Monday, October 20, 2014

Happy Respiratory Care Week

October 20-26 is Respiratory Care Week.  The theme this year is "Bringing Breath To Life."

Some say the best way to celebrate the event is to host activities in honor of respiratory therapists, or to educate people by making awareness of lung diseases like COPD and asthma to the community.

I, however, am of the belief the best way to celebrate it is to get free things, and it doesn't matter whether its in the form of knowledge or material items.

Happy Respiratory Care Week.

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Sunday, October 19, 2014

4000-539 B.C.: First civilizations advance medicine, part 3

Inanna on the Ishtar Vase
(French museum Louvre)
She was the goddess of love,
war, fertility and lust,
and was associated
with the City of Urek.
(From  Wikepedia)
Everything in ancient Sumeria, Akkadia and Babylonia was created by the gods, even the people.  They were created from the mud of the land, mud that was brought in by the flow of the river, and spread over the land during the floods or inundations.

While the floods were feared, they were needed, because the mud contained the fertilizers necessary to fertilize the land so crops could be grown.  The mud was also fertilizer to mankind, and from this mud grew civilization.  The people were created by the gods with the implicit purpose to perform labor for the gods, and serve the gods. 

Even the king was a servant of the gods. Part of the king's responsibilities was to maintain order among the people, yet his job also was to perform celebrations to the gods.  One such celebration involved the king climbing to a room at the top of the Ziggurat "in which the fertility goddess Inanna lived. The king was married symbolically to a priestess representing the goddess.  Inanna would then see that the king's city prospered." (Foster, page 46)

The king's other job was to make sure each person did his part.  All food and all profits were taken to the temples and belonged to the gods, and in return each person was given whatever food he needed to feed his family.  The people worked hard from sun up to sun down, and in return for all the hard work the people were offered a promise by the god they worshiped of protection.  They made sure the sun rose to begin the day, and the moon came up at night.  They made sure the crops came up, and that the floods or disease did not take them away before they were harvested.  They made sure ideas were created to allow for better methods of taming the land and animals and people. They made sure the year began as expected, and that the floods came to fertilize the land before crops were planted.  He or she kept the people healthy, and gave them new life in the form of healthy children.  
Early chariots on the Standard of Ur, ca. 2600 BC. (from Wikepedia)

So long as the god was fed, clothed, housed, worshiped, and celebrated appropriately, they offered such protection.  When bad things happened, it was because the person, or the society, did something to offend one or another of the gods.  So belief in these gods provided an incentive for the people to be good, and to do what they were told by the ruling classes. This system allowed for the best use of resources.  

With better use of resources, and because crops were so well controlled, some people had time to specialize in things other than producing and preparing food. For this reason, people started to specialize.  Some people became basket weavers, others became potters, some became priests, some became scribes, some became physicians, some became merchants, some became traders.  (Foster, page 43) 

And chances are that whatever family you were born into, you performed the same job as your father or mother; there was very little chance for advancement in society, or change.  The people must have, at times, become overwhelmed by feelings of burnout, apathy and inanition from performing very hard work, and working long hours, usually from sun up to sun down.  

This must have made life very gloomy for the Sumerians.  Their open borders must have made them fear invasion from the north, south, east and west.  They also feared invasion from spirits and demons from the air around them, spirits and demons that were ubiquitous, peering among the trees, the clouds, and even from under the beds in homes, and in the back of dark closets (kind of like what appears in kids' rooms to this day).  They also had to fear the floods, and locusts and other bugs that could destroy crops and kill animals needed to feed themselves and their families.  They also had to fear plagues that killed many of their friends and family, and the fact that eight out of ten infants either died in birth or in the first year of life didn't help matters either.

So they had a very gloomy view of life, and they also had a gloomy view of death. Many of their legends suggest they believed in hell after death, and so they learned to worship their gods for the day, year and life in general to continue.  Perhaps the only solace among these people was worshiping the god, and "hope" that life would continue.  Yet at some point this view of gloom or nothingness after death failed to motivate the people, who took little pride in their lives as a result.  So at some point one member of the ruling classes created a legend of glory and riches after death. This type of mythology must have provided a better incentive to get the people to behave in this life to prosper in the next.

