Thursday, November 7, 2013

The Vaccine Question

Everyone who knows me knows that my hobby is infectious disease. I devour everything I can read on the subject. From the historical accounts to the science of treatment and cure or the failure of science to find either a treatment or a cure. I read about outbreaks, containment and fear of outbreaks and what is done to prevent them. I love epidemiology and virology. Of course you can't be immersed in the subject and not read about vaccines and vaccination campaigns. I even read about the ethics and civil rights surrounding those.

That being said, there's a lot of debate right now about vaccinations. You can't be a parent and have someone question whether or not you will choose to vaccinate your child.

The anti-vaccination crowd says that the doctors and vaccination companies use fear mongering to pressure people into putting poisons into their bodies. Make no mistake about it. The fear mongering is alive and well on their side as well. Fear of seizure disorders and Guillian-Barre, autism, etc.

And then there are the vastly uninformed. I've actually had people tell me that no doctor or vaccine ever really cured anything. That the eradication of certain diseases have been because of improved sanitation, not vaccines or improvements in medication.

Those statements are made purely out of ignorance. We have enjoyed several decades of freedom of deadly infectious diseases uncommon in the history of the world due to the combination of improved knowledge and sanitation efforts and through advances in medical technology.

All that being said, I have not vaccinated my children.

If my opinion could be summed up, it was best done by Dr. Russell Alexander when he gave his opinion to a committee about whether or not the government should push a nation-wise vaccination program in 1976 in fear an influenza pandemic was about to strike.

He said, "My view is that you should be conservative about putting foreign material into the human body. That' always true... ... The need should be estimated conservatively. If you don't need to give it, don't."

For better or worse and for those who have asked, here is my guideline for vaccination:

1. Risk Assessment
Some terrible diseases we commonly vaccinate against are pretty much gone from the US and have been gone for several decades. Unless traveling outside of the country or a new outbreak occurs I see no reason to vaccinate my children from those diseases.

Some diseases are mild and the natural immunity has proven to be superior to the artificial immunity. I choose not to vaccinate my child for those.

Some diseases are devastating but contracted through sexual or blood contact. I will reevaluate the need to have my children vaccinated for said diseases when they reach the age where they might be sexually active or come in contact with contaminated bodily fluids.

Some diseases are devastating and still alive and well in the US. I choose to monitor where outbreaks occur and make informed decisions based upon the risk assessment to my family.

2. Determining the Risk of Adverse Reaction
There are vaccines out there that are not commonly given because the chances of adverse reaction are higher than the chances of contracting the disease. But if there were an outbreak it would be better to risk an allergic reaction or lesser symptom than death from the disease.

Every medication has the possibility of side effects, some more-so than others. These days there are many claims that vaccines cause a wide variety of illnesses. How can you know if a vaccine is the cause?

Every year a certain number of people die from heart attacks, strokes and other random illnesses. Every year children are diagnosed with autism. And every year people naturally come down with sicknesses even as strange as Guillian-Barre. The trick is to look at the national average of a particular disease occurring without a vaccine and then to look at the average of that disease occurring in those who have received the vaccine. Unfortunately it's backward science. There usually isn't a need to look for those kinds of causes and effect issues until a certain disease seems to become more prevalent.

The questions occurring right now in many mom circles are the questions of autism and allergies. These seem to be sky-rocketing in the last decade. Is it because of vaccines or is it, in part, because we have gotten better at diagnosing illnesses in individuals we previously assumed to be within the bounds of normal?

There are a lot of people who say that doctors and drug companies cover up evidence of adverse reactions out of greed. Can there be some of that? Sure. But after having read account after account of doctors and scientists who have labored for years and donated their research and tests, spent thousands out of their own pockets to bring a cure to a certain disease out of the concern they have for their patients and their lives, I don't for a second believe that every doctor out there who advocates vaccination does it out of greed. These people see the worst these diseases can do to a human and many feel the risk of a milder reaction far outweighs a reoccurence or contraction of these diseases.

