Covering All Bases in the ER

Photograph Source: Dedric Cherry – CC BY 2.0

Trying to remove a proliferation of weeds growing into the siding of our house, pulling out ivy and unidentified vines, and digging out incipient maple trees, I have on a long-sleeved rash guard and pants with socks as protection from mosquitoes and no see-ums and other insects. Though I’m wary of DEET, I probably should be wearing it.

While I’m doing this my husband circles the grounds with a manual push mower. For him and a certain tiny subset of enthusiasts, it’s the only decent, rational way to mow the average lawn (usually he needs to be jumpstarted).

Like homeowners everywhere presiding over tiny plots of grass for the last half century, our neighbors are mostly unaware there’s an alternative to power mowers. The wealthier among them hire lawn services: Three or four men arrive in a large flatbed truck, pull down the gangplank and unload one or two tractorlike vehicles which they methodically drive around till every blade of grass is cut. While this is being done the owners vacate the property—never actually witnessing the labor done on their behalf—treating their neighbors to the pollution and noise.

“Landscaping” can be hard, miserable work. Never do more than an hour and a half in one day—or even that–if you can avoid it. Sweat pours down my face—if I stay out here in this getup much longer I’ll have a heat stroke.

The next day sections of my face begin to look red. By Tuesday, bright streaks appear.

My primary care provider—whose office is located only a few blocks from my home—can only be reached circuitously, through a central switchboard rotating among various distant states. The phone lines are fully automated; and in this Rube Goldberg type system the only way to speak to a human being is by pressing an extension indicating you want to make or cancel an appointment. The operator who answers can contact the clinician’s office staff to place a call-back request.

They’re part of a network of practices affiliated with a major Manhattan teaching hospital—and the new face of rural medicine, I guess.

At the height of the Covid pandemic last year, scheduling a virtual appointment using their MyChart app required either an Apple ID or a Google ID. Even if you passed this hurdle, passwords routinely failed; there was zero tolerance for those unable to obtain an Apple ID or a Google ID.

They insist upon scheduling “wellness visits” twice a year (or in my husband’s case, four times a year, though he’s in extraordinarily good health). But God help you if you have a serious problem that’s not an emergency—you have to try to reach them through this Byzantine network, petition them to call you back–and good luck, esteemed supplicant, this could take place 24 hours later. Today, the operator at the other end of the line (in Florida) informs me my provider’s away this week.

Fortunately a nurse practitioner who treated me at a clinic when I gave up on telehealth during the pandemic last year has joined the outpost of another teaching hospital in a vacated bank building nearby. She’ll make an exception and agrees to see me just this once–but to get any more appointments in the future I’ll have to make her my primary care provider.

The second I mention I’d been weeding, she identifies my rash as an allergic reaction to poison ivy; I am relieved that in a few weeks this ailment will run its course. Not so fast, she says—first it will get worse. She recommends an oral steroid–or at least a topical steroid—to relieve the anticipated symptoms.

Absolutely no, I say. Why mess with my immune system? I’m not even experiencing any itching or pain.

However by Wednesday, my face and neck are largely covered by the rash; my cheeks begin to swell. My husband doesn’t think it looks so bad. But I’m keenly aware the skin near the bridge of my nose is covering the inside corner of my eye.

I Google “poison ivy allergic reaction”— which is considered to be treatable at home–as long as you show no sign of anaphylaxis. It’s not contagious–and only spreads by touching the plant or things coming in direct contact with it; they contain an oil called urushiol secreted from the plant’s leaves.

However all the sources warn, if the rash affects your eyes or privates seek medical attention. That evening the swelling of my eyelids partially obstructs my vision.

The gold standard in urgent care here where I live is the CityMD clinic—out on the main highway about 12 miles away–it opens at 8 a.m., but the line forms hours earlier. Many go there for primary medical care, for Covid testing, and the lines are long. For me the drive’s traumatic. The local hospital, on the other hand, is three blocks away.

It’s 5 a.m. Except for an elderly patient being prepared for admission the ER is eerily quiet—it’s the graveyard shift–and when trouble does come it’s bound to be serious. To see a doctor I’ll have to wait; no one can say how long. They tell me I have the option of seeing a physician’s assistant.

She soon arrives, inspects the rash, and hears me explain its etiology. A medical assistant draws blood and positions me for a vision test.

Everything comes out OK and I have no fever. But the PA is not entirely convinced it’s a simple case of poison ivy.

Her diagnosis : “r/o [rule out] cellulitis vs erysipelas.’ (Which is medical jargon for the exact opposite—meaning you can’t rule them out.)

These are serious and uncommon conditions–which she proposes to treat with steroids and antibiotics. As I’m unwilling to destroy my immune system and intestinal flora based on a very tenuous diagnosis, she hands me a tube of clobetasol propionate—a strong topical corticosteroid. (When I go online it says never put this on your face.) If things get worse, she says I should come back to the ER.

