Monday, 22 August 2016

Advice

Getting advice seems to be a problem from the moment we are born.  Well, not so much getting advice, but listening to it.  Parents warn their children not to run with scissors, put on a jacket, wash their hands, and STOP HITTING YOUR BROTHER.  As children get older, the advice gets more serious: look both ways crossing the street, drive slower, STOP HITTING YOUR BROTHER (that one never seems to change).  This advice seems pretty self-explanatory, though children always seem to argue about it.  But other things we tell children need to be explained: why it's stupid to smoke, why it's necessary to put on your seat belt, why you should STOP HITTING YOUR BROTHER.  And then there is some advice that just shouldn't need to be given.  It is so easy to understand and so damned obvious that it shouldn't even need to be mentioned.

Like "Don't put things in your butt."

Since I just mentioned it, it clearly needed to be mentioned.  To Jack (not his real name™) in particular.

Now before I continue, yes this is another rectal foreign object story, and yes I just posted one a couple of weeks ago.  But this one is just Too. Damned. Good.  So here it is for your reading pleasure and distinct anal discomfort.

My RFO patients have thus far all been men, and Jack was no exception.  What makes him slightly different is his age.  All of the other men in whose rectums I've spelunked have been in their late 30s or early 40s.  In other words, old enough to know better than stick something (Coke bottle, butt plug, dildo, etc) in their asses.  Jack, on the other hand, was in his late 60s.  So WAAAAAY old enough to know better than to stick something in his ass.

Jack came in around midnight complaining of, you guessed it, a pain in his ass.  Apparently he wasn't satisfied with the variety of toys available at his local sex shop, so he decided to make his own.  Now a quick perusal of Google will reveal a wide variety of do-it-yourself sex toy kits.  Yes, I checked.  For science, really.  These evidently were also not good enough for Jack and his, uh, needs.  No, instead of some commercially available silicone toy kit, he decided wax would be better.

Vanilla-scented wax, to be precise.

I walked into Jack's room to see an elderly-looking man in Standard RFO Position - somewhat on his side with a grimace on his face.  I decided not to beat around the bush.

Me: OK, what did you put in there?
Jack: *grunt* It's a candle.
Me: . . .
Jack: *grunt*
Me: And why did you . . . Ugh, never mind.  How long has it been in there?
Jack: *grunt* Two . . .
Me: Oh, just two hours?
Jack: . . . days.

Yes indeed, Jack had melted down a vanilla-scented candle, molded it into an apparently pleasing shape, and inserted it into his rectum.  Two fucking days ago.  He had been trying in vain (obviously) to remove it manually.  He had tried an enema.  He had tried stool softeners.  But last I checked, none of those things can melt wax.

The object was easily palpable in his rectum, but it felt fucking huge.  There was nothing for me to grasp, no way for me to remove it easily.  So off to the operating theatre we went.

Once he was asleep I could do a more thorough exam.  Unfortunately the exam was exactly the same.  It still would not come out.  Most foreign objects can be grasped with some special graspers and will slide back out the way it went in.  But not this goddamned thing.  There was no lip, no flap, no anything on which to gain any purchase.

So I did the next best thing: I crushed it.  That is not hyperbole or exaggeration - I literally put the grasper in his rectum and closed the jaws around the thing, crushing whatever part of it I could into bits.  I then removed those bits and went at it again.

The next 20 minutes of my life consisted of breaking off another small piece and removing it (along with some of the plastic wrapper which he had not bothered to remove), all the while taking care not to grab any portion of his rectum (that would be considered bad, as you can imagine).  Finally it was small enough to remove the remainder, and everyone in the room breathed a large sigh of relief.  I think I even audibly grunted in Jack's place when it came out.

The next morning Jack felt much better.  I gave him his discharge instructions, as well as what he could expect over the next several days.  And predictably I also gave him a bit of advice that should never actually need to be spoken aloud:

1) Don't EVER stick anything into your rectum ever again.
2) If you decide to ignore #1, don't wait two days to seek help when you can't get it out.

Tuesday, 16 August 2016

Learning

I love to learn.  When I was a child I had to read books or *gasp* listen to my teachers.  But nowadays the entirety of human knowledge is contained on a tiny device I keep in my pocket, and any information I could possibly want is simply a finger tap away (Hmm, why did Nicolas Cage change his name from Nicolas Coppola?).  My mantra in life is "Any day you learn something new is not a wasted day."


Well, that's only partly true.  My real mantra is "Don't be fucking stupid", but that doesn't look quite as nice on a picture:

Actually I take that back.  I think it looks pretty damned spiffy.

Anyway, learning is one of the few true joys in life.  There are so many things to learn about, so many topics, so many funny cat videos on YouTube.  One of the best things about medicine (and surgery in particular) is that there are always new things to learn.  New drugs are discovered, new surgical techniques are perfected, new diseases are described, and new treatments are devised to conquer it.

And people discover new ways to act fucking stupid.

When I was a child I thought Russian Roulette was a "game" played only in movies like The Deer Hunter.  But no, it turns out that there are some people stupid enough to have played (and lost) in real life.  And I found out recently that despite the horrendous stupidity that must by definition be inherent in the game, there are still people fucking stupid enough to play it.

Like Tracy (not her real name™).

This should not be a difficult concept to grasp for anyone with more than two brain cells to rub together, but pulling the trigger of a loaded revolver may result in a projectile coming out of the business end very fast.  Even if the gun only has one bullet in it, there is still at 16.67% chance that dangerous things will happen.  That's a phenomenon that is generally regarded as bad, especially when the gun is being pointed at something important, like, for example, a person's head.  Apparently Tracy and her friends weren't aware of the concept, because they all decided to play while "partying". 

Nevertheless, somehow nobody lost.  Perhaps the gun wasn't actually loaded, or perhaps they all got very lucky.  Regardless, the game ended, and no one ended up with a bullet-sized hole in his or her cranium.  But the luck would run out a short while later when the game changed from Russian Roulette to Russian Poker.

I had never heard of Russian Poker before, but apparently instead of pointing the gun at your own head, you point it at someone else.  In other words, stupid goes to stupider.

If you can't hear that foreboding foreshadowing music, then you aren't paying close enough attention.

Tracy was clearly sick when she rolled through the trauma bay doors just before noon.  Not sick like *cough cough* but sick as in I'm About To Die, Please Help Me.  

"Hey there Doc, this here is Tracy.  She's 16, shot once in the lower abdomen.  I can't see any other wounds.  Her heart rate is around 120, blood pressure is about 90."

My Inner Pessimist started yelling at me, "Move faster, dummy!"  I already was moving fast, goddammit.  My Inner Pessimist can be a bit of a dick sometimes.

She was sweaty and had that glazed Don't let me die look in her eyes.  We stripped her clothes off quickly, and the medics were right - a single gunshot wound to the left lower abdomen near the pelvis.  We turned her on her side to examine her back, which superficially looked normal.  I then parted her buttocks (while the medics gaped) and found the other gunshot wound on the left butt cheek.  (Note to all future trauma surgeons out there - ALWAYS LOOK BETWEEN THE BUTT CHEEKS.)

My Inner Pessimist started yelling louder.

Take two fingers and put one on your left lower abdomen beside and below your hip bone and one on your left butt cheek.  Don't worry, go ahead - no one is watching.  Good.  Now imagine a line between those two fingers.  There are a lot of very important structures there - small intestine, colon, iliac artery, iliac vein, ureter, possibly even the bladder.  A hole in any of them could be bad, but an injury to the iliac artery can easily cause fatal bleeding.