Since all the work was done by the peasants, which were most of the people, some people had time to sit around and think.  One of the first problems they had to think about was how to keep track of crops.  They needed to measure land, and they needed to keep track of who brought in food and who didn't.  They needed to keep track of all sorts of such official records, and they had no means to do it.  This problem was resolved when they invented the cuneiform (wedge-shaped)  system of writing sometime around 3200 B.C., and many believe this was the final requirement for the creation of the world's first civilization.

The first form of writing was picturesque, where the picture represented an idea. Yet eventually the writing was created where small wedge shaped pictures, pictograms, were drawn into onto clay with stylus, perhaps a small reed.  The characters were adapted by the Sumerians, Akkadian (Babylonians), and the Persian, according to dictionary.com.

The words were read from right to left.  Yet sometime around 2000 B.C. a group of people called the Phoenicians developed a society at the eastern end of the Mediterranean (what is now Syria, Lebanon and Israel).  They were famous for their ports, such as in Tyre, where other nations sent ships to trade goods and services.  They were also seafarers, and built great ships for traveling the seas looking for people to trade with.

Phoenicians originally lived in the land of Canaan and were called Canaanites, although the ancient Greeks referred to them by a red (phoinos) die they exported, and this is how they obtained the name Phoenicians.  (Kingfisher, page 90-91)

The Phoenicians are believed by many to be the first to create a written language, even before the Sumerians, and even before the Egyptians. (need reference). Although some speculate they adapted their alphabet from Semitic speaking people in Egypt.  Either way, their language used symbols to represent sounds, was read left to right, and consisted of 30 letters (all consonants). (Kingfisher, page 90-91)

Because they were traders, and came into contact with many other nations, they were able to share their culture, including their language.  Perhaps it's for this reason they are often referred to as the inventors of the alphabet and phonics (use of sounds to create speech and words). During the ancient Babylonian civilization the Phoenician language was adapted into Mesopotamian culture.

The invention of writing is key to our history of asthma and respiratory therapy, because without it there is no way that medical recipes could have been written down and shared from one generation to the next. It made it so that each generation didn't have to start from scratch, and knowledge could be learned and expanded upon.  The accumulation of such knowledge is what has allowed modern asthma experts -- the scientists, researchers, and physicians -- to advance asthma wisdom to where it is today (and it's pretty impressive as far as I'm concerned). Yet it would take a while for this form of writing to be adapted by the main civiliations.

In the meantime, cuneiform was the main form of writing among most of the people of Mesopotamia.  Cuneiform was learned by scribes, who used a stylus, and carved these pictures onto clay tablets that were then heated and sun dried or dried in ovens, and were portable.  This made it possible to record events, such as when the floods occurred, when the sun rose and set. This made it possible to create the first books and the first calendars. This made it possible to monitor the level of the waters.  This made it possible to track the planets and stars, and write down recipes of food and medicine, and myths and legends and  religion.  It made it possible for ideas to grow and mature, and, thus, it made it possible for civilization to begin.

This made it possible to write books, with each stone tablet representing one page.  Each page was marked by the symbol of the god, and this was probably done so the god would protect it and bless the person who used the information inside.  This was essential, because priest/physicians needed the help of the gods in curing their patients.  And each tablet had the last word of the last tablet so the reader knew what sequence to read them, and which tablets went together. (Sigerist, page 383)

So the various tribes of Mesopotamia blended their cultures together in forming the civilization of Sumeria and allowing it to grow and prosper.  For example, the Phoenicians are often credited as being the first to make glass, and they introduced glass making to the Sumerians.  (Hooper, Yahoo.com) The Chaldeans are often credited as being the first sky gazers, and they introduced divination and medicine to the Sumerians.  As Sumerian civilization died out, Sumerian culture was adapted by the Babylonians, Assyrians, and Persians.  

It's also believed that Thales, the first Greek philosopher who lived around 50 B.C., was a Phoenician.  As he traveled Mesopotamia, and later introduced his philosophy to Greece, he must have spread both Phoenician, Sumerian, Babylonian, Assyrian, and Persian culture to Greece. Among the wisdom he would have taught the Greeks was of Mesopotamian medicine.  (Hooper, Yahoo.com)

References:  See post "2000 B.C.:  Assyrian physicians will treat your dyspnea"

Saturday, October 18, 2014

4000-539 B.C.: First civilizations advance medicine, part 2

So with Urek as the capital of Sumeria, its god, the god of the sky, became the chief among all the gods.  He was Lord of the Heavens, Lord of the Constellations, Lord of the spirits and demons. The great legends and myths of Urek became known to all the people of Sumeria.  They all learned of legends and myths such as how the gods created the world from mud, and how a mighty king of Urek by the name of Galgamesh set off on a great adventure with his friend Enkidu to defeat the monsters and demons that were wreaking havoc on the world.  After the gods killed Enkidu, a saddened Galgamesh set off on a quest to find eternal life.

