Super Bugs. A Super Big Problem.

Doctors have been warned about it for decades. If we did not stop over-prescribing antibiotics the day would come when antibiotics would not work anymore. Some of us listened, many of us didn’t and society is about to pay the price. There has been an outbreak of a nearly unkillable bacteria at UCLA Medical Center.  

The long tubes called endoscopes that are threaded down the throat and into the upper intestinal tract for certain procedures became contaminated with a particularly nasty strain of a common bacteria, one that is resistant to the most potent antibiotics. As a result of the contamination over 150 patients were exposed and a number have died. Even if this were the first outbreak of a resistant strain of bacteria there would a cause for worry.

It is not the first outbreak and there is reason to be seriously concerned. Common infections have been growing increasingly resistant to antibiotics for decades.

Staphylococcus Aureus is a common bacteria that can be found on the skin of 25-50% of healthy individuals. It is the most common cause of skin infections and can cause severe illness when it enters the blood stream. Originally sensitive to penicillin, resistant strains were discovered within just years of the antibiotic's first use in World War II. By the 1970’s penicillin was no longer effective at all.

As newer forms of antibiotics were effective against Staph there was not widespread concern. Methicillin was a readily available and relatively inexpensive alternative, and it was effective. Resistance to Methicillin was known but it was rare. Methicillin Resistant Staph Aureus (MRSA), was found in only 5-10% of hospital and nursing home infections and was almost never seen in the community. Things changed in the late 1990’s. The incidence of MRSA exploded, up to 50% of Staph infections were resistant in many hospitals. 

Within just a few years MRSA was no longer just a hospital problem. It spread into the community and healthy people began to develop severe skin infections and abscesses. I witnessed the epidemic in my practice. Prior to 2001 I treated 1-2 skin abscesses a year in the office. By 2010 I was treating 1-2 abscesses a week. The bacteria had not only become widely resistant it had become much more aggressive! Hospitals have now been forced to develop new screening and isolation procedures to prevent staff members from inadvertently spreading the disease. The world has changed forever.

The problem of resistance is not limited to rare infections. E. Coli is the bacteria responsible for the majority of urinary infections. When I was an intern in 1990, in the hospital in which I worked  ampicillin was effective against E.Coli 72% of the time and cefazolin was effective 90% of the time. Just 23 years later, UCLA (just a few miles away from where I trained), reported that ampicillin was effective only 32% of the time and cefazolin in only 68% of cases. The trend is discouraging. If something doesn’t change we may run out of effective antibiotics in our lifetimes! How does this happen?

A study I read several years ago helped answer the question. Researchers in Israel cultured all of the children in a daycare. None of them tested positive for resistant strep bacteria. One child was treated with antibiotics for strep. A few weeks later the researchers tested all of the children again. 40% of the children tested positive for resistant bacteria! Antibiotic resistance was contagious!

When a person takes an antibiotic all of the bacteria sensitive to the antibiotic die. The only bacteria left are the resistant ones. Through a variety of mechanisms one bacteria can pass its resistance on to another one, so harmless resistant bacteria can pass resistance on to harmful ones. When these resistant bacteria are passed from one person to the next the resistance spreads through the community.

In smaller “communities” such as hospitals where antibiotics are widespread the danger of passing resistance is much greater, which is why this is where outbreaks often begin. The MRSA story reminds us that hospital resistance may not stay in the hospital, and the E. Coli story reminds us that resistance is not just a hospital problem.

Since the problem of resistance and overprescribing antibiotics is well known the question arises, “Why do doctors keep writing needless antibiotic prescriptions?” The answer is simple. Patients want them and doctors are afraid to say “No.”

I deal with this issue almost every day. Patients come in with an obvious viral illness and argue when I say antibiotics are not indicated. Science, studies, statistics and the stories of antibiotic resistance do not matter to these patients. They “know their body”, “just can’t afford to be sick right now”, “want to nip this in the bud before it gets worse” or “have a friend who had this and he took antibiotics and was better in 2 days.” I often am left with a choice. Do the right thing and have them leave disappointed or angry (and maybe not come back) or do the wrong thing and have them leave happy.