She needed to be in the operating theatre - NOW.

Ten minutes later we had her in the theatre where we first put in a bladder catheter, and her urine was clear yellow - good, the chance of a ureter or bladder injury was fairly low (though still not zero).  Five minutes after that I had my hands inside her abdomen.  There was a fair amount of blood, but no catastrophic bleeding.  Inner Pessimist quieted down somewhat as I breathed a brief sigh of relief and quickly examined her colon and found it to be normal (another happy surprise).  My Inner Pessimist finally stopped yelling as I ran her small bowel and found one small bullet hole, which I stitched closed.  I found the entry and exit wounds in the left lower abdomen/pelvis, and the bullet had missed the iliac vessels by less than 1 cm.  It had also missed the sigmoid colon by 1 cm, the bladder by 2 cm, and the ureter by 1 cm.

Now that is lucky.

A few days later as she was recovering she told me the story of how she got shot, including the game of Russian Poker that she had evidently lost.  "I didn't even know they had guns when I went to the party," she told me.  Yet that apparently didn't stop her from participating.  Any reasonable person would, oh I don't know, LEAVE.  

But fortunately being a surgeon means constantly learning, and if there is one thing this episode taught me, it was to update my mantra:

Thursday, 11 August 2016

Quotes

WARNING: DO NOT READ THIS AT WORK OR NEAR ANYONE WHOSE OPINION OF YOU MATTERS

People talk too much.  I've often said that a closed mouth gathers no feet, but no one seems to listen, probably because they're too busy flapping their gums.  Despite the fact that everyone on the planet seemingly talks nonstop (my children included, unfortunately), some truly great notable quotes have managed to avoid getting buried by the mundane and banal:
I have a dream. - Dr. Martin Luther King, Jr
To find yourself, think for yourself. - Socrates
That's one small step for man . . . - Neil Armstrong
I will not let anyone walk through my mind with their dirty feet. - Mahatma Gandhi 
This above all else: to thine own self be true. - William Shakespeare 
As you can see there have been some pretty goddamned great quotes over the course of human history.  But as with everything, there are two sides of the story.  As great as those quotes are, some others have said some really fucking stupid things:

Yes . . . they actually wrote that.  Fucking imbeciles.  To be fair, if you were to put a microphone on Trump at any time of day, you'd probably get many more quotes that would fit quite nicely on any Stupidest Quotes list.

Anyway, sadly none of the really good quotes have been either A) said by me or B) directed to me.  And since this egotistical little blog is all about me, I thought I'd share probably the greatest thing anyone has ever said to me. 

Brace yourselves. 

Anyone who knows anything about this stupid little blog knows that my favourite thing in the world is the RFO.  In case you aren't clear on what an RFO is, you can read more about them here, here, or here.  I may make it seem like RFOs are very common, but sadly they are not.

Hmm . . . reading back that last paragraph, I make rectal foreign objects sound incredibly creepy, even creepier than they actually are.  Let me explain so I don't sound quite so creepy.  The reason I like removing them so much is because it is usually a very simple procedure, and it is a remarkably satisfying experience.  

Hmmmm . . . that explanation didn't really seem to help things at all.  Damn.

Ok fine, you want the truth?  You really want the truth?  You think you can handle the truth?  FINE!  Yes, I enjoy taking things out of people's asses.  There, I said it!  Are you happy now?  I enjoy it, and if that makes me a disgusting human being, then so be it.  But before you turn away to vomit, consider this: It takes only a few minutes, patients feel better immediately, they often require little-to-no anaesthesia, and they usually are able to go right back home.  How many other surgical procedures are able to make that claim?  Very few.

Did that help at all?  Still no?  Well damn.

Anyway, back to the story.  

The call from the emergency physician came in just before midnight (of course), and it was the same as all the others:

Doctor Emergency (not her real name™): Hey Doc, I have a guy here with something stuck.
Me {suddenly fully awake}: Something?  What is it?
DE: I don't know, and he won't tell me.  I can feel it, but I can't get it.
Me: I'M ON MY WAY.

I may have sounded a tad too excited, because when I arrived a few minutes later, Doctor Emergency looked startled, like she was about to call a psychiatrist on me.  Apparently I need to learn to tone down my excitement a bit.

A quick glance at the patient's X-ray told me two things: 1) There was no evidence of perforation (good), and 2) whatever "it" was was not metallic (also good - that usually makes it easier to grab).

I walked into the room and introduced myself to Antonio (not his real name™), who seemed entirely plussed.  That was fairly extraordinary - I was expecting him to be at least a little nonplussed.  Regardless, I decided not to beat around the bush and got straight to the point:

Me: Hi there, I'm Doctor Bastard.  So what is it?
Antonio: It's an anatomically correct dildo.  Well, actually I guess technically it's a dong.

Uh . . . well that was unexpected.  I felt somewhat stupid because I had no idea that there was a difference, so I asked him.

"You see doctor, a dildo is just a phallic object, but a dong is shaped like a penis and has balls."

Oh.  Well ok then.

After absorbing that information (and silently wondering if I will ever have occasion to use it again), I asked him how long it had been stuck.  Six hours, was his answer.  SIX FUCKING HOURS.  He had apparently been trying (and failing) to remove it for quite some time before giving up and resigning himself to the fact that he would need to seek professional help.

And that's where I stepped in.

A rectal exam gave me all the information I needed.  I could feel it just a few centimeters above his anal verge, but as is usual in these situations I couldn't grasp it.  Fortunately I had thought ahead and had stopped by the operating theatre front desk for a few supplies, including some heavy duty grasping clamps.  \

After a bit of light sedation, Antonio lay down on his side.  I inserted the clamp into his rectum along my finger, felt for the flange, and grabbed it (making sure not to catch any rectal tissue).

"Ok Antonio, are you ready?  One . . . two . . . three . . . PUSH!"

After about 10 seconds of grunting, pushing, pulling, screaming, and prayer, out popped this:
Most of the time all that grunting and pushing results in a baby.  No such luck for Antonio.

Though I figured I knew the answer to my obvious question already, I decided to ask it anyway.  Do want your dong?  And that's when Antonio hit me with the greatest thing anyone has ever said to me:

"Um, no.  I don't think my wife wants it back."

In my entire medical career I've rarely had to suppress a laugh as much as I did at that precise moment.  But suppress it I did.  At least for a few minutes until I got back to my car.

And then the hilarity of imagining Antonio giving his wife her dong back, trying to explain where he had been, and where it had been, fell over me.

I'm sure she would have said something notable.

Thursday, 4 August 2016

Gish gallop part 3

I am publishing this a bit early since I'll be on a well-earned vacation next week.  I may do some writing while I'm shooshing down a ski slope or basking in the sun under a palm tree with a fruity beverage or hiking through the mountains or relaxing lakeside, but no promises, folks.

With that said . . .

Welcome to part 3 of my 95874-part (apparently) series on anti-vaccine Gish gallops.  {EDIT: This is part 3 of 3.  I can't do it anymore.}  I congratulate you on making it this far.  If you haven't read Part 1 and Part 2, you haven't missed much except for the usual antivax cherry picking, intentional misdirection, hand waving, half-truths, lies, damned lies, and outright fucking lies.  If you'd really like to subject yourself to such balderdash, either A) go back and ready them, B) bash your head against the wall, or C) just head over to Natural News or whale.to.  (all three would probably hurt equally as much).  Bullshit is all Natural News and whale.to publish.  Seriously, I haven't seen one single article on either site that I would call reputable.  It really and truly is all bullshit.