Galgamesh met a man named Utnapishtim who was granted eternal life by the gods after he survived the Deluge with one of all the animals (a story similar to that of Noah).  Utnapishtim told Galgamesh about a magic herb that would grand eternal life that was at the bottom of the sea.  Galgamesh found the magic herb, but it was stolen by a serpent, who then developed the ability of renewed life by shedding it's skin.

Still, there would have been ongoing disagreements among the rules of the other city-states, and at various times one or another of these city-states ruled over Sumeria, with its god moving to the head of the hierarchy of Sumerian gods.  It's legends were learned by the people.  Yet even as this happened, the legends and gods of the previous ruling city-states continued to be worshiped.

In either case, Sumeria started out as a democracy and ended as a monarchy. One person made himself king, ruler of all Sumeria, and he chose his successor when he died (which probably was his son in most cases).  (Foster, page 46) 

An assembly of elders and warriors of the monarchy were required by the gods to make sure all the people did the work of the gods, and so members of the monarchy had time to sit around and think.  They also had time to collect things other than simply food and things that were essential to life.  They learned they could obtain more "things" by taxing the slaves of the gods, who were more than willing to offer the goods they produced because they believed in the myths created by the kings and the king's people.  

Through taxes the kings collected items of pottery and gold.  They collected wood carvings.  They collected an abundance of food.  They made the god's slaves build for them some of the most impressive structures of all the land, and the people did this because they thought they were doing the work of the gods.  So in this way, Sumerians were among the first to amass a collection of material items, many of which have been discovered by archeologists.  The Sumerians and Babylonians worshiped these items as opposed to the gods, and perhaps it was in this way the Biblical story of the Tower of Babel unfolded

The writers of the Hebrew Bible made bold predictions regarding the Babylonians, and to the plight of archaeologists and historians, the boldest of these predictions came true.  As noted by Plinio Prioreschi in is 1998 history of medicne:
"The Mesopotamian civilization differed greatly from its contemporary and neignboring Egyptian civilization.  It has been pointed out that whereas the latter was characterized by confidence in the powers of man and by a frontier spirit full of youthful self-reliant arrogance, the 'mood' of the Mesopotamian civilization is well expressed in a quotation from the Galgamesh Epic: 'mere man -- his days are numbered; whatever he may do, he is but wind.' As if to express the same difference, the Egyptian pyramids still stand to proclaim the power of man, whereas the prophecy of Jeremiah (51:37) that 'Babylon shall become heaps' has come to pass, as all that was built in Mesopotamia has crumbled to dust."(Prioreschi, pages 427-8)
So the melancholy nature of the people of Mesopotamia was well known, and this may have played a role in their ruthless nature.  And perhaps this was the reason the various Sumerian city-states created laws,  or codes, that people were required to follow.  Many of these rules were very strict, such as an eye for an eye, a tooth for a tooth, and a hand for a hand.  It was all an experiment, you must understand, because they had no examples to learn from.  This was completely unlike the members of the Constitutional Convention when they got together in Philadelphia around 4,700 years later, who had many examples to learn from as they were creating the U.S. Constitution. The problems faced by the Sumerians had never been faced before, and the solutions were the first solutions.
Sumerians, Babylonians, and Assyrians created armies and armed them with
knives, swords, spears, and arrows.  This was necessary both to control the
people amid society, but also to protect themselves from enemy nations and,
of course, to fight wars.  (Weaponsandwarfarecom)

Another problem was motivating people to do the work, and to fight wars.  Perhaps the first democracies didn't work because, left alone, people weren't willing to make the sacrifices necessary for the collective. Or perhaps these weren't true democracies, and they weren't formed correctly.  Perhaps a ruler was only chosen during times of strife, and between strife people and city-states were left to do as they pleased, and this was part of the problem, or why problems ensued.

