You Don’t Need to Come to the ER at 3am for “Strep Throat”

May 15, 2009

Among the more frustrating ER visits that you will never see on your favorite TV medical drama of choice is that of the 3am visit for possible “Strep Throat”. The sad reality though, is that this is something that we as a medical community have contributed to in a potentially large way. Some people are afraid of Strep because of the supposed connection to Rheumatic fever, while others are just uninformed (putting it nicely) and think that getting that holy prescription for Amoxicillin will make their discomfort go away in a space of hours (which it doesn’t). I guess I should be glad that most of them don’t come in trying to get Percocet to kill the pain (which doesn’t work well in this case either).

Regarding the whole strep and rheumatic fever issue though, I came across an article a few months back that addresses this issue. I will reproduce it at the end of the post for whoever would like to read it, but since it is medical speak to a degree, I thought it might be thoughtful to at least summarize it for those who don’t have the time or medical background to read it.

Basically, the article states that our current understanding that untreated Strep results in Rheumatic fever comes from only one large study that appears to be an anomaly. Two more recent and rigorous medical studies show that there is actually a relatively low risk of Rheumatic fever connected to Strep, and that the number of cases of serious side effects from our overly generous use of antibiotics far outweigh the risks of the limited number of cases of Rheumatic fever in this matter. It recommends against use of antibiotics in this case, but I wonder if the damage is already done? Trying to explain this to the average soccer mom would more likely result in a complaint than a “Oh thank you Doctor for looking out for our best interests!”.

In today’s internet society, too many people come to the doctor looking to get an order filled as opposed to getting an evaluation and medical advice. We keep saying that it is Burger King and we are not here to fill your order, but that message seems to have been missed by Hospital Administration and the general public.

For those who may be interested, here is the article:

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Antibiotics for Strep Do More Harm Than Good
By David H. Newman, MD

Military and civilian medicine have always been intertwined, but nothing compares to the strange tale of Warren Air Force base in the 1940’s. Perched on the high plains outside of Cheyenne, Wyoming, the combat training center was, mysteriously, a bacterial cauldron. For more than a decade virulent strains of group A streptococcus caused unprecedented rates of pharyngitis among the trainees, and history’s worst epidemic of rheumatic fever.

A small cadré of military researchers at the base seized the moment, executing a provocative series of trials that tested the potential of antibiotics to prevent post-streptococcal rheumatic fever. Roughly 2% of the trainees given placebo in their studies developed rheumatic fever, while under 1% of trainees given antibiotics experienced the disease. For every 50-60 trainees treated with antibiotics, the researchers had successfully prevented one case of rheumatic fever. It was a small, but decisive victory.

Prior to the epidemic at Warren Air Force base there was little interest in ‘strep throat’. During the twenties and thirties in the Unites States, sore throat care focused on diphtheria, “the strangling angel.” The characteristic ‘bull neck’ and the dreaded grey pseudomembrane led to a gruesome, asphyxiating death for thousands of children each year. Comparatively, strep throat was a minor nuisance that often received little more attention than the common cold. But by the 1940s vaccination programs had nearly eradicated diphtheria, and antibiotics were becoming widely available. When the Air Force studies were reported in the early 1950s, they resonated. Rheumatic heart disease was common among adults, making its prevention seem immediate and intuitively important, and antibiotics for a bacterial infection made good sense. Identifying and treating ‘strep throat’ quickly became a staple of medical education, and little has changed.

The problem, of course, is that one can only prevent rheumatic fever where it may plausibly occur. Outside of Warren Air Force base in the 1940s, is rheumatic fever a plausible risk? Apparently not. There have been only two other cases of rheumatic fever ever reported in a pharyngitis study, both in 1961. In fact, despite large, contemporary studies tracking tens of thousands of strep throats in the general community, many of whom received placebos or no treatment, there hasn’t been a case of rheumatic fever reported in a study for nearly fifty years. When the incidence dropped to less than one per million in the general population in 1994, the Centers for Disease Control and Prevention stopped tracking rheumatic fever entirely.

