Polypharmacy – Taking Too Many Medicines

April 30, 2009

One of the questions I get all too often from my patients, particularly the older ones who are way too many medications, is “Will this new medicine react with the ones I’m already taking?”

I answer by telling them, “Scientifically, we know how one medicine reacts with another. When you add a third one though, everything we know goes out the window. How about if you’re already on ten or more medicines?”

Sadly, many of our parents and grandparents, are on way too many medications. And this phenomenon has already trickled down into our generation and that of our children! I routinely see college students who are on 3-4 medications: an anti-depressant (seems like these are almost as universally used as aspirin used to be), an ADHD medicine (seems pretty standard for a lot of kids these days as well), birth control for many girls and then whatever variety of meds they may be on for asthma, allergies or other medical conditions. Our bodies have literally become pharmacies and then we wonder why we get so sick!

Statistically – especially for the providers out there – the likelihood of a patient complying with a regimen of medical treatment goes down by 50% when you reach four daily medicines. That means that half of your patients (who are on at least 4 meds) will be taking medicines not at all, haphazardly or in the wrong way out of confusion, forgetfulness or carelessness.

How to solve the problem? From a patient perspective, talk to your provider if you are concerned that you are on too many medications. See if there are any combination products that can help you lower the number of medicines that you are on. Secondly, remember that not every problem requires a pill or prescription. This is especially true when it comes to medications for depression. This is a serious subject though which I hope to write a proper post on soon.

From the provider perspective, remember to do no harm. Closely examine your patient’s medication list to make sure there are no redundancies – a very common occurrence. Also, try to help your patient’s find non-pharmacological ways to deal with their problems.

A friend sent me this great video made by Cafe of Life that probably says it better than I ever could – hope you like it as much as I did. Click here to watch.


Laying on of the Finger

April 29, 2009

healing_fingerPart of my mission with this blog is to help those outside of the medical realm to understand how much BS we often have to sift through in order to get to the bottom of things. Case in point, I get word that EMS is bringing in a potential “neurological injury”.

Let me tell you, neurology and nerve injuries are not on anyone’s list of favorite things to deal with in medicine. They’re confusing, complicated and then you have to deal with neurosurgeons – the medical equivalent of getting sodomized with a baseball bat. So, needless to say, I was worried.

Finally the patient rolls in, appropriately strapped to a spine board and in cervical precautions. He looks scared and worse yet, he’s not moving. He’s a young person, maybe in his mid 20’s, which makes it a recipe for true disaster. So, I carefully start getting the story.

Turns out that John and his girlfriend were having some fun at home and started chasing each other around the dinner table. But then suddenly John hits something and crashes to the ground, unable to feel anything below his waist. His girlfriend starts to panic and calls 911.

My first instinct was to get on the phone with neurosurgery, and get this guy into the right hands ASAP.  But the image of a baseball bat makes me think that I should at least do a thorough neurological exam on this guy first. I start with his cranial nerves, which seem normal above his waistline. Beyond that though, he has no pain response, no movement and no sensation whatsoever in his legs. I’m starting to sweat.

Last on the list though is to check rectal tone. When someone is truly paralyzed below the waist, they almost always lose their muscle tone in their anus and rectum, as well as losing control of their ability to control their bladder. Put simply, they urinate and defecate on themselves. Yet John’s tighty whity’s are Clorox clean. Hmmm? Maybe he was lucky enough to preserve this area I’m thinking. But, like it or not, I have to do the rectal exam.

As I start pulling his underwear down, for the first time it seems, John starts to look anxious. “What … what are you doing??!!”, he blurts out.

I explain, “I have to do a rectal exam … basically involves me putting my finger in your ass to check your muscle tone. It will help me to understand your degree of paralysis.” I have the nurse put the lubricant on my finger and just as my cool, gloved finger touches his anus, something miraculous happens.

John’s butt cheeks clench so tight, and his previously “paralyzed” legs snap shut and come off the backboard with truly impressive force.

