Zika Virus – an update on the latest developments

Mosquito born viruses are nothing new, nor are viruses that harm a fetus if the mother gets infected while pregnant. (chicken pox, rubella)  So what makes a country (El Salvador) tell its women not to get pregnant for 2 years?

What is Zika Virus?

Zika virus is in the same family of viruses such as West Nile, Yellow Fever and Japanese Encephalitis.  It is not a new virus, being first seen in Africa n the 1940s.  With world trade, like other insect borne viruses, it has spread.

Zika virus is contracted when bit by an infected Aedes mosquito.  It generally causes a flu-like illness, and resolves in a week or so.  Most people who contract it do not seek medical attention or realize that they even had Zika, assuming it was a more typical cold or flu.

In the past year, however, Brazil and other countries in Latin America have reported a huge increase in babies born with microcephaly – small skulls and incomplete brain development.  Babies born with microcephaly have developmental issues ranging from mild functional delays to severe birth defects. Infection with Zika virus during pregnancy has been linked to the increase in microcephaly, prompting the World Health Organization to call Zika an epidemic.

Currently, there is no treatment for Zika virus, and there is no vaccine. Efforts are being focused on prevention – avoiding areas with high rates of Zika and controlling the mosquito population/avoiding mosquito bites.

Zika has been shown to be transmitted via sexual contact and blood transfusion, but there have not been any documented cases of microcephaly from these routes of infection. There is no evidence that getting pregnant after recovering from Zika causes harm.

What is currently being done?

  • Vaccines are in development, but it will be at least 3 years before a vaccine is available
  • Research is being done on mosquitoes – giving them infections that make them unable to transmit the virus
  • Research on how to prevent microcephaly from occurring in the setting of an infection is ongoing

Current recommendations

  • El Salvador advised women to avoid pregnancy for 2 years
  • CDC travel advisories have been issued for women of childbearing age and pregnant women to avoid countries with Zika
  • Avoiding mosquitoes – bug spray and protective clothing if traveling in endemic areas
  • Men who have traveled to Zika areas are advised to use condoms with their pregnant partners for the duration of the pregnancy
  • New York’s Department of Health is offering free testing to all women of childbearing age within 2 weeks of travel to an endemic area, with or without symptoms

Take home points

  • Zika virus causes a typical flu like illness in most people
  • It has been linked to microcephaly in infants of women infected during pregnancy
  • Current efforts are aimed at preventing bites/exposure to Zika
  • If you have recently been to an area where Zika has been transmitted, testing is available through the CDC and local Departments of Health

The path to wellness begins with a proper diagnosis

Ranking Doctors – “mine’s the best”

The baseball world elected Ken Griffey Jr. to the Hall of Fame with the highest percentage of votes ever.  Without doubt he is one of the best to play the game, deserving of all the honors he won over the course of his career.  Yet for all his success at the plate, he got a hit less than 1/3 of the time he was at bat.

I started to think about how other professions rank their members – athletes by statistics, business people by profit margins, attorneys by cases won, pilots by safety records, etc.  But how are doctors ranked?  Everyone dies eventually, so survival is not specific enough.  Ask anyone for a doctor recommendation and they will say theirs is “the best”.  After all, who would go to a sub par doctor (or any professional)?  We may not want to acknowledge it, but everyone can’t be the best – its statistically impossible!  As the punchline says, “What do you call the person who graduated last in their med school class?  Doctor”

How are doctors ranked?

Since there is no medical hall of fame, the first question to ask about a ranking is who is doing the ranking and what perspective are they coming from.  Insurers rank by “cost and efficiency.”  Doctors rank other doctors on reputation, technical skill and experience.  Patients rank us on their own experiences and expectations.

If you are a patient, you can look at multiple online or magazine sources for “Top Doctors” rankings and opinions. But just as I’ve hated movies and restaurants that got great reviews (and vice-versa), if what you need isn’t what the doctor you see provides, it’s not the right fit.

Insurers and Medicare rank doctors on how they perform on cost and utilization – they look for doctors that don’t deviate from the norm – not doing too much or too little.  In other words – those that do average things.