3. Know What The Vaccine Is Going To Do And What It Won't
Some vaccines protect against a disease for life. Some vaccines only protect against a disease for a certain amount of time. Some vaccines only protect against a certain strains of a disease leaving you susceptible to variations or new strains. New strains mutate all the time and therefore new vaccines must be taken often to inoculate against the new strain. Some people wonder why they should bother, then and why the push to vaccinate when it will not last? The hope is for partial immunity. A perfect example of this is the flu. The flu virus is constantly mutating and a new mutation could easily be deadly. If you are immunized from part of the virus, if it comes back in a more violent form you may still get sick but you may not die whereas someone who did not receive any vaccination or natural immunity may very well succumb completely to the disease. The hope is to save lives, not necessarily save you from ever getting sick.

The influenza virus is one of the scariest viruses out there. We think of it as relatively harmless and a few days off work but the truth of the matter is that the flu killed more people in 1918 than the Black Death. Not only is it extremely viral but as many as 17% of people who contract the flu can asymptotically carry and pass it along without ever getting sick themselves. This makes the flu very difficult to contain. There is an international network of scientists and labs monitoring the flu virus all over the world due to the fear and even likelihood of a deadly pandemic. Deadly outbreaks have been successfully contained in places like Hong Kong because of the efficiency and speed of this network.

In my life, I have gotten a single flu vaccination. It was required for work.

I have a very VERY healthy respect for the flu but I do not fear it. When I hear reports of H5N1 spreading and not being contained I will start to line up for the flu shot but until then I'm going to trust a deadly mutation has not occurred and should I contract the flu I will have nothing more than a few miserable days ahead of me.

3. One Vaccination At A Time
If you give an individual 9 vaccinations at one time and s/he has an adverse reaction, how do you know which vaccine is the culprit?

This has been a huge concern amongst parents. These days children are expected to get about 44 doses of about 14 different vaccines before s/he enters kindergarten. That's a lot to give in a very short period of time. Some of the vaccines are lumped together so that even if you are only getting one shot you are getting three different vaccinations. Three shots in a single day can mean nine different doses. It's easy to rationally see how that can be overwhelming for a little body to take in.

I believe in individual dosing for a specific threat of disease and giving time to watch for adverse reactions as well as for the body to build immunity. Certain vaccines can be obtained individually rather than grouped together though some cannot be. Or, rather, your caregiver may not be inclined to prescribe and fool around with obtaining an individual dose. That's for you to battle out with your caregiver. But if you know what you want and where your caregiven can order it from he might be inclined to help you out.

The only time I would break the "one at a time" rule would be if I felt there was an imminent collapse of our medical system on the horizon. In which case I would blanket immunize.

4. Know the Brand of Vaccine
Many people do not know that there are several brands and versions of vaccines. When they say, "I got all my shots as a kid and I'm fine so I see no reason not to vaccinate my children" what they are essentially saying is, "I ate a lasagna my great grandmother made for me when I was a kid and I liked it so there's no reason my child won't like the store bought lasagna I put on her plate today."

Ingredients change. Vaccines are grouped together or apart. Different companies have different cocktails, some with controversial ingredients, some don't. Those ingredients and cocktails come and go. And you won't (and can't) know what you are injecting yourself or your children with without researching the brands your doctor has and their side effects and what they are expected to do.

If you plan to get a vaccine and are concerned, call ahead and ask the brand of the vaccine you are going to receive and then research it individually. If there is another brand that looks more appealing you can certainly ask your provider if it's possible to get that brand (they may not know it's available) or search for a provider who administers that brand.

I choose to be conservative about what I inject into mine and my children's bodies but I understand that science and medicine have their place. I will use them if I feel the need. And make no mistake about there the need is out there that can come calling at any time. If you choose not to monitor places like the CDC's website for information on diseases and track outbreaks then perhaps blanket immunization is for you. If you believe it's all a conspiracy of greed and control and that medicine does no good then that's your choice, too.

Tuesday, March 26, 2013

The EMT Guide to Rebandaging a Tattoo

I got my first tattoo.