So all was well in the ER. I wasn’t going to get sodomized by neurosurgery after all, John had a “miraculous” recovery and I temporarily became known around the ER as “Jesus”.

What had happened? I will never know for sure, but I’m pretty sure John was alright before EMS even arrived to his house. How far could this ruse have gone? Who knows? Why was he faking it? The promise of a disability check, for sympathy, thought it would be a good joke – your guess is as good as mine, but he wasn’t the first and he unfortunately won’t be the last person trying to pull the wool over our eyes for some alterior motive.

Nude Psychiatry

April 28, 2009
Shirt and shorts required.

Shirt and shorts required.

I had this patient come in for a fall this weekend – seems like everyone was falling for some reason. He was in his sixties and had recently lost his job as a marital counselor because the foundation he worked for lost 1.5 million dollars in the Bernie Madoff scandal. Till that point, he had been sober for eight years, but the news was too much for him. So he went to the bar and got hammered.

Came home totally stinking drunk, and freshly unemployed to boot, so his wife said she had enough of him and told him to get out. So the marriage counselor was having marriage problems and not approaching them in the way that he probably advised others to do (at least I hope not).

Since this poor soul had fallen while drunk, the nurse asked him to get into a gown so that I could check him for injuries from the fall. I walk in and find a pleasant gentleman sitting on one of the chairs in the room. As we get into the physical exam, he tells me about some bruises and abrasions he suffered from the fall and proceeds to lift up the gown to show me his abdomen.

He didn’t tell me though that under that gown, he was totally naked. Just naked and casually sitting on a chair reading a magazine. Personally, I don’t prefer that any of my skin touches anything in an ER patient room.  But he, on the other hand, didn’t seem to mind plopping his naked genitals (i.e., free-birding) right down on that cloth lined (read absorbent) chair that others before him had bled, vomited, urinated and God knows what else on before. Either that or he really trusts generic hospital brand Lysol.

This reminded me of a patient we had a few months back in our psych room. She was about 50 and depressed. One of my colleagues went in to see her and being that it is the psych room, it is monitored on CC TV. As he was interviewing her, I noticed from my peripheral vision that she was successively taking off her clothes. Right down until she was totally naked and just sitting there answering his questions. It was a most unusual site to behold.

I mentioned this encounter to one of my other colleagues who is a serious triathlete. He told me that this was nothing compared to the guy that visually tortured him for months when he used to go swimming at the YMCA. This guy used to strip down to nothing but his socks and shoes and spend a good half hour riding the air-dyne (fan bike) in full view of all to behold. Not a nice image.

So, all-in-all, not sure if these are just nudists who happened to need to come in to the ER or what? But there is no doubt that we sometimes get to see way more of our patients than we ever intended to – and in most of these cases, have to live with the nightmares.

The Bottle’s Been Going Down

April 27, 2009

liquor_lockAlcohol. Too many stories, hard to know where to start. I have so many things to say about alcohol, but too tired at the end of this shift to start. But I think you might enjoy this little tale from today’s smorgasboard of delinquents.

Ms. Weetod, someone I have come to know very well, comes in today with her parents for uncontrollable nausea and vomiting. Usually these patients, the ones with uncontrollable nausea and vomiting, are snacking on chips and drinking a soda (or like Nurse K’s patient – eating a double cheeseburger) , but not Ms. Weetod. She’s 45 and living with Mom and Dad because she sunk her life down the toilet with all the liquor she’s had all her life. I saw her last week when she had a seizure in Wal-mart and she told me that she hadn’t drank for a month, that she was cleaning up her act. That’s what you might call confabulation (the replacement of a gap in a person’s memory by a lie that he or she believes to be true).

So today her parents tell me that they are “very concerned” about her vomiting and that she must be very sick. Now I don’t ever drink and have never gone to a bar, so I usually have a tough time with the smell of alcohol on a person’s breath. But after she breathed in my general direction,  I was already feeling a little lightheaded. But the parents said that she couldn’t have been drinking. So, I decided to check an alcohol level in addition to all the other usual suspects.

