Smallpox

VACCINATION CONSTERNATION

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On February 4, 1976, a nineteen-year-old army recruit at Fort Dix died of what the CDC determined was an influenza strain genetically similar to the 1918 H1N1 swine flu virus that caused a worldwide pandemic. Fearing another pandemic, CDC pushed for mass vaccination Then-President Gerald Ford (who facing re-election) figured mass American deaths would be politically unforgivable if nothing was done, agreed and fast-tracked a vaccine.

A few months later the pharmaceutical industry demanded federal indemnification against liability for any adverse reactions before releasing the vaccine. Then, as now, such a move created public suspicion and distrust of both the government and the vaccine. That skepticism was furthered after several reports linked the vaccine to recipients developing Guillain-Barre syndrome,  a rare disorder in which the body’s immune system attacks nerves causing weakness and sometimes paralysis severe enough to require ventilator support.

The pandemic never materialized as that flu strain was far less dangerous than initially thought. But the damage to the idea of vaccines being lifesaving miracles had been done.

That fall I had the dubious honor of being interviewed on camera by one of the local TV stations in Rockford, IL after getting a swine flu shot. When asked why I wasn’t hesitant to get the vaccine, I said something stupid like, “I should know about these things; I’m a medical student!”

But the real reason I got that vaccination and continue to do so was because I grew up during the 1950s and 1960s. Our parents lived through the times of no vaccines and witnessed the devastation. Immunizations were miracles of science and our parents were determined we would have a better (and healthier) life than they did.  

The current anti-vaccine movement started in the 1980s and has only grown since then, thanks to the Internet, anti-science politicians and Andrew Wakefield’s thoroughly discredited claim that vaccines caused autism. Most of those people either didn’t experience or chose to forget what life was like prior to vaccines, which calls for a review of pre-vaccine devastation.

In 1892 Canadian physician Sir William Osler called pneumonia “the old man’s friend” because it often claimed the elderly already suffering from debilitating disease. (Osler died of pneumonia in 1919.) Thirty to 40 percent of people who developed pneumonia died before widespread use of antibiotics. Even now, antibiotic resistance among the more than 90 serotypes of Streptococcus pneumoniae can make treatment difficult.

A polysaccharide vaccine against 23 streptococcal serotypes, PPSV-23 (Pneumovax ® Merck), was released in 1983. A pneumococcal conjugate vaccine (PCV7) was released in 2000; it was replaced in 2013 by PCV13 (Prevnar13 ® Pfizer). So now us old people can die of slower, more expensive diseases like Alzheimer’s, chronic congestive heart failure and cancer.

Smallpox, a contagious disease caused by the variola virus, produced fever, vomiting, generalized body aches and a characteristic pustular rash that frequently resulted in terrible scarring. Sometimes smallpox infections left the victim blind or dead. A vaccine became available in 1961 and was given until 1972 when it was declared eradicated in the United States. In 1978 Janet Parker, a 40-year-old photographer, was the last smallpox fatality.  The WHO declared smallpox eradicated in 1980.

All of us who received a smallpox vaccination have a cratered scar on our upper arms. Mine has all but faded but I wore it like a badge of honor.

Polio, caused by the poliovirus, is a disease whose symptoms range from none (75%), through common viral symptoms such as fever, headache, nausea and stomach pain (20%) to progressive, devastating neurological damage (5%). Many victims suffered weakened and deformed limbs or outright paralysis. (President Franklin Roosevelt was 39 when he contracted polio in 1921 and became unable to walk, but he hid it well from the public.) Sometimes the virus affected the ability to breathe, requiring patients to spend a good deal of their lives in an iron lung, long before the invention of modern ventilators.

Our parents were terrified because everyone knew someone who had contracted polio. People blamed cats, dogs, public drinking fountains, swimming pools and beaches for spreading polio before its fecal mode of transmission was identified. One of my high school classmates, born in 1954, contracted polio which weakened one leg. Sixty some years later he still wears a heavy leg brace.

Jonas Salk is remembered for created the inactivated polio vaccine (IPV) which was released in 1955. Albert Sabin created an oral polio vaccine (OPV), released in 1961. Kids my age got the OPV on a sugar cube that had been dosed with the vaccine. Currently IPV is the only vaccine available in the US but OPV is still used in other countries.

Diphtheria, a bacterial illness caused by the Corynebacterium diphtheriae, creates a toxin that destroys respiratory tract tissue. The resulting grey “pseudomembrane” makes breathing and swallowing difficult and gives the breath an odor described as a “wet mouse.” The toxin can wreck the heart, kidneys, and nervous system if it circulates in the blood. About 10% of victims died from diphtheria before a vaccine was developed.

Pertussis, also known as whooping cough, is a contagious bacterial respiratory disease caused by Bordetella pertussis. Infection produces a severe hacking cough that can last for 10 weeks, accompanied by a “whoop” sound with inhalation. Severe coughing fits can lead to fractured ribs. It was sometimes fatal in infants prior to a vaccine; it is still common in underdeveloped countries.

Tetanus, once commonly known as “lockjaw,” is caused by the bacterium Clostridium tetani, found mainly in damp soil. (My mother always told me one developed tetanus from stepping on a rusty nail, which never made sense. It was due to bacteria in the soil around old, rusty nails.) It produces a toxin that causes painful muscle contractions (tetany), often affecting jaw and mouth muscles.

DPT, a vaccine for diphtheria, pertussis and tetanus was developed in 1949, combining diphtheria and tetanus toxoids (inactivated forms of toxins) with killed pertussis cells. I got vaccinated when I was five years old and spent a couple of nights in the hospital after developing hives. I never got a tetanus booster after that, but the hives were more likely a reaction to the pertussis component. A newer vaccine, TDaP, which used pertussis antigens rather than killed bacteria (aP = acellular Pertussis) was released in 1981 and replaced DPT in 1997.

