Airmail, Part 3

Responding to Reader E-mail from 30,000 Feet


 
 

Howard Rodenberg, MD, MPH, Dip(FM) | | Monday, November 26, 2007


Editor's note: As you'll recall, Dr. Rodenberg was on his way to Salt Lake City to speak at EMS Today when he finally found time to go through his e-mail in-box. This article is part 3 of a three-part series he wrote in response to feedback on his various articles. Click here for Part I and Part II.

Smallpox vaccination

I wrote a lengthy article on smallpox vaccination ( Smallpox: The Big Story, Part I , Part II and Part III) that prompted some interesting questions. Brian Nicholls of Seattle is facing the prospect of smallpox immunization as a member of his agency s biohazard response team and asks if there has been any work on a killed vaccine with fewer side effects than the traditional live vaccinia inoculation (Dryvax). In fact, there has been a new development in smallpox vaccine technology. The National Institutes of Health has just reported on initial trials with a smallpox vaccine known as the Modified Vaccinia Ankara (MVA) formulation. This vaccine uses the same live vaccinia virus as the current preparation, but the virus has been weakend so that it cannot multiply and infect mammalian cells.

Although we don t know yet if the efficacy of the MVA vaccine is equal to that of the current live smallpox procedure, it seems to hold great promise. Animals receiving the MVA preparation had no obvious skin response, and administration of MVA before use of the traditional vaccine also blunted or eliminated the typical blistering response seen with Dryvax. These results suggest that the side effect profile of the new vaccine is likely much improved. Monkeys vaccinated with the new preparation developed an immune response similar to that seen with the traditional vaccine, and no monkey given the new vaccine died despite administration of a lethal dose of monkeypox.

You may be asking how you test a smallpox vaccine. After all, if we re trying to keep smallpox out of the population, you wouldn t want to reintroduce it into the world, even to a few laboratory mice. What they do is use a lethal dose of monkeypox, a related virus, to test the efficacy of a smallpox vaccine. You may remember that monkeypox made the news last year when several people in the Midwest were infected by pet prairie dogs.

(Speaking of Seattle, I think I ve stumbled across a Great Truth of EMS. I was preparing a talk about Current Controversies in Prehospital Cardiac Care when I noticed that almost all of the studies showing the best outcomes were from places like Seattle, Canada or Scandinavia. In thinking about why this is true, I came up with several possibilities. One is that the EMS systems are just better up there. A second is that because winter is so long, wet and cold, nobody has anything to do except hang out in donut shops waiting for cardiac arrests. The third explanation, and the one I like best, is that it s so cold up there that when you drop, you instantly become hypothermic. This slows your metabolism and allows you to handle low-flow and no-flow states better than you would in warmer climes. According to this hypothesis [which we ll modestly call the Rodenberg Theory of Geographic Survival], when you drop in Florida, the sidewalk is hotter than you are so you start to saut brain cells almost immediately, severely reducing your chances for successful resuscitation. I figure the way to prove it [as if we actually have to prove anything in EMS remember the MAST pants?] is to get volunteers to drop on specific days in January and July, in specific locations throughout the world. It s been pretty tough to recruit folks to arrest for science, but I m still trying.)

Scott Melton asks when the studies on smallpox vaccine side effects in military personnel were performed. In looking through the published summaries, it appears that the work in the 1960s and 1970s was mostly based on civilian data, and that the military data cited are linked to the federal Phase I Pre-Event Smallpox Vaccination Plan. This effort reported outcomes among 325,000 military personnel as of May 2003. This is probably why Mr. Melton recalls never hearing of any problems when he received the vaccine during his military service, other than the polite instruction to not touch the scab and then touch your generative appendages (I m really pushing for euphemisms here). Personally, I think this represents sage advice for any scab, anywhere.

I mentioned one literary source to get a sense of the impact of smallpox on society in C.F. Forester s Horatio Hornblower novels. Larry Davis of Atlanta points out that there is also a description of both the illness and the 18th-century inoculation process in David McCullough s best-selling biography of Founding Father John Adams. It s on pages 141 144 in my copy, and the prose is riveting. It s well worth the read, as is the whole book.

The public service paradox

A recent note from South Carolina concerned my article about Delving into the Paradoxes of Public Service . The author made the observation that within the civil service system, there s some job protection when doing the right thing is contrary to policy. As one who now works for the state of Florida, I had to roll this thought around in my head for a bit. It s an incredibly subtle insight and one that requires an explanation.

