Sunday, June 5, 2016

Please Don’t Take the Z-Pak!

We have been having a terrible spring this year in St. Louis as far as pollen and mold go. Perhaps it’s been the mild temperatures since late February combined with more rain than usual. At any rate, I know that I have been blowing my nose and have had red, itchy eyes a lot more this year than I have had in many previous years. In addition, my pediatric colleagues and I have certainly been seeing a lot more of these sorts of symptoms in the kids in our practice. It’s been tough for kids and parents – as well as for the many friends who ask me what they should do about it.

What I say is that, with the stuff that’s floating around in the air right now, most people are going to have some nasal stuffiness and irritation, even if they don’t have an official diagnosis of allergic rhinitis, a.k.a., nasal allergies. Look at your car windshield, I’ll say, what did it look like this morning? Green stuff, they’ll say, I had to use the windshield washer and wipers before could I drive anywhere. Right, I’ll say, and you’re breathing that stuff into your nose too. This is where I should see a light bulb go on, and then I can say, so what we need to do is clean that stuff out of your nose. The reason you’re stuffy, the reason you’re sneezing, is that this is what our body does to get rid of the bad stuff we breathe in.  The mucus in your nose is there to capture all this possibly bad stuff – dust, mold, pollen, bacteria, viruses, fungus – that floats around in the air we breathe before it goes any further and gets down into the lungs. (Fun Fact #1: The average adult produces about a quart of mucus every 24 hours in your nose, throat, and lungs. Fortunately, it’s not produced all at one time. We create it slowly, and it acts like flypaper to capture this bad stuff, then transport it to our throat where we unconsciously swallow it and send it all hurtling down to your stomach – more on that later – where the mucus gets digested and recycled. Enjoy your lunch!) The more bad stuff you breathe in, the more mucus your body produces to get rid of it. You can help to get rid of it by getting some salt water, i.e., saline, nasal spray and spritzing that up each nostril and then blowing your nose. That cleans your nose out the same way your wipers clean your windshield. And since it’s not a medicine, it doesn’t have medication side effects so you can use saline spray every couple of hours if you need it. This may even help red, itchy eyes a bit since tears are always being produced in the upper eyelids by the lacrimal glands (from the Latin “lacrima,” a tear) and then are swept across the eyes by the eyelids to wash away the stuff that lands on your eyes from the air. In that way the tears and eyelids are also very much like that windshield washer/wiper analogy. This then drains into the lacrimal duct, a tiny tube which goes from the inner corner of each eye (the opening of which is often seen as a little dimple in the pink stuff at that corner of the eye) and runs down into the nose. (This is why you often have to blow your nose whenever you watch a movie based on a Nicholas Sparks book. Those tears have to go somewhere!) This all then drains down your throat into your stomach where any infectious stuff is supposed to get destroyed by the acid in the stomach. (Fun Fact #2: Yes, that’s why we have stomach acid. The stomach, as the first stopping point for foreign matter that enters the body, is essentially an acid bath that sterilizes whatever enters there, and this helps to keep us from getting bad infections. So stomach acid is not just there to annoy you when you’re doing your taxes.) If you clean out the lower end of the lacrimal ducts with saline spray in the nose, your eyes might drain better and get that irritating stuff out of there. (You can also massage the bridge of your nose below the eyes to compress the ducts, pushing the mucus down and clearing them out a bit.)

Then there are the sinuses. Why do we even have sinuses? One recent paper in “The Journal of Laryngology & Otology” [2009 Jan;123(1):4-8] concluded, “The paranasal sinuses may act simply to improve nasal function; certainly, it has been demonstrated that they may act as an adjunct in the production of nitric oxide and in aiding the immune defences of the nasal cavity. However, there is a distinction between utility and evolutionary origin. It may still be that the sinuses arose as an aid to facial growth and architecture, or persist as residual remnants of an evolutionary structure with an as yet unknown purpose, and in doing so have found an additional role as an adjunct to the nasal cavity.” In other words, no one really knows. As a singer, I know that they certainly do have a role in vocal production, and when I’m stuffy, it makes a difference in how I sound – and how much I feel it’s fair to charge an audience! The thing is, they’re there, a group of four paired air-filled rigid, pouch-like spaces that surround the nasal cavity. Each of them has essentially one way out, a small opening, called an ostium. If you have a lot of mucus building up in a sinus and it clogs up an ostium, it can cause pain and tenderness. And if bacteria are clogged up in there, it may cause a problem.

