choosing wisely

Monday, February 3, 2014

After two weeks of being inundated with expert analysis, the unexpected Seahawk domination in the Super Bowl was a reminder that no matter who predicted what, the game still needed to be played to learn the final score. The same situation happens daily in medicine, where no matter what approach statistics recommend, it’s what happens to the patient that really matters.

Every couple of months, I get a print out telling me the most common bacteria that cause a variety of infections in my hospital and what antibiotics are most likely to work. If I make the right diagnosis and write the proper prescription, the odds are that the patient will get better. It is a leap of faith that both the patient and I, as the physician, need to take since aside from clinical judgment, there usually is no black and white evidence that the treatment choice is correct.

Most people can figure out that they have an infection; the harder part is deciding whether it is caused by a virus that will usually get better on its own or whether it is caused by a bacteria and may need an antibiotic. Most people suffer through cold and flu season and survive by drinking plenty of fluids, resting and letting the body’s immune system fend off a virus. Some infections need medical care and if the decision to prescribe an antibiotic is made, the choice is very much like betting on the Super Bowl. All you have to do is pick a winner.

Some choices are relatively easy. Most uncomplicated bladder infections are caused by the bacteria E.Coli and there are many antibiotics that are effective. In women, the diagnosis is often made by history (frequent urination that burns) and a urine sample that looks infected under the microscope (containing white blood cells and bacteria). Choose a sulfa drug, quinolone or furantoin and likely the infection will be cured, but there are potential complications. Quinolones like Cipro and Levaquin can damage bone growth plates and should not be used in kids younger than 18. They also can also rupture tendons, so should not be used in people who have had recent strains. Pregnancy can also affect the antibiotic choice. And in males, urinary tract infections are not routine and need more investigation.

Pneumonia, an infection of the lung, is often treated as an outpatient, especially in younger patients. Symptoms include fever, chills and cough that brings up yellow/green sputum, then add the doctor hearing crackles or wheezing when listening to the lungs and perhaps a chest x-ray to make the diagnosis. The first cousin to pneumonia is acute bronchitis, an infection of the breathing tubes that tends to be caused by a virus and the treatment is supportive meaning, no antibiotics. But for those with pneumonia, the antibiotic choice often is regional depending upon those infectious disease statistics. Doxycycline is a reasonable first choice but can’t be used in kids because it discolors tooth enamel. It can also cause a sun sensitivity rash, not a problem in the frozen tundra of Wisconsin during winter months but could be an issue if you live near the beach. Augmentin, a souped up amoxicillin, and quinolones are other options. The treatment is based on a leap of faith because most times, the offending bacteria is never found or even tested for. Blood cultures take days to return and by then treatment has begun. Even for patients admitted to the hospital, if those cultures are obtained, the bacteria may not be isolated and even if it is, the result doesn’t routinely change treatment. The best guest antibiotic is usually right guess…usually.

Skin infections and abscesses are tougher. The most common bacteria culprits are strep and staph, including the MRSA (methicillin resistant staph aureas) that gets all the press. In some cirmcustances, the infections co-mingle and patients are routinely prescribed antibiotics that will treat both. If an abscess needs to be lanced and drained, there is some controversy in the literature about what to do. Some doctors advocate using antibiotics while other say that draining pus is enough to allow the body to heal itself. Sometimes statistics are less than helpful in guiding the way.

So why the big deal about picking the right antibiotic and perhaps picking no antibiotic at all. Bacteria have a tendency to adapt to their environment, evolve and develop resistance when exposed to antibiotics. The over prescribing of antibiotics has become a public health emergency. While expert recommend the indication, the type and the duration of an antibiotic prescription, the message is often a difficult sell for the doctor to make to the patient. Patient satisfaction increases when doctors take the time to discuss what they are thinking and how the diagnosis and treatment plan were made. However, it may be easier to give the patient a prescription rather than take the time to explain why antibiotics are not necessary. The patient may be a little irritated in not getting a pill to take to make things better, thinking that their visit was a waste of time. Both patient and doctor get frustrated when the first treatment option fails and another prescription may be needed.

