Monday, February 23, 2009

Redemption Song

Out this weekend with La Belle Fille and her friends. I have kept my head down in her locale for a while, after failing to win her friends over with my drunken ranting. This weekend shaped up as dinner with her folks, who I do seem to have won over. All well as usual, with good food and wine, and the odd "Top Five" discussion.

The opportunity for redemption arose after dinner, when her friends texted to summon us for a pint. One pint became two, and ended up as karaoke in a Chinese restaurant. Brilliant, although slightly intimidating, as LBF has the voice of an angel, and her friends all sing above the average, whereas I can't hold a tune for shit.

Anyway, the point is that I was able to go out and have a few drinks without offending anyone, and act just like a normal person.


LBF's singing partner's flatmate is very protective of LBF, and less than enamoured with me; she took great offense to me appearing to 'coach' LBF at her singing (which I wasn't), and then there followed the great 'lighter' misunderstanding.

I did try; but I guess you can't please all the people all the time.....

Mack The Knife

It is a curious phenomenon, oft observed in buses, that one waits for ages, then 3 come along at once.

And so it is sometimes in the ED...

While we get our fair share of trauma, we don't see much knife crime, and almost no gun crime. This last weekend, we got all our knife wounds at once. It's always slightly concerning when two fellas pitch up in short order, with similar sounding wounds. Not only does it raise concern that the Department might struggle to cope, but furthermore, that the two might have wounded each other - in which case, bedding them down next to each other in Resus is ill advised.

In this case, while I suspect the two wounds might have been related, they certainly didn't seem to have been inflicted mano y mano.

Number one had what I think of as the disemboweling cut - a transverse cut across the abdomen, running from east to west. His body habitus probably saved him from having to hold his guts in, but he'd been given a few other wounds for his trouble, and still won a trip to theatre to repair the damage.

Number two just had the one wound, but a good, solid stab. Providence decreed that his wound was right sided, and that he be attended by one of the pre-hospital guys with military experience. CT showed us the depth of the wound, and how lucky he was to have missed all the relevant clockwork. It's hard to convince someone with a new six inch air vent in their chest and belly that they've had a lucky escape, but he could have been a lot worse off.

Number three was one of our regulars, and the wound self inflicted and, apparently, less serious. It is a raw deal when you inflict major trauma on yourself as a cry for help, and arrive to find your wound is, at best, number three on the list of knife wounds waiting for a surgeon.

As far as I know, both the patients with wounds inflicted upon them did alright; i can't help but wonder how things might have been different if either, or worse both, wounds had been an inch or two transposed...

Friday, February 13, 2009

OK, So I Lied...

More on vaccines.

I have taken no small pleasure in following the recent skirmishes over MMR, and vaccinations in general. I enjoy a good debate, but must confess to occasionally being driven to distraction by what I have found.

I am continually frustrated by the terribly closed minded attitudes I have encountered among those with feet firmly planted in the ant-vacc lobby. I suspect they feel the same about those of us who are pro-vacc.

We both cling to our evidence, and both are ready to deny the strength of the other's claims.

Fair enough. History is full of such claim and counter claim. What disappoints me is that, to my mind, the pro-vacc 'evidence' meets certain arbitrary criteria that define the strength of evidence, and the anti-vacc material does not.

To which, the anti-vacc lobby cry "foul"; the evidence is fake, it's a conspiracy.

Playing Devil's Advocate, if that were so, might not their evidence also be fake? Might the Hero of the anti-vacc lobby, Wakefield, be, in fact a liar of the highest order?

No; they will not allow it.

One rule for the goose, and another for the gander.

I am also slightly disappointed by the regularity that debate turns to name calling, or nonsense verse:

"Oho!' said the pot to the kettle;
"You are dirty and ugly and black!
Sure no one would think you were metal,
Except when you're given a crack."

"Not so! not so! kettle said to the pot;
" 'Tis your own
dirty image you see;
For I am so clean -without blemish or blot-
That your blackness is mirrored in me"

This is a reply, out of context lifted from JABS. They seem to have a great number of regular contributors, mostly specialising in selective interpretation of facts - tho in the interest of fairness, I mean selective in that it differs from my interpretation - and 'clever' insults. By all means, pay them a visit. Paranoia strikes deep, and all that...