At Warren Air Force base only 50-60 recruits were treated to prevent one case. Today, preventing one case would likely require antibiotic treatment for hundreds of thousands of strep throats, making it a mathematical certainty that antibiotics will do more harm than good. For each case of rheumatic fever prevented in modern practice, a few dozen patients either die or suffer near-fatal anaphylaxis, toxic epidermal necrolysis, colitis, or other antibiotic reactions, and many thousands more suffer diarrhea, rashes, and yeast infections.

Fortunately, rheumatic fever has been declining for a century, starting well before the introduction of antibiotics. While strep throat is no less common today, ‘rheumatogenic’ strains have dwindled, leading epidemiologists to conclude that antibiotics have little or nothing to do with rheumatic fever’s disappearance. Changes in hygiene, nutrition, population crowding, access to care, and changes in the bacterium are all felt to be important factors, which explains why the disease is now typically seen most in third world settings.

There are, arguably, other reasons to consider antibiotics for pharyngitis, but the evidence does not rise to support them. The Cochrane group estimates a 16-hour reduction in symptoms with antibiotics, but ibuprofen, acetaminophen, or a single dose of corticosteroids is as good or better, with fewer side effects. And while peritonsillar abscess may be minimally reduced by antibiotics, abscesses typically present primarily rather than after strep throat, and in most cases are easily treated. No studies have shown that antibiotics reduce the transmission of strep or reduce other complications.

The administration of antibiotics for strep throat, endorsed universally by practice guidelines and professional societies, is based exclusively on data from the world’s most concentrated epidemic of rheumatic fever. Using this to guide modern therapy is like administering antibiotics to prevent bubonic plague.

The essence of evidence is its ability to point us toward truth, and we must first understand what truth we seek. We do not ask whether antibiotics may be useful during a military epidemic of rheumatic fever. We ask a different question. We ask if antibiotics are beneficial for every day strep throat. Those who have written our guidelines and crafted our recommendations have, unfortunately, failed us. The strange tale of Warren Air Force base is a lesson in evidence: The only way to get an answer right is to pay attention to the question.

David H. Newman is the author of
Hippocrates Shadow (Scribner $26)

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Our Laziness and the Rise of Diabetes

May 11, 2009

A few days ago, I was attending an interesting CME that was focused on the rise of Diabetes in the US and the world. It was an interesting educational forum because of the ever decreasing age of Type II Diabetes (non-insulin dependent) that we see in medicine. When I was in medical school only a decade ago, Type II Diabetes was considered a condition that people generally only got when they were middle-aged or beyond. Young people with Diabetes were Type I (insulin dependent) almost by definition.

But in recent years, we have been seeing a steady decline in the age of the onset of Type II Diabetes. One ER colleague recently had a 12 year-old girl in the ER with a blood sugar of 850! She ended up being a new Type II diagnosis and did not have ketoacidosis which just shocked everyone involved in her case. Unfortunately cases like this though are becoming more and more common, with the age of onset being as low as 7 or 8 years of age in some cases.

What is Diabetes though and why are the demographics changing?

Diabetes is a condition where the body is unable to properly use sugar (glucose) due primarily to a problem with the hormone Insulin. Insulin is naturally produced in the pancreas and helps the body’s cells to absorb glucose from the bloodstream so that it can be used as an energy source.

To make a metaphor, it would be like saying that oil is sugar, but it can not be used by your car until it is first processed in a refinery (insulin). Without a proper refinery, all the oil in the world just sits around and cannot be used for fuel.

Type I Diabetes is where the person’s pancreas no longer makes Insulin and it is the least common form of Diabetes. Type II Diabetes though is where in the beginning of the course of disease, the body has trouble using the Insulin in its body. In fact, people with Type II often even have elevated levels of Insulin. Why do these people have trouble using the Insulin they already have? Because, amongst other things, they usually have increased amounts of fat tissue (they are overweight) and fat results in ever increasing degrees of resistance to insulin.

