Evidence-Based Medicine

A Chinese Proverb says, "The birds of worry and care fly over your head, this you cannot change, but that they build nests in your hair, this you can prevent."  The recent development about the heartbreaking story of the Vava'u boy has not shooed away the birds of worry amongst Tongans both locally and abroad.  It seems to have increased the flock.  The Tonga Health Ministry stated that it was a sad and deadly case of Methicillin-Resistant Staphylococcus aureus Pneumonia (MRSA-PNA). The public's reaction was predictably full of colorful languages, pain, resentment, anger, and worries.    It stirred mixed emotions, concerns, and raised a dozen questions that I haven't been able to dust off in the past few days.

The article that reported the Ministry of Health's statement did an acceptable job describing MRSA.  I am happy because that will save me from writing too much medical jargons in this post.  However, I personally feel that the article should've given appropriate information about culture-positive Pneumonia (PNA).

I have diagnosed and treated pneumonia during my many months of Internal Medicine, Family Medicine, Emergency Medicine, and Infectious Disease rotations.   A detail discussion will be too long for this post.  However, for my purpose here, I want to point out that if culture-positive pneumonia was contracted while at a Hospital, then the abbreviation is HAP.  If it was contracted from the community, then it is referred to as CAP.  These are extremely important distinctions.  It is so we can conveniently label the origin of the Pneumonia.  It also allows Healthcare providers to determine which is the appropriate antibiotics therapy and assess the mortality risks.  So keep these abbreviations in mind and they will appear later on in this post.

I also know MRSA fairly well.  I see and treat them more often than I would like.  They are just nasty and dangerous little bugs that are highly contagious.   So when I read MRSA-pneumonia, my concerns were in form of questions that I quietly asked "Did he get it at home/village?"  "Did he get it at the hospital?"  "Was he on proper isolation while he was at the hospital?"  "What was the initial antibiotic therapy?"  It is standard protocol at all hospitals (at least in the US), that any pt that is tested positive for MRSA, whether via nare-swab, sputum, wound culture, or blood culture, MUST BE IN ISOLATION.   This also means that anyone that come in close encounters with that patient will have to be properly gloved and gowned.

If you have read my previous posts, you probably picked up on it by now that midway through my post, I am always reporting some scientific research and statistics.  I love them and I love numbers.  I agree, it is probably the most boring part of my blogs.  However, it is the most important.

There is a phrase in medicine that is uttered multiple times throughout the day.  You will hear it on the Medicine Ward, Surgical Ward, ER department, Outpatient clinics, Operating Room and etc.  If you are a fan of the show DR. HOUSE, you may have heard it.  "WHAT DOES THE LITERATURE SAYS?".  (BTW I am not a fan of that show but I have seen half an episode during Medical school because one of our lecturers made us).  This practice is known in this field as "EVIDENCE-BASED MEDICINE".  I first heard about this phrase and the phrase I wrote about last time; "First, Do No Harm" at my in-laws kitchen while my wife and I were dating.  I have heard my father-in-law on multiple occasions uttered these phrases.  I didn't quite understand them then but I couldn't escape it during medical school and I can't escape it now.

Anyways, here's what some of the literatures say about culture-positive Pneumonia.  Scott T. Mitek et al.  reported in the Antimicrobial Agents and Chemistry, Oct. 2007 these statics:

a) The most common pathogens/bugs/germs in culture-positive Pneumonia is MRSA (~25%), Strep. pneumoniae (20%), P. aeruginosa (19%), MSSA (14%), and H. influenza (9%)

b) HAP (hospital acquired pneumonia) has a 68% prevalence

c) those with HAP (pneumonia)  has a death rate of ~25% and CAP (pneumonia) has a death rate of 9%.

d) they also found that getting the wrong initial antibiotics was higher for HAP (28%) versus CAP (13%)

These numbers are screaming loud and clear.  Any healthcare provider who's encountering patients with signs and symptoms consistent with culture-positive pneumonia (like our little brother from Vava'u) must ask "WHAT DOES THE LITERATURES SAY?"  These data and others alike would cause you to widen your eyes, perk up your ears, and turn on your sixth sense as a healthcare provider.  It will caution you that such condition are no small issues and must be completely worked up and treated.  It should remind you that you must put on your Sherlock Holmes persona.  Why? Because if your patient has a culture-positive Pneumonia such as MRSA-Pneumonia, 68% likely they got it from the hospital, there's a 28% chance you will give him/her the wrong antibiotics initially, and 25% chance they will die.  So, do diligence and always remember that an effective way of shooing birds of worry for both the sufferer and the healer is EVIDENCE-BASED MEDICINE!  (Unless of course you want them build a nest or you simply Don't Care.)

I SWEAR...Primum non nocere; First Do No Harm!

