Masks and Dark Glasses

As a seasoned medical provider, I can't tell you the importance of actually "seeing" the patient. I have always had issues when people come in wearing dark glasses. Since the eyes are the window to the soul, I find it very difficult to have an effective medical encounter with someone wearing dark glasses. When you address a particular medical question, you instinctually look at the eyes for response. Is the person making direct eye contact? If your patient is a teenager, are they "rolling their eyes" at you? Are they gazing downward? Before I start any medical encounter, I ask the person to please remove their dark glasses so I can see them, and not my own reflection.

Morgan / CC BY 2.0

H1N1 flu pandemic has hit our area big time. We set up a "flu station" in the lobby where people can use hand-sanitizers and pick up a surgical mask to wear. When I enter the examining room now, it is not uncommon for everyone to be wearing masks - except me.

Just like the eyes, I also like to see a person's entire face. I want to see if they are smiling, grimacing in pain, or frowning at me. If a person had both a mask and dark glasses, I would just assume they had a big paper bag on their heads. Just like the dark glasses, I ask them to remove their masks once they are in the examination room. I don't know how Westerners can practice medicine in the Middle East. If I saw a person wearing an Islamic burqa, I am not sure how I would react. But at least, could see her eyes.

The Lone Ranger wore a mask, like no one would really recognize a well-spoken man in clean white clothes, riding a white horse along with this companion, an Indian that speaks like Tarzan. Bank robbers and train bandits wear a scarf or bandana over their mouth and nose. Spiderman wears a full face mask apparently so you won't recognize him as Peter Parker. Superman doesn't wear a mask, but uses a pair of dark-rimmed glasses when he changes into Clark Kent - another clever disguise designed to fool idiots. A guy in a ski mask coming to my front door would definitely get a rise out of me.

Josh Westbrook / CC BY-ND 2.0

If someone walked into a bank today, wearing a surgical mask and dark glasses, they would definitely get the attention of the security guards. Halloween is just around the corner, so our pediatric practice allows the staff to dress up, without masks, of course. Masks typically scare kids, even surgical masks. We don't get the Trick or Treat crowd in our rural neighborhood anymore. I sort of miss them.

The first time that I saw people in public wearing surgical masks was in Japan many years ago. Japan is a crowded, but highly-organized and respectful society. When I inquired about the masks, I assumed that people were protecting themselves from the germs of others. To my surprise, it was the people in the masks who were trying to keep their germs to themselves. They had colds or influenza and did not want to infect others. This is a very respectful hygienic practice that we rarely see in the U.S. People on the subways in the U.S. will just about sneeze in your face; or sneeze in their hands just before the grab the hand rails.

I have been exposed to so many cases of H1N1, that I expect that I have some residual immunity. I have been endured numerous sneezes and coughing in my direction. I have held contaminated hands. I have wiped noses of children. If and when the H1N1 vaccine arrives, I am not really sure I need it. I will take it for my patients, of course, but I suspect that I am either immune from prior infections, or darn lucky.

One provider was complaining this week that he had to wear to complete biohazard suit, complete with a battery-powered air filtration system and full spaceman helmet when he was examining a baby in the ICU. The baby was in protective isolation. He said it was impossible to listen to heart or lung sounds using a stethoscope while wearing a space helmet and noisy respirator.

Until this pandemic is over, we must all learn to tolerate people in surgical masks - even when they are surgeons. It could be worse. We could all be wearing those space suits.

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The 2009 Flu Season: Ready or Not; Here it Comes!

In a medical office that cares primarily for children and adolescents, the summer months are very manageable. We even have open appointments on the same day. However, when school starts, the flood gate of illnesses will start to come in.

High on the list of fall season illnesses has got to be influenza. The H1N1 strain of influenza (formerly called the swine flu) still has health officials worried. Now that H1N1 has been officially declared a worldwide pandemic, no one is really sure what will happen when the real flu season begins. Are we going to have thousands or even millions of victims? Should we expect massive school closings and work absenteeism? In this fragile economy, will this pandemic push us over the edge? No one really knows, but planning for the worst-case scenario is probably prudent.

