Monday, August 31, 2009

The Difficult Patient


I am willing to bet that patients do not know that the medical community talks formally about "The Difficult Patient". Courses are taught on how to handle these patients and there is even an ethics study on Medscape about it. So what is the difficult patient?

Every practice encounters them and they come in many varieties. They are the patients who abuse the staff, miss appointments repeatedly, "lose" their prescriptions for pain medication and then demand instant refills. They may not follow up with important tests or stop taking needed medication and then show up with acute medical problems. Some doctors have a low tolerance for patients who are not "compliant" but even the sainted physicians experience "difficult patients".

So when the therapeutic relationship is damaged, doctors are taught the ethical ways of firing a patient from the practice. Once a relationship has been established, a physician may not abandon a patient. Medical ethics demand that a physician may discharge a patient from the practice only after attempts to resolve the matter have failed. Adequate replacement care must be available and the patient's health should not be jeopardized in the process. The physician must ensure that the reasons for discharging a patient are justifiable and ethical.

Once the doctor- patient relationship has broken down, the doctor must make sure:
  • She has done everything possible to address the patient's problems
  • She has informed the patient of the consequences of his actions, both for his own health and his relationship with the physician; and
  • She must tell the patient that he would better off with another physician and help the patient find another doctor.
Ending a doctor- patient relationship should be a rare event. Like any relationship, there should be discussions that take place openly long before things get bad enough for the doctor to "fire" the patient.

Of course, an unhappy patient needs only to leave a practice and move on. But all physicians know that one disgruntled patient will tell 20 friends about his bad experience.

Sunday, August 30, 2009

Kidnapped Dugan a Victim of Stockholm Syndrome


The details of the terrible kidnapping of 11 year old Jaycee Dugard, found 18 years later living in squalid conditions after being abused by her abductor, are emerging and the case is worse that we could have imagined. He is a registered sex offender and a wacko and no one is saying anything about his wife, who was also in on the prolonged abuse. Dugard tragically became the mother of two children that she conceived at age 13 and 17, at the hands of Phillip Garrido, the kidnapper.

Over her 18 years of captivity, she had chances to escape. They lived in a neighborhood in Antioch, California, which is hardly a rural environment. She was kept isolated but apparently not completely confined. She even helped Garrido in a business card company and delivered supplies with him to customers. Why would she remain in such bizarre conditions?

The answer lies in a well known psychological condition known as the
Stockholm Syndrome. It occurs when a captive cannot escape, is isolated, terrorized and threatened with death. But the perpetrator also shows episodes of token kindness and there is a type of brainwashing that occurs when the victim starts to identify with the abductor.

Millionaire heiress Patty Hearst, who was kidnapped by the Symbionese Liberation Army, underwent a form of Stockholm Syndrome after being coerced into believing their extreme cause was legitimate.

A young child of 11 would have no power in such a hostage situation and could easily believe that her parents no longer cared (NOT TRUE) or her abductor wanted to love her. These mind twists occur during extreme stress and fear and are actually a survival strategy.

Forms of Stockholm Syndrome can be found in abused children, battered women, prisoners of war, cult members, incest victims and concentration camp prisoners. A common theme in all of these abusive situations is that the victim perceives the inability to escape from the situation. It is a type of learned helplessness and the abuser assures the victim that only by cooperation, can they be safe. The other aspect that is critical for Stockholm Syndrome to occur is isolation.

Jaycee Dugard is already feeling guilt and confusion about the long situation. She and her two daughters, ages 11 and 15, will need gentle psychotherapy for years, to be able to understand what has happened to them.

In the meantime, Phillip Garrido will likely plead insanity and should be locked up in solitary confinement for his entire life. No rehab, no therapy. These types of sexual predators are not curable. There needs to be one strike and no parole. Period.

