The flu vaccine: Good enough isn’t, but it has to be for now

As December has rolled in, flu season is upon us and will soon be in full swing. If Australia provides any indication, which it often does, of what we might be in store for here in the US, then we are likely in for a rough season. In the time leading up to flu season, scientists in the US always pay close attention to influenza trends in the Southern Hemisphere in places like Australia to provide an idea of what we might expect in the States.

Data coming out of Australia is causing concern amongst scientists due to record high numbers of case incidence and outbreaks in the country in addition to increased numbers of hospitalizations and deaths per year due to influenza.

Flu season, the seasonal flu vaccine, and discussion of the prospect of a universal flu vaccine was discussed in a recent New England Journal of Medicine article authored by Paules et al.

Millions of people worldwide come down with the flu each year, and hundreds of thousands die as a result of the flu annually. People I talk to and information I see on social media sometimes ignorantly stakes the claim that this issue is not centric to the United States, which couldn’t be farther from the truth. As the article correctly states, the United States is burdened with anywhere from anywhere from 140,000 to upwards of 700,000 influenza-related hospitalizations and thousands die annually right here in our backyard at home.

Influenza is subject to a process known as antigenic drift, where the the virus’ proteins change over time. It is because of this process that new flu vaccines come out every year based on data from elsewhere in the world regarding what antigenic changes are occurring.

Sometimes the annual influenza vaccine is not as effective as intended due to changes in the antigens on the virus after it has already been decided what antigens the vaccine for that year will target. Alternatively, a strain of the virus with a different set of antigens could predominate over the predicted strain for that year. By no stretch of the imagination is it a guessing game, but rather the annual vaccine composition is a calculated prediction based on worldwide data.

Keeping this in mind, there are years where the vaccine is largely ineffective such as the vaccine in 2014-15 where the vast majority of the circulating strain in the United States differed from that year’s vaccine as mentioned in the NEJM article.

Despite the imperfections of the annual vaccine, it undeniably remains an essential public health tool and IT IS ALWAYS BETTER TO GET VACCINATED THAN NOT. Based on data put forth by the Centers for Disease Control (CDC) in the United States, it is likely that tens of thousands of cases of the flu in the United States alone every year. Get vaccinated. Flu season is already upon us, but if you still haven’t gotten vaccinated it isn’t too late. Every major pharmacy still has flu shots. I even just got my own relatively recently. An ironic aspect of medical school is that while it is a duty of ours to promote and encourage patients to make smart choices for the sake of their health, we sometimes don’t have the time to do the same for ourselves, but I still found time. It takes 15 minutes.

Given the imperfections of the flu vaccine, the NEJM paper makes the claim that we can do better. I agree. I think we can and we will. Ideally, with time, researchers will continue to work diligently towards a universal flu vaccine that is capable of providing adequate coverage for the virus despite its antigenic changes. The work for does not stop and will not stop, as it shouldn’t, until a universal vaccine is available for all. However, if this was an easy thing to accomplish, it be available already.

Going skin deep: Is a tattoo ethically binding?

There’s currently an image in heavy circulation making its way around the internet of a hospital patient’s chest tattooed with the words “Do **not** resuscitate”, accompanied by what is assumed to be the man’s signature. This 70 year old patient arrived at an emergency department unconscious with elevated blood alcohol levels. He did not have any form of identification on him, and his healthcare providers did not have an identifiable means by which they could contact the patient’s family.

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Photo credit to the New England Journal of Medicine and the

The healthcare team was unable to reverse the man’s unconscious state and were left wondering whether or not it was appropriate to continue care, or should they honor the patient’s tattoo. A DNR order is a medical order written and signed by a doctor and the patient that instructs care providers to not do cardiopulmonary resuscitation (CPR) if a patient’s heart stops or they stop breathing.

This patient’s case, including the picture of the tattoo, was recently published in the New England Journal of Medicine.

The doctors and nurses taking care of this patient initially continued treating the patient so as to “not choose an irreversible path when faced with uncertainty”, so they began resuscitating the patient. However, an official DNR order, which requires informed consent of the patient and acknowledging signatures by both the patient and their doctor, was eventually found. With this additional evidence, it was decided that the patient’s wishes ought to be honored. Care was withdrawn, and the patient passed away.