So having smashed several brand new computers while writing my last update and with another brand new computer in hand, I'll now continue slogging through the Gish gallop that is Kelly's Marvelous List of anti-vaccine resources.

When we left off at the end of page 4 (that's right, only 12 more pages to go, folks), Kelly was introducing an article about the Cantalago virus, a mild, self-limiting disease of Brazilian cows and their handlers that lasts about 3 weeks.  In it, the authors describe how the virus may have been derived from a smallpox vaccine strain that escaped into nature.  I hadn't heard of the Cantalago virus, so I was intrigued, and I actually learned quite a bit here (see antivaxxers?  That's called having an open mind.  You should try it sometime).  A bit more antivax-style research (read: a Google search) led me to a fascinating study of  the new virus' history and its genome.  It seems a strain of vaccinia from a smallpox vaccine sent to Brazil from France in 1887 was able to escape and then use cows as a natural reservoir.  The argument that Kelly is making here is, "Look!  A vaccine caused a new disease!  It's bad!"  But I would pose this question: which is worse, a mild and self-limiting disease that lasts for 3 weeks, or FUCKING SMALLPOX, a horrid scourge on humankind that killed 500,000,000 people in the 20th century alone?  What the hell is wrong with these people's brains that makes them completely unable to understand the concept of a risk:benefit ratio?

Moving on.

Starting on page 5, we have Graham Ewing's cesspool article cesspool that antivax activists love to tout.  In fact, it appears as #108 on Ginger Taylor's list of 124 articles that don't in any way prove vaccines cause autism.  I didn't go into detail about this particular piece of shit before, but I will here because what the fuck, I seem to enjoy torturing myself (and, by association, you people).  Ewing quite definitively concludes that "sensory dysfunction and systemic failure, manifested as autism, is the inevitable consequence arising from subtle DNA alteration and consequently from the overuse of vaccines".  Inevitable consequence?  Wow, strong words!  And what evidence does Ewing use to support such a definitive conclusion?  None.  NONE.  He provides no evidence in support of the conclusion, and he consistently proves that he doesn't understand the articles he cites.  Nor does he offer any new actual evidence himself; instead he simply spreads typical antivax lies throughout.  Think what I'm saying is just hyperbole?  Oh ye of little faith.  Allow me to quote from Ewing himself: "Vaccines are not subject to double blind clinical trials despite the evidence of vaccine-drug interactions and perhaps also of vaccine-vaccine interactions."  However, a simple 0.851-second Pubmed search for "vaccine double blind" would have shown Mr. Ewing that there are 2938 hits of double-blind placebo-controlled trials of vaccines and cured him of this particularly mendacious bit of stupidity.

But wait, there's more.

Ewing also states that vaccines aren't 100% effective.  No one actually claims this, though antivaxxers like to say that vaccine advocates claim this (except that we don't).  But to make his point he uses an article from 1977 about the risks of the pertussis vaccine despite vast changes in the vaccine (not all of them good, admittedly) since then.  He also uses the typical antivax argument that 60% of victims in measles outbreaks have been vaccinated.  What he (and all antivaxxers, it seems) continue to fail to understand is simple statistics.  For example, in a typically vaccinated school with 100 students, 90 of them would be vaccinated (approximately).  Say 8 students become infected, 6 vaccinated and 2 unvaccinated.  That means 3-times as many vaccinated are infected, right!  THAT'S SO TERRIBLE!  VACCINES DON'T WORK!  Wait wait wait, no that is not what it means.  It means that 6/90 vaccinated students (6.67%) were infected but 2/10 unvaccinated students (20%) were infected.  See the difference?  Antivaxxers don't.  Plus, the disease tends to be much milder in those who have been vaccinated.  Antivaxxers don't mention that little nugget either.

Ewing also makes wild statements like "In general, vaccines may be influenced by antibiotics" with no support whatsoever other than an article from 1994 about vaccine-related polio in Romania, which has nothing to do with antibiotics whatsoever.  Seriously, that is his reference for that claim.  I have no idea what Ewing was smoking when he wrote this bullshit, but now that I've read it, I want to keep it as far from me as possible.  I also have no idea why antivaxxers include it among their most favourite sources that supposedly prove why vaccines are so horrible.  Actually, yes I do: because they haven't read it.  Or if they have, they don't have the processing capability to realise what utter bullshit it is.

Now I'm going to take a happy little break from this shit while I fix the crack in my desk where my head just hit it 178 times.  I also need to exchange computers.  Again.

. . .

Ok, I'm back.  Still with me?  No?  I can't say I'm surprised.  I'm barely still with me, and I live here.  Be glad you aren't inside my brain with me right now.  Though if you were you'd probably learn some fun new curse words.

Next up is not an article, but a letter to the editor about the purported relationship between the hepatitis B vaccine and diabetes.  Not evidence, just a letter.  Skipped with alacrity.  But don't worry, Kelly gets back to this topic later.  Stay tuned.

Next is an article demonstrating that injecting certain adjuvants can induce lupus-related antibodies.  In mice.  The authors go on to say "Whether this is relevant in human vaccination is a difficult issue due to the complex effects of vaccines and the fact that immunotoxicological effects vary depending on species, route, dose, and duration of administration."  Does Kelly mention this?  Of course not.

I told you she would get back to it.  The next article on Kelly's list isn't an article at all.  Again.  It's another letter to the editor of the BMJ refuting the conclusion of another article.  The original article states "It is unlikely that H influenzae type b vaccination or its timing cause type 1 diabetes in children."  Did you get all that?  Let me explain.  No, there is too much, let me sum up.  Basically the authors of the actual research article in question found no statistically significant increase in the incidence of type-1 diabetes in children after getting the HiB vaccine.  The author of the letter that Kelly cited basically is saying "But yes it does!"  And who is the author of the letter?  That would be Dr. J. Bart Classen, CEO of Classen Immunotherapies which touts that it researches "finding safer ways of using commercially available products including chemicals, drugs and devices" on its website.  Dr. Classen believes the HiB vaccine is causing an increase in diabetes in children despite multiple studies, meta-analyses, and Cochrane reviews which refute him.

NEXT.  I'm getting more and more frustrated with Kelly and her list.  I think I'm on my 9th computer so far today.

Next article we have a group of scientists that induced anti-phosopholipid syndrome (an autoimmune disease) in mice using tetanus vaccine.  Kelly doesn't comment on it, presumably because she doesn't understand a word of the abstract, which is filled with complex sciencey terms like "molecular mimicry and polyclonal B-cell activation" and "monoclonal antibody (MoAb) T-26 specific for TTd and anti-β(2)-glycoprotein I".  Another word she didn't understand was "hyperimmunization".  That's right, the scientists purposefully used a higher than normal dose of tetanus toxoid in order to induce a hyperactive immune response.  Did Kelly mention this?  Of course not, since it completely invalidates the point she tried (and failed) to make.

We have Tomljenovic and Shaw next.  I've discussed them before (see paper #115) and will not do it again except to say that they are rabidly anti-vaccine and this paper is a series of hypotheses which have all been disproved.

