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Whooping Cough: Still Lurking

The 3 year old girl sat quietly on the exam table as her mom described her symptoms.  “A couple of weeks ago she had what just seemed like a cold.  Then she developed a little cough.  But day by day it’s just gotten worse and worse.  She’ll seem fine in between coughing spells  but when she starts coughing she just goes and goes until she finally has to take a big breath in.  Sometimes she coughs so hard it makes her throw up.  And night-time is terrible; that’s when it really picks up.”

That description is quite typical for whooping cough, also called pertussis, and sure enough the nasal swab we used to test this little one came back the next day positive for pertussis. Whooping cough gets its name from the “whooping” sound that is made when gasping for air after a fit of coughing.  It is sometimes called “the 100 day cough” but it often drags on even longer.  Worldwide there are still an estimated 30-50 million cases of whooping cough yearly with about 300,000 deaths.  Pertussis is particularly prevalent in the many nations where vaccination rates are low.  One study found that, in eight countries where immunization coverage was reduced, incidence rates of pertussis surged to 10 to 100 times the rates in countries where vaccination rates were sustained.

In the U.S., before pertussis immunizations were available, nearly all children developed whooping cough. Between 150,000 and 260,000 cases of pertussis were reported each year, with up to 9,000 pertussis-related deaths.  Since the onset of routine vaccination, pertussis has fallen to about a 10th of that number of cases and last year, for comparison, there were 18 deaths from pertussis.  Case numbers show that children who haven’t received pertussis vaccine are at least 8 times more likely to get pertussis than children who received all 5 recommended doses.

The majority of deaths occur among infants younger than 3 months of age and more than half of infants less than 1 year of age who get pertussis are hospitalized.  That’s why, besides the need to start vaccination of infants promptly at 2 months of age, vaccination of preteens, teens and adults – including pregnant women – is especially important for families with new infants.   Unfortunately, this little 3 year old is from a big family who doesn’t immunize, and the disease is quite infectious.

Here’s the tricky thing about whooping cough: It starts just like a cold, followed a few days later by an increasing cough.  So at first, it really doesn’t seem like anything very serious.  By the time the cough has really shown itself to be something suggesting whooping cough, antibiotics (such as azithromycin and other relatives of erythromycin) only slightly change the course of the illness.  Antibiotics do at least render the person non-infectious which is no small thing given how highly contagious it is.

So, what are the take-home messages?  Old, and potentially deadly, illnesses like whooping cough are still around and can rear their ugly heads, especially when vaccination rates fall.  So be sure and protect yourself, your kids, and your community with timely immunization.  When whooping cough is around, there is no need to panic, but there is certainly a need to be vigilant.  Even minor respiratory symptoms need to be checked out early to stop the progress of this miserable, and potentially dangerous, malady.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835


Respiratory Syncytial Virus (RSV)

“He’s really just been moving a little slower than usual and not eating or drinking as much… and he’s kept a fever for a few days.  Oh, and I noticed he seems to be breathing a bit quicker than usual, and just seems tired.  Other than that just cold symptoms with a runny nose and a cough.  Finally I decided to bring him in to be checked.”  Mrs. Clay, a young mom of a cute but tired-looking 3 year old boy, was relating the recent chain of events that had landed her son, Tommy, in our office after 5 days of symptoms.

Tommy looked deceptively OK.  He just sat rather placidly on the exam table waiting for me to check him over.  He didn’t look like he was in any particular distress.  When I listened to his lungs there were no crackles or wheezes, just normal breath sounds.  But those breath sounds were at a rate of almost 60 breaths per minute – two to three times the normal rate for him.  And his oxygen level from the pulse oximeter was an even 90% when a healthy 3 year old should be in the high 90’s.  It was all enough to convince me he needed a chest x-ray.  Sure enough, the x-ray showed pneumonia on both sides.  That made my next decision easier – next stop, Children’s Hospital in Knoxville for what ended up being a two day hospital stay for supportive treatment.

The cause of Tommy’s pneumonia was respiratory syncytial virus (RSV).  During these days when we are seeing schools close due to illnesses, we are seeing flu, strep, flu-like viruses, and yes, RSV.  RSV is the leading cause of lower respiratory tract infections (think pneumonia, and a wheezing condition called bronchiolitis) in infants and young children. In the U.S. each year, 4-5 million children younger than 4 years old acquire an RSV infection, and more than 125,000 are hospitalized.

Symptoms of RSV infection may include fever, cough, rapid breathing, shortness of breath, fatigue, wheezing and other abnormal lung sounds.  In young infants, apnea and cyanosis (turning bluish) may occur.  Of course with any of these symptoms at a significant level it would be wise to have a child examined, their lungs listened to, and their oxygen level checked.  When appropriate, there is a fairly easy in-office test that can be done to confirm or rule out RSV.        When it comes to treatment, it is mainly supportive – keeping them hydrated, making sure they are not getting exhausted with their breathing, being sure they are maintaining a good oxygen level.  Those who have more severe cases are the ones who end up in the hospital on IV fluids and oxygen.  There are also some rather rarely-used meds and preventives used primarily on the very young or those with congenital heart and lung conditions.  Otherwise, bronchodilators help only a few and most of the other treatments such as steroids haven’t really proven themselves in studies.  So all-in-all, treatment is mostly to support the patient while their body fights off this rather miserable virus.