By a stroke of sheer luck, I manage to advance a long-delayed appointment with a dermatologist to the following Monday.

But today is only Friday, and a thick, grainy rash covers my entire midriff and the rash is also spreading to my groin. All sources warn if this happens you should seek prompt medical attention. At mid-morning both a doctor and a resident are present in the ER. Young, bright, and fresh out of medical school, the resident completes a brief exam (maybe not the groin). He exits the room, and returns with water and two capsules: a steroid (Prednisone) and an antibiotic (Clindamycin)–it’s not a high dose of prednisone he assures me, only a moderate dose (40 mg)—which I ingest without protest–as if he were handing me a thermometer or a dressing gown.

I’m given a prescription for a 7-day dose of Clindamycin–an antibiotic—and a two-week dose of Prednisone–a steroid.

Only much later do I realize that in diagnosing me with “Unspecified contact dermatitis due to plants, except food. Concern for cellulitis/erysipelas,” he’s simply deferring to the previous diagnosis of the PA—which constitutes my hospital record.

All antibiotics–in the course of killing bacteria–end up creating drug-resistant strains. And they all kill gut bacteria that is beneficial—in this respect Clindamycin is the worst. A delayed side effect–severe diarrhea–can occur suddenly up to two months after you stop taking it.

Pseudomembranous colitis is a potentially lethal condition commonly associated with clindamycin, but which also occurs with other antibiotics. Overgrowth of Clostridiodes difficile, which is inherently resistant to Clindamycin, results in the production of a toxin that causes a range of adverse effects, from diarrhea to colitis and toxic megacolon.” Even healthy people are increasingly testing positive for c diff–which must be treated with an even stronger antibiotic.

One of the most widely prescribed drugs used to treat bacterial infection, it’s never indicated for an allergic reaction like poison ivy.

The reason that three full days into my seven-day antibiotic regimen I’m just now reading about Clindamycin on Wikipedia and other sources is I’ve been focused on the other medicine.

Prednisone is the oral version of a class of drugs called corticosteroids—used to treat conditions such as arthritis, breathing problems, allergies, skin conditions, and other problems.

Steroids alleviate inflammation, pain, and discomfort by temporarily placing the immune system on hold. And in so doing they can weaken the immune system, and worsen or reactivate an infection.

One is advised not to get a Covid vaccine (or any vaccine) for up to two weeks after taking steroids–and possibly longer–as they will be ineffective. In order for your immune system to learn to mount a response to Covid it must be healthy and functional to begin with.

Prednisone is an older drug–patented in 1954. Its approval so many decades ago and current status as a generic drug in widespread use effectively precludes much continuing research, as such studies would have no source of funding. So much knowledge about the drug is really assumption based on anecdotal evidence rather than a solid body of research.

However a CDC study did find that among those fully vaccinated for influenza a single corticosteroid injection greatly increases the risk of subsequently getting the flu.

The problem is that in dosages exceeding two weeks, patients must “taper” off of the drug gradually. Steroids cause the adrenal glands to produce less of their natural steroid hormones. You must let the adrenal response slowly recover—by no means should one abruptly stop taking steroids. As a result you can end up on them for a long time.

Anyway, I want to know what I should do right now. Should I start taking them? I call the network’s afterhours on-call physician, even though they routinely say, “I haven’t examined you so I can’t give you any advice. Go to the ER.” This time she says, “I haven’t examined you. Do what your doctor says.”

What is most confusing: Although I’m instructed to take the steroid for only two weeks, the container I’m given at the pharmacy is filled to the brim–with 320 (5 mg) pills–as though they’re preparing me either for the apocalypse or a long-term dependency on the drug.

Anyway I decide not to start taking it. Monday finally rolls around. I see the dermatologist. My rash has noticeably improved–he thinks the single 40 mg dose of Prednisone I received at the hospital was entirely sufficient to speed my recovery.

Upon thorough examination he sees no evidence of infection and doubts there was any. It’s a simple case of contact dermatitis, an allergic reaction to poison ivy.

To be on the safe side, though, just go ahead and complete the 7-day course of Clindomycin.  Can’t he see the sheer insanity of what he’s saying? I insist I need to stop taking it. He allows it would not be unreasonable.

I finally get to see my primary care provider (for a biannual wellness visit) and he assures me he would never have prescribed Clindamycin for poison ivy. But OK, the ER doctor gave it to me on the outside chance it could be something else—he was covering all bases.

“If he failed to prescribe a medication you needed you’d sue him. “

So from his standpoint it’s safer to overprescribe?

“And you did get off the steroids as soon as your condition improved.”

“Yes, but they all advise you never to do this–they tell you if you stop taking it there is a danger the symptoms will return.”

“And I feel I have to defend the resident,” he says, “because he never prescribed 320 pills for you.”

I look at the ER record on his screen–and sure enough he’s right: A “transcription error” caused the pharmacy to mistake the total dosage (320 mg) for the total number of pills.

Kathy Deacon can be reached at stradella3@msn.com.