Your tonsils are glands on each side of the back of the throat. Their job is to help trap bacteria and other germs that cause infections. Sometimes, however, they can become infected themselves, a condition known as “tonsillitis“. Most cases of tonsillitis are caused by viruses, but bacteria may also be the culprit. The average age is between 5 and 15 years old.
Once, tonsils were commonly removed (known as “tonsillectomy”) in young children at the first sign of infection. In the 21st century, the procedure is much less common. Recurrent bacterial infections or severe symptoms may still require removal, a simple procedure (see link) in the hands of an experienced provider, but difficult for the family medic. The best option, therefore, in austere settings is identifying and treating as early as possible.
(Note: I had my tonsils removed at age 5. At least they gave me some ice cream afterwards! Joe Alton, MD)
Use of a tongue depressor helps visualize the area. Common signs and symptoms of tonsillitis include:
• Red, swollen tonsils
• White or yellow coating or patches on the tonsils
• Sore throat
• Difficult or painful swallowing
• Enlarged, tender glands (lymph nodes) in the neck
• A scratchy, muffled or throaty voice
• Bad breath
Since tonsillitis is often seen in children too young to give a good history, look for:
Loss of appetite
difficult or painful swallowing
Drooling or difficulty breathing (signs of a severe case)
Treating someone with tonsillitis can include some of the following:
A soft diet
Acetaminophen or ibuprofen is helpful for pain, but aspirin should be avoided in children due to Reye’s Syndrome.
Although viral tonsillitis isn’t improved with antibiotics, Penicillin or amoxicillin works for bacterial infections if taken by mouth for ten days. If Penicillin is not an option due to allergy, azithromycin may be substituted. These drugs are available in veterinary equivalents at fishmoxfishflex.com.
Amoxicillin 500-875 mg orally twice a day or 250-500 mg orally every 8 hours for 10 days
Penicillin V 500 mg orally twice a day for 10 days or 250 mg orally four times a day for 10 days
Azithromycin 500 mg orally once a day for 5 days
Penicillin V 25-50 mg/kg/day divided by four and given every 6 hours for 10 days
Amoxicillin 50 mg/kg/day orally in 2 or 3 divided doses for 10 days
Food contamination is a constant concern in the United States, especially from imported produce. In normal times, U.S. citizens take for granted the ability to buy bananas in Montana in February. As long as we import food, we must be especially careful to eliminate subtropical and tropical pathogens from our food.
A number of different disease-causing organisms especially put humans at risk; one of these is Cyclospora cayetanensis. From May to late August, 2020, more than 1100 laboratory-confirmed cases of food contamination due to Cyclospora (known as cyclosporiasis) were reported in 34 states. In most cases, fresh imported produce, especially greens and vegetables, were identified as likely origins.
Cyclospora is a one-celled parasite that is a natural inhabitant of the tropics and subtropics, where it seems to cause outbreaks that are seasonal in nature. The U.S. cases, however, occurred in people who had not recently visited the tropics before symptoms began.
THE LIFE CYCLE OF CYCLOSPORA
Cyclospora is spread by people ingesting food or water contaminated with feces containing Cyclospora oocysts (essentially a thick-walled fertilized ovum). Unlike some similar parasites, however, the oocyst needs time (usually, at least 1–2 weeks) after being passed in a bowel movement to become infectious. Therefore, it’s unlikely that Cyclospora can be passed directly from one person to another. More likely, the oocysts contaminate crops or water sources.
SYMPTOMS OF CYCLOSPORIASIS
Exactly how food and water becomes contaminated with Cyclospora oocysts isn’t fully understood but, once the oocysts “hatch” in the human body, the microbes enter the intestinal wall. Some symptoms then begin to manifest. They start an average of 7 days after ingestion of the infective version of the oocyst and can include the following:
Watery diarrhea (most common)
Loss of appetite
Bloating, increased gas
Nausea and vomiting
A typical case would cause watery diarrhea, with frequent, sometimes explosive, bowel movements. Vomiting, body aches, headache, fever, and other flu-like symptoms may be noted. Interestingly, some people infected with Cyclospora have no symptoms at all.
If untreated, the illness endures for a few days, but some cases last a month. Some victims experience improvement and then relapse several times during the progress of the infection. Although not life-threatening, long-term fatigue and other problems are a possibility.
Once the organism is identified in a stool sample, cyclosporiasis can be effectively treated with the combination sulfa drug trimethoprim-sulfamethoxazole (TMP-SMX). The usual regimen for adults is trimethoprim (TMP) 160 mg plus sulfamethoxazole (SMX) 800 mg (one double-strength tablet) twice daily for 7–10 days. The veterinary equivalent is FISH-SULFA FORTE. No effective alternatives have been identified yet for those allergic to sulfa drugs. In this case, most immune-competent people will recover without treatment and with good hydration.
Avoiding any food or water that might be contaminated with feces is the best way to prevent infection. Routine chemical disinfection is less effective for Cyclospora than for most other bacteria or parasites.
1)Washing hands with soap and warm water after touching fruits and vegetables. Also, be sure to clean cutting boards, dishes, utensils, and counter tops between the preparation of meat, poultry, and seafood and fruits and vegetables.
2)Preparing all fruits and vegetables thoroughly under running water before eating, cutting, or cooking. Remove any damaged or bruised areas on fruits and vegetables. Firm items like cucumbers or melons should be scrubbed with a clean brush dedicated to the purpose.
3)Storing properly by refrigerating cut, peeled, or cooked fruits and vegetables within two hours (preferable sooner). Separate the storage of fruits and vegetables and raw meat, poultry, and seafood.
It should be noted that routine chemical disinfection is less effective for Cyclospora than for most other bacteria or parasites. No vaccine exists and immunity isn’t long-term: Recurrence of infection is not uncommon if re-exposed.
Summer is here with a vengeance and parts of the Midwest and Southern U.S. are experiencing record high temperatures in major heat waves. Officials predict a high-risk situation for 200 million citizens as places as far north as Buffalo, NY hit 90 degrees Fahrenheit for a week straight, while Pheonix, Arizona will have multiple days in the 110s. The air temperature in Death Valley, California may reach as high as 125 degrees.
