An attack on cough medicine

Cough medicine has become the bane of my existence since getting to Thailand. Every single patient with a cough, from infant to adult,  wants "cough medicine" (well the infant doesn't ask, but their adult asks for them). I've had it up to here with freaking cough medicine. IT DOESN'T WORK. No studies have found that any "cough medicine" works for cough or the common cold. Studies have compared all the cough medicines out there with placebo and have yet to find that the medicines work better than good 'ol rest and rehydration. I'm doing my best to explain that to my patients here. I think the translator that works with me most frequently is getting sick of hearing me say "No, I don't think you need cough medicine. In fact, cough medicine doesn't work! I usually recommend hot tea with honey." I think I need to make up a pamphlet so I can just hand it to my patients, rather than having to repeat myself like a broken record 15 times a day. 

I had two patients in particular today that pushed me over the edge with the cough syrup thing. 

Toward the end of the afternoon a middle age Thai woman presented with a cough. Upon sitting down in the examination room, without speaking a word of Thai I could tell this was her chief complaint. She had a dry, persistent cough, that I'm sure was annoying to her. Through the translator I soon find out that she has had this cough for one year. Yes, chronic cough, my favorite as an emergency physician. After many back and forths between the translator and the patient, that typically takes eons since they're talking about god knows what details of her illness, I learn that she has been to multiple clinics over the course of the year and has been on many medicines. None of which she knows the names of. She has been on multiple rounds of antibiotics, and she might even be on some now! But she is not sure. Sometimes she feels better, but nothing makes the cough go away. She doesn't smoke, has no prior history of asthma or COPD, but does have a lot of exposure to second hand smoke and dust from the road near her house. She denies any prolonged constitutional symptoms, but states that for about a week she's feeling more fatigued than normal. Her vitals are normal, normal O2 sat on room air. Exam with normal lung sounds, and otherwise nothing else remarkable, other than this persistent dry cough that is worse when I have her lie down. 

"She came in to the clinic today because she has a neighbor who was prescribed cough medicine from here that worked really well, so she wants that cough medicine" says the translator. NOOOOOOOOO. If this woman thinks that of all the random medicines she's been on, cough medicine is going to fix her 12 month cough...I can't even. 

Of course, I nearly lost it right there, but held it together. I did an xray, gave her a salbutamol neb (maybe reactive airway?), did an ECHO and lung ultrasound--all of which were not entirely helpful, and ultimately tried to explain to her that perhaps this was reactive airway disease, possibly allergies, possibly post nasal drip, etc..and that I'd prescribe her a bunch of medications to see if any of it helped. With pleading eyes, she explained to the translator that she really just wanted to the cough medicine. Of course I didn't let her leave with JUST the cough medicine, but I had to break down and prescribe it to her...along with azithromycin, prednisone, cetirizine, chlorpheniramine, and daily inhalers...who knows, maybe that special cough medicine will do the trick?

Just before leaving the hospital around 6pm, a 4 year old girl came in with her father and grandmother with a cough. I'll keep this history brief: 

4 year old otherwise healthy female presents with cough that started ONE HOUR PRIOR TO ARRIVAL. Fine prior to onset. NO other symptoms. Family thought she felt warm then too. No congestion. NOT COUGHING on exam. Vitals normal. Exam without any wheezes, lungs are clear. She looks like a peach. 

Assessment: Cough one hour PTA. Unlikely to be anything at all. Not even clear that this is viral. Doesn't appear to be in distress, unlikely inhaled foreign body. No evidence this is reactive airway disease. 

Plan: go home and have a popcicle. 

Of course the family asks my favorite question--does she need cough syrup? One of the Thai physicians that I have been working with was there translating for me and knows full well how I feel about cough medicine at this point (I have been going off on his personal use of the stuff). I told him that I felt very strongly that this little girl should NOT have any cough medicine as there was absolutely no indication for this (she didn't even have a cough!) and the adverse side effects do not outweigh the lack of benefit. He laughed and seemed to translate this to the family, and we went on our merry way. BUT as I was leaving the hospital I saw the nurse putting together their prescriptions that Dr. Chang Noi had written without me knowing, which included chlorpheniramine syrup. I lost it. He was right there next to me, putting his face in his hands in coy embarrassment as I asked him very intently "WHY? What is the medical indication for this?" He of course didn't have one, and more or less said that patients want medicine when they come to the hospital. I again strongly disagreed with him and expressed my concern. 

I believe that patients want us to reassure them when they are sick, or concerned they are sick. More importantly, patients want us to use our brains to prescribe the appropriate care that we deem necessary when they come to the hospital. It doesn't take a medical degree to say that cough medicine works for cough, it takes that medical training (or even just reading the New York Times) to know that in fact cough medicine does NOT work and can be dangerous, especially in the pediatric population. 

I have a long fight ahead with this cough medicine stuff here in Thailand...either I'll get through to the patients here or they'll stop coming to me because I'm not giving them that "magic cough medicine stuff". 

Thanks for listening.

xoxo

SED