The choice is difficult enough to begin with but is compounded by the reality that doctors today are judged according to patient satisfaction surveys and are reviewed on Yelp. One unhappy patient with a grudge can cost a doctor thousands of dollars in bonuses and business. Because of this the problem will never be corrected by doctors alone. Patients need to get involved.

Patients need to educate themselves and others about the dangers of antibiotic overuse. (They can start by sharing this post!) We all need to learn to allow minor illnesses to run their course and to reserve antibiotics for those rare circumstances when there is no other choice. The world is changing and we are faced with a harsh choice. Do we want to treat our sinus congestion today, or do we want to survive our pneumonia tomorrow? It appears we cannot do both.

-          Bart

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References-

http://www.pathnet.medsch.ucla.edu/department/cliniclab/microbio/amic.pdf     http://newswise.com/articles/day-care-centers-spread-antibiotic-resistant-bacteria http://wwwnc.cdc.gov/eid/article/7/2/70-0178_article

After the Oscars, Recognizing the Real Winners

Normal people don't win Academy Awards. Normal people don't get nominated or get to attend the ceremony. Most normal people go through life without recognition or honor. They wake up each day and go about their business, doing what they need to do and have to do, playing their part in the theater of life in the roles they have been assigned. Mothers and fathers, craftsmen and laborers, managers and employees, all are essential and few are recognized. Watching the Oscars caused me to stop for a moment and consider some of those in my life whose performances in the last year have been truly remarkable. Here are some of my award winners for the last year-

Best Doctor in a Starring Role- Ehab Mady, a specialist in Vascular Medicine. Over and over again he has made the difficult diagnosis and gone the extra mile, providing stellar service and amazing care, even when payment wasn’t guaranteed. He is truly a life saver. .

Best Pastor in a Supporting Role- John Coulombe, the hardest working pastor I know. As the primary pastor to the senior adults in a church of thousands he is always in demand, performing funerals and comforting the grieving, organizing events and developing ministries. He speaks several times a month, tirelessly advocates for the church to be truly intergenerational and still finds the time to be a source of encouragement to me. He never seeks the limelight but his light shines.

Best Produce- Mr. W,  Patient who runs his own construction company while battling chronic and severe pain from a severely damaged ankle, prostate cancer and a heart condition. In his extra time he leads a Bible study, and he never complains. Each time I see him he manages to encourage me. 

Best Director- Peter Mackler, the Executive Director for Government Relations for Memorial Care. He puts in long hours and countless miles, traveling to Washington DC and Sacramento advocating on behalf of doctors and patients, most of whom will never know how hard he has worked for them. I have seen in him action and benefited from his counsel.

Best Special Effects- The Parents in my practice with special needs children who juggle work schedules, school conferences, and doctor’s appointments, the spouses holding the family together while their husbands and wives battle serious illness, the countless people who each day put one foot in front of the other and simply get it done. They challenge and inspire me.

As I consider all of these people I am reminded that the true stars in this life are not the ones up on the screen, behind the podium or on a stage. The true stars are more likely to be in the audience or behind the scenes.

- Bart

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Home Births, Hospital Deaths

By the time she arrived at the Emergency Room she had already lost a lot of blood. She was rapidly transferred from the ambulance to an ER bed and within a matter of minutes the life-saving transfusion was started. Had she waited just minutes longer to call for help she may not have survived. Her new baby would have been motherless.

For the doctors in the emergency room the treatment was common, a matter of routine. The reason for her brush with death was not. Post-partum hemorrhages are usually handled on the maternity floor, not in the emergency room. If her baby had been delivered in the maternity floor the bleeding would have been handled faster and the transfusion averted. Unfortunately she had chosen to avoid the maternity floor and have her baby at home. Her decision almost cost her life.