As a counterpoint, may I recommend JABSLoonies. I enjoy this blog, recently discovered, immensly, tho, again, in the interests of fairness, this is largely because I agree with the author. And it's funny.

The debate rages on...

My current tuppence worth:

I had measles, mumps and rubella as a child. Yes, I'm fine, thanks for asking. But I still remember them, and they were shit. I did not enjoy them one iota; why would you wanna put anyone through that?

If, as has been claimed, MMR cause autism, why has there not been a decline in autism cases in line with the rise in measles cases and decreased uptake of MMR vaccination?

Why, as so many commenters claim, when vaccinated children get one of these diseases, do they not stop and consider how the disease has come to be prevalent in the community at all.The fact that vaccinated individuals can still fall ill is not news, but claims that because they do, vaccination doesn't work seems only to shore up the idea that vaccination doesn't work if people don't get vaccinated. You don't seriously expect me to believe that the disease is only prevalent in the vaccinated, do you?




Seriously, if any of my readers have strong beliefs re: MMR and autism, why have cases not gone down with the fall in MMR uptake?

Tuesday, February 10, 2009

For What It's Worth...

Today, I realised that i had not allowed anonymous coments on this blog. I've changed that, in the spirit of open-ness and all; I'd rather you i.d'd yourselves; it lends a certain degree of responsibility to commenting, but from now on, if you wanna remain hidden in the shadows... go ahead.

Monday, February 09, 2009

On Vaccines, Liars and Ranting (3)

Last on this, promise.

On the idea that multivacc overload the immune system. Why doesn't DTP cause problems then? This 3 shot has been around for ages, and in fact, as well as diphtheria, pertussis and tetanus now contains haemophilus influenza b (last time you saw epiglottitis, anyone? anyone? Bueller?) and polio. That's right: 5! And kids aren't exploding with immune catastrophe. They also get meningitis c and pneumococcus in short order too, and seem to get by quite well...

Also, some people resent the idea that vaccines contain 'foreign' material. So what? We stick foreign material in ourselves all the time, and are often none the worse for it. Natural products are not necessarily safer, and it is fallacy to suggest that they are. I remember being accosted by some animal rights protesters when I was collecting for a cancer research charity. They suggested I must have been driven mad by eating too much beef - at the height of the BSE scare. We need to get over the slightly irrsational fear of things that seem un-natural to us. I don't care if my vaccine is steeped in monkey kidney extract, or my botulinum anti-toxin is extracted from horse piss, as long as it works.

//Rant over

On Vaccines, Liars and Ranting (2)

And we go on....

I have a wearying suspicion that people like myself will never convince the gainsayers; I can always be accused of bias, and, if I'm honest, I'm undoubtedly prone to a form of selection bias. I have preconceived ideas, so am not as open minded as I think.

Some people will never believe anything other than what they believe.

I'm sorry to harp on about Ms Barnett again, but she provides an excellent example. She mentioned in her recent broadcast that she was told, when it was discovered that she had high blood sugar, that she had diabetes. "I didn't have diabetes", she retorted, "I had high blood sugar. My blood sugar is now normal".

I don't have any more info on her high blood sugar, so can only speculate. Some people like labels, some don't. High blood sugar isn't normal. If not diabetes, what was the cause? To say "high blood sugar" isn't enough. Impaired glucose tolerance? Sit any better? And to say that "my blood sugar is now normal" doesn't help either... is that because you lost some weight, started exercising and changed your diet? You say 'high blood sugar', I say 'diet controlled diabetes'.

My point is that people can be very selective about what they believe. Labels perceived as 'bad' are often shunned, or rejected. Labels that excuse or explain, often embraced. My old bugbear irritable bowel syndrome is one of these. I was always taught it is diagnosis of exclusion; that is to say, all other causes of your symptoms have been looked for and discounted. So why not call it "Nothing Wrong With Me Syndrome"; ""I'm A Bit Sensitive To My Peristalsis Syndrome"?

