3 glasses of water per day) it’s easy to go to a moderately dehydrated state and not have any realization. Laboratory medical doctors may miss the clinical signs of dehydration and simply add additional medications to combat the worsening medical illnesses secondary to dehydration.

In addition to drinking water it’s important to eat food. Food consists of fruit, vegetables, meat or some form of protein, and may include dairy products. There are people who do not eat food. They consume lots of calories from sugar or simple carbohydrates. But they fail to eat food over the course of a day. Rice, bread, tortillas, potatoes, carrots, corn, alcohol (even beer or wine), all convert to sugar and if you have problems with blood sugar (as in diabetes) you can’t eat them if your blood sugar is too high. Normal blood sugar runs between 90 and 120. There is no such thing as an individual blood sugar reading. I’ve had people tell me what “normal” is for them. There is just normal and abnormal. If you are over 120 you are too high. My mother was a diabetic. She died of complications of diabetes. Her complication was a heart attack. It is a common complication of diabetes. She would point to her diabeteic diet card and show me that it allowed her to eat bread. Yes it does. One slice. Not a loaf. Not when your blood sugar is 200. If your blood sugar is between 90 and 120 you can have a slice of bread. It’s better to have it when it’s 90 than when it’s 120. My blood sugar hasn’t seen 90 in 2 years. To lower my risk of a second heart attack I’m reducing my blood sugar and trying to keep it around 100. It runs 110. There is a strong family history of diabetes. The more I can control my blood sugar now the less risk I will have. I already have the lines in my fingers. I already have diabetic neuropathy and retinopathy. I just haven’t got diabetes. I just have all the clinical not the laboratory signs of diabetes. So I can recognize 8 to 10 years in advance that I am diabetic. It gives me lots of time to control the disease before I will ever need medication. Medication will be late in the disease process. That’s true with lots of clinical medicine. Clinical symptoms show up often before laboratory symptoms show up. The reason is because the criteria for the recognition of a disease in clinical medicine is different than for laboratory medicine.

Clinical medicine looks at people and notices details. Fine details. It’s used (or is supposed to be used) in the television program House. You shake hands with someone. You feel the hand. Is it warm or cold? Is it damp or dry? Is it soft or calloused? Is there a tremor? What does it look like? What do the nails look like? What does the palm look like? What is the color of their skin? Then you move to the face. Do they look at you? Do they make eye contact? Are their eyes clear? Are their eye lids open, not pale, even, not runny or reddened? Are their lips pale, made up, are their teeth in place, are their cuts in the corners of their mouth? Is their hair combed? Are they wearing a wig? Are they losing hair? Are there discolorations on their face or neck? How do they move? You get the idea. It’s details.

I met a woman with a large brown spot on her face. It was indented. I had asked her her medical history. She hadn’t mentioned it. It was basal cell cancer. Brown pigmented, pinkish, mottled in places. It would need a biopsy to confirm the diagnosis. It’s slow growing, so there is not a rush for a diagnosis. There were other things wrong with her that led me to suspect she had cancer besides the spot on her face. She had more problems besides cancer. I asked her if she had seen a skin doctor for her face. The skin thing was obvious. She had seen lots of specialists. She hadn’t mentioned it. She then told me it was cancer. She had had it removed a couple of years ago. It was basal cell. It had come back. She hadn’t returned to the doctor to have it removed again. Her doctor hadn’t noticed it. He doesn’t look at her when she comes in. She was surprised I had mentioned it. She wasn’t expecting me to actually “see” her.