There was a time when I could give away flu shots, even with all of my persuasive arguments. At the opening of a new urgent care facility several years ago, the owner's decided to give free flu vaccines to everyone on our first Saturday. The clinic opened at nine AM. The crowd began forming hours before. By the time we arrived at the clinic, the line of people, mostly an impatient mob of assertive and highly-vocal senior citizens, stretched down the street. Expecting a smaller turn-out, we only had one medical assistant assigned to the flu shot clinic. Even at full pace, the most she could administer was about one injection every five minutes or so (including registration and medical history). That is only about twelve an hour if everything went smoothly. There were at least 200 people in line! You do the math. As the hours progressed and tempers flared with the waiting crowd, someone announced that we were running out of vaccine. Lord, help us if that happened. I was sure that I would be caned to death during the inevitable riot. Some quick thinking resulted in "rain checks" for the ones at the back of the line. They weren't happy about it, but when you run out, you run out.

Because of this past experience, I often fear for my own personal safety when we run out of vaccine in our office. For the last two years, we were frequently required to ration our rapidly-depleting stores of vaccine to the most critical patients. I sure hope that the supply this year will be plentiful. I would hate to see those angry mobs again. The federal government, known for their efficient way of handling public health issues, promises there will be plenty of vaccine to administer. We will see.

Each person may need THREE flu vaccines: one for the regular seasonal flu and two for the new swine flu strain (one now, and then a second booster in a month). Multiply that by the number of patients we see in our clinic every day (over three hundred), and we may have a shortage of medical assistants just to administer them.

A few days ago, I had three patients come in to evening clinic. All had been to an orientation and band camp at the local high school, and all three were very ill with flu-like illnesses. I saw two of them; one was positive for Type A flu (H1N1 is a type A flu) and started on Tamiflu, and the other was negative. My partner saw the third patient and clinically diagnosed him with influenza and started him on Tamiflu. The next day, the news service had picked this up - "Three Confirmed Swine Flu Cases in Local High School." I suspect that one of the parents called the media. First, it takes about two weeks to confirm the one type A case was H1N1 or not, so there are no confirmed cases at the moment. Of course, this would not a newsworthy. As you might imagine, the school system went into panic and sent out phone announcements to all of the parents. This resulted in dozens of people streaming into our office to be tested for H1N1, none of which even had classic symptoms or known exposure.

All three of those students, including the one that may have had H1NI, wanted to go to school anyway, where they would have freely shared their illness with umpteen others. This is exactly how local epidemics begin.

One of the parents worried because a neighbor, three houses down, supposedly died from H1N1, so she was worried if the flu could be airborne this far, or if fleas on rats could have carried it to her home! Apparently, she is confusing influenza with the Bubonic Plague. So much misinformation...

We have not received any flu vaccines in our office, not even the seasonal flu, but I suspect the demand will be high. If the new H1N1 vaccine is approved, and I suspect it will be, then I can only hope that we get our share of vaccine to distribute.

All medical providers hate to ration vaccine, but high on the list of people to get the vaccines first would be the medical providers. It is not that we are looking out for ourselves first, it is just that we are on the front line to get an infection. Since influenza is contagious a day BEFORE, we could be infecting hundreds of people without knowing it.

Ready or not, the 2009 Influenza Season has really begun (or perhaps, never ended from last year). Medical providers are on high alert. Health departments are gearing-up. Are we really ready? That is the big question.

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Three Summer Problems That Get Under My Skin

With the exception of the H1N1 (swine) flu that surprised all of us, the spring and summer months are typically a time when we see a drastic reduction in respiratory infections, like colds and ear infections, and see an increase in "warm weather" health issues.

Soon, schools will be closed for the summer months so the kids can help plow the fields and bring in the crops (sarcasm). Other families will be traveling to their favorite vacation spots, camping, having picnics, hanging out at Little League games, or swimming.

