vaccine - curious question

[rback33]

Some good came from it though in that it gave me a good laugh.

Well if laughter truly is the best medicine then I have cured a LOT of people today... the amazing thing is that this is the first time I have done this

 

[IslandTractor]

We're not really in disagreement .... But I would never criticize another doctor's work (or anyone else's) when I don't have the necessary facts to justify it.....And in the case at hand, the facts aren't there. Period.

You are correct we are not that far apart. However, the attitude that the doc is always right unless the evidence is absolutely nailed down and totally without question is something I don't accept. I was critical of a series of interventions that is unfortunately quite common and far more often than not are the result of sloppy thinking/medicine. My read on the original post was that 1) doc thought it was definitely a sting and 2) the thought there was a local allergic rxn. There are many reasonable ways to manage that situation including observation and follow up without any therapy much less multiple prescriptions. Of course there are situations where empirical therapy is justified, happens every day in every practice. However there is also a lot of polypharmacy (for you tractor nuts out there that is prescribing lots of drugs without good cause in a shotgun type approach) out there and I think the public needs to be more tuned in to it so they resist and don't foster it. Docs often complain that their patients demand medication but part of the reason for that is that through over prescribing the docs train the patients to expect it and because it it faster to write a few scripts than to take time and explain the situation. Whatever happened to patient education and watchful waiting? I don't mean to suggest the doc's actions in this situation were outrageous, unfortuantely it is fairly common practice around the world. It just isn't good practice.

I'm getting back to important tractor stuff now.

 

[IslandTractor]

Rust is not a requirement for tetanus.

You're completely correct. I have no idea where the notion that rusty nails were critical came from except through association with puncture wounds in the outdoors. The organism is primarily found in the soil especially where there is contamination with animal or human excreta. Tetanus as a disease is extremely rare in the USA these days with less than a few dozen cases a year. It is a good idea obviously to have a tetanus booster every decade but you don't need one after a skin puncture indoors in most situations and you don't need one after a bug bite.

 

[Bird]

Docs often complain that their patients demand medication but part of the reason for that is that through over prescribing the docs train the patients to expect it

I'm sure that's right, but I also wonder how much of it is due to the huge number of TV commercials. If those commercials weren't selling those drugs; i.e., if they weren't working, the manufacturers would quit running them after awhile. And usually the tail end of the commercial makes it sound as if the side effects are worse than the problem the drug is supposed to treat.

 

[IslandTractor]

Commercials and ads for public viewing have been part of the equation for the past decade or so at most. The general phenomenon is much older so I don't think the commercials started it. Also, there aren't any commercials for antibiotics by and large and those are some of the most commonly overprescribed drugs.

Human nature is probably to blame. When we get sick we want to put something magic into our bodies to remove the sickness. Even the most primative societies behave the same way. Even animals do it. Current over prescribing is just a modern high tech varient on the theme. While old "remedies" were often harmless placebos (chicken soup, tea, etc etc), modern pharmaceuticals typically are double edged swords and are less safe when used inappropriately.

 

[N80]

It is interesting that after nearly 20 years in medicine I have never seen a case of tetanus. Never seen a case of small pox, never even seen a case of mumps. It has been a while since I saw a case of chicken pox. There are several reasons for this: 1) the immunization program in this country works pretty well and 2) I've never practiced outside the US.

In WWI tetanus was a major source of battlefield casualties, I've heard it accounted for more than bombs and bullets.

 

[N80]

Commercials and ads for public viewing have been part of the equation for the past decade or so at most.

Actually, the historical root of the problem does lie with advertising and the problem of overprescribing antibiotics started with penicillin. When it first became widely available it 1) was a virtual magic bullet in a world in which the vast majority of deaths resulted from infectious disease and 2) it was utterly unregulated, sold without prescription and was advertised widely and wildly as a cure for virtually any medical problem, infectious or not. Thus the popular and persistent view of antibiotics as a cure all.

But, as mentioned, I don't know of any current direct to consumer ads for antibiotics.

And let me explain what we med geeks are talking about. First, the more antibiotics are used, particularly for conditions in which they are not actually useful, the more the bacteria become resistant to the antibiotics. This often leads to very common types of bacteria not responding to even powerful antibiotics. This is mostly a problem for people who are very sick and in the hospital (in which case such infections can be fatal) but it can also be a problem in simple skin wounds in healthy people and even with some things like sinusitis.

Second, the most common way antibiotics are overprescribed is when they are used to treat conditions that are porbably viral. Antibiotics kill bacteria not viruses. Bacteria cause things like wound infections, sinusitis, some ear infections, pneumonia, bladder infections and some intestinal problems. Viruses can cause similar infections but most commonly virus present in the form of the common cold or a stomach 'bug'. A common cold caused by a virus will make you perfectly miserable for 7-10 days, 14 in some cases. As we all know "there is no cure for the common cold" and you just have to treat the symptoms and ride it out. Antibiotics do little or nothing to help a cold go away.