Low and behold, her EtOH level comes back at about .360 – close to five times the legal limit depending on what state you’re in for those who are unfamiliar with alcohol readings. Now I personally would have probably been dead at .30, and rigor mortis at .35. Granted this is not the highest I have ever seen – I think that would be .460 in someone who also remarkably happened to be awake. The human interest side of this story is not the height of her alcohol level, but the poor gullable people she was living with these days – good old Mom and Dad.

Knowing that I would be shattering their hopes, I bravely walked into the room. She immediately told me, “I feel so sick!” I couldn’t help it and replied, “Maybe you should stop hitting the alcohol.” Dad – with a look of shock on his face – says, “Alcohol? Where are you getting it from?” She tries to lie and says nowhere, so I casually mentioned how her alcohol level was enough to snocker everyone else in the room. Then Dad comes out with his classic, never-will-forget-this-one remark that showed just how honest and innocent this Mid-west couple was. He says:

So that’s why my bottle has been going down! (meaning the level of alcohol in his bottles had been mysteriously decreasing over the past few days) 

I’m not sure if he thought it was evaporating or what exactly?  But I didn’t have the heart to tell the old guy that not only was the bottle level going down, but that in reality, he was probably missing a few bottles at that. The awesome nurse that discharged him told them what they needed to hear though by saying that they needed to get rid of all the alcohol in the house. Guess I don’t need to tell you though about the dirty look she got from our dear Ms. Weetod who was clearly unhappy that we were getting into her private goldmine. Either that, or Dad needs to put a lock on his liquor.

Swine Flu: Epidemic on Our Hands?

April 26, 2009
Duct Tape. Save Yourselves! The End is Near!

Duct Tape. Save Yourselves! The End is Near!

I’m almost glad that I will be having some time off in the coming days because with all of the insanity regarding the swine flu racing through Mexico City, and now in certain parts of the US. News reports thus far have done what they have become exceedingly good at in recent years – scaring people. Remember duct taping your windows in case of a nuclear strike? Probably about as effective as hiding under your desk (what they officially taught the last generation to do in case of a nuclear strike). So what do I expect will happen?

Starting soon – in a city near you – ER’s will start getting loads of visits from people suspecting they have swine flu (had our first one already today). What are the symptoms you might ask? Same as any other kind of flu – fever, cough, fatigue, body aches, nausea/vomiting, lack of appetite, etc.  Pretty vague right? But there must be a way to get tested right?

Yes, there is a test. Whew, you must be thinking! But, the test needs to be done at a public health lab. So, in other words, it might take a while to get results. But there must be something I can do right?

Sure, if you notice these vague symptoms and get to your doctor within 48 hours of the onset of your symptoms, then you can get antivirals. “What are antivirals?”, you may ask. They are very expensive medications produced in very limited quantities that have totally variable rates of success. What does that mean? It means good luck.  Beyond that, only two out of the four available class of antivirals “seem to be effective” per the CDC. So what happens then if you get to your pharmacy and they’re out of Tamiflu or Relenza (the two that “seem” to work)? If you can’t get it within the first 48 hours then its not worth taking. But you’re not dead yet.

The CDC recommends routine precautions to prevent the spread of infectious diseases: “wash your hands often, cover your nose and mouth when you cough or sneeze, avoid close contact with sick people. If you are sick, stay at home and limit contact with others”.  So, I’m following their advice and staying away from sick people by not working until this fear campaign takes a rest.

The thing that really bothers me though is scaring people over something when there aren’t reasonable options for reassurance.  The last thing I want to see is a run on ER’s and people who are minimally ill, but maximally worried, depleting whatever supplies of antiviral are available (even if doesn’t work so effictively) so that later waves of possibly sicker people will not be able to get treatment.

