Sunday, October 31, 2010

Medical Marijuana

When I was an Intern I took care of an elderly gentleman who was dying of lung cancer.  Mr. Washington had spent much of his life as a sharecropper in the deep South.   Mr. Washington was alone without family and his cancer had spread to his bones and his brain.   He no longer had a wife and his grown son had died several years ago. He had stopped eating and was just skin and bones.  I could see that he had once been a robust black man.  It was pretty clear that this would be his last admission to the hospital.  If I knew then, what I know now, I would have pushed for him to be in a hospice program.  But I was just an Intern and I didn't know much at all.

I had a full caseload and many patients coming and going each day.  The workload for Internal Medicine was extreme and I worked my first 35 days without a day off.  Mr. Washington was my favorite patient.  He was elegant and charming and polite.  He cared more about me and my education and my state of mind than his own.  It was clear he was in a great deal of pain but he didn't complain.  He didn't want to be knocked out with pain killers.

One day on rounds I asked Mr. Washington if he had ever tried smoking marijuana.  "Oh, honey, I've certainly had my share of weed.  Do you think it might help?"  I replied that I didn't know but it might help with his anxiety and take the edge off.  I admitted I didn't have any access to it and couldn't really prescribe it.  This was 1983.

When I rounded on him the next day, Mr. Washington looked a lot more comfortable.  He had a sly look in his eye and he reached under his cover and offered me a tightly rolled joint.  "This is for you if you want it", he said. "It was a splendid idea and I had a friend bring it in to me.  It is helping a lot."  I laughed at his ingenuity and told him he should save it for later.  I got the distinct impression that he wanted me to stay and chat awhile but I had a new admit and was running from patient to patient.  "I'll be back later", I said and I meant it. "I want to hear all about your life."  I just knew it would be a fascinating story and I thought I would learn something about life from him.  He seemed at peace with his cancer and his dying.

The next day I walked into his room and he wasn't there.  Mr. Washington had died that night.  The nursing notes said he didn't require pain medication and that he was comfortable.

I never heard his life story and I regret that. 

photo is taken in 1935 of an unknown sharecropper.

Happy Halloween

Friday, October 29, 2010

Red Yeast Rice Supplements for High Cholesterol

People are always on the search for "natural" ways to stay healthy and reduce cholesterol.  Chinese red yeast rice supplements have been touted as a natural, safer way to lower cholesterol compared to statin medications.  The yeast that grows on a particular type of rice contains a family of substances called monocolins, which lower cholesterol by inhibiting cholesterol production in the liver in the same manner as prescription statin drugs.  Some studies have shown as much as a 15% drop in cholesterol.

All of this sounds good until you dig a little deeper.  Supplements are not regulated by the FDA and a new study in the Archives of Internal Medicine showed that different brands of red yeast rice supplements showed dramatic variation in levels of active ingredients.  Furthermore some contained toxic manufacturing byproducts.

The researchers analyzed capsules from a dozen different manufacturers.  They found the consistency was far from standard, even thought they all were labeled as containing 600mg of red yeast rice extract.
The total monacolin levels per capsule varied from 0.31mg to 11.15mg.  Four brands showed levels of citrinin, which is toxic to the kidneys, with ranges from 24 to 189 ppm. (parts per million).  Citrinin is produced by Monascus, Penicillium and Aspergillus species.

Unfortunately, the authors of the Archives study did not share the names of the supplements with the readers so we are left to ponder!

Say what you will about pharmaceutical drugs, I think we all benefit from the FDA oversight and knowing that there is some standardization and safety in manufacture and distribution.  Supplements can range from completely ineffective to potentially dangerous with contaminants or unknown side effects.

Red Yeast Rice Supplements should be used with caution.

Thursday, October 28, 2010

The Man with the Eyeball Tattoo

There seems to be no end to stupidity and this man from Toronto, Canada is right up there at the top for crazy ideas.  He actually tattooed his eye by injecting the sclera with ink.  It took 40 injections of ink to complete the color transformation.  Despite the painful appearance, the eye can be easily anesthetized (numbed) so the needle does not hurt.

Despite the fact that this is reported as the "first" eyeball tattoo, I did a little research and other body manipulation fans have done the same thing.  All we can do as physicians is give people the scientific facts.  Here it is:

This type of body modification is extremely dangerous and could lead to blindness.

Thanks to KM for the tip

Tuesday, October 26, 2010

What Caused This Woman to Faint?