Measles is a very contagious viral illness caused by the rubeola virus which has gone by many other names: red measles; English measles; hard measles; seven-, eight- or ten-day measles. Infected people, mostly children, develop cough, fever, runny nose and itchy eyes followed by a generalized flat rash 3-5 days later. While most recover without any problems, measles complications include ear infections, bronchitis, pneumonia and encephalitis. (Adults often do poorly with childhood diseases, especially measles.) About 100,000 people around the world, mostly children under 5, die from measles every year. Measles was declared eliminated in the United States in 2000 but there were 1,282 cases in 2019, largely due to people lacking vaccination.

Mumps is a viral illness that causes parotitis (swelling of the salivary glands) but can also affect the breasts, pancreas, meninges (the tissue covering the brain and spinal cord), ovaries and testicles. Mumps used to be a common cause of aseptic (non-bacterial) meningitis and hearing loss in children before widespread vaccination. Death from mumps is rare.

Rubella, also known as German measles or three-day measles, is a viral disease that causes fever, headache, runny nose and a distinctive fine rash that spreads from the face to the trunk and then arms and legs. The infection is usually mild, and most children recover quickly, but complications include pneumonia leading to death, encephalitis causing deafness or intellectual disability, or a ruptured spleen. Up to 70% of women with rubella develop arthritis.

Congenital rubella syndrome (CRS), characterized by cataracts, congenital heart disease, intellectual impairment or hearing deficits, can occur in babies whose mothers contracted rubella during pregnancy. There were 12.5 million cases of rubella in the United States during the 1964-1965 rubella epidemic with a staggering toll.  Women lost 11,000 pregnancies from miscarriage, stillbirth, or abortion and 2,100 babies died after birth. Of the 20,000 cases of CRS identified, 11,000 were born deaf, 3,500 were blind and about 1,800 suffered intellectual disabilities.

Varicella (chickenpox), another annoying but potentially dangerous childhood infection, is caused by the varicella zoster virus (VZV). It produces small blisters that eventually turn into scabs. Complications include skin infections from open blisters, pneumonia, encephalitis, bleeding and sepsis. There were over four million infections and around 100 deaths annually before a vaccine was released in 1995. Shingles (postherpetic neuralgia) is a painful re-activation of VZV along nerve paths.

MMR/MMRV: In 1963 inactivated and live attenuated measles vaccines were released in the US.  The inactivated vaccine didn’t offer sufficient protection and was discontinued in 1967. The live attenuated vaccine caused fever and rash in recipients and was withdrawn in 1975. A combined measles, mumps, and rubella vaccine (MMR) was released in 1971; varicella was added (MMRV) in 2005.

Zostavax, a live, attenuated vaccine to prevent shingles, was released in 2006. Shingrix, a recombinant, adjuvanted zoster vaccine, was released in 2017, replacing Zostavax in November, 2020.

I had chickenpox, because DPT, polio and smallpox were the only available vaccines at the time. When a neighborhood kid developed chickenpox, other mothers would send their kids to a “chickenpox party.” We’d pass around a contaminated drinking glass to contract chickenpox and “get it over with.” Some parents still engage in the practice despite having a vaccine, thinking “natural” immunity is preferable.

I also had all the other childhood viral illnesses – measles, rubella and mumps. When I developed mumps, my mother chastised me for any activity, saying “You’ll be sorry if it goes down on you!” She was talking about mumps orchitis (painful testicular swelling from the mumps virus that can lead to shrunken testicles and, rarely, infertility) but I had no idea what she was talking about and she didn’t bother to explain. That I have three kids indicates no apparent gonadal damage.

MORBIDITY AND MORTALITY
BEFORE AND AFTER
VACCINE DEVELOPMENT

Other communicable diseases and vaccines

Hepatitis A, formerly “infectious hepatitis,” is an acute liver infection caused by the Hepatitis A virus (HAV). It is acquired by ingesting virus passed through feces, usually from contaminated food or water. It causes fever, nausea, abdominal pain, jaundice, and dark urine. Complications are rare but infection can lead to acute kidney failure as well as hemolytic and aplastic anemias. Fulminant hepatitis, which leads to liver tissue destruction, is rare and has a death rate of up to 80%.

A vaccine against HAV was released in 1996 and infection rates declined until 2016. The US has struggled with a Hepatitis A outbreak which began in 2016 and was linked to person-to person contact (drug use and homelessness) rather than contamination. There have been 37,121 cases reported across 35 states with 348 deaths as of December 18, 2020.

Hepatitis B, formerly “serum hepatitis,”is an acute liver infection caused by the Hepatitis B virus (HBV). It is acquired through

  • unprotected sex with an infected individual
  • sharing drug paraphernalia or personal items
  • tattooing with unsterile equipment
  • passed from pregnant mother to fetus
  • human bites

Signs and symptoms are the same as for HAV; however, about 50% of infected people may have no symptoms. Complications are similar to those of HAV; about 200-300 people die of fulminant hepatitis each year. A vaccine was released in 1986. It is recommended for all newborns and anyone not previously vaccinated.

There are about 800,000 to 1.4 million people in the US with chronic hepatitis with and additional ,5000-8,000 becoming chronically infected every year. Most annual deaths linked to HBV are due to the consequences of chronic infection: cirrhosis (3,000-4,000) and liver cancer (1,000-1500).

Hepatitis C, D and E are forms of viral hepatitis caused by Hepatitis C (HCV), Hepatitis D (HDV)and Hepatitis E (EV) viruses. There are no vaccines for these three viruses. HCV can be treated (the Hep C medication for which its creators incessantly run commercials costs $94,000) but there are none for HDV and HEV. HEV infection usually resolves spontaneously.