Even in places where the air temperature isn’t as high, the “heat index” is surpassing the 90s, 100s, and the 110s. The heat index is a measure of the effects of air temperature combined with high humidity. Above 60% relative humidity, loss of heat by perspiration is impaired and exposure to full sun increases the reported heat index by as much as 10-15 degrees F. All this increases the chances of heat-related illness such as heat stroke and heat exhaustion.
In the next few weeks, we can expect the power grid to be challenged by tens of millions of air conditioning units set on “high”. Major health issues may arise if the electricity goes out and people have to fight the heat with hand fans, like they did in the “good old days”.
Things are even worse in the city. Buildings and roads replace open land and vegetation. Concrete and asphalt surfaces in the sun become much hotter than air temperature, resulting in a “heat island” effect in large populated areas. Rural areas are more moist and cool, leading to less heat-related emergencies.
Another factor may increase the risk of heat-related emergencies. Homes without air conditioning will not only become sweatboxes, but many people cooped up in closed environments are a recipe to increase the number of COVID-19 cases (so much for the summer giving us a break from the pandemic).
HEAT WAVES ARE NATURAL DISASTERS
You might not consider a heat wave to be a natural disaster, but it most certainly is. Heat waves can cause mass casualties, as it did in Europe when tens of thousands died of exposure (not in the Middle Ages, but in 2003). India, Pakistan, and other underdeveloped tropical countries experience thousands of heat-related deaths yearly.
HOW HEAT KILLS
So how exactly does heat kill a person? Your body core regulates its temperature for optimal organ function. When core body temperature rises excessively (known as “hyperthermia”), inflammation occurs, cells die, and toxins leak. Fatalities can occur very quickly without rapid intervention. Even with modern technology, hyperthermia carries a 10% death rate, mostly in the elderly and infirm. Those who are physically fit, however, are not immune.
HEAT EXHAUSTION AND HEAT STROKE
The ill effects due to overheating are called “heat exhaustion” if mild to moderate; if severe, these effects are referred to as “heat stroke”. Heat exhaustion usually does not result in permanent damage, but heat stroke does; indeed, it can permanently disable or even kill its victim. It’s a medical emergency that must be diagnosed and treated promptly.
Simply having muscle cramps or a fainting spell doesn’t necessarily signify an imminent heat-related medical emergency. You will see “heat cramps” often in children that have been running around on a hot day. Getting them out of the sun, massaging the affected muscles, and providing hydration will usually resolve the problem.
Heat exhaustion’s signs and symptoms include:
Nausea and vomiting
Temperature elevation up to 105 degrees F
If no action is taken to cool the victim, they could easily progress to heat stroke. In addition to all the possible signs and symptoms of heat exhaustion, heat stroke will manifest as loss of consciousness, seizures or even bleeding (seen in the urine or vomit). Breathing becomes rapid and shallow. Shock and organ malfunction may ensue, possibly leading to death.
In heat stroke, the skin is likely to be red and hot to the touch, but dry; sweating might be absent. Once the body core hits 105 degrees or more (it varies from person to person), thermoregulation breaks down and the body’s ability to use sweating as a natural temperature regulator fails. In heat stroke, the body core can rise as high as 110 degrees Fahrenheit or more.
(Aside: The highest body temperature ever recorded was 115 degrees: On July 10, 1980, 52-year-old heatstroke victim Willie Jones of Atlanta was admitted to the hospital with a temperature of 115 degrees Fahrenheit. He spent 24 days in the hospital and recovered.)
In some circumstances, the victim’s skin may actually seem cool. Despite feeling “clammy” to the touch, it’s important to realize that it is the body core temperature that’s elevated. You could be misled unless you take readings with a thermometer to reveal the patient’s true status.
When overheated patients are no longer able to cool themselves, it is up to their rescuers to do the job. If hyperthermia is suspected, the victim should immediately:
Be removed from the heat source (for example, out of the sun).
Have their clothing removed.
Be drenched in cool water (with ice, if available)
Have their legs elevated above the level of their heart (the shock position)
Be fanned or otherwise ventilated to help with heat evaporation
Have moist cold compresses placed in the neck, armpit and groin areas
Why the neck, armpit and groin? Major blood vessels pass close to the skin in these areas, and cold packs will more efficiently cool the body core. Recent studies by the military suggest that cold packs to feet and hands are also helpful.
Oral rehydration is useful to replace fluids lost, but only if the patient is awake and alert. If your patient has altered mental status, he or she might “swallow” the fluid into their airways; this is known as “aspiration” and causes damage to the lungs.
Heat stroke is preventable in many cases. The Arizona department of health recommends the following:
Drink at least 2 liters (about a half-gallon) of water per day if you are mostly indoors and 1 to 2 additional liters for every hour of outdoor time. Drink before you feel thirsty, and avoid alcohol and caffeine.
Wear lightweight, light-colored clothing and use a sun hat or an umbrella to deflect the sun’s rays. Use sunscreen if available.
Eat smaller, more frequent meals instead of large ones.
Avoid strenuous activity.
Stay indoors as much as possible.
Take regular breaks if you exert yourself on warm days.
In a heat wave, it’s important to check on the elderly, the very young, and the infirm regularly and often. These people have more difficulty seeking help, and you might just save a life if you’re vigilant. You can bet there’ll be more than one heat wave this summer, so know the warning signs and how to help those with hyperthermia.
In my recent article “Suture Basics For The Off-Grid Medic “, I gave some thoughts on suture materials, especially as they apply to closing skin lacerations. Your skin is your armor, and anything that breaches it can cause a life-threatening infection.
Although the decision to close a wound should never be automatic, simple skin lacerations can often be cleaned and closed successfully by the off-grid medic. Sutures are just one of a number of ways to accomplish this goal and allow acceleration of the healing process. Today, we’ll discuss the qualities of suture needles.
(Note: This article is for educational purposes only. If the medical system in your area is intact, seek it out to treat lacerations or other medical issues!)
Suture needles are made of a corrosion-resistant stainless steel alloy that is sometimes coated with silicone to permit easier tissue penetration.
