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.

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ankles, knees and money

Monday, December 17, 2012

It’s not often that an athlete forgoes technology and replaces it with common sense. It is a nice teaching moment when Carmello Anthony of the New York Knicks will be resting a sprained ankle and sitting on the bench without the benefit of an x-ray or MRI. In the real world, sprained ankles are common and there is little to do aside from RICE (rest, ice, compression and elevation) and perhaps a little ibuprofen as an anti-inflammatory. X-rays tend to be less than helpful, yet so many patients wanted a picture taken, and so many doctors agreed to order them, that researchers came up with the Ottawa Ankle Rules to decide who really needed an x-ray. An x-ray is NOT needed, if there is no tenderness along the last two inches of the medial and lateral malleolus (the bones that protrude on the inner and outer aspect of the ankle) and the inability to take 4 steps either at the time of injury or in the ER. A foot x-ray is NOT needed if there is also no tenderness over two bone sin the foot, the 5th metatarsal and the navicular. (You’ll need to click here to see where those two bones are located). The Ottawa rules can decrease the number of x-rays taken by more than 40% as long as the doctor can persuade the patient to believe in the physical exam and that a ligament has been torn, the definition of a sprain. It may be easier now that Mr. Anthony has shown the way.

Adrian Peterson is challenging the single season NFL rushing record just a few months after undergoing knee surgery to repair a torn ACL (anterior cruciate ligament). The accomplishments on the field are as impressive as those in the OR. The running back benefits from team, especially the work of the offensive line that blocks for him. Even the most elite running back depends upon those in front to open the way. Similarly, the skills of the surgeon require a commitment for the patient to undergo months of rehabilitation and the patient needs the skills of the physical therapist to lead the way. Mr. Peterson’s nickname is AD (All Day) which likely describes how long he spent in the gym to rebuild the quadriceps and hamstring muscles that protect and move the knee. It’s amazing that a two inch long ligament can take months and a team of experts to heal. But it also takes a ton of football players to rush for just a couple of yards.

When the Powerball jackpot payout climbs to the hundreds of millions of dollars, it is sometimes difficult to appreciate how life changing that amount of money that can be. For some pro athletes, the numbers can be just as astronomical. Whether Matt Holliday is worth $120 million dollars over seven years is difficult to determine. There aren’t many people who have 40,000 fans show up to watch them work along with another few million television viewers, radio listeners and the internet streamers. To get a sense of what $120 million can buy in the medical world, consider that it is the funds needed to immunize all the citizens of 20 poor countries. Closer  to home, those millions could build a state of the art hospital, equipped with labs, operating rooms, elevators and carpeted waiting rooms, to meet the medical needs of a half million people. Doctors and nurses not included.

Life goes on even in the wake of tragedy and yet it is hard to take a deep breath and try to ignore the violence of Newtown, or even hide those thoughts and images. I cannot imagine the strength of the teachers who sheltered the children and the fear all those in the school felt. I am only hopeful, as I am for all my patients who pass away, that they did not suffer. I pray for that.

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