how medication works

Sunday, May 3, 2015

Manny Pacquiao lost the fight of the decade but perhaps not the battle of the excuses. ESPN’s quoted the boxer as saying that “he didn’t want to make alibis or complaints or anything…[but] it’s hard to fight one-handed.” The people in his corner asked that he be injected with an anti-inflammatory in the dressing room just before the bell rung, but were denied permission by the Nevada Athletic Commission because the injury was not previously disclosed. Pacquiao’s trainer said that the requested anti-inflammatory had been previously used in training camp and was on the approved list by the US Anti-Doping Agency.

There are two potential injectable anti-inflammatory medications that are used to treat acute or chronic injuries. The first is hydrocortisone or any of the myriads of corticosteroids that are used to decrease inflammation. They are very effective and by decreasing inflammation, the patient’s pain may also be relieved, but it takes 48-72 hours for the medication to have an effect. The second injectable anti-inflammatory is ketorolac (Toradol), which is a nonsteroidal anti-inflammatory, is an effective medication and is often used as a non-narcotic alternative for acute pain management.

For many medications, the presumption is that the injected medication is “better”, working faster and being more potent. Patients are surprised that isn’t necessarily so. If Mr. Pacquiao was interested, almost 20 years of medical research has shown that ibuprofen (Advil, Motrin] taken by mouth works as well as the injectable Toradol. Testing patient pain levels at 0, 15, 30, 60, 90 and 120 minutes found no difference at any time interval. The only benefit to Toradol is that it is injectable, and therefore helpful when people are vomiting or cannot have anything to eat or drink.

Other medications are similar in that their action works quickly when taken by mouth. An allergic reaction may be a true emergency, especially if there is difficulty breathing, shortness of breath, wheezing or difficulty swallowing. These are all potential disasters that can be associated with anaphylactic shock and calling 911 is a reasonable first step. The second step is taking diphenhydramine (Benadryl) by mouth. Surprisingly, its onset of action is relatively quick when taking orally, starting to work within 15-30 minutes. Hopefully, by the time the patient arrives in the ER, the medication is kicking in. For those patients who develop hives as their allergic reaction, the oral Benadryl may be all that they need.

As much as its important to know how quickly a medication work, it’s just as important to know when the effects begin to fade. For pain medication, that allows the prescribing provider to know how often to recommend taking the drug. Take it too quickly and the accumulation of the drug within the blood stream may lead to an overdose; delay too long and there will be gaps in pain control. The same thought process goes into prescribing long term medications for most medical ailments from seizure control, to heart failure to diabetes. Understanding the pharmacokinetics of a drug, how it’s absorbed, how the body metabolizes it and how it’s excreted, is crucial to know when and how much to take.

For Mr. Pacquiao, the shoulder injury may have put him at a disadvantage in the fight. While the Athletic Commission didn’t allow injectable medications, not considering alternatives might have been a difference maker. But when all was said and done, there would be little opportunity to complain when the judges’ scoring was not in his favor.


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medical draft day…the match

Monday, April 27, 2015

After months of speculation, the NFL draft of college players will finally happen this week. Fans will celebrate their good fortunes or bemoan their perceived loss as each of the 256 college players picked, are assigned to their new team. Meanwhile, the coaches, scouts and other management personnel may have their career longevity significantly affected depending upon how well the rookies impact the success of their new teams. But it’s not life or death, even if fans may think it is, when a future star wears a different jersey. Interestingly, the draft that has life and death implication concluded a couple of weeks ago, in anonymity, except for the tens of thousands of new doctors who learned their educational fate.

Graduating from medical school is a definite accomplishment, but rather a hollow one. The four years of undergraduate studies and four more years of medical school only qualify the newly minted MDs to open another door to access further training. The MD degree does not allow them to practice medicine; instead, it is the entry requirement for post- graduate training that can last three to seven years or more. This is residency training, so called because historically, the new MDs would literally live in the hospital where they trained. Graduating residency is the ticket to begin the practice of medicine and it all begins with the draft.


The National Residency Matching Program is the NFL draft of medical schools. Senior medical students decide upon their hoped for medical career, from primary care (family medicine, internal medicine, family practice) to specialties as diverse as obstetrics to dermatology to psychiatry to surgery. From there, it’s a search for the teaching hospital that has the program they are interested in pursuing, with hopes that the hospital residency program is interested in pursuing them. There are application forms, letters of reference, tours and formal interviews, no different than the NFL pre-draft evaluation process. The difference has to do with the scale of the draft.

There were over 40,000 docs-to-be in the 2015 NRMP draft trying to secure one of about 30,000 slots. The medical students list their preferred programs, the hospitals rank their wish list and a computer does the matching. At the end of March, the fate of each group is decided. The hospitals find out the quality of their new class of residents, while the medical students find out where their new home will be, come July.


Most applicants find a place to train, but some do not. The playing field is not necessarily the same for each applicant. More than 22,000 are senior medical or osteopath students who trained in the US. There are 6,000 American students who studied abroad and another 10,000 foreign medical grads. Add about 2,000 who have applied in previous years and the pool of hopefuls is complete. Those who do not get a spot in the first round, scramble to find a place to train. It’s just like an undrafted free agent who goes from team to team asking just for a chance to play. These students want and need a place to complete their medical studies, because without at least a year of postgraduate training, they do not qualify for a medical license, the golden ticket to care for patients.

While fans of the Buccaneers, Titans and Eagles fret about their first round pick and whether it is a Jameis Winston or Marcus Mariota, the NRMP is a real difference maker for communities. More often than not, new docs tend to live near where they train. They are familiar with the hospitals and neighborhoods, they may have started families and settled into the schools and community and have settled into homes. As well, the local doctors and hospitals have had years to assess their potential colleagues, and try to recruit the brightest and best to stay nearby.

The good news for 2015 is that about 13,000 of the 30,000 slot matched into primary care, meaning that 2018 will see a bumper crop of docs ready to cure the world, or at least help people help themselves become healthier. Their careers will span decades and touch the lives of thousands. And yet, those seminal decisions, affecting the lives of many generations, occurred in the obscurity of an NRMP computer program. If only it had the hype of the NFL and the daylight that draft day will bring.

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