Friday, August 28, 2009

Kidnapped Girl Found In California After 18 Years


The shocking story of an 11 year old girl, snatched off the street at Lake Tahoe and found 18 years later after being held as a sex slave captive, is all over the news. Kidnapped at age 11, little Jaycee Dugard was found in Antioch, California, living in a squalid tent in her abductors back yard, with two children he fathered. The kidnapper, Phillip Garrido is a known sex offender and was on parole for a sex offense in the 90's. At least one suspicious neighbor had called police over two years ago, yet a home visit by sheriffs found nothing amiss. The car he used to kidnap the girl was still in the junky back yard, broken down and covered with a tarp, along with the sheds and tents that housed the kidnapped woman and her children. Somehow this parolee got away with this in a regular suburban neighborhood.

There are so many questions in this case and some answers may emerge over time. The tabloids will run wild with speculation and this story will eventually fade from the pubic eye.

I am proud to say that in medicine we have a process we use to investigate serious events and learn from them. Medical mistakes are not caused by one event or one person. They occur because we deal with complex systems and when a number of random things occur together a serious error can happen. If there is an error, we do a "Root Cause Analysis" (RCA).

A Root Cause Analysis is a rigorous problem solving method, undertaken so changes can be made so the problem never happens again. Here is an example of how it would work in the hospital world:

Let's say a patient receive the wrong drug and died from it. As soon as the error was discovered a team would be formed with a top administrator and every person involved in the problem. This might be the nurse, the pharmacist, the charge nurse supervisor, the quality and safety expert and the physician. This team would go through every step in medication administration from the actual manufacture and labeling of the drug to the ordering and administration. They might uncover a problem in how the drug was stored or how the label looked identical to another label. They might find drug names that are nearly the same, just begging for an error to be made. They might find a problem with the nurse being interrupted as she was preparing the drug. Or a patient's name band that was on the wrong wrist. The hundreds of variables in just administering one simple medication would be broken down and investigated for process improvement and change.

Does law enforcement do a Root Cause Analysis of the many steps that go wrong in a case like the Dugard kidnapping? What about the parole process? What about investigations (to the house after a neighbor report) that were cursory?

Did the police do a RCA after the mistakes that were made in the Polly Klass kidnapping? Or the Elizabeth Smart kidnapping in Salt Lake City? Could there have been some process improvement that would have allowed rescue in this known sex offender before 18 years had passed?

These situations beg for a RCA and changes in how law enforcement can better protect us. Perhaps they could learn from how we do it in the hospital.

Wednesday, August 26, 2009

Hip Fractures Decline


A study was published this week in JAMA that shows the incidence of hip fractures has been steadily declining in Canada and the United States from 1985 through 2005. The study surprised the medical profession because even through their were more older people in the population, there were actually fewer hip fractures. This is great news because when older people fall and fracture their hip, a large percentage never walk again and it is a downward spiral to a nursing home and death.

No-one knows the reasons for the decline but there are some good theories. Since health and nutrition play a big role in bone strength, perhaps better nutrition throughout the past 20 years has made osteoporosis (bone loss) less prevalent. A greater bone mass means less chance of fracture. Adding to this theory is that heavier people have greater bone mass and we all know we are getting fatter and fatter.

The bisphosphonate medications may also have played a role. Fosamax, Actonel, Boniva came on the scene in the mid 1990's. They are taken by less than 20% of older women for osteoporosis and preserving bone, so the effect is likely small. But more women took Estrogen replacement (HRT) during those years so that might have impacted bone health and prevented fracture.

The war against smoking has ramped up over the past 30 years and cigarettes are linked to osteoporosis and weak bones also. I think the decline in smoking has played a role too.

It is probably a combination of things that has led to the decline in hip fractures since 1985. The body is a complex organism and many environmental and lifestyle factors impact how healthy we are and how long we live.

Tuesday, August 25, 2009

Primary Care Doctors Have Had Enough


Dr. Vance Harris is a primary care physician in Redding, California. His essay featured on CNN Health is a chilling warning to our Nation and why ignoring primary care will doom health care reform. I want you all to read it.