Reading this paper for the first time was perplexing in many ways from my perspective. Imagine inserting yourself into the shoes of that patient’s doctor and how you might react. Take away the official document, which supported the message of the tattoo and patient’s signature.

What if there was no DNR order officially signed by the physician and the patient? What if you were this unconscious patient’s physician and had no other data or information off of which you could make your decision? A critical question that comes to mind is whether or not that tattoo currently reflected the wishes of the patient. It’s tough.

Honestly, I don’t believe there is a truly right or a wrong answer, which is a scary reality because the ramifications here are life versus death. Since the time of this article’s publication on November 30 in the NEJM, many health professionals have taken to social media to voice their opinions on the matters surrounding how this case should have been approached (see this Tweet and its thread of responses). Seemingly everybody has taken a different stance on the matter. To me, this is not surprising because an issue like this requires much moral and ethical consideration.

In the ethics course at my medical school, the most interesting aspect of the course were our group discussions. The groups consisted of a small number of medical students, a physician, a hospital chaplain, a member of the hospital ethics team, and a lawyer. We would discuss different challenging cases, requiring us to defend how we would plan to manage the care of a patient and their specific ethical issue. Should you transfuse with blood products? Should you operate? Should you intubate? Should you withdraw care? When push came to shove in many instances, these overarching questions, with implications of live and death, were the questions we had to ultimately ask ourselves. The answers are often not clear cut. They are challenging. These sorts of questions inherently require us to draw upon our own experiences, moral compasses, and value systems in order to make an ultimate, often life-altering, decision on behalf of another human being.

Another key takeaway I had after finishing my medical ethics course was how important it is to keep a few ethical principles in mind when considering these sorts of dilemmas. Autonomy, beneficence, justice, and nonmaleficence.

Autonomy is a respect for the patient’s wishes, but it’s not quite that simple. While the patient ultimately makes decisions regarding their medical care, physicians must first create an environment wherein the patient can make an informed decision. The concept of beneficence centers around the idea of maintaining the welfare of the patient at the forefront of the physician’s intents and actions. The principle of justice is the obligation of the physician to do what is fair and just for the patient. Lastly, nonmaleficence centers around that common catch phrase amongst physicians for them to do no harm.

All this is to say that when it comes to making some of the toughest decisions related to medicine, the answer is almost never obvious. There is often no gold standard of practice or meta analyses of data on which we can base our decision. It just goes to show the humanity of healthcare providers, and we must have confidence not only in our medical training but also our moral compass in order to do what is right for the patient.

*For the purposes of full disclosure, this opinion piece I wrote was accepted for publication to be shared on kevinmd.com as well as Doximity’s Op-(m)ed and will be available there as well in the very near future. I’ll edit the blog to link the articles in when available. That said, I still retain the rights to the piece, which is why I’m still able to share it on my personal blog.*

This could be interesting… Or maybe it won’t be.

I’ve often thought about starting a blog/website for a few different reasons. I’ve always liked the idea of getting my thoughts down on paper (literally and/or figuratively) but never thought it through enough to develop a means by which I really felt compelled to do it and more importantly, do it consistently.

I also like to think that at least a few of my ideas, experiences, reflections, etc. are worth sharing with others whether it be for the purpose of education/learning, humor/entertainment at my expense, or just to let others know they aren’t alone when it comes to things that aren’t so fun to talk about.

I like to think of this as a jumpstart on my 2018 New Year’s resolution.

If there ever will be a time for me to get into the groove of this, it’s now as I take time away from medical school, which I’m sure I’ll be posting about on here at some point.

You can expect me to share content from all aspects of my life, ranging from medicine/science to running/training and finding awesome coffee & books plus mantras that inspire me and keep me going. There also might be the occasional political rant thrown in there too. ***YOU’VE BEEN WARNED!***

I hope that in time as I continue to populate the page with content, everybody who checks it out will find a shared interest or a common ground on some level.

Hopefully the elimination of net neutrality doesn’t end up hindering you guys’ ability to access this site… Oh no… I just thought about that. And I already got political in my first post. Shoot. ANYWAYS.

If nobody else, I’m sure my mother and grandmother will frequent the site to boost my page views and probably my sister/friends as well for the purpose of poking fun at me (Hi Mom & Nanny but not you, Karly).

Happy to have you along for the ride! This could be interesting… Or maybe it won’t be.

Cheers, y’all!

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