I also hate seeing people get worried over something which in many cases is no different than getting Influenza. Influenze kills lots of people every year – approximately 36,000 deaths and more than 200,000 hospitalizations are directly associated with influenza every year in America according to the Journal of the American Medical Association. I’m not sure about you, but I don’t change my lifestyle or schedule because of Influenza. Do we really need to change our lives because of the Swine Flu?

There Should Be a License for Parenting … or Maybe a Test

April 25, 2009

If I only had a dollar for everytime I have seen people in the ER who wouldn’t be able to properly parent a goldfish, yet for some reason have 2-3 kids; I wouldn’t be working right now. Really though, I think a whole blog could be devoted to the subject of inadequate parenting. Yet, the following story really stood out in the sea of poor parenting that I see on a daily basis.

I get a call from police who tell me that they are bringing in an 11 year old. I thought it was a prank and asked them if he was a little tough for the force to handle. Then they told me no, that it was serious. They had been called out to a home by a mother who stated that her son had gone crazy and started to beat her. They came out the first time and settled things down and left. Then they were called out again for the same issue. This 11 year old clearly wanted to put a serious hurt on his mother. The second time police came though, he started to scuffle with them as well. And so now, he was coming to the ER for what sounded like a transfer to a psych facility for adolescents.

When I get around to seeing this young hellion, I am surprised by how small he is sitting in the psych room chair. The very experienced nurse who had triaged him told me that he wasn’t telling her anything. No comments whatsoever. So before going in, I did a quick check on adolescent psychiatric beds in the state. The closest available bed was 4 hours away. I use that technique a lto because it is amazing how cooperative a person can get when they realize how far away they are going to be sent. I have often wished I could transfer to another country – that should really get them to cooperate.

So now it’s time to talk. I make it straightforward and simple for this young man. I spoke to him in a stern, no nonsense manner. If you don’t want to talk to me, that’s fine. I already have a place for you to go and it won’t be quite as comfy as home. If, on the other hand, you want to plead your case and explore other options, then you had better talk. And so he opened up to me with great reluctance. What he said though, I didn’t at all expect.

Doc: So, why were you beating on your mom?

William: Why shouldn’t I? Everyone else does?

Doc (shocked): What do mean everyone else does?

William: All her boyfriends hit her before when she didn’t listen. So I told her to do something and she wouldn’t listen, so I hit her.

Doc: And you don’t think that its wrong to hit her.

William: No.

For me, that was totally unexpected. Obviously, this boy’s mother had been in more than one relationship where she was domestically abused. We put a lot of focus on the women in these cases, but sometimes we underestimate the effect this has on the children. Children learn so much from watching what we do – the main reason why in parenting we always encourage parents to do what they say. You can say whatever you want, because children are going to learn more from your behavior and actions than from your words. Your words will have the most impact when they are backed up by supporting actions.

So, now I was stuck. It wouldn’t be entirely right to penalize this boy now, since he was only doing what he had been taught. I’m sure he was very confused since he had not only never been taught that this was wrong, but was actually shown that it was right. So, mom and I had a little conference to discuss this matter.

I explained to her that clearly, she had been part of the wrong message to this boy. She totally agreed with me and said that she had made some poor decisions and that she had furthermore always given this little boy decision making capacity in the home. He was, for lack of a better term, the man of the house and the head of the household. She errantly thought that allowing him to make decisions would be a good step in helping him mature, but what it had done, in this particular environment, was give him the idea that he was in charge. He was the boss, at least in his own mind, and no one had yet challenged that concept. That explains why he even scuffled with police. He was probably asking himself why they were getting involved in his private domain.

At the end, I got through to him that he should be his mother’s protector. He doesn’t want someone to slap him around, why would he allow someone else to do that to the mother he loves so much? Worse yet, why would he do it himself? I told him that he had one chance to make me a believer and that I would give him his golden opportunity to convince his mother to take him back home. When his mother went back to give him the chance to apologize, I saw the behavior of a true 11 year old child. He wept and went down on his knees telling her how sorry he was for hurting her and how he should have protected her. They both cried and I felt as if we had made an impact. We had changed the course maybe before it was too late. Only time will tell.