A suture needle has three sections: the point, the midportion or body, and the swage. The swage is the “end” of the needle and is where the thread is attached. The midportion is usually curved at an arc, and the point is, well, pointy.
Before about 1920, suture needles had “eyes” and string was separate; the surgeon had to thread the eye of the needle. Since then, sutures became a single continuous unit. This process of connecting suture needle and string is called “swaging”.
Swaging dealt with a number of disadvantages associated with using separate needles and thread. In the old method, two lengths of string were formed on either side of the eye. Passage of a double strand of suture through tissue led to more tissue trauma and, perhaps, a higher risk of infection. Also, the suture string was more likely to become unthreaded or frayed.
THE IDEAL SUTURE NEEDLE
Suture needles perform based on a number of qualities, including strength and sharpness. The strength of a needle refers to its resistance to deformation during use, limiting the amount of trauma to tissue. Sharpness measures the ease of penetration into tissue and is dependent on factors involving not only the point, but the shape of the body of the needle.
Just as suture thread has ideal characteristics, the effective suture needle would be:
Made of high-quality stainless steel
The smallest diameter possible
Stable in the grasp of the needle holder
Capable of running suture material through tissue with minimal trauma
Sharp enough to penetrate tissue with minimal resistance
Sterile and corrosion-resistant to prevent introduction of microorganisms or foreign materials into the wound
Rigid enough to go through tissue, but flexible enough to bend before breaking
Not all suture needles meet the above criteria, but will suffice for the basic needs of the medic.
There are a number of different needle types variations at the point, body, and swaged end:
Cutting Needles: The shape of the suture needle on cross-section may vary dependent on the particular need. The point of this shape to have more cutting edges. On cross section, it appears triangular. These needles are effective in penetrating thick, firm tissue, like skin.
There are two common types of cutting needles. “conventional” and “reverse”. Conventional cutting needles have the third edge of the “triangle” on the inner surface of the needle. Reverse cutting needles have the third edge of the triangle on the outer surface of the needle’s arc. The reverse edge is even stronger and able to penetrate tendons and other tough tissues, while decreasing the amount of trauma during the procedure.
Tapered Needles: These needles are round on cross-section and can pass through tissue by stretching more than cutting. A sharp tip at the point becomes round, oval, or square shape as you approach the swage. The taper-point needle minimizes trauma in delicate and easily-penetrated tissues such as organs or intestinal lining.
Blunt Needles: These don’t come to a sharp point, but are rounded at the end. These are best used for suturing liver, kidney, and other delicate organ tissue without causing excessive bleeding.
The body of a needle is important for interaction with the needle holder instrument and the ability to easily transfer penetrating force to the skin. A needle must be stable in the jaws of the needle holder to give maximum control and prevent bending.
The midportion comprises most of the needle’s length and is commonly curved into a 3/8 circle arc for skin or 1/2 circle for close spaces. Of course, other curvatures are available. Straight needles may be used if dealing with easy-to-reach tissues such as certain types of skin closures.
Next time, we’ll discuss the instruments you’ll use when closing a laceration with sutures.
COVID-19 cases may again be on the rise as a second wave of infections coincide with the reopening of many businesses throughout the United States.
Perhaps the first thing I should mention is that a second wave is going to occur as society reopened. I repeat: Regardless of the timing or the measures taken, at one point or another there is going to be a second spike in cases. This is to be expected; It’s what many pandemics do. Health officials and political policies can do little to stop it.
If we look at previous infectious disease outbreaks, like the Spanish Flu of a century ago, it’s clear that there were, not two, but three waves in Spring and Fall of 1918 and winter of 1918-19. Each wave claimed its share of victims.
Most health officials have long stated that more cases are expected. Social distancing, face coverings, and other important measures to prevent spread of infection may be breaking down. In some cases, it’s because of what I call “COVID fatigue”. People are weary of staying home, donning personal protection equipment, and avoiding the restaurants, movie theaters, malls, and other staples of normal American society. The New Normal compares poorly to the “good old days”.
Even for those who have adjusted to pandemic prevention guidelines, current headlines have sparked nationwide mass protests which are spilling over internationally. As you can imagine, large demonstrations don’t follow the rules of social distancing and hamper efforts to stop the spread of infection.
Public policy may also play a part. Reopening too quickly due to COVID fatigue-fueled anger may cause large numbers of new cases, while staying in semi-permanent lockdown must eventually throw the nation into a major economic depression. The balance is so delicate that a perfect solution is almost impossible to achieve. Either option is fraught with risk.
All of the above factors make it more likely that a second wave will be significant, but how significant? Will we see just a ripple in the pond or a massive tidal wave?
Others aren’t as pessimistic. Columbia University virologist Dr. Vincent Racaniello said, “I’m hoping we can continue our lives without having to go back into quarantine in the fall, because we’ve learned that distancing and face masks can really make a difference.”
Indeed, we have learned much about SARS-CoV2, the virus behind the COVID-19 pandemic. Besides social distancing, we have come to realize the importance of mass testing, and keeping close track of contacts. With a contagious disease, we have to know who is capable of spreading it. With workplaces beginning to reopen, this information becomes essential.
We have also realized the importance of having personal protection items in our medical kits. Surgical and N95 masks are considered to be for medical workers only, leaving the average citizens with a limited array of less-effective cloth coverings. These were endorsed by health officials, but only because of the lack of standard supplies.
Yet, many folks ended up becoming “medical workers” when someone in the family came down with a mild to moderate case of COVID-19. You can bet that there will be more face masks to go around in future outbreaks; many of these will be made in the U.S.A…(continues)
Many animals, (insects, spiders, shrimp, crabs) have an exoskeleton as a protective covering. Humans have their skeleton on the inside, so we depend on the largest organ of the body, our skin, instead.
Skin represents the armor that protects the body from invasion by debris and microbes. A breach in that armor increases the chance of infection that may spread throughout (called “sepsis”) and become life-threatening.
As such, there are circumstances where a break in the skin should be closed with materials known as sutures. The decision to close skin should not be automatic and depends on many factors (discussed in previous articles on this site). Once that decision is made, however, the correct choice of suture material impacts the strength and effectiveness of the healing process.
