Tag: treatment

The Fly in the Currant Cake

barnstormingblog46 Comments

Nothing seems to please a fly so much as to be taken for a currant;
and if it can be baked in a cake and palmed off on the unwary, it dies happy.
~Mark Twain

Today I will wrap up 45 years of uninterrupted training and doctoring. Most of that time, I have worried I’m like a fly hiding among the black currants hoping to eventually become part of the currant cake. 

Maybe no one has noticed. These days we call it the “impostor” syndrome. Mark Twain knew all about currant cake and how easy it was for a fly to blend into its batter.

Even while bearing three children and going through a few surgeries myself, I’ve not been away from patients for more than twenty consecutive days at any one time.  This is primarily out of my concern that, even after a few weeks, I would forget all that I’ve ever known. In fact, half of what I learned in medical school and residency over forty years ago has evolved, thanks to new discoveries and clarifying research. I worried if I were to actually to step away from doctoring for an extended time, then return to see patients again, I would be masquerading as a physician rather than be the real thing. A mere fly among the currants palmed off on the unwary.

If being truly honest, those who spend their professional lives providing medical care to others always share this concern: if a patient only knew how much we don’t know and will never know, despite everything we DO know, there would really be no trust left for us at all.

Of course, some say, didn’t the COVID pandemic prove our ignorance? Physicians started at Ground Zero with a novel virus with unclear transmissibility and immense potential to wreak havoc on the human body … or cause no symptoms whatsoever. We had no collected data to base prevention or treatment decisions: would masks just protect others or would they only protect ourselves, or maybe they protect both? Could a common inexpensive anti-inflammatory/antimalarial drug be beneficial or would a parasitic wormer medication be somehow effective to fight the devastation of the virus?

Effective treatments are still being sought all these months later; others have been debated, studied and discarded as worthless.

Or would this pandemic finally resolve thanks to effective yet controversial public health mandates while rapidly distributing highly effective vaccines developed from many prior years of carefully performed research?

During the past 16 months, your next door neighbor, or the loudest tweet on Twitter proclaimed more expertise than the average medical professional and definitely had a stronger opinion. At least we doctors knew how much we didn’t know and how much was simply guess work based on experience, good intentions and hopeful prayer. Gradually, while lives were lost, including too many of our own, real data began to trickle in so decisions could be made with some evidence backing them. But even that data continues to evolve, day by day, as authentic medical evidence always does.

That doesn’t stop all the “quack” flies out there from climbing into the batter pretending to be currants. With so much rapidly changing medical information at everyone’s fingertips, who needs a trained physician when there are so many other resources – sketchy and opportunistic though they may be – for seeking health care advice?

Even so, I am convinced most patients really do care that doctors share the best information they have available at any point in time. None of us who are doctoring wants to be the “fly” in the batter of health care.

As I meet with my last patient today, I know over forty years of clinical experience has given me an eye and an ear for the subtle signs and symptoms that no googled website or internet doc-in-the-box can discern.  The avoidance of eye contact, the tremble of the lip as they speak, the barely palpable rash, the hardly discernible extra heart sound, the fullness over an ovary, the slight squeak in a lung base.  These are things I am privileged to see and hear and about which I make decisions together with my patients.  What I’ve done over four decades has been no masquerade; out of my natural caution, I am not appearing to be someone I am not.  This is what I was trained to do and have done for thousands of days and many more thousands of patients during my professional life, while passing a comprehensive certification examination every few years to prove my continued study and changing fund of knowledge.

The hidden fly in the currant bush of health care may be disguised enough that an unwary patient might gobble it down to their ultimate detriment. I know I’ve not been that doctor. I’ve been the real thing all these years for my patients, even if I’ve seemed a bit on the tart side at times, yet offering up just enough tang to be exactly what was needed in the moment and in the long term.

And someday, hopefully not too soon, I will die happy having done this with my life.

