Pop Tops and the Personal Health Record

I blew out my flip-flop. Stepped on a pop top. Cut my heel, had to cruise on back home. “Margaritaville” - Jimmy Buffett, 1977

Quick Summary

• Healthcare systems might have become computerized, but you still can’t count on easy access to your records years later, when you’ve moved across the country or the doctor’s office has closed.

• In this article, I show an example of why it matters, and why I’ve always thought it makes sense to keep your own medical records.

• Various efforts to commercialize a Personal Health Record (PHR) have come and gone, but right now there are a lot of Boomers who wish that their vaccine records from 60 years ago had been saved somewhere they could access them today.

Stepped on a Pop Top

If you’re too young to remember them, pop tops were the ring-tabs that us Boomers pulled to open our cans of beer in the 60s and 70s. They didn’t stay attached to the can like tabs do today, so lots of pop tops became litter. They were kinda sharp and could certainly cut your foot.

So you’ve got a nasty gash on your foot after walking barefoot through the mud.

Now What?

Strategy A: What would Jimmy Buffet do? He would have booze in the blender, and soon it would render that frozen concoction that helps him hang on.

Strategy B: What would your grandmother say? “When was your last tetanus shot?” (Do you remember?)

Tetanus is one of those things that keeps appearing in the history of human civilization. I’m using it to make a point, which is that maybe it makes sense to keep a lifelong Personal Health Record – like the chart they keep about you in your doctor’s office, but instead you maintain it for yourself, forever.

Tetanus through history. It’s more gruesome than you might think.

Many people associate the need for a tetanus shot with a deep puncture wound from a rusty nail. It’s not the rust, though, but the dirt which is likely to contain spores of a bacteria called Clostridium tetani. The spores are found everywhere on Earth, in soil and especially in animal poop. When the puncture wound introduces C. tetani into a deep tissue space where oxygen levels are low then the spores can germinate. As the bacteria grows, it releases an incredibly potent tetanus toxin which blocks our nerve signaling molecules, resulting in the muscle spasms that give the disease its common name – “lockjaw.”

There’s an Egyptian medical document written in hieroglyphics around 1600 BC, now known as the Edwin Smith Papyrus. It is a medical record, clearly written by a master clinician to educate other physicians. It deals with military surgical care in 48 types of trauma. Case 7 describes a case of tetanus in a patient with a severe head wound. It’s a little gruesome – skip this quote if you’re sensitive.

“…his brow is wet with sweat. The muscles of his neck are taut, his face is flushed, his teeth and his back. The odour inside his skull is like sheep/goat excrement. His mouth is bound, his eyebrows drawn, his face as if he was weeping. He suffers stiffness of his neck. Therefore do not treat the ailment.”

Today we interpret this hieroglyphic note to mean that the soldier’s wound has become infected with C. tetani, and the tetanus toxin is causing muscle spasms in the neck, back, mouth, and face; he has lockjaw. And the lesson from the 3600 year old papyrus was that this was not an illness that could be treated.

More than three millenia after the Egyptian soldier, another soldier was wounded. This casualty of an 1809 campaign of the Napoleonic Wars was treated by Charles Bell, a Scottish civilian surgeon who had a side hustle illustrating studies of neuroanatomy. Like the ancient Egyptian soldier, Bell’s patient developed typical spasm of the jaw, face, neck, and back. Bell painted a picture, again as a teaching tool so that other physicians could learn from his experience.

You can see the painting. It’s also little gruesome. Follow the link if you like this kind of stuff. Skip it if you don’t.

The Wounded following the Battle of Corunna: Tetanus Following Gunshot Wounds. Charles Bell (1774–1842)

The point is, tetanus has been around forever, and it’s not a good thing to get. Today the disease still kills thousands of people every year, mostly infants in low-resource developing countries. Infection of newborn umbilical cords by unsanitary birth techniques is almost always fatal; this has been substantially reduced by public health efforts in recent decades.

So that’s tetanus, the disease that your grandmother was trying to ward off when she reminded you about a tetanus shot. It’s not just rusty nails; high-risk wounds for tetanus are any penetrating or puncture wounds, dirty wounds (including bites by humans or animals), and wounds with dead tissue (like burns, broken bones that poke through the skin, crush injuries, and frostbite.)

Before there was a tetanus vaccine, there was tetanus anti-serum from horse blood.

The trench battles of WW I with fragmenting explosives in the manure-rich fields of Europe led to many dirty penetrating wounds. Wounded British soldiers returning from France to hospitals at home frequently developed tetanus. A prevention program was initiated to give the wounded men an injection of concentrated horse antibodies against tetanus toxin. As soon as this program was implemented mid-October 1914, the rate of tetanus among wounded soldiers dropped dramatically.