Employers have a different perspective – they want a doctor that fills a need – either specific skills or ability to see patients in a way that improves the reputation and revenues of their system.

How do you research a doctor?

When researching a doctor, you can check basic credentials – license, board certification, medical board sanctions are bare minimums.  Your first question should be – what are you seeing them for?  If you are looking for a diagnostician, such as an Internist, your needs are very different than if you are having heart surgery.  What you need will determine what you are willing to accept.  In your Internist, you want someone who listens to you, is empathetic and helps answer questions about your symptoms.  In a Cardio-thoracic surgeon you may care less about their bedside manner and more about their technical skills.  The length of your relationship is different as well – I’ve known many of my patients for over a decade, whereas an orthopedic surgeon who fixes your knee may only be part of your life for a few months until you are healed.

Most surveys of what patients say make a good doctor have little to do with training, malpractice complaints or cost and efficiency.  It is mostly a subjective assessment – personality, listening, empathy – the things we call bedside manner.  Studies bear this out as well – even when the outcome of care does not end well, doctors with good bedside manner and communication skills are sued less than those who are less liked by their patients.

I like to think I’ve got a good bedside manner – but also recognize that I’d have a lot of empty space in my schedule if I was wrong in 2 out of every 3 diagnoses!  The funny part is listening and using my “soft skills”makes getting the diagnosis right much easier – 90% of diagnoses are made by history.

I don’t expect to see my name on ESPN any time soon, I’m quite content when patients leave the office feeling heard, with a plan to move towards health.

The path to wellness begins with a proper diagnosis

Teachers are another profession without a hall of fame – but what if they had their own network?

Start Spreading the News…

Start Spreading the News…

I am thrilled to announce the next phase in my journey as a Physician.  After 3 years in Arizona, I am returning to NYC and will be practicing at NYU Langone Medical Center’s Internal Medicine Associates.

I have thoroughly enjoyed living in Arizona – it was a wonderful experience for my family, and I have grown as a physician.  I learned new skills, encountered diagnoses that I don’t often see on the East Coast and saw a two health care system merge and deploy a new Electronic Health Record system.  All changes that helped me see the challenges that both physicians and patients face in the coming years.

As I shared the news with my colleagues and patients in Arizona, the response was usually “sad for me, happy for you” and jokes about getting out of 119 degree summer days.  I am grateful for the support I have received!

Since I trained and had been affiliated with NYU since graduating from medical school, the news of my return has been like coming home – incredible enthusiasm from colleagues and former patients alike.  A response that again makes me feel grateful for the relationships I have built over the years – and reminds me of why I chose Internal Medicine as a career.

So I will say goodbye to excellent Southwest fare (best guacamole ever), and hello to Atlantic Ocean sushi, real bagels and pizza!  And look forward to NYC saying “AAHH”

Wishing health and happiness to all, and to more blogging now that my summer of transition is coming to a close.

The path to wellness begins with a proper diagnosis

Happy 4th of July – Keep it SAFE

As we enjoy the 4th of July, a reminder from TheDiagnosisMD to stay safe this holiday weekend.

Fireworks are beautiful to watch – the sounds, color and spirit evoke great memories for many.  Some of my favorite 4th of July memories

  • 20 years ago on call during my 4th day of Internship at Bellevue Hospital watching 2 minutes of fireworks on the East River from the cafeteria window
  • A fireworks show at Pine Hollow in Long Island, NY with friends after a BBQ dinner
  • Fireworks at my daughter’s camp while serving as the camp doctor

What each of these events had in common was that they were done by professionals, with firefighters on standby to be sure that everyone was safe.

Emergency Rooms see over 5000 firework related injuries a year, with half of them in people under age 20!  Fingers, eyes and burns are the most common injuries.  Even sparklers burn at close to 2000 degrees – so children should not use them without close supervision!

So lets enjoy the show – let those who are trained entertain you – and keep it safe!

http://www.cpsc.gov/en/Safety-Education/Safety-Education-Centers/Fireworks/
http://www.cpsc.gov/en/Safety-Education/Safety-Education-Centers/Fireworks/

Ebola in the US – what’s next!?