THE IDEAL SUTURE
All wound closure methods have their advantages and disadvantages. Your choice should depend on the careful evaluation of the wound, as well as an understanding of the properties of a given suture material.
The optimal suture should be:
· Easy to use
· Strong enough to hold wound edges together
· Able to retain strength for the time needed to heal
· Unlikely to cause infection, tissue reaction, or significant scarring
· Reliable in its everyday use with every type of wound
It’s difficult to find a single suture type that meets all of the above criteria, but there are many that will do if chosen properly.
The time needed for healing should impact the choice of suture materials. The interval it takes for a tissue to no longer require support from sutures will vary depending on tissue type:
Days: Muscle, subcutaneous tissue like fat, and skin
Subcutaneous tissue is sometimes called the “hypoderm”. It’s connected to the deep layer of skin (the “dermis”). The skin and muscle in many areas of the body are separated by a layer of subcutaneous fat. Fat will appear as yellowish globules below the whitish dermis.
Weeks to Months: Fascia or tendons
Fascia is connective tissue beneath the skin that attaches, covers, stabilizes, and compartmentalizes muscles and other internal organs. A tendon is connective tissue attaching a muscle to a bone.
CATEGORIZING SUTURE DIAMETERS
Around a century ago, the average suture consisted of a needle through which a separate string was threaded. This method was used for thousands of years until the process of swaging was invented. A swaged suture has the thread built into the blunt end of the needle, making surgical sutures a single unit for the first time.
In the United States and many other countries, a standard classification of sutures has been in place since the 1930s. This classification identifies stitches by type of material and size of the “thread”.
The first manufactured sutures were given sizes from #1 (thinnest) to #6 (thickest). #4 suture would approximate the string on a tennis racquet.
As technology advanced, even thinner sutures were produced that were titled beginning at 0 (pronounced “oh”). Just like double-ought buckshot is bigger than triple-ought, 2-0 (pronounced “two-oh”) suture is thicker than 3-0 (pronounced “three-oh”). If you are doing microsurgery, you’re going down all the way to 8-0, 9-0, or 10-0. Size 7-0 is about the diameter of a human hair.
The suture thread used should be the smallest size which will give adequate tensile strength to keep skin together. Finer sutures have less tissue reaction but are more difficult to handle for the inexperienced. The off-grid medic should consider using somewhat thicker sutures that can be more easily handled.
In addition to diameters, sutures are classified as absorbable and non-absorbable. An absorbable suture is one that will break down spontaneously over time (but not before the tissue has mostly healed).
Absorbable sutures have the advantage of not requiring removal. They can be used in a number of deep layers, such as muscle, fat, organs, etc. A classic example of this is “catgut”, actually made from the intestines of cows or sheep. Since these sutures are made from multiple fibers, they remain extremely strong in the first few days of healing.
Catgut is usually found in “plain” and “chromic” varieties. Plain gut absorbs very quickly but has a tendency to cause tissue inflammation. When dipped in a chromic salt solution, catgut retains tensile strength in the body longer and causes less of a reaction, while still remaining absorbable.
Gut sutures are used today to close tissue that heals rapidly, such as vaginal lacerations from childbirth or in the oral cavity.
Newer absorbables are synthetic. These include:
Monocryl (poliglecaprone 25)
Dexon (polyglycolic acid)
These sutures retain their tensile strength for varying lengths of time. They cause less tissue inflammation due to an absorption process different than that of gut.
Vicryl sutures are used for approximating muscle or fat layers, as well as lower layers of skin. Maxon and Monocryl can also be used for soft tissue as well as for cosmetic procedures where visible sutures aren’t desired. PDS is used to stitch muscle and fascia tissue.
Besides the classic synthetic sutures, new subtypes such as Vicryl Rapide, Vicryl Plus and PDS II exist. These may take less or more time to dissolve than the originals.
(Aside: Every physician has their own preference for sutures that relate to their experience, schooling, and other factors. For example, it is considered old-fashioned by many to use stitches for closing surgical incisions on skin, as most close skin wounds with staples. A randomized, clinical trial, however, found that women who had C-sections with dissolvable stitches were 57% less likely to have wound complications than those whose wounds were closed with staples. I used this method (known as a “subcuticular” closure) with good results for 20 years.)
Nonabsorbable sutures are those that stay in the body indefinitely or, at least, for a very long time. Normally. They are best used in skin closures or situations that require prolonged tensile strength.
Nonabsorbable sutures can be used in deep layers in certain situations. They cause less tissue reaction, although a small remnant may be felt where the body’s immune system walled it off (known as a “granuloma” or “encapsulation”).
Nonabsorbable sutures can be separated into synthetic single-stranded monofilaments and braided natural or synthetic multifilaments.
Single-stranded monofilaments include Ethilon (nylon) and Prolene (polypropylene). Braided natural multifilaments include braided surgical silk or cotton. Ethibond is the most commonly-used synthetic multifilament.
Monofilaments like Nylon are slightly less likely to harbor bacteria, whereas braided multifilaments have tiny nooks and crannies which may serve as hideouts for microbes. The difference in infection rate is very small, however.
Monofilaments also glide more easily through tissue, but may require more knots to stay in place than a braided multifilament like silk. While multifilamentous thread tends to come out straight, monofilaments retain the same S-shape in which they were packaged. This is more an annoyance for the inexperienced than anything else.
Braided surgical silk is easier to handle than nylon, especially for novices, and is often used for teaching purposes. 2-0 and 3-0 are sizes considered too thick by many surgeons, but are useful for teaching aspiring off-grid medics to learn surgical knot-tying. Although scarring may be more noticeable, this is a secondary issue in survival scenarios.
The off-grid medic must know skills ordinarily not taught to the average citizen. Wound closure is one of these skills, but must be combined with a working knowledge of when closure is appropriate and when it isn’t. We’ll discuss these issues in future articles.
The Altons at Doom and Bloom Medical have an article up about Reopening After a Pandemic – what it looks like, the CDC recommendations, and federal and state plans.
The COVID-19 pandemic has rampaged throughout the planet, but a few encouraging signs are giving some citizens the impetus to emerge from their homes. Although the number of cases and deaths continue to rise, several countries have flattened or are clearly on the far end of the bell curve.