Dr. Vance says, "No one is talking about this on the national level. If they don't address these issues, then good luck having physician assistants provide the safety net with two years of training. Good luck getting newly trained physicians once they see our salaries. Good luck finding internists in your community with only 1 percent of medical students going into Internal Medicine.

Good luck recruiting primary care specialists when we are projected to be short 39,000 by 2020, according to the American Academy of Family Physicians. And nearly half of all doctors surveyed by the Physicians' Foundation have said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely. "

Read the well written article by Dr. Vance for more details on how screwed up our health values and reimbursements are.

Monday, August 24, 2009

Where Germs Hang Out


Who knew there was a "Hygiene Council", comprised of global experts in the field of public health and infectious disease? These folks actually conduct an Annual International Home Hygiene Study. Keep in mind that one of the corporate sponsors of the council is Lysol, but, who cares as long as they tell us where germs hang out. Well, here is what the 2009 survey of bacteria and viruses found out about where the germs linger:
  • TV remote . This is no surprise to me, considering how the men in my home hold and protect the remote like it is precious gold.
  • Tub and shower. I would think the germs would be washed away with the soap, but apparently they linger. (Lysol anyone?)
  • Pet food dishes. My cat demands a fresh, clean dish with each meal so no problem here.
  • Kitchen sponges. (Came in at number 1) Put them in the dishwasher on the hot cycle.
  • Microwave touch screen. Think about the microwave at work. The medical term is "Ewwww!"
  • Light Switches. (Lysol anyone?)
  • Baby changing table. Isn't this one just common sense?
  • Kitchen faucets. (looks like another call for Lysol)
I appreciate these Hygiene folks, measuring the bacteria counts so we can all feel safer. Compared to Health Care Reform, this subject is just warm and fuzzy.

Sunday, August 23, 2009

America Has the Best Health Care in the World?


Let's get honest, OK? American does not have the best health care in the world. Europeans and Canadians are not flocking to our borders to get to our health care. It is time we realize that we can learn from our neighbors and we don't have to claim we are the "best" at everything. It makes us look really stupid in the eyes of the world.

Here are some facts. We do spend the most money on health care in the world. We do spend the highest percentage of Gross National Product (GDP) on health care and we do spend more dollars per capita than any other country on Earth.

The claim that the United States has the best health care in the world has been proven false by every broad metric used. The World Health Organization and the nonpartisan Commonwealth Fund rankings rate the U.S. last of the Western industrialized countries. The WHO ranks us 37th of all measured countries.

The Commonwealth Fund says, "Among the six nations studied—Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2006 and 2004. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, efficiency, and equity. The 2007 edition includes data from the six countries and incorporates patients' and physicians' survey results on care experiences and ratings on various dimensions of care."

The U.S. also lags in information technology. (We have been awaiting a robust electronic medical record for 10 years) and in coordination of care and in measured quality outcomes.

One of the ways we improve in health care is when we face the brutal truth. How can you make improvements if you don't know where you are starting from? If you truly believe you are the best in the world...there would be no need for health care reform.

Perhaps that is why these myths and lies are being propagated.

Thursday, August 20, 2009

Billy Mays Dies But Was it Cocaine?


It was sad to hear that the TV pitchman Billy Mays (age 50) died in his sleep from a heart attack. I must admit I have seen him pitching oxi-clean when I was channel surfing late at night. (Yes, I do rarely watch TV when I am not blogging.) I've always been fascinated by TV pitchmen (Sham-Wow) and how they can convince you that their product is a "must have".

So now I really must speak out against the irresponsible press release of the Hillsborough County Medical Examiner that states cocaine was a contributory cause of death for Billy Mays. His autopsy showed coronary artery disease and hypertension.

He did not have active cocaine in his system at the time of death. Cocaine metabolites were found on a toxicology screen and these metabolites can remain for 30 days in some tissue and up to three months in hair.