Labels also haunt vaccination. Where the MMR is alleged to have a link to autism, it now turns out that there is no proven link, and that Wakefield, a man who would give Nixon a run for his money in the integrity stakes, fudged his results. He is a liar.

But: people need a cause. We are very bad at accepting that sometimes, shit happens, and we don't know why. Autism, and autistic spectrum disorder is poorly understood, especially in terms of its epidemiology. And, I think, it makes it easier for people to deal with to have an identifiable bogeyman. And when evidence, good solid evidence to the contrary is produced, time and time again, people shake their heads and think cover up.

Anecdotes are not evidence, but in cases of harm, will often carry more weight. So, I can produce reams of paper testifying to the absence of a demonstrable relationship between the two, and it all goes to the wind in the face of one parent saying: "My kid had MMR and caught autism"

Yes, I know the cases number in the hundreds and thousands. There's still no link. Look at Japan.

Were the kids teething at the time? Maybe it was their teeth that done it. It wasn't MMR. I have no financial incentive to say that. The evidence simply doesn't lie.

The reverse doesn't seem to be quite so true. We all (I think) accept that smoking is bad, but very few campaigners trot out people who smoked 100 a day and didn't get cancer as evidence that it's safe.

If some children are going to get autism, usually in the second year of life, and most children get the MMR in the second year of life, there will be a temporal relationship. That does not prove causation.

We sit in a privileged position, able to ask why we should vaccinate. Kids are meant to get diseases; we have forgotten how bad they can be, we have never seen children die in their scores, never sat on wards hand ventilating children with Polio.

I have seen children desperately ill from diseases that vaccination might have prevented; I have shared their terror, watched their pain.

It shouldn't be enough to say 'I didn't vaccinate my lot, and they're all right'. What about the next poor bugger who gets it, and isn't. Will you sit with them, and defend your right not to vaccinate to their grieving parents?

No, of course you won't.

I will.

More On Jeni Barnett

Further to my last post about Ms Barnett, one of her prime complaints was about scaremongering; she did not need to be frightened, she said. scare tactics, she said, were unfair, and un-necessary. I concur, heartily. And yet she happily read out a message from a caller alleging that vaccines have cancer causing chemicals in them. No evidence, no sourcing, just that. When questioned about it, she referred to a previous caller who had said the same thing. And... you can find it on the Internet.

Well that's done me. Irrefutable. Cast iron.

You can find pretty much anything on the Internet. (Barring of course Ms Barnett's broadcast, which her lawyers have made difficult to find...)

That really is on a a par with saying "a bloke down the pub told me..."

Shouldn't we expect better?

She does make a valid point, however. Scare tactics often don't work, and may not be apt. But it begs the question: As your doctor, should I conceal the truth from you, so as not to scare you?

She mentioned a couple of examples. She referenced a doctor telling her her daughter, who had had recurrent ear infections, would die if she didn't use an inhaler. Whatever one thinks of the veracity of this tale, and I would at the very least suggest the diagnosis was something over and above an ear infection, don't we, as doctors, have a duty to tell the facts?

If I think someone will die without treatment, surely I must tell them?

The alternative might be a mother grieving over the corpse of a child wailing "no-one told me it was this serious..."

Yes, we are sometimes hamfisted, poor communicators. But don't you deserve the truth, even when it's a bit frightening?

Argument s Against...

I saw a comment fly past in the ether recently, suggesting that the commenter knew MMR was responsible for autism, and until the Government /medical profession produced an alternative explanation for every single case, they would continue to do so.

It is very difficult to explain something poorly understood. Scientific method does not always work that way, and it is closed minded to imagine that it does.

For example:

I have a theory that homeopathic medicines are in fact poisoning us, and causing stupidity, and possibly gullibility too. Oh, and IBS. (Irritable, not inflammatory).

My reasoning is thus: people who take homeopathic remedies, and believe they work appear stupid and gullible to me. There also seems to be an increased frequency of IBS among these people.

I also think it is affecting the general populace, because surely some of the active ingredient in many homeopathic remedies (which I believe is a water molecule with the memory of some other molecule, depending on the remedy) is re-entering the water supply, after being pissed out. Actually, as it becomes more dilute, it's potency increases, so some of what comes out of my tap must be fairly potent.