Testing in the U.S. has surpassed 10 million and the percentage of severe cases requiring ventilator support are dropping somewhat compared to total cases.
Although some pandemic supplies are still generally unavailable to the average citizen, hospital staffs (in our area, at least) seem to be getting more personal protection equipment than before. While still accepting donations, Cleveland Clinic Florida states on its website: “…through months of planning for the pandemic it had “adequate supplies and medical equipment…”
Aside: This may not be the case everywhere. If you have a lot of extra personal protection equipment, consider donating some to your local hospital in case of a second wave of COVID-19 cases.
While we are beginning to get more optimistic with regards to public health, the financial news is terrible. 36.5 million unemployment claims have been filed. Businesses are reaching the point of no return; some brick-and-mortar enterprises may not survive if they don’t reopen soon.
And the customers? Just because the businesses are reopening doesn’t mean the patrons will come flowing back. Many people have been traumatized and are scared to venture out into the New Normal. Some have been able to work from home, cook dinner instead of eating out, and otherwise fend for themselves. They won’t be seeking these services outside the home so much anymore, even if money isn’t an issue.
The Centers for Disease Control and Prevention (CDC) recently released a detailed 17-page document of its recommendations for reopening. Some believe the criteria may be too strict. The battle between public health and public policy continues.
What are the criteria that must be met before reopening occurs in the U.S.? The federal government is giving leeway to state governments, but there are 50 states, and almost as many different plans of action.
The federal government (and most states) want a phased approach to return to normal (or at least the New Normal). Optimally, certain milestones should be reached before beginning phases:
SYMPTOMS: The federal government recommends that the reopening should begin when there is a downward trajectory on the graph of cases of influenza-like illnesses (ILI) within a 14-day period as well as a similar trajectory specific to COVID-19 signs and symptoms.
CASES: The federal government wants to see a downward trajectory of documented COVID-19 cases within a 14-day period, or at least a downward trajectory of positive tests as a percentage of total tests conducted with a 14-day period. This assumes at least a similar (or larger) quantity of tests performed during the same time period.
HOSPITALS: The goal is to have a robust testing program in place for at-risk healthcare workers with a particular interest in checking for antibodies against COVID-19. Also, hospitals would need to have no or few patients requiring “crisis care”.
The Altons at Doom and Bloom Medical have an article up on fever – what is it? Why does it happen? What should you do about it?
COVID-19 is running rampant throughout the globe. Contagious and sometimes deadly, it’s likely to cause severe illness in millions and ruin economies before it’s done.
You probably know the classic symptoms: Fever (also known as “pyrexia“) occurs in 88 percent of cases, followed by a dry cough. One in five or six go on to develop pneumonia. Of these, a percentage will succumb to the disease. You should know about these symptoms and others associated with COVID-19 and other infections. Today we’ll discuss fevers.
Why do we get fevers when we’re sick? There seems to be a body of evidence that suggests a higher body temperature kills many viruses and bacteria that do just fine at a normal temperature (98.6 degrees Fahrenheit). Fever is a weapon against disease-causing organisms.
What constitutes a fever? An elevated body temperature, of course, but how high? In medical school, I learned that it wasn’t a fever until you hit about 100.4 degrees Fahrenheit. This equals 38 degrees Celsius. In older people, the immune system is often too weak to mount that high a temperature. Any elderly person at 99.6 or so should be considered as “febrile” (having a fever).
Your temperature is a fluid statistic, however. In the morning, it is lower than it is in the late afternoon or evening, sometimes by a degree or more. The temperature also varies dependent on the method used to measure it.
In the past, people used mercury thermometers. These were made of glass and required no battery, a useful item long-term off the grid. Unfortunately, they could break, causing cuts and dispersing mercury (a toxic substance).
Today’s thermometers are electronic and non-toxic. There are various types on the market that use the mouth, armpit, rectum, ear, and forehead. Compared to the standard normal oral temperature of 98.6 degrees, you can expect:
A normal armpit reading to be one half to one degree lower (97.6)
A normal rectal temperature to be one half to one degree higher (99.6)
A normal temperature using an ear thermometer to be one half to one degree higher (99.6)
A normal forehead scanner (such as those used in many airports) temperature to be one half to one degree lower (97.6)
So, if a person’s temperature is 100.4 F orally, it could be 99.4 in the armpit or forehead and 101.4 in the rectum or ear. Rectal temps are thought to be most accurate, while armpit temperatures are thought to be least accurate.
Note: An oral thermometer reading may be inaccurate if you ate or drank something recently. A precise value may not be obtainable for 15-30 minutes afterwards.
The ability to use the thermometer properly is an important factor. This isn’t difficult for adults that read the instructions, but a fussy, sick toddler may not cooperate. In this case, a rectal temperature reading may be the most accurate.
Many use the ear thermometer. This is also known as a tympanic thermometer, named after the tympanic membrane or “eardrum”. Tympanic temperature readings average about the same as rectal. To be accurate, take the temperature in both ears and use the highest reading. The reading may be artificially elevated if you have been laying on your side with your ear on a pillow. As well, it’s said that those with a very short, curved ear canal may not have reliable results. This is a tough one to tell unless you ask your doctor to take a look during an exam.
“Forehead” thermometers actually scan the temperature of the temporal artery. This item is superior to forehead strips, which are better at measuring skin temperature than body temperature. Be aware that they can be expensive.
The Alton’s at Doom and Bloom Medical has up an article discussing the infectiousness of Covid-19, and they also announce that their new book Alton’s Pandemic Preparedness Guide: Emerging and Current Viral Threats is now on sale.
If you’ve paid any attention to the worldwide pandemic of COVID-19 or watched movies like Contagion, , you’ve heard the term “R-nought”.
The R-nought (or reproduction number) is the 100-year-old brainchild of a public health expert in demographics named Alfred Lotka. A disease’s R-Nought, he said, is the number of cases that will occur in a population if an infected person is placed in the middle of it. Not just any population, however; one that hasn’t been exposed to the infection in the past.
