On today’s vote in Ireland

I have taken care of many HIV-infected gay men over the years. Some died from the complications of advanced AIDS. I think those preventable deaths were largely due to stigma, fear, and discrimination which led to delayed diagnoses of HIV. Today I am pondering Ireland’s surprising vote to legalize gay marriage. A major victory, this will hopefully reduce homophobia. If the Irish can change, why can’t we all?

Oliver Wolf Sacks, always “On the Move”

I just finished reading Oliver Sacks’s memoir, On the Move, and decided to write a quick blog review of this exceptional book. (If you want to read a professional book review, I suggest Michiko Kakutani’s in the New York Times or Will Self’s in the Guardian).

Sacks surprises the loyal readers of AwakeningsThe Man who Mistook his Wife for a Hat, and An Anthropologist on Mars with extreme tales from his youth. For example, he had a penchant for powerlifting/bodybuilding, amphetamines, hitchhiking with truckers (he goes by his middle name of “Wolf,”) and motorcycling through rural California. The peaceful-appearing neurologist even comes off as as frightening at one point, when a car full of teenagers tries to run him off the road. Sacks, 260 pounds, pursues them on his motorcycle brandishing a club, “like the mad colonel astride the bomb in the final scene of Dr. Strangelove.”

Sacks loves taking care of patients, but struggles to fit in and develop a career in medicine. He is fired from his job at Beth Abraham Hospital.  In his early years, despite publishing several well-received books, he has no faculty appointment in a department of neurology. “I am a gypsy, and survive— rather marginally and precariously— on odd jobs here and there,” he writes to one medical student.

Swimming is a theme of the book. In the water, some of his best ideas develop:

“The greatest joy of all was swimming in the placid lake, where there might be an occasional fisherman lounging in a rowboat but no motorboats or jet skis to threaten the unwary swimmer. The Lake Jeff Hotel was past its prime, and its elaborate swimming platform and rafts and pavilions were completely deserted and quietly rotting. Swimming timelessly, without fear or fret, relaxed me and got my brain going. Thoughts and images, sometimes whole paragraphs, would start to swim through my mind, and I had to land every so often to pour them onto a yellow pad I kept on a picnic table by the side of the lake. I had such a sense of urgency sometimes that I did not have time to dry myself but rushed wet and dripping to the pad.”

It could be argued that writing is actually the love of Sacks’s life (he kept over 1000 journals)

“I am a storyteller, for better and for worse. I suspect that a feeling for stories, for narrative, is a universal human disposition, going with our powers of language, consciousness of self, and autobiographical memory. The act of writing, when it goes well, gives me a pleasure, a joy, unlike any other. It takes me to another place— irrespective of my subject— where I am totally absorbed and oblivious to distracting thoughts, worries, preoccupations, or indeed the passage of time. In those rare, heavenly states of mind, I may write nonstop until I can no longer see the paper. Only then do I realize that evening has come and that I have been writing all day.”

Sacks touches on one of the central criticisms of his work, the accusation (in my opinion, unfounded) that he has taken advantage of his patients for his literary career. How was it possible for Sacks to “write about these patients and even film them, yet continue to be seen by them as a trustworthy physician, not as someone who had exploited or betrayed them.”  

Sacks doesn’t answer the question directly, but I come away from “On The Move” trusting that he had his patients’ best interests at heart. This is an important issue for we physicians who want to write about our work. (This theme was also explored by Dr. Anna Reisman in an essay in The Atlantic.)

The bravest and most surprising part of Sacks’s book are the discussions of his sexuality. He describes his mother’s furious reaction when she learns that he is gay.

“You are an abomination,” she said. “I wish you had never been born.”

Sacks withdrew from his mother but felt guilty about it the rest of his life. He lost his virginity in Amsterdam while drunk (it is unclear but appears that he may have been raped).

Sacks then developed a relationship at the age of 20 with a man named Richard Selig:

“We would go on long walks together, talking about poetry and science. Richard loved to hear me wax enthusiastic about chemistry and biology, and I lost my shyness when I did so. While I knew that I was in love with Richard, I was very apprehensive of admitting this; my mother’s words about “abomination” had made me feel that I must not say what I was. But, mysteriously, wonderfully, being in love, and in love with a being like Richard, was a source of joy and pride to me, and one day, with my heart in my mouth, I told Richard that I was in love with him, not knowing how he would react. He hugged me, gripped my shoulders, and said, “I know. I am not that way, but I appreciate your love and love you too, in my own way.” I did not feel rebuffed or brokenhearted. He had said what he had to say in the most sensitive way, and our friendship continued, made easier now by my relinquishing certain painful and hopeless longings.”

At times while reading this book, I felt sorry for Sacks’s isolation. He lives far from his family in England and has no partner or children. In addition, as the memoir goes along, Sacks’s parents, siblings, and close friends die off, one-by-one. But happily, Sacks finds new love at the age of 75, with a writer named Billy Hayes. It is a lovely way to end this powerful memoir:

“We often swim together, at home or abroad. We sometimes read our works in progress to each other, but mostly, like any other couple, we talk about what we are reading, we watch old movies on television, we watch the sunset together or share sandwiches for lunch. We have a tranquil, many-dimensional sharing of lives— a great and unexpected gift in my old age, after a lifetime of keeping at a distance.”