               

I recently read here on FB (I have not verified the story) about a young boy from Vava'u who recently passed away at Vaiola Hospital.  Supposedly the boy and his mother were flown in from Vava'u after a sad ordeal of neglect by the Doctors and Nurses there.  He first presented with abdominal pain but was sent home.  This repeated a few more times over a period of weeks before he was admitted but received no treatment.  After days of begging, the mother and child were flown to Tongatapu.  They were repeatedly accused of trying to get a free plane ride to the main island.  I would like to emphasize again that I haven't verified the story.  However, it has caused me to reflect on my duties and responsibilities as a Healthcare provider and the oath that I am under.

These pictures were taken at our White Coat Ceremony (2010), where in addition to receiving our official clinical white coats, we took upon us the Modern Version of the Hippocratic Oath.  Basically, we made an oath and swore that we will do no harm to our patients either by commission or omission.  That's the short and straightforward version.

I think about this oath everyday...multiple times during the day.  I think about it early in the morning when I think about what my day in clinic or the Operating Room will be like.  I think about it as I drive to and from work.  I even think about it when I'm laying in bed counting sheep.  Whether patients understand and agree with my Assessment and Plan or they think I don't know what I'm talking about, I still remind myself "First do no harm".

I must admit, it is difficult at times.  Especially when you are dealing with "Drug-seekers".  They flip out when they hear "I see that you were seen yesterday at the ED and was given (pain killers XYZ) enough to last you a few days, so I am not going to give you any more today".  They get loud and animated.  They become disruptive and the encounter becomes awkward and uncomfortable for both parties.  I assume in their minds they are thinking "You are not wanting to help me".  In the meantime, in my mind I'm thinking "I'm trying to save you from yourself".  They are the extreme and they are pretty easy to sniff out.  The more challenging ones are those with malingering or fibromyalgia.  Everything everywhere hurts.  Now, don't get me wrong, these are legitimate medical issues.  They definitely remind you of one of the paragraph from that oath:

"I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug."

I recently read that various centers in the US are conducting research on how touch therapy helps improve wound healing, pain, anxiety, arthritis, and fracture healing.  Incredible!  So, even science now is driving the point home; medicine is both science and art!

Now, back to our unverified story.   There are many questions to be answered both from a moral and medical standpoint.  If the version on fb is accurate, perhaps we can ask: "Do you remember the oath you took?".  "Do you remember that medicine is both science and art?"  "Do you remember that we do not treat fever chart...but a sick human being?"  We can go on and on.

I will get off my high horse now.  My apologies!  I can't even begin to imagine the sorrow that this mother is going through.  My prayers are with her and her family.  I am saddened by the life that is lost.  I am grieved by the hearts that are broken and disappointment by the trust that has been violated.  There's nothing that I can do to bring the boy back.  However, I will let his story, regardless of the details, be part of my reminders.  I took the oath and swore when I first put on that freshly pressed white coat; Primum non nocere.

All are Dying!

My last entry, Suka is Poison,  ended abruptly and dramatically.  Suka --> Poison -->Death.  It was by design.  However, my intention surely was not to leave you with a sense of pessimism or to become as we refer to in our house "A Debbie Downer".  Nor was I intentionally employing a scare tactic.  Rather, my objective was to be short, direct, and bluntly honest...the kind of thought-process commonly found amongst Tongan parents (at least the ones I know).  I wish to clarify here, that my statement wasn't meant to suggest that if you become a suka/diabetic, you will die right away.  Nope, absolutely not.  We are all embarking in a mortal journey that will eventually come to an end.   As the German Philosopher Arthur Schopenhauer eloquently stated "Life is a constant process of dying".  However, it is natural for all of us to want to go through the process of dying with grace, dignity, and comfort.  It is our moral duty to respect life and to be responsible stewards of our bodies.  We have spent endless time, resources, and energy despite frustrations, failures, and disappointments in our quest for a longer, comfortable and more enjoyable life.  This is evident in the evolution of our engineering, diets, and social infrastructures.  Therefore, it is pertinent to understand that which gets in our way of attaining such goals.

Suka's effects on the body and its many systems/organs are decisively destructive.  A detail and complete physiological discussion will be time consuming,  tiring,  and quite frankly boring.  Trust me, I've read many-a textbooks and peer-reviewed articles and they all are.  So, I will attempt to be relatively plain and simple.

The saying "Misfortunes never come singly" is ever so true when it comes to Suka.  It almost always come with two bad companies, 1. High blood pressure/Toto Ma'olunga and 2. High Cholesterol/Ma'olunga e Ngako.