In the 1950s, epidemiologist George MacDonald used it to describe the contagious potential of malaria. He suggested that, if the R-nought is less than 1, the infectious person will transmit to fewer than one other person and an outbreak will eventually peter out. On the other hand, if the R-Nought is greater than 1, the disease will spread. Seasonal flu carries an R-Nought of 1.28, while the current COVID-19 is probably closer to 3.
Probably? Certainly, the R-Nought represents important data regarding an infectious disease. Why, then, probably? Because different sources may report different R-Noughts for the same disease based on a number of factors. It’s not just the nature of the virus itself.
Estimation of the R-nought primarily relates to 3 parameters:
how long a person is contagious
the likelihood that contact with a susceptible person will end in transmission of the disease
the frequency of contact between the infected individual and the susceptible population.
Let’s take them one-by-one. The first is how long a person is contagious. Certainly, you want to quarantine someone during their infectious period, but, with COVID-19, that period is not known for certain.
For SARS, it was about 14 days, so that’s what they’re using for the related SARS-COV2 (the name for the virus that causes COVID-19). There are outliers, however, that range from 20-37 days. With a range that wide, how do they figure out when you’re no longer contagious?
If COVID-19 testing is available, they have determined three criteria for considering release from isolation:
• You no longer have a fever without using fever-reducing drugs.
• Symptoms like cough or shortness of breath have improved significantly.
• you have received two negative tests in a row, 24 hours apart.
• You have had no fever for at least 72 hours without using fever-reducing drugs.
• Symptoms like cough or shortness of breath have improved significantly.
• At least 7 days have passed since your symptoms first appeared (I was surprised at that last one; perhaps 14 days is more prudent).
Aside: Recovering COVID-19 patients might be surprised when they feel better but are told that the X-ray still shows signs of pneumonia. This is because the x-ray appearance of pneumonia commonly seems to lag behind the patient’s clinical appearance.
The second parameter is how likely is it that contact with a susceptible person ends up in infection. That depends partially on the characteristics of the virus itself, but It might also depend on a person’s age, general health, lifestyle, or even bad habits.
Older folks may get it as often as younger folks, but seem to do worse across the board. In one study, if you were in your twenties and got COVID-19, your chances of dying was 0.2 percent. If you were in your eighties, it was closer to 22 percent.
What about bad habits? Consider smoking: Most COVID-19 victims are men. in China, 50% of men smoke there as opposed to about 5% of women. Therefore, you can probably conclude that women have healthier lungs, on average, than men.
Cultural differences might also play a role. In Iran and certain other countries, most men work or spend a good amount of time outside. From this, we can infer that they might be exposed more often than women, who probably spend more time at home.
The third parameter is the frequency of contact between the infected individual and the susceptible population. For example, there are people that are known as “super spreaders”. A super-spreader is an individual who is more likely, for one reason or another, to infect others. 20% of infected individuals are responsible for 80% of transmissions to others.
Although South Korea is held out as a model of success in the containment of COVID-19, that wasn’t always the case. In mid-February, confirmed cases of SARS-CoV-2 infection suddenly jumped in that country. The Korean CDC attributed the increase in cases to “Patient 31“, who had participated in a mass religious gathering in the city of Daegu.
In New York, a lawyer contracted the illness and then spread it to at least twenty other individuals in his community in New Rochelle. In the early going, he was thought to account at one point or another for more than half of coronavirus cases in the state
Super-spreaders aren’t confined to viral disease, 100 years ago, a woman named Mary Mallon worked as a cook in New York. She was an asymptomatic carrier of the bacteria Salmonella Typhi, and passed that disease to more than 50 other people, giving her the nickname “Typhoid Mary“.
Terminating Typhoid Mary’s employment and quarantining super-spreaders and their contacts helps, but only if it’s done rapidly. In South Korea, it can be said to be successful. In New York, well, not so much.
There’s more to R-noughts than those 3 parameters, like testing issues, the availability of personal protection equipment to a community, and much more. It’s interesting to think about what the R-Nought of the 1918 Spanish Flu would have been if it occurred today with commercial air travel so common.
More updates on issues relating to the pandemic in the near future.
We live in a world where established safety measures, if followed, prevent a lot of injuries. Unfortunately, they’ll never prevent all injuries. There were an estimated 45 million incidents of trauma in the U.S. last year that required an emergency room visit. Car wrecks, outdoor injuries, industrial accidents, and other mishaps contribute to a whole lot of hurt in good times. That leaves us to wonder: How would this change in bad times?
Let’s face it, people get injured and sick whether or not there’s a rescue helicopter on the horizon. Broken bones, bleeding, sprains, and other issues will need to be treated.
If the modern emergency system breaks down, is overloaded, or simply too far away, someone in the family or group will become the highest medical asset left. Certified or not, they’ll be the end of the line with regards to the medical well-being of their people. Without equipment and know-how, deaths will occur that could’ve been prevented with a good medical kit and knowledge of basic first aid.
People prepare for the worst by accumulating food, water, personal protection items, and more. The wisest of them also stockpile a good supply of medical equipment and medicines as well. In a short-term event, those with training and equipment will save many lives. But what happens when the medic bag is empty?
All is not lost. Necessity, they say, is the mother of invention. The resourceful will make do with found objects. A variety of items on the trail or in abandoned buildings can serve as medical supplies. All it takes is an instinct to explore, a good eye, and some imagination.
Before we begin, it should be mentioned that the medical improvisations below are stopgap measures for dire situations when traditional medical resources and treatment are not available — unfortunately, the current Coronavirus / COVID-19 outbreak may be one such circumstance, if it continues to worsen. Improvised methods are rarely as successful as modern technology and equipment (if used properly). Having said that, some of the strategies below might just save lives in times of trouble.
WATER BOTTLES AS FILTERS
You can last quite a while without food, but only about three days without water. Even when there’s a water source nearby, you can’t see the microscopic organisms that make you sick. In survival settings, more lives may be lost by diseases due to contaminated water than bullet wounds.
With a clear plastic PET (polyethelene terephthalate) bottle, you can make water safer. It shouldn’t be hard to find; approximately 500 billion are produced every year. Unless you have a purpose-built water filter like the Sawyer Mini or LifeStraw, you’ll need containers to: 1) filter out particulates that make the water cloudy, and 2) destroy disease-causing microbes in the water.