It was a decision that I had repeatedly and strongly argued against. I was her doctor for the first 4 months of her pregnancy. She had made it clear that she wanted a “natural” experience and I had promised her that this could be done in the hospital. I understood that many women preferred a natural delivery and had extensive experience managing natural childbirth. I was confident that her wishes could be honored and promised her they would. When she made the decision to deliver at home I had to resist and released her from my care. From my perspective as a doctor and as a father choosing home birth was and is one of the most selfish choices a woman can make.

Home birth goes against the two values that define obstetrical practice- Protect the health of the mom. Protect the health of the baby. These values guide all obstetrical care. The maternity unit is the only place in the hospital where the health care team begins with healthy patients and then works to keep them that way, so bad outcomes are especially tragic. Everything done by the nurses and doctors is directed at early identification of problems and preventing complications. The only acceptable outcome is a healthy mom and a healthy baby and no action or decision that makes that outcome less likely is tolerated.

While the goal of healthy mom and healthy baby is non-negotiable there is plenty of room for maternal choice during the course of labor and delivery. Birth positions (sitting, squatting, lying down), analgesia choices (epidural, narcotic or none at all), eating during labor, avoidance of IV lines and episiotomies, early nursing and skin to skin contact were all a part of births I attended. I often bent over backwards to meet the mother’s needs even if it meant spending extra hours in the hospital. My willingness to honor maternal wishes had one limit- I would not do anything that put the baby at risk. This is why I opposed home delivery.

In spite of opposition from the medical profession home birth seems to be making a comeback. While there are many possible explanations for the trend the facts support the conclusion that the choice to deliver at home is less about love and health and more about personal feelings and selfishness.

The patient who nearly died of a hemorrhage gave reasons for desiring a home delivery that were typical. She wanted a natural delivery and the experience of delivering at home in a supportive and comfortable environment. These desires seem worthy but they are not, for both place the feelings of the mother ahead of the health of the baby. Babies have no recollection of the room in which they are born, do not grow up feeling more loved and desired because the lights were low and the bed was soft. The baby does not care. Home deliveries are all about what the mother wants and not about what is best for the child. Is this not the very definition of selfishness?

The argument against home delivery is simple. It needlessly places the baby’s life at risk. While the risk is not massive (life threatening complications are rare in most pregnancies) the risk is always present. The American College of Ob-Gyn estimates that newborn mortality in home births is triple that of babies born in a hospital. Why would a loving mother make a choice that needlessly increased the chance that harm would come to her child? What warm feeling or joyous experience can justify that risk?

Current research suggests that as many of one in three women attempting home delivery will need urgent transport to a hospital due to a complication in labor. The transfer rate is lower for women who have previously delivered vaginally but it is still significant. Like every physician who has practiced obstetrics for any length of time I can share a number of stories where being in a hospital delivery room saved the life of a mom or baby.

Consider this analogy- If a young mom announced that she was foregoing the use of an infant car seat because she wanted the child to be in her lap while she drove she would be reported to the authorities. Her arguments that it made her feel close to her child, that bonding was important and that the risk of accident was low would fall on deaf ears. It would not matter that she was a safe driver and that because of cell phones medical help was never more than a few minutes away. Everyone would agree that it was irresponsible and selfish to risk the life of her child in such a way. How is this different than choosing to deliver a baby at home?

I have heard that home birth is gaining in popularity, part of the recycled fad of interest in all things “natural.” I doubt this post will change the minds of those who do not trust the knowledge or intentions of the medical profession but there is one thing of which I am certain. When it comes to the place of birth the baby does not care about the experience. No one remembers their birth experience.

Everyone remembers when a baby dies.

-          Bart

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A Phone Call from an Insane Man Brings a Life Changing Lesson

“I am the prophet Elijah. Shave your head and come to me.” The words over the phone would have been disturbing to hear from anyone but the fact that they came from someone I knew and loved was frightening and caused me to fear for his safety. He was clearly out of his mind. What could I do? I saw only one option. I called the police on my friend.

I had known him for years. He had his quirks and idiosyncrasies and had made more than his share of foolish financial decisions but I had never thought him to be mentally ill. It was when the strange calls and Facebook messages started coming that I knew he was in real trouble.