Employers often require healthcare workers to provide evidence of immunity to HBV and other communicable diseases prior to employment. I got the HBV vaccine in the early 1990s

Haemophilus Influenza type b (Hib) is a bacterium, not a virus. It primarily infects infants and children under 5 years, and can cause meningitis, pneumonia, bacteremia (bacteria in the blood), and epiglottitis, a potentially life-threatening swelling of the epiglottis. There were about 20,000 cases of Hib and 1,000 deaths annually before a vaccine was released. The polysaccharide vaccine released in 1985 did not work well in children under 2 years and was replaced with conjugate vaccines in 1987.

I recently got my first COVID vaccination; I’m a healthcare worker who still has contact with mostly older people. I expect there will be more adverse reactions reported as there’s a big difference between several thousand people in a vaccine trial and tens of millions of people being vaccinated.

None of us should want to live in a world in which easily preventable diseases with significant morbidity and mortality run rampant because we no longer have sufficient herd immunity.

Featured Image © Can Stock Photo / joloei

Election Postmortem

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Here are my thoughts on the shitshow that was the 2020 Presidential election

Polls missed it again!
Pollsters in 2016 predicted Hillary Clinton would win but didn’t recognize how many people despised her. Instead third-party voters in Michigan, Pennsylvania and Wisconsin, whose vote totals were many times his margins over Hillary, handed the election to Trump. This time Biden won those three states.

Biden was supposed to win in a landslide and a Blue Wave was going to usher in a Democratic Congress to magically transform everything. So what happened?

Polls suffer from selection bias; they are only as good as the people who choose to answer them. I don’t answer any phone calls I don’t recognize and I’d rather slit my throat than talk to a pollster. But there’s a subset of the population – those on the far ends of the political spectrum – that will gladly tell anyone how they feel about the issues. The people in the middle, both Liberal and Conservative leaning, either doesn’t want to be bothered or don’t want to tip their hands.

I’m not sure polls have any practical use besides inducing false hope to some, despair to others, or a reason for the media to turn the election into a day at the greyhound track with Bugs Bunny.

The “Blue Wave” was a ripple.
Democrats overestimated their chances of defeating Republican incumbents. Anyone hoping for a major Democratic takeover of Congress ignored political reality. Every voter can choose ONE Congressional rep, TWO Senators and ONE President.. Mitch McConnell and Lindsey Graham were re-elected, despite being hated by millions. You can’t vote out another state’s candidates.

Progressives pinning all their hopes on Bernie or any other “progressive” candidates are delusional. You can elect Jesus Christ Himself to the Presidency, but as long as Moscow Mitch controls the Senate, you won’t get any closer to universal healthcare or free college.

Biden won without groveling to progressives.
I didn’t see or hear as much “the candidate needs to earn my vote!” bullshit that dominated the 2016 race. Maybe third-party voters realized the past four years of Trump were far worse than a Hillary Clinton presidency. I’m sure there are some who “held my nose” and reluctantly voted for Biden, but I don’t expect them to openly admit it.

But the progressive agenda may have cost Democrats House seats.
More than 72 million people voted for Trump, and they equate “progressivism” with socialism/communism. I can only guess as to their reasoning, but I think it’s a combination of viewing government as the enemy and not wanting “those people” getting something for nothing. Hispanics in Florida, especially Cuban-Americans, are and the Florida Democratic Party apparently did little to persuade them otherwise.

Conor Lamb, a 36-year-old moderate Democrat from Pennsylvania’s 17th district who won re-election in a Republican area, said:

“I’m giving you an honest account of what I’m hearing from my own constituents, which is that they are extremely frustrated by the message of defunding the police and banning fracking. And I, as a Democrat, am just as frustrated. Because those things aren’t just unpopular, they’re completely unrealistic, and they aren’t going to happen. And they amount to false promises by the people that call for them.”

We’re not likely to get universal health care or Medicare for All in my lifetime. It will require almost unanimous Congressional approval, a President willing to sign the legislation, and a Supreme Court willing to uphold it against the inevitable legal challenges. It will also need a comprehensive plan on how to transition a $4 trillion industry to a single payor as well as adequate funding in perpetuity.

I don’t see it happening until millennials, especially women, make up a sizeable proportion of Congress and we have a female president. We are headed in the right direction but change will be incremental, not radical. To paraphrase Paddy Bauler, Chicago 43rd ward alderman and barkeep, “The country ain’t ready for reform!”

Democrats need to win statehouses.
Republicans control more than half of the state legislative bodies in the US and that is where voting laws and redistricting happens. The Democrats failed to make any gains in 2020. Texas isn’t going to turn blue anytime soon. Georgia is probably more purple than blue. And there are a lot of crazy people in Michigan, where Republicans have been actively undermining Governor Gretchen Whitmer’s efforts to combat coronavirus.

All politics are local.
 A lot gets decided at the state and local level. Arizona, Barry Goldwater’s home state and long a bastion of conservatism, legalized recreational marijuana and raised taxes on incomes over $250,000. Mississippi legalized medical marijuana and replaced the Stars and Bars on its state flag with the state flower.  South Dakota legalized recreational and medical marijuana. Florida – Florida! – voted to increase the minimum wage to $15/hour over the next six years. So there is a glimmer of hope.

Don’t expect a honeymoon.
As of this writing, Trump has refused to concede. A lot of Trump supporters think the election was fraudulent and Biden will be an “illegitimate president.” Republicans, as with Obama, have no interest in reconciliation or cooperation.

Many of us on the other side aren’t willing to forgive or forget four years of animosity, ridicule and lies. Trump and his supporters vilified immmigrants, Muslims, people of color, Black Lives Matter, anti-fascists, liberals, intelligence and education. They cheered when a 17-year-old kid from Illinois killed two protesters in Kenosha, Wisconsin with an assault rifle, and then started a Go Fund Me page for his legal expenses. Pulitzer Prize winning journalist Leonard Pitts, Jr. put it this way:

“…Trump and his supporters broke this country, and it will take years to repair, if we ever do. They didn’t care then, and as far as I can tell, they don’t care now. So as an African-American student of history — and frankly, just as an American who loves the ideal of America, the truths held self-evident and more perfect union of America — I ask you not to ask me what I will do to reconcile with those people. Here’s a better question:

What will they do to reconcile with me?…”

Democrats need to stop preaching to the choir.
Biden and company need to figure out what conservative voters want and/or need and if it’s even possible. These are the people who thought that Trump contracting coronavirus showed courage rather than stupidity. They embrace authoritanianism; they want a dictatorship as long as it doesn’t affect them. In 2019, a woman in Florida, bemoaning the poor federal response to Hurricane Michael, said Trump was “not hurting the people he needs to be hurting.” Yes, some of your fellow Americans are that vindictive.

