The Amalgamation of Critical Care & Infectious Disease

When I decided, upon the completion of my infectious disease fellowship in 2009, to pursue another year of training in critical care medicine, I was perceived crazy given the rigor of such a fellowship and the fact that I was (and still am) an ID addict. (Plus, I had also completed a combined residency in Internal and Emergency Medicine).

My answer to those who questioned my motives was that I didn't want to be an ID physician who steps back once the patient becomes critically ill and requires ICU care. Critical care physicians are trained to be adept at almost everything and often need little to no consultative help from other sub-specialists, leaving the ID physician with little to add. The ICU is also the place where infectious disease often reach their culmination--particularly infections I am very interested in such as emerging infectious diseases and influenza--and I like the unique challenges of managing all aspects of the patient's care, which is the role of a critical care physician. I have a similar sentiment regarding Emergency Medicine, where all these diseases initially present. 

Last night in the ICU served to reinforce my sentiment.

Overnight I admitted two patients with severe infectious diseases, one of which required extraordinary interventions to keep alive. That patient, transferred from a rural hospital with likely influenza pneumonia, progressed throughout the night from requiring moderate amounts of ventilator support to ultimately, after a series of rescue interventions, being placed on ECMO. Trying to halt the onslaught of the infection and the resultant failure of multiple organ systems was extremely challenging.

It is these challenges, inherent in working in an ICU, where the melding of infectious disease and critical care medicine reaches its apotheosis and its what I like to do.

Vitamins: Should They Go The Way of The Flintstones?

I am often asked about what individuals can do to protect themselves from infections, particularly the common cold. 

If one goes to any convenience store it's easy to find several "immunity boosting" concoctions consisting of several vitamins (B-complex, C, etc) which are non-trivial in cost.

Does vitamin supplementation have any effect on the rate of respiratory infections or the like? (One major caveat, I am assuming the consumption of a regular diet in the developed world by an immune competent individual.)

The answer is no.

Studies have repeatedly shown that vitamins, especially D and C, have no effect on the rate of upper respiratory infections. Of course, these facts don't stop the hordes of people that swear by them from spending money on what could be duplicated for about $1--with better taste, in my opinion--by consuming a can of V8.

Moreover, vitamin supplementation--as such--has not proven to be efficacious for any reason (mortality, etc) prompting a great editorial in Annals of Internal Medicine entitled "Enough is Enough: Stop Wasting Money on Vitamin and Mineral Supplements" with which I totally agree. 

The Flush Heard, but not Smelled, Around the World

This Christmas I learned about a seemingly popular gift, at least in my network: Poo-pourri. Poo-pourri is sort of the equivalent of pre-exposure prophylaxis against...the stench of feces. 

One sprays the liquid into the toilet bowl prior to use and the oils contained in the substance neutralize/mask the odor. 

Since my writing is ostensibly educational, a few facts:

• The sulfur-containing products of intestinal bacterial are what produce the characteristic odor
• The repertoire of different bacteria present in one's stool is severely altered, for the long term, by antibiotic use for -- a phenomenon that explains how C.diff infection occurs and the rationale for fecal transplantation for severe or recurrent cases
• A toilet can serve as a rocket launcher for fecal bacteria creating a toilet plume, though this is not thought to be an infection risk (with one caveat below)
• The Flush Heard Round the World: during the SARS pandemic in 2003, a SARS-infected visitor to a large residential housing complex in Hong Kong experienced diarrhea and his flush created an aerosal the sparked hundreds of cases (see my take on a recent paper on this topic)

Proctologists have nothing on infectious diseases physicians.

Vicks VapoRub: Smell Good while Avoiding Antibiotics

It seems like several of my friends and acquaintances have some sort of viral illness, either gastrointestinal or respiratory in nature. 

Currently, we are in the midst of influenza season with reports that H1N1 is again causing severe disease--some of which I have seen myself in the ICU.

Along with influenza, other respiratory viruses such as RSV are circulating and capable of causing mild or even severe illness. While there are antivirals available for influenza, there isn't much to do for the other viruses.

Today, I was asked by one of my friends what he should do for chest congestion.

I said "How, about a Z-Pak?"

Just kidding.

What I recommend is a combination of a few things:

• Ibuprofen or naproxen for fever, aches, pains, and headache
• DayQuil (or the generic version of it) for symptomatic relief of congestion, cough, etc.
• Vicks VapoRub

My friend employed Vicks VapoRub and seemed to immediately report improved symptoms. While anecdotal evidence is not trivial more robust data on the efficacy of Vicks VapoRub in improving sleep of sick children and their caregivers and symptoms (albeit in children) exists. 

My friend wanted to know how Vicks VapoRub work and I didn't really have a good answer so I did a little checking. 

The ingredients include menthol, camphor, and eucalyptus oil and the mechanism of action seems to stem from the ability of menthol to stimulate the TRPM8 channel resulting in improvements in respiration.

So, instead of reaching for antibiotics try VapoRub--you'll feel better and you'll smell better (that's not even considering antibiotic-associated diarrhea).

If VapoRub became the fragrance of the season, we would all be better off. 

Even Rudolph Can't Escape the 4th Horseman

Every organism is plagued with its own infectious diseases, many of which are specific to the species. Hamsters and gerbils don't get infected by exactly the same pathogens. With pets and other domestic animals, many of these microbes  have the capacity to jump to humans and cause a zoonotic infection,

Reindeer are no different.

Some reindeer infectious diseases, which likely impact the ability to engage in reindeer games, include:

 🎄 Reindeer Pest: high mortality infection with Clostridum septicum

🎄Necrobacillosis: severe hoof infection  

🎄Foot and Mouth Disease

🎄Lyme Disease

🎄Pasteurellosis

There also other myriad infections, including nematodes, that can be found in reindeer populations which have implications for reindeer meat intended for human consumption.

None of these diseases, however, is known to cause severe erythema of the nose so Rudolph's affliction will remain a mystery.