Excellent article today in NY Times about Big Pharma creating new diagnoses in millions of people with the help of a few doctors. Check it out at:
In the “pages” section. See how my baby niece got tortured by the system.
Welcome to my new and improved blog site. The post “Batman” will get you started with a funny personal story on how nature and a health care “system” conspired to almost kill me. That led to an introspective period and I ended up writing a bunch of short pieces on various aspects of health and health care that might be helpful to the average healthcare “consumer.” Everything here is my own opinion and not of any of my various employers or colleagues unless specifically stated. Credit and references are given when possible. If you see something I’ve plagiarized or not given credit for please alert me! Comments are welcome and appreciated.
Nick Sartor, M.D.
Chap 1 = my near death experience
I thought I’d start off this narrative with a little anecdote about myself: I promise not to carry on too much in this fashion but I think if you see where I’m starting from you’ll be more likely to come round to my way of thinking, which is what I hope.
Nick’s adventures with bats.
One lovely Sunday afternoon after returning from church, just when I was about to enter into the sweet land of dreams and luxurious laziness on my living room couch I heard my 4 yr old son and my wife hollering and running through the hall.
I Jumped up, went into protective husband/father mode. I quickly assessed the situation and in a very manly fashion ushered them into the safety of the master bedroom slamming the door behind us. After collecting my wits (and waking myself up) my wife proceeded to recount the tale of woe. Apparently our son had left the kitchen door open and a bat had flown into the kitchen. We have plenty of bats around but I’d never seen one at high noon. I reached into the closet and retrieved a heavy leather coat, some gloves and my boots. In a manner that would have made Ernest Hemmingway proud I reentered the hallway and began my search for the perpetrator. Despite due diligence, the intruder could not be located. As I mentioned, Bats are not terribly uncommon creatures in our neck of North Carolina. In general we love them. They eat a lot of less desirable bugs and appeal to my senses as the only true flying mammals. They are normally nocturnal and that one would deign to disturb my Sunday slumber was concerning. I attributed it to a possible disruption of HIS Sunday afternoon sleep with a slight detour into an open door. Obviously he had retrieved his senses and returned whence he’d come.
I reported back to Keegan and Carolyn that the coast was clear. After everything had settled down they decided to go for a walk in the woods with our brave (but previously conspicuously missing) border collie Callie. I opted for a quick return to dreamland and returned to my lovely well worn sofa.
Sometime later, I’m, not sure how long, I felt a strange brushing around my ears. I thought our son was gamely trying to wake me up. I brushed away the annoyance only to have it return. I sat up ready to get back at him with some precision tickling when our friendly flying mammal cruised right past my nose into a corner of the living room.
Now I happen to be a doctor so I now realized it was war with this critter. Either I capture him and have his brain biopsied or I would have to get rabies shots. Bats are, unfortunately, not uncommon carriers of rabies. They also have extraordinarily fine teeth. They can bite you and you don’t even feel it! It’s a big problem in pediatrics. If you find a bat in a room with a child that can’t reliably report the incident (I.e. any infant or sleeping child) you have to presume he was bitten. As such you need to either prove the bat does NOT have rabies or give the child both Immunoglobulin AND vaccination shots to immunize them. The immunoglobulin is a BIG dose injected directly in the bite site and the vaccination consists of 1 shot at the time of the bite and 5 more shots over the next month. The only way to get out of this official recommendation is to capture the animal and have it’s brain biopsied to prove it doesn’t rabies.
Using my weapon of choice, a laundry basket, I cornered the little guy in our piano room and threw the box over his head. Right at that time my family returned from their walk. The dog came in and started investigating as I shouted “STAY OUT – BAT!!!!!”
Not knowing how to get hold of animal control on a Sunday afternoon, We called the sheriff’s office and they paged the animal control officer on duty. We were thoroughly impressed as the officer drove out to our country home from Chapel Hill in less than 30 minutes. He put on a pair of heavy gloves and procured the beast from under the improvised plastic cage and placed him in a bag. He would take the animal out to the state lab in Raleigh and we would have an answer by the next day. The bat didn’t appear particularly sick and it was his estimate that we were going to be fine. As an aside we investigated some termites hanging out in one of the logs we were sitting on and discussed the gustatory qualities of such. My son was very impressed when the officer sampled a termite taster and declared them delicious.