Last month, the first Ebola patient was brought to the US – a physician infected in Africa and brought back to the US for treatment.  I reviewed Ebola and that case in a earlier post on 8/2/14. That was a controlled transfer, just as the 2 other known cases transported to the US for treatment were. On September 30th, the first case of newly diagnosed Ebola in the US occurred, in a person who had recently traveled from West Africa to Dallas, Texas.

Once in the US, he went to an Emergency Room for fever.  He was sent home with antibiotics. He returned 2 days later when his symptoms had progressed and his travel history was noted. He was quarantined, tested and diagnosed with Ebola.  Why he was discharged after the first visit has been blamed on a computer error and then on poor communication between the intake nurse and the doctor. Since I wasn’t there I can only hypothesize that the truth is somewhere between.

Since being admitted to the hospital, his immediate contacts have been isolated and a HazMat team is cleaning the apartment where they stayed.  The CDC is monitoring about 50 more people he may have had contact with and so far, no one has developed fever – the first sign of Ebola.

What does this mean for the US now?

Ebola is a virus, causing fever, body aches, headache and sore throat. Unlike most viruses, it can also cause internal bleeding. You need to have symptoms to be contagious, and the incubation period – the time from exposure to symptoms is 2 to 21 days. Treatment is mostly supportive – meaning fluids and oxygen, although experimental treatments are in use as well.  It is likely that the death rate, nearly 50% in West Africa, would be much lower in the US due to better facilities, quarantine and access to care.

Ebola is spread by fluid contact – meaning you need to directly come into contact with secretions from an infected person – similar to HIV or Hepatitis.  It is not an airborne virus – meaning a cough or sneeze won’t spread it.  It also does not live long on surfaces. Therefore, if none of this person’s contacts develops symptoms, then the current US outbreak will be over.

That said, it is likely that another traveler will bring the virus to the US. Modern air travel makes this more likely, even with screening at both the departing and arriving airports.  Vigilance in the doctor’s office and Emergency Department will be needed to quickly identify potential cases – and most importantly, a travel history!

For updates from the CDC

The path to wellness begins with a proper diagnosis 

 

Ebola Virus – Is truth stranger than fiction?

Earlier today a plane landed in the US carrying a very sick person.  They are being transported to Emory Hospital to be treated for one of the scariest infections that exists – Ebola Virus.  This person contracted the virus in West Africa caring for other victims of the same infection, and is now being brought to a special infection control room for treatment.  Ebola has been featured in many books and movies – usually as a weapon or shown in a widespread epidemic of plague-like proportions.  But what is Ebola, and what is more accurate – truth or fiction?

What is Ebola?

Ebola is a virus and like other viral illnesses, causes fever, body aches, headache and sore throat.  Unlike most viruses, it can also cause internal bleeding, causing it to also be known as “hemorrhagic fever.”  It is native to Africa, and was first found along the Ebola River.  It is thought to live in animals such as monkeys, bats or rodents, but exactly where is unknown.  It can spread to humans from contact with an infected animal, and is spread from infected person to another by contact with body fluids – blood or other droplets.  It is not an airborne virus like the flu.  
Symptoms can be seen from 2-21 days after exposure to infected fluids.  Ebola has a 40-90% fatality rate – which is why it evokes such fear and makes for thrilling subject matter in books and movies.  Outbreaks are usually limited by isolating the sick and preventing further spread of the virus – since humans are not the natural host, the outbreak burns out.

What is happening in Africa?

There have been sporadic outbreaks of Ebola in Africa since we began tracking such things.  The last was 2 years ago in Uganda and The Democratic Republic of the Congo.  Both outbreaks involved less than 100 people.  This pattern has been seen over the past 10 years.  This map shows all cases since 1976 – both locations and number of cases.
In March 2014, the first West African cases were reported, and as of the end of July, over 1300 cases and 700 deaths have been reported in Guinea, Sierra Leone, Liberia and Nigeria.  This outbreak is far larger than the usual outbreaks; in fact this epidemic has more cases than the last 10 years combined.  Why this outbreak is larger and growing is not clear.  Analysis of the current Ebola Virus shows it to be a common form of the virus, not a “superbug” or mutant strain, which would mean that the population is either more susceptible or not able to isolate patients safely to avoid coming into contact with infected secretions.