Photo: blmurch

Poison Oak: Like the swallows returning to Capistrano or the blooming for spring flowers, I started to see my first cases of poison oak this week. In our area, poison oak flourishes along a popular bike trail, near the river. All it takes is an innocent brush-by of this toxic plant and you will be rewarded with a pretty impressive, itchy skin eruption a day or so later. Children (and adults) often use the more private, wooded areas as make-shift restrooms, increasing the chance of skin exposure to those more delicate areas. Camping areas that permit open fires often see children actively collecting twigs to add to the smoky fire pit. Being downwind to a poison oak-laden fire will likely expose those happy faces.

Contrary to popular belief, poison oak dermatitis is not contagious. You cannot catch it from another person, but you can catch it from the clothes or shoes they were wearing, or even from the bicycle tires. Any object contaminated with the oily oleoresin of the plant can potentially cause this allergic skin reaction. This oil is very stable and can remain on unwashed objects for a long, long time. The oil can also reside on the fur of your loving pets.

There is really no such thing as a mild case of poison oak if you happen to be the person who has it. It can be absolutely miserable for weeks unless it is definitively treated. I am a big fan of a course of oral steroids (No, not the body-building, Barry Bonds-type steroids). Topical hydrocortisone can only do so much. Treating the itching with colloidal oatmeal baths and antihistamines are usually necessary.

Photo: nicolaitan

Mosquito bites: If it were possible to lose weight by being bitten repeatedly by mosquitoes, I would be thin as a rail. I am literally a mosquito magnet. It can be over 100 degrees, and I will be wearing a long shirt, long pants and hat, smelling of DEET.

Our local mosquitoes still seem to find a hidden place that is unprotected and have lunch...on me. The DEET products do help somewhat, but once I am bitten, I will immediately have an allergic response - big welts that itch like crazy.

I have to plan my garden work during the heat of the day when mosquitoes are not active. I built a bat house, and I never kill a lizard or frog; all creatures that eat them. I would love to eat dinner outdoors on the deck, but I do not lose, yet another battle, with hungry mosquitoes. I have tried Citronella, bug-zappers, and toxic fog to no avail. Even when I am huddled inside, I see them repeatedly pounding on my window glass like those zombies in the Night of the Living Dead.

We are seeing more and more cases of West Nile Fever in our area, so my unique ability to attract mosquitoes has me a bit worried. I have always wanted to travel to Central America and the tropics, but unless I walked around in a huge mosquito net, I would most likely come home with malaria or yellow fever.

Photo: mugley

Sunburn: Humans always seem to underestimate the burning power of the sun - solar radiation. A heard a talk at a medical meeting a few years ago, where the female dermatologist said there should be "no pain treatment" for a teenager with sunburn. She stated that teenagers must experience the pain in its full intensity in order to remember to use sunscreen and protective clothing next time. In Australia, where melanomas are rampant, children are required to wear hats to school as a part of their school uniform. On the beaches, children wear full body swim suits for sunburn protection. It seems that most people in the U.S. are complacent when it comes to sun exposure. Sure, they apply a sunscreen once or twice while at the beach, but many varieties simply wash off after a few minutes in the water. Most have to be re-applied every two hours.

If you do get sunburned (and it is usually your own fault), treat it like any other thermal injury. Cool it down with cold compresses. Take some ibuprofen for the inflammation and use of soothing skin lotions. The best defense is always to avoid the sun, but if you cannot - avoid the sun between 10 AM and 4 PM when the ultraviolet rays are most intense. Use a good sunscreen product that protects against UVA and UVB rays with an SPF (sun protection factor) of at least 30. However, sunscreen is not permission or an excuse for increasing sun exposure.

My brother was diagnosed with melanoma several years ago (it was completely excised) and several of my friends have had melanomas. Nearly every person who is diagnosed with melanoma has a history of at least one, blistering sunburn. Try not to let it happen to you.

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H1N1 Flu: But, They're PIGS!

Photo Credit: Laurel Fan

I knew this would happen. The Swine Flu is not a nice name. It sounds kind of dirty and unappealing. Jews and Muslims do not like pigs; animal rights activists do. The pork lobby and the commodities market for pork bellies do not favor the name. You have to change it, so let's call it H1N1. I guess everyone will know that the "N" stands for neuraminidase. Everyone else can just call it the H1N1 (high-knee) flu.