Even more concerning, endocrinologists state that at the time a person is diagnosed with Type II Diabetes, they have already burned 50% of the cells required to make Insulin naturally. That means it is only a matter of time before they will come to require Insulin on a daily basis to survive. This is not as much of a problem if a person is diagnosed at the age of 55, but when they are diagnosed with Type II at the age of 20, it is a definite problem with major medical consequences.

So one of the main factors that is contributing to the alarming rise of Diabetes in our society – particularly in younger people and even children – is increasing obesity. ASD reports that in 1962, statistics showed that the percentage of obesity in America’s population was at 13%. By 1980 it has risen to 15% — by 1994 to 23% — and by the year 2000 the obesity progression in America had reached an unprecedented 31%! Obesity is now the second most preventable cause of death after smoking.

Watching a movie like Super Size Me, the award winning documentary by Morgan Spurlock where he went on a McDonald’s only “diet” for 30 days and almost went into liver failure, we see how a small soft drink and small fries in the US is the biggest you can get in other countries. They don’t have a medium, large or super-size. When it comes even to breakfast cereals, you find that the sugar content is different in the US than say Australia. School cafeterias are being replaced by food plazas with McDonald’s, Pizza Hut and Taco Bell. We are too busy to cook at home anymore and so we now regularly eat out or order in. Kiplinger’s Magazine reported in 2000, that the average American eats out at least 4.2 meals per week.

One patient, who later got Diabetes, used to go everyday to her mailbox – which was about 20 feet away from her front door – by getting into her car, backing out of the garage, reaching into the mailbox and then driving back into the garage. Are we too lazy even to walk 20 feet to the mailbox? For those that have seen the animated movie Wall-E, the picture of the future of mankind is truly frightening.

The Future?

The Future?

For those that are fans of Jim Gaffigan, he once did a routine on Fast Food Delivery which was very funny, and at the same time so sad. He said, “I love delivery because it involves two of my favorite activities: eating and not moving”. Then he wondered aloud when it would come to the point where we would expect the delivery man to actually feed us as well because we would get too lazy to lift the food to our mouths. Let’s not get there.

I hope that something in this post will encourage you to start working on a better life for you and your children because to be honest, the medical resources aren’t there to handle a country where 30% of the population has Diabetes; even in a country as wealthy and blessed as the US. Let’s turn this boat around now before we run aground.

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Hydroxycut and Fad Diets

May 6, 2009

little_girls_smallA sad day in dieting occurred late last week with the pulling of Hydroxycut – the famed dieting pill (as seen on TV). The FDA is now warning consumers to immediately stop using Hydroxycut.  Apparently, Hydroxycut has been  associated with a number of serious liver injuries ranging from jaundice and elevated liver enzymes, an indicator of potential liver injury, to liver damage requiring liver transplant. One death due to liver failure has been reported to the FDA. Other health problems reported include seizures, cardiovascular disorders, and rhabdomyolysis, a disorder of muscle cell destruction that can lead to kidney failure.

Of course, news like this thins out the competitive field a little bit. True there are still pills out there on the market that promise that you can eat all the Twinkies, Hardee’s thick burgers and Oreo milk shakes that your heart desires without a nanosecond’s worth of exercise. For example, there’s always Alli – the non-prescription strength version of Xenical – which promotes weight loss by decreasing absorption of fat by the intestines, thereby reducing the number of calories you absorb. It also gives you diarrhea and nasty farts that leave skid marks in your underwear. And that’s on a low fat diet. Try that Hardee’s heart attack burger while on Alli and you my friend will understand the true meaning of pain while you spend the next 2 hours on the crapper.

By the way, did you know that the name of the man who popularized the toilet was Thomas Crapper? The guy who actually invented it was Sir John Harrington, hence the usage of “going to use the John”.  Ah, but I digress.