It began with his impulsive decision to move in with a woman he had just met. He was an avowed Christian and the decision was against all he said he believed in. For him to make such a choice after only a few dates was deeply concerning. It was during that conversation telling me about his new found love that I realized something was seriously wrong. He wasn't making any sense.

His speech was fast and pressured and he darted from one topic to the next. His attitude toward me was unusual as well. He had always respected me and often come to me for advice but in this conversation he had elevated himself to the role of counselor. He repeatedly tried to tell me what was wrong with my life, what to do and where I was off course. The change in demeanor was drastic. It seemed his view of himself had expanded overnight. Halfway into the conversation it dawned on me. He had bipolar disease and he was manic.  

When people enter the manic phase of bipolar disease it is almost impossible to reach them. The chemical imbalance in the brain leads to grandiosity, a sense of superiority that makes receiving counsel or advice from others impossible. In his case his grandiosity included hyperspirituality. He claimed that God was speaking to him and giving him remarkable insights that he had to share with me. 

I begged him to get help, but he would not, could not, listen. Within a few days he was fully psychotic and standing on the top of his still moving and driverless car yelling at the world to repent. In a very proud Facebook message to me he described how he fled from the police and ran to a church parking lot before being taken into custody. He was placed on a psychiatric hold, but he somehow escaped from the facility and holed up in a local hotel. It was from the hotel that he sent me the message claiming to be the prophet Elijah. 

It was months before I heard from him again. He was significantly better but still displayed some of the signs of the disease. He was hypomanic, overly focused on competing in sports and showing poor judgment in finances. I asked if he was still taking his medications. He wasn’t. I asked if his psychiatrist had made the decision to stop the medications. He hadn’t. My friend had decided on his own that he no longer needed the medication. I looked him in the eye and told him as seriously as I could, “You have a mental illness. Your thinking is broken. You don’t get to make this decision. See a psychiatrist and do what he tells you. Period.” He promised he would, but he didn’t.

We don’t talk anymore. In my mind there is nothing to say. I find it hard to engage in small talk when the most important thing in his life, his mental health, is not being addressed. I am like a broken record to him, saying the same thing over and over, “See a psychiatrist, see a psychiatrist.” I mourn the loss of relationship but must accept there is nothing I can do.

I recently had a patient come in who was eerily similar. I had seen him three years earlier and diagnosed him with bipolar disease in the hypomanic stages. Remarkably, I was able to get him to see a psychiatrist. One he started to feel better he took himself off of all of his medications. When he came back to see me it was for a skin condition. He was quite surprised when I declined to treat the skin problem until he saw a psychiatrist. I told him what I tell all of my patients who refuse my recommendations, that bad medical care was not an option.

“You can get bad medical care all over town but you can’t get it here, " I said, "In this office we do what is best for you.” As I had with my friend a few years ago I explained that he could not allow broken thinking to guide him in making decisions about his health. Because of his disease he needed to listen to an expert who had his best interests at heart. I reminded him that although he felt normal now, once the disease turned into the manic phase he would be unable to listen to medical advice. He had to see a psychiatrist.

When I think of these stories I think about how we all do this to varying degrees. We place way too much confidence in our ability to figure things out. Our marriages can be falling apart, we can be struggling at work, battling to stay sober or dealing with anger but we don’t seek counsel from those who can help us. We think we can do it on our own and we trust our own broken thinking to guide us. How foolish we are.

It takes incredible effort and humility to ask for help but that is the path to success and health. I came to grips with this myself 5 years ago when anxiety disorder and panic attacks invaded my life. I swallowed my pride and went to see a psychiatrist. I remember how freeing it was to say, “Tell me what to do.” It was hard to trust and put myself in someone else’s hands but it was necessary and it was a turning point for me.

Would that we all learn this lesson. Often the road to wellness begins by simply asking for help.

-          Bart

Are You Smart Enough to be President?

“Do you believe in evolution?”