Trump won in 2016 by appealing to their sense of being neglected by both parties but did little or nothing for them. Coal jobs didn’t come back. His trade war with China crippled soybean farmers.  Middle-aged white men, especially in the Mountain West, are dying by suicide at twice the national rate. Many of those people voted for Obama in 2008 and 2012. The Democrats can win them back but not with progressive demands to defund the police, enact a Green New Deal and promising Medicare For All.

Otherwise, we risk Trump 2.0 in 2024, and that could truly be the end of the United States.

© Can Stock Photo / tintin75

Keynote Address

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Transcript
Society for Maintaining Integrity on The Earth
Inaugural Meeting
Opening Remarks and Keynote Address

Good morning. I’m Michael, the Chair of the Ethics Department at the Society for Maintaining Integrity on The Earth and I’d like to welcome you to this inaugural meeting. It’s good to see all of you who accepted our invitation, and I’m looking forward to meeting with all of you individually. These are exciting times for all of us as we embark on this new project.

I’d also like to introduce Peter, our database administrator and technical wizard. Say hello, Peter. (Peter smiles, waves, and mumbles a greeting.) Peter will be leading the afternoon computer training workshop. He will also introduce the new phone app for Android and iPhone. This allows much faster access to information you’ll need to assess any situation. We haven’t yet activated the function because we still want you allow time for deep contemplation before acting.

A few housekeeping items before we get started. Lunch will be from 11:30 am until 1:00 pm in the Grand Ballroom. Be sure to bring the tickets that are behind your name badges. A bus for your spouses’ slash significant others’ activities will leave from the main entrance at 1:15pm and return in time for dinner.

Joseph Stalin famously said, “Everyone has the right to be stupid, but some people abuse the privilege.” I’ve been active since the first Homo sapiens appeared, weeding out those whose excessive stupidity threatened humanity’s survival and progress. Sometimes it was so rampant that I’m amazed you’ve accomplished anything in the past ten thousand years.

My job was much simpler in prehistoric times. There were fewer people and natural selection – what you call Darwinism – was very efficient. If you were persistently stupid, some ferocious beast decided you might make a nice snack (with a little subliminal suggestion from yours truly). Irritating the rest of the tribe might get you thrown into a volcano, justified by the flimsy excuse of “appeasing the gods.”

Now and then Administration had to periodically step in and thin the herd. Destroying almost everyone and everything with The Great Flood was regrettable, but that instilled the fear of The Almighty in the survivors, at least for a few centuries.

Later I experimented in Ancient Egypt, using the more articulate among the masses – Moses, David and others – to provide blatant warnings. The Pharaoh got nine warnings before the smiting began. I think DeMille’s casting of Yul Brynner was genius and I must admit a certain fondness for that stunt with the Red Sea.

A millennium and a half later, Administration had a great idea. Why not send Himself to live among the people? You recall how well THAT worked out. After the Resurrection the stupid in power – it’s amazing how the latter attracts the former – treated the disciples rather badly. Even a well-written manual wasn’t good enough for some – yes, I realize men don’t like to follow instructions – but then using it to inflict unspeakable pain has been humanity’s most despicable perversion.

Earthquakes, fires, the Black Death – all managed to keep the great unwashed under some control. That is, until things improved over the next couple of centuries and people began throwing caution to the wind. We found ourselves back at square one. The Renaissance was but a brief respite from idiocy. Humanity been remarkably resistant to guidance and reason.

By the twentieth century I had to become less subtle in my messages. That guy on the street, the one dressed in rags who held the sign that said, “The End is Near?” He wasn’t crazy; he was a walking Public Service Announcement. Targeted individuals who noticed but ignored the obvious hint later met with an unfortunate “accident.”

But the burgeoning population made it difficult for me to keep up with the workload. Social media has brought out the worst in people and you can thank those media czars for record levels of stupidity. Administration decided I needed some help, and that is where you come in.

You’ve all been selected for various reasons, for the Lord works in mysterious ways. Some of the people close to you probably wondered, “Why him (or her) and not me? I could do a damn good job of smiting!”  We appreciated their enthusiasm but there’s more to it than just summarily dispatching everyone who irritates the crap out of you. One of this morning’s sessions will cover the guidelines for choosing those most deserving. Our next session will discuss why you were chosen.

Thank you for attending and I hope you all find these talks illuminating.

The Prostate Saga – Rehab

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WARNING: This post contains material of a sensitive and sexual nature. If you are easily embarrassed or squeamish, you might want to sit this one out.

I saw the Urology Department Physician Assistant the week after my surgery to take out my catheter. She gave me a prescription for 50mg sildenafil (generic Viagra) tablets and told me to take a half tablet every night “to keep the blood flowing” – a prophylactic Roto-Rooter®. I made an appointment with her and the Vacuum Erection Device Clinic for January as “the December clinic had already passed.” I was supposed to talk with the clinic about acquiring a “medically approved” vacuum erection device in January, but I pushed to get it ordered in December since they run upwards of three hundred bucks and I’d met my deductible for the year.

I got a mysterious text message from FedEx alerting me to a delivery from upcrx.com that required my signature. Often “signature required” means either someone is sending alcohol, or the IRS wants to do an audit. Google helped me find University Compounding Pharmacy in San Diego but did nothing to alleviate my confusion.