Losing weight is easy and it is hard.  To lose weight you need to eat less calories than you burn – easy in concept, hard in practice. One can also increase their activity level and decrease the amount of calories they consume and they will lose weight.But that won’t keep people from trying to find the magic lazy bullet which allows them to do nothing, eat anything and still have a beach bod. So let’s take a look at some popular, and not so popular, fad diets.

The Tapeworm Diet – Someone actually thought it would be good to eat one of these disease causing parasites. Hey, they’ll just eat all the excess food right? Wrong. Just like any pregnant woman will tell you, parasites eat what they want first and then you get the left-overs. So tapeworms get first dibs on your vitamins, nutrients and minerals. That’s why people with tapeworms usually develop ascites (big round pot-belly). I think I’ll pass thank you.

The Lemonade Diet – Popularized by Beyonce Knowles before filming Dream Girls, this disaster was originally called The Master Cleanser Diet by its creator, Stanley Burroughs in the early 40’s. Stan was a therapist once charged with second-degree murder after a patient died from one of his treatments. The diet eliminates toxins and “congestion” that have built up in the body, and because it doesn’t provide a complete source of nutrition, it is actually consider fasting more than a diet. Beyonce did lose 22lbs in 14 days on this diet, and the diet generally seems to have had good results with others who dare to try it either in Hollywood or elsewhere. Side-effects include lethargy, depression, dizziness, nausea, trouble concentrating, headaches and the one other one … oh yeah, death.  Use at your own risk.

The Paleolithic/Caveman/Stone Age Diet – The hunter-gatherer diet was introduced to modern times in the mid 70’s by a GI doc named Walter Voegtlin, with many variations since. Basically, if you can hunt it or collect it from a plant or tree, you can eat it. That means no dairy and no grains though. Hence the diet is essentially made up of  lean meat, fresh fish, vegetables, nuts, berries and fruits. No sugary calorie bombs or processed, preserved, cancer-causing excuses for food to fatten you up. Good for rapid weight loss in a healthy way but somewhat difficult in practice since you miss out on dairy and grains.

The ABS Diet – Newer kid on the block, created by David Zinczenko, the editor for Men’s Health. For many years most athletes and bodybuilders have applied the same basic fundamentals of the ABS diet to their dietary programs. These principles include eating often (5-6 times per day), a focus on building muscle, eating lean proteins, and striving to eat whole unrefined carbs.The Abs diet is made up of 12 ‘power foods’. One meal per week is designated as a ‘cheat’ meal – where you eat anything you want. The power foods are Almonds (and other nuts), Beans, Spinach (and green veggies), Dairy (fat-free or low-fat milk, yogurt, cheese), Instant Oatmeal (unsweetened and unflavored), Eggs, Turkey (and lean meats), Peanut Butter, Olive oil, Whole grain breads and cereals, Extra-protein whey powder and Raspberries (and other berries). It is a lifetime dieting plan with excellent results and a practical approach.

If none of these seem up your alley, here is one that I think we can all agree on every now again:

The Stress Diet:

This diet is designed to help you cope with the stress that builds up during the day. Breakfast

  • 1/2 grapefruit
  • 1 slice whole wheat toast – dry
  • 8 oz skim milk

Lunch

  • 4 oz lean broiled chicken breast
  • 1 cup steamed spinach
  • 1 cup herb tea
  • 1 small cookie

Afternoon Snack

  • Rest of the cookies in the package
  • 2 pints of  ice creamof your choice
  • 1 jar hot fudge sauce nuts, cherries, whipped cream

Dinner

  • 2 loaves garlic bread with cheese large sausage, mushroom and cheese pizza
  • 1 Liter of your favorite soda pop or cola
  • 1 bag of nachos with tub of hot cheese and salsa sauce

Late Evening News
Entire frozen cheesecake eaten directly from freezer

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Non-Pharmaceutical Pain Management Options and the Vicodin Virgin

May 5, 2009

Ok, it’s time to take a small break from all the jokes and wild stories, and time for a more serious article. Being outside the US for the past few days, I get a new perspective on certain issues like pain management for example. As a child visiting extended family, I can still remember my grandmother’s pure joy when my father gave her a bottle of Motrin. She had been using Aspirin to treat her osteoarthritis. She called him a few days later and thanked him for the miracle medicine. How much was she using? One 200mg tablet a day to control her moderately severe arthritis.