Carolyn and I went back inside to recover from our adventure. At that point I said “Honey, take a look here on my neck, do you see anything?
“Well, “ she said, “I think I see 2 little hematomas (bruises) here.” “WHAT” I said? “Stop teasing me!” “No, really, I do” she said. I started having palpitations. I ran up to the bathroom and got a closer look with a mirror. I could just barely see what she was taking about. Two little teeny weeny bruises on my left neck. Now I was getting a bit agitated. Rabies, you see, is “INVARIABLY FATAL.”
Look at the picture of my neck. Note the 2 little red/purple spots. Those are bat teeth marks. The orange is betadine left after washing off. The first thing to do with ANY bite is to thoroughly clean it with soap and water.
O,K., not to be histrionic it’s only fatal if not treated . As far as we know no one who has been treated “in a timely fashion” has “failed therapy” (“Failed therapy,” in this case, means DEAD). Nonetheless, I was a bit rattled. Carolyn and I have been through a ton of stuff with her health. In fact she had already nearly died three times by that juncture (more on that later) but I had been pretty healthy. Other than rolling my car in a stupid oppossum avoidance maneuver I haven’t even been to a doctor in years. “Calm yourself” I said. I ran back to my books. I got on line. I searched the literature. I was going to be fine. Right?
The next day was a Monday and I had the day off. My son stayed with me on Mondays and we hung out doing guy stuff like splitting logs and changing oil on my fleet of old cars. I tried to keep my mind off the whole bat adventure and was doing OK till I got a call in the early afternoon from the animal control officer.
“I’m not sure how to tell you this doc ,” he said, “but the animal was positive for rabies.” “Oh” I said calmly. “I guess I’ll be heading to the ER.” “I think that might be a good idea” he said. I thanked him and hung up. Now I was actually scared a bit. I really shouldn’t have been. I should have had all the confidence in the system. I mean I WAS the system. We are the best, right? Unfortunately rabies immunoglobulin is not something the average doctor has in his office. It’s very valuable stuff. You have to collect blood from people who have been vaccinated (such as veterinarians, zookeepers, animal lab workers etc.) and then siphon out all of the antibodies against rabies and purify it into a shot to give to poor idiots like me who get bitten by rabid animals. The whole thing is then given to the person who has been bitten in order to give them an instant immunity. You basically borrow the immunity from others for the 30 days or so it takes to get your own immunity up by taking a series of immunizations. I called the ER at the hospital where I work. Using the “this is doctor Sartor” line I got through to the attending physician and laid out my situation for her. Did I mention I was going fairly rapidly on the road at this time with my toddler son in tow? Well OK I as speeding like a BAT out of hell! As the lawyers would say “TIME IS OF THE ESSENCE” You see rabies is a funky infection. It can take a while to get you but no one is sure how long is “awhile.” It’s a virus that is carried in the saliva of infected animals. After a bite the virus gets into a local nerve around the bite site and starts working its way toward your spinal cord. Once it gets there it starts crawling up your spine to the base of your brain. You won’t really have any symptoms till it gets to your brain but once it gets there your cooked It can take a LONG time (like 9 months!) to do this. It probably depends on where you’re bitten. Did I mention I as bitten on the NECK! For you non-doctors in the crowd, the NECK is very close to the BRAIN. Needless to say I was a bit freaked out. After what seemed an interminable time the doctor informed me they did have the stuff and said they would be waiting for me. I was happy about this because my next stop would have been another 25 minutes away at our arch rival’s hospital (DUKE for those of you who dislike blue devils).
I go to the hospital several times a week. My wife works there everyday. I got off the exit from the main road and headed to the ER. I COULDN’T FIND IT! They were doing construction (they always are) and had re-routed the ER traffic. Chapel Hill has some crazy sign ordinance about the how big the signs can be. There isn’t enough room on the signs to print it in Spanish, which has caused many problems and at least one very unfortunate death of a child. BUT I SPEAK ENGLISH! REALLY WELL ACTUALLY! And I can read too.