The package arrived the following week. I scrawled my name on the driver’s tablet and I now possessed my very own prescription “Austin Powers Swedish Penis Enlarger.” I wasn’t supposed to use it until after my postoperative appointment in January, and then only “under medical supervision,” lest I somehow injure myself.

I had an appointment in January with Dr. Fine for a postoperative visit. The PSA level I’d had drawn the previous week was undetectable; I’d get a PSA level done every three months for a year, then every six months if all went well.

He asked about my recovery.

“It’s going fine. The big incision burned every time I moved but that went away in a week and I used the Norco maybe three times. I got by on Tylenol. And I’m back to my pre-surgical level of incontinence.”

His eyes lit up!

“You should really see one of the pelvic physical therapists. There are a couple of people who specialize in male incontinence therapy.”

“I’m fine.”

“You really should consider it; nip it in the bud right now.”

(Like I have the time or inclination to have some dude teach me Kegel exercises, which I’d taught women for decades.)

“Ok, I’ll give them a call.” (No, I won’t.)

Many physicians are hardwired to offer as many labs, procedures, and referrals as possible. That is probably why sleep studies have been such a standard for anyone who is fat, diabetic, hypertensive, and/or chronically tired. He gave me the phone number which I tossed into the trash on my way to the car.

It’s been seven months since surgery; I don’t wear underwear shields anymore and the urgency is almost nonexistent. I may not be able to write my name in the snow but it no longer feels like I’m trying to urinate through a urethra in a death grip.

The following week I saw the P.A.  She had asked me to come in early because she had to go somewhere. Today she was a little frantic and hurried through her instructions.

“You’ll be talking to Jonathan about the vacuum. Stop taking the Viagra while you are using it. Try the Viagra after a couple of weeks. If you don’t see any results after several tries, it’s time to open this little white bag and take the pill that’s in there. If you’re still not getting any results after 2 months, you need to come see me. Here’s an instruction sheet. Now I have to go…”

My next stop was the pretentiously named Vacuum Erection Device Clinic. I figured I’d be in a classroom with several other men discussing our surgical recovery, led by a physician in the requisite white coat giving us a talk on the mechanism of tumescence and how our recent surgery had interfered with function.

Instead, I went to another room and met with the “physician liaison” (read: equipment rep).

“I’ll need to order your device and when it comes in, we can talk about how to use it.”

“Uh, I got it last month.”

“Ok, then. Here’s what you do. Put it over your penis. Pump the vacuum for five or ten seconds, then wait forty-five seconds. Release the vacuum, wait a minute, and then pump it again for five to ten seconds and wait forty-five seconds. Do that for 10 minutes a day. If you have any questions, here’s my card.”

I wasted an afternoon for this?

How an erection works.

The cross-section of the penis looks like a cartoon monkey face. The shaft of the penis contains two spongy cylinders, the corpus cavernosum; a sizeable artery runs through each. A vein flanked on each side by an artery and a nerve runs above the corpus cavernosum. All this is surrounded by a layer of fascia, like a hot dog casing. A third spongy tube, the corpus spongiosum, surrounds the urethra and runs the length of the shaft below the corpus cavernosum while the dorsal penile vein runs the length of the shaft on top. All this is enclosed in loose tissue and covered by thin, flexible skin.

The arteries in the corpus cavernosum normally aren’t fully open, which is why men don’t have permanent erections. When the brain is stimulated, a combination of nerve impulses and chemical signals open the arteries which fill the corpus cavernosum with blood. The engorged tissue presses on the veins, blocking return blood flow and, voilà, an erection is born.

It’s been suggested that men hit their sexual peaks at 18 and it’s downhill after that. Research, however, shows men’s testosterone levels peak in their 30s before gradually declining. Getting an embarrassing, spontaneous erection for no apparent reason disappeared by my late teens.  Sexual function can decline as early as one’s 40s; I started noticing a difference in my late 40s. Other things can affect sexual drive and function besides purely aging:

The nerve bundles required for achieving an erection are often damaged during a radical prostatectomy. Scarring around my prostate required taking out the neurovascular bundle on the right side. The left side was spared but the trauma from surgery is enough to keep the remaining nerves from doing their job. It may take up to two years before being able to achieve an erection with or without ED drugs. If that doesn’t work, the alternatives are injections into the penis or penile implants.

This is my device. It has both battery-operated and manual vacuum pumps which attach to an acrylic cylinder. There are five silicone rings (sizes 5 to 9); the cone is used to slip a ring onto the other end of the cylinder. The ring ejector twists to push the ring onto the penis before removing the cylinder to maintain the erection. The body shield is that circular thing resembling a old-fashioned floppy disk drive and provides a barrier to prevent scrotal skin from being sucked into the pump. The gel is used to form a seal around the base of the pump and to lubricate the penis; without it the penis will drag along the cylinder wall like an anchor on concrete.

Note to self: make sure to grab the correct white squeeze tube: the lubricating gel tube, not the menthol gel I use on sore muscles.

The Vacuum Erection Device, aka the “Austin Powers Swedish Penis Enlarger”

The caveats in the instruction manual were disturbing.

“Vacuum therapy may cause a small “blood blister” on the head of your penis. This is normal and not harmful.”

“The rings may bruise the base of your penis. Some bruising is normal and should not be cause for alarm.”

Wait, what? In what alternative universe is a bruised and blistered penis “normal?”

“If you wear a ring for more than 30 minutes, you may severely bruise or damage your penis.”

So, if that happens, do I just get a new one from Amazon with 2-day Prime delivery?

I looked over the instruction sheet I’d gotten from the P.A.

You were given samples of ED medication to try at your leisure. Please use the paper form you were given (to) track your response and side effects of each medication. The goal is for you to try one tablet every 3rd day followed by (significant) stimulation.

  • Tablets work better on an empty stomach
  • Tablets take one hour to become effective
  • Space out your trials by 2-3 days at the minimum

If tablets do not work, you may still have intercourse with the vacuum rubber bands.