Of course, the founding fathers learned all those years later that democracies never work, because they require every person to stay up on politics, and Lord knows people don't do this.  With most people refusing to vote, or not understanding the need to, or not being interested, one person in power almost always becomes the divine ruler.  This is what happened in ancient Rome, and in ancient Greece, and many times, over and over, throughout history.  Yet the people around Mesopotamia did not know this as they were creating the first governments.

So, perhaps due to the failures of democracies, for whatever reason, monarchies were established.  Perhaps the most powerful king of one of the city-states stood up to the challenge and was accepted as king of the civilization.  It became his job to motivate the people to do the work of the gods, as, after all, they were created by the gods to be servants for those gods.  At least that's what the people were told.  This was the best way, perhaps, for the ruling parties to obtain and maintain order.  This was the best way to make progress.

Picture of Ziggurat in the public domain.
Yet even the king himself was a servant to his god, and this god lived in a temple. Such temples were impressive structures that were built on hills or mounds.  Some of these city-states may have been built around such mounds, although some of the mounds may have been created by human labor. The mighty temples upon them were called Ziggurats. 

Public buildings were built around these temples, and among these buildings were palaces for the ruling class, homes for the priests and even schools and libraries. Wrapped around these mounds were homes made of mud brick and reed sticks that were "closely packed together along narrow, winding streets." (Kingfiisher) 

Surrounding these were many fields where crops were grown (mostly grain) and tamed animals roamed.  Surrounding these were nearby towns, much like today's cities have suburbs. (Foster, 38-39)
The Tower of Babel by Pieter Bruegel the Elder (1563)(from Wikepedia)

The purpose of the Ziggurat was to provide a home for the god or goddess of the city-state to live. These temples were impressive structures, and originally they were made of mud-brick, the same as the individual homes.  When there were floods sometimes the mud would wash away, and the people would  band together to rebuild the temples.  When they did this they made the temples bigger and larger than before, and far more impressive  As greater knowledge and material was obtained, these temples were made of rock, material that did not wash away by the floods.  Many of these structures, although warn by centuries of the rain and sun beating upon them, are still available for modern people to enjoy. Some speculate that the temple built by the people in the city-state of Babylon was the Tower of Babel referred to in the Bible. (Foster, page 39)

To be continued...

References:  See post "2000 B.C.:  Assyrian physicians will treat your dyspnea"
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Friday, October 17, 2014

4000-539 B.C.: First civilizations advance medicine, part 1

To understand how you might have been treated if you were sick in the ancient world, it's important to understand where and how people lived back then, and what people believed.  Medicine was often blended in with mythology, and mythology was based on the culture formed by the land and the people living among it. 

Random and violent flooding of the Tigris and Euphrates rivers created a "fertile crescent" in and around the land between the two rivers.  For over a thousand years groups of people migrated to the area, and ultimately came together to create the world's first civilization.  If you were short of breath, this change would have a significant impact on your life, and your options for a cure.

Mesopotamia was not a civilization; it was a term used by the ancient Greeks in reference to the land between two rivers.  Likewise, since Mesopotamia refers to the land between the two rivers only, "It is, therefore, an inaccurate designation for Babylonia and Assyria, since it does not include the Euphrates Valley."  (15, page 1)

Sometime around 10,000 B.C. people who migrated to the area, and those who continued to migrate into it, found that its rich soils were ideal for the cultivation of plants.  People quickly learned about the various crops in the area:  flax, date palm, leeks, millet, sesame, onions, lentils, wheat and barley.  They also learned about fruit, such as figs and grapes, and various herbs and spices. Around 9,000 B.C. they learned to plant their own crops and tame the animals that lived there. They built huts of reed and mud (clay), and lived amid the landscape which consisted of a plethora of palm and olive trees. 
Scene of Sumerian City-State (http://oxford.library.emory.edu)

They learned quickly that managing the land, and irrigating the crops, took a major effort, and it was nearly impossible to tackle mother nature while working solo.  So it only made sense for the various groups of people in the area to work together for the common good.  They pooled their minds, labor and time and came up with methods of building impressive aqueducts and channels for controlling the flow of water through the land to irrigate the crops. Clans and families turned into villages, which turned into towns, which turned into cities, which, by around 3,500 or 3,000 B.C,. grew into huge cities, each wrapped around a temple on a hill where a god or goddess lived. 