It's a photo-realistic bird on my left shoulder blade. But that's not important. Or at least not the point of this blog.

After lying on my stomach for four hours getting a needle repeatedly stuck in my back the artist cleaned the tattoo, folded a paper towel in half, taped it to my shoulder blade and sent me downstairs to pay and get my "tattoo care sheet." 

It goes like this:


Shower normally
Wash tattoo 2 to 3 times a day with antibacterial soap
Apply just enough ointment to keep tattoo moist
Apply sunscreen to keep tattoo from fading


Soak tattoo in any way (bath, lake, pool…)
Never pick scabs
Do not re-bandage tattoo unless instructed otherwise
Do no sue alcohol or peroxide; soap and water only
While the advice was pretty much what I expected it should be, I was surprised by the recommendation that one should not re-bandage a tattoo.

I'm an EMT. Wound management is kind of important to us and a huge part of that management is covering the wound to keep debris and other nasties out of it. Keeping a wound covered also helps with keeping it moist and promotes healing. It can also help reduce swelling and scarring. These are all GOOD things. 

So, when I got home I went against my medical training and tried to do what the sheet recommended. Except the chaffing of my shirt and sheets on my tattoo was bad. Not to mention I was losing a lot of moisture due to the cold, dry, winter climate and my tattoo was getting tight and uncomfortable. Adding more ointment would help until it rubbed off on my shirt or chairs or couches and I kept thinking about much easier this would be if I could just rebandage my tattoo. So I started to do some googling to determine why it was not considered good to re-bandage a tattoo.

What I found was a lot of opinion based on hear-say that was probably based on misunderstanding, bad hygiene and ignorance. But before we can list the reasons people give about why you shouldn't rebandage a tattoo we have to talk about what a bandage is and what it is not.

What is passed as "bandages" in the tattoo industry are improvised at best and would not go very far in the medical community. These days the "in" thing to do in tattoo parlors is to cover the tattoo with plastic wrap, tape it up and call it a day. In my case, my artist put two pieces of tape over top of a paper towel and called that a bandage. No wonder infection is cited as a fear of re-bandaging. If your idea of a bandage is to cover a wound with a dressing that cannot breathe (plastic wrap) or a non-sterile paper towel you very well may have problems.

There is also a difference between a bandage and a dressing. The dressing is the part of a bandage that makes contact with the wound. The bandage is the part that holds the dressing in place. In a standard bandaid, the white cottony part that you would place over the cut is the dressing, the part with the adhesive is the bandage. To shorten the terminology we all just said bandage to refer to the entire thing. But if your tattoo is 7x12 inches you are not going to find an all-in-one dressing/bandage combo to fit it and so you are going to have to improvise your own dressing and a bandage. 

When I think of a dressing I think of a sterile, permeable (breathable) pad of some sorts. And there are MANY to choose from and cheap. There are even pads that specialize in NOT adhering to wounds. They come in a number of sizes and many of them can be unfolded to cover very large areas or taped together to make the desired size or shape.

Because you do want a tattoo to breathe I would use only medical tape to hold a dressing in place and not worry about any kind of bandage unless I was expecting to get the dressing dirty or wet. For your average tattoo, however, a sterile dressing held in place with tape is more than enough.

So what are some of reasons given for not re-bandaging a tattoo and are they valid? Let's see...

The bandage will adhere to the tattoo and damage it as you attempt to remove it.
I this sort of true. As we all know, a tattoo is damaging to the skin. In terms of the damage it does it is very similar to an abrasion which is a superficial (shallow) area of damage to the surface of the skin. Think skinned knee or elbow. They don't usually bleed a lot but they can produce a clearish liquid called plasma which is the liquid part of blood. It contains clotting factors that will adhere to a dressing or bandage. If any blood or plasma dry to a bandage and are pulled off it can reopen a wound and hinder healing or make a wound worse.

But is it something to worry about? Not really. You can purchase special dressings designed not to adhere to wounds. Also, warm water breaks down the bond of blood and plasma and one can very gently remove a dressing from a tattoo by simply running warm water over it until it falls away from the body. No pulling necessary and no added damage to the skin or tattoo.