A curious paper detailing an increased risk in multiple sclerosis after Hepatitis B vaccine is next.  "Fatally flawed" doesn't begin to describe this mess.  First, they describe the trial as prospective, which it most certainly is not.  When authors don't understand the research terminology they use, that's strike one and two.  Strike three is when they identify 438 eligible cases but only include 163 of them, but then do the main statistical analysis on 11 of them.  ELEVEN.  Strike 4 is the refutation of this study by the author of a study which found the exact opposite.

Another study trying to link the hepatitis B vaccine to MS comes up next, though the author states (and Kelly quotes), "Hepatitis B vaccination does not generally increase the risk of CNS inflammatory demyelination in childhood.  However, the Engerix B vaccine appears to increase this risk, particularly for confirmed multiple sclerosis, in the longer term.  Our results require confirmation in future studies."  Confirmation, however, has not been found.

More hypotheses are next.  "Hepatitis B vaccine might be followed by various rheumatic conditions and might trigger the onset of underlying inflammatory or autoimmune rheumatic diseases. However, a causal relationship between hepatitis B vaccination and the observed rheumatic manifestations cannot be easily established."  That's it.

I can barely even comment on the next one without smashing yet another keyboard, but I'll try.  Sigh.  Here goes.  It's Tomljenovic and Shaw again, and this time it's 2 case studies of teenage girls who died unexpectedly after getting the HPV vaccine.  Sounds pretty damning, right?  Well, no.  The 19-year old girl died 6 months afterwards.  Her autopsy was negative, but the authors curiously say it "allegedly revealed no evidence of neuronal loss or neuroinflammatory changes", which sounds strangely accusatory.  The 14-year old was found dead in the bathtub, and the autopsy again showed no underlying brain inflammation, but it did show ischemic encephalopathy (damage due to lack of oxygen), exactly what one would expect in someone who drowned.  But but but but the authors re-examined brain specimens and found evidence of anti-HPV antibodies in the girls' brains, indicative of vaccine-induced cerebral vasculitis, inflammation of the blood vessels.

DAMNING EVIDENCE!

But perhaps you've heard of Johns Hopkins?  Duke University?  Vanderbilt University?  Columbia University?  Researchers from those institutions reviewed this article and found, well, I'll let them explain: "On review, the CDC-CISA working group identified scientific concerns with the article, primarily, interpretation of histopathology and immunopathology methods.  These concerns negate the authors’ conclusions and significantly limit any interpretation of the results shown in the paper."  Basically their methodology was shit, their interpretation was shit, and their conclusions were based on said shit.

And now, good grief, is an article by, oh my, Burton Waisbren, who has published several articles on, ugh, chronic Lyme disease, and, *sigh*, how MMR causes autism.  I can't even.  I won't even.

We're making progress here, folks.  We're on page 6 now!  Only 10 more . . . to . . . go.

Next is an article from the Medical Hypotheses journal.  Yes, it's just a hypothesis.  Skipped.

I have no idea what Kelly thinks the next article proves, except that self-limiting diseases are self limiting.  Kikuchi-Fujimoto disease causes enlarged lymph nodes and fevers, it has an unknown cause, and it goes away by itself.  This is a case report of a girl who was diagnosed with KFD after getting two vaccines.  It went away.  That's really it.

I think my favourite example of cherry picking and not understanding the science is next.  This is an animal study with baboons, which were immunised with either the whole cell pertussis vaccine or the acellular vaccine, which is known not to be as good as the whole cell version (it does not last as long or protect as well).  Animals which got the acellular vaccine did NOT get the severe disease, but they still were colonised with the bacteria and were able to transmit the infection to other animals.  The baboons that got the whole cell vaccine were also protected but cleared it faster.  Where the abstract says "Baboons vaccinated with aP (pertussis vaccine) were protected from severe pertussis-associated symptoms", Kelly annotates "(NOT TRUE)".  Really?  Is she calling the authors liars?

Anyway, the point Kelly is making here is that animals (and by extrapolation, people) who get the acellular vaccine (which is everybody these days) can spread the infection to others.  OH  NO!  TERRIBLE!  And I agree, that is rather terrible.  But do you know who else can spread it?  UNVACCINATED PEOPLE.  The difference is that the ones who get the acellular vaccine won't get the severe life-threatening disease, unlike unvaccinated people.  Kelly and her ilk try to make it out that only people who get the acellular vaccine can spread the disease.  BZZZZZZZZZT wrong, Kelly.  They essentially become asymptomatic carriers.  The unvaccinated become symptomatic carriers.

I've only gotten through 7 pages, and I'm going to stop.  I skipped down a bit and found a bunch of case reports, "aborted fetal cells" scaremongering, SV40 scaremongering, vaccine shedding scaremongering, XMRV stupidity (it's a lab contaminant and cannot infect humans), and half a page of whale.to links.

But then a quote on page 13 caught my eye, and I thought I'd share it here:
Pure bloody evil - blatant conflicts of interest endangering the health, safety, health rights freedoms, rights to individual informed consent to treatment and individual rights to refuse treatment.
These corrupt bastards are nothing but vaccine industry whores and pimps and we the people won't stand by and let them forcibly inject us all. This will create a revolution of people demanding their full human and health rights freedoms not being told what to do by the corporate whores and pimps and the revolving doors to Governments and the web of deception and conflicts of interests/corruption all through it like sewer pipes.
And there you have it, folks.  This is what these people think.  We are "pure bloody evil" and "corrupt bastards" (well, they're half right) for pushing vaccines.  I don't think anything else really has to be said.  Kelly decided to put this in her "educational document".  This is supposed to be science?  Seriously?

I literally cannot say anything as damning as they say themselves.

And with that, I am done with Kelly and her list.  I apologise for putting you people through this bullshit.  If anyone needs spare computer parts, I think I have a few memory chips and various cards and boards that aren't completely smashed to bits.  There seem to be several "Q" and "BACKSPACE" keys scattered across my floor too.

Monday, 1 August 2016

Gish gallop Part 2

WARNING: This is Part 2 of a multi-part response to yet another anti-vaccine crackpot, so proceed at your own risk.  

When we left off at the end of Part 1, I had decided to skip down a bit on page 1 of Kelly's already-ridiculous 16 page "document" a bit.  It had taken me hours to slog through just the first half of the first page that was supposed to educate and awaken me on the dangers of vaccines.  By the end of part 1, I had learned a lot, but the vast majority was about the mindset of these antivaccine lunatics.

With that lovely and stimulating preface which is sure to make you want to read on, we're moving on.

The utterly preposterous "Vaccines didn't save us" bit from the ironically titled "Child Health Safety blog" predictably shows up.  This has been roundly destroyed by Dr. David Gorski far better than I ever could, so I will leave that steaming pile of bullshit alone and refer you to Dr. Gorski for full details.  The TL;DR version: it's total bullshit.  There is then a link to a story about why Japan banned the MMR (due to increased reported side effects) and switched to separate vaccines.  That sure sounds damning, right?  What Kelly and her colleagues don't tell you (cherry picking, anyone?) is that even after Japan completely eliminated MMR in 1993, their rate of autism continued to rise just as fast as it was before.  The only thing that tells me is that MMR doesn't cause autism.  I wonder what Kelly and her friends think it means.  We don't know, because they gloss over this little nugget.