Since the cities each had their own governments, and since there was no government connecting the cities, these cities were referred to as city-states. The largest of these city-states were Ur, Urek, Eridu, Lagash, and Kish. (Kishinger, page 20-21)

Yet as individual clans and families must have realized they could not manage the land alone, so the various kings must have gotten together and come up with some form of treaties.  They must have figured that by working together they could better protect the crops from mother nature and from the plunder of savage people.

Perhaps after a massive flood, or a massive attempt at plunder, one of these kings stepped up as supreme ruler of all Sumeria.  This would have been one of the key moments in the creation of civilization.  The king would have amassed the the armies into one huge military to defeat enemies and protect the nations who volunteered soldiers to the effort.

Yet all this good came as a result of destruction. People migrated to this area because food was plentiful, yet this was only possible due to the flooding of the rivers, which, unlike those of the Nile, were completely random and unpredictable.  As waters quickly spread across the land it wiped out everything in its path, including homes, crops, animals, and humans.  Yet it was by living through this chaos for many years that the men and women of the region learned to manage the waters and perhaps the people as well.

So if civilization grew out of chaos, we can also say that learning how to manage civilization also grew out of chaos.  At first the various groups of people would have worked independently, perhaps even fighting among another.  Some would have been fortunate to beat the floods and prospered, while others would have failed and either perished or forced to start anew.  Those who failed would have been eager to learn the methods of those who succeeded, and this in and of itself may have been the seed of the more advanced civilization that rose from the lands around Mesopotamia.

Perhaps one of the first problems of all these people coming together was the inability to agree on what to do and how to do it.  Plus there would have been the natural yearning to greed and lust, and perhaps this drove some people to fight their peers for power and glory.  There would have been disagreements, and sometimes all out fights, some perhaps to the death.  There would have been fights as to who would be king of Ur, or Urek, or Eridu, or Lagash, or Kish.

Regardless of who won these inner-city battles, the leaders of each of these city-states must have gotten together for a massive blending of their minds. It must have been agreed upon early on that some form of government was needed.  So each city-state initially agreed to vote for a leader, or governor, or king, who served a term.  This governor made rules for the city-state, perhaps with the permission of a group of elder sages and a group of warriors.  With their guidance and permission they decided how to get the people to work together for the common good.  Then the king's term ended and another ruler was selected for that city-state. (Foster, page 46)

They put their ideas together and this resulted in a series of discoveries and inventions that made it easier to manage the lands.  They invented better tools for tilling the land and building structures.  They invented the potters wheel so making pottery was easier and quicker.  They learned how to build aqueducts and channels to manage the floods and flow of water through the land, and temples to house the gods and the people (the god's slaves).

Yet their would have been the development of individual pride and envy, and greed and lust, among the rulers of the people.  Then there would have been continuous disagreements among the assembly of elders. There would have been all out fights, sometimes to the death.  At some point there must have been a massive flood that destroyed all that had been made by the Sumerians, and one of these kings stepped forward to be the supreme ruler of all the land. Or perhaps there was an increase in the number of ox stolen by savages who were trying to feed their own families.

Regardless, one of these kings was granted supreme power over all the city states to get over some crisis.  After the crisis was over he probably gave back his power.  Yet there must have been one king whose ego grew so huge that he believed he could remain king forever.  He wanted to rule all of the then known world.  He refused to give back his power.  The gods and legends of his city-state became known to all of Sumeria, and the main god of his city-state moved to the head of the hierarchy of Mesopotamian gods.

The king of one of the other city-states was unhappy about being controlled by this one ruler, and his pride grew.  Perhaps this was the king of Urek.  He surreptitiously gathered his asspembly of elders, and he petitioned them to attack the ruling city-state, and defeat the supreme king.  But the assembly of elders, perhaps, refused to grant the king this power.  Yet the king refused to give in, so he had his men murder the members of the assembly who disagreed with him, and he sent his troops to war anyway.  He won battles in stunning fashion, perhaps surprising the ruling party.

To be continued...

References:  See post "2000 B.C.:  Assyrian physicians will treat your dyspnea"

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CDC dumping responsibility on the nurse is just wrong

Compliments of Happy Hospitalist
So a second nurse who worked with Thomas Duncan has been diagnosed with Ebola. Most of you probably already knew that. She needed to get home so she could make some preparations for an upcoming wedding, so she needed to fly from Dallas to Cleveland.