Anyway, I've known friends who became stupid and gullible within days of starting homeopathy. I plan to do biopsies of these folks intestines, and am confident they will show concentrations of water molecules at the biopsy sites. Failing that, I will emulate my hero, Andrew Wakefield, and fudge some results.

The homeopaths will of course deny this; that is because they have a financial incentive in pushing their sugar pills and diluted water. Maybe they have evidence to support my claim, but have hushed it up. Either way, I will not give up my belief until they offer a convincing alternative explanation for every case of IBS...

On Vaccines, Liars and Ranting

What follows may turn to ranting. I apologise. It may also run long, so be 'serialised' as it were.

Jeni Barnett is a radio commentator, or radio personality, or something. She seems, to me, to represent the ill informed middle classes. A recent broadcast on her show has re-ignited the debate on vaccination, and in particular, the MMR.

Dr Crippen, always a worthwhile read, has waxed lyrical on the subject. His posts can be found here and here and here. He links to several,other sites, also worth reading, so I won't replicate his work. Ms Barnett's take can be found here, and here.

As ever, this is a subject fraught with peril. Tempers flare on both sides, and there is considerable risk of simply degenerating into name calling.

It is however a subject that makes me particularly angry. Actually, having listened to excerpts from Ms Barnett's show, I think everything about her may make me apoplectic with rage.

To clarify my position, I am an Orthodox practitioner, Western trained and educated. I have little experience of alternative therapies, but have made some study of what effects they purport to have. I do have strong opinions on this, but I try to be open minded where I can. (Altho LBF may not believe that)

It's worth saying that I am, unreservedly, in favour of vaccinations.

They work. This is simple fact. It is not opinion, it is not anecdote. It is cold, hard fact.

Part of the problem, however, is how one defines "fact".

Some people will always question fact; this is, in general, a good thing. But there seem to be a breed of folks who will continue to refute evidence that is contrary to what they believe.

Ms Barnett suggested that the figures for measles cases might be being spun - that there were figures being withheld. She admitted she did not know what these figures were, "because they are being withheld" For what reason, or by whom, I am not sure. But if you forever believe that the truth is being concealed from you, my words will carry little weight.

If vaccines do not work, where is small pox? When did you last see a child dying of diphtheria?

Are they solely responsible? No; of course not. Hygiene has played a part, increased sanitation, better nutrition all play a part. But if better hygiene were all it took, why do we still get viral infections? Glandular fever hasn't been banished by the teachings of Semmlweis, nor the common cold.

I have seen a few comments suggesting that germs do not cause disease, and that this is why vaccines cannot work. I really don't know how to answer that. I would find it equally hard to convince someone that the Earth is round. Koch must be spinning in his grave.

By "work", do I mean 100% effective, 100% safe? No; that isn't true either, but, on balance, they're safer than having the diseases.

Sunday, February 01, 2009

Quantum Of Time

The shortest unit of time measurable; thetime between before I told you the diagnosis, and the time after I've told you.

Everything changes, all at once. Right now, that moment feels like it's lasting forever, but when you look back, you'll realise, it really didn't take any time at all.

I saw her, sitting on the trolly, twirling her hair; maybe this gesture belied her nerves. She had an idea something wasn't right: that's what drove her to the ED, late on this cold, unforgiving night. We all agredd and ordered up the CT, a big dose of rays for one so young, but the history demanded it. Cried out for it.

Maybe we knew before, but the scan and its report spelled it out. Once written, can't be taken back.

I looked from the report to you, surrounded by family; all waiting.

And I'm glad you weren't my patient.

Super Sunday

If there's a better sports commentator than John Madden out there, I don't wanna know about him.
While my heart lies with the AFC, and my beloved Dolphins, I can't help but find myself rooting for the Cards. Sadly their offense hasn't done much first time out, and their defence didn't inspire a great deal of confidence either.

I'm not sure I've got what it takes to go the distance, mind...

Death By Duck

Lessons we learned this weekend:

A night that begins with red wine, moves to good scotch and finishes with curry and lager may result in good times, but does not make for a clear head.