Here's some statistics (I love numbers...I know, nerdy), Dr. Simonson in the Diabetes Care Journal in 1988 said that High Blood Pressure/Toto Ma'olunga prevalence is 2 times likely then in non-diabetic patients.  It is important to review here the two different types of Suka that I mentioned in my last entry.  Those with Type 1 Suka are born with it and High blood pressure is normally not present at the time of diagnosis.  However, for Type 2 Suka, high blood pressure was almost always diagnosed at the time of diagnosis.  Please bear in mind that there are multiple factors that play into this close association and I chose to address them later.  Anyways, back to the statistics.  This means that my Suka adult relatives are twice as likely to have Toto Maolunga in comparison to my non-Suka  ones.  This is unfortunately impressive.

High Cholesterol/Ma'olunga e Ngako was reported by Harris in the Diabetes Care in 1991, to be present 70% of the time in those diagnosed with Diabetes/Suka.  That is incredible.  It means that if I have 10 adults in my family with Type 2 diabetes, at least 7 of them will also have High Ngako.

So, you can insert here "Sai ke tau 'Ilo" if you didn't already at some point above.  MHK!  So, this is where it gets scary.  You take these three; Suka, Toto Maolunga, and Maolunga e Ngako together and they will attack you right at the heart of the matter...literally

According to the American Heart Association;
1.  68% of Suka people that are 65 years or older die from some form of heart disease, and 16% die of Stroke (heard of this guy?)
2.  Adults with Suka are 2-4 times more likely to have Heart Disease or a Stroke than those without Suka
3.   Suka is one of the 7 major controllable risk factors for Cardiovascular Disease.

Now, these are just the few of the handiwork that these guys do on the heart.  We haven't started on the others such as Atherosclerosis, Peripheral Neuropathy, and kidneys/Kofu Ua and the dreaded D word; DIALYSIS (we will save that for later).

Ok, enough with the Doom-n-Gloom.  The good news is, with proper medication and lifestyle modifications, these guys can be tamed.  However, it is a CHOICE.  One that is difficult but doable, restrictive but liberating, and small but of extreme value.  A choice that needs to be made multiple times a day everyday.

Let me close with this wise counsel from Madame Chiang Kai-shek, that grand lady of China.

"If the past has taught us anything it is that every cause brings its effect, every action has a consequence.  This thought, in my opinion, is the moral foundation of the universe...In the end, we are all the sum total of our actions.  Characters can not be counterfeited...character requires time and nurture for growth and development.  Thus also, day by day, we write our own destiny; for inexorably we become what we do.  This, I believe, is the supreme logic and law of life."

Suka and his compadres are "no respecter of persons" and they seek take away grace, dignity, and comfort from our process of dying if we fail to impose control on them.  #SukaIsPoison #controlSuka #protecttheheart #BeatSuka

Suka is You!

In The Art of War (a very good read by the way...or so I was told.  haha.  I cheated and listened to it on tape), Sun Tzu wrote "If you know the enemy and know yourself, you need not fear the result of a hundred battles.  If you know yourself but not the enemy, for every victory gained you will also suffer a defeat.  If you know neither the enemy nor yourself, you will succumb in every battle".   So, in my Tony Montana voice, "Shay ello to my lil frien"; Diabetes Mellitus!!

Who (yes, I'm referring to Suka as a who instead of a what) is Diabetes Mellitus/Suka?   Diabetes, derived from diabetes in Greek which means siphon or pass through and mellitus is of Latin origin which means honeyed or  sweet.  So, in diabetics, there's excess level of sugar/suka in both the blood and the urine, a condition that was once referred to as "pissing evil" (excuse the language).  Originally, the condition was first referred to as diabete in English, but a certain Thomas Willis added "mellitus" in 1675 due to the sweet taste of urine.  Willis, however, was not the first to discover "sweet urine".   The Greeks, Indians, Persians, Chinese, and Egyptians did centuries prior  (wonder how they determined that one!).  I am certain that my Polynesia Ancestors discovered this too and somewhere in our vast oral histories and legends are clues.  Ok, getting back to the point; At its most basic definition, it is the condition where the body "does not properly process food for use as energy".   

At the Physiological level (bear with me as I try to avoid medical jargons and gibberish), diabetes is a disorder where there's a defect in Insulin secretion, insulin action or both.  This is referred to as type 1 (lack of insulin production, a condition which you are born with) or type 2 diabetes (insulin is made but body isn't responding to it, a condition you acquired), thank to Sir Harry Himsworth and his work which he published in 1936.  

Insulin, a hormone that is produced in the pancreas (known in Tongan as 'Ate Pili or 'Ate Loi, I could be mistaken) facilitate the entrance of suka/glucose from the blood stream into the body cells for energy production.  So, it's like what they teach at 'Iate University; "No work, No dinero".  No insulin, no sugar going to body tissues.  Simple! Right?