It all comes back to playing the odds. No matter how much data an analyst crunches, the Super Bowl needs to be played to determine the final score. The same is true for being sick. No matter what the latest data provided by the local infectious disease committee, even with the right diagnosis, the choice of treatment may not work and a new game plan is needed.


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chest wall injuries

Monday, March 18, 2013

There is a great regional rivalry when it comes to barbeque and which style makes ribs taste better. Is it the marinated Memphis, the Kansas City rub, the Carolina vinegar or the plain smoke of Texas? Regardless, we rarely think of the meat we eat as the muscles that help animals, including us humans, breathe. For those who have bruised or broken rib, or like David Wright of the Mets, pulled a rib muscle, it is an injury that is hard to ignore and harder to fix. After injuring an intercostal muscle, Mr. wright couldn’t play for the US national baseball team and returned to spring training to try to mend before the start of the baseball season.

Intercostal muscles are those that are attached to and located between the ribs and are responsible for moving the chest wall during breathing.  We breathe like a bellows with the ribs swinging out and the diaphragm (the muscle that divides the chest and abdomen) pushing down, sucking air into the lungs. Exhaling reverses the process and air is pushed out of the lungs. There are three layers of intercostal muscles that do the work of the rib movement, the external intercostal, the internal intercostals and the innermost intercostals, share the work of breathing and any injury to these muscles affects the ability of air to get into and out of the lungs. The muscle is often injured with a twisting motion; imagine a batter swinging while at bat, or lunging for a line drive in the field. But the injury can also be due to a direct blow, where the ribs don’t break but the muscle take the brunt of the injury.

Muscles don’t like to be hurt and when injured, go into spasm to protect themselves. The diagnosis is usually pretty easy. The patient often knows that they fell or twisted with immediate onset of pain. Sometimes, though the mechanism of injury is a little tougher to find and may be as simple as an aggressive cough or sneeze. Often a chest x-ray is done and not to look for broken ribs. Instead, the most important consideration is the under lying lung. Did the injury cause a collapsed lung (pneumothorax) or a pulmonary contusion (bruise)? It isn’t worth the extra x-rays and radiation to look for a broken rib, since it doesn’t affect treatment.

Chest wall pain, whether it is from the rib or intercostal muscle causes the body not to want to take a deep breath. It hurts too much and the body isn’t stupid. This is not necessarily a good thing when it comes to the ability to breathe. Failure to take a deep breath prevents the lung from fully expanding and those dark and warm crevices are prime breeding grounds for infection, leading to pneumonia. For that reason, treatment is focused on pain control and deep breaths. This plan, however, delays healing, trading length of recovery for pneumonia prevention.

Normally when a muscle is injured, the treatment is rest, ice and compression, allowing the damage to heal. Hurt your arm and a sling is prescribed. Hurt your leg and you get crutches. But the opposite treatment is recommended for the chest wall injury and with every breath the injured muscle fibers are ripped and stretched, delaying the healing process.

It may take 4-6 weeks for an injury to heal. Sleeping is tough and many patients find that sleeping upright or in a recliner is easier, since the ribs don’t have to lift up against gravity like they do when lying flat. Still after a few hours of sleep, those muscles go into spasm and the first twist and move in the morning after they finally get comfortable can be excruciating and dreaded beginning on morning number 2. Fortunately, one morning, perhaps in a couple of weeks, that first move hurts a little less and there is a light at the end of the tunnel.

Ice is one of the basics of treatment, as is ibuprofen as anti-inflammatory, but wrapping ribs prevents deep breaths and is no longer recommended. Instead, many patients get sent home with an incentive spirometer, a plastic toy that gives a visual clue about how deep the needed breath has to be. All this suffering is inflicted to prevent pneumonia, the lung infection characterized by fever, cough and shortness of breath.

Intercostal muscle injuries are frustrating. While Mr. Wright and the Mets hope that he heals quickly and is ready for opening day, there is no quick fix to shorten the recovery time.  And just like barbeque, you know it’s ready, when it’s ready…a not a moment sooner.

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