My ID photo from my first year of medical school 1976
45 years later…

A new book from Barnstorming is available to order here:

A Prescription for Maggots

barnstormingblog3 Comments

You can’t say you haven’t been warned: there are creepy crawlies in this post

Things I will never like:
1. Drying off with a cold, damp towel.
2. The feeling of seaweed wrapping around my legs.
3. Anything that was popular in the 70’s.
4. Licorice, yam, or raisins.
5. That high-pitched screech that babies make.
6. Writhing maggots.
~Bill Watterson from It’s A Magical World: A Calvin and Hobbes Collection

A fly maggot photo from a recent Atlantic article on maggot therapy found here

A few weeks ago, I had a bit of home-made potato corn chowder left over that I added to our compost bin in our barnyard. It isn’t often that much animal protein makes its way into the bin so when I checked on the compost a few days later, I was amazed to see it teeming with fly maggots in the midst of their Thanksgiving feast. Ordinarily pictures and videos of maggots would not find their way to this blog. People might be looking at this blog while eating their breakfast or lunch and writhing maggots are not something you are expecting to see. My apologies in advance and now is the time to delete delete delete.

Therefore: a trigger warning. Don’t scroll down further if you would rather avoid seeing (and hearing) creepy crawly things.

My first medical exposure to maggots came while examining the leg and foot wounds of the homeless folks I helped care for when training in an inner city emergency room. Peeling off old ragged stockings and socks would often reveal more than dirty feet – in fact, the maggots may have been somewhat beneficial in those cases yet we were quick to dispose of them.

Maggots are, in fact, fascinating creatures with potential therapeutic value, notwithstanding their gross-out factor. This week in a brief Atlantic article found here, there is a summary of a recent study in France comparing typical surgical debridement of venous ulcers of the skin with maggot therapy. Maggots were faster in cleaning the wounds but didn’t enhance eventual healing any more than traditional surgical care. There wasn’t a difference in the discomfort level as long as the patient didn’t know which therapy was being used. For those who had been randomly assigned to maggot therapy in one study, an astounding 89% said they would opt for the insects over surgeons if faced with needing wound care in the future.

I’m not sure what that says about surgeons, but it is a great compliment to maggot larvae!

Here is a formal cross-referenced evidence-based summary from UptoDate.com about wound treatment with biologic methods:

Biologic — An additional method of wound debridement uses the larvae of the Australian sheep blow fly (Lucilia [Phaenicia] cuprina) or green bottle fly (Lucilia [Phaenicia] sericata, Medical Maggots) [42,43]. Maggot therapy can be used as a bridge between debridement procedures, or for debridement of chronic wounds when surgical debridement is not available or cannot be performed [44]. Maggot therapy may also reduce the duration of antibiotic therapy in some patients [16].

Maggot therapy has been used in the treatment of pressure ulcers [45,46], chronic venous ulceration [47-50], diabetic ulcers [42,51], and other acute and chronic wounds [52]. The larvae secrete proteolytic enzymes that liquefy necrotic tissue, which is subsequently ingested while leaving healthy tissue intact. Basic and clinical research suggests that maggot therapy has additional benefits, including antimicrobial action and stimulation of wound healing [43,47,53,54]. However, randomized trials have not found consistent reductions in the time to wound healing compared with standard wound therapy (eg, debridement, hydrogel, moist dressings) [55,56]. Maggot therapy appears to be at least equivalent to hydrogel in terms of cost [56,57].

Dressing changes include the application of a perimeter dressing and a cover dressing of mesh (chiffon) that helps direct the larvae into the wound and limits their migration (movie 1). Larvae are generally changed every 48 to 72 hours. One study that evaluated maggot therapy in chronic venous wounds found no advantage to continuing maggot therapy beyond one week [48]. Patients were randomly assigned to maggot therapy (n = 58) or conventional treatment (n = 61). The difference in the slough percentage was significantly increased in the maggot therapy group compared with the control groups at day 8 (67 versus 55 percent), but not at 15 or 30 days.

The larvae can also be applied within a prefabricated “biobag”, commercially available outside the United States, that facilitates application and dressing change [58-61]. Randomized trials comparing “free range” with “biobag”-contained larvae in the debridement of wounds have not been performed.

A main disadvantage of maggot therapy relates to negative perceptions about its use by patients and staff. One concern among patients is the possibility that the larvae can escape the dressing, although this rarely occurs. Although one study identified that approximately 50 percent of patients indicated they would prefer conventional wound therapy over maggot therapy, 89 percent of the patients randomly assigned to maggot therapy said they would undergo larval treatment again [62]. Perceived pain or discomfort with the dressings associated with maggot therapy may limit its use in approximately 20 percent of patients.