So why do doctors prescribe antibiotics for a cold? Well, it is very complicated. Many symptoms of a cold can be similar or identical to those of a sinus infection, tonsilitis, pneumonia, etc. So there can be confusion. Also, a common cold can lead to a secondary infection such as sinustis, pneumonia or an ear infection. That complicates things even more.

But, the main reason is this: A person gets a cold. Fever, cough, runny nose, nasal congestion, sore throat, body aches, fatigue. For 3-4 days they fight it with over the counter meds, etc. By day 5 they are fed up and go to the doctor. Doctor looks them over, thinks its probably a cold, but could be a sinus infection. Doctor also wants to feel like he's helping and giving patient his money's worth and so prescribes him a Z-pack (popular 5 day antibiotic with a cool sounding name and red pills). Two days later, bingo, they are cured and happy as a clam and the doctor looks so smart and helpful. Right? Nope. What really happened is that the patient came in on day 5 of a virus that got better on day 7 like they almost always do. The antibiotic didn't have a thing to do with it. But to the patient is seems like it did and he tells his friends and family to go in and see Dr. Smartguy next time they get a cold and he'll fix 'em right up with a Z-pack.

Then it gets even worse. This patient's friend now gets a cold and comes to see Dr. Smartguy on day two of his cold. He tells Dr. Smartguy he really wants a Z-pack. Dr. Smartguy knows better but wants to make patient happy. Patient gets his Z-Pack and two days later (4th day of cold) he's no better. Worse even. Why? Its the natural history of a common cold. So he goes back on day 5 and tells Dr. Smartguy that the Z-pack didn't work. He needs something stronger. Dr. Smartguy has now painted himself into a corner and he's too busy to go into details about microbiology and gives the patient a big gun, gorillacillin antibioitc, usually reserved for serious infections. Patient starts gorillacillin on day 5 of illnes and two days later, bingo! he's well again. Thank goodness for gorillacillins right? Nope. He just got better because his cold followed its natural course and got better on its own.

Then it gets worse. This guys now requests a gorillacillin every time he gets a runny nose and tells his friends and family to do the same. That's how it all gets out of hand. And when thousands of doctors do this with many thousands of patients, the bacteria start to become resistant to our gorillacillins and then we have no gorillacillins.

So, let a cold run its course. And if your doctor tells you that you have a cold, trust him, give it some time.

This has been a public service announcement for the benefit of non medical folks so I don't want to hear any Ivory Tower egg heads making technical corrections. It is obviously way more complicated than this, but, you get the picture.

 

[Tom_Veatch]

...
And usually the tail end of the commercial makes it sound as if the side effects are worse than the problem the drug is supposed to treat.

I especially like those commercials for sleep aids where the stated list of side effects include ... drowsiness...

Well, duhhh!!!

 

[roxynoodle]

I am a person for whom antibiotics were overprescribed for sinusitis. Ok, they might have worked had my sinuses been able to drain. You may have read my post in the farm animal forum. I was kicked in the face by a horse and had multiple fractures. My right maxillary sinus had numerous pieces of broken bones that formed a large mass. Well, for 4 years that mass remained because nothing had been seen on the initial catscans other than that my sinuses were filled with blood. I am not a doctor but to me sinuses filled with blood = a problem. They didn't even believe me when I told them my jaw was moving around. The jaw ended up having to be cut off and bolted back on because it had healed in the wrong place. Needless to say my doctors gave me antibiotic after antibiotic to cure the sinus infection. I now have had a sinus infection for 10 years. It isn't fun and my hearing has been affected. I eventually changed doctors and the new doctor seemed to be sympathetic to the overly prescribed antibiotic problem. Now he's looking for the easy way to get a patient out of his office and everytime he sees me, that's all he wants to give me. I know doctors are extremely busy, but the prescribe meds, get out of my office tactic is not helpful. Right now I suspect I could have West Nile virus. At the least I have something I've never had before and others in the area have had it (and I have the symptoms of a mild case). What did he give me? An antibiotic. I have been sick since last Monday (week and a half). I may be looking for a new doctor again.

 

[IslandTractor]

....

So, let a cold run its course. And if your doctor tells you that you have a cold, trust him, give it some time.

This has been a public service announcement for the benefit of non medical folks so I don't want to hear any Ivory Tower egg heads making technical corrections. It is obviously way more complicated than this, but, you get the picture.

I agree with every single word of that entire post.

 

[IslandTractor]

I am a person for whom antibiotics were overprescribed for sinusitis.