Skipping down a bit more, there is a link to the ridiculously named "National Vaccine Information Center", which is, according to their mission statement, "dedicated to the prevention of vaccine injuries and deaths through public education and to defending the informed consent ethic in medicine".  In reality, they are 100% antivaccine, and their president, Barbara Loe Fisher, is #131 in the Encyclopedia of American Loons.  There is no other information on the link, just the link.  So the reader is left to wonder the significance.

Next are multiple links to Age of Autism, followed by multiple links to Natural News (which incidentally has now become my go-to source for comedy).  Natural News is a hive of pseudoscience, conspiracy theories, and outright bullshit (but heck, they do have a store!)  I can therefore skip these with aplomb and panache without any reservation whatsoever.

One of the next sources is a link to the Sierra Leone Times.  Hm . . . curious.  Upon clicking it, it refers to a Natural News article (ugh, of course) about the varicella vaccine being ineffective in South Korea.  I had to search for the paper, and upon reading it I discovered that Kelly actually had a point - the 2014 study found that the chicken pox vaccine was only found to be 54% effective with a high breakthrough rate and little amelioration of disease.  The authors' conclusion, however, was not "THIS VACCINE SUCKS!", but rather "This vaccine sucks and we need a better one".  Indeed, looking at the statistics in other countries (for example in the US where a different and much more effective vaccine is used) reveals a startling difference:
But Kelly didn't list this site in her sources, now did she.  The fact is that vaccine wasn't great, but there are better ones available that are quite effective and very safe.  Kelly doesn't want you to know this, however.

After more sanevax and healthimpactnews links (more head-crushing antivax comedy masquerading as information), I skipped forward to the next page where I was dismayed to find a bunch of Facebook links.  Now last time I checked (and feel free to correct me if I'm wrong), Facebook is not exactly a bastion of peer-reviewed science.  In fact, I'm not aware of any peer-reviewed science having been published on Facebook.  I have no idea what Kelly thought Facebook posts were supposed to prove, so I skipped them without a second thought.  If there is any useful information in any of the links, I have to assume it will be contained in the rest of Kelly's expansive document.

There's also a link to a story about an outbreak of mumps where 8 university students were infected despite being fully vaccinated.  However, again what Kelly's friends don't tell you is that the mumps portion of MMR is 88% effective (less than both the rubella and measles portion), and the infection is typically milder among those vaccinated compared to the disease that unvaccinated people get.  And let's again remind ourselves of the protection rate of not being vaccinated: That's right, 0%.  And since most people are vaccinated, it is likely that a majority of the patients in any outbreak will be vaccinated.  That's just simple statistics, folks.

You'll now have to pardon me as I slogged through (read: skipped) more Facebook links, YouTube videos, Huffington Post posts, Natural News bullshit, Vaxtruth balderdash, Vaccine Impact poppycock, No Vaccine hooey, and Health Impact News codswallop.  Bullshit bullshit bullshit, more bullshit, and AAAH, here we go.  A Pubmed article.  Finally!  Now we have some literature.  Ok let's see . . . it's uh, wait, an article from 1950 about the similarity of the mousepox virus to the cowpox virus, and variola to vaccinia?  I don't, uh, yeah, um . . . hm.

There's also a horrible piece of hypothetical pseudoscience from Theresa Deisher who holds a PhD in Molecular Cellular Physiology and should be capable of some good science, but nay.  She purports that foetal DNA fragments in vaccines may combine with our DNA and do bad things.  My oh my.  I can't even begin to touch on this as well as Dr. Gorski did here.  This is nothing but fear mongering.  Know what else contains DNA?  MEAT AND  VEGETABLES.  Ever heard of mutant chicken-people laying eggs and pecking people's eyes out?  (Listen up, Hollywood - that's a great fucking idea for a movie.  Call me.)  The likelihood of tiny bits of foreign DNA recombining with ours is thiiiiiiiiiiiiiiiiiiiiiiiiiiiis close to 0, and the likelihood of that tiny bit of DNA being useful AND recombining with native DNA in a way that would be functional is approximately the likelihood of James Cameron making my Chicken People movie AND me winning the lottery every week for the next 1.93 million years.

Approximately.

As I scrolled down to page 3 (yes, after all that we're still only on page 3 out of 16), a very prominent name nearly popped off the page: Johns Hopkins.  And it's actually a link to a story the Hopkins website!  Huzzah!  Something credible!  But alas, it's a study about brain inflammation in autism, which is one of antivaxxers' latest obsessions, it seems.  The hypothesis seems to go a little like this: autistic brains have more inflammation, and vaccines induce the immune system, and yada yada yada AUTISM!  But Kelly and her friends missed one little detail: THE VERY FIRST LINE: "While many different combinations of genetic traits can cause autism . . . ".  But no, they ignore that little tidbit to make the giant leap to a false conclusion.  I have no problem with the hypothesis that microglial cells are activated in brains of autistic people, but there is no evidence that vaccines induce this.

Right after Hopkins was another name I recognised: CHOP (Children's Hospital Philadelphia).  The link goes to the aluminum information page.  Aluminum is another favourite target of antivaxxers because they don't understand it.  At least, that's the only reason I can think of.  Anyway, CHOP very clearly details how much aluminum is in each vaccine dose versus how much is ingested in the diet (about 26 times as much in the diet if a baby is fed soy-based formula), though I will acknowledge that proportionally more aluminum is taken up and enters the circulation when it is injected than when it is ingested.  No, it is NOT injected directly into the bloodstream.  Dr. Paul Offitt explains this very nicely in a video ON THAT PAGE.  This seems to be another self-destructive link for Kelly (though her ilk are not very big fans of Dr. Offitt).

Towards the bottom of page 3 (YES, STILL ONLY PAGE 3) there is an article from the journal Vaccine (which also published the excellent Taylor meta-analysis) entitled "Annual influenza vaccination affects the development of heterosubtypic immunity".  Hm, good title, good article - this should be good!  It states that getting a flu vaccine (ie against the H3N2 subtype) may inhibit immunity against other subtypes of the flu virus (ie H5N1) and which "highlight(s) the importance of the development of vaccines that provide protection against influenza A viruses of all subtypes".  The underlying message of the article is that the flu vaccine is probably the least effective vaccine we have, so we need to a better one.  Kelly's annotation here says "(of course the answer is MORE and BETTER vaccines)"  Well no Kelly, not necessarily more, just better.  But isn't that what we should want?  Better vaccines?  It doesn't say it's unsafe, it doesn't say it has massive severe side effects, just that it isn't that protective.  So I don't remotely understand the controversy here.

Moving on to page 4.

The first article discusses how maternal antibodies from mothers vaccinated with MMR protect newborns from measles, mumps, and rubella for 3.3, 2.7, and 3.9 months respectively, and 3.4 months for varicella.  Babies of unvaccinated mothers had about 2 months additional protection.  However, MMR and varicella vaccines are not recommended until 12 months, meaning that ALL children are unprotected for at least 6 months, relying instead on herd immunity to protect them.  Even Kelly must admit that lower vaccination rates would lead to higher infection rates, especially in highly susceptible infants, and even Kelly must admit that's bad, right?  RIGHT?

