Who Dies from Typhoid?

Hardly anybody.  In America, anyway.

This is why it was so shocking to hear that one of our translators in Haiti – a healthy father with children – died of typhoid fever recently.

I didn’t work much with this particular translator, Daniel, mostly because he spent so much time interlocuting between our group and the local community leaders, especially in Noyo.

I spent my second week in the very rural village of Noyo, and my experience there was vastly different than the one I had during my first week in Thomaseau.  The physical village looks like a bunch of twig huts that all unrolled themselves from one giant ball as it bounced down a mountainside.  

Despite this scattered layout, the people there were a tight-knit bunch; working with them required constant communication.  Work of the kind we did in Haiti brings with it nearly endless opportunities for misunderstanding.  Daniel was a big part of that because he was well-connected with the local leaders.  

A few times, I wondered what besides common humanity kept the locals from simply overrunning our tiny isolated clinic, taking all the medicine and holding us hostage.  We’re not just talking about picking up some bling bling, either.  They could demand HUGE ransoms for each of us, and never be in poverty again.  

I thought about this frequently in Noyo because the village clings to lost and forgotten hillsides so far from roads that you can’t find it on most maps.  We hiked for over an hour to get there.  And the road that brought us to the beginning of our hike arguably ended miles back from where we actually stopped our battered 4-wheel drive monster trucks.

I think the moral fabric of Haitian culture gets most of the credit for keeping us protected during our time in the mountains.  But some also should be given to people like Daniel, who moved easily between native, locally-powerful villagers and obtuse, big-hearted, mildly-guilt motivated Americans.

 More than once I saw disappoinment in the faces of patients as I sent them out the door with not much more than a toothbrush and some TUMS.

I’m sure I projected a bit, but often I felt their dismay at my ineffectiveness in the midst of so many very real problems.  I could almost hear some of them say, “This is all you have for me?  Look at all that medicine in the back of the church!  Look at those nice tents you live in!  Look at that nice watch and thousand-dollar camera you have.  All you have for me is some antacids?  Do you know that I could feed this child for weeks with just the money I could get for your sparkly watch?  How is it worth that much to you?  How can you still cling to your expensive camera when it could feed a family for months?  Is that moral?

If you claim to be a Christian…how is this not a sin?” 

Often I reflect on how much I care about my children – the lengths I would go to protect and provide for them.  In that light, I do not think I would be nearly so gracious if it were my child wasting away in my arms and some rich foreign king gave me only calcium tablets and a toothbrush (until we ran out of them and just gave the calcium).

Although the Haitians displayed celestial graciousness because I believe they are by nature a gracious people, translators like Daniel helped undergird that goodwill.

Being Haitian, he could agree that yes, these people come from a rich country and enjoy many things that people can’t even dream of in Noyo.  

But he could also point but these particular people don’t have as much as it seems.  He could explain that these kings used a very large amount of their own money just to be there, in the suffering, trying to help however they could.  He could explain that even with the best medicine, their children might still be very sick.  He could point out that ALL the medicine we have left over will be given to the village, to the most in need.

 

It takes over 100,000 of these (Salmonella) to cause typhoid fever in an average human. A closely-related organism - Shigella - only needs about 100 to cause disease.

Typhoid fever shouldn’t kill anyone.  It causes some fevers, some abdominal pain, some gnarly diarrhea and maybe some delerium.  Throw any of a number of antibiotics at the problem, and the odds of dying from it drop to about 1%.  If I gave you a 99% chance of winning big in Vegas, I bet you would put a good part of your inheritance on those odds.

 

Even untreated, typhoid fever is fatal in only about 30% of cases.

So Daniel’s story is a tragedy simply because death is a tragedy.  His death is a tragedy because there is a wife somewhere who loves him and is now alone.  It is a tragedy because there are children huddling around their mother wondering in pain and incomplete understanding what happened to Daddy.  It is a tragedy because his role was so valuable to our work and efforts in Haiti.

But most agonizing…Daniel’s death is a tragedy because it didn’t need to happen.

I KNOW What This Is

No, you don’t.

In medicine, certainty is a very dangerous thing.  It’s ok to be certain about things like the price of gas or your dislike of prunes (couldn’t blame you).

Certainty in medicine is quite another.

And, although politically incorrect to say it, I’m finding a frustrating amount of unjustified certainty among the ranks of the “mini-docs”.  By mini-doctors, I mean all the permutations of lesser-trained white coat-donners.  The PA’s, ARNP’s, Dr. RN’s, LPN’s, etc.

Hello. I'm not-quite-a-doc. I know EXACTLY what you have.

Exposed to about 1/3 of the training of the average primary care M.D. (if that), these sorta-doctors function in American medicine with nearly complete autonomy (and are constantly pushing for more).

I have no problem with these relatively new additions to the medical field.  I myself criticized my training as too long, redundant and costly while enduring it.

But the more I work with patients who see them, the more I run into decision-making that is flat-out problematic.

I should mention that many P.A.’s I’ve trained with were clearly smarter than me.  A couple of the ARNP’s I currently work with are easily as  bright or brighter than my – shall we say – earth-friendly mental wattage.

But I’ve learned that smart brains often don’t  lead to good medicine.  In my opinion, what makes the best medical decision-maker is an acute awareness of ignorance.

You could call it intellectual humility, if you wish.  It could be that all the hours of training in medicine really just cultivates this humility to refinement.  I can see the value of that.

In the last week, I have dealt with numerous decisions of certainty in medicine that were completely unjustified.  All were made by PA’s and ARNP’s.  As patients described their experiences, I could tell their previous providers were of the para-doc variety even before they confirmed it for me.