Sinusitis is one of the more difficult issues in this whole business. Your case is actually quite atypical due to your trauma so what I am about to say does not apply directly to you.

There are, as N80 mentioned above, a few factors that make sinusitis such an issue. For starters, it is actually very difficult to diagnose accurately unless it is fairly advanced. The reason for that is that the symptoms of early or even moderately advanced sinusitis are virtually no different than the symptoms of an ordinary common cold. There are no easily performed laboratory studies that help distinuguish bacterial sinusitis from a cold and even xrays are fairly useless. The xray of someone with early to moderate sinusitis look virtually identical to the xray of someone with a cold. (Bizarrely, radiologists have no diagnostic code for common cold as a cause of these findings so inevitably report such findings as "consistent with sinusitis" which puts further pressure on the doc to treat) This is a big part of the problem. Physicians are confronted with perhaps half a dozen or more patients per day during the winter months who are complaining of prolonged cold symptoms. The docs know that at most 10% actually have a bacterial sinus infection but they have no good way to distinguish those from the others during a single office visit. Ideally they would take the time and educate patients (patient patients ) and send just about all of them home without antibiotics but with the understanding that a few of them might need to be reevaluated in a few days, especially if symptoms are worse. Time pressure, economics and general patient expectations and even fear of malpractice conspire to convince the doc to prescribe an antibiotic "just in case". It is a slippery slope however as it soon becomes just "standard practice" to prescribe an antibiotic for just about anyone with cold symptoms (to a greater or lesser extent in many practices). There have been studies done in the US showing that up to half of all patients who have a discharge diagnosis of "common cold", a clearly viral illness, will leave the office with an antibiotic prescription. That's nuts. But, as pointed out, the way we got there was through a combination of factors that focus on both the doc and the patient being impatient and not wanting to wait for 90%+ of those colds to simply resolve with time. There was a very interesting study done on students at the University of Virginia about thirty or fourty years ago where a group was intentionally infected with a simple cold virus and then asked to keep a symptom log book. They almost all had typical cold symptoms for the first 4 or 5 days but what was really striking is that a full quarter of them continued to have cough and nasal discharge for up to three or four weeks before it finally resolved. So, it is actually "normal" to have those symptoms for much longer than any of us is happy about and they do eventually resolve on their own the vast majority of time. None of the students was treated for sinusitis and they all recovered without antibiotics but that was fourty years ago before "sinusitis" became a fad diagnosis (to be sure it is also a real dx but probably the vast majority of what is called sinsusitis is really just persistent cold symptoms in the USA). Today it is standard to consider someone with cough and runny nose for more than 10 days to have sinusitis. Clearly that set of criteria grossly overdiagnoses the problem but it is used and even shorter periods of time often applied in clinical practice. It's one of those connundrums where if you set the diagnostic criteria higher you'd miss some of the real cases and if you set it low (as we have) you end up "diagnosing" a lot of people with sinusitis who are really just getting over a cold.

There is surprisingly little good science showing that antibiotics are important in the management of what is typically diagnosed as sinusitis. Clearly in some cases (the real bacterial ones) it is critical but for the "average" case it is not so clear and most patients simply resolve the symptoms over time just as the students from UVa did. Essentially that is because what is being called sinusitis is really just the prolonged normal resolution of viral common cold symptoms. There is a huge industry surrounding sinusitis however as the pharmaceutical companies especially but some practicitioners as well, depend on continued over reaction and over prescribing. The phenomenon of diagnosing and treating sinusitis is really only about 20-25 years old in the is country. Before that it was a relatively uncommon diagnosis so there is pretty good evidence that this whole "sinusitis" thing is largely unfounded. Kinda like how in the 1950's every kid had his or her tonsils out until years later it became clear that if you did not take them out they eventually healed anyway and you avoided surgery....today we still take them out occasionally but much less often than before. Similarly ear infections were over diagnosed and over treated in the 90's and 90's and are now being less agressively managed. It will be a while longer before both public and medical practitioners are reeducated about the sinusitis business so we can anticipate continued pressure to prescribe and over prescribing for a while longer. Patients can help by simply recognizing that common cold symptoms persist for weeks, not days and by holding off on trips to the doctor unless they are getting worse after the first few days of a cold or they have a new symptom such as fever a week after the initial symptoms. The other important thing you can do is to drive tractors as much as possible thereby staying out of contact with other humans and thereby lowering your risk of acquiring a viral infection.

 

[BB_TX]

Since we are getting into long distance diagnosis , I will expand a little farther.
She was digging thru the closet when she felt a sharp sting on the back of the arm/shoulder area. Threw everything down and got out but never saw what stung her. This was Friday evening.
By Saturday afternoon, the spot was puffed up considerably. Redness all around and spreading across her shoulder. Even her eyes were a little puffy. Not really much lingering pain although the spot was tender. Not wanting to chance waiting until Monday to see her regular doctor, we went to a primary care clinic where she was given the tetanus shot and something for the allergic reaction.
By Tuesday, some swelling still present. Redness still present all across her shoulder even more than before and some rash breaking out. Went to her regular doctor. He gave her some other things including the steriods.