In the civil service system, things do tend to slide from time to time. To get rid of an employee past their probationary period is exceedingly difficult to do, and to make the system work, the case must be airtight. It s sometimes not enough to simply note that one is unable to do their job. You must navigate the entire spectrum of evaluatory procedures and disciplinary actions, issue repeated corrective action plans and allow the employee to exhaust every avenue of grievance against the intended termination. Depending on the nature of what happened, even behavior considered insubordinate might be viewed by another as protected whistle-blowing.

That said, once the case is airtight and everything is done by the book, the system itself works pretty well. So the observation that it would be hard to get rid of someone for doing the right thing, even something contrary to policy, is essentially correct assuming that another party in the grievance process (or the court of public opinion remember, we answer to the voters) agrees.

And it s probably also correct that in a private agency, one has less protection from being disciplined when doing the right thing if that action is contrary to policy when the employment rules are looser than the state s. (I m not too familiar with fire and EMS union rules, but I would suspect they grant some of the same protections and processes to employees. The question that arises, however, as to who supports the employee when doing the right thing is also contrary to union policy or thought.)

Setting the record straight

As we wrap up, I need to acknowledge that several readers noticed I had erred in the attribution of a quote in my column about career changes ( Caught in a Trap? How to Avoid an EMS Career Crisis ). In that work, I said that Albert Einstein was responsible for saying, Genius is 1% inspiration and 99% perspiration. In fact, they were actually the words of the great inventor Thomas Alva Edison. For the record, the second line of Edison s quote is equally memorable: Accordingly, a genius is often merely a talented person who has done all of his or her homework. And just so Einstein fans don t feel neglected, I ll go ahead and note that, in a related vein, the Swiss genius once said, The secret to creativity is knowing how to hide your sources.

I usually don t mind making a correction on facts like these, but one note was especially galling. That s because it came from my own younger brother Hal Rodenberg (when did he learn how to read?). Until recently, he worked for the tobacco giant Philip Morris, calculating how much the other tobacco companies would have to chip in for their part of the lawsuit settlements. In fairness to Hal, he s often pointing out that the Altria Corp., of which Philip Morris is a subsidiary, makes many other fine, less carcinogenic products. These include Kraft Macaroni and Cheese, Kool-Aid, Velveeta, Minute Rice and other healthful staples of this adult s household.

He did, however, come up with a useful comment about Mr. Edison, citing him as the Hardest Working Man in Science. This brings to mind a wonderful image combining the legendary inventor with Eddie Murphy s classic Saturday Night Live James Brown Celebrity Hot Tub sketch ( Gonna turn on the light bulb! Light bulb! Yeah! It s hot! Hot hot hot hot hot! ). Two points to the sibling.

(Speaking of my family, all three of the Rodenberg offspring took interesting turns in life. We grew up in nice, Midwestern, upper-middle class suburbs. We went to college and got our degrees. And what happened to us? My brother worked for the tobacco death merchants; my sister, who teaches juvenile offenders in Joliet, Ill., is fondly referred to by the family as Prisoner # 061972; and I spend weekend nights restraining the intoxicated and dealing doxycycline. I m sure our folks often sit before the fire at the ol family homestead and wonder what went wrong.)

Finally, I want to note that one of my erstwhile correspondents, Richard Wells (he of the legendary Asparagus Disputation of 2003) has had an article written in the Harvard Law School Alumni Bulletin about his career shift, from corporate attorney to paramedic. What a great way to let significant national policymakers like most of the executive branch, the Supreme Court and many members of Congress learn about prehospital care from one of their own. We owe him one for sharing his story. Of course, he s still wrong about the vegetable. And no, I m not bitter that Harvard rejected my freshman application many years ago. I never think about all the lost opportunities, educational advantages, social connections or chances to serve my country as a senator or an ambassador or just to marry real money and drink martinis in the summer house in the Hamptons (wherever that is). But I m not bitter. Never. Not me.

As always, I appreciate the patience of those who wrote, but to whom I was unable to promptly reply. If you do write, please let me know who you are. It s hard to talk to a generic e-mail address. And, as they used to say at the end of a remarkably bad Sid and Marty Krofft show on Saturday mornings so long ago, Don t forget to write! We love to hear from you. The Bugaloos


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