The Duck Ages of Folk Medicine: The Good, the Bad, and the Quacks

There I was minding my own business, doing my talk show host thing with my guest wonderful John Milandred, and then the cruelty happened... The technological universe decided to chew up my broadcast and spit it out like a leftover burrito. It was almost as if the botnet of the evil underworld attacked our stream. (Image refers to the book "Slow Death by Rubber Duck" that can be found on http://slowdeathbyrubberduck.com/)

Fortunately, after the whining, belly aching, and beating the computer like a red-headed stepchild in an alien family, my show was saved by Ed Corcoran, the founder of Survivalist Magazine, whom stepped in like a technology superhero. He jumped on the air, covering the broadcast silence with his talk show host expertise. (Ed is the host of the exceptionally rated The Complete Survivalist Show which airs 7 pm to 8:30 pm central time on KPRN-DB the Prepper Podcast Radio Network. You can find out more information on this tech hero on http://www.prepperpodcast.com/Host-Bios.php.)

Anyway enough about the technology gliches and hero talk show hosts, I've got a lot of folk medicine to talk about. Due to the infraction of the technology demons, we lost a bit of valuable time on air and I wasn't able to cover the amount of folk remedies that I had hoped to. (Granted, it was fun having both John and Ed on at the same time, bashing each other like two conquistadors fighting over the prize gold: my audience. ;). My listeners are the best.)

Before I begin describing the best and worst of folk medicine, I'm going to take a tiny detour to discuss the history of advances in medicine.

The History of Medical Stubborn Blindness

I know what you're thinking: "A history lesson? Nooooo!" Oh, come on. You know you love history. Besides, this is all about how medical professionals can be so pigheaded and dumb, when they think they know everything. Everyone loves a good medical community bashing. I'm a doctor and I eagerly get out the sticks looking for the medical pinnata. ;)

Just so you know as if you haven't already guessed, there is a stubborn tendancy within the medical establishment to ridicule its own members if they present ideas different from the mainstream. Oh yeah, its all about the jealousy. Because a lot of those scorned by the medical community tend to be the fathers of true medical advances. Yep, the green-eyed monster strikes again.

A brilliant physiologist named William Harvey was one of the most prominent men ridiculed in this manner. He was the personal physician to King james I. Yep, they definitely hated him. In 1628, he discovered the true circulation of blood. Before him, all medical beliefs on the body's blood circulation came from a dinosaur physician named Claudius Galen (birth 129 AD to 199 AD), whom argued that arteries were just to cool the blood and the heart was the major heat source of which the lungs "fanned" it and discharged "vapors" through the skin. Yeah, there you have it: the heart of our home is the microwave, according to pre-Harvey medicine. This ideology stated that there were two separate blood circulations: the Natural System being the venous blood flow and the Spirit System which was the arterial.

Harvey argued that the flow of blood traveled through the body as if in a circuit, connecting both the venous and arterial systems. For this discovery, he was humiliated and mocked. And it wasn't until after his death, that the medical community of the time finally accepted his discovery as fact.

On my show last night, we discussed the situation surrounding Hungarian-Austrian physician, Dr. Ignaz Semmelwiess (1818-1865). During his lifetime, upwards of 20 to 30% of women and children died during and shortly after childbirth. This was believed to be due to something called "childbed fever" or "puerperal fever," which led to septicemia and death. One of the members of the Clostridium family of bacteria is often accredited with this condition.

He discovered that his medical students that came directly from performing autopsies on mothers that died of puerperal fever to deliver babies from healthly mothers without washing their hands, had higher rates of death among their patients.

So Dr. Semmelweiss argued that doctors should wash their hands between patients. He even went so far as to develop a chlorine wash: a little rough for today's standards of antiseptic handwashes, but still effective. The medical community went for a WWF smackdown on his reputation, ridiculing him to the point of destruction. Heaven forbid that doctors should have to wash their hands! The punk beastards drove Dr. Semmelweiss to a mental breakdown where he died in an insane asylum. All because they were stubborn and didn't want to change what they felt was the standard of medical care. Only years after he died did Dr. Semmelweiss's physician hand hygeine become recognized as an essential advancement in medicine.

The use of nitric oxide in dental work and the use of vitamins in the treatment of diseases and the prevetion of diseases were also met with the same vehement disgust by men too stubborn to look past their own noses.

The moral of the story: Medical advances are always ridiculed by those who are too stupid to realize that something different might just be worth looking into.

Most of the folk remedies that are scientifically proven are still seen as subjects of ridicule by many in the medical community. Granted, there are many old folk remedy wives' tales that should remain just tales, but the remedies that actually work are often lumped in with the quackery as though the modern medical community can't get rid of the stubbornness of their predecessors. Thus the cycle of persecution and unwillingness to investigate different avenues of medicine perpetuates.

Folk Medicine: Fact, Fiction, and Flat Out Quackery

Okay, I know, I should start with the factual evidence behind many folk remedies, but I so have to tell you about some of the funnest quackeries I have ever heard of. I know. I know. You want to refer me to the history of stubborn medical people that I just wrote.... but seriously, you are going to love these ones.

Goose poop for treatment of pimples. I discussed this one on the air. Mmmm mmm mmm! Now, that's a facial mask that brings a whole new meaning to "getting to the bottom of the problem." Fact, pimples are caused by bacteria and oil glands that like to have a party together. Second fact, poop is full of bacteria, most of which is extremely harmful.

This idea comes from the age old wives' tale that dog dung was a good treatment for inflammation and wounds. Yep, some brilliant person in the dark ages decided that rolling around in dog feces would cure everything from baldness to the plague. Another good reason why those times were called the dark ages.

I'm beginning to think that it all started like this:
A nobleman stepped in a big pile of steaming dog poo.

A noblewoman whom he was trying to court sniffed the air and asked, "What foul smell is thus?"

Nobleman lies, as do all those trying to score a chick: "'Tis... uh... um... my medicine for knight's foot. All that jousting needs a... ah... potent medicine, milady." (Yeah, potent as in poo. And thus started the dog dung fad.)

Clipping toenails for a year will cure asthma. This one was perpetuated in the 1800s. This might come from "the toenail bone is connected to the lung bone." LOL. Okay, for the record there is no toenail bone and no lung bone, and contrary to popular belief they are not connected that directly as for toenail clipping to treat asthma.

Biting into a live black or rattlesnake will ensure good teeth and prevent toothache. I love that one. I wonder how much the live snake will appreciate that "remedy." I think it is self-explanatory as to why it fits into the quackery realm.

A sty in the eye can be cured by rubbing it with a live black cat's tail. Now, we got to appreciate the live black animals motif in these folk fakeries. Do you think the cat will be obliging to this quackery?

Okay, enough of the fun quackeries. Now onto the folk remedies that actually work.

Prickly-ash tree bark for oral analgesic. The Prickly-ash tree, also called Zanthoxylum americanum, is a shrub/tree that bears throny branches, aromatic leaves, and a seriously kicking analgesic bark.

As John Milandred said on the Little Prepper Doc show, Native Americans have been using prickly-ash tree bark for toothaches, stomach aches, and inflammation. John indicated that taking an inch of the bark and popping the bitter crud into your mouth produces a numbing effect greater than that of novocaine.

The science behind this is that the bark contains active chemicals such as tannins, ligins, coumarins, and alkaloids. Tannins for example have been proven in studies to have antiinflammatory, mild analgesic, antibacterial, and antiviral properties. Ash tree bark is contraindicated in pregrancy, nursing mothers, and those that have intestinal or stomach ulcers.

A good recipe for prickly-ash tree bark tea is to simmer 1 to 2 tsps (or 5 to 10 grams) of crushed bark in water for 15 minutes or to chew the bark uncooked to relieve tooth pain.

Maggots as a natural form of debridement. The little disgusting wormy fly larvae are the best natural form of debridement in existence. The nasty little critters eat only dead and diseased tissue leaving the healthy living tissue behind. A good story of this was a homeless man came into the ER for foot pain. The doctor looked down at his foot and saw a moving boot of squirming maggots. After almost losing his lunch, the doctor bravely sends in the nurses to clean off the man's leg and give him a good shower. Once the maggots were removed, the tissue left behind on the foot was clean and healthy. The maggots had done their work, preventing gangrene from setting in.