 

[dmccarty]

IslandTractor and N80,

Thanks for such a great discussion. I HATE taking antibiotics since they seem to upset my stomach. zPac seems to work though.

I get pressured at work to go to the Doc to get "fixed".

So what I got out the conversation is, unless I'm getting worse, just ride it out. And that the symptoms may linger for weeks.

Did I get that right?

Later,
Dan

 

[IslandTractor]

IslandTractor and N80,

So what I got out the conversation is, unless I'm getting worse, just ride it out. And that the symptoms may linger for weeks.

Did I get that right?

You got it.

Each person knows their own body better than any physician can in a 10 minute office visit. If you are slowing getting better that is par for the course after a bad "cold". You may feel worse in the morning (clogged up feeling) but so long as you are basically getting a bit better each day there is very little additional help you can get from medication.

 

[N80]

So what I got out the conversation is, unless I'm getting worse, just ride it out. And that the symptoms may linger for weeks.

When I (one out of one doctors surveyed) get an upper respiratory infection I take ibuprofen for aches, pains and fever, a decongestant for stuffiness and maybe a non-narcotic cough suppresant. I have a sample closet down the hall with nearly every brand name oral antibiotic and I don't touch them. For me, a cold almost always lasts for two weeks, just as IslandTractor mentioned. Even if it lasts a little longer I don't bother with the antibiotics. In my younger days I did raid the sample closet for antibiotics but over the years, if I looked at things objectively, I realized they never seemed to help.

And, as mentioned, even for many, if not most bacterial infections like sinusitis and middle ear infections and bacterial bronchitis, your body will take care of the problem without antibiotics, and probably even better than antibiotics. It just takes time.

So when these flare up, if you are concerned then see a doctor. But if he doesn't prescribe anything don't worry about it and don't think he is ineffective. He's determined that you probably don't need anything. If you get worse or symptoms persist, check back with him.

 

[roxynoodle]

Thanks for the discussion, docs, it was very informative. I have also had surgery twice on the sinus. The first time was 4 years after the accident to remove the mass of broken bones, a broken bone that was in my nasal passage and to ream out the sinus opening at the top of the maxillary sinus. 3 years later I seemed to be in as bad of shape and that catscan showed more broken bones in the sinus and that the opening that had been reamed out was collapsing, whether because it was weak structurally or due to the bacteria, it wasn't certain. The ENT removed the bones and put a new hole under the large fracture line hoping it would be able to drain then. I use saline nasal spray to try to keep it open and clean. Sometimes it helps and sometimes it doesn't. But, honestly, I really don't want any more holes so until I get to the point where I feel like my entire head is being crushed by vises in all directions, I just try to live with it. I have wondered if they could just go in and clean it out once in awhile instead of trying to create new sinus openings?

 

[Soundguy]

As a follow up. I calle done of my friends who is an xray tech in an er. he 'polled' some of the MD's there about tetanus. No one he asked had actually seen a case of tetanus, or heard of a case.. though all said.. that basically, it was very treatable, even after onset of the muscle spasms, due to advancement in meds.. like chemicals to reduce the spasm, as well as imune globulin, and good antibiotics, pain management.. etc. They basically said,.. that at least in the uS.. as long as you get into the hospital before you have stoppe dbreathing.. you will likely survive.. etc. I take it 3rd world countries don't have it so good.. med or cleanliness wise.

Soundguy

 

[willfick]

Then too, a cockspur on a farm with horses is about as likely a tetanus vector as we're to find in a (at present) first world country.

 

[RichNJKubota]

I don't recall where I heard this but here goes...
If you get cut once in a while by rusty metal or get dirt in the cut then you are getting "vaccinated" by being exposed to the rather common bacteria that caused tetanus.
So, no booster shot needed in this case and no worry of getting harmed.
Anyone heard this before?

 

[Bird]

I don't guess I'd heard that, Rich. A few years ago, I was wearing sneakers (used to call them "tennis shoes") when I stopped to visit a neighbor and while there I went to help him load some cattle in a trailer and in the process, I stepped on a mesquite limb and one of the thorns went right through the bottom of my shoe and into my foot. Of course, all I did was pull it out and went on with what we were doing at the time. When I got home and took the shoe off, the sock and shoe were a bit bloody, but not too bad, but the next day I stopped by a doctor's office and got a tetanus shot. It's the only tetanus shot I can remember getting, and now I can't remember when that was; about 6 or 8 years ago though.