We know that cocaine has inflammatory effects and vasoconstrictive effects...both of which are bad for the heart and other vessels. Cocaine can also cause sudden death from arrhythmia. But since he did not have cocaine in his system at the time of death, there is no way a Coroner could know if he was a one time user or a habitual user. There is also no way they could blame atherosclerotic heart disease on cocaine, unless they knew he was using it habitually.

Billy Mays wife said, "We were totally unaware of any nonprescription drug usage and are actively considering an independent evaluation of the autopsy results".
The family called the cocaine abuse charge a "speculative conclusion" and said it distracts from Mays' ultimate cause of death — untreated hypertension.

I have no idea if he was a habitual cocaine user, but the medical examiner should be more discrete about leaving a lasting negative legacy and ruining the reputation of a man who cannot defend himself.

Wednesday, August 19, 2009

Malignant Hypertension Effect on the Eye


Ever wonder what the doctor is looking for when she shines the light into your eyes, up close and personal?

This is what she sees if the patient has severe hypertension. The retina shows blurring of the optic disc (in the middle left) and the white areas are called "cotton wool spots". The blurry part at the bottom is a partial retinal detachment. The patient's blood pressure was 220/150.

Tuesday, August 18, 2009

Preparing for Flu


The hospitals I work in are gearing up for the flu season. The H1N1 (Swine) flu is on everyone's radar and we just don't know if we will be slammed with patients. Preparedness is the name of the game and nurses, doctors, infection control experts and risk managers are coming together to make sure policies and protocols are in place before we are hit with emergencies.

Here is what we know now. H1N1 flu is still present across the globe and in the United States, 477 deaths have been reported. This is not unlike regular flu. We do know that this strain is especially virulent in pregnant women and hospitals are particularly concerned about protecting them from infection.

The instant screening tests (rapid influenza diagnostic tests) are not able to distinguish novel H1N1 flu from other seasonal flu, nor can they provide information about sensitivity to drugs. The tests for confirming H1N1 flu take weeks and are not readily available in clinics or hospitals.

Hospital employees who are in contact with patients who have flu are expected to wear a special "fit mask" and if they have unprotected close contact with a patient suspected of H1N1 flu, that employee is to take prophylactic medication (Tamiflu) or be off work for 7 days.

We are trying to decide if all visitors to patients hospitalized with flu should be limited. I believe our first duty is to the patient and to keeping other patients and employees safe. For that reason, if a person is sick enough to be in the hospital with flu, I believe all visitors should be screened and limited. That policy has not yet been codified.

If a flu epidemic does manifest this fall, we will likely set up triage areas to keep suspected sick people away from the emergency department and other areas of the hospital. If there is a surge, how should screening of asymptomatic visitors at hospital entry be handled? If a large percentage of employees cannot come to work, how will the hospitals function?

We are still meeting to decide the answers and provide the best patient safety and care for influenza.

Sunday, August 16, 2009

Obama Considers Insurance Co-ops


All it took was ranting crazies talking about "death squads" and the Obama administration is caving on health care. No public option..no health care reform. The idea of a "health co-op" is unproven anywhere in the world. There is no model to tell us how it would work, how it would deliver care or how much money it would cost.

The healthcare industry loves the idea of co-ops and says it would provide the competition needed for real choice. Well guess what? We already have competition between insurers. We have Blue Cross, Anthem, Blue Shield, Aetna, Cigna, United Health Care and hundreds of others to choose from. Do we need more choices that we cannot afford? Will the co-op be required to take the people with pre-existing conditions? How would a co-op hold down costs?

With the world wide embarrassment of thousands of people lining up in Los Angeles for free health care, you would think the white house could sail through true reform. Was it audacious to hope that we could really have change?

The Health Care Bill will not be effective without a public option. We will spin around for another few years appeasing insurance companies who support this compromise. We will remain the only major industrialized country in the world without national health care.

Thursday, August 13, 2009

Fix Medicare


Dear President Obama,
I am in favor of Health Care Reform and I agree with you that universal coverage and eliminating the abuses that both patients and doctors have suffered at the whim of the for-profit insurance industry must be curtailed.