Common side effects – headache, facial flushing, nasal congestion

If you are on Cialis and are experiencing leg cramps – Please stop Cialis immediately as Cialis can sometimes be linked to tendon inflammation, possible rupture.

Oh, goody!

I discovered the vacuum doesn’t work immediately, which was disappointing. One cannot hope to instantly inflate the penis like a balloon that a clown twists into animal shapes for kids at a party. At first it took fifteen minutes to achieve anything resembling an erection, which decreased to around five minutes after three months. The least they could do is make pumps entertaining with indicator lights and an alarm that goes off when one has reached maximum height (or is it length?).

Anyone who played with a vacuum cleaner hose as a kid knows it can inflict some pain if left on a body part for too long. Moving blood into a penis with negative pressure is an uncomfortable process and certainly not erotic. And few things are worse than having a large chunk of scrotal tissue suddenly sucked into the cylinder along with a testicle. The barrier did not help at all; it was too flexible and got drawn in as well.

It didn’t take long for one of the rings to break and the replacements cost twenty bucks each. I ordered a different kind of ring that looked like a flat, silicone bagel (the penis goes through the hole and the surrounding material blocks wandering skin, but it was for a rival brand and didn’t fit my pump. I found another type that looked more like a foam-lined chip clip (or a cigar cutter). I settled on a silicone loop I bought from Amazon.

The battery pump died after a month. The company said they’d send a replacement which never arrived, and I don’t feel like calling them again. The manual pump is equally effective but using it leads to spasms in my right thumb and pain in my right wrist, caused by old nerve damage from two separate lacerations. The recommended forty-five seconds on, one minute off did nothing, even after multiple attempts over three weeks. I finally just pumped and left the vacuum on for several minutes while amusing myself with my Kindle game. (I may not have sexual function, but at least I’m doing my part to delay age-related dementia!) My erections promptly deflated as soon as I released the vacuum, despite the ring. There was never sufficient rigidity to close off the penile veins.

I then tried using 100mg sildenafil without the pump or any kind of stimulation. I got a slight flush but nothing. A few days later I made another attempt. I got distracted doing other things but applied the pump three hours after I took it. I got a reasonable erection which again deflated after taking off the pump and using the loop. I tried the pump again and then manual stimulation which made it last a little longer but still wasn’t anything to write home about. And all this took about 25 minutes, not including the minimum one hour wait for the drug to take effect.

George Burns said, ““Sex at age 90 is like trying to shoot pool with a rope.”

But all is not lost. Men can have orgasms without an erection, although it may take some mental adjustment. If you’re a New Ager into Tantra (and you have a lot of patience), you can have an orgasm using just your mind. Radical prostatectomy removes the prostate and seminal vesicles, meaning there’s no more semen, along with the sphincter between the urethra and the prostate, which normally prevents retrograde ejaculation (semen going into the bladder instead of out the penis). The result is climacturia, the release of urine with orgasm and a common side effect of the surgery. One can prevent this with an adjustable loop around the penis, muscle training or surgery, but emptying the bladder beforehand is the simplest.

More information than you ever wanted to know, eh?

Finally, nothing is more important during post-prostatectomy rehabilitation than a loving and supportive partner. Peg says she would rather have me alive and annoying than six feet under, and for that I am grateful.

Monkey illustration © Can Stock Photo / yayayoyo

The Prostate Saga, Part 2

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It’s a good thing Dr. Fine’s reputation preceded him, or I might not have stayed long enough to meet him. But first, a segue into the genesis of my ire.

When Corporate America took over health care administration, it decided physicians had wasted too much time taking care of patients instead of generating revenue. Large health care organizations began buying up individual physician practices and, in some cases, taking over hospitals. Younger physicians loved this idea: they got a salary, paid vacation and none of the administrative hassles of running a private practice. (I plead guilty, as I joined an HMO for those reasons. I was a poor businessman and I admitted it. The problem was, in many cases, I knew more about business principles than the people signing my paychecks.)

Older physicians balked at being controlled and some of them resisted as long as they could. If you didn’t play ball, The Corporation would find ways to shut you out. If you didn’t contract with the predominant insurers, you became “out of network” and a lot more costly to patients. Other older physicians saw the handwriting on the wall and retired early, the lucky bastards, to stay at home, engage in hobbies, travel or annoy the wife full-time.

We traded autonomy for financial security and ended up with neither.

The Corporation now controlled everything, including your ass, so it could dictate how you did your job. One physician I knew 25 years ago, a hospital employee, said, “I have guys in three-piece suits telling me what to do. And I do it.” Thus, the standard 10-minute appointment was created. No matter how complex the patient, physicians were expected interview, examine, diagnose and treat a patient in the allotted time before moving onto the next one. Or should I say “mooving on”, since patients were now herded through like cattle. (I often threatened to play the Rawhide theme in the hallway during my HMO days. “Head ‘em up! Move ‘em out!”)

If you were a specialist, you got 20 or 30 minutes for consults, even if the patient had cancer. No “wasting time,” like my gyn oncology professor during residency, who spent an hour discussing ovarian, uterine or cervical cancer with women who were still in shock from the diagnosis.

And now, back to our regularly scheduled blog post.

Dr. Fine’s office booked a 30-minute visit at 2:50 p.m. Peg and I arrived about 15 minutes early; she was still in a wheelchair after having foot surgery.  I checked in, sat down and waited. And waited. And waited.

About 40 minutes later a nurse, nursing assistant or whatever, appeared in the door to the inner sanctum and bellowed, “David.”  I got up and wheeled Peg through the open door.

Halfway down the hall, the nurse said, “David, what is your date of birth.”

I told her and she said, “Oh, wrong David.” So, I wheeled Peg back to the waiting room while the correct David was whisked away.

Twenty minutes later she reappeared. “David.” Once again, I wheeled Peg down the hallway, but not as far this time before she realized my date of birth didn’t match what was on her tablet. And, once again, I wheeled a now pissed-off Peg back to the waiting room.