When there is a pandemic on the horizon, governments must have scapegoats, or in this case, a scape-pig. During the last major pandemic, we called it the Spanish Flu just to tick off Spain who refused to provide information about flu deaths in their country during World War I. We could have called it the German Flu, but everyone already hated Germany and we already named a type of measles after them. It should have been named the Kansas Flu since this is where it started, but Kansas is such a nice place. There is no place like home, Toto.

Later on, we had the Asian Flu or Hong Kong Flu. This may have been more appropriately named, since this strain of influenza did originate in China. God forbid that we call this one the Mexican Flu. Mexicans are having enough problems as it is with those drug wars and a crash in the tourism business. Just yesterday, a patient informed me that their Mexican cruise has been canceled by the cruise company due to the flu pandemic.

I wish they would have had a contest and let the American people name this flu. There could be call-ins and text messages, like the American Idol. How about the al-Qaida Flu? I thought this was a good one until I heard there was a guy in Cleveland named Al Kida. That would not have been fair to him. He already lives in Cleveland. Oops, I did it again. What I meant to say was, "I love Cleveland." WKRP! Wait, that was Cincinnati. Now I have Kansas and Ohio upset. How about the Kim Jong-il Flu? This is another good one; it already has "ill" in the name.

This morning as I was getting my morning flu briefing from Matt Lauer, I discovered that the name was changed yesterday to the it's scientific name - the H1N1 influenza, after many pigs were needlessly slaughtered in Egypt and people stopped buying pork in the grocery stores. Regardless of the reassurance that you cannot catch swine flu from processed pork products or uninfected pigs, people are not convinced. I am sure glad that pigs do not cause autism, or do they? Now, I did it. Oops.

A slip of the tongue or joking can really backfire nowadays. Poor Joe Biden. Much of the morning news was filled with White House spokesmen that were trying to explain what Joe "really meant" so the American people can relax and say, "Whew! Now I feel better." VP Joe is staying home and will not be traveling on commercial airlines, subways, and buses, like he normally does (sarcasm). The air transportation czars were up in arms with the approaching summer travel season defending the cleanliness of their planes. Personally, that would be like defending the cleanliness of those Mexican pigs.

Granted, most commercial airlines do have HEPA filters to scrub the air of pathogens. While this may help a little bit, it is not going to protect you against the sneezer in the seat behind you that just blew up the back of your hair, or the snotty-nose kid that wipes his hands all the way down the aisle to the bathroom, where God knows what happens inside. Between flights, airline personal empty the seat back pouches of all of the trash we stuff in there, including napkins, Kleenex, and I am sure, but have no conclusive proof - dirty diapers. They probably vacuum up the pretzel crumbs at some point at the end of the flight days. Peanuts are no more. They may try and sanitize those stinky toilet closets and load up the TP containers, but they DO NOT SANITIZE those planes. How can they? Viral pathogens can remain on surfaces for hours, and we only have a short time when people disembark and others board. Pathogens will remain on those tray tables, even in the upright positions (germs do not fall off). They will remain on those cloth seats. They are on the call button and that little air deflector that you point at the sneezer behind you. Pathogens are everywhere, so if you are going to get sick, this is the place. I included airplanes high on my list of the Dirty Dozen - the Twelve Dirtiest Places. My feelings have not changed any more than the airline's traditional hygiene practices.

Pigs do have hygiene issues, but we do not hesitate to harvest heart valves from them, or use them to test our pharmaceuticals. It's not bad enough that we make fun of their appearance and eat them, now we have to blame a pandemic on them. Researchers feels that AIDS originally came from monkeys, or from someone monkeying around with monkeys. If that is really true, then why haven't we taken it out on those monkeys? Monkeys are cute, that's why. Pigs? Not so much, although those Vietnamese potbellied pigs are sort of cute in piggy sort of way.

Arnold on Green Acres was not only cute; he was one of the more intelligent mammals in Hooterville. Porky Pig, in spite of the fact that he does not wear pants, is an American icon. Of course, not having genitalia sort of excuses him. People love to "pig-out" or go hog-wild. Actors ham it up. Pigs wear lipstick. Politicians talk about pork-barrel spending. Little girls wear pig-tails. Hell's Angels ride hogs. People hog seats on the bus, assuming they are still riding a bus now that Joe gave 'em up. Sue-EEEEE!