But I also want you to fix Medicare. Medicare is so bureaucratic that expanding it in its current form would be the death knell for primary care physicians and many community hospitals. The arcane methods of reimbursement, the ever expanding diagnosis codes, the excessive documentation rules and the poor payment to "cognitive, diagnosing, talking" physicians makes the idea of expansion untenable.

May I give you one small example, Mr. President? I moved my medical office in April. Six weeks before the move I notified Medicare of my pending change of address and filled out 22 pages of forms. Yes, Mr. Commander in Chief...22 pages for a change of address. It is now mid-August and I still do not have the "approval" for my address change.

I continue to care for my Medicare patients and they are a handful. Older folks have quite a number of medical issues, you see, and sometimes it takes 1/2 hour just to go over their medications and try to understand how their condition has changed. That is before I even begin to examine them and explain tests, treatment and coordinate their care. Despite the fact that I care for these patients, according the Medicare rules, I cannot submit a bill to Medicare because they have not approved my change of office address.

I have spent countless hours on the phone with Medicare and have sent additional documentation that they requested. I send the forms and information "overnight, registered" because a documented trail is needed to avoid having to start over at the beginning again and again. I was even required to send a signature from my "bank officer" and a utility bill from the office. Mr President, I don't have a close relationship with a bank officer so this required a bank visit and took time away from caring for patients...but I certainly did comply.

I am still waiting to hear from Medicare. At my last call they said they had not received yet another document, but when I gave them the post office tracking number, they said it was received after all. They could not tell me when or if they will accept my address change.

I have bills stacking up since April and I just found out that they will not accept them if they are over 30 days old. I have cared for patients for 5 months and will not receive any reimbursement from Medicare. The rules state I cannot bill the patient or their supplemental Medicare insurance either.

Believe me, Mr. President, I commend you for taking on such a huge task. Please also know that Medicare reform is needed along with health care reform.

A loyal American ,
Internal Medicine (aka: primary care) physician

Universal Health Care



Wednesday, August 12, 2009

Gallup Well -Being States


A Gallup poll is done each year to rank the best and the worst states for population "well-being". The well-being index score is an average of of six sub-indexes which examine life evaluation, emotional health, work environment, physical health, healthy behaviors and access to basic necessities. They interviewed more than 170,000 adults over age 18. This "first half of the year" report is a precursor to the annual report. Maybe it isn't too late to make changes and get your well-being up.

Americans in Hawaii and Utah continued to lead the nation in well-being in the first half of 2009, with the two states having switched places since 2008. West Virginia and Kentucky maintained their status as the states with the lowest well-being.

Four of the top 10 scoring states -- Iowa, North Dakota, Kansas, and Minnesota -- are in the Midwest. As in 2008, many of the states with lower Well-Being Index scores are located in the South. Nevada is the only Western state in the bottom 10.

I'm not sure what relevance this has to daily life, but it is interesting and it confirms for me that Hawaii is my favorite state.

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Tuesday, August 11, 2009

Will Obama Cave on Health Care?

Healthcare reform is heading downhill fast as Obama starts to cave on some essential principles. He is a smart guy, with smart advisors, but the watered down version of reform that Americans may be getting will be disappointing at best and possibly a financial disaster for the American people.

Unless the government is able to control costs, health care reform will be a failure. The Administration is showing willingness to cave on two critical aspects of reform: controlling drug costs and having a "public option".
Big Pharma is exerting massive pressure to disallow price negotiations and it looks like Obama may just go along with this extortion to get them to support the plan. George Bush struck the same deal with the pharmaceutical giants when Medicare enacted the Part D drug coverage (ie: no ability to negotiate price) and that was a huge bonanza for Big Pharma. Their bonanza means sky rocketing prices for all of us.

The public option is also loosing steam as the insurance lobby mounts pressure. Last year, UnitedHealth took in about $81.2 billion in revenues and WellPoint saw nearly $61.6 billion, with Aetna taking in nearly $31 billion and Cigna about $19.1 billion.

