Maurice A. Ramirez, DO, CNS, CMRO

An ounce of soap is worth a pound of medication!

I think too often the public’s attention is captured by new medical discoveries while forgetting older methods that have worked well for us for years.

I have not seen any recent articles on the use of probenecid with Tamiflu, or the use of bacteriophages to treat our present MRSA epidemic.

If given my choice, I’d pick a box of masks, gloves and a bar of Dial soap over 10 caps of Tamiflu to avoid the flu.

What are your thoughts on it?

I agree that the industrialized nations of the world as a global  society and medicine as a profession have both become far too dependent on ever escalating doses of medications to solve major public health problems. The great medical philosopher Benjamin Franklin once said, “An once of prevention is worth a pound of cure.” Your masks (in 1918 a handheld cloth handkerchief), gloves and soap will do far more to treat future epidemics and pandemics (influenza, MRSA, SARS, or who knows what) than any pharmacologic agent.

The problems with any pharmacologic solution are side effects, resistance, compliance and prescribing practice. Our current MRSA problem is the direct result of the overuse of antibiotics, especially for “prophylaxis” after low risk lacerations and “treatment” of upper respiratory infections most of which are viral. Add to this the fact that many patients save “left over” antibiotics from prior prescriptions only to use them at a later date thus creating two incomplete treatment periods and bacterial resistance rapidly develops leading to MRSA (and other resistance problems).

Bacteriophages may one day hold the promise of disease targeted treatment, but chaos theory as it relates to mutation and genetics dictates that resistance will eventually develop even to these targeted therapies. The best solution is the oldest, a correct diagnosis linked to a specific and conservative treatment with full compliance to the treatment on the part of the patient.

The use of probenecid to raise the serum levels and area under the curve for Tamiflu (or Relenza) is an interesting theoretical solution to the need for double dose antivirals to treat H5:N1. Unfortunately, the degree of serum level elevation and area under the curve change that would result from probenecid in a given patient is unpredictable. Further, increase serum drug levels, whether from increased dosing or probenecid, will increase side effects including psychosis, depression, suicidality, toxic epidermal necrolysis and Stevens Johnson reactions. Like any pharmacological solution, risk and benefits must be weighed and Ben Franklin’s lesson must be updated for the new millennia...

An ounce of soap is worth a pound of medication!

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Identify, Notify, How?

During a recent planning session for a Catastrophic Health Incident Response Plan work shop the problem of victim identification / family notification was identified. What is your solution?

Your question touches on the key issue of priorities during a disaster response, most significantly in the initial hours after an event (when resources and information are most limited). Given the limited resource environment, any solution must conform to a resource allocation (business triage) model.

Most in disaster and emergency management would agree that the most important goal during the response to an event is the preservation of life. Close behind in importance is the prevention of further loss (preservation of property and resources); then the dissemination of information. Somewhere after these three (and perhaps a dozen more priorities) is the identification of the dead and the notification of families. The problem is that the notification of the families of survivors and the notification of the families of patients is too often lumped into the same priority category with the notification of the deceased. This means that families remain separated from survivors and patients increasing the psychological impact and pain caused by the disaster. Counterbalancing this need to reunite is the fact that the most limited resource in the early hours and days of a disaster response is people. Given the relative priorities of preserving life and mitigating loss, diverting resources to reunification is difficult to justify operationally while it is simultaneously difficult to delay morally.

The most obvious solution is to utilize resources not already dedicated to other early response activities. Unfortunately, untrained volunteers are of little assistance in the notification process and may inadvertently create hardship and confusion with a mistaken notification. Automation of the notification process using systems such as EMSystems, EMTrack, IRIS, or KatrinaSafe.org is less resource (personnel) intensive and in the case of KatrinaSafe.org, requires minimal orientation (great for those volunteers above). The problem with automated systems is that the system must know where to send the information so that the families can find it. EMSystems, EMTrack and IRIS collect information as part of other functions (effectively resource neutral) and send information to the Joint Information Office or the Emergency Operations Center. The JIO and/or EOC then must deal with notification and the resources required for that process. KatrinaSafe.org requires resource utilization to enter the survivor information, but notification is via a computer matching system in which the family enrolls on the internet (effectively resource neutral). The ideal would be some merger of these existing systems such that the already collected information were filtered to KatrinaSafe.org or another similar national system and then matched to the searching families without further resource utilization.

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