Monday, November 24, 2014

In today’s world, most doctors will only know about many childhood illnesses from textbooks. Aggressive immunization strategies have mostly eradicated measles, mumps, rubella and whooping cough, so imagine being an NHL team doctor and wondering why a player is feeling fatigued and has extra-large swollen glands in his throat. That’s is the story surrounding the locker rooms of the Minnesota Wild, St. Louis Blues and the Anaheim (used to be Mighty) Ducks. The latest Duck Is Corey Stoner, who has now joined teammates Corey Perry and François Beauchemin with the diagnosis.

Outbreaks of mumps happen in clusters and often younger adults who live in clusters are affected. Mumps virus spreads by droplet infection from coughing, sneezing or even talking, as the virus hangs out in saliva and mucus. It is contagious enough to be passed on from cups and eating utensils or even from counters and other surfaces. It’s not surprising that if one hockey player were to be infected that others on the team would be at risk. Colleges are also hot spots for transmission and the University of Idaho is now sorting out how many dozen students are infected.


Mumps causes inflammation of the parotid gland, located at the angle of the jaw and is responsible for making saliva. The infection is self-limiting and causes symptoms one would expect from a virus, malaise, fatigue, fever and chills in addition to the swelling. There is no treatment except for supportive care including rest, drinking lots of fluids and controlling fever. It’s hard to avoid a person who has mumps because the incubation period, where the virus has invaded the body but symptoms have yet to surface, is usually a little more than 2 weeks but can be almost a month. And after the mumps symptoms are noted, the patient is infectious for another 9-10 days

The best treatment is immunization. Mumps was prevalent before the routine MMR immunization was licensed in 1967 in the United States and is more than 99% effective. The first immunization is given at age 12-15 months and the second at 4-6 years. But even those who have been immunized may be exposed to the disease and not have enough antibodies to fight it off. This is where herd immunity comes into play. If not enough people participate in getting their kids immunized, the potential for infection outbreaks exists. There are many personal reasons that parents have not to immunize their children, from religious belief to fear that permanent complications will occur. However, each decision to avoid immunization affects the rest of the population as a whole and if the percentage of non-immunized people increases, so does the risk of disease spread. For most childhood infections, including mumps, at least 85% of the population needs to be immunized but for measles and whooping cough, that number climbs to almost 95%.

But if the treatment of mumps is just supportive and the patient gets better, then why the big worry? It’s all about the side effects. Before immunizations, mumps was the most common cause of viral meningitis. Other major complications include temporary or permanent deafness, pancreatitis and inflammation of the ovaries or testicles. The latter two may result in sterility, especially if they occur in younger adults.

It comes as no surprise then, that NHL teams are scouring their locker rooms whenever a team comes to town that has a player with mumps. If it takes a month for symptoms to surface, the player may not know that they are contagious and for that reason, it may be that more people on the three affected teams could get sick, even if their immunizations are up to date. Patients ask that question all the time. I’ve done everything right and yet I’ve become ill…why? Unfortunately, the answer is outside the realm of medicine and it is less than satisfying when the doctor answers… just because. Perhaps the question of the wrong expert but it’s hard to get an emergency consult from a theologian.

This entry was tagged , , , , , ,

pain control

Tuesday, November 18, 2014

Interesting events were happening even before  one NFL game was played this weekend. Team physicians were visited by Drug Enforcement Administration investigators to see what narcotics and other restricted medications might be in their possession as they travelled along with their players to away games. The DEA actions might be part of an investigation triggered by a player class action lawsuit that alleged indiscriminate pain medication distribution by doctors, trainers and coaches, in an attempt to return injured players to the game.

It is not illegal for physicians to prescribe and also dispense narcotic medications, but there are stringent rules, regulations and paperwork that needs to be followed. Most often, physicians prescribe drugs and pharmacists dispense them. There is a check and balance in place to help patients understand dosing, side effects and potential medication interactions. For narcotic prescriptions there are more legal layers in place. A physician not only needs a medical license, but also a DEA certificate (and in some states like Texas, a state controlled substance license). There is a whole other set of regulations in place and documentation required if a doctor decides to dispense narcotic pain pills. This is where NFL team doctors may run afoul of the law. DEA certificates are assigned to a specific location, so a team doctor in Seattle cannot use the same DEA number in Miami. Narcotics for commercial use cannot usually be transported across state lines and there needs to be a medical record that notes the diagnosis and rationale for prescribing pain pills. Then comes the dispensing issue, with documentation matching inventory and prescriptions, and medication lot numbers and expiry dates in case a medication recall should occur.

That physicians sometimes inappropriately prescribed pain pills is not the real story. It all has to do with the expectation of patients and family when it comes to pain control. Perhaps one of the most influential changes in the practice of medicine occurred when pain was promoted as the fifth vital sign. But where blood pressure, pulse, respiration rate and temperature can be objectively measured, pain is very subjective. When zero became no pain and ten, the worst one could imagine, patients were expected to decide their own vital sign and expectations of pain control slowly changed. There are hospital quality indicators that ask nurses to assess pain status, regardless of whether the patient visit is associated with an injury or illness. Patient satisfaction scores often ask the patient to rate how well their pain was managed and this has led to perhaps to a societal expectation of a pain free experience.

The NFL experience proves different. Collisions on the field yield bumps and bruises, broken bones and torn ligaments and yet players want to play as soon as possible. Their coaches and general managers also want them back on the field. Pain medications, whether it is an injection of Toradol (an anti-inflammatory) or a couple of Vicodin pills (hydrocodone-acetaminophen combination) will mask the pain but not necessarily help recover from an injury. Yet playing is important. The average NFL player’s career lasts less than 100 games and there is always another player to take an injured player’s spot on the roster. Playing in pain is expected.

The real world is different. Most pain cannot be completely resolved but can be controlled. Patients should not suffer but the expectation of zero on a pain scale is unrealistic. Patients with new onset abdominal pain or broken bones can have their pain controlled so that they don’t suffer, but pain free may not be possible. Too often it is difficult for the patient, nurse and care provider to understand each other’s perception of pain. While a patient may be suffering significantly and coping by talking on their cell phone, the provider may see that patient chatting away and presume that the pain is not intense. Or vice versa. A patient who is trembling and sweating on the gurney may not see their pain as severe enough to need help.

Unfortunately, there are less than scrupulous physicians and less than scrupulous patients. Some doctors can’t say no to a patient who asks for narcotics and some patients either abuse or divert their narcotic prescription. Aside from DEA regulations, states have set up websites that allow physicians and pharmacists to monitor the number of narcotic prescriptions and the number of pills that have been dispensed to a patient. And for those who decide to divert their narcotics, there is a healthy incentive to sell their medications on the street. Oxycontin (a long acting pain medication) can sell for $1 per milligram. A prescription of 40 mg tablets taken twice a day for a month works out to a street value of about $2,500.

Somewhere between “a little pain never hurt anyone” and “there is no trophy for hurting” lies the reality of medical care. Trying to measure pain is difficult since it is different for every patient. In the NFL, pain is better when the player can return to the game but that level of pain may not be tolerable for a frail patient with cancer or a broken hip. In the end, doctors and patients have to talk to each other, manage expectations and goals. Somehow that does not translate well to a zero to ten pain scale and deciding appropriateness of care based on something that is so subjective seems unfair to both patient and physician.

This entry was tagged , , , ,