So now let’s talk about bacteria for a minute. Bacteria get a bad rap. We have been programmed to think of them as being irredeemably awful, like the slimy, snarling, evil principle target in a POV shooter game. In reality, though, probably less than one percent of bacterial species cause human disease. And because of how our immune system works, even a lot of those potentially pathologic bacteria exist on or in our body with no problem because we keep them under control. A lot of that control has to do with fluid flow. For example, most of the time, people don’t “catch” bacterial pneumonia. What happens is that something else, perhaps an irritative problem like we’ve been discussing or asthma or a viral illness, has increased the production of mucus in the lungs significantly, and you can’t clear out the mucus. Bacteria like pneumococcus, which can cause disease but often are just part of our body mass of bacteria (Fun Fact #3: the average adult’s body mass includes anywhere from 1 to 3 percent microorganisms, e.g., in a 200-pound adult, that’s 2 to 6 pounds of bacteria. Yeah, I know…), are usually already in our lungs, and as they reproduce, are routinely disposed of by the mucus transporting them up to the throat and then down to get fried in our stomach. But when air passages get blocked, they have nowhere to go, they multiply, creating a critical mass of bad stuff, and you get sick.

You don’t need to be a plumber to know that clogged pipes are a bad thing. And our bodies are made up of all kinds of systems of pipes and fluids: the circulatory system carrying blood; the digestive tract carrying food and eventually stool; the pancreatic ducts carrying digestive juices; the biliary tract carrying bile; the urinary tract carrying urine; the respiratory tract carrying air. Even our central nervous system has fluid that is produced in the center of the brain and then travels down, bathing and cushioning our spinal cord, getting reabsorbed in the lower back. If fluid stops anywhere, it’s a problem, and stuff that our body doesn’t like starts to grow. Think about a mountain stream: Water splashing over rocks so crystal clear that you can see at the bottom of the creek bed. If that stream drains into a stagnant pool, we now find still, murky, greenish water that you can smell before you see it. Stuff grows there. This is what happens in your body when fluids don’t flow.

So back to our sinuses: Yes, this can happen. Stuff can build up in our sinuses and lead to infection. However, as with that stagnant pool, sometimes clearing out that blockage may be all you need to do to flush out the bad stuff and clear or prevent an infection. When it comes to sinuses, that may simply mean using the saline spray, drinking more water to make your mucus thinner, spending time in a humidified environment, and staying away from irritants. (And since I haven’t said this yet, I’ll say it now. If you smoke, quit. If you’re around smokers, insist they smoke outside. The particulate load in smoke is huge and can easily overwhelm the ability of your respiratory membranes to 1] produce enough mucus to capture it all, and 2] clear away the mucus once it’s loaded with all that crap. And if you think vaping is any better, you’re wrong. There’s more and more evidence to show that it causes just as many problems as plain old, bad old cigarettes. Just walk away.)

So if your sinuses can get blocked up and you can get a bacterial infection there, why am I starting this whole thing with, Please don’t take the Z-Pak? Well, because that might be the worst thing you can do.

Remember Fun Fact #3? That 1-3% of your body is bacteria? Well, they’re not just there for the hell of it. They’re there because over time your body and its various systems, including your immune system, have figured out which bacteria you can live with and which might even be helpful. For example, the normal bacteria on our skin and in our mouth, what we call our bacterial flora (Fun Fact #4: I live on Flora Place! Not because of all this, but it’s a nice coincidence), help to prevent us from getting yeast infections in those places. We commonly see yeast infections in newborn babies because they come into the world essentially bacteria-free from being in the womb with mom’s membranes intact. It takes a while for babies to build up that bacterial flora and sometimes a type of yeast called candida gets there first causing a cheesy white irritation in the mouth called thrush and/or a reddish candidal diaper rash. Why those two areas? Well, candida likes to live on parts of the body that are warm and moist and dark and relatively sheltered from the air, and the inside of a baby’s mouth and the inside of a baby’s diaper both fit those criteria. After babies establish their normal flora, candidal infections become much less common. In fact the most common cause of a recurrence of thrush or candida diaper rash is, you guessed it, antibiotics.