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Solving Summer Fever in Early Pregnancy

Happy that our new article is online… if you don’t have access, and want to read it, email me and I’ll send you a copy.

A 37 year-old woman (G3P1) presented at 8 weeks gestation with 3 weeks of fever, cough and malaise.

Fever in early pregnancy is often due to common infections such as those due to respiratory viruses and urinary pathogens. Viral infections such as Epstein Barr Virus (EBV), Cytomegalovirus (CMV), or Human Immunodeficiency Virus (HIV) leading to mononucleosis or a mononucleosis-like illness are high on the differential diagnosis of this young patient with weeks of high fevers and nonspecific symptoms…

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Don’t mess with Staph Aureus

Imagine you are an internal medicine resident on call overnight in the hospital. You admit a patient with high fevers of unclear etiology. The patient had blood cultures drawn in the emergency room (before antibiotics, thank goodness) and is started on empiric vancomycin and cefepime. The next day, the micro lab calls you and says that her blood cultures are growing “Staphylococcus Aureus.”

You recall from medical school that Staph Aureus is divided into two groups, the feared “MRSA” and the less-feared “MSSA.” But at this time you don’t know if the patient has MRSA or MSSA. It’s a good thing you have your patient on vancomycin in case the bacteremia is due to MRSA. But is your patient on the correct treatment?

You may not know what’s going on behind the scenes, in the micro lab, and that can help you manage her infection.

After the blood cultures turn positive, a gram stain is performed and the isolate is plated on the appropriate media. Direct non-standardized Kirby-Bauer plates are then performed which can give you a preliminary “hint” if the patient has MRSA or MSSA. If the plate has a small zone of inhibition around “FOX” (oxacillin), and P (PCN), that suggests MRSA (see photo below). If there is a large zone of inhibition, that suggests MSSA.

I suggest you phone the micro lab at this time, and ask for the “blood room” and request that the technician look at the Kirby-Bauer plate. If the isolate looks like it’s likely going to be MSSA, you should continue the vancomycin but add nafcillin (and drop the cefepime). Nafcillin is better than vancomycin or cefepime for MSSA. If the isolate looks like it is going to be MRSA, you should continue the vancomycin (and drop the cefepime). And get 2 more sets of blood cultures.

The next day you will have your official sensitivities in the computer with your quantitative MICs, and you will know if the Kirby-Bauer guess was correct. If it’s MSSA, you can drop the vancomycin and continue nafcillin monotherapy. If it’s MRSA, you can continue vancomycin monotherapy.

Meanwhile, I hope you are looking hard for the source of the bacteremia and are thinking about where staph aureus may have gone (heart valves, bones, joints, abscesses, etc). Get an infectious diseases consultation to help you. If there’s anything I’ve learned in my ID fellowship, it’s “don’t mess with Staph Aureus.”

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Bob Moses here in Boston

It was a powerful evening tonight at the Museum of African-American History with a lecture by legendary civil rights activist Bob Moses. Among the most salient parts of his talk were his emphasis on understanding American history’s three eras, from 1787 to the 1860s, from the 1860s to 1960s, and from the 1960s to present, and his argument that as a country we “lurch forwards and backwards.” Because of recent events (anti-gay legislation, the repeal of parts of the Voting Rights Act, rising inequality, lack of quality public education), America is currently “lurching backwards” in our third era, said Moses. Where will that lead us?

Other parts of his lecture I found especially moving were his frightening description of being “grease-gunned” (machine gunned) in 1963 by the KKK while driving to Greenville, Mississippi (“it kind of tattooed the side of the car”), while the driver Jimmy Travis was shot. In addition, the recent deterioration of the right to vote; and anecdotes regarding many of the iconic leaders from the civil rights movement, including James Meredith, Bayard Rustin, Ella Baker, and Medgar Evers.

Bob Moses received a MacArthur “Genius Grant” and has worked intensively on the Algebra Project, trying to improving public school math education. He argues that “sharecropper education” is alive and well in America and math literacy is a necessary and neglected skill. He asked, somewhat rhetorically, “are we mature enough as a country to talk about if we need a constitutional right to a high quality education?”

Certainly politicians in Washington DC aren’t mature enough. American will only fulfill her promise if citizens organize at the local level, as Bob Moses did in Mississippi in the 1960s, and continues to do to this day.

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Can I get a caramel frappuccino with a side order of insulin?

Iora Health has been in the news recently for its innovative practices, including an article last week in the New York Times. The author of the article, Margot Sanger-Katz, writes, “The ultimate goal is hundreds of practices across the country, a kind of Starbucks for health care. (The company recruited one executive whose last job was opening Au Bon Pain franchises).”

Sounds a bit corporate. Is Iora Health is really the answer to America’s health care woes? How does Iora’s patient population compare to those served by America’s struggling, chronically underfunded network of (not-for-profit) community health centers, for example? I put the question to Twitter.

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The rest of our storified debate

Can the White House stop Antibiotic-Resistant Bacteria?

Yesterday, President Barack Obama urged Congress to double the funding to confront the danger of antibiotic-resistant bacteria facing America. Concurrently, the White House released their National Action Plan for Combating Antibiotic Resistant Bacteria (NAP) which outlines a “whole-of-government approach” over the next five years targeted at stopping antibiotic resistance.

Do you think the NAP is going to actually reduce the transmission of antibiotic-resistant bacteria? Please drop me a line.