are Rabies cases in the USA missed by doctors?

from Sci Alert:

Over 90% of Human Rabies Cases in The US Aren't Detected, Study Finds

the story is that they found a person got rabies from an organ transplant. And the donor was never diagnosed as dying of rabies.

I remember a similar case in Texas where we had once sent a person for a heart transplant.

Records show it was only the fourth time in US history that an organ transplant procedure had transmitted the rabies virus (Lyssavirus rabies) from an initially undiagnosed donor. But what if these kinds of records are wrong?

Even though the Michigan patient fatality represents only the fourth known case of a transplanted fatal rabies infection – the first such instance occurring in 1978 – given how rare organ donation itself is, something just doesn't add up.

if you extrapolate the data to the general population it might suggest hundreds of cases are missed.

Carbon monoxide poisoning

 Carbon monoxide is a silent killer. And this case on Homicide Hunter starts out as a ritual suicide and an investigation finally revealed it was an accident in venting the furnace because the landlord did a DIY instead of paying for an expert.

the problem of concussions and minimal brain damage

 there was a lot of talk awhile back about football causing concussions and brain damage. And of course, boxers developing punch drunk symptoms has sort of been known for decades.

So StrategyPage has a long discussion here of how concussions can cause symptoms that overlap the symptoms of post traumatic stress syndrome.

These included over a quarter million cases of traumatic brain injury, more commonly called concussion and over a hundred thousand cases of PTSD or Post Traumatic Stress Disorder that were discovered among combat veterans since September 11, 2001...

In the last decade it has become clear that injury and disability from PTSD and concussions from explosions were more of a factor than previously thought. Many troops, because of exposure to roadside bombs and battlefield explosions in general, developed minor concussions that, like sports injuries, could turn into long term medical problems. Often these concussions were accompanied by some PTSD.

 

Examining medical histories of World War II, Korea, and Vietnam War vets showed a pattern of later medical problems among many concussion victims. The same pattern has been found among athletes and accident victims who suffered concussions.

the good news: there are now better ways to diagnose these problem

The bad news: no good treatment for them. 

Pain pills and trauma care

People rarely die of prescription opioid medications they are prescribed. 
Well, duh. Sounds about right.

even those on high doses for chronic pain don't get "addicted": They might need to be withdrawn slowly from the medicine, but the psychological problems of addiction are not there (i.e. they take it to get rid of the pain not to get high).

The opioid crisis got bad after I left practicing medicine and moved here, but I know of two deaths in people who stole narcotic medications from cancer patients and died of an overdose. One was a known druggie, but another was a 13 year old girl at a party who was told to "drink this" and did. She was unpopular so obeyed the girl who gave it to her (probably as a joke). The source of the narcotic was the girl's grandmother, who kept liquid morphine for break through pain in her purse. Sigh.

but the dirty little secret is that the little old ladies often sell or borrow pain pills from each other because... arthritis pain.

A lot of older people just use a single mild opioid tablet at bedtime so they can sleep.


Yes, NSAIDs are just as good: indeed, for a lot of pain they are better, because they relieve inflammation: but in the elderly they have the risk of bleeding ulcer and kidney damage, so may kill more people than prescription opioids. So which are safer? It's hard to do a "clean" study, since the abuse cases and suicides confuse the statistics LINK

as for the suggestion to use Paracetamol (Tylenol), sorry: it just doesn't work as well, and it only lasts for 4 hours so you have to take a lot of pills to stay comfortable and again they do not relieve inflammation (which causes pain).

Drug abuse is a societal problem.

But of course, if you acknowledge it is Chinese fake percocet/ oxycontin /Fentanyl being smuggled in via Mexican drug cartels, you might have people actually saying yes build that wall to keep out drugs.

and my question: Where are the churches here? Isn't this a moral weakness to use drugs to get high? And how many take drugs because they were in despair, and no one was there to comfort them?

Ah, but PC churches have different priorities: Too busy worshipping Pachamama and changing Wikipedia pages for their enemies I guess...
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The Good news: from StrategyPage: Freeze dried plasma will save lives.

you give it to people suffering from blood loss. Plasma has been used since World War II (one of my professors was in charge of the blood bank using this to treat D Day casualties) but the new version is portable and doesn't require refrigeration.

The bad news: The French have been using it since 1994, and the US military has been using the French version since 2010 but is still trying to get the paperwork done to make it for the USA.

Article on the history of treatment of shock with plasma and blood transfusions and with IV fluid. LINK

A black physician, Dr. Charles Drew, developed the logistics of providing blood to the injured used in World War II.

His pioneering research and systematic developments in the use and preservation of blood plasma during World War II not only saved thousands of lives, but innovated the nation’s blood banking process and standardized procedures for long-term blood preservation and storage techniques adapted by the American Red Cross.

The Strategypage article notes other lifesaving methods devised for the military and now used in civilian life, such as hemecon and woundstat, used to stop bleeding and the abdominal belt to stop internal bleeding from the aorta.

not mentioned: Don't forget the helicopters.