Poultices. The variations in poultices is as broad as an elephant's boxer shorts. Hot oatmeal poultice was used to draw foreign objects out of the skin that are unobtainable by tweezers. Mustard chest poultice is a combination of crushed mustard seed and water (enough to make a paste) with a 4 to 1 parts flour. Place it on the chest of a respiratory patient, changing it every six hours. It has been shown to help in the lymphatic flow of fluid out of the lungs.

Meat tenderizer poultice is a combination of meat tenderizer powder and spit or water to make a paste that is used for sting relief in bee stings. The enzymes in the meat tenderizer breakdown the proteins in bee and wasp stings. Ed Corcoran indicated that honey also can be used for sting relief.

Onions to avoid viral illnesses. One of the interesting findings was that the onion farmers that would sleep a bag of onions next to their beds never came down with the Spanish influenza. Instead, the virus was found in the onions that they slept with. Mmmm.... some people prefer wives, these guys preferred onions. On a more serious note, onions were known for their "drawing power" in folk medicine. In actuality, onions have superb air filtration properties, which collect airborne viral particles, pulling them from the air.

Living the pioneer life. John Milandred, the founder of Pioneer Living, actually practices what he preaches. He lives in a pioneer-style environment without the "technological essentials" of microwaves, plastics, and gas stoves that the rest of us can't live without. He also organically grows his own fruits and vegetables, as well as eats pure and healthy foods. Some people call him an alien because he never gets sick. He has no idea of what the flu is like because he has never had it, nor has he ever taken any vaccinations for it either.

On the opposite hand, environmental researchers Rick Smith, who is the executive director of Environmental Defense in Canada, and Bruce Lourie who is the President of the Ivery Foundation have proven that living the modern-day life might not be so healthy.

In their book, Slow Death By Rubber Duck, Smith and Lourie spend four-days in a "technology-rich" environment eating only foods microwaved in plastic containers, out of cans, and cooked in teflon-coated pans, living on flame-retardant coated furnishings, and enjoying the comforts of synthetic carpets. Prior to their four-day excursion into a surburban condo, the two men had their blood and urine levels of 7 different toxic chemicals measured for baseline. After the four-days, they were measured again to see if the levels of toxins had increased. Sure enough they had tripled and in the case of one chemical known as triclosan, it had multiplied by nearly 2,900.

After the 24-hours of the tuna-eating mercury test, Bruce Lourie started experiencing early symptoms of mercury toxicity such as severe irritability, loss of memory, and anxiety. According to their book, he didn't remember much of that day, which is charcteristic of mercury poisoning. Also his blood results revealed that his blood mercury level had increased far above the "safe" zone indicated by the United States Environmental Protection Agency.

So there is something to be said about the folk remedy of natural and organic living.

It looks like it is time for me to go.

If you didn't get a chance to listen to the Little Prepper Doc show live on Friday, Nov 4th 2011, you can still listen to it on http://www.prepperpodcast.com/Prepper-Doc-Show.php.

Thank you and TTFN.

The 1st Little Prepper Doc Show!

Hello world! Okay, tonight was my first live broadcast on KPRN-DB, the Prepper Podcast Radio Network (http://www.prepperpodcast.com/Prepper-Doc-Show.php).

Yes, it was nerve racking. Seriously nerve racking as if you look up to see a big smelly sumo wrestler was about to squash your head with his bare-naked bum and you have only two seconds to get out of the way.

I was so nervous that I even made a mistake in my speech: I meant to say Coccidiodomycosis (or also called, Coccidiodomycoses) which is a fungus that caused lung infections in California after the earthquake. Instead I said Cryptosporidium which is a protozoan that causes diarrhea. LOL.

Blast those $5000 words! There are so many of them that when you break out into a cold sweat from nerves they start stumbling over each other out of your mouth. Total word salad. Except my word salad was like adding tomatoes to a fruit salad and then adding a spoonful of pepper: it just should never happen.

Anyway, it was fun broadcasting live. From now on, I will have at least one post per show to give further information about the material mentioned in the Little Prepper Doc show.

For those of you that don't know about the Little Prepper Doc show, it runs similar to this blog talking about the ins and outs of preparedness medicine. Next week I will be talking about folk remedies: Do they work and how they work. Please Stay tuned. The Little Prepper Doc show runs Friday nights at 8pm central time.

If you have any questions that you want answered on the show or subjects that you want to hear more about, please email them to disaster_medicine@yahoo.com with "Little Prepper Doc" in the subject line.

Thanks to all of you that listened to my broadcast today. If you missed it, you can download it at http://www.prepperpodcast.com/.

Take care. Love you all!

The last of the Cephalosporins

Antibiotics are interesting drugs. I think they are the only class of pharmaceutical agents that alternative medicine practitioners still consider beneficial. I have heard one naturopath refer to all other drugs as spawn of Satan, but I think that was a little harsh: I wouldn't exactly say "spawn." I'd say "love-child."

The reason for more alternative medicine practitioners to nod at the use of antibiotics, especially in times of disaster, is the speed by which antibiotics work when compared to natural antimicrobials. Natural medicines work much slower, taking weeks to months to accomplish what one medication will in a matter of days. Secondly, the occurrence of sexual assault, human bites, respiratory infections from dangerous soil bacteria, and some zombie bites ;-) most likely will increase during disastrous times.

As a result, sexually transmitted diseases (STDs) incidences will climb. Thus making certain antibiotics essential to have, especially those that treat Chlamydia (which can cause infertility, ectopic pregnancies, and pelvic inflammatory disease), Gonnorhea, Sypillis, Trichomonas, and any new infections that could arise in post-apocylptic situations.

In a nutshell, antibiotics are must haves. Where you get them from is your business, as long as they are from regulated pharmacies. I, personally, promote going to your preparedness-minded healthcare practitioner and explain your need for prepping with a few items, especially for travel purposes. You may get a good prophylactic prescription or two. Canada might also be a good option.

Another avenue that is popular among preppers is to acquire antibiotics from veterinary pharmacies. In fact, I have been asked a great question about animal antibiotics by a member of the American Preppers Network named Rightwing Mom. I decided to answer her here, just because it was such a good question. She asked concerning the safety and efficacy of veterinary-grade antibiotics in humans, especially fish and bird antibiotics. (Image taken from http://www.petconnection.com/blog/2008/07/09/more-veterinary-drug-alerts-from-fda/. Also, there is a lot of good information on this site as well.)

The USDA and FDA regulate the antibiotics given to food-producing animals. Thus, the antibiotics given to cattle, for instance, are more likely to be safe and effective if used in humans, as opposed to those drugs given to non-food animals such as dogs, cats, and non-poultry birds. Fish antibiotics are still ambiguous to me. Fish farms do use them, but I am not exactly sure whether these are also under the same regulatory conditions as beef. It seems that they would be, but I still remain unsure.

In order to standardize animal pharmaceutical information, the University of California-Davis, North Carolina State University, and the University of Florida run the Food Animal Residue Avoidance Databank that provides label information for all food animal drugs, especially antibiotics. For more information on veterinary uses of human-grade antibiotics in food-producing animals refer to the FARAD site at www.farad.org. (It also provides a warning news flash concerning radioactive fallout contamination of food-producing animals. I think that might be an interesting side note to look into.)

The FARAD site provides an algorithm concerning the safety of pharmaceuticals that are to be given to food-producing animals. This might be of interest to those that have thought of purchasing animal-grade antibiotics. I can not advocate this avenue, but if you do choose this route of obtaining medications, it is better that you understand all the precautions and safety issues out there.

Anyway, that being said, antibiotics are great drugs. They sometimes come at great prices, and unfortunately, they sometimes come at such high prices that your Piggybank craps its pants...because that little pig knows you're going to take a hammer to it just to get them. Third and fourth generation Cephalosporins are some of the best drugs, but they often come at a price. (Image taken from eDrugSearch.com.)

For example, one of my favorite third generation Cephalosporins, Cefixime is nearly $300 per 100 milligrams. That's the same price as two sutures during a cardiovascular surgery. Yes, two small 5-0 sutures cost a patient approximately $150 a piece, which partially explains two things: one, why cardiac surgeries are so expensive and two, why sterile sutures are hardly ever seen in preparedness kits.