We get a user’s manual with every product, no matter how trivial. We are required to have a license to drive a car, to undergo safety training when it comes to firearms, to attend job orientation when we get our first job bagging groceries. Yet for the most important job in the world, most people think they need no training at all. If we want a brighter future, me thinks we need to make a bigger effort in this issue today.

For your consideration:

But really, on a more serious note:

Internet Date Goes Horribly Wrong

April 23, 2009

You're hot An interesting thing happened last weekend. My own Romeo and Juliette … from Hell that is.  We had two patients come in from a car accident by EMS. Here is their story; a story that deserves a movie deal, or at least a Saturday Night Live skit.

John and Peggy.

John, a portly 275lb, unemployed alcoholic was looking for love. But unfortunately, love wasn’t look back in his direction. So he tried the internet. Peggy, an equally portly 255lb, gainfully employed assistant manager was having trouble finding the right man and also thought to try her luck on the internet. It was a match made in heaven, or at least in Heaven-Hill.

Their love on-line seemed to blossom, until they could hold themselves back no longer and just had to meet. John unfortunately had a suspended license (damn DUI’s), so Peggy would have to go and pick him up. They decided to go someplace exotic, someplace intriguing, a place where they could look deep into each other’s eyes and hear one another’s sweet words. They decided to go to a bar.

At the bar, they drank and drank. Maybe they imagined that the alcohol would make them appear more enticing (ahh, the famed beer goggle).

They hoped for the arrows of Cupid to pierce deeply into their hearts, but instead they discovered that the alcohol only brought on the spear of Ares (Roman god of war). Their arguments led them to decide that maybe it was best to go home. But Peggy was nice enough to at least drive the drunk and stupid John home.  John, alcohol having removed his ever so thin veil of “niceness”, told Peggy she needed to take a certain route to get him home.

Peggy, on the other hand, thought that John’s liquor was talking instead of his “brain”, and she decided to take another road to get him back to his hometown. I guess her route would have eventually gotten him home if they had driven long enough in such a great circle, but we will never know the answer to that intriguing question. Why?

Because poor John became so angry at his dear Peggy on their way home, that he decided to grab the steering wheel at 50 mph and spin it around. He apparently thought that this would be a good idea and help put her on the “right road” as he tells it. Unfortunately for our dear couple, the car rolled and landed in a ditch awaiting the fine men and women of EMS.

Upon arriving, EMS immediately recognized that they were in the middle of a love nest and decided to transport our  Romeo and Juliette together in the same ambulance. Although it sounded to everyone else like they were arguing and blaming each other, as well as calling each other @$%&*# and the ever-endearing ?*&$%#!, I’m sure that this was just John and Peggy’s own special love code. We on the other hand in the ED had to give them separate rooms. That didn’t stop them from yelling at each other across the hall though. Oh no, love like that just can’t be stopped.

They were both drunk – John weighing in at an alcohol level of .31 and Peggy (the driver) coming in a close second with a .20. State Police was present to give them citations by which they could immortalize their first date. Who knows, maybe they may even consider tying the knot when they show up for their court date. Although some may see Peggy losing her license for drinking and driving as a tragedy, my sentimental side sees it as an opportunity for them to take long, romantic walks along the highway together.

At the end of it all, it turns out that even though John was chomping at the bit to leave and get out of his spine precautions, the poor soul had suffered a broken neck. Yep, a good old C2 fracture. It would be a wonderful reminder of his first date with Peggy. Peggy would only end up with a few scrapes and bruises to remind her of their first meeting though. Ahh, a first date to remember. Just hope I’m not around for their next one!


* Note – a case like this illustrates the great importance of radiographically clearing a C-spine when you are dealing with an intoxicated patient. Don’t be misled by their lack of pain and get a good radiographic exam.