To improvise a filter, you’ll need the following items that you might find by scavenging, or in your medical kit…
In situations when hospitals may be overwhelmed or understaffed the WHO has released guidance for Home Care of patients with mild symptoms. All concerned patients should be first be evaluated in a medical facility before home care is initiated. These measures are meant to decrease public contacts and the spread of disease, and decrease the patient load on hospitals during epidemics and pandemics .
Learn which patients may be asked to stay home during illness and when they should be hospitalized. A link to a medical facility should be established for the entire duration of any home home care until all symptoms have cleared and the facility releases the patient and resolved. This connection will allow family members and the patient to be reassured there is contact with a medical professional for questions and concerns.
Home care takes planning and education about personal hygiene, basic infection prevention and control protocols, and how to safely care for the sick person without spreading it to other household members. Recommendations (from the World Health Organization) are detailed in this video. Also see our How To Build A Sickroom video.
Wishing you the best of health in good times and bad,
The SARS-CoV2 virus, newest member of the coronavirus family has proven to be especially contagious, with over 80,000 cases and 2700 deaths so far. Cases of COVID-19 (the name for the disease) have been reported in more than 30 countries and community-wide outbreaks are confirmed in places like Italy in Europe, Iran in the Middle East, and South Korea (among others).
Although the grand majority of cases are still in mainland China, more cases are being reported outside China than inside these days. South Korea has more than 1,260 cases and one of them is a U.S. soldier. Italy has 320 cases and 12 dead. Iran only claims 139 cases but 19 deaths, much more than the 2 percent fatality rate seen in other countries. Most suspect this means that many tens of thousands are still undetected.
Meanwhile, The Centers for Disease Control and Prevention (CDC) gave an opinion that “the immediate risk of this new virus to the American public is believed to be low at this time,” while also saying: “It’s not so much a question of if this will happen anymore but rather more a question of exactly when”.
Despite the many cases that are popping out throughout the world, Most U.S. experts and World Health Organization (WHO) officials believe that COVID-19 is not yet at pandemic status. If the COVID-19 outbreaks all over the world aren’t a pandemic, what is?
The World Health Organization should consider following their own definitions for pandemic disease. The different WHO phase alerts for infectious disease outbreaks are:
Phase 1: The disease is found circulating in animals; no known infections in humans. An example would be an outbreak in 2019 of vesicular stomatitis virus, a disease that affected more than a thousand premises holding horses. No cases were reported among humans, even those who worked daily with the animals.
Phase 2: The disease has caused proven infection in humans. The bird flu affected millions of poultry as well as a number of people who lived and worked in close contact with them.
Phase 3: Small clusters of disease occur in humans but do not affect entire communities. Measles virus may affect a number of non-vaccinated people in an area, but the large number of vaccinated individuals prevents it from running rampant.
Phase 4: The disease affects entire communities. The disease now qualifies as an epidemic, but the risk for a pandemic, although increased, is not certain. With COVID-19 in early 2020, large areas in China were saturated with cases but no major community-wide outbreak had originated anywhere else for a time (outside of a cruise ship). Since then, other countries are reporting spikes in cases, with cases in South Korea doubling over the course of one day. In my opinion, COVID-19 has now passed this stage.
Phase 5: Spread of disease between humans is occurring in more than one country in a region. The Ebola virus outbreak of 2014 is an example of this phase; cases affected communities in several different adjacent West African countries but no community outbreaks occurred outside of the region. In 2020, COVID-19 cases in nearby nations like South Korea and Japan are starting to accumulate, just as Ebola did in West African countries in 2014.
Phase 6: Community-level outbreaks exist in at least one additional country in a different region. With Ebola, cases in North America and Europe didn’t originate there and the infection didn’t take hold locally in any significant manner. Influenza, however, commonly reaches pandemic status on an annual basis.
COVID-19 in 2020 is developing large numbers of cases of human-to-human transmission outside of China. With outbreaks in Italy, Iran, South Korea, and elsewhere predicted to get worse before they get better, it’s clear you’ve got a pandemic on your hands. Right now.
I say this not just because of the cases that have been reported, but because we can only surmise that the number of cases documented is less than what really exist.
That doesn’t necessarily mean that real numbers are being held back. Statistics may be affected by the limitation on lab facilities to test for a disease. In some emerging infectious diseases, no test may be accurate enough to give proven results. In the COVID-19 outbreak, a number of people have tested negative using the current technology and still show symptoms.
Quarantines of entire cities in the face of a dangerous disease may lead those who are mildly ill to stay inside their homes and not seek care in overcrowded hospitals. As a result, many cases may not be counted.
Sometimes, however, a government may put out inaccurate numbers in an effort to avoid panic in its citizens. Certain regimes may limit the dissemination of information to give an unclear picture of the epidemic’s real effect on the country.
For example, we have no idea of how many cases of COVID-19 may exist in North Korea, a nation which borders China and most certainly has been affected. Yet, the government is completely silent about the SARS-COV2 virus.
When people are prepared, they can purposefully and rationally act to decrease their chance of infection. But to get prepared, most people look to their government’s health agencies for advice. Those health agencies should alert citizens with enough time to get the supplies they need and prepare.
Epidemics don’t just make people sick; they also disrupt the chain of supply. China, a major producer of face masks, has already mandated that they are no longer for export. In the U.S., many personal protection gear items are already scarce.
It’s important to know that there’s no need to panic. Hopefully, the CDC opinion is correct in its assessment that the immediate risk to Americans is low . If we are to weather this storm, however, we need to be shown the black clouds on the horizon. Declare a pandemic and let’s work to get our communities ready with a plan of action. Complacency can be hazardous to your health.
Having knowledge of infectious diseases and how to treat them is very important, but you’ll be more effective in preventing their spread by having some supplies. Which supplies? That all depends on the nature of the disease itself and the risk that the healthy population will be exposed to it.
Before you can be a successful caregiver and heal the sick in an epidemic, you must avoid becoming one of its victims. Viruses can be very contagious (like the airborne common cold) and have a low fatality rate. Alternatively, a disease may have a high fatality rate (like Ebola) and be less contagious (it’s not officially thought to be airborne). Rarely, a really infectious agent may be both very contagious and lethal (like The Pneumonic Plague in the Middle Ages).