Anyway, the third and fourth generation Cephalosporins are the drugs you would buy at Tiffanys or Sax Fifth Avenue. In fact, some diamonds are probably cheaper than a IV bag of the fourth generation Cephalosporin called Cefepime.

Third generation Cephalosporins cover infections caused by gram negative bacteria, such as Esherichia coli (which is responsible for the recent food poisoning outbreak in Germany), Klebsiella, Moraxella catarrhalis, Niesseria species, Pseudomonas, Enterobaceteriacae, and Proteus, etc. They also cover gram positive bugs like Staphylococcus and Streptococcus.

The fourth generation is made up of one drug in the US. Yep, Cefepime IV is all by himself, lonely and... costly. This drug covers methicillin-sensitive Staphylococcus aureus, all and I mean ALL gram negative bacteria. Cefepime may be a loner, but carries a big gun.

So let's start with the third generation drugs: They usually have a "tri", "taxi", or "tazi" in their name, with a few exceptions such as Cefdinir and Cefixime.

Ceftriaxone (Rocephin): Only administered intramuscularily or intravenously, Ceftriaxone is the drug of choice in doctor's office for one quick shot. This is a good drug for pneumonia, bronchitis, Gonorrhea, Haemophilus influenzae, Serratia, acute ear infections, septicemia, bone and joint infections, meningitis, Niesseria infections, pelvic inflammatory disease (PID), surgical prophylaxis, epididymitis, endocarditis prophylaxis, and Typhoid fever.

Adult Dosing: 1 to 2 gram IM/IV every 24 hours with a maximum of 4 grams per 24 hours.

Child Dosing: Not for neonates, especially those with hyperbillirubinemia. Children can be given 50 to 75 mg per kg body weight given once a day. The total daily dose should not exceed 2 grams.

Side Effects: Allergic reactions, watery diarrhea, and tea colored urine.

Ceftazidine (Tazicef): Also given IM/IV, Ceftazidine acts similar bacteria as Ceftriaxone, except not as much coverage.

Adult Dosing: 1 gram IM/IV every eight hours. This drug requires renal dosing adjustment to 500 mg per every 24 hours.

Child Dosing: Can be given to neonates less than 7 days old: 100 mg/kg/day divided every 12 hours. Older than 7 days old and greater than 1200 grams weight then give 150 mg/kg/day divided into eight hour doses.

Children one month to 12 years old are to be given 90 to 150 mg/kg/day divided into doses given every eight hours.

Side effects: Agranulocytosis, seizures, and C. difficile diarrhea.

Cefdinir (Omnicef): This Cephalosporin is given orally. Hallelujah! Finally, a third generation that can be eaten. Yum! It treats community-acquired pneumonia caused by H. influenzae and Strep Pneumoniae, and Moraxella catarrhalis. It also covers acute exacerbations of chronic bronchitis, sore throats, sinusitis, ear infections, and skin infections caused by staph or strep.

Adult Dosing: 125 mg to 300 mg given orally every 12 hours. For instance, the treatment dose for pneumonia is 300 mg by mouth every 12 hours for 10 days.

Child Dosing: Can be given to children older than 6 months of age. The average dose is 14 mg/kg/day given by orally divided in 12 hour increments.

Side effects: This drug can has some nasty adverse effects. For instance, it cause Steven-Johnson Syndrome, toxic epidermal necrosis, neutropenia, hemolytic anemia, aplastic anemia, serum sickness, nephrotoxicity, and hepatotoxicity.

Cefixime (Suprax): I love the name of this drug: Ce- fix-i-me S'up-ra. (Which sounds a lot like "Say fix a me up, yo."). Another good oral medication, Cefixime treats urinary tract infections, ear infections, sore throats, Gonorrhea, and bronchitis.

Adult Dosing: 400 mg by mouth once a day. For regular gonococcal infections, 400 mg once will cure it. If the condition is disseminated gonorrhea then it will take 400 mg once a day for 6 days. Children 12 years old and greater than 50 kg in weight can be given the adult dosage.

Child Dosing: Can be given in children older than 6 months of age at dosing of 8 mg/kg/day in a single dose by mouth.

Side effects: Erythema multiforme (big red spots all over your body so that your friends can nick name you spot), Steven-Johnson-Syndrome, and hemolytic anemia. Keep in mind these are rare.

Cefepime (Maxipime): Here's our fourth generation loner that lives in his basement and never comes out unless there is a great need for his superhero-big-gunness: Cefepime's mother often wonders if he will become the next Uni-bomber. Only administered by IV/IM, Cefepime is usually for complicated urinary tract infections, kidney infections, used for immunocompromised patients as infection prophylaxis, skin infections, and complicated intra-abdominal infections.

Adult Dosing: 1 gram to 2 grams by IV/IM every 8 to 12 hours.

Child Dosing: Can be given in children older than 2 months of age at doses of 50 mg/kg every 12 hours.

Side effects: Encephalopathy, leukopenia, hemorrhage, and aplastic anemia.

For all those of my regular followers that were expecting my usual absurd humor, I have to admit that I am so tired that my serious doctor mode has come out. I know, it's sad. Why did I have to be trained to be serious? But yes, it does happen. ;)

Hope you enjoyed the Cephalosporins. Next time: the Marvelous Macrolides.

TTFN.

Cephalosporins: The Next Generation

Cephalosporins, the next generation. That sounds like I'm starting a trailer for Star Trek. Now, all I need is some guy with a deep voice saying, "Cephalosporins will go where no one has gone before."

Man, that's creepy. Especially if you think about Captain Cephalosporin Kirk that goes after every bug princess in the galaxy. "Hey bacteria babe, how you doing?"

Contrary to popular belief, I'm not a huge Star Trek fan. If a pointy eared guy comes up to me, with a psycho split-fingered sign, saying, "Live long and prosper," I'd mace him and run screaming. Then I'd feel bad and give him the card of a plastic surgeon friend of mine. Because somebody has to do something about those ears.

Anyway, back to the message at hand: Second-generation Cephalosporins.

These are the moderators. They have no mnemonic device for their names, because their names are all over the place. As antibiotics, they have more Haemophilus influenzae coverage than their predecssors and have added coverage of anaerobes, Enterobacter species, Providencia, and Morganella. On the other hand, they have less gram positive cocci coverage. What does that mean for us? They don't cover staph and strep infections like the old timers, but they do cover more gram negative bacilli, such as Bacteriodes.

Cefuroxime: Also called Ceftin and Zinacef, Cefuroxime has more coverage of H. influenzae, Enterobacter and Proteus than Cefazolin.

Cefuroxime is administered largely via IV and has a stable shelf-life. It is approved for H. influenzae meningitis which is unresponsive to other medications. It is preferred in ampicillin-resitant strains of H. infleunzae. In addition to that it is highly active against Moraxella catarrhalis, which is a common cause of otitis media, sinusitis, cholecystitis, gonorrhea, lyme disease, tonsilitis, bronchitis, and pneumonia in patients with underlying chronic lung conditions.

Normal Adult Dosage: 500 to 750 mg by IV per every 8 hours. Treatment is usually finished up with oral dosing of 250 to 500 mg every 12 hours.

Child Dosage: It can be used in children older than 3 months. Orally 30 mg per kg per day with a maximum of 1 gram per day. IV dosing is 75 to 150 mg per kg per day with a max dose of 6 grams per day.

Cefoxitin and Cefotetan: The Cephamycin twins. These Cephalosporin twins are known for their activity against Bacteroides, E. coli, P. mirabilis, and Klebsiella. The twins are emotionally stable and take on seriously mutated beasts together.

Yet, Cefotetan lives longer than it's twin. Cefotetan has a longer half-life than Cefoxitin, making its dosing less frequent. It is also more active than Cefoxitin, because the foxy one is spending too much time at clubs.

These two drugs treat infections of the womb (amnionitis and endomyometritis), aspiration pneumonia (pneumonia caused by vomit entering the trachea), human bites (now this is a good one when the Zombies come ;) ), eye cellulitis, community-acquired pneumonia, liver abscess, pelvic inflammatory disease, and surgery prophylaxis.

Normal Adult Dosage:

Both drugs are only administered by IV or IM. 1 to 2 grams every 6 hours. If given by IM, a Cefoxitin injection is painful, but the dosing is the same as IV. Can be given up to 12 grams per day.