She knew she was in contact with Thomas Duncan, so she called the CDC to get approval to travel by air. She said she had a fever of 99.8 degrees, and because that was under the 100.4 degrees CDC officials say is necessary to diagnose and spread Ebola, they told her it was safe for her to fly.

Now that she has been diagnosed with Ebola CDC officials are blaming her, saying that she lied. So instead of blaming themselves, instead of taking responsibility for their own incompetence, they are blaming the nurse.

It's not the nurses and doctors who are incompetent, it is the people running the CDC who obviously have no clue what they are doing.  Nurses and doctors are ready and prepared to deal with critical situations in the manners in which they are trained.  If they have breached protocol, then it's the protocols that do not work.  They just make up numbers like 100.4, instead of using common sense. The protocols supercede common sense.

People need to realize that these people, the ones running government organizations like the CDC an CMS, are the ones who keep forcing hospitals to do this and to do that, and yet they have no medical experience whatsoever.  They are incompetent at what they are doing.

While CDC officials have said over and over that hospitals are ready for an Ebola patient, recent evidence shows otherwise.  Most hospitals do not have Hazmat suits, and, as Glenn Beck showed, even if CDC protocol is followed, the Ebola virus could easily contaminate nurses and doctors.

Most hospitals are not prepared, and it's not the fault of the hospitals, and not the fault of doctors and nurses.

At the present time there is no outbreak of Ebola in the U.S., only a few isolated incidences. However, the fact two nurses have become infected is evidence enough of the incompetence of the people running the CDC and their protocols.  It shows the idiocracy of their theories.

What we need to realize is that those running the CDC are basically nothing more than philosophers and theorists who sat around all their lives criticizing everything everyone else has accomplished thinking they could do better. But then they get into powerful positions and they force their ideas on healthcare workers thinking healthcare will get better, safer, and less costly.

Yet what we are realizing is that their theories have made medicine worse, less safe, and more costly. We are realizing that their theories do not work, that they are clueless about how to run healthcare, and it's dangerous.

What we need are common sense approaches to healthcare made by nurses and doctors, not philosophers and theorists. We need people with medical knowledge handling the Ebola, not another partisan politician being named Ebola Czar.

This makes me feel much safer, knowing that Ron Klain, who has absolutely no healthcare experience, is the Ebola Czar.  It makes me feel safe that our borders are open and, because we can't offend people, we have to keep them open.

(On a side note here, did you know we already had an Ebola Czar?)

Yet we don't find much common sense in healthcare these days.  Instead we have these theorists and philosophers running important organizations like the CDC during one of the most critical moments in our history.  It is blatantly obvious they have no clue what they are doing.

Now they are being called on their incompetence in allowing this nurse to get on an airplane, and so, instead of taking responsibility for their incompetence, they are blaming the nurse.  It's sad and scary to say the least. 

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Thursday, October 16, 2014

The impact of the Ebola scare on healthcare workers

How many lives will be lost before we close our borders,
as 10 nations already have, to Ebola stricken nations.
Failure in this regard might be the deadliest mistake
 our country ever made. A huge, or two-thirds majority,
of Americans agree with me that our border needs securing.
Two nurses in Dallas are now infected with the deadly virus,
and all we had to do to prevent this from occurring
was prevent flights from Africa from landing in the U.S.
Banning travel to and from infected nations
is something that could easily be done.
Update:  While the U.S. refuses to close its borders,
five west African nations are proud to say,
they have stopped the spread of the disease
by securing their own borders.

I get the influenza vaccine every year because I have asthma and it's highly recommended.  Yet I honestly don't feel safer as a result of getting it as even the Centers for Disease Control and Prevention (CDC) says it only reduces your chance of getting the flu by 15 percent.

The CDC says that, unlike other viral infections like the common cold, the influenza virus can cause "severe illness and life threatening complications." Yet while 5-20 percent of the population will get the disease each year, with 200,000 requiring hospitalizations, the death rate remains at 0.5 percent.

While it should be taken seriously, and surely we should all do our part to try to eliminate the spread of this disease during the course of our work and our daily lives, this 0.5 percent is nothing when you compare it with the Ebola virus.