In a truly virulent outbreak, healthcare providers are at serious risk. During the Ebola epidemic of 2014, being a medical worker was one of the principal ways to get (and die of) the disease. In 2020, the physician who first tried to warn the world of the coronavirus COVID-19 epidemic was, unfortunately, also one of its casualties.
Because of the risk to medical workers, strict protocols regarding what items a caregiver should wear are formulated and constantly modified based on new scientific evidence. A uniform way to to don (put on) and doff (take off) equipment is very important in safeguarding healthcare providers
PROTECTIVE GEAR TO WEAR
Here is what we think you should wear if you are taking care of a highly contagious patient. First, we’ll discuss which armor would give you the most protection. You should have…
• Coveralls (with head and shoe covers; some come with hoods and booties built-in)
• Masks (N95 or N100)
• Goggles or face shields (to be used with, not instead of, masks)
• Nitrile Gloves
Shoe covers and built-in attached booties alone do not give you enough protection. Rubber boots should be worn and can be sanitized between patient encounters.
ABOUT FACE MASKS
Medical masks are evaluated based, partially, on their ability to serve as a barrier to very small particles that might contain bacteria or viruses. Masks are tested at an air flow rate that approximates human breathing, coughing, and sneezing. The quality of a mask is determined by its ability to tightly fit the average human face. The most commonly available face masks use ear loops or ties to fix them in place, and are fabricated of “melt-blown” coated fabric (a significant upgrade over woven cotton or gauze)…
The Altons at Doom and Bloom medical have a short article up on what is a coronavirus and basic prophylaxis. The article was published on Jan. 22nd, so the numbers of confirmed cases and deaths have risen.
Last week, we reported on a mysterious ailment first reported Dec. 8th, 2019, in Wuhan, China. Wuhan is the seventh most populous city in China with 11 million people. The previously unknown disease is now identified as a type of coronavirus. Medical officials are currently classifying it as a “class B” disease, which puts it in the same category as HIV/AIDS and Sudden Acute Respiratory Syndrome (SARS).
The rapidity and spread of the disease is impressive: When I began writing this article earlier in the day, there were 440 cases and 9 deaths, up from 200 cases last week. Later in the day, 555 cases and 17 deaths have been verified and other provinces in China are beginning to report cases.
(Note: I first reported on Ebola in early 2014, when 86 cases were reported. The epidemic eventually reached a total of 28,000 cases and 11,000 deaths.)
Chinese authorities have taken the drastic measure of placing the entire city of Wuhan under quarantine, including the suspension of train and airline service, a step that suggests that many more cases are still unreported.
(1/23 update: Several U.S. airports are now conducting health screenings)
Although little is known at this point about the virus, it is certain that the disease is respiratory in nature and that human-to-human transmission (including medical personnel) is likely. For most respiratory infections, contagion is usually by airborne particles.
The first U.S. case has just been identified in a 30-year-old man from the state of Washington who recently arrived from China. Similar coronavirus victims have been found in Japan, Thailand, Taiwan, and South Korea, almost all traced to an origin in Wuhan.
The Wuhan virus is from the same family of coronaviruses as SARS, which killed over 800 people worldwide in an outbreak toward the end of 2002. It is also similar to Middle East Respiratory Syndrome (MERS), another epidemic disease. Although not officially named, the new virus is designated 2019-nCOV.
Coronaviruses are viruses made from RNA genetic material. One of the larger RNA viruses, coronavirus is so named from the Latin “corona” (crown or halo), from projections on the virus which give the appearance of a crown.
Coronaviruses are thought to be responsible for a large number of common colds in humans. Coronavirus colds seem to be associated with more major symptoms like fever or sore throat than colds caused by rhinoviruses, another common cause. 2019-nCOV seems to cause even worse respiratory symptoms than the typical coronavirus. Coronaviruses can also lead to pneumonia, either directly or through a secondary bacterial infection due to a weakened immune system.
ABILITY TO CONTAIN THE VIRUS
Chinese officials are probably wise to enact quarantine orders, as there is only one lab (called a Biosafety Level 4 lab or BSL-4) in their entire country with the capability of handling severe outbreaks. Luckily for them, it is located in Wuhan. The facility can care for victims of highly contagious diseases like SARS, Ebola, etc.
Personnel in a BSL-4 lab are subject to the strictest protocols: They must change their clothing on entering and shower upon exiting. Full-body hazmat suits must be worn while working in the lab and decontaminated afterwards. The facility is required to be a separate building or a wing properly isolated with separate air filtration systems.
The chances of spread of the new coronavirus is increased by the upcoming Chinese New Year, when it is thought that millions of Chinese citizens will be traveling throughout the world.
(1/22 Update: China has just issued a travel ban for the city of Wuhan; public transportation in the city is also suspended)
Having learned lessons from our experience with Ebola, the United States is better prepared to deal with highly contagious outbreaks of infection.
HISTORY OF RECENT VIRAL OUTBREAKS IN CHINA
The presence of any biosafety 4 lab (BSL-4) inside China at all is due to the 2003 viral SARS outbreak. SARS reached epidemic proportions quickly, with 8000 cases leading to 750 deaths worldwide. Chinese authorities hope to have 7 such units built by 2025, but only the Wuhan lab is operational.
Although the use of face masks is common (and wise) in China, Wuhan has declared their use manadatory while in crowded locations. This requirement is causing a shortage of masks in the area, which could eventually lead to the same worldwide.
WHAT TO DO ABOUT CORONAVIRUS AND OTHER VIRUS OUTBREAKS
As of yet, no cure nor vaccine is available to combat coronavirus. Treatment at present focuses on treating symptoms and supporting a victim through the infection, while protecting the healthy from the disease.
Contagious illnesses like coronavirus, however, may morph into epidemics, or is widely distributed enough, pandemics. If you are preparedness-minded, you might consider a personal protection “pandemic kit” (or several) and plan out how you would care for a person with a contagious disease if the hospitals were full. Have you thought about what goes into putting together an effective epidemic sick room?