Child Dosage:

The twins can be given to children older than 3 months of age. 80 to 100 mg per kg per day divided into 8 doses to be given every 4 hours. Cefotetan has a maximum of 6 gram per day.

Cefaclor: Brand name Raniclor, this antibiotic is great for otitis media and pharyngitis. There isn't a lot to say about this drug. It likes to keep to itself.

Normal Adult Dosage: 250 to 500 mg by mouth per every 8 hours. If renal impairment then give 50% of the usual dosage, unless the kidney problems are severe in which case you would administer approximately 25% of the usual dose.

Child Dosage: 20 to 40 mg per kg weight of child per day divided into 3 doses, to be given every eight hours. For a maximum of 2 grams per day.

WARNING: This drug can cause a severe condition called Sick Serum Syndrome which can lead to death. Another reason why it likes to keep to itself: it's trapped in self-loathing.

Well, that's it for the second generation.

TTFN

Cephalosporins: The First Generation

Cephalosporins are another group of antibiotics that have cross-allergies with Carbapenems and Penicillins. But these are my favorite group. They cover pretty much everything at a relatively low cost... kind of like thugs. You pay a small price and they'll beat up anyone you want: It's beautiful.

Cephalosporins are a great mix of guidos. Some are the brute squad that tackle the dumb masses of bugs. Others are expert snipers that pick off the hardest bacteria one by one.

So if you have a patient suffering from a mutated little nasty, you can send in Specialist Cephalosporin with his little gun and that sucker is gone in no time. It's so pretty. It brings a tear to my eye.

Basically, there are so many Cephalosporins out on the market looking for work that they formed their own class system which is grouped into generations based on age. ;)

The old timers are the first generation. They love a good bingo game and can knit a sweater like you wouldn't believe. The moderate mild mannered adults are the second generation. These guys buy minivans and live in suburbia. The third generation are the gamers, they spend their days playing video games until they reek. The fourth generation are the secret ninjas that only come out to go all Bruce Lee on some big bacteria than disappear back into the darkness of the pharmaceutical shelves.

In other words, each generation covers a different group of bacteria. For the purposes of this post, I will only discuss the first generation. In next few posts, we will discuss the other generations.

The first generation covers the gram-positive bugs such as Staph and Strep. I know what you're thinking: everything covers Staph and Strep these days. Well, that's because of two things:

One: There are more species of Staph and Strep than there are Friday the 13th movies.

Two: Staph and Strep love to mutate.

Yep, these bugs mutate more than the Teenage Mutant Ninja Turtles. More than the X-men. More than New York City sewage gators. And scarily enough, more than that glowing pizza under your kid brother's bed that he tried a dirty underwear and foot fungus experiment on.

So there you have it: that's why we have a billion antibiotics out on the market that kill Staph and Strep.

Back to the subject at hand, the first-generation Cephalosporins treat more than just Staph and Strep, they attack Escherichia coli, Proteus mirabilis, Salmonella, Shigella, and Klebsiella species as well. But they do not cover Listeria or Enterococcus.

An easy mnemonic device by which to distinguish first generation Cephalosporins is by finding an "L" in their generic name. Granted, not every first generation has an "L" in its name, there are some rule breakers such as Cephapirin and Cephradine, but the most commonly used first generations do, so it is a helpful device.

So, let's use Cephalexin as an example. Notice the characteristic "l" in the middle of the generic name. I know that the trade name also has an "l" in it, but most others don't, so we will refer the mnemonic device to the generic names.

Cephalexin: This is probably the most prescribed first generation Cephalosporin there is with the most common use for it being respiratory tract infections. These are Streptococcus pneumoniae and Streptococcus pyogenes respiratory infections.

Even though penicillin is considered the first drug of choice in treating Strep infections, there has been a lot of resistance to penicillin. Cephalexin is markedly more effective at eradicating strep found in the nose and throat.

Other indications for use include Otitis media (Strep, Staph, Haemophilus influenzae [not to be confused with the influenza virus], and Moraxella catarrhalis), skin infections, and genitourinary tract infections, including acute prostatitis (Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis)

Normal adult dosage: 250 milligrams by mouth one pill every 6 hours. Strep infections may require 500 mg every 6 hours. Bladder infections require the 500 mg every 6 hours for 14 days.

Child dosage: 25 to 50 mg per every kilogram in weight of the patient. If the child is younger than one year old then give the dose every 12 hours.

Side effects: Rash, fever, colitis, aplastic anemia, and gastritis with or without nausea.

Drug interactions: Doesn't get along well with Probenecid. I'm beginning to think that Probenicid is the problem drug since it doesn't enjoy the company of any Carbapenems, Penicillins, and Cephalosporins.

Increases the serum levels of the diabetic drug Metformin. It really likes to hang out with it, and causes decreased blood sugar levels in patients taking Metformin.

Cefazolin: Hey, what do you know, it also has the characteristic "l" in its name. This is the artist otherwise known as Ancef that is administered only by injection. I call it the prissy chick of the bunch. It needs to be diluted. It needs refrigeration. It needs you to pick out the green M&Ms out of the bowl and to bring it chocolate dipped strawberries on pink plates. Because how dare you bring it normal strawberries on white plates!

It has the same coverage as Cefalexin, but is a much more aggressive antibiotic. Hey, it's a diva. You pamper it, pay a fortune for it, and it seriously kicks tail when it does its job.

In addition to the infections that Cefalexin treats, the IV-infused Cefazolin treats gram-positive septicemia, biliary tree infections, endocarditis, epididymitis (infection of a part of the testes; men appreciate this drug), and surgical prophylaxis.

Normal adult dosage: uncomplicated conditions require 250 mg to 500 mg by IV or by intramuscular injection every 8 hours.
Severe or life-threatening conditions require 1 gram to 1.5 grams given by IV every 6 hours.

If given IM then dilute with sterile water. Inject it into the patient's butt. Yep, have them bend over. The shot is a total pain in the A.

IV for an adult can be diluted in 50 to 100 mL of any of the following: Normal Saline solution, Lactate Ringer's solution, Dextrose W, and 5% Sodium Bicarbonate. The most commonly used are D5W and Normal Saline.

Child dosage: A total of 25mg per every kg weight of child per day, to be given IV over 6 hour increments, with a dilution volume at 125 mg per mL fluid.

Side effects: Similar to Cefalexin, but needs dosing adjustments in patients with kidney failure. (Cut the dose strength by half)

Same Drug interactions as all first generation Cephalosporins.

Cefadroxil: Also called Duricef, this antibiotic has the similar coverage to Cephlexin. Cefadroxil's edge is that it is especially effective for pharyngitis or throat infections, such as Strep throat.

Skin infections and urinary tract infections are also covered by this particular Cephalosporin. And like the rest of the first generation of Cephalosporins, Cefadroxil is a pregnancy category B drug, so it is relatively safe for pregnant women to take.

Normal adult dosage: 100 mg by mouth twice a day

Child dosage: 30mg per kg weight of the child per day. This can be divided into two doses.

Other First generation Cephalosporins: Cephalothin, Cephaloridine, Cephapirin and Cephradine.

The four compadres pretty much like kicking bacteria butt as any Cephalosporin does, but these shouldn't be used in patients with severe kidney problems.

Other than that, they're great drugs. Besides, they look great in bunny ears.

Hope you enjoyed the first generation. Next time, it's the second generation, known as the moderators. ;)

TTFN

Carbapenems: Who Comes Up With These Names?

There's always a scientific reason why drugs are given certain names: It's called a bored scientist with too much time on his hands is trying to win a game of Scrabble.

"Carbapenem is not a word."
"Yes, it is."
"No, it isn't. It's not even in the dictionary.""
"It's the name of a... a... um, drug that I'm creating. Yeah, that's right. It's the drug I'm working on."

Just for you, I will unravel the mystery of how names of pharmacological agents came about. The influence of the alphabet song makes its mark on the anti-platelet medication abciximab. The owners of the alphabet song are suing for copyright violations.

One scientist was up late one night watching the movie Maverick and the antiviral drug Maraviroc drug was born.