Treatment

Ebola is a virus, and there is no specific treatment proven to kill the virus.  So, we treat it like we do a cold – support the patient with fluids and nutrition, and hope their immune system will defeat the virus.  There are experimental treatments that have been shown effective in animals, but no human trials have been performed as yet.  Doctors and hospitals have been receiving alerts from the CDC to increase awareness so doctors encountering people traveling from West Africa with fever are evaluated for possible Ebola, and to implement appropriate infection control procedures – just like we do for other contagious diseases.  The patient transported to Emory will be placed in an isolation room and treated by those who train to handle infectious material, limiting the chance of spread of Ebola to the US population.

What does this mean for us?

The average person should not be concerned with catching Ebola, even if you are in the vicinity of Emory Hospital.  Ebola is not an airborne virus – meaning you need to have direct contact with infected droplets to be infected.  You can not catch Ebola by breathing the same air as someone who has Ebola.  In addition, the plane the patient travelled on was not a commercial flight and was set up to prevent the spread of droplets.  Same for the ambulance that took the patient to the hospital.  So I do not think there is a high contagion risk in the US.  The CDC has issued a travel advisory, recommending non-essential travelers leave the affected areas in West Africa, and for those in the US to avoid travel there.  They are also implementing screening and reporting systems to identify and isolate potentially sick people boarding planes from the area, as well as decontamination procedures for the airlines, as they have done with other infections like SARS.  So as frightening as Ebola is, and no matter what happened in that movie you saw, there is little risk of infection to the average person.

The path to wellness begins with a proper diagnosis

Misdiagnosis – A Second Opinion

Earlier this week, I saw a segment on the Nightly News claiming 1 in 20 people have a misdiagnosis – based on a new study that had come out that day.  That error rate translates into 12 million Americans per year.  As a physician I find that number startling.  As a physician who specializes in making the proper diagnosis, and who advocates that you can’t be well without a proper diagnosis, I wanted to delve deeper into this report.  If accurate, I am making 1 or 2 mistakes a day!

What was the study about?

So how did they make the claim that 1 in 20 patients have a misdiagnosis?  How was a misdiagnosis defined?

The study looked at 3 earlier studies and combined the results.  One was a study in a primary care setting that defined a potential error as an unscheduled hospitalization or return visit within 14 days of the initial appointment.  Then they looked at the records of those cases to decide if a misdiagnosis occurred – defined as the information to make a correct diagnosis existed at the time of the first visit.

The other 2 studies looked at delay of diagnosis for colon cancer and lung cancer.  They defined a misdiagnosis as lack of follow-up of a “red flag” – an abnormality or symptom that should trigger further evaluation.

What did they find?

In the primary care study, they found 177 errors in 1343 records.  In the colon cancer study, they found 26 errors in 291,773 records.  Finally, in the lung cancer study, they found 127 errors in 587 records.  These results were combined and applied to the US population to come up with the number of 1 in 20 mistakes or 5% of the US population having a misdiagnosis – based on 330 errors found in 293,703 actual reviews.

What does this mean?

No profession is perfect – we are all human – so errors are a matter of consequence – if I was a baseball player who had a .950 batting average, I’d be playing for the Yankees.  Errors happen in medicine, just as in any profession.   It is less critical if you are told you have allergies when you have a cold – both are treated similarly and not life threatening.  However, being told your chest pain is heartburn when you are having a heart attack can have serious consequences.

A misdiagnosis is a serious issue.  Trying to define the rate and circumstances where a misdiagnosis occurs should be studied more, and ways of improving the practice of medicine explored.  I do feel the statistical manipulations in this study and generalizing their results to the entire US population oversimplified this issue.

I reviewed the thought process of a physician in an earlier post.  It involves re-evaluating a person’s symptoms as more information comes in.  Being willing to reconsider a diagnosis is key to being a good doctor – and avoiding a misdiagnosis.

I hope this review of a headline helps put it in perspective.  I plan to do this regularly – a second opinion of health news.  So, if you see or read a story you’d like to learn more about, let me know – I’ll give you A Second Opinion.

The path to wellness begins with a proper diagnosis