Tetanus cases per thousand wounded soldiers in British home military hospitals after being wounded in the manure-rich trenches of WW I France.

With the introduction of tetanus anti-toxin in the middle of the second month of this chart showing Sept 1914-Nov 1916, the case rate dropped.

Chart from: Bruce D. NOTE ON THE INCIDENCE OF TETANUS AMONG WOUNDED SOLDIERS. Br Med J. 1917 Jan 27;1(2926):118-9. Illustration by Alan Heldman.

While the anti-toxin was effective, the human immune system often recognized the horse antibody proteins as foreign, producing an illness known as “serum sickness” with fever, rash, and joint pain. And the effect of the horse antibodies against tetanus lasted only days or weeks, so re-treatment was required with every new wound or subsequent surgery.

Trying the New Tetanus Vaccine in WW II

As the US military prepared for the possibility of entering WW II, plans for preventing tetanus were reconsidered, because now there was an alternative to the horse blood anti-toxin. The new product was called tetanus toxoid, and it was an inactivated form of the tetanus toxin. It stimulated the human immune system to be able to recognize and neutralize tetanus toxin. It was a vaccine – a relatively new vaccine, with limited data. Nonetheless, a huge potential advantage was recognized if it worked to pre-treat soldiers who would soon travel around the world and face combat far from hospitals. Military doctors believed that the effect of the new vaccine would be longer lasting than the horse antibodies, and that vaccinated casualties would not need horse serum treatment. Knowing which soldiers had been vaccinated before they entered combat was considered so important that the year was recorded on each soldier’s metal dogtag -- as “T43” for tetanus toxoid given in 1943.

The new vaccine certainly seemed to work well. Reporting results on the "Health of the Army," at the conclusion of the war, Surgeon General Norman T. Kirk wrote in 1946:

"The record for the prevention of tetanus was especially remarkable. In spite of the many thousands of battle wounds in which tetanus has always been feared as a deadly complication, there were only five (5) deaths from tetanus during the entire war, and only two (2) of these were in soldiers who had been properly immunized."

Current recommendations in the USA are for children to receive an initial series of tetanus vaccine in combination with other vaccines, another dose at age 11-12, and for adults to receive a booster every ten years. That’s why many grandmothers looking at the cut on your foot would ask whether your tetanus shot was up to date. Do you really remember for certain when you last had a tetanus booster? Could it have been more than ten years ago?

Now as it turns out, there’s a pretty good case to made that for most people, a booster every 30 years might be good enough. I’m not sure whether ten or 30 years is better, because the data on this issue are not strong enough to make me certain. But that’s beside the point for today, because I am not here to argue about vaccines. (There are enough people yelling about vaccines these days!) My point is that an adult ought to have access to their own health information. To own a master copy. To control its use and sharing. A digital dogtag?

Dogtags for Everything?

The US Army in WW II knew that rapid access to information about a tetanus vaccine could make a difference, so they put the information on the dogtag, where it stayed with the soldier. Despite the digital information revolution, I still don’t have the equivalent of a health digital dogtag, more than 80 years after the US Army figured out that it mattered.

Beyond the tetanus shot records, I can think of hundreds or thousands of other bits of health information that might be useful for you someday, but are lost, or locked in a doctor’s office, or scattered onto hundreds of different computer servers, inaccessible to you when you need them.

Why Does Access to My Records Matter?

Today, prompted by outbreaks of measles among unvaccinated children in the US, many adults may wonder whether they are immune to measles. You might find guidance like this from Yale Medicine.

• If you were born before 1957, you almost certainly got measles during childhood and are presumed to be immune.

• (Unless you are a health-care worker, in which case unless you have proof of immunity, you should consider getting a measles shot.)

• If you were born after 1957, get a measles shot if you don’t have written proof of vaccination.

• If you got your measles shot between 1963 and 1967, you might have received a less effective vaccine. If you aren’t sure, you should get a shot.

• Try to find your childhood vaccination records.

• You can also get a blood test to see if you have antibodies against measles, indicating immunity.

For many baby boomers, the interpretation of this guidance is a challenge. I was born in 1962. My parents are not alive for me to ask. I certainly don’t have copies of my school immunization records, my pediatrician’s notes, or anything to tell me whether I got a measles shot and if so, what kind! The health departments in Alabama where I grew up responded to my query; they don’t have any records for me. I am left wondering whether and how I was vaccinated against measles.

For myself, I wish that I had a personal health record that went all the way back to the beginning. Some people will reasonably decide that it’s more trouble than it’s worth. What do you think? Have you tried to make and keep a PHR? Comments are open for discussion.

In upcoming Substacks, I’m going to try develop the idea of a truly personal health record. Having made my point about vaccine records, the next essay (Food in America) will begin to look at nutrition data, its uses, abuses, and potential value.