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Bird Flu? Swine Flu? Mexican Flu?

Last year, it was the bird flu panic. People stopped eating chicken (you can't get it that way), feeding pigeons, and worried about living along migratory bird routes. Many stockpiled is oseltamivir or zanamivir - antiviral flu medications - and waited anxiously for cases to appear in their neighborhood. The bird flu is still out there (somewhere) and a few cases are still popping up from time to time, but it was not the worldwide pandemic that it promised to be.

Now, we have the swine flu panic and public health departments are gearing up for what could be another potential disaster. Since a particularly-virulent flu bug was the cause of the last worldwide pandemic in 1918 and resulted in several million (yes, million) deaths, we tend to take notice.

This pandemic occurred during the height of the First World War and was erroneously dubbed the Spanish Flu, apparently to take the heat off of the good people in Kansas where it actually started. Other flu pandemics and epidemics have been called the Hong Kong flu since many of these strains were identified first in China, where people, birds, and pigs live in much closer proximity. Since the swine flu appears to have originated in Mexico, I suspect someone will start calling it the Mexican Flu. Influenza by any name is just as concerning.

The swine flu virus tends to live quite contently in pigs, hence its namesake. However, flu viruses have an annoying tendency to mutate and adapt, sometimes making the jump from pigs to humans (or birds to humans). When it jumps species, the next step is the worst of all - human to human transmission. The Type A strain of swine flu (H1N1) is transmitted from human to human. So far, nearly 1300 cases have been reported including over a 100 deaths in Mexico. There are at least seven cases in the U.S. now. Incidentally, you cannot get swine flu from eating pork or pork products. Don't throw away your stockpile of Spam or Honey-baked Ham.

Today, one case was reported in our local neighborhood at a Catholic school. The school is now closed until further notice and several frightened parents have brought children in to be tested. We have one parent coming in today (in a mask) because her child owns a pig. Although their pig has not traveled to Mexico to visit relatives, they want the child tested. Our local health department has gone into high gear and heightened surveillance to prepare for the worst, should it happen; although when we tried to send in a specimen today, the Health Department was closed! Within the first hours of work today, we have received numerous instructions on the proper way to collect specimens from any person that has vague "flu-like" symptoms such as fever, cough, or sore throat (just about ALL of my ill patients have those).

Several years ago, there were three cases of meningitis at one local high school. For months, people would not even shop in that town, or allow their children to play in the McDonald's playground. I am surprised there weren't guard towers and razor wire surrounding the town.

Right now in Mexico City, large gatherings of people such as sporting events or church services have been canceled and millions of surgical masks have been handed out. I haven't seen this many surgical masks since I went to Japan. In Japan, people often voluntarily wear surgical masks on subways when they are ill to protect their fellow travelers. You don't really see that level of courtesy in the U.S., where someone is likely to sneeze or cough directly in your face. During the 1918 flu pandemic, movie houses and taverns in the U.S. were closed in large cities and yes, people were wearing cloth masks or handkerchiefs over their mouths and washing their hands.

People tend to panic when these things public health issues happen. Misinformation and fear often trumps common sense. We had a person today, who was exposed to a neighbor, and this neighbor was exposed to a parent who had a child in kindergarten who goes to the school where there was one case of confirmed swine flu. Whew!

A year ago today, my wife and I were driving through Mexico to deliver children's clothing to an impoverished area in Baja. At that time, we were not worried about influenza, just the drug wars along the border that so far, has taken the lives of over eight thousand people. Medical care in Mexico can be sparse and many of those deaths may have been because people did not have access to medical services soon enough. As of today, there were no confirmed swine flu deaths in the U.S. and I pray that the Mexican health officials can contain this virus before there are any more deaths in this country.

Until the breadth and extent of this potential pandemic is confirmed, people should just relax, get the facts, follow the news, wash their hands, avoid getting downwind of a sneeze, and wait until the public health department offers specific instructions for your particular area.

It is still okay to still eat a BLT.

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