Clinical medicine meant evaluating people in their community, often in their home, certainly in their language. Los Angeles is home to people who speak lots of languages. I no longer see people in their homes or at their bedsides. I see people with interpreters. I do attempt to communicate with people directly in their native language whenever possible. Even if it is one or two words it changes the evaluation. It changes it in one or two ways. It either means to the person being evaluated that I speak their langauge and that they should work with me that I am one of them not against them or it means that I know everything that has gone on between them and the interpreter and they must now tell the truth. I had a depressed Hatian woman who after asking me my name the third time I said “je suis Margarite.” She then said several sentences in French all happy. We talked about my trip to Paris and to the Carribean. She talked about missing her culture and speaking French. She was not depressed for 5 minutes out of an hour. It was a pleasure to see her like that. I had an Armenian woman I counted to four for in Armenian. Her jaw dropped open. She stared at me. She had been attempting to malinger up to that point. She asked where I was from. I said California. She asked about where my family was from and I said Ireland, from Cork. She then did very well continuing to look perplexed. She just wouldn’t fake badly for someone who spoke Armenian, even if it was just a few words. The same is true with Japanese, Vietnamese, Korean, Russian, even Gypsy sometimes. I’m fairly fluent in Spanish and in Los Angeles speaking Spanish is becoming expected. I have Spanish speaking relatives. I have an ethnically diverse family. That’s not expected. I have relatives that are Cuban, Portugese, Philipino, and African American. My immediate family is racially diverse as is my extended family. I was exposed to multiple languages and ethnic groups as a child.

When I was going to people’s homes to do evaluations I could see how they lived. I could see what they ate. I could see what they had in their refridgerators or freezers or on their counters. I could see how they prepared food. I could see how they kept their house. I could see how they kept their medications. I could see how they organized their lives. I could see how they interacted with their family or extended family and pets. I could see how they kept poisons, dangerous materials, or hazardous equipment. I could see where they lived.

I went to my brother’s house in Sonoma. He has had three heart attacks and a stroke. He is 18 months older than me. He has diabetes, neuropathy, asthma, and arthritis. He smokes. He doesn’t exercise all that much. He has a poor diet and uses insulin. Sonoma has some of the best food in the world. I cooked for him. I had him test his “uncontrollable” blood sugar before and after the meal. We had vegetables and fish. I made a desert out of yoghurt cheese and berries. His blood sugar at the start of dinner was 145. At the end of dinner it was 150. Within an hour it was 155 and within 2 hours it was back to 145. There were no sugars in the meal apart from a couple of berries. These were well managed by his medication. The food was great. He watched me cook it. I showed him his blood sugar was not “uncontrollable.” There was a lot of food. It was mainly vegetables. There was 3 ounces of fish per person. The next morning he wanted toast. I had him test his blood sugar before and after eating toast. One slice. He started at 130 before. 150 after. Within an hour it was at 200. after 2 hours it was at 220 and he didn’t feel well. He used insulin to bring his sugar down. The correlation was clear. Eating bread, even a single slice caused his blood sugar to skyrocket over several hours. Despite this, my sister in law tells me that he still decides to eat bread. That’s his choice. He still smokes. Despite asthma, despite heart disease. That’s also his choice. Both will shorten his life. He just can’t tell me he doesn’t know that.

Adults get to make bad decisions about their health. Clinical medicine allows psychologists to show people early the impact of their decisions. It doesn’t make people change their decisions. It may help influence them. People still can choose. Psychologists can provide information, motivation strategies, assistance in keeping to schedules or strategies, or help with compliance. We can lead people. We can’t force them.

Children watch adults and have a lot of their health care decisions made for them. Food choices and fluid intake are especially critical in developing children. As adults get lax about their own health they are also getting lax about the health of their children. We are seeing diseases in children which were formerly seen in middle aged adults. It’s not just obesity. It’s malnutrition coupled with obesity. It’s depression as a consequence of malnutrition. It’s inattention as a consequence of dehydration.

Psychotherapy will not fix lack of food or water.

There is news about psychiatric medications once again. Children who are prescribed stimulant medications for attention deficit disorder are at a slight possibility of risk of heart problems. Women who take medications for depression, specifically selective serotonin reuptake inhibitors (SSRIs) like Prozac can also get heart problems and their babies, exposed prenatally can have withdrawal symptoms. So what are people to do for attention problems or depression?