“I’m here for antibiotics, Dr. Secretwave101.”

“Really?  What for?”

“I have pneumonia again.  I had it 5 times last year.  I just have to come in and get antibiotics for it.  It’s such a pain!”

“PNEUMONIA?  FIVE times in a year?  Are you sure?  Confirmed by chest X-ray?  Do you know the organism?  Bacterial each time?  Which lung?  Was it a particular lobe?  Were you hospitalized?  Did you have pulmonary scarring as a child?”

“Uhhh.  I don’t know any of that stuff.  I just need the medicine.  I always just come in with this cough and get the medicine.”

Pneumonia is a big freaking deal.  Real pneumonia kills people.  Like, healthy, not-old, not-sick people.  Real pneumonia almost never hits someone 5 times in a year.  Once, and you’ve had a tough previous 12 months.  You get it 5 times and you’re basically telling me that you’ve spent the previous year in a hospital with chest tubes, IV meals and a bag to catch your pee.

There were two problems with the patient encounter.  One, the patient wasn’t well educated by her provider, who clearly had numerous opportunities to clarify things for her over the previous year.  She didn’t have pneumonia 5 times, she had a cough.

The provider also never worked up the cough to see what it actually was.  No X-rays.  No sputum cultures.  No pulmonary function tests.  Just antibiotics.  Broad-spectrum antibiotics.

In another post, I will describe why throwing antibiotics toward a cough with no evidence of bacterial involvement is absolutely catastrophic for the long-term survival of the human species.  That statement is a rare instance on this blog where I’m not stating hyperbole, either.

Antibiotic resistance is real, and the results of it will kill you.

I also recently recommended that my sister-in-law take her son into an urgent care center to be evaluated for what sounded like strep throat.  That would be, Streptococcus Group A pharyngitis.

“Did you know,”  I asked her, “why we treat strep throat?”

“Well, he could get really sick, right?”

“Yes, but not from the throat infection.”

“So, we’re not treating the throat?”

“No.  That goes away.  Most pharyngitis is viral and goes away.  Even bacterial goes away.  We only need to treat one specific cause of pharyngitis, Group A Strep, because it can also cause heart disease, kidney disease and all kinds of other stuff.”

“I didn’t know that.”  She replied.

I didn’t either.  Not until years into my training.

The next day, I found that my nephew was taken to a P.A. at the local Urgent Care and without a culture or any other objective work up, he is diagnosed with “strep throat” and given antibiotics.

“I don’t even need to test this, the symptoms are so classic.”  The “doctor” reportedly said.

Two days later, the boy’s little sister gets sick.  There’s no culture from the back of brother’s throat.  We have no idea if what he had was viral, bacterial, fungal or nothing at all.  He may not have even needed the antibiotics, and likely didn’t have the right ones if he did need them.

Now we have no idea what his sister has.  Is it the same thing?  Is it something new?  I guess we’ll just throw some antibiotic at her, too and say they both had STREP THROAT, even though we have no evidence of this.

Did my nephew's throat look like THIS? Did anyone even look?

Certainty in medicine flat-out leads to bad medical care.  Everybody has the urge to think they’ve got this or that totally nailed from time to time.  Doctors too.  Maybe doctors more than other health professionals.

But my experience so far is that certainty increases with less training.

My warning to you is this:  If your health care provider is CERTAIN about your health problems, you don’t have a very good doctor.  Humility comes from a wide differential diagnosis.

In nature, the humble survive; the proud die.

Rosacea + Swelling?

I saw a patient for a partner in clinic recently who has rosacea. She has struggled with it for years, but it has gotten worse recently. She has agreed to have a picture of her condition posted here for everyone to see:

Rosacea is a common skin condition. The most frequent symptom is facial flushing, usually right over the cheek bones. Also common are erythema (redness), sometimes with little red blood vessels visible under the skin and sometimes roughness also. There’s actually 4 types, but the biggest thing for most people is the redness. Nobody knows what causes the problem. We know genetics play a role, but it also seems to be brought on most commonly by things like: emotional stress, hot drinks, alcohol, spicy foods, exercise, cold or hot weather, and hot baths and showers.

The problem for this patient is that the areas are also swelling. It’s hard to see in the picture, but at times she has had swelling to the point that a friend wondered if maybe she had elephantiasis (lymphedema) of the face. This patient has said that the swelling is as distressing as the bright red cheeks.

Historically, the pt. has taken amoxicillin for about 8-10 days to treat the problem and things have improved. This isn’t the most common antibiotic for rosacea, but it has worked for her. However, she has had 3 outbreaks in the past month, all with bad swelling. As soon as she stops the antibiotics, the problem comes back.

I’ve already seen this pt. together with a dermatologist, and he was a bit intrigued himself, so I’m not the only ingnoramous at this party. Her primary care doc – who knows her best and has treated her outbreaks many times – is suspicious that she may have another problem entirely. While seeing her, I took blood tests that argue against lupus, infection or other systemic inflammatory problems.

So, what does she have?

Don’t know for certain. Rashes are lame. I never know what they are for sure. The swelling is not a symptom that is commonly seen in association with the rosacea seen by some of the senior docs in our clinic. However, at least one source I found says that the swelling can be even the ONLY symptom at presentation.

So, I’m going with rosacea. Of the 4 types, I think she has Erythematotelangiectatic type. I picked that one of the four because it’s the longest and least-pronounceable and thus makes me appear smart and medicaly. But is also seems to most closely fit her symptoms. Why it is worsening is another question I can’t answer. I can only hope it gets better on our treatment plan. Like many autoimmune conditions, rosacea doesn’t really ever go away, we just keep it under control as much as possible.

And, sometimes, we give it really long sub-names too.