After circling around for what seemed like forever (probably 90 seconds) I put the truck in 4 heel drive and drove over a big obnoxious berm into the temporary parking lot. BIG BREATH. “YOU ARE GOING TO BE FINE.” My son was asking me all kinds of questions like what as going to happen to the poor bat. “BAT” I wanted to scream. I kept my cool an explained to him that Mr. Bat had sacrificed his brain for my benefit. We would explain it to PETA (people for the ethical treatment of animals) later. I walked into the ER to check in. They diverted me to “urgent” care. “uhh excuse me but his is an EMERGENCY!!!” I wanted to scream. Instead I collected my wits and approached the desk.
“INSURANCE CARD!” demanded the clerk.
I wanted to scream again.
I got out my card
“Take a seat” she said. “the wait is about 3-4 HOURS.
I almost had a coronary on the spot.
I took a seat. I looked at my watch.
I got my hospital badge out of my wallet, took my son’s hand and swiped the lock on the door and walked back into the ER.
“HEY” said the clerk, “YOU CAN”T GO IN THERE”
I walked back to the doctors area and found my colleague who greeted me kindly and walked me over to a smaller exam room. At that point a very militaristic nurse came running after me with a thermometer yelling “you aren’t checked in yet – we need to take your blood pressure.” “My blood pressure,” I stated somberly, “Is very high! I just got bit by a rabid BAT!” She mumbled a bit about obnoxious doctors (guilty but hey…) and weighed me in. They sent an intern and a medical student in to enjoy the ruckus and look at my war wounds. It seemed to be taking forever to get the “stuff” ready.
Finally two nurses come in wielding 2 syringes. They turn there backs to me while donning latex gloves and tell me to drop my drawers.
“What for?” I asked innocently. “Well we have to give you these two shots of immunoglobulin.” “In the butt?” I asked. “Well Ye-es” they sang in chorus, looking at me as if I’d gone to some offshore Medical School.
Now here’s where being a doctor may have saved my life. You see they either didn’t know, hadn’t been instructed or simply were too used to doing things a certain way to realize that they were about to commit a serous error. You see the rabies in the bats salivary glands had gotten into my neck. It was now infiltrating a peripheral (neck) nerve after which point it would start working it’s way towards my spinal cord and then into my brain. At which point, well, you remember, DEAD. The injections need to be given (to quote the package insert) “in and around the area of the primary wound.” Now, although others have often called me a pain in the butt, my butt was not in pain at all.
“Oh no” the nurses cried, “We’re not giving it to you in the neck!”
“Fine,” I said, “Find someone who will. FAST”
So I don’t want to make a big big deal about this but the point is simple – people make mistakes. Doctors, Nurses, Patients. It usually takes 2-3 before something bad happens. The first mistake was making me wait in the waiting room after we already had all the information we needed to do something. This is what is called “efficacy based medicine.” It is different than “evidence based medicine.” I’ll get in to details later but suffice it to say we know that giving this immunoglobulin for rabies works. No one who’s gotten it “in a reasonable time” has died. I did not want to be the test to see exactly how long to wait. It’s mostly a communications breakdown with interference from “protocol” leaving no room for common sense. It’s a double edged sword of course. If the nurse started deciding who did and who didn’t need blood pressure checks before getting into a room then some would need them and not get them. Not knowing the injection method for rabies immunoglobulin, however, was potentially a pretty bad thing. Lucky for me I was able to A) bypass the system and B)have the knowledge to divert the train before the disaster. What happens to the rest of you? One thing is to bring someone with you – a “patient advocate.” Often you, as the patient, are just too worried, hurt etc. to think it out straight. If the person is in the health care field that CAN be good. As long as they don’t get too obnoxious. Mostly you just sometimes need somebody there to say “hey, did you…..” So in preparation for the next time you are a patient, educate yourself – read on.