A Trekkie fan created the drug Android (an androgen receptor antagonist) after Data and his rival the Star Wars fan named the arthritis drug Anakinra after the infamous Jedi. May the force be with your anti-arthritic medication.

And if that's not fun enough, scientists get even more creative by stringing together words to form a name, just because we aren't confused enough by the goofy ones already out there.

So there are the ones named after a phrase such as bend-over-must-sting like the alkyating agent that can only be administered by shot named Bendamustine (the company even goes as far as giving it a trendy brand name of Treanda).

I'm just waiting for a scientist whom after eating a couple moldly sandwiches, gives up on a game of Scrabble to do a marathon of Lord of the Rings and youtube. Here could be the name of the newest antipsychotic medication: "Mypreciousmypreciousstarwarskidmeetswizisin."



Then there are the pharmacological agent names that are just plain cruel. These are the ones created by evil mad scientists that prefer torturing people with oxymorons.

My favorite of this category is the colonoscopy preparation called "GoLYTELY." Nothing is more of a rude awakening than this name. If it's not bad enough that you have to go in for a camera the size of Florida up your rear end, the mad scientist in his great evilness decided to psyche you out with the name "Go Lightly." Now, it's a bold-faced dirty lie; there is no "lightly" about about it. In fact, historians believe that Go LYTELY used to be an explosive device created by secret agents to turn vegetarians into salad shooters.

But at any rate, some socially-poor-but-economically-rich schmuck coined the term Carbapenems from the phrase "carve a pretty penny out of them" and we have a really cool class of antibiotic drugs; some of which are quite expensive.

Like, I mentioned in the last post: Carbapenems have cross-allergies with penicillins. So if a penicillin puts a rash spawned by Hitler on your butt then carbapenems try to match it with a rosy rash of their own.

The Carbapenems are a class of antibiotics that attack the cell wall of susceptible bacteria.

They cover a wide spectrum of bacteria. Carbapenems are kind of like Scarface with his big-A machine gun, shooting up everything. "Say Hello to my little Carbapenem!"

Seriously, Carbapenems are the big guns, saved for the life-threatening cases. And following the grand tradition of all hard hitters, they are administered IV. So, you have to get your butt shot before you feel their effects.

Carbapenems handle meningitis (Meropenem), sepsis, endocarditis, ventilator-associated pneumonia, urinary tract infections, bone infections, and complicated intra-abdominal and pelvic infections.

In a few words, they cover the gram-positives like Strep and Staph, similar to the penicillin group, but in addition to that, they also cover some seriously nasty gram-negatives and a few strains of Pseudomonas. But they don't kill Legionella or MRSA. Too bad. Oh darn, the elderly are going to have to avoid sitting near old air conditioners and MRSA sufferers are going to have to find some other drug. Yet they kill anaerobes! So, they are good for bullet wounds and some scary stuff that that incubates in the gut. Woohoo!

The one major flaw with the Carbapenem class is that they can cause dangerous seizures in patients with kidney problems. Have bad kidneys? No Carbapenems for you!

Ertapenem: Does not cover Pseudomonas. It's the only Pseudomonas-lazy Carbapenem out there. It's so lazy that it doesn't even have the gram-positive bug coverage that the other drugs in this class have. So if you're a burn patient with Pseudomonas or have a serious gram-positive bacterial infection, then don't bother with this drug. It will just disappoint you. You'll end up hating each other and heaven knows if it will try to sue for your house. But it is a pretty cheap date, if you're not into spending a lot of money and don't care about Pseudomonas.

And you might as well know that cheap dates like Ertapenem are often antisocial losers: it hates to work with the bipolar medication valproic acid (Depkote) and the drug Probenicid. They fight a lot.

Ertapenem does have its good points: it is a category B drug and is relatively safe to take during pregnancy and while breast feeding. Also, it loves kids older than 3 months old. So it's kid friendly.

Trade name Invanz, Ertapenem is only administered by injection. And just like a cheap Coyote-Ugly needs a shot of Vodka, Ertapenem needs a shot of lidocaine prior to administration just so you can handle dealing with it.

Not at all good for meningitis, but is awwwwwesome for intra-abdominal infections, urinary tract infections (use as last resort), community-acquired pneumonia (if Azithromycin doesn't work), and wound infections.

Normal Adult dose: 1 gram of Ertapenem by IV once a day over a course of 5 to 14 days depending on the severity of the condition.

Side effects include increased platelet count, vaginitis, altered mental status, chest pain, and liver enzyme elevations.

Imipenem: Trade name Primaxin, this Carbapenem includes Cilastatin. Not to be used with antivirals or cyclosporine. Also, not good for our pregnant friends, but loves children. Takes walks on beaches in the moonlight and is not so antisocial as its cheap-A brother.

Imipenem is used for endocarditis. Okay before I continue I have to state some of the ground rules of catching endocarditis. If you are a needle-drug user, you will get endocarditis. Generally this kind of endocarditis is caused by Staphyloccocus. No ifs-ands-or-buts, IV drug users will get endocarditis at some in their drug-using career. Night sweats, chills, unexplained sickness that lasts for weeks with a racing heart rate sometime after heroine injection equals bad case of endocarditis.

People that have heart valve problems may get Streptococcus mutans/viridans endocarditis from visiting the dentist. So dentists generally give prophylactic antibiotics to prevent it. Imipenem is used to cover these difficult cases of endocarditis and it is administered intravenously.

Other conditions that it covers include serious gynecological infections, intra-abdominal infections, sepsis, lung infections, bone/joint infections, Pseudomonas, and multi-bacterial infections.

Normal adult dose: 500 milligrams by IV given every 6 hours over the course of 10 days.

Side effects include confusion, drug fever, psychic disturbances, and in patients with kidney failure, seizures. So don't give it to Psychics with renal failure that want to drive buses.

Meropenem: Also called Merrem IV because it is given only by IV, this Carbapenem has some serious side effects like Stevens-Johnson Syndrome and Angioedema. Yeah, I hit you up front with those. I didn't wait to get you all excited about this drug, make you fall in love with it, and then smack you down with the "this drug can kill you if not used properly" statement. See, I care about your feelings.

One phrase for this drug: Kicks the crap out of meningitis. Yep, this one takes the Louisville Slugger and beats the holy snot out of any gram-positive bug that even dares to venture into your meninges. This is the drug that you would want to marry if you suddenly get "the headache that kills" and trust me, it won't disappoint you. It also can be used for complicated pelvic/abdominal infections such as appendicitis and peritonitis as well as serious skin infections.

Normal adult dose: 1 gram by IV per every 8 hours over a 10 day course.

But as you know, with any classy date, there comes a hefty price tag. This is one expensive drug. Sell your car and your house... and maybe a few of your children and you can pay for this Carbapenem, because it will "carve a pretty penny out" of you.

So that ends my discussion of Carbapenems. There are no more in the class. I think Ertapenem's antisocial behavior has ruined the chances of any other antibiotics joining them. Well, technically there is Dorkipenem (Doripenem) but he's the really really really expensive brother.

The following is a good site concerning wound infections, bacteria, viruses, etc. that is totally worth reviewing:

World Wide Wounds

TTFN.


For all those Star Wars Scientist fans out there when Scrabble isn't good enough:

Bugs and Penicillin Drugs

Before you go to the black market to buy antibiotics and a kidney for Uncle Earl, there are somethings that you should know.

One: Kidneys are hard to get past the TWA. They like to collect them. It's a hobby.

Two: Not all antibiotics are created equal. Even the Founding Fathers, Martin Luther King, and Bugs Bunny would agree.

Some antibiotics cover bacteria that cause upper respiratory infections, while others treat bladder infections and entercolitis. Some treat sore throats and some treat STDs. But none of them treat viruses. You see there is some old school thought that antibiotics are superheroes that fight crime, leap tall buildings in a single bound, and cure the common cold. Not going to happen. Penicillin won't stop H1N1. The Z-pack won't stop a bullet. And Ciprofloxacin won't bring your ex back. Not going to happen.

Antibiotics have their limitations. So for the next few posts, I'm going to talk in depth about the different classes of antibiotics and what they are best used for.

The first class of drugs are called the penicillin family. Penicillin was discovered when a scientist left his moldy sandwich close to a petri dish filled with nasty bacteria. Seriously, who does that? Who leaves their sandwich next to a growing pile of killer bacteria? What was he trying to do? Save it for later? Yum.