The tattoo will be unable to breathe. 
This is only true if you are using an occlusive (water and air-tight) dressing such as plastic wrap. If you are using a sterile, permeable dressing this is not an issue.

The tattoo will get infected.
Again, this is only an issue if you are using a non-sterile dressing and not washing the tattoo properly. Slapping on a paper towel and leaving it for a couple of days so that your sweat and bacteria can fester an grow can very much cause an infection. Carefully washing the tattoo and putting a clean, sterile dressing on once in a while can actually help prevent infection.

The dressing will pull the color from the tattoo. 
I have searched and searched and searched and have not found a single reliable source for this claim. The ink of a tattoo is inserted under the outer layer of the skin called the dermis into the lower layer of skin known as the epidermis. This is where your sweat glads live and below where new skin is formed (so that you simply don't slough off your new tattoo). It is not easily extracted from your skin. If it were, we would all be losing our tattoos in our sleep on our pillows and bed sheets. If your cotton shirt will not pull out your color a sterile dressing won't either.

That being said, you WILL bleed color from your tattoo for a few days. Your skin and body were not made to hold ink and just like your skin will attempt to expel a sliver, it will attempt to expel the foreign substance known as ink from itself. This is completely normal and should not be taken as a sign that your ink is being "drawn out."

It will slow the healing process.
There is no evidence to suggest this is true. At least not if the tattoo is bandaged properly. In fact, it goes against what we known to be true about wound management which is that a covered wound heals faster.

So, should you or should you not re-bandage a tattoo?

It's totally up to you!

One account I read from a medical doctor suggested treating the tattoo like a sunburn. Keep it clean, keep it moist and if it feels better to bandage it then bandage it. Just bandage it properly and change the dressing frequently, especially if you are still seeping blood or plasma, working in a dirty environment or sweating.

Below is what I would recommend to anyone getting a tattoo as far as aftercare is concerned:

1. Remove the initial bandage within the two-hour time frame recommended by most artists. Do so by running warm water over the bandage to loosen any clots or dry blood so as not to open a wound.

2. After properly washing your hands (at least 60-seconds or good scrubbing with soap and hot water) wash the tattoo with soap and warm water. Do not use peroxide or rubbing alcohol as these products can damage and dry out your skin and tattoo.

3. Apply a thin coat (thin enough to barely make the tattoo shine (for a tattoo that covers my entire shoulder blade I use only a pea-size)) of some kind of ointment. A favorite is A&D. If you can keep it open, then do so, making sure to protect against sun exposure or soaking in pools and baths (where bacteria live).

4. Shower like normal.

5. There are plenty of reasons to bandage a tattoo. You need to work and don't want to get it dirty. It is in a location where clothing will chaff. You want to sleep and not get ink and blood on your sheets. Your skin is sensitive and looses moisture fast and you need help keeping the tattoo moisturized. If you can keep from having to bandage the tattoo, great! Leave it alone. But if you feel you need to rebandage the tattoo do the following:
    a. Pick up a package of non-stick, sterile dressing pads in an appropriate size.
    b. After properly washing your hands and tattoo, apply a thin layer of ointment to the tattoo (this will help with both the moisture and with keeping the tattoo from sticking to the bandage).
    c. Unfold or tape the pads together with clean medical tape until you have a dressing that will cover all sides of your tattoo.
    d. Being careful not to touch the part of the dressing that will touch your tattoo, apply the dressing to the tattoo and tape on all sides to clean, non-tattooed skin (avoid putting tape on any parts of the tattoo).
    e. To remove the dressing, remove the tape and then run the entire area under warm water to dissolve any potential blood or plasma clots that may be adhering to the dressing. Keep running water over the dressing and tattoo until the dressing falls away. Do not pull or forcefully remove.
    f. Change the dressing at least once a day, more if sweating or it gets soiled.

6. Do not pick any scabs or dry skin and be careful to keep the area moist.

7. After a few days, switch from ointment to a non-dyed and non-perfumed moisturizer.