Different women appeared at the magic door, calling names as if they worked in a cheap restaurant, and patients disappeared.

It was now 4:15 pm. I’m normally a quiet, patient type (you shaddap and stop laughing!), but even my patience was wearing thin. The first woman we saw opened the door and called, “David.”
“Which one?”
“Last name Rivera?”
“Yeah, that’s me.”

We were herded into a pen patient room and a few minutes later a very sweet assistant came in to verify my information on the computer terminal (paper charts have all but disappeared). She apologized for the wait and said Dr. Fine would see us soon, but he was running behind.

Peg smiled but said, “We’ve been waiting a long time. Dr. Fine better be a rock star!”

The SYT swallowed and assured us Dr. Fine was indeed was, figuratively speaking, on par with Jimmy Page.

We could hear snippets of Dr. Fine’s conversation with another patient. Another 15 minutes elapsed, then yet another nurse/assistant came in with two books. I don’t recall the titles, but they could be titled, “You and Your Prostate,” and “What You Need to Know about Prostate Cancer.”

“The doctor will be in shortly to discuss your diagnosis.”

Now I was pissed! “I’m a physician! I KNOW my diagnosis; Dr. Ky and I have talked about it and I’m here to talk about getting a surgery date scheduled!” I thought If you’d looked at the record before barging in here, you’d know what’s happened and why I’m here.”

Finally, Dr. Fine entered the room and I understood why he was running late. He greeted us and apologized for running late. “Discussing a new diagnosis of cancer with a patient takes some time and I don’t want them to feel rushed.”

Ok, you earned your rock star status.

He talked at length about Gleason scoring in general. A Gleason score of 6 suggests one’s cancer is likely to grow slowly while a score of 8 and above is likely to be more aggressive and spread quickly. My score of 7 (4+3) put me at intermediate risk and was more concerning than a score of 3+4.  Then he talked about Tumor, Node and Metastasis (TNM) staging and how that relates to overall survival; my cancer stage was T-IIa, meaning no metastases or node involvement. (For more information, go to the Urology Care Foundation educational materials page and download the Localized Prostate Cancer guide.)

Notes from our discussion of prostate cancer and treatment options

We then discussed treatment approaches. I talked about the risks of radiation in my previous post, but the biggest drawback is it turns the prostate to mush. If the cancer recurs, taking out the prostate is next to impossible. Doing surgery first leaves radiation as an option for recurrence.

Surgery removes the prostate completely and, potentially, all of the cancer, but has its own set of risks. Immediate problems include recovering from surgery, including having a catheter in one’s bladder for a week. The surgeon has to cut the urethra (that tube from the bladder to the outside) to remove the prostate, and then sew it back together. One is likely experience some degree of urinary incontinence once the catheter comes out; they recommended getting a large supply of “adult incontinence underwear” along with pads that look like what women wear after delivering a baby.

Surgery removes the seminal vesicles and potentially some nerves along with the prostate, guaranteeing temporary or permanent erectile dysfunction. I would be taking a low dose of the “little blue pill” (sildenafil) every day to “promote blood flow” back into a limp penis. I’d have a checkup six weeks after surgery and then go to the Austin Powers Swedish Penis Enlarger clinic to learn how to use a $300 “medical grade” acrylic cylinder and vacuum pump. For some reason they discourage procuring the much cheaper products available at your friendly neighborhood adult toy store as it could “result in injury.” (Like Ralphie getting his tongue stuck to the frozen flagpole in “A Christmas Story?”)

We agreed to a surgery date right after Thanksgiving. He gave me a card for the Patient Navigator, someone who is supposed to “guide you through the process.” I talked with her once; she told me someone from the hospital “will call you with a surgery date within a couple of weeks. Then someone will call you a week before surgery with questions and instructions.” I used to impart that information to my patients at the end of our visit and didn’t need someone to do it for me.

I saw one of the Urology Department P.A.s (physician assistant) to teach me Kegel exercises, which help control the inevitable leaking bladder after surgery. Women learn Kegels when they are far younger, since they have only one urethral sphincter to men’s three.  I told her I’d been wearing protection for months to which she replied, “Welcome to our world.” The visit lasted only a few minutes. Peg had taught me abdominal core and Kegel exercises to do while driving to client’s houses. She did a better job and for free.

About a week later someone from the hospital’s scheduling department called me while I was driving to a client’s house. My surgery would be on December 2 at 7:30 a.m., a wretched time, as I’d have to be there about 2 hours earlier for preparation (which often takes about 30 minutes). 

“I’m wandering around the Chicago suburbs so now isn’t a great time to talk. How about you give me a call next Monday when I’m home?”

“Ok, that would be fine. In the meantime, I’ll send you preoperative instructions through our website and we can go over them next week.”

 She called and went over my medical history – current and past illnesses; the medications I took; allergies to medications – before going over the same instructions she’d sent the week before. I realize it may seem redundant, but there are people handicapped by a Y chromosome who don’t read or listen and need all the reinforcement they can get.

“Back in the good old days, I used to do all this myself.” 
She replied, “You probably weren’t that busy back then.”

Bullshit. I routinely saw 25-30 patients a day in the office and worked in women with acute problems. I did my own preop H&Ps (history and physical) and dictated it on the hospital’s transcription line. Years later, wrote my reports in MS Word and hand delivered them to avoid hearing, “We can’t find your H&P. Did you forget to dictate it?”

Preparing for surgery

Physicians go through “informed consent” with a patient before surgery or a significant treatment. Ideally, a physician explains what s/he proposes doing, what it is meant to accomplish, the risks and benefits of the procedure (including risk of death, if appropriate), and what might happen if the patient refuses. Then the physician gives the patient time to ask questions, have those questioned answered and, often at the end, sign a permit for said treatment or surgery.