The next citation is a review of the chicken pox vaccination program in the US, published in the Vaccine journal in 2013.  While they state the program is effective (with chicken pox reports dropping 72% from 1995 to 2000), it was not found to be cost effective due to increased morbidity.  The authors also state that the vaccine doesn't offer long-term protection.  This is no surprise to anyone who understands how these vaccines are supposed to work.  They certainly weren't a surprise to Marin et al who conducted a meta-analysis of varicella vaccine effectiveness (published in March 2016).  They found an overall effectiveness of one dose of the vaccine was 81% and a 98% effectiveness against moderate/severe varicella.  In other words, one dose of the vaccine is pretty damned good at preventing chicken pox, but REALLY DAMNED GOOD at preventing severe chicken pox (a booster has now been recommended).  Is it cost effective?  Perhaps not, but that shouldn't matter nearly as much.  It should be expected that preventing disease will not be free.

Next up we have an article from the CDC.  Now I'd just like to point out that to many antivaxxers, the CDC is a completely evil, vile, and thoroughly fraudulent organisation that must not be trusted for any reason.  Unless the CDC reports something potentially bad about vaccines, because then whatever the CDC says is gospel.  Anyway, this article details how the pertussis vaccine may select for Bordetella pertussis bacteria which carry a particularly nasty promoter which makes them more virulent.  Note that this article does not say the vaccine doesn't work (though the acellular version is well-known to be less effective than the whole cell version), nor does it say that the vaccine is dangerous.  Is this nasty strain of B. pertussis a good thing?  Of course not.  But using an article like this in an attempt to invalidate vaccination is ridiculous.  Articles like these are useful for researchers to learn about how these bugs work so they can stop them.

The next article is a bit of hand-waving and cherry picking about Haemophilus influenzae, a bacteria which can cause numerous infections, notably meningitis.  The vaccine protects against H flu type b, not a.  During the 1-year period after Hib vaccination started, Hib meningitis dropped by 69% (HUZZAH!) but H flu type a meningitis increased by a whopping 800%.  Now before you go all crazy let's look at the actual numbers.  The incidence of Hib meningitis was 2.62/100,000 person-years before vaccination and 0.81 after.  The incidence of H flu type a meningitis was 0.02/100,000 person years, or 131 times lower than Hib, and it went up to 0.16, which is still 5 times lower than the incidence of Hib after vaccination.  Want some proof of cherry picking?  Kelly uses these two quotes directly from the article's abstract: "Hib immunization contributed to an increased risk for H. influenzae type a meningitis through selection of circulating H. influenzae type a clones" and "the incidence for H. influenzae type A meningitis increased 8-fold".   But the VERY NEXT SENTENCE in the abstract is this: "The risk attributable to serotype replacement is small in comparison to the large reduction in Hib meningitis due to immunization."  In other words, the vaccine led to an increase in a very unusual subtype, but that increase was FAR less than the DECREASE in the more common type.

Cherry picked indeed.

And there was yet more cherry picking ahead.

Next up is an article showing that the rotavirus vaccine effectiveness in Nicaragua was only 58% due to vaccine-type virus genes recombining with wild-type viruses.  But not only did Kelly fail to mention the very first line of the abstract (where it happens to mention an effectiveness rate of 90% in developed countries), she also conveniently forgot about (or doesn't know about) a study from Finland entitled "No evidence for selection pressure by universal mass vaccination with RotaTeq® vaccine."   A similar study from Brazil found the same thing, and a systematic review from South Korea found it to be safe, effective, and cost-effective.

We're still not even 25% through Kelly's list, and I'm fucking exhausted.  I can't imagine how the three of you who got this far actually feel.

I think I'll pause there, because this long stupid article is too long, too stupid, and too something-else-I-can't-think-of-right-now.  There will be more in part 3, and I'll probably end it all there.

The article, that is.  Not me.  I'm not committing suicide over this bullshit.

Monday, 25 July 2016

Gish gallop Part 1

WARNING: This is another anti-vaccine post, so proceed at your own risk.  If you don't like that, then turn back now etc etc.

WARNING #2: This may be my most ambitious undertaking yet.  Hold onto your hats.

If you've never heard of a Gish Gallop, prepare to be inundated.  Named after creationist Duane Gish, the Gish gallop is a fallacious debating strategy in which one buries his opponent in a torrent of information which may or may not actually support his platform yet makes it impossible for said opponent to rebut each one due to sheer volume.  It is a frequent tactic of pseudoscientists, especially antivaxxers, as we saw here quite recently.

If you think that post was long and involved, you ain't seen the proverbial nothin' yet.

With that out of the way, I'm a fan of vaccines.  Obviously.  I like them a lot.  I think I've made that clear here, and I make it abundantly clear on Twitter as well.  Vaccines are wonderfully complex little concoctions that stimulate the immune system and prevent several relatively benign disease which can become horrific and potentially deadly diseases, scourges on mankind that tortured humans for centuries.  Entire hospitals were devoted to treating smallpox victims: POOF, they're now obsolete.  Millions of children were hospitalised and thousands were killed every year by diphtheria and measles; outbreaks of those are now mostly relegated to history books (though there are still a handful of mortalities annually).

But as with everything, vaccines have risks.  Fortunately these risks are either fairly innocuous (malaise, injection site pain, fever, febrile seizure) or fleetingly rare (anaphylaxis 1:1,000,000, ADEM so rare that statistical analysis is difficult).  Other purported side effects (such as autism, autoimmune diseases, etc) have either not been definitively linked to vaccines or have been definitively not linked.

Still, the antivaccine cohort presses on for reasons known only to them.  Their claims seemingly are getting more outlandish by the day:
  • vaccines don't work (of course they do)
  • vaccines are injected directly into the bloodstream (no they aren't)
  • vaccines cause autism (no they don't)
  • vaccines cause autoimmune diseases (hasn't been proven)
  • vaccines are filled with "toxic garbage" (seriously?)
  • vaccines are being used for population control (SERIOUSLY?)
  • vaccines are being delivered via chemtrails (no really, they actually claim this)
Despite the mounting lunacy, the antivaccine group remains relatively small, though extremely vociferous.  And it is exactly this vociferousness which makes them seem larger than they actually are.  One of them (who respectfully asked not to be named and will henceforth be called Kelly (not her real name™)) was "educating" several pro-vaxxers on Twitter  about "vaccine damage" and mentioned that she had compiled a list of resources.
Normally I don't butt my nose into others' conversations unless there is a good reason, but this seemed a Very Good Reason.  A document?  Sixteen pages??  Sources???  Though I was suspicious that her "sources" would be rabid antivax websites such as truthkings.com, whale.to, naturalnews.com, and the paradoxically named vaxtruth.org, I was holding out hope that I was wrong.  And if I was wrong, it should be absolutely marvelous.  As we just saw recently with Ginger Taylor's ridiculous list of 124 studies purporting to show a link between vaccines and autism (SPOILER ALERT: it doesn't), antivaccine "research" is usually poorly thought out and/or doesn't show remotely what they think it does.  But Kelly seemed different . . . somehow.

I asked Kelly for a copy of her document (WITH SOURCES!) and she emailed me one forthwith (available for your downloading pleasure here).  In her email, she not only attached the document, she also made some, ah, shall we say questionable recommendations.  For example, she suggested I watch the movie "Trace Amounts", a rabidly antivaccine "documentary" not dissimilar to disgraced former-doctor Andy Wakefield's recent catastrophe "Vaxxed".  She also suggested I read several antivaccine books including Raising a Healthy Child In Spite of Your Doctor by Robert Mendelsohn, MD, and Saying No to Vaccines by . . . ugh, fucking seriously?  Sherri Fucking Tenpenny (not her real middle name™)?  When someone has their own page on the Encyclopedia of American Loons where she is called "an abysmally crazy promoter of woo", you know something bad is about to happen.