Surely your likelihood of getting Ebola is nothing to your chances of getting influenza, although if the Ebola virus makes its way to your hospital, and you your skin comes in contact with the virus, you will in all likelihood get the disease.

They used to say that Ebola wasn't airborne, although now they are saying that it can be spread by droplets in the air.  For instance, if a person with Ebola coughs onto a surface, the Ebola virus can live for up to seven days, infecting any person who touches that surface.  So you could also get it this way.

This might explain why even people who have been wearing Hazmat suits have still contacted the Ebola virus.  You won't hear this in the news, but of the 4,447 reported deaths this year due to the Ebola virus, 233 of those were trained nurses and doctors.

This death rate among the medical community included highly trained doctors, such as the Medical Director of the two largest hospitals in Liberia.  The number includes United Nations doctors.  The number includes two healthcare workers from Doctors Without Borders teams.

Most, if not all, of these medical workers were wearing full Hazmat gear.  So could you imagine if this disease comes to a hospital near you?  Are you equipped with Hazmat gear?  Probably not.

We should also look at the positive side here.  It was reported that about 70 healthcare workers were in Thomas Duncan's room, and 68 of these did not get the disease.  Still, the fact that two did get the disease leads us to believe there are holes in whatever protocols were followed.

That said, the World Health Organization (WHO) now report that the Ebola virus death rate is up from 50 percent to 70 percent.

This means that of the 8914 people reported to be infected with the virus this year, 4,447 (including 233 healthcare workers) died.

Yet WHO also notes that these numbers are probably not even the real numbers. They say the real numbers are probably much higher due to difficulties in reporting.  In fact, back in August one cemetery worker in Sierra Leone said tons of bodies had been delivered to the cemetery he works for, yet the Sierra Leone Health Ministry had reported only 10 deaths

WHO also estimates that, if the disease is not under control soon, as many as 10,000 people may diagnosed with the disease per week by December.

I described the history of this disease in my post Ebola now in the U.S.  While there is certainly no reason to panic, it's not such a bad idea to bescared, especially those of us in the health care industry, as fear causes people to become prepared.

Based on initial reports coming from the nurses union at Texas Health Presbyterian Hospital Dallas where two nurses have now apparently contracted Ebola from a patient named Thomas Duncan who later died of the virus, there were many breeches in protocol at that hospital.  In fact, two weeks after the fact the hospital is apparently still not prepared.

Based on what we are hearing from those investigating the response at this hospital, one has to wonder if other hospitals are ready.  We must wonder if the U.S. is as ready as we have been told by the CDC.  We were told the U.S. was ready for it.  We are not.

A Detroit area hospital, which is near Detroit Metro Airport where patients with Ebola are most likely to fly into if their destination is Michigan, tested their Ebola response yesterday.  Perhaps this is something we will see more of in the days and weeks ahead.

In the meantime, our government should keep infected people from Libia and other infected nations from crossing our borders, and it must educate hospital personnel as to what needs to be done to prepare for the worse case scenario.

It should stop the nonsense of screening patients for the disease before they board airplanes, because obviously this system is not working.

Obviously people can get on airplanes before they show symptoms, they can lie about where they've been, and they can get across our porous borders. It's been done since the beginning of time, when people become infected you quarantine them.

Obviously the CDC, including its director Thomas Frieden, has no clue how to handle the disease. The outbreak was first reported by the CDC in march, and here we are in the middle of October and it still has no clue what to do. When he was working for Mayor Bloomberg he had no problem telling people they couldn't buy anything bigger than 16  ounces that contains Coke or Pepsi for their own good, but he can't restrict travel to prevent the spread of a deadly disease for our own good. This makes no sense to me.

We should not be politically correct by not banning flights just because of fear this might hurt the economy of a nation that was founded in the 1820s or 1830s because of American Slavery.  Nothing against the people of Liberia, but if the Ebola virus continues to find new hosts, more economies than just the Liberian economy will suffer.

In my opinion, saving lives trumps saving economies.  If we can save lives by restricting travel, it should be done.  Period!

Surely a pandemic in the United States or Europe is unlikely, and we should keep it that way by restricting travel to West Africa.  At least ten other countries have already done it, and it can easily be done here too.  Even people who previously championed against restricting travel are now opposed to it.