So, what's the big deal if the suka/sugars are NOT getting "out of my dreams and get into my car"?  Wait....that's a cheesy song from the 80's.  I mean out of the blood and into the body tissues?  Well, I wish I could say that it's no big deal.  I desperately want my Southern born-n-raised patient to be right when she said "It just means I'm extra sweet".  But no, it is a big deal and no, it doesn't mean you are extra sweet.  It is quite the contrary...it is a slow-acting poison, and it was William Shakespeare who asked "If you poison us do we not die?"

SUKA SUKA

The Hungarian writer Frigyes Karinthy theorized that "anyone on the planet can be connected to any other person on the planet through a chain of acquaintances that has no more than five intermediaries."  Stanley Milgram in his experiment "The Small World Problem" showed that Karinthy was on to something.  His findings led to the now popular term "6 degrees of separation".  Unlike the Milgram's "The small World Problem" and "6 degrees of separation", Diabetes is a 'Big World Problem' and it's only a '1 degree of  separation'.

Diabetes, Diabetes mellitus, DM2, or SUKA in Tongan is a nasty non-communicable disease (NCD).  In the US alone, diabetes affects about 30 millions Americans and an additional 7 millions aren't even aware they have it.  According to Diabetes.org, it cost the US approximately 300 billion (yes, with a B) per year.  That's $1 in every $5 in healthcare dollars spent in the care of someone with diabetes in one year.  Each day,  3800 Americans will be diagnosed with Diabetes for the first time,  another 200 will undergo an amputation related to diabetes.   Another 136 Americans will start treatment for end-staged renal disease (ESRD) for the first time and it doesn't end there.  Another 1,796 will develop retinopathy which lead to vision loss and blindness.  These numbers are staggering and regrettably ever growing.

According to a study that was done in 2002 that is now published in the American Diabetic Association, the prevalence of Diabetes in Tonga is 15.1%, 80% of which are undiagnosed, a scary steep increase from 7.5% from 25 years earlier.  I do not know, or more accurately, I haven't found the dollar breakdown for diabetic care in Tonga.  However, a quick glance and compare of the aforementioned sets of statistics may cause one a brief episode of vertigo.  It sure did me.  These number suggests many things.  One of which is the safe presumption that each of us, within hug-range, knows someone or someones that is/are plagued by Suka.  They could be parents, siblings, cousins, uncles, aunties, or grandmas and grandpas.  They could be your neighbor, your favorite teacher, or your lest favorite in-laws (I love all of mine, so don't get no ideas now).  Hack, they could also be your doctor!  If there's one thing that 'mankind vs. alien invasion' movies have taught me it is always "You've got to understand them to defeat them".  So, now you know what my next few posts will be.  #BeatSuka

WRITE!

It is 2:30 am, the house is utterly quite, the wife and kids are sound asleep, and not a single sound from our 16 months old boy (very rare btw).  I'm sitting on the couch, the AC and the ceiling fan are tirelessly battling the Phoenix hot summer night (truly grateful).   My mind is restless as usual, except tonight, it is with a tinge of uneasiness and I'm unable to diagnose it.  We just finished a 4 hour orientation of brand new resident doctors who are starting in a few days and perhaps I am anxious about how they are going to handle the load of residency; Long hours, endless reading and learning, non-compliant patients, unforeseen post surgery complications, middle of the night pages from the floor or the ER, and etc etc.  Or may be it was the news I received today that my father called in sick to work (a true rarity) because he's not feeling well.  Perhaps it's the reality that I where ever we move to next might be our home and where we will plant some roots for the next few decades.  "I have to keep my mind occupied, I have to enervate it".  So, I started with reading about world events; from more significant 'Brexit' to not so crucial 'Messi retiring from the National team', and of course Facebook (just being honest here).  Unfortunately, none of those did the trick.  So, I decided to do work related reading and I came across this frightening piece of statistic from and article titled Causes of death in Tonga: quality of certification and implications for statistics by Carter et al.  Popul Health Metr 2012,

"Mortality from diabetes for 2005 to 2008 is estimated at 94 to 222 deaths per 100,000 population for males and 98 to 190 for females (based on the range of plausible all-cause mortality estimates) compared with 2008 estimates from the global burden of disease study of 40 (males) and 53 (females) deaths per 100,000 population."

By now, I have read the paragraph above over and over and the sting seems to get worse each time.  Now, the leash on my mind is shortening and it is zeroing in on a few more scientific articles about the havoc Diabetes is effortlessly wrecking in Tonga.  I am not feeling discouraged at all, instead, I am feeling motivated.  "What can I do?"  Part of the answer came swiftly and clearly; WRITE.

It has been 5 years since I last wrote on this blog.  I have, on multiple occasions, thought about writing again but I was so good at finding reasons not to.   I shall make the utmost effort to suppress those thoughts and embrace the reasons to write and lovingly discuss these issues not just as a healthcare provider but also as a son, a grandson, a husband, a father, a brother, a cousin, an uncle, a neighbor, and of course a TONGAN. #TongaMaaTonga