The country I am presently visiting is one of those places where you don’t need a prescription for most medications. You just go to the counter and ask for whatever … an antibiotic course, an asthma inhaler, a skin cream, an anti-emetic; whatever. So I did a little research on pain medicines recently. I asked the pharmacist at the counter what I could use for “severe” pain; you know, the good old “12” on a scale of 10 that we usually see in the ER.

The pharmacist reaches into one of the glass cabinets and pulls out some Cataflam (diclofenac) – an anti-inflammatory somewhat stronger than Rx-strength Ibuprofen. So I look at the box for a moment, and ask if they have something stronger, because my pain “is really bad”. I ask if maybe they have something like Ultram.

The pharmacist looks at me funny, and says that yes they have Ultram but only with a doctor’s note. She then asks me why I don’t try the Cataflam because it is one of the best pain medicines available. Clearly she was treating me like what I like to call a “Vicodin Virgin”.

What is a “Vicodin Virgin”, you might ask? It’s a person who has managed somehow to treat their assorted aches and pains throughout their life thus far without the use of narcotics. By this I don’t mean to say that the use of narcotics equals abuse, but somehow there is a large group of people out there who have gotten through their broken bones, wisdom teeth, headaches and even post-partum pains with non-narcotic methods. I am one of them and clearly this country had a lot of them too.

So this post is for such people. People who have no interest in Vicodin or Percocet for their pain management, and prefer something more natural or at least something that won’t make them goofy, nauseated and drowsy. This post is for you if you are concerned about using something that can be addictive and something which does little more than turn off the pain signal in the brain as opposed to helping pain at the site.

Again, I am not condemning people that use narcotic medications in the indicated way. So don’t get the wrong idea.

For the rest though, I like to divide non-pill based pain management into three broad categories: topical, behavioral and manipulative. Of course, there are other options available, but these are the ones I prefer when talking to patients.

Topical pain management is in my lowly opinion one of the truly underused modalities in medicine today. This is somewhat of a pharmaceutical option of course, but so unused that I wanted to discuss it. It includes creams and ointments like Tiger Balm, Icy Hot, Aspercream and even generic Walgreen’s brand “muscle cream”. The active ingredients are usually menthol (the smelly one), salicylates and capsaisin in any given combination. For most people with muscle aches, strains and sprains, these topical treatments can really go the distance in a safe way.

The second modality is behavioral and has Biofeedback and Progressive Muscle Relaxation (PMR) at the top of a short list. Biofeedback is a treatment technique in which people are trained to improve their health by using signals from their own bodies. Physical therapists use biofeedback to help stroke victims regain movement in paralyzed muscles. Psychologists use it to help tense and anxious clients learn to relax. It has become recognized through several well designed studies to be an effective part of a pain management program. It has even shown success with such severe pain syndromes as Sickle Cell crisis. Progressive Muscle Relaxation is also effective in pain control, as well as good modality in controlling the anxiety associated with pain; although these effects are lesser in degree and more dependent upon the ability of the patient to focus.

The last category involves manipulative techniques. Most people think of osteopathic medicine or chiropractic manipulation first when seeking relief from pain, and for a significant subset of patients these treatments are subjectively very helpful. The reality with all manipulative treatments though is that they are very dependent upon the person doing them. Massage is another manipulative technique which has been shown to be very useful and very effective in managing pain as was demonstrated in this review article in the Annals of Internal Medicine. In medical school, I had the opportunity to work in massage therapy for some time and personally witnessed the powerful effect it had on chronic pain.