For some reason, those responsible for preventing an Ebola outbreak in the U.S. are asleep at the switch, and it's scary sad.  Yet fear not, because we got our flu shots.

Here is a demonstration of how CDC recommended protocol may not prevent the spread of the disease.

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Wednesday, October 15, 2014

Studies conclude: Atrovent can't hurt

There does appear to be evidence that supports the theory that giving ipatropium bromide (Atrovent) for the treatment of asthma and COPD flare-ups in the emergency setting may be beneficial.

According to Aaron SD et al in 2001, the following results were discovered:
  • Data from 10 studies of adult asthmatics, reporting on a total of 1377 patients, were pooled in a meta-analysis using a weighted-average method. Use of nebulized ipratropium/beta2-agonist combination therapy was associated with a pooled 7.3% improvement in forced expiratory volume in 1 sec and a 22.1% improvement in peak expiratory flow compared with patients who received beta2-agonist without ipratropium. 
  • Similarly, randomized controlled studies of pediatric asthma exacerbation and a meta-analysis of pediatric asthma patients suggest that ipratropium added to beta2-agonists improves lung function and also decreases hospitalization rates, especially among children with severe exacerbations of asthma. 
  • The adult and pediatric studies did not report any severe adverse effects attributable to ipratropium when it was used in conjunction with beta2-agonists.
  • In conclusion, there is a modest statistical improvement in airflow obstruction when ipratropium is used as an adjunctive to beta2-agonists for the treatment of acute asthma exacerbation. In pediatric asthma exacerbation, use of ipratropium also appears to improve clinical outcomes; however, this has not been definitively established in adults. It would seem reasonable to recommend the use of combination ipratropium/beta2-agonist therapy in acute asthmatic exacerbation, since the addition of ipratropium seems to provide physiological evidence of benefit without risk of adverse effects. (1)
In a comparison of Ventolin given without Atrovent and Ventolin given with Atrovent, Watanasomsiri A1, Phipatanakul W. concluded:
Of 74 children randomized and enrolled in the trial, 71 had complete data for analysis. Thirty-three children were in the control group and 38 were in the treatment group. Both the percent change in PEFR and the change in percent predicted PEFR at any time were higher in the treatment group, but these findings were not statistically significantly different. The number of subjects with at least a 100% percent predicted PEFR at any time point was greater in the treatment group. (2)
They concluded:
Although this study did not demonstrate a significant advantage in clinical score and PEFR, the trend toward additional effect of ipratropium bromide was consistent with previous studies. (2)
In comparing treatments with ipatropium bromide alone, or albuterol alone, or both together, Ward et al concluded:
The two drugs in sequence produced greater bronchodilatation than either used alone, and the mean peak expiratory flow rate rose by 96% in four hours. Thus giving ipratropium bromide in addition to salbutamol in severe asthma enhances the bronchodilator effect. (3)
The bottom line here is that, while there is no conclusive evidence atrovent will help with acute exacerbations of asthma, side effects are negligible.  That seems to be the mantra for using most respiratory medications: it can't hurt.

Both medicines have received an expanded role, for not only are they prescribed together (usually in the form of Duoneb) for asthma patients, they are prescribed together for nearly all lung ailments, including those not proven to benefit from this type of therapy.

There are some physicians who will allow the respiratory therapist to limit the frequency of atrovent to every four hours.  However, there are many physicians who order Duoneb even for continuous breathing treatments.

So what are your thoughts?

References:
  1. Aaron, SD, "The use of ipratropium bromide for the management of acute asthma exacerbation in adults and children: a systematic review," Journal of Asthma, October, 2001, 38 (7), pages 521-530, accessed on 5/18/14 http://www.ncbi.nlm.nih.gov/pubmed/11714074
  2. Watanasomsiri A1, Phipatanakul W., "Comparison of nebulized ipratropium bromide with salbutamol vs salbutamol alone in acute asthma exacerbation in children," Anal of Allergy, Asthma and Immunology, May, 2006, 96 (5), pages 701-706, accessed 5/18/14, http://www.ncbi.nlm.nih.gov/pubmed/16729783
  3. Ward, M.J., P.H. Fentem, W.H. Smith, and D. Davies, "Ipatropium Bromide in Acute Asthma," British Medical Journal, Feb. 21, 1981, 282 (6264), pages 598-600, accessed 5/18/14, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1504444/