Now don’t get me wrong: If I have a really good suspicion from a child’s history and physical exam and maybe blood or urine or skin or throat tests that detect the presence of bacteria that this child actually has a bacterial infection, antibiotics can be lifesaving and should be used.

But when it comes to sinusitis, that is, a sinus infection, here are some of the things a doctor really needs to find to consider the possibility that this might have a bacterial component that needs treating:
·      Facial pain or pressure
·      Nasal stuffiness
·      Nasal discharge
·      Loss of smell
·      Cough or congestion
·      Fever
·      Bad breath
·      Fatigue
·      Dental pain
And all this needs to have been going on for at least 10-14 days. Even then, you and your doctor may decide that it’s best to try things that will help drain your sinuses, like draining that stagnant pool, before going to an antibiotic. Things we talked about above like increasing your water intake, saline spray, a humidified environment, eliminating irritants, and perhaps medications to thin out the mucus, decrease the amount of mucus, or reduce inflammation.

Whatever else, your doctor should see you and examine you before prescribing anything. Treatment should be individualized based on what’s going on with you. Even then, if your doc prescribes a medication, please ask what good it’s going to do and what problems it might cause. I assure you your doctor will look at you differently if you ask these questions. We doctors are used to people telling us that unless they get a prescription, usually an antibiotic, they feel like we’re not talking care of them. Since we have only so much time and we are often given the very clear message that only a prescription is going to satisfy you, a lot of docs see this as a Kobayashi Maru* scenario, give up, and write a script for something, often a Z-Pak, just to get on with the day.

In 1977, my sophomore year medical school pharmacology professor at Creighton University said something in a lecture that has stuck with me ever since. “For every good effect a drug has, it will have at least ten bad side effects. You better be damn sure that that one good effect is going to be good enough to outweigh those ten bad side effects.”

The problem with “I called my doc, and he called me in a Z-Pak” – a phrase I overhear with some regularity at the gym, the supermarket, rehearsals, restaurants – is that the bad effects of antibiotics are serious, and we know they are getting worse.

First, for the individual, antibiotics not only kill off the bacteria you want to kill off but bacteria all over your body. This not only can lead to yeast infections in, say, the mouth and the groin, but to changes in your bacterial flora that took your body’s immune system years to create. Some of the new bacteria that come in to take the place of your established bacterial flora may not be as friendly to your body’s ecosystem, much as rabbits were devastating to the flora and fauna of Australia in the 19th Century.

More importantly for all of us, bacteria, like all living things, evolve. And they evolve astoundingly fast because they reproduce rapidly. Depending on the species of bacteria, under ideal conditions bacteria can replicate as often as every 20 minutes. Think of that: a new generation every 20 minutes. If we think of humans as having a generational timespan of 20 years, this means that a species of bacteria can evolve as much in one year as human beings have over the past half million years – essentially our entire existence as a species. This is why we have been reading more and more stories about antibiotic resistant bacterial “superbugs” and why some scientists are warning that we may be heading for a “post-antibiotic era” when we will no longer have effective anti-bacterial coverage for what were once easily-treatable infections.

So here’s the point of this whole thing:
  •         Do things to take care of your body’s plumbing. Drink water, don’t smoke, use a saline nasal spray if you’ve got some pollen-y crap up your nose.
  •          If you get sick, talk to your doctor.
  •      If at all possible, see your doctor.
  •      For your own sake, please do not demand a specific treatment from your doctor. Start a conversation with your doc about what might be going on with you and the best way is to deal with it.
  •      If your doctor recommends a prescription, ask questions about what that medicine is supposed to accomplish and what downside you might expect.

*For those of you who are not Trekkers, the Kobayashi Maru scenario is a no-win test for Starfleet trainees in which the cadet receives a distress signal stating that the civilian freighter Kobayashi Maru has struck a gravitic mine. There is no way to save both the freighter and the cadet’s ship. The only person who beat the test was a cadet named James T. Kirk who surreptitiously reprogrammed the simulator so that it was possible to rescue the freighter. Despite not following the rules, Kirk was awarded a commendation for “original thinking.”

As patients and as doctors we have created our own Kobayashi Maru no-win health care scenario where patients feel they have to make demands and doctors feel they have no choice but to meet them, even when these actions are not in anyone’s best interest. Be original, reprogram your encounter with your doctor, win at the Kobiashi Maru, and don’t accept the Z-Pak, or any treatment, without a complete explanation of what it should do for – and might do to – you.