So, these are just some of the more widely accepted and evidence based therapies that exist out there for people coping with pain and trying to avoid narcotics for one reason or another. Speaking globally, they do work and there are millions of people around the world who have succeeded in managing their pain effectively without the use of narcotics and their associated dependence. I hope some of these suggestions may prove useful as a springboard to readers – whether they be dealing with pain themselves or interested in helping their patients to find alternative ways of managing their pain.

And enough already with the Toradol allergy. We know what that really means.

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Surgical Masks – The Swine Flu Placebo?

May 3, 2009
The Insanity Continues

The Insanity Continues

Arriving to my destination country yesterday, I was greeted with two guys wearing medical masks and holding some kind of alcohol spray in their hands. They were interviewing people – mostly attractive looking women for some strange reason – and asking them where they had come from and if they were feeling “OK”. They had their masks on pretty loosely which just looked stupid.

Of course, Swine Flu is all the rage on the global stage these days. There has been a sudden interest in wearing surgical masks at many airports (I was thinking of marketing medical masks in pastel colors – let’s at least be fashionable right?). Mexico has become a black stamp with other nations canceling flights to Mexico, cruise ships avoiding Mexican ports like the plague and Mexicans traveling to other countries being subjected to extra questioning and possible quarantine. Some countries are even lumping Americans into this group as well because of the rising number of cases in the US.

Which brings me to the main question – do these masks people have chosen to wear really do anything? One US Public Health official was recorded as saying that they “give people something to do”. Hey, it may not prevent you getting sick, but at least you will trick your mind into thinking you are ok. Nice placebo.

For the general public, and those medical personnel who were sleeping during their infectious disease seminars, there are two types of masks used in medicine. The loose fitting “surgical” mask type and then a respirator type of mask.  These pictures will illustrate the various types:

Tie-on Surgical Mask

Tie-on Surgical Mask

N95 Respirator

N95 Respirator

The important difference between these two is their usage. The surgical type of mask is usually loosely fitting and PROTECTS OTHERS from your germs. It also protects the wearer from droplets like blood.

The respirator on the other hand PROTECTS YOU from other people’s germs. We wear them in the hospital when we are dealing with people that have tuberculosis and we have the person with the potential tuberculosis wear the surgical type of mask so they don’t infect others. Respirators are  specially fitted so as not to leave gaps for air-borne germs.

What type do most people wear in crisis moments like these though – they wear the surgical type of mask, and they often wear it incorrectly, like leaving the bottom ties untied, or covering only the mouth and not the nose. These masks would be great if YOU have the swine flu and want to be considerate enough not to spread it to others, but do nothing more than give you the warm fuzzies, fogged up glasses and a sweaty face if you are trying to avoid getting it.

To learn more about the properties of each type of mask and when they should be used, click here for an excellent summary in medical speak.

In the meantime, you can always use a mask to help pick up unwitting foreign girls or to express your thoughts on the continued insanity of  Swine Flu.

swine-flu-fashion-masks

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No, We Don’t Need to Land in Scotland!

May 2, 2009
Fish or chicken? Should've had the pasta.

Fish or chicken? Should've had the pasta.

As I had mentioned before, I am on vacation for the next couple of weeks. I thought I would be getting away from the stupidity of swine flu (now called H1N1 flu to protect pork sales), but it looks like I landed right in the middle of stoopid yesterday.

I’m on an international flight and heading towards Europe. Mid-way through the flight I see a crowd gather near one of the galleys and then a frantic sounding flight attendant gets on the mic and calls for one of her associates. I figured it was likely a medical emergency of some sort and followed the hurried attendant.

At the galley, I find a young man laying on the floor breathing O2 through a mask with two disoriented looking passengers fiddling with him. I tell them that I am an ER doc and they tell me that they are paramedics from Europe. The story is that this guy got up to go to the bathroom and became presyncopal (almost fainted) and called for help. I ask the scared looking flight attendant for the medical kit so I can assess this guy.