First, look at the information rationally as it applies to you and your situation. No one should be taking medication if it isn’t needed. So be sure that medication is required prior to starting on any psychiatric medication. Let me go a step further. How do you know if medication is needed for attention problems or depression? First, non-medication treatments were tried. For attention problems, treatments involve parenting, behavior work in the classroom and behavior work at home. Sometimes a psychologist can be involved in providing behavior specialty work. sometime a specific professional called a behavior specialist is involved. School and clinical psychologists can be used to treat comorbid problems with emotional problems and academic difficulties that often accompany attention problems. Cognitive and interpersonal therapies can be used to treat those in addition to standard counseling. For depression, cognitive therapy seems to have the most research to show it is as effective as medication for mild and some moderate depression. There are some interpersonal therapies and some other types of therapies that also report effectiveness but don’t yet have the same research support behind them. Supportive psychotherapy, where someone just asks how your day is going and tells you when to come back after listening to you, is not very effective at all for any form of depression or anxiety. Therapy requires some form of activity on the part of the therapist to be effective.

Very severe forms of attention disorders or severe depression require medication. All medications cause side effects. Very few medications are specifically researched as safe or effective for children. Risks increase the younger the child is and the higher the dose of the medication. It’s important to understand how medications work to understand what goes wrong with the side effects. Stimulant medications increase the heart rate to increase the functioning of a specific part of the brain-the frontal lobe. The medications are excreted from the body from the kidneys and processed through the liver. Several things can go wrong. The heart can speed up too much or beat wrong causing an arrythmia or heart attack. The liver can stop processing the chemical or the kidneys can shut down. All these things can be fatal. Of all the millions of children taking stimulants, 24 had heart problems and died. Lots more had liver problems and some drugs got taken off the market a few years ago. The kidney problems are far less frequent. Seizures are less frequent, and are almost never fatal. The same effects can happen with caffeinated soda for the same reason. Caffeine speeds up the heart. People die from ephedra. People in college die from caffeine overdose with cardiac arrythmia during finals and mid-terms. Sure, they had pre-existing heart problems they never knew about and they added a drug they thought was safe. No-dose and Jolt Cola and other stimulants are considered so safe they are sold over the counter. For most people Ritalin and Strattera are safe and effective. For a very small minority there are unknown preexisting problems that the medication points out. But for anyone, if they suddenly get short of breath, complain of chest pain, start sweating profusely, get pain radiating down their arms or through to their back, even if it’s a child, they need medical attention. Heart attacks happen in childhood as well as in adults.

A similar thing is true for SSRIs. These antidepressants block the reuptake of serotonin all over the body. They have a significant impact of the GI tract, the spinal cord and the brain. The impact on the brain takes several weeks. The impact on the spinal cord and GI tract is within a few days. The people who notice an almost immediate impact to SSRI’s are responding to this GI and spinal cord impact. Pain due to muscle disorders and GI problems may be medical causes of depression that may have been overlooked in the initial diagnostic workup. Significant repose to an SSRI within 2 to 3 days of onset suggests a medical, not a psychological, cause of depression. There is a very small percentage of people who have some very strange symptoms with SSRIs. Seizures, abnormal bleeding, and heart problems as well as problems with metabolism of the chemicals cause difficulties with these medications. People who have a history of these types of problems should review their histories carefully with their prescribing MDs prior to choosing these medications and monitor their ongoing treatment carefully.

Especially with the SSRIs, it’s important that the medication be taken every day without fail. Intermittant use of medications like these ensures that the medications will not work correctly to reach the brain and will limit the impact only to the GI tract and spinal cord. episodic use increases the risk of side effects that reduce with time such as nausea that primarily have their impact on the GI tract.