Infants hospitalized for RSV are at higher risk for subsequent wheezing and abnormal pulmonary function and this increased risk may persist for up to 10 years or longer. RSV’s role in causing subsequent reactive airway disease (asthma) remains controversial. By age 3 almost all children have had at least one episode of RSV.  It is primarily in those well under a year of age that the illness can, rarely, be life-threatening. Unfortunately recurrent infection can occur and usually produces illness lasting 7-10 days rather than the typical 3-4 day illness caused by most colds.  Even the elderly can get severe RSV infections and November through February tends to be peak RSV season in Tennessee. So if those respiratory symptoms seem a bit worse or are dragging on longer than expected, best to get them checked out and see if those three letters, RSV, have gotten you.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835


Bell’s Palsy

Patty relates her story: “So I’m out for a nice dinner with my husband and it’s so embarrassing — as I’m drinking my water, it keeps dribbling out of the corner of my mouth.  At first I think I’m just being spastic and hope he didn’t notice.  But it keeps happening and I laugh and tell him my mouth doesn’t seem to be working right.  So he looks at me, and instead of laughing he suddenly looks scared and says, ‘C’mon we’ve got to get you to the hospital.’  What I didn’t know is that when I laughed, one side of my face moved normally and the other barely moved at all.  Of course he’s thinking, stroke!”

This account turned out, happily, to not be a stroke, but rather a condition called Bell’s palsy.  Of course, when in doubt it’s always best to get immediately to the ER and make sure it isn’t a stroke.  Bell’s palsy involves a loss of function of the facial nerve.  This is the nerve that triggers most of the movements of the muscles of the face.  So Bell’s palsy results in rapid paralysis or weakness of the facial muscles on one side of the face, usually progressing over up to 48 hours. The cause still hasn’t been totally nailed down.  It can happen at any age, but its peak prevalence is in 40-49 year olds.

When Bell’s palsy first strikes, it can be tough to distinguish from a stroke.  One clue is that with Bell’s palsy the forehead muscles on the paralyzed side don’t move.  So if you ask the person to raise their eyebrows or wrinkle their forehead, nothing happens on the paralyzed side.  On the other hand, when a stroke is the cause, the forehead muscles are usually spared and still move (wrinkle) on both sides – we won’t get into the whole reason for that, but it’s one way to help distinguish the two.

Along with the one-sided facial paralysis, Bell’s palsy may cause altered taste and loss of tear production on the affected side.  There also may be pain around the ear and sometimes vision is blurred on the affected side.

Treatment involves first making sure it’s Bell’s palsy and not a stroke.  If the symptoms aren’t clear-cut, a cat scan or MRI of the head may be done immediately since successful stroke treatment is often dependent on the timely use of clot-busting meds. If Bell’s palsy is diagnosed, steroids are the preferred treatment and antiviral agents may sometimes improve outcomes slightly as well.

The good news is that in 80-90% of cases, the symptoms slowly clear over a few months’ time.  In the meantime, the affected eye needs to be protected with frequent lubrication, and sometimes taped shut overnight to avoid drying out and damaging the cornea. Facial physical therapy is sometimes used but hasn’t really proved to make much of a difference in the rate of recovery. Various surgical procedures are used only rarely to aid eye closure in those cases where the paralysis proves permanent.

So, having Bell’s palsy certainly beats having a stroke, but it’s still no picnic.  It can sometimes be very slow to resolve, or rarely, may not ever fully recover.  If it strikes you or someone you love, and you’re not sure what it is, get to an ER and let them make sure it’s not a stroke.  Once you’re sure it’s Bell’s palsy they can help you to protect your eyes and give you meds that maximize your chances for a full recovery.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835






Reignite Liberty’s torch

The American dream for healthcare needs strong medicine.

The inscription on the Statue of Liberty which is taken from the poem New Colossus written by Emma Lazarus says in part,

Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tossed to me,
I lift my lamp beside the golden door!

Over the last several decades the medical economic model has encouraged physicians to seek out otherwise well and healthy patients.  It was inadvertently done and without any malicious intent but the pressures were real.  The system requires such enormous documentation and coding that it has encouraged patients to conform to the box in which they are placed.  It discourages individualism in favor of protocols.  It celebrates documentation of such things as smoking rates yet hinders the affordability of medication to stop smoking.  The system wants to categorize and number patients and let them be a resource to run through it’s machine.  When patients want to be individuals, freely making their own healthcare decisions, then the system runs poorly.  Those individuals with complex and personal needs become burdensome to the system and often are subtlety shunned.

From it’s foundation Trinity has been principled in seeking to serve those who need care.  These are “the tired, the poor and the huddled masses” to whom Ms. Liberty proclaims refuge.  In this week of political celebration or protest (depending on your viewpoint), we want to again reiterate our stance on seeking to serve those who are sick and hurting.  We stand ready to care for all patients of all conditions.

We do this in several ways.  First our walk in clinic serves the community six days a week in a personal and compassionate manner.  Our charges for services are some of the lowest in the area.  We dumped the double standard charge model years ago where the uninsured paid substantially more than the insured.  Today, anyone who is cared for in our practice will pay the same amount regardless of insurance status.  For anyone who pays in full at the time of service, they will receive the same discount that has been negotiated by the the insurance companies.  Everyone pays the same.

Second, our depth of resources for our patients to truly become healthy are unparalleled across the country let alone Knoxville.  We offer a full range of experts to help patients treat, reverse, and cure their chronic illness with nutrition changes, exercise programs, wellness plans, stress management, sleep improvement, and Biblical counseling.  We have seen patients reap large rewards of weight loss, medication reduction, and reclaiming their lives as they progress through the programs.

Lastly, our Direct Primary Care program is offering discounts to new patients with chronic conditions.  Any new patient that completes their first member appointment with the Direct Primary Care program by the end of Inauguration Day and has one of the three biggest chronic, pre-existing conditions of diabetes, high blood pressure, or high cholesterol for which they are receiving at least one prescribed medication  will have their registration fee of $125 waived.

Trinity Medical Associates is reigniting Liberty’s torch for all people to receive the highest quality medical care.  Call today for an appointment and come be part of the new American healthcare dream.