Biobag of maggots on a wound from http://www.uptodate.com

The STARZ show Outlander (a show and series of books by scientist Diana Gabaldon I thoroughly enjoy) used real maggots in the fifth season of the show when in 18th century America, wife (and surgeon) Claire successfully treats her husband Jamie’s snakebite wound with the larvae. Actress Caitriona Balfe describes her co-starring maggots in this brief video:

image from Starz – Outlander Season 5 Episode 9
image from Starz – Outlander Season 5 Episode 9

So there are still things to learn about medical therapies we used in the past which have been sidelined or forgotten in our push for modern treatment modalities. The days of leeches and maggots may not be over after all.

And now for video, complete with little maggotty sound effects — scroll down

Maggots in our compost bin – enjoying corn and potato chowder leftovers

A new book from Barnstorming is available to order here

(no maggot pictures in this book, I promise!)

Returning on Foot

barnstormingblog3 Comments

foggy827183

 

oaklane6

 

They work with herbs
and penicillin.
They work with gentleness
and the scalpel.
They dig out the cancer,
close an incision
and say a prayer
to the poverty of the skin.

…they are only human
trying to fix up a human.
Many humans die.

But all along the doctors remember:
First do no harm.
They would kiss if it would heal.
It would not heal.

If the doctors cure
then the sun sees it.
If the doctors kill
then the earth hides it.
The doctors should fear arrogance
more than cardiac arrest.
If they are too proud,
and some are,
then they leave home on horseback
but God returns them on foot.
~Anne Sexton “Doctors” from The Awful Rowing Toward God.

 

harvestmoon

 

cloudsandponies2

 

Let me not forget how humbling it is
to provide care for a hurting person
and not be certain that what I suggest
will actually work,

to be trusted to recommend the best option
among many~
including tincture of time,
wait and see,
try this or that.

Like other physicians who tumble off
at a full gallop, having lost balance
between confidence and humility,
I sometimes find myself unseated and unsettled,
returning on foot to try again to make a difference.

 

 

sunsettony2

 

sunsetnatetomomi

 

 

 

 

Obscurity in Medicine

barnstormingblog2 Comments

photo by Josh Scholten

Be obscure clearly.
~E. B. White

As a family doctor, I work at clarifying obscurity about the human condition daily, dependent on my patients to communicate the information I need to make a sound diagnosis and treatment recommendation.  To begin with, there is much that is still unknown and difficult to understand about psychology, physiology and anatomy.  Then throw in a disease process or two or three to complicate what appears to be “normal”, and further consider the side effects and complications of various treatments — even evidence-based decision making isn’t equipped to reflect perfectly the best and only solution to a problem.  Sometimes the solution is very muddy, not at all pristine and clear.
Let’s face the lack of facts.  A physician’s clinical work is obscure even on the best of days when everything goes well.  We hope our patients can communicate their concerns as clearly as possible, reflecting accurately what is happening with their health.  In a typical clinic day we see things we’ve never seen before, must expect the unexpected, learn things we never thought we’d need to know, attempt to make the better choice between competing treatment alternatives, unlearn things we thought were gospel truth but have just been disproved by the latest double blind controlled study which may later be reversed by a newer study.   Our footing is quicksand much of the time even though our patients trust we are giving them rock-solid advice based on a foundation of truth learned over years of education and training.   Add in medical decision-making that is driven by cultural, political or financial outcomes rather than what works best for the individual, and our clinical clarity becomes even further obscured.

Over thirty years of doctoring in the midst of the mystery of medicine — learning, unlearning, listening, discerning, explaining, guessing, hoping,  along with a little silent praying — has taught me the humility that any good clinician must have when making decisions with and about patients.  What works well for one patient may not be at all appropriate for another despite what the evidence says or what an insurance company or the government is willing to pay for.  Each person we work with deserves the clarity of a fresh look and perspective, to be “known” and understood for their unique circumstances rather than treated by cook-book algorithm.  The complex reality of health care reform may dictate something quite different.

The future of medicine is dependent on finding clarifying solutions to help unmuddy the health care decisions our patients face. We have entered a time of information technology that is unparalleled in bringing improved communication between clinicians and patients because of more easily shared electronic records.  The pitfall of not knowing what work up was previously done will be a thing of the past.  The risk and cost of redundant procedures can be avoided.  The patient shares responsibility for maintenance of their medical records and assists the diagnostic process by providing online symptom and outcomes documentation.   The benefit of this shared record is not that all the muddiness in medicine is eliminated, but that an enhanced transparent partnership between clinician and patient develops,  reflecting a relationship able to transcend the unknowns.

So we can be obscure clearly.   Lives depend on it.