I felt like Kelly and I were getting off on the wrong foot, not that she knew that.

In her email Kelly also revealed that she belongs to a nonprofit group which includes the words "Vaccine Choice" in its name (she politely asked that I not name the group).  While that may superficially sound fine, "vaccine choice" is a thinly veiled façade for "antivaccine".  These ridiculously disingenuous people actually expect us to believe that they are actually pro-vaccine, but they are only pro-SAFE-vaccine.  But wait . . . "Pro-safe-vaccine" sure sounds great, right?  I mean, who in their right mind would be against safe vaccines!  No no no, in their strangely addled minds, "safe" means "100% risk free".  And nothing, not even this organic recycled non-GMO BPA-free gluten-free bottle of water, is 100% risk free.  So based on all that preamble, I fully expected Kelly's list to be some combination of A) not terribly factual, B) cherry-picked, and C) utterly unreliable.

I would not be disappointed.

Still, Kelly was very gracious and polite, so I promised to return the favour.  She asked me not to "blast" her on Twitter, so I assured her I would go over her list thoroughly, thoughtfully, carefully, and with an open mind.  I offered her the opportunity to rebut any critiques, but she declined, saying, "It's quite presumptuous that you believe that you can not only educate me, but also an entire community of people that include doctors, nurses, and attorneys with a specialization in vaccine law."

Yes, we had definitely gotten off on the wrong foot.

I felt it was rather hypocritical of Kelly to expect me be educated by her "sources" and yet believe that she had nothing to learn from me.  Shame on me, I suppose, for assuming an antivaxxer would be as open-minded and willing to learn as she expected me to be.  As is usually (always) the case with antivax "literature" I expected it to get deep very quickly, and I was again not at all disappointed.

Believe it or not, that's my thoughtful and open-minded opinion.

Kelly's list starts off innocently enough with a website containing vaccine package inserts.  There is no comment, just the link.  I therefore can't comment on the purpose of that, but I have my suspicions.  You know what . . . No, fuck that, I will comment.  The package inserts are on her list because they contain the word "autism", and these people seem to think that is either the pharmaceutical company or the FDA (or both) admitting that the vaccine causes autism.  Of course it means no such thing.  It is simply a statement that someone was diagnosed with autism at some point after getting the vaccine.  It doesn't suggest or imply that the vaccine caused it.  Everyone who knows the purpose of pharmaceutical inserts and what they mean understands this.  Antivaxxers still don't despite having been told it umpteen times.

Perhaps Kelly could have learned something after all.  Oh well.

The next three items on her list are Gish Gallop blog posts which supposedly contain peer-reviewed research.  While I hypocritically dislike blog posts being used as evidence, in the interest of fairness I decided to sift through it nonetheless.  The first, which prominently displays links to the NVIC and Why Not Vaccinate, is comprised of 87 articles, so I knew cherry picking was dead ahead.  And yet again, I was not disappointed.  No, I will not be going over all of them because I have neither the time nor the patience to do THAT bullshit all over again, and anyway I suspect many of them were in Ginger's list that I thoroughly obliterated a few months ago.  But I picked a few at random before I smashed my keyboard and had to go buy another one (ok, that may not be precisely true).  The first article describes increases in cardiorespiratory events after immunising premature infants.

OH EM GEE!  CARDIORESPIRATORY EVENTS IN BABIES!  WE ARE KILLING BABIES!  HOW CAN WE BE SO BARBARIC!

Now slow down there, chief.  First, these "events" are just a transient decrease in oxygen levels or a transient decrease in heart rate, either of which comes back to normal after a bit of tactile stimulation.  A Dutch study found the same thing, and both sets of researchers do not recommend not vaccinating, simply monitoring the babies for 1-2 days after vaccination.  And this only pertains to premature infants.

Not impressed AT ALL.  Next!

The next article describes supposed increases in neurodevelopmental problems after thimerosal-containing vaccines.  There are several problems with this ridiculous "study": first, the "study" was based on VAERS reporting.  Just like with the vaccine inserts, all the occurrences in VAERS mean is that something happened at some point in time after a vaccine was given - no causality, just afterwards (otherwise known as the post hoc ergo propter hoc fallacy).  To illustrate just why this sort of VAERS-based study is such horseshit, there are deaths from car accidents on VAERS.  No, seriously:
Second, thimerosal has been taken out of every single childhood vaccine except certain multi-dose influenza vaccines, and thimerosal-free flu vaccines are available.  Third, thimerosal has been shown not to cause autism and autism-spectrum disorders quite definitively in this meta-analysis of over 1.2 million children.  Oh, and in case you forgot, IT ISN'T IN CHILDHOOD VACCINES ANYWAY.

Since the title of the article includes "neurodevelopmental disorders" and thimerosal", I was surprised and disappointed that Ginger Taylor hadn't put it on her list of 124 studies.  Maybe she'll put it in her next update.

Sigh.  0 for 2.  Next.

Ooh here we go!  Next is an article from the British Medical Journal!  Excellent, finally some meat, right!  It's the BMJ!  Well . . . no.  It's not a study at all, rather a letter stating that the flu vaccine caused side effects in Australia, including febrile seizures in 1/110 children who got it.  Unfortunately for Kelly (and the letter's author), 1) this is a well-known fact, 2) febrile seizures are common after vaccines, 3) febrile seizures are benign, and 4) febrile seizures do not increase risk of seizure disorders or other developmental problems later in life.

Well this isn't going very well at all for Kelly, is it.  0 for 3.  How about the next source?

HAHAHAHA  no.  The next is a link to "The Greater Good" movie, an antivax "documentary" like "Vaxxed".  I skipped it with alacrity and decided to move on to the next source.

Next is another Gish Gallop, this one courtesy of The Refurbished Rogue (What a great pseudonym!  Maybe I should change mine from DocBastard to something with a little more ZING).  I wasn't terribly hopeful when the author started with "This list is just a thrown together list and pretty helter skelter", but I started dutifully at the top.  First off is . . . wait wait wait, is that really an article from the "Medical Hypotheses" journal about how vaccines may cause autism?  Goodness yes, yes it is.  Where shall I begin?  Well, A) It is merely a hypothesis and nothing more, and B) vaccines don't cause autism.  Do they not understand what "hypothesis" means?

Next is the Singh article that appears as #26 on Ginger's list that I thoroughly razed previously.  After that is an article about the effectiveness of the pertussis vaccine, which states that the vaccine was 53-64% effective and concludes, "Tdap vaccination was moderately effective at preventing PCR confirmed pertussis among adolescents and adults".  Apparently Kelly believes "moderately effective" means either "ineffective", "dangerous", or both.  It is common knowledge that the acellular pertussis vaccine is less effective and does not confer as long-lasting immunity compared to the whole cell vaccine, but guess what the effective rate of not vaccinating is?  FUCKING ZERO.  50-60% is literally infinitely better than 0%!  In their minds, anything less than 100% safe and 100% effective means it is 0% useful.

God damn it.  Moving on.

The next one on the list appears to be an opinion piece on ethics with a broken link, so instead of chasing after it like I did with Ginger's broken links, I skipped it.  Next is the other Singh paper (#13 on Ginger's list) which I discussed (read: trashed) previously.  In case you couldn't slog through that one, the author has been criticised for using unsubstantiated and unvalidated lab tests, and his finding has not only not been replicated, it has been refuted by several other studies.  In other words, everything that guy just said is bullshit.