It’s important when reviewing medications and medical histories with a treating MD to review all over-the-counter herbs, vitamins, supplements and prescription drugs as well as medications you may be borrowing from others (not a good practice). You may also want to review them with the pharmacist when you fill your pescriptions. If possible, fill all your prescriptions at the same pharmacy. With computerized tracking systems, potential drug interactions can monitored and hopefully avoided at the pharmacy. In addition, it’s always important to eat a normal diet and drink an adequate amount of fluid (6 to 8, eight ounce glasses of fluids a day).

Eat food, drink water. MDs don’t seem to tell people that. I still see people on weird diets not drinking enough water and getting dehydrated. They get sick in weird ways. Medications don’t work and their body doesn’t work right. It’s important on stimulants and antidepressants to eat and drink fluids. It keeps the body systems working right. It helps the medications work right too.

A pandemic is an epidemic that spreads around the world. There is a current infection which is killing off a lot of different kinds of birds in several countries now. A lot of people are worried about it. The main people that should be worried about it are the people who raise birds.

There are some rules about sanitation that don’t get followed everywhere. If you have a sick bird, don’t eat it. If you have a lot of sick birds wear a mask when you clean them up and dispose of their waste products. Wash your hands when you come into contact with animals.

These rules are hard to follow if your birds live in your house. Lots of people in Asia have their birds live very close to them. My mother lived in Hunan for a time. She had a pet bird. No, she didn’t get bird flu. She got the anticipated heart attack. But people get to live in fairly close quarters with chickens, pigs, ducks, geese and turkeys. They live on rural farms. They know their animals. They are poor. They sell their animals in open markets in large groups. People are in close contact with animals all the time. As a result people catch viral infections that migrate from animals to humans.

This is the case with the H5N1 virus. Mainly is goes from 1 bird to another and causes the bird to become sick. Lots of people who regularly live among birds are appaarently immune to the infection. Young people and some older people who come into contact with sick birds become sick. So far there have been no cases of any people transmitting the virus to other people.

But what people are worried about is that if someone with the flu catches H5N1 then it might be possible to transmit this virus to another person. It will take up to 36 hours for that peron to know they are sick. By that time the first person may have infected many other people. Computer models of H5N1 with influenza A make it look like it might have up to a 50% mortality rate. About half of the people who contract the disease may die. That figure may be erroneously high. It’s based on the people who get sick from H5N1 now and from the flu now.

The regular flu kills somewhere around 10,000 people a year in the US. Most of these are the elderly, the very sick, and children. It’s a complication of diseases already present and weakened immune systems. No one pays much attention to “flu season.” People get a fever, chills, a sore throat, and are miserable for several days. The flu is caused by a virus. There are preventive flu shots for at risk groups to lessen the risk of getting into that 10,000 or so group that dies from the illness. A year or so ago it was predicted that there was going to be a very bad flu season and few flu shots. Lots of elderly people lined up to be vaccinated. There were shortages. The one major lab had it’s license pulled and vaccines had to be imported. There was a big outcry. As it turned out, the “flu season” that year was relatively mild.

So now people are trying to think about what to do for a pandemic. By and large this is an intellectual exercise. What would you do if you were the last person alive? What would you do if a tire came off your car while driving? What would you do if your house was on fire? What would you do if someone approached you with a gun? What would you do if you saw a lost child crying? What would you do if a virus to which few people had immunity was going around the globe? These are all things people can think about. A government needs to think about the last one. They should have some sort of basic plan in place.

We had a bad flu when I was a child. It was in the late 1950’s. Both I and my brother caught it. Lots of people were sick. We recovered. But people have the memory of the stories of the Spanish Flu pandemic. It killed lots of people. People get scared about something like that coming back.