Anyway, the mold on the sandwich annihilated the bad bacteria because it was the freakishly powerful penicillin. Bwahahaha!

Thereafter, penicillins have saved millions of lives over the years, especially during the World Wars. So kudos to that perky mold sandwich, it saved the day.

Personally, I have a love-hate relationship with these antibiotics. Penicillins love to give me a rash the size of Kansas. And I hate the swollen tongue and gasping for breath that comes afterwards.

Every class of antibiotics has a chance of causing an allergic reaction: we can't necessarily play favorities. But I do want to mention here the cross-reactions between penicillin allergies and those to certain other classes of antibiotics.

As much fun as it is to watch a patient balloon up after administering a drug, we doctors don't like doing it. So we try to avoid giving penicillins to people whom have already demonstrated allergic reactions to cephalosporins and carbapenems. And vice versa due to cross-reactivity between these classes. Cephalosporins and carbapenems will be discussed in later posts.

Penicillins are beta-lactams. What does that mean for us? Diddly squat. That's a scientific term that I would rather put a red-hot poker through my eye than explain. But what we can take away from this is that the penicillin class of beta-lactams has some serious weaknesses.

Let's put it this way. Bugs are smart. The mutated little beastards have figured out a way to kick the living snot out of penicillin beta-lactams, rendering them less effective against certain super chains of bugs. Freakish beastards.

So what are penicillins good for? That's a good question. They treat infections caused by gram positive bacteria, such as Streptococcus and Staphylococcus... and okay, anthrax as well (yes, anthrax. Penicillin can kick anthrax butt). Some listeria coverage and there is also syphillis and gonorrhea coverage. See STDs had to sneak in there somewhere. (Image taken from http://www.newworldencyclopedia.org/entry/Penicillin)

And you're thinking, darn I left my microscope in my other camping jacket... so can you just tell me what conditions I can use the blasted drugs for.

Oh, sure. Why not? It's not like I have a 7:00 am surgical case that I have to get to tomorrow morning. ;-)

(Before I continue, I must again stress that penicillins are only to be used in patients that do not have penicillin, cephalosporin, or carbapenum allergies.)

Here are a few examples of what antibiotics in this class are used for:

Amoxicillin is the pediatrician's favorite drug for otitis media or ear infections. It is also the first line choice for Strep throat and prevention of bacterial endocarditis in patients with heart valves undergoing dental work. It can be used in anthrax treatment and prophylaxis. This drug has all but replaced penicillin in a lot of conditions.

Ampicillin: I love this drug. It's the only penicillin that won't kill me. I appreciate that. Technically, this drug belongs to a subclass of penicillins called the aminopenicillins, which were created to handle more resistant strains of bacteria. Others within this class are Augmentin (Amoxillin + clavulanate, which has more gram negative bacterial coverage than other penicillins), Unasyn (Ampicillin + sulbactam)

This drug has beautiful gram positive coverage and some gram negative coverage. This is your urinary tract infection drug, because it goes all WWF smackdown on Escheria coli. It also is the drug of choice for listeria meningitis. Ampicillin is one of the few penicillins that can cross the blood brain barrier. If you have a resistant case of meningitis in an immunocompromised patient, especially if he/she is an infant less than one month of age, give them ampicillin.

Unasyn is a more aggressive form of Ampicillin with more coverage of bugs such as Serratia, Enterobacter, Pseudomonas (swimmers ear and wound infections in burn victims), and Legionella (air conditioner related pneumonia in elderly). It's general indications are for gynecological, intestinal, and skin infections.

Oxacillin: This one's fun, because it's named after a bull and can seriously kick bacteria bum. Oxacillin treats recurrent Group B Strep (GBS) infections and is great for pregnant women when ampicillin doesn't work and for neonates suffering from GBS infections. GBS is transmitted through the vaginal canal during delivery to the infant. If there is a vaginal delivery at home, the chances are that the baby is going to acquire a GBS infection and could die. GBS infection signs of fever, lethargy, grunting, nasal flaring, pale or blue appearance, and difficulty feeding occur mostly within the first 24 hours but can occur up to 6 days of life.

Note: Oxacillin can only be administered via intramuscular injection or intravenously. Neonate doses are approximately 50mg/kg/day every 12 hours.

Timentin: A combination drug (Ticarcillin + clavulanate), Timentin is similar to Augmentin but doesn't cover Legionella. Yet, it covers Clostridium difficile, which is the most foul-smelling diarrhea you will ever smell. It makes Giardiasis smell like roses. Consider it a kind of Post-traumatic Stress Disorder for your nose, because if you smell C. diff once, then you will never mistake it again.

C. diff is the diarrhea most common in hospitalized patients which are already on enough antibiotics to kill an elephant. The most common antibiotic associated with acquiring C. diff is Clindamycin. So if you have a patient that was given Clindamycin and afterwards, suddenly gets the Great Stink of all diarrhea then you pretty much can guess it is C. diff. Treat them with Timentin or oral vancomycin and be done with the juicy squirts.

Zosyn: The brand name for piperacillin + tazobactam, Zosyn has the same coverage of the aforementioned penicillins, but with increased ability against Pseudomonas. This drug should be used in conjunction with an aminoglycoside to cover severe pseudomonas infections in burn victims. You can tell a pseudomonas infection by its characteristic blue-green color it causes in wound tissue and the sweet grape-like scent.

Okay, who was the guy that said, "Mmm! I so want to sniff that wound. I bet it smells like grapes."

Well, I hope you enjoyed my ode to penicillins.

TTFN

Code Brown

Do you ever wonder what would cause doctors to run screaming in terror? The answer is a Code Brown. (Image taken from maxupdates.tv.com)

In the hospital setting lots of codes are used to notify personnel of important and dangerous events. For instance, Code Blue means cardiac arrest. Code White generally means stroke. Code Pink means an infant has been kidnapped. Code Black can mean act of terrorism or bomb is on the premises depending on the hospital. Code Red or Orange generally means fire. Code Brown is much much more dangerous... it's patient diarrhea.

I was rounding with the usual herd of doctors and medical students, when we came into the room of an inebriated patient. He was a frequent-flyer for his alcohol and was on a withdrawl protocol which included him wearing nothing but a hospital gown. When asked who he was he stood up proud and tall and said, "Abraham Lincoln."

Just then a tsunami of liquid brown Montezuma's revenge shot out of him all over the floor and on the shoes of a couple residents. After a few girly screams from the men, someone shouted, "Code Brown!"

You should have seen the stampede of doctors rush out the room. I think my attending physician knocked over a couple nurses and a beefy orderly to get out. People were flying. Doctors were gagging. One managed a "Diaper change stat!" between his dry heaving.

Only the third year medical student remained in the room like a deer caught in headlights. The poor guy froze in terror as the Great Stink filled the air around him in tufts of gas that smelt worse than-a-skunk-taking-a-bath-in-a-garbage-can-after-eaten-a-rotten-corpse. Fortunately, the nurses rushed in to save the day. Nurses are heroes.

In the wilderness and disaster setting, diarrhea is not so comical. It actually can be life-threatening. Cholera-- which is a glorified name for explosive watery diarrhea-- killed thousands in the past and still kills many in developing countries today.

The mechanism by which diarrhea becomes dangerous is through the profuse excretion of vital electrolytes in the constant bowel movements. It is through an osmotic effect in your bowel. Yep, that's definitely what you want to read about. You've set down with a big beefy burger about to take a bite and I'm talking to you about explosive bowel movements. Yummy.

Anyway, back to what I was saying before: this massive electrolyte loss results in heart arrhythmias which develop into heart attacks. So the Centers for Disease Control and the World Health Organization have developed inexpensive means to counterbalance this.

Now just so we are on the same page: I'm only talking about diarrhea here and am not including dysentery (bloody diarrhea), pandemic flu (unless it is a strictly diarrheal flu), and zombie attacks (which cause you to crap your pants).

The first part of the treatment: Measure the diarrhea/liquid lost from the body and give the patient the exact same amount in clean or sterile fluids.

As for replenishing electrolytes, I've gathered together some options that you can do at home or in the wilderness:

First option: Mix one Liter of clean (sterilized, boiled, or filtered ) water with Two Tablespoons sugar and one-half tablespoon of salt. Mmm yummy.