 Dear Dr. Brayer;
My mother, age 66, fainted while she was at work.  She was taken to the emergency room and was evaluated for hours, including a CT scan of her head.  They could not find a reason and sent her home.  Could it have been a stroke that didn't show up?  
Thanks, Heidi

Dear Heidi,
The medical term for fainting or sudden loss of consciousness is syncope.  It occurs when the blood flow to the brain is not adequate to supply oxygen and glucose and fainting can occur after only 5 seconds of hypoperfusion.   It is actually pretty common and even after careful evaluation, no cause can be found in 60% of cases.

It would be rare for a stroke to cause syncope and they do not usually go together.  A patient might have a brain hemorrhage that would cause a severe headache followed by a loss of consciousness, but that is different from a simple faint and those patients do not spontaneously wake up.  Strokes usually cause sudden weakness on one side of the body or face and a severe stroke can cause a coma but the patient does not spontaneously wake up a few minutes later as they do with fainting.

The most common cause of syncope is from emotional stress, pain or standing too quickly with pooling of the blood in the lower legs.  It is common for soldiers standing at attention to faint for the same reason.  Dehydration or exhaustion can also cause syncope.  One type of syncope in men is called "micturation syncope" where they faint with urination. The cause is unknown but it usually happens at night after a deep sleep.

More  serious causes are from irregularities of the heart or a seizure.  These conditions can be found with a good history, understanding the events before and after the syncopal episode, physical exam and cardiac tests. 

The majority of children and healthy adults have no structural heart disease to account for fainting.

Sunday, October 24, 2010

First Do No Harm

One of the ancient principles of medicine is Primum non nocere, the Latin phrase that means "First, do no harm".  It means that sometimes doing nothing is a better decision than doing something that might cause more harm than good.  It is an ethical precept for physicians, but it becomes harder and harder to adhere to as more and more exotic tests and treatments are at our disposal. 

But just because we can do tests or surgery, doesn't mean we should.  Looking at the whole patient; their lifestyle, beliefs, support system and activity level, should be part of the analysis and decision.

There are so many ways and times in treating patients, that doing nothing can be the best decision.  A prime example is Mr. Leon Sanit who is 97 years old.  Mr. Sanit lives in Los Angeles and plays tennis every single day at 11 A.M.  He was diagnosed with bladder cancer and doctors recommended surgery that had a 50% chance of extending his life.  Here is a guy with an active life,  playing tennis at age 97, who has wisely decided to forgo surgery and just enjoy himself.

The risks of surgery in a 97 year old are considerable.  The convalescence and recovery itself are risky and would certainly impact the good time he has left in his life.  The odds of him ever being back on the tennis court are considerably lower than the chance he would live longer.  

I know of another elderly man (a friend's father) who had prostate surgery for prostate cancer, even though he was over 80 years old and had a lower Gleason score, which means it is a slower growing form of cancer.  I was upset to learn his physicians had recommended surgery.  He had a bad post op course and never really returned to his pre-op activity level.  He died within a year of the surgery. Doing something, was worse than doing nothing.

One way patients can help a doctor stop and consider the recommendation for surgery or treatment is to ask, "if this were your mother/father/wife...would this be the treatment you would recommend?"  At the very least it slows the process down and makes it a more thoughtful one.

 Mr. Sanit article from Tennis, Nov 2010

Saturday, October 23, 2010

Cholera in Haiti

I still follow the aftermath of the Haiti earthquake closely and have continued contact with our Haitian interpreters that I met this year on the Sutter Health Helps Haiti medical mission.  Our physicians and nurses worked in St. Marc, (three hours north of Port-au-Prince) at St. Nicholas Hospital, the epicenter of the new Haitian Cholera outbreak.  Boston based Partners in Health (PIH) runs the hospital there and the villages surrounding the area had been drinking water from the river, that is presumed to be contaminated.   Reports are that the 200 bed St. Nicholas Hospital is overwhelmed with the influx of patients and other areas of Haiti are also showing cases.

The news of the cholera outbreak is not a surprise to me, considering the sanitation problems.  At this writing, over 3,000 people are reported to be sick from Cholera and over 200 have died.

What is Cholera?  Cholera strikes poor countries, where water sources are contaminated and public sanitation is compromised.   The bacteria is Vibrio cholerae and a toxin that the bacteria produces causes an infection in the small intestine that produces watery diarrhea,  vomiting and belly pain.  It is transmitted through contaminated drinking water and food.   The symptoms occur about 5 days after infection and the patient can lose massive amounts of fluid very