Right now there’s no need for people to be afraid. Birds, on the other hand, should be awfully worried. There is a current bird pandemic. Birds have been reported to be sick in Mongolia,Vietnam, Indonesia, Romania, Tibet, and a sick bird was stopped from entering the country at customs in England. Birds will continue to spread the virus along normal wild bird migratory paths and along the routes used for smuggling exotic birds and poultry. As long as the virus stays with birds, with a few cases of birds to people, there is no problem. The US has good surveilance on sick birds. Sick birds in most places are killed and the flocks are killed. In small family farms, especially in Asia and in other third world countries, what people do is eat sick animals after they kill them. Not a bright idea. So, predictably, those people seem to be getting sick. To stop sick birds from possibly entering the food supply some countries like Canada have proposed a ban on poultry from China or all of Asia. It’s a proposal. In most cases it’s not needed. Good, safe food handling is needed. Most viruses are killed with proper food cooking and freezing. If you undercook meat or poultry you get sick. Poultry needs to be done to an internal temperature of 180F. The juice should run clear when the bird is punctured with a knife when taken out of the oven.

If you own birds try to keep them separate from your home. Don’t let them wander in and out of your house. Give them their own space. Make them their own small house and keep it enclosed to keep away migratory birds. If you have a sick bird, keep it away from the rest of the birds and get it tested by your vet for bird flu. Most birds are dying of Newcastle disease and not H5N1. It’s a different type of bird virus, and doesn’t transmit readily to humans. It’s common this time of year. If your sick bird dies, don’t eat it. If your sick bird dies don’t feed it to other animals. If your sick bird dies don’t compost it. Have your bird examined and necropsied. Governments are looking to contain H5N1 virus. It can wipe out large bird manufacturers. Contact your vet for assistance. Yes they may quarantine your farm, but you may save a lot of other livestock and you may ultimately save some lives.

As for antivirals, there are currently several on the market. Tamiflu is the one getting the most press. Flumadine and Symmetrel are othera. Acyclovir is an antiviral for herpes type viruses. Epivir-HBV is effective against hepatitis B. Repitol is effective against hepatitis C. Combivir, Crixivan, Emtriva, Hivid, Viracept, Viramune, Zerit, are AIDS medications. Synagis is effective against the RSV virus. There are other antivirals on the market as well. My list here was designed to cover the manufactures of antivirals, all of whom have the capability to produce anti-influenza drugs.

So what stops the big pharmaceutical companies from producing anti-flu drugs? Several things. There’s a limit on the profit the drug companies can make from producing vaccines for children. The US has a low cost vaccination program for children which limits profit. Second, there’s a limit on how the SEC wants the profit documented for shareholders. Lastly, since all drugs have side effects and some people get sick from vaccines, people sue the manufacturer making it a problem to produce vaccines for very large numbers of people. So big business will want to either limit the number of people who will get their vaccines or limit litigation or both.

So here is the worst case of a pandemic of H5N1 in the hypothetical. Remember this is an intellectual exercise. There is no human to human transmission of the virus in existance. But if there is, then the US is planning to develop 20 million doses of vaccine. The H5N1 in computer models (and remember the computer model is believed to be overestimating mortality) is 50% and the majority of death is for victims at age 49 years and younger. The average is 14. If you develop the vaccine then at least 1% of the people vaccinated will develop some side effect to the vaccine itself. Side effects will range from mild to severe. The severe side effects may include the possibility of death. 50% of the people who get sick who are not vaccinated may die. There are around 6.5 billion people in the world. If a flu pandemic occurs, everyone will consider whether or not to be vaccinated. There will not be enough vaccine to vaccinate everyone. Some people will not want to be vaccinated. Some people will not be able to be vaccinated based on how the vaccine is developed. It’s likely that concern over who will get the vaccine may be worse than the pandemic itself. If you recall what happened last year with the flu vaccine, that’s what happened.

At some point in our future there will be some illness which travels around the globe. It’s likely to be some type of virus. We have global travel and a global economy. It’s important to put safeguards in place and to plan now for things that might happen. It’s also important to keep in mind that for the most part these are intellectual exercises and there is no need for panic.