No wonder they oppose real "choice". Without the public option, it will be status quo, business as usual for the health care insurance industry, with the addition of millions more (currently uninsured) policy holders, paid for by our taxes. For the rest of America, it will mean huge rising premiums and continued denial of claims.

Obama has said he will not "draw a line in the sand" and is trying for a bipartisan solution. Giving up the public option just to get the acquiescence of the insurance lobby makes no sense. The insurance industry exists to make a profit for their investors (they are succeeding), not to improve the health care of a Nation.

Health care reform was supposed to do that, but it looks like it will be unable to slow costs, or provide much in the way of real change.



Saturday, August 8, 2009

Are Americans Stupid?


I like to see the best in everyone, but when I follow some of the "town hall" meetings on health care reform, I have to ask... Are Americans really stupid? What is with the recent town hall meeting in South Carolina where an elderly man stood up and told his Congressman to "keep your government hands off my Medicare."

Huh? Buddy, I got news for you. The government is the "single payer" for your Medicare benefits. The government already decides what it will pay for or not. The government already has a bizarre formula for reimbursing doctors and hospitals. Every young worker under the age of 65 is paying every month for your Medicare so you can go to any doctor or hospital you want.
Mr. Ignorant, I have a question for you; "Do you want to give up Medicare and buy some insurance on the open market, like the rest of us suckers?"

I flipped on Fox news last night (Yikes!) and watched a rally in San Diego. Someone said health care reform would make them "go before a government board to determine if they can get a test". The government will take your "life and death decisions into their own hands. " "He (Obama) wants to ram this down the throats of the American people without any debate."

Without any debate!

Bill Maher (of HBOs "Real Time with Bill Maher") comes up with New Rules. Read his latest for a laugh and a cry on how stupid Americans can actually be. My favorite quote from his New Rules on stupid Americans is:

"And these are the idiots we want to weigh in on the minutia of health care policy? Please, this country is like a college chick after two Long Island Iced Teas: we can be talked into anything, like wars, and we can be talked out of anything, like health care. We should forget town halls, and replace them with study halls. There's a lot of populist anger directed towards Washington, but you know who concerned citizens should be most angry at? Their fellow citizens. "Inside the beltway" thinking may be wrong, but at least it's thinking, which is more than you can say for what's going on outside the beltway.

And if you want to call me an elitist for this, I say thank you. Yes, I want decisions made by an elite group of people who know what they're talking about. That means Obama budget director Peter Orszag, not Sarah Palin"

Thursday, August 6, 2009

Does Lumigan Work to Grow Eyelashes?





Last year I blogged about a new FDA approval for Lumigan (Bimatoprost) ophthalmic solution for glaucoma to be used as a safe way to grow eyelashes. I thought the readers of EverythingHealth would enjoy seeing if it really worked.

You be the judge..the before photo shows eyelashes (with mascara, of course) before using Lumigan. The 2nd photo shows eyelashes after 6 weeks of use. The manufacturer states it takes 8 weeks for full benefit.

Wednesday, August 5, 2009

Nurses Assaulted at Work


Who knew that being a nurse could be a health hazard? A study published in the Journal of Nursing Administration shows that violence against nurses working in the emergency department is at an all time high. A 69 question survey of nurses showed that 25% of them had been assaulted at work more than TWENTY TIMES in the past three years. Almost 20% had undergone verbal abuse over 200 times during the same period.

Respondents who experienced frequent physical violence and/or frequent verbal abuse indicated fear of retaliation and lack of support from hospital administration and ED management as barriers to reporting workplace violence.

OK folks, this is just unacceptable. Nurses in emergency departments work damn hard. They are doing triage to determine who is sick and who just "doesn't have a doctor" to see the pink eye. They deal with blood, vomit, lice and trauma.

Every day at work brings interaction with drunks and mentally ill patients. They assess patients who are "found on floor" and are unconscious. They talk with and assist ambulance drivers, paramedics, crazed family members, angry physicians and patients who are having the worst day of their lives.