Second option: Pedialyte, Infalyte or equivalent medical electrolyte drink. Moderately expensive.

Third option: 1/2 strength Gatorade. I like this one personally. Gatorade is always on sale. And the mixture is one part water and one part Gatorade. Simple. Quick and it replenishes fluids and electrolytes at the same time.

Fourth option: Hikers electrolyte packs. One pack per liter of water.

Fifth option: I call this the kid friendly option is fruit pops, popsicles, or Jello. Man, I love Jello's versatile nature.

Naturally Disastrous Diarrhea:

In disaster settings, profound cases of diarrhea appear when sanitation gets ignored in the face of calamity. I know. I know. The last thing on your mind when an earthquake or tsunami hits your house is "darn, now where am I going to go the bathroom?"

As you all know, contamination of drinking water is imminent. Diarrheal cases increase, some of which can be infections similar to those found in developing countries, such as typhoid, E.Coli strains, Clostridium difficile and cholera. The key to managing these conditions is lots of clean water and electrolytes as mentioned above.

Most common overall regardless of disaster or not, viral gastroenteritis or the "stomach bug" is a watery diarrhea with aches, cold symptoms, chills, and nausea and vomiting. These are also treated with rehydration and electrolytes but are not nearly as severe as the above mentioned conditions.

I do want to mention one more form of diarrhea, which technically classifies as a dysentery condition, but in light of the earthquake, tsunami, and nuclear power plant disaster in Japan, this condition is worth mentioning.

Radiation enteritis is an inflammatory condition characterized by bleeding and painful straining during bowel movements. The diarrhea results from malabsorption due to inflammation of the mucosal lining of the intestines. This condition can persist for 2 to 3 months even after treatment, which is surgery. Yet, avoiding dairy and fats can help alleviate symptoms and promote nutrient absorption. Also, this is the one condition which I will suggest taking loperamide to prevent diarrhea.


Wild Bowels in the Wilderness:

The diarrheal infections in the wilderness setting are much more manageable than those found post-disaster. Giardiasis and Staph aureus are the most common types found in backpackers. In fact, giardiasis is so common that it is called backpacker's diarrhea.

Staph aureus diarrhea is the Mario Andretti of diarrheas. It acts up fast, it moves fast, and it goes away fast (unless you are immunocompromised). Staph diarrhea usually occurs from improper washing of camping dishes in non-sterilized water. Within 4 hours after ingestion, a profuse watery diarrhea and stomach cramping begin. Doesn't generally require treatment due to the fact that it lasts up to 24 hours in non-immunocompromised people.

As for Giardiasis, it's as slow as your grandpa Harold. It takes anywhere from 1 to 2 weeks after exposure for symptoms to start. So if you go camping, don't hold any board meetings or go to classy place 1 to 2 weeks afterwards. Trust me, it won't be pretty.

Giardia comes from drinking river or lake water in mountainous regions.

Symptoms include putrid smelling flatus (sorry bean burritos didn't do it to you), egg-smelling halitosis, watery diarrhea or greasy stools, abrupt onset of abdominal cramps, fever, bloating, nausea and vomiting. These symptoms are cyclic and occur over months with short periods of relief then the cycle begins again. Giardiasis can last for years if not treated. The first line treatment is metronidazole (Flagyl). (See http://www.drugs.com/metronidazole.html for more information on Flagyl.)

I hope you enjoyed this explosively squishy post.

TTFN.

Lobsters are Hemostatic Agents Too, Part II

Okay, so there are no lobsters in this post. I know, I know: it's sad. I'm crying inside too. So for all those missing lobster references, I have decided to include this adorable picture. Who couldn't love that little lobster's face?

When I edited my last post, I half-wondered how many people went searching on the net for homemade chitosan recipes. "Mmmm tastes like lobster." Again, I must stress to the adventurous teenagers out there: Chitosan is not to be covered in butter and eaten, even if it is made from lobster exoskeletons.

Anyway, onto the next group of hemostatic agents.

Thrombin

Topical thrombin products like Evithrom, Recothrom, and Thrombin-JMI are considered part of the biologic hemostatic agents group. Naturally derived from an enzyme involved in hemostasis, thrombin products promote the body to form clots.

Sixty years ago in some dark castle without cable TV, some mad scientist got bored, thought "hmmm, I wonder what would happen if I churn blood like butter" and now we have thrombin. "It's alive! It's alive!"

Seriously, thrombin was isolated from clotted blood products sixty years ago and now we have a perfectly bio-identical hemostatic agent. Happy day.


Thrombin products come in several different types based on the type of plasma it was made from. Cow plasma products such as Thrombin-JMI (King Pharmaceuticals). These products can produce severe histamine reactions and increased antibodies in hemodialysis patients. So the side effects in some individuals have been dangerous increases in coagulation like pulmonary embolisms and on the opposite spectrum, severe decrease in clotting leading to hemorrhage and death.

Not a good choice to use as a hemostatic agent unless you want to create an even bigger mess. "Darn! The cow killed another one." (Image from http://skirmisher.org/weird-shit/cow-chucks-grass-prefers-live-chicken-dinners-as-next-best-thing-to-kfc/)

Companies such as Evithrom, Omrix, and Johnson & Johnson developed human plasma derived thrombin, which has less side effects.

Recombinant human thrombin products like Recothrom (ZymoGenetics Inc.) were also created by companies to reduce the amount of side effects that occurred with thrombin administration.

Cyanocrylates

Dermabond: Need I say more. It's a beautiful product that is commonly known about. People love it, because its the superglue of suturing products.

The cyanoacrylate family of agents are liquid monomers that reapidly react with water to form glue-like polymers. Dermabond and other cyanoacrylates are great for replacing sutures. These are more a class of wound closure products than hemostatic agents, but they deserve some attention. Otherwise they will feel left out and develop psychological issues... and have to see counselors spending hours talking about how we didn't give them attention and so that's why they have to go steal stuff from dollar stores. So, let's talk about cyanocrylates.

They were invented in 1942. A lot of the most amazing medical devices, surgeries, and triage advancements were developed in World War II. The worst war in the world's history produced some of the very best medical inventions of the 20th century. Then in Vietnam, another tragedy of humans killing humans, medicine again benefited from the heroic deeds of military medicine.

Dermabond and its constituents (octyl-2-cyanoacrylate, butyl-2-cyanoacrylate) have the advantages of rapid application, faster tissue repair time, and less need for suture follow up. They also act like waterproof barriers. (The following image shows a shoulder wound sealed with dermabond instead of sutures. Image taken from http://www.orthosupersite.com/view.aspx?rid=25358)

Dermabond and superglue originally evolved from the same product back in the 1940s and so have very similar capabilities. I have talked about superglue as a wound sealant in a past post.

Superglue can be a good disaster medicine tool. It is around the house, easy to come by, and has many of the same properties as dermabond, but with some major flaws: Superglue cannot and should not be used in deep and/or jagged-edged wounds. It also is acidc in nature and produces a chemical burn to tissue it touches. Lastly, it bonds to skin extremely well and a naive person can get glued to their patients... which works well for those loving couples that never want to be separated. But as for the rest of us who want to move on in our lives, superglue should be used with caution. Also, for the love of all that is medical: please don't use superglue (or dermabond) in armpits and buttcheeks. Not a pretty picture.

Dermabond, on the other hand, was chemically created to have a less acidic nature than its commercial cousin, but it does have its own cons. Just like superglue, it is not a good agent for wounds with jagged edges. Also, dermabond can easily breakdown in the presence of antibiotic ointments or petroleum jellies. (A good rule of thumb is to avoid scrubbing the wound or applying anything to it for 7 days after dermabond use.)

Cyanoacrylates are largely used for stopping bleeding in small wounds as a waterproof barrier, which makes them great in wilderness and disaster settings where rain and flooding can be more prevalent. As for their fastness, full binding strength is achieved in less than 2.5 minutes.

Glutaraldehyde Cross-Link Albumin Agents:

Okay, glutaraldehyde cross-link albumin agents is a mouthful to say. So let's just call them Glutes, because everyone can handle Glutes a lot better.