The opening scene of MASH shows the helicopters bringing in the wounded, but in the last 30 years, helicopter transfer for civilians is becoming more common: Indeed, when possible they will land at your car accident site or near by (e.g. in parking lots) to take you to the Emergency room in some isolated rural communities.


the bad news: Consumer reports laments often they are used when alternative transport is available, leaving the person with a huge bill. But the problem is that when you call the ambulance, you don't often know how serious is the injury, or if the patient might die at the less equipped local hospital, or deteriorate during the long ambulance ride (when I worked in Northern Minnesota, it was 6 hours to Minneapolis and three hours to Fargo by ambulance... and in rural Pennsylvania a trip that is ten miles by map might take an hour and 30 miles by the mountain roads).

This article about a central Pennsylvania auto accident discusses how people are rescued and transported by medivac helicopter. 

I know the area.

Boalsburg is 30 minute drive to state StateCollege and another one hour or more drive to Altoona and in this case, the helicopter landed in a nearby parking lot.

the maps insist it is only a 45 minute drive to drive the 49 miles, but that is not true: that assumes the car accident happened near the interstate highway, that there is perfect weather, and that you can break the speed limit... 
And the dirty little secret is that it is hard to care for a critical patient in a noisy moving ambulance or in a fixed wing transport...

(I have no experience in the helicopters but these medevacs are well equipped, with experienced personnel, so things are less primitive than when I used to make ambulance runs in ambulances or in the fixed wing Cessna owned by the local undertaker that we used to borrow in the 1980s to transport people 150 miles to Rapid City from the Reservation).

My son in law is a Medevac pilot, Keep him in your prayers. 

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In World War I, those suffering mental problem from combat were said to be suffering from "Shell shock".

And the SP article cited above notes that yes, post traumatic stress syndrome is more common in those who had mild brain concussions from IED explosions.

While largely the result of being exposed to a lot of combat, it was, by the late 1990s, realized that head trauma, usually from being too close to a lot of explosions, played a part as well. Work on PTSD continues, especially now that more methods have been developed, including medicines...

more HERE. 

however PTSD also occurs in civilians who had traumatic experiences. WEBMD discusses diagnosis and treatment.

Joe Kenda (of Homicide Hunter) discusses:

Kenda knows he suffers from post-traumatic stress disorder similar to what military veterans experience, and the show is a way for him to release some of the pent-up stress that still eats away at him to this day.

“It doesn’t go away,” says Kenda, who worked his way up to commander of the Major Crimes Unit. “You can’t un-see those things, you can’t not think about them, and you can’t forget them, even though you want to...

There are certain events that will trigger a memory, and it’s startling. Imagine having a nightmare while you’re awake. That’s what it can be sometimes.”

Sigh. Been there, done that. We docs see a lot of horrors too, cases of suffering we couldn't stop, or abuse cases or accidents, or of treatment that didn't work,  and you keep busy so just put the memory in a box and carry on. But after retirement, the memories pop back suddenly, and all I can do it give the problem to the Lord...

sigh.

(cross posted from my regular blog.)

Plasma substitute and red tape

StrategyPage has an article on plasma that does not need refrigeration but the military can't order any because the FDA regulations stand in the way

U.S. SOCOM (Special Operations Command) is gradually getting access to freeze dried plasma (FDP) for use by their combat medics. Plasma is used to replace clotting and other essential blood components in emergencies. It is not whole blood but is taken from whole blood and must be kept refrigerated. FDP is not yet legally available in the United States so SOCOM has been using French FDP, which the French military has been producing and using since 1994...

The problem was that in the United States the FDA (Food and Drugs Administration) needed an American firm to produce FDP that they could put through their testing and approval process. There were problems with finding an American firm that would and could do it and then going through the FDA approval process. It was estimated that this would take until 2020 to complete. 

and that isn't the only battle field innovation saving lives:

Dealing with massive blood loss has always been a seemingly unsolvable problem. While tourniquets have been around for thousands of years, these devices only work on limbs. Preventing death from most other rapid blood loss situations was achieved after 2001 with the development and widespread use of powders and granules that could quickly stop the bleeding. First (in 2003) came special bandages like the Chitosan Hemostatic Dressing (more commonly called HemCon). This was basically a freeze dried substance that caused rapid clotting of blood and was incorporated into what otherwise looked like a typical battlefield bandage. This bandage greatly reduced bleeding, which had become the most common cause of death among wounded American troops. This device was a major breakthrough in bandage technology. Over 95 percent of the time, the HemCon bandages stopped bleeding, especially in areas where a tourniquet could not be applied. This did not work when the abdominal aorta was involved. HemCon was followed by WoundStat powder to deal with some of the bleeding that HemCon could not handle. While medics, and troops, prefer the bandage type device, there are situations where WoundStat (a fine granular substance) is a better solution (especially in the hands of a medic). Only the medics got packets (usually two) of Woundstat powder. That's because this is only needed for deep wounds and has a theoretical risk of causing fatal clots if it gets into the bloodstream.