Most of the nurses do this with grace, competence and good cheer.

I understand that crazy and impaired patients will be verbally abusive. That is why strict protocols are needed to ensure a safe workplace. If a patient assaults a nurse there needs to be a hospital protocol that is enacted immediately...security called, police notified, action taken. The nurse needs full support and protection. Period.

Omega 3 Fish Oil Benefits the Heart


I continue to write blogs about the benefits of Omega 3 FFA fish oil and I'm doing it again. A new review published in the American Journal of Cardiology shows that fish oil supplements benefit almost everyone. This includes people with heart disease and atrial fibrillation as well as healthy people with no problems.

The researchers from Ochsner Clinic in New Orleans reviewed all published studies of Omega 3 FFA. The most compelling evidence for cardiovascular benefits comes from four controlled trials of almost 40 000 participants. These patients were randomized to receive Omega 3 Fish Oil EPA with or without DHA ( both ingredients are found in supplements) in studies of primary prevention, after MI (heart attack), and most recently with heart failure. They found it prevented death from heart disease. The benefits were seen in sudden death and subsequent heart attack events.

So how much Omega 3 fish oil should a person consume? Dr. Lavie, the lead researcher said,

"If somebody really were eating salmon and tuna and mackerel and sardines, and they were doing that several times a week, then they wouldn't need to be taking a supplement. But in the US, at least, very few people are going to eat the therapeutic doses of fatty fish."

Lavie and colleagues recommend that healthy people consume at least 500 mg per day of EPA/DHA--equal to around two fatty-fish meals per week--and that those with known coronary heart disease or heart failure get 800 to 1000 mg per day EPA/DHA. There does not seem to be any harm if too much is taken, and super large doses are prescribed for people who have triglyceride abnormalities.

These are easy supplements to buy and take. You do not need a complicated regimen of supplements. I took my Omega 3 Fish Oil tablets today.


Tuesday, August 4, 2009

Awesome Toilets- Why Don't We Have Them?


The toilet is one of the most important inventions for good health and comfort. But, except for pulling a chain vs. pushing a handle...not much has changed in the last 100 years in the United States. Since it is a device that is used by 100% of us several times a day...you would think it would be a technology ripe for innovation.

Leave it to the Japanese. They have a loo that can do all of these things for the user:

* Cleanse “front and back” with three separate streams of water
* Dry “front and back” with air blowers
* Warm the seat
* Automatically put down the seat (a feature cleverly dubbed the “marriage saver”)
* Illuminate itself with a programmable nightlight
* Monitor medical conditions by preforming urine tests
* De-ionize the air to remove odors
* Play a soothing waterfall or birdsong soundtrack “to drown out embarrassing noises.”

If you are into saving the environment (...and aren't we all?), the new toilet means you don't need to squeeze the Charmin as much and they are better at consumption of water. (By the way...have you checked out the price of toilet paper these days? Talk about price inflation.)

I think it is time for us to get some state- of- the- art commodes. Bring on the Toto Toilet!

Health Care in Other Countries


I was reading the comments to an article in the New York Times (please don't go out of business,) about getting sick on vacation and I was struck by the people who travel abroad and need to access emergency health care. There were 92 comments from readers about their vacations and what happened when they got sick.

The people who got sick in the USA talked about the expense of "out of network" fees or how long they waited in urgent care or emergency departments. About 90% of the comments were about getting sick in countries that have a single payer health system and how great it was.

Several comments had experience with Denmark health care; "Yes, in Denmark there are doctors on call who come to see the ill. He prescribed an antibiotic, said that if I didn’t improve he would hospitalize me, and left. No charge! I improved, my daughter took the ferry to Denmark, and we spent time visiting relatives. I was 65 at the time and never felt so sick before or after."

In Canada: "All of this with little wait time and not a penny cost except for parking in the hospital parking lot. Travel mileage and parking is tax deductible if you have to travel out of your own community. My prescription drugs are free as I am over 65 now. There is a $100 deductible charge annually for drugs.

