The Good Fight

On the subject of the main plot line, I don't really there's anything I want or need to say -- it was pretty well covered in the episode. Reactions to blood transfusions occur in about 20% of all cases; the incidence of serious reaction of plasma proteins (which is what happened to Corina) happens in about 1% of all transfusions. The development of bloodless surgical techniques and blood replacement products is, in my mind, one of the most exciting fields in medicine today; it's driven primarily by Jehova's Witnesses who need blood but who can't accept it. This isn't the first time we've dealt with blood replacement products on the show -- remember the Hemo-Aide study with Corday and Romano last year? Same kind of thing. (I'm kinda curious as to what happened to that.)

Carter's jump into public health: Ah, tuberculosis, my old friend and nemesis. I would almost call the TB problem funny, were it not so serious -- for the better part of a century, from the late 1800's on to 1984, the United States and most areas of the world saw a steady decline in TB cases, owing to improved public health, better drugs, and better treatment options. Then, in 1985, the trend reversed itself and TB reared its ugly head again; a disease we thought we'd beaten became a problem once more. You can attribute all sorts of factors to the rise in TB cases: homelessness, drug use, HIV infection, the inability of a lot of TB carriers to complete their treatment, and, of course, the arrival of multi-drug resistant strains of the disease.

Statistically speaking, TB kills nearly three million people worldwide every year. As of the current (December 13) edition of the Morbidity and Mortality Weekly Report (always a good read when you're depressed), the US shows 13,443 new TB cases this year; it killed about 1,100 people in 1996, the last year for which data is available. Keep in mind this is down from about 15,000 in the 1950's, so despite the increase in cases and the return of the disease, we're still nowhere near the same level of mortality.

The CDC recommends that TB be treated with at least four, and sometimes six, drugs at a time, and that patients actually take the damn things. Multi-drug resistant TB crops up because patients don't comply with the treatment regimens. (This is true for just about all bacterial infections -- take your drugs until they're gone! Please!) Recommended drugs are INH, rifampin, pyrazinamide, and either streptomycin or ethambutol for at least two months; there are other dosing schedules that are used in different circumstances, though in my experience, 8 weeks of daily therapy followed by 16 weeks of twice-weekly or thrice-weekly therapy produces the best results and best chances for full compliance.

TB may well kill thirty million people in the next ten years, so naturally, control of the disease is high on everyone's list these days under the "public health" heading. Carter did some good by finding an active TB case in a Chicago neighborhood, potentially preventing the spread of the disease much further. (Although I'd imagine he'd be sweating the TB test that's coming up for him fairly soon, depending on County's infection control policy. For what it's worth, we get screened for latent infection every three months; I'd imagine County's policy is consistent with this, which is based on CDC recommendations.)

On Carter's dislocated shoulder and Lucy's reduction: kids, don't try this at home! For every two dislocations I see, there is at least one person who claims to "know" how to correctly reduce a dislocation; these people are full of crap. The only thing you can really do with a dislocated shoulder is the same thing you can do for a fracture in the field -- immobilize and get the person to medical care. Use ice if it hurts. In hospital, analgesia is administered to manage pain and reduce the anxiety and the muscle tension that comes with a dislocation -- interns and residents like to use midazolam (often way too much) to sedate the patient and relax them. I like to use methohexital because it produces very deep muscular relaxation making reduction of a dislocation a piece of cake, a trick taught to me by an orthopod. Some folks like to use ketamine on the theory that it's safer (less impact on respiratory drive than methohexital), but since the drug's so short-acting anyway (5-10 mintues), I figure I can sit around and make sure the patient doesn't quit breathing while they're out.

I made a lot of references in here to the CDC -- this is the Centers for Disease Control and Prevention, a branch of the United States Department of Health and Human Services, and possibly the most useful government agency after NASA. I love these guys. They're the best source for information about what kills Americans and have a better Web site than Health Canada or the World Health Organization. WHO doesn't carry statistical information on their site, which is annoying as hell. CDC gives it away free. These guys rock my world.

Pay 'em a visit -- they're using your tax dollars, after all: http://www.cdc.gov/