This ritual is supposed to ensure the patient makes a well-informed, intelligent decision while also minimizing the risk of litigation in the event of an adverse occurrence or outcome. In reality, a pissed-off patient can always claim “I didn’t know what I was agreeing to” and some lawyer will take the case. So, many of us believe there is no such thing as truly “informed consent.”

My approach to informed consent for surgery went something like this:

“You need to be at the hospital two hours before your surgery time. They will get you ready for surgery (but it doesn’t take two hours, so you’ll spend a lot of time picking your butt). When everyone is ready, one of the nurses will take you to the operating room, put you on the table, hook up EKG leads and strap you down, so you don’t roll off. (Sometimes we will pick our butts waiting for anesthesia to stroll in.) I will be there before you go to sleep. This procedure is going to take about x hours. You’ll go to the recovery room for about an hour and then sent to your room (inpatient) or sent home (outpatient).

“All surgery comes with some risks: risk of bleeding, infection and injury to something inside. You also have a 1 in 60,000 risk of dying from anesthesia, but you are much more likely to die driving your car, especially in the winter when there are a lot of idiot drivers around.” (For the curious among you, the risk of death from a motor vehicle accident is 1 in 103. I can’t find the odds of dying from stupidity, but the Darwin Award people keep a nice tally.)

If I was tying a woman’s tubes (tubal ligation), I added this:

“You also need to understand nothing is perfect, including tubal ligations. About three out of every 1000 women getting their tubes tied get pregnant, sometimes many years later. A few of those pregnancies will end up in the uterus, but many get stuck in the tube, causing an ectopic pregnancy which can kill you  if not treated. So, if you ever think you are pregnant, you need to see a physician right away.” (I met a woman in Tennessee who had an ectopic pregnancy 13 years after her tubal ligation. She had been bleeding vaginally (and internally) for a few days, not realizing she was pregnant. I found 1300cc of blood in her abdomen.)

Now, that approach was too vague and informal for Ms. “Expectation Management” who thought researching every possible surgical complication was a fine idea, and then expected ME to grill my surgeon on how the team was prepared to avoid them.

I know a lot of the possible complications, which is why I hated gyn surgery! I’m more like Peg’s sister, Michele: Ignorance is bliss.

The day before surgery I had to drink only clear liquids and do a bowel prep. I drank a bottle of magnesium citrate, which is far easier to take than the gallon of NuLYTELY® I had for my colonoscopy prep. But, because a bowel prep can screw up one’s electrolytes, they told me to drink a 20oz bottle of Gatorade four hours before surgery. Yep, 3:30 a.m. Sleep is overrated.

We arrived at the hospital parking lot about 5:30 a.m. and trekked what seemed like a couple of miles to Surgical Registration. I checked in with a woman who was too alert for such an abysmal time. We waited for about 20 minutes, then someone led us on another trek to Pre-Op where I changed into a hospital gown and hopped onto the gurney.

My nurse was an adorable, diminutive redhead with freckles and a pixie cut, too alert and too cheery. She put EKG leads on my chest, a blood pressure cuff on my arm, and poked my finger to check my blood sugar, and started an IV, all while telling me what I needed to do.

“You remind me of my wife.”
“Hey, you brought her here, I didn’t.”

I started laughing so hard she had to retake my blood pressure after I calmed down.

I talked with Dr. Pierce, the anesthesiologist, and reminded him of my paradoxical reaction to Versed (midazolam), a drug used for anesthesia induction and conscious sedation. Dr. Fine appeared a little after 7:00 am for some last-minute discussion and reminders. Surgery would take about two or three hours and I would go home in the afternoon if everything went well.  Then the OR nurse put a bonnet on me, had me kiss Peg and rolled me down to the room. I slid onto the table while the anesthesiologist and the scrub tech introduced themselves and got me ready.
The last thing I remember hearing was, “This might sting a little as it goes into your vein.” Click here if you want to see Robotic Assisted Laparoscopic Radical Prostatectomy .

When I woke up 3½ hours later, it seemed as if only ten minutes had passed. I felt pretty good in large part to the local anesthetic injected around the trocar sites. Even the catheter wasn’t uncomfortable.  I had something to drink and the recovery room nurse had me walk down the hall.  I was home by 3:00 and really happy I didn’t have to stay in the hospital.

The following week wasn’t bad, either. I didn’t have to get up at night because of the catheter. Peg got up at 1 a.m. that first night to empty the bag, but I cut my liquid intake in the evening and emptied it about 11 p.m. which got me through the night. I had six stab wounds for the trocars but only one hurt if I coughed or move wrong, and that only lasted a week. I took three hydrocodone tablets, mostly at night, and used acetaminophen the rest of the time.

My abdomen after surgery
My incisions

The pathology report came back by the end of the week:

Surgical pathology report
Prostatectomy Pathology Report.
A. Right neurovascular bundle margin, excision:
-Neurovascular tissue, negative for malignancy.
B. Prostate, radical prostatectomy:
-Prostatic adenocarcinoma, Gleason score 4+5 = 9.
-The margins of excision are negative for tumor.
-Focal extraprostatic extension, left posterolateral, for a total span of 5 mm.
-Uninvolved seminal vesicles.
C. Bilateral pelvic lymph nodes, excision:
-Six lymph nodes, negative for tumor (0/6).
D. Posterior bladder neck, excision:
-Fibromuscular tissue, negative for tumor.
E. Anterior bladder neck, excision:
-Fibromuscular tissue and focal urothelium, negative for tumor.

So, the cancer cells were worse than the biopsy and it had already peeked out beyond the prostate. Having negative margins means the bad stuff was confined to what was taken out. Surgery turned out to be the more prudent approach.

The catheter came out the following Monday. I had to change underwear frequently for a few days but was back to my pre-surgical level of incontinence by the end of the week. It felt strange being able to urinate like I did before my prostate started squeezing my urethra.

I had an appointment for the Vacuum Erection Device Clinic in January, but that is a whole ‘nother story.