Now of course, everyone is worried about one thing – SWINE FLU. I can read their scared minds … “Oh no! We’re all gonna get swine flu and die horrible deaths!”. But when I assess the patient, after pushing the very eager, overly wound up paramedics away, my first question is, “How much have you had to drink?” Previous experience with airline medical emergencies has taught me that, just like on the ground, alcohol factors into a lot of emergencies.

After establishing the fact that he didn’t have half a cart of Jack Daniels, my next set of questions focuses on flu symptoms (fever, nausea/vomiting, body aches, fatigue, cough, runny nose, etc.). He was only nauseated, likely from the near fainting. No medical history, on no medications.  Then I hear one of the paramedics talking with the flight attendant about an emergency landing in Scotland and I get really peeved.

Dealing with the totally awesome EMS personnel in the States, I get used to them understanding chain of command and knowing when to defer. I imagine that many EMS personnel in Europe are also the same, so not sure what was up with these jackers. I tell the flight purser that I am the medical doctor in charge and that an emergency landing is not necessary at this point in time and that everyone should chill. Too many cooks in the kitchen.

Getting back to the sick person, I observe another flight attendant trying to put the leads from the automatic defibrillator (AED) on the patient – one on the stomach and the other near the right shoulder. It was like doing a code on the floor – total cluster. I was totally expecting to see the “paramedics” preparing to inject this poor guy with some epinephrine or something.

So, what was the sick guy’s story? He was majorly sleep deprived (typical for many people preparing for international travel), been staying awake on lots of caffeine and probably not having enough fluids to replace all the ones he was urinating out. Add to that, the chicken meal he ate on board.

The AED shows a very temporary sinus bradycardia (slow heart beat) at about 40. While I was checking his blood pressure, it went back up to normal between 65-72. I think it was because he was overhearing the “paramedics” from Hell discussing totally inappropriate interventions. His blood pressure turned out to be 110/70. My team of boners tried to get a blood sugar and failed. But by this time, the guy was saying he was feeling better and wanting to sit up. His “fight or flight” response was probably in high gear overhearing the things being said.

Catastrophe averted for the moment. I told the sick guy to contact me directly if he started to feel woozy again and to avoid the “paramedics” at all costs. The flight attendants were thankful for the man’s quick recovery and for services provided.

In the last hour of the flight though, I was heading up near the sick guy’s seat and see his wife standing and looking concerned. He was feeling woozy again and luckily I arrived at the right time (read – before Beavis and Butthead). I had him lie down and put his feet up. Checked his pulse and it was regular at about 65. He was very nauseated again. To avert another medical emergency landing, I went to the head purser and told her that the guy was stable and not to be worried. I would stay with him until we landed and inform her of any changes.

Within minutes, the guy was feeling and looking back to normal – a good sign that he was likely dehydrated and getting vasovagal. A few nice passengers near-by offered to move so that he could lay down across four seats. Beavis and Butthead arrived soon enough with an O2 tank (incorrectly set-up). Once again, they by-passed me to tell the captain to land ASAP. I think one of them was trying to impress one of the attendants or something.

Just before we landed, sick guy vomited up his chicken. I was sitting right in front of him and immediately after I asked him if after vomiting he felt better or worse. Although it’s not so evidence-based, I have found over the years that with food-borne illnesses (commonly called “food poisoning”) that people generally feel better immediately after vomiting – likely because of the reduced toxin load in their stomach. On the other hand, vomiting from flu syndromes usually results in a person feeling even worse and more fatigued. Maybe it was the chicken after all?

We arrived to our destination after a hurried landing and had to wait on board until this country’s EMS came on board to load up the patient and take him to the airport medical facility. I gave report to the ER doctor that accompanied the team and gave my new friend (sick guy) some farewell advice and a good-bye. My advice was get some IV fluids and some rest. After he was gone, I had to reassure several passengers that there was no flu threat and that they should all be ok.

That is, unless they had the chicken. Glad I ate the pasta.


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.