Glute products, like Bioglue, are most commonly used in cardiovascular surgeries, especially those involving aortic dissections and valve replacements. These are produced from companies like CryoLife and created in 1999. They come in cartridges and yes are shot into the wound. Before a bunch of crazy teenagers gets excited about shooting stuff into people's wounds, Bioglue products act more like cheese-wiz then staple guns.

Guess what. These producats are also made from cows. So the next time you're eating that steak, just think, that T-bone could have been a hemostatic agent. Mmmm Mmm good!

The cons with these products are that they may have mutagenic effects. So forget about the vat of toxic waste or the radioactive spider, you can be a superhero from messing with your Glutes. These are another product that shouldn't be applied near nerves and may also cause allergic reactions.

Morals of today's post: Cows can kill. Superglue is your friend or it can glue you to your friend. Don't stick glue in armpits or on butt cheeks. And handle your Glutes with caution.


Well, that's enough medical talk for today. TTFN.

Lobsters are Hemostatic Agents Too, Part I

You know there is something to be said about the ingenuity of our current hemostatic agents. I mean seriously, who would've ever looked at a lobster and thought, "Hmmm, I bet that's going to make a great hemostatic agent.

Well, some smart and now rich beastard did, and as a result we have Chitosan, one of the most common hemostatic agents on the market. (Chitosan is derived from chitin found in the exoskeletans of crustaceans.)

Another brilliant hemostatic agent made from something you wouldn't expect is Arista, which is a polymer made from potato starch. (Image taken from http://www.flickr.com/photos/beckendorf/ )

So we have hemostatic agents from sea cockroaches and Idaho spuds. In addition to those, there are less commonly known but just as ingenious hemostatic agents that deserve attention. The following is a starter list of the various products out on the market.

Gelatin Foams:
There is always room for jello.

Normally, I like to promote gelatin powder, which is a nonsterile, but effective hemostatic agent. Why? Because it has a few added benefits:

First benefit: You will not get hauled to the nuthouse for using powdered gelatin as a clotting agent. "I swear she said a lobster would stop the bleeding!" equals time in a loonybin.

Second benefit: It is a fast clotting agent that is very easy to buy. Seriously, you don't have to drive down to Mexico and beat off drug cartels to get it.

But for the purposes of this post, I am going to talk about the more surgical grade gelatin foams. Who doesn't love a good foam? Gelatin foams began to be used in 1945 and were manufactured from the gelatin found in animal hides. These gelatins were whipped and baked until the formed a sponge foam.

They come as a powder which you mix with a sterile saline solution (preferably) or sterile water to form a paste.

These products include: Gelfilm, Gelfoam, and Surgifoam. Gelatin foams create a type of matrix that instantly clots a wound site. These are used mainly for small blood vessel bleeds, bone bleeds, and venous seeping.

The benefits are that they are absorbed by the body within 4-6 weeks, have a neutral pH, and are nonantigenic or don't cause antibody reactions.

These can be used with oxidized cellulose wrapping. (This is shown in the Springer image to the left)

There are some cautions with these products. Gelatin foams swell. So, they should not be used in closed spaces within the body, especially near nerves.

Truthfully, you shouldn't be sticking anything, even your hands, in people's bodies to begin with if you are not a trained physician. This goes double for procedures in wilderness and disaster environments. So keep your hands out of other people's orifices. Leave that for us doctors: We get selfish over those things. "My prostate exam. Mine. Mine. Mine."

There are particular surgical techniques that we use gelatin foams for which include penetrating traumas where organs are pierced through. We use an oxidized tubular plug filled with gelatin foam, which is held intact by titanium clips or sutures, and insert it into the hole. I'd tell you more but the rest is a trade secret. ;)

[Note: Trade secret is another term for "I'm not telling just to prevent a bunch of doped teenagers from trying it with their grandma's green jello and a straw."] (Image taken from http://simplyrecipes.com/recipes/grandmas_pineapple_cucumber_lime_jello_salad/)

One of the companies that manufactures gelatin foam products is the Pharmacia and Upjohn Company, which is a subsidiary of Pfizer.

I still prefer gelatin powder, because it's around the house. In fact, I have used a mixture of gelatin powder, a few drops of sterile water, and some topical antibiotic on a baby's hemorrhaging wound and it worked effectively within seconds.

For more information on Gelfoam.

Oxidized Cellulose:

These products are called Surgicel Nu-Knit and Surgicel Fibrillar. Developed in 1942 from decomposing wood pulp to regenerate cellolose fibers, oxidized cellulose conforms more rapidly to its surrounding environment than any other hemostatic agent. (Image provided by the medical kit company Baycan http://www.baycanmedikal.com/eng/index.php?option=com_content&view=article&id=14)

Oxidized cellulose creates a clotting matrix that has a consistency similar to cotton. With its low pH, oxidized cellulose has a great antibacterial effect. It doesn't stick to surgical instruments or gloves and it typically dissolves in the body in 2 to 6 weeks.

Do not moisten before use, because it has a greater hemostatic capability when it is dry.

Cautions: It may cause inflammation of the surrounding tissue, so don't use it anywhere near nerves. And for the love of all that good and holy, don't use it on hemorrhoids; it's not a pretty picture.

It is manufactured by Ethicon, Johnson & Johnson.

Bone wax:
Historically, bone wax used to be a mixture of salicylic acid (made from the inner layer of white willow bark), almond oil, and beeswax. (Image taken from Cardinal Health showing their product Sharpoint Bone Wax http://www.cardinal.com/us/en/distributedproducts/ASP/901.asp?cat=surgerycenter)

Currently, surgeons use a nonabsorbable mixture of paraffin, isopropyl palmitate, a wax-softening agent, and beeswax. They apply is to the cut edges of bone to stop bone marrow bleeds. It blocks the bleeding channels in bone marrow, and is easy to handle. You seriously just wipe the stuff on the bone edge like a jelly puddy, but after you are through clotting the wound remove as much of it as possible to prevent bone granulomas from forming (only in 2% of cases).

I have seen bone wax used to stop bleeds from the cut edges of the sternum during cardiothoracic surgeries.

Companies like Johnson & Johnson and Ethicon Inc. market and sell bone wax to hospitals.

Ostene:
This is a pluronic copolymer blend that is a biocompatible alternative to bone wax. They look and feel the same. The use is similar to bone wax.

The only difference is that ostene is water soluble and bone wax isn't.

This is marketed by Ceremed Inc. in California.

Microfibrillar Collagens:

You know when a group of hemostatic agents have enough different names to put a CIA agent to shame, they are seriously cheap to create. Some of the products within this group include Helistat, Helitene, Ultrawrap, Avitene Ultrawrap, Instat, Avitene, EndoAvitene, Avitene Flour, and Avitene Ultrafoam. (Image is of Avitene Flour taken from Bristal Healthcare which is a distributor of these products http://www.bristalhealthcare.com/avitene_63.html)

These products are made from cows. No. Rubbing a cow on your wound doesn't work either.

These products come in various forms: sponges (Aviten Ultrawrap, Aviten Ultrawrap, Helistat), pads (Instat), fluffy white powders (Instat powder, Helitene, and Avitene Flour), and nonwoven compressed sheets (EndoAvitene, Avitene).

Microfibrillar collagens (MFC) work by increasing the surface area for platelets to react upon. Platelets are blood cell fragments that are involved in clotting. Hemostatsis occurs within 2 to 5 minutes. It doesn't swell and is absorbed within 8 weeks.

Because MFCs work through platelet clotting, these are not effective in patients who have thrombocytopenias. On the other hand, it works exceptionally well in patients with normal platelets even under massive amounts of heparin.

Other facts: MFC is most successful in treating a large oozing bleed. It sticks to gloves, so it should be applied with DRY surgical instruments. Also, remove excess MFC from the wound site because it binds to nerves and dermatome surfaces causing pain and numbness.

Companies that manufacture these products include: Davol (Avitene Flour, Avitene, EndoAvitene, Aviten Ultrawrap and Ultrafoam), Integra Inc. (Helitene and Helistat), and Ethicon Inc. (Instat).


Morals of the story: Keep all hemostatic agents away from nerves. Keep your hands out of bloody holes. And don't use expanding hemostatic agents on your hemorrhoids.

Have a nice day!

This is Christine your friendly neighborhood medical blogger signing off. TTFN!