There is never a wait time if your condition requires immediate attention.I would be happy to explain the above to any non- believer in the USA"

In Spain;" While traveling in Spain last year my 10 year old son had an asthma attack. Our state side medication gone, we walked into a local pharmacia which promptly supplied us with the medication for $3.

The same meds in NY would have required a doctor visit, a prescription and cost $40."

If you believe these experiences, you want to get sick in France, the UK, even Cairo, rather than the United States. There were a few horror stories about missed diagnosis and even a dirty hospital in Rome but overall the consensus was that it is easier, cheaper and quicker to access care abroad than in the U.S.

One comment; "As a physician, I would MUCH prefer to be a traveler in Canada or France than an uninsured -or underinsured - American."

Saturday, August 1, 2009

Prison Tennis





I spent this morning on the "yard" at San Quintin Prison, playing tennis with the inmates. The prison has a tennis court, built right in the middle of the yard with hundreds of inmates shuffling about, shooting hoops, playing dominoes, working out or just milling about.

The guys who play tennis are a remarkable bunch. They are serious about their game, play whenever they can during the week and are really happy on Saturday morning when authorized "outsiders" come to play with them.

We play round robin; first team to 4 wins and a new foursome takes the court. They seem to have an understanding among themselves about who plays when. It is competitive but, believe it or not, very gentlemanly. Everyone is encouraging, with lots of high-fives and there is no cheating or bad line calls. The best part is when I am not playing, I am sitting on the bench with the guys, just chatting.

The tennis players in San Quintin are without attitude or posturing. Some do yoga or go to school. Some work in various prison jobs like making furniture, or stocking or cleaning cell blocks. Keep in mind some of these guys are there for life and they look pretty young to me.

In case you are thinking they have a soft life there, playing tennis and hanging out with civilians, think again. One guy showed me his lunch. It was 2 slices of white bread, a piece of bologna and mustard with a handful of corn chips. They can not receive gifts from the outside. If they have the money, they can order things from a catalog (tennis shoes, clothes, food items, personal supplies) every three months up to 30 lbs. There is no internet, no ipods, no electronics, no cable TV.

People ask if I feel "safe" there and I must say I do. Certainly the tennis players are respectful and warm. The other prisoners in the yard watch us but keep a respectful distance and no-one has ever made a comment or shown any aggression. Of course there are 4 guard towers with guns pointed down at all times.

One of the tennis inmates told me this cell block is less troublesome and there is less gang activity or fighting. Most of them are long timers or even lifers. I was told that "Bert", one of the guys I played with before was finally released after 23 years. I hope he is playing tennis on the outside.

For a look at how it is playing tennis in San Quintin, watch this.

Animal Diseases

Pregnancy Q&A


If you are pregnant, ever knew a pregnant woman, or ever want to be pregnant...these questions and answers should be very useful. (Thanks to Raymond for the laugh)

Q: Should I have a baby after 35?
A: No, 35 children is enough.

Q : I'm two months pregnant now. When will my baby move?
A: With any luck, right after he finishes university.

Q : What is the most reliable method to determine a baby's sex?
A: Childbirth.

Q: My wife is five months pregnant and so moody that sometimes she's borderline irrational.
A: So what's your question?

Q : My childbirth instructor says it's not pain I'll feel during labour, but pressure. Is she right?
A: Yes, in the same way that a cyclone might be called an air current.

Q: When is the best time to get an epidural?
A: Right after you find out you're pregnant..

Q : Is there any reason I have to be in the delivery room while my wife is in labour?
A: Not unless the word 'child support payment' means anything to you.

Q: Is there anything I should avoid while recovering from childbirth?
A: Yes, pregnancy.

Q : Do I have to have a baby shower?
A: Not if you change the baby's nappy very quickly

Q : Our baby was born last week. When will my wife begin to feel and act normal again?
A: When the kids are in university.