For fuck's sake, enough with the goddamned Gish Gallops.  Let's get off this train and find another ride, and we'll see where Kelly takes us.  Well, next we have the CDC website for lists of vaccine ingredients.  Again, no comments from Kelly here, but it's clear she's trying to point out the scary-sounding ingredients like aluminum hydroxide, formaldehyde, monosodium glutamate, polysorbate 80, thimerosal, and all the other not-so-actually-terrifying ingredients for those who either understand science or trust those of us who do.  Fortunately they are all really only scary to those who don't understand not only the tiny doses but also that they have all been studied exhaustively for decades and have all been found to be safe.

We're not even halfway through the first page here, folks.  Fifteen-and-a-half pages left to go.  I'm not even kidding.

In the interest of time and my own sanity, I'm going to pause here.  I literally cannot take another minute of your time (or mine) to continue this.

For now.

Part 2 will be coming next week.  Depending on how thoroughly I dissect the remaining 15 1/2 pages, there may be Parts 3, 4, 5, 6, 7, and 5682.


Monday, 18 July 2016

Obesity

For those of you who follow this stupid blog and understand how it works, you've probably already guessed that the title of this post compared to one of my previous posts is no coincidence.  For those of you who don't follow, well why the hell don't you?  There's a little "Subscribe to SftTB" button over on the right, just under the "Follow me on Twitter, dammit" button.  So go push one of them.  Or both of them.  It takes less than 2 seconds and will make me happy.  Or happier.  A little bit, at least.  Dammit.

Anyway, even though I'm a surgeon, I still believe in promoting healthy habits.  I know, I know, I'm supposed to be a stupid automaton with a scalpel and no brain, and public health is supposed to be the domain of general practitioners and blah blah blah.  Fuck that.  I see obese patients, I treat obese patients, and I operate on obese patients, and they happen to be much harder to take care of.  Their surgeries are much harder than those of thin patients, there is a much thicker layer of fat to get through, it's more difficult to visualise the structures I need to see (read: not accidentally poke a hole in), and there is a much higher risk of wound problems.  So though you may consider this to be a tad self-serving, I'm very interested in keeping people a healthy weight.  When it comes to trauma surgery, being obese just isn't helpful.

Or so I thought.

If you believe TV and movies (*cough* Game of Thrones *cough*), any penetrating knife wound to the torso is immediately fatal, unless you're the hero, in which case you have at least 18 seconds to either A) breathe the name of the attacker so you may be avenged, or B) tell the nearest bystander to tell your wife you love her; only then will you exhale your last breath so that the aforementioned bystander may run his hand down your face and close your eyelids which I'm pretty sure wouldn't really work at all in real life.

In reality, stabbings are bad (obviously), but not usually fatal.  I've written about this subject before, but for a really quick recap, most stabbing victims have entirely treatable injuries.  Though the various injuries may be life threatening, most of these folks not only make it to the hospital alive, but due to the intervention of hard-working trauma surgeons, they leave it alive too.  Like Liam (not his real name™).

Only not for the reason you may think.

I don't know if people keep their knives locked up during the day or what, but stabbings only seem to happen at night, usually around 3 AM.  Sometimes people surprise me and come in at 2:45 or 3:15, but it's pretty consistent.  Liam was no different - he got stabbed just before 3 and came in right after 3.  I was having a dream about bacon when my pager woke me (god damn it), so off to the trauma bay I went.

I got there a few minutes before Liam arrived, and a nurse filled me in on the details she had gotten from the crew en route - youngish male, multiple stab wounds to the chest and flank, tachycardic (fast heart rate), but a normal blood pressure.  In the ensuing 6 minutes before Liam arrived, I continually ran through my mind all the possible injured organs, which included . . . well, all of them.  Literally.

The medics didn't seem too concerned as they moseyed down the hall a few minutes later.  Liam, on the other hand, looked near death.  He was sweaty, his eyes were glazed over, and he was thrashing all over the bed.  In the trauma bay this is almost always a sign of shock - real haemorrhagic shock, not the "Oh my, I just saw a dead animal on the side of the road and now I'm in shock!" bullshit.  So I again ran through my internal list of potential Very Bad Things that could be causing his impending death.

"Hey Doc, this is Liam," the medics started.  "Thirty years old.  Stab wound to the left upper abdomen and left flank.  He's been tachy the whole time, last blood pressure was 155/90.  Diminished breath sounds on the left, but his sats have been fine."

I absorbed this information quickly as they moved Liam from their stretcher to ours.
  • Tachy - fast heart rate, could be bleeding.  If not bleeding, it's probably bleeding.  If it isn't bleeding, it's still probably bleeding.
  • Normal blood pressure - if he's in hypovolemic shock, it's stage 1 or 2.  Good.
  • Diminished breath sounds on the left - he probably has a pneumothorax or haemothorax
  • Oxygen saturation is fine - he's young and has healthy lungs, so he's compensating for his injury.
This internal evaluation took exactly the two seconds that elapsed until Liam was settled on our stretcher.  He was already completely undressed, so I examined his wounds:
  1. A 2-cm wound in the left lower chest (not the upper abdomen . . . maybe)
  2. A 2-cm wound in the left lower flank/back
  3. A 2-cm wound in the left lower abdomen
None of the wounds was bleeding, so my job became to figure out where the knife went and what (if anything) it penetrated. The first could have entered the abdomen, hitting the stomach or intestine; or it could have gone into the chest, hitting the lung (bad) and/or heart (really bad).  The second wound could have hit the kidney and/or colon, and the third could have injured the small intestine, colon, or both.  The easiest (and most painful) method to determine this is also the most obvious: stick a finger in the hole and see where it goes, and if the finger enters a body cavity, you have your answer in 2 seconds.  I must have been in a good mood that night because I injected some local anaesthetic before digitally probing all three wounds.  Fortunately all of them seemed to go nowhere, just into soft tissue.  Other than the fact that Liam was morbidly obese, the remainder of his examination was completely normal, including completely normal lung sounds (not diminished on the left as was reported).

My Inner Pessimist began yelling at me.  "The medics are wrong, stupid!"

I actually agreed with my Inner Pessimist for a change, though Liam still looked near death.  Something didn't add up.

Sadly digital wound probings are notoriously unreliable, and any trauma surgeon that relies solely on that modality is making a grave (and possibly fatal) mistake.  So off to the CT scanner we went.  By this time Liam had calmed down significantly, his vital signs had completely normalised, and he was no longer sweating.

Ten minutes later my Inner Pessimist started laughing his ass off.  The scan showed that the knife had penetrated only Liam's rather copious subcutaneous fat in all three locations.  There were no serious injuries, no injured organs, nothing.  Just a guy freaking out over a few tiny lacerations.  He wasn't in shock he was just shocked.

Liam's wounds were irrigated, anaesthetised, and repaired within the half hour, and he was walking out of the trauma bay with a huge smile on his face a few minutes later.  It must be awfully satisfying to go from thinking you're going to die to walking home in the span of an hour.

Had Liam been thinner, the knife could have easily done some major damage, and he could have been facing a major surgery (or two or three) or even death instead of leaving the trauma bay in an hour.

Don't misunderstand me, I am in no way advocating major weight gain here.  But if you do plan on getting stabbed in the future (which I wouldn't recommend), you may as well stock up on ice cream, Oreos, and Coke and get started now.  After all, you have a life to save - yours.