There are a number of questions I would ask an aspiring presidential candidate if given the chance, but this is not one of them. In a world where ISIS is on the move in Iraq and Iran is working to develop nuclear capability, where nations in Europe are facing overwhelming debt and Russia has invaded Ukraine, in a nation with so many underemployed or not looking for work and with congress seemingly unable to accomplish anything, a candidate’s views on the origins of life seem rather irrelevant.

Nevertheless this is the question posed to Wisconsin governor Scott Walker by a British journalist during his recent trip to London. Some folks back home were critical of Walker’s dodge of the question and attacked him for being anti-science. The question was a bit of a set-up, for Walker is the son of a Baptist minister and likely to believe that God played a role in the creation of the universe. This belief in God has not hampered his ability to govern the state of Wisconsin so it is silly to make it an issue. That did not stop the journalist from asking it.

So why was the question asked? I believe it was an attempt to find a way to easily discredit Governor Walker. The reasoning seems to be that intelligent people believe in science and since evolution is science believing in it is a measure of one’s intelligence. There is only one problem with this reasoning. It is false.

As a physician I took a LOT of biology courses, including biochemistry, molecular biology and evolutionary biology. I learned the material well enough to graduate Magna Cum Laude. People have accused me of many things over the years but I have never been called unintelligent.

In spite of all of this education I don’t believe the theory of evolution provides a reasonable explanation for the complexity of life we see on earth. While evolution may have appeared reasonable in the time of Darwin advances in molecular biology and genetics have revealed obstacles to the theory that Darwin could not have imagined.

A single gene for a single protein can consist of thousands of units of DNA. The protein can be non-functional if a few units are lost, changed or out of place (sometimes a single mutation can be damaging). This means that for evolution to occur thousands of molecules need to randomly line up in perfect order. Even if that were to occur, the new protein would be useless unless it improved the function of the organism, which means that several thousand other randoms things needed to occur as well. This is a monumental challenge! When we think of the amount of DNA that would have to be correctly assembled to code for such dramatic developments as sight or flight the odds against evolution are, from a molecular perspective, even more astronomical. This makes random evolution statistically impossible.

As impossible as I believe it to be, the point of this post is not to debate evolution. The complexity of such a discussion is beyond the scope of any blog. The point is that intelligent, well-educated and reasonable people, people who are well-versed in the subject, can reach the conclusion that the theory of evolution does not adequately explain the observable world. This conclusion is thoughtful and rational. Because of this, Scott Walker does not need to shy away from his beliefs and neither do any of us who believe in a Creator. 

The manner in which we can confidently assert our faith was illustrated several years ago when I engaged a friend in a discussion about evolution. He initiated the discussion at a baseball game. He considered himself an "Evolution buff" and well-versed on the subject. In spite of this he did not have a basic understanding of molecular biology or genetics or of the remarkable complexity of life. When confronted with the reality of the massive amount of information needed to encode for the simplest life forms he assumed a defensive posture and retorted, “Well, You can’t prove there is a God!” My reply caught him off guard.

“I do not need to,” I responded. “The burden of proof is on the person with the least likely explanation. Say we were walking together on a beach and came across sea shells scattered on the shore. You declared that the shells were carried there by the waves, I disagreed and said a child with a basket had come along and scattered the shells on the sand. In such a case the burden of proof would be on me.

If we came across sea shells that spelled out the words “Have a Nice Day,” and you again declared the work of the ocean and I again argued for the work of a child, the burden of proof would be on you.

The amount of information contained in the simplest life form is infinitely greater that a few words on the beach. You day it is random chance, I say it is a sign of an Intelligent Being. I do not need to prove anything. You have the least likely explanation. The burden of proof is on you.”

With that the discussion ended. He did not walk away convinced of my position but I do believe he walked away knowing that my position was neither naïve or ignorant. Something to think about the next time someone is mocked for believing in a Creator.

-          Bart

If you have an interest in learning more about the subject I encourage you to check out Reasons to Believe, an organization of scientists and researchers who believe in a Creator. Remember you can share this post with friends, subscribe to the blog and receive posts via email, or follow me on twitter @bartbarrettmd