Wednesday, July 6, 2011

The Creeping Terror

Ah, summertime.  The pace of work in the ER accelerates with many out of town visitors.  The medical "bill of fare" changes too, more minor injuries and such.  My personal record for a single shift was 8 fish hooks removed, although in fairness a couple of them were treble hooks with more than one hook embedded.  (I count per hook).

And another somewhat perplexing warm weather fave is much in evidence.  The tick bite.

People have an unreasoning fear of crawly things.  I wonder if it dates back to classic 1950s black and white sci-fi movies.

Well, alright, that one might create a legitimate reason to come to my ER, but I am here to say that the huge majority of human-crawly encounters are not emergencies.

Ticks are nasty little critters.  And on occasion do transmit things like Lyme disease.  But with one or two minor exceptions there is no cause to go to the Emergency Room with tick bites.  I have been giving my 3.5 minute chat on tick issues so often that I can more or less do it while still asleep.  I suspect in fact that I have a few times.

Deer tick on left and wood tick on right.  Just to make life interesting the deer ticks come in smaller versions that resemble walking grains of pepper.

Point 1.  Wood ticks cause only local irritation.
Point 2. Same is generally true of deer ticks, but if you are going to get Lyme disease etc from one it will be from the one you did not find. Especially the immature, or nymph, version.
Point 3. Deer ticks removed promptly do not give you problems beyond said local irritation.  There is some debate about whether the magic number is 24, 36 or 48 hours.
Point 4.  This is the rash of Lyme disease:

It is usually not subtle.  And it generally shows up a week or so after the tick-human interaction.  If you wait two hours in the lobby to show me a tiny red dot you are going to be disappointed.  Sometimes you see people with up to a dozen such bullseyes.

Most people with Lyme disease are mildly ill.  We treat them with an antibiotic called doxycycline.  I guess we would just dump it into the watertower every year in April were it not associated with some side effects like stomach upset and a very impressive light sensitive rash.  (mental arithmatic on treating borderline cases is when does the potential for side effects exceed the potential for avoiding consequences of not treating).

The really icky thing you can get from deer ticks is Ehrlichiosis.  No rash.  You ache from head to toe, sort of how you would feel if loan sharks had sent goons to beat you up with baseball bats.  High fever, chills, headache.  Before we figured this one out we struggled mightily with the concept that Lyme disease might not always have a rash*, and that it was sometimes mild, sometimes nasty.  We have blood tests that will generally give us the answer here (imperfect, but tests plus clinical judgement ain't bad). 

Point 5 and final.  If you feel like you have been beaten up by loan shark goons it is indeed legitimate to come to the Emergency Room.  But keep an open mind as to the diagnosis.  I have seen purported tick borne diseases actually turn out to be other things.  Like pneumonia, sepsis, kidney infection, acute myocardial infarction, side effects of cholesterol lowering medications.

Oh, and a few of my clientele do get beaten up on a recurring basis, so I always ask about that too.

(necessary disclaimer.  Like all clinical judgements this has some complexities.  There are odd presentations of tick borne diseases just as with all other conditions.  And there are shortcomings to both our technology and our wisdom.  Do not use the internet to diagnose and treat potential illness.  I append a couple of links regarding Lyme and Ehrlichiosis, which has recently been renamed.  I don't care for the new name, Anaplasmosis, so I am remaining old school.)

Lyme disease
ehrlichosis. oh, ok, anaplasmosis

*yes, this probably does happen, but without infallibility of both blood tests and patients it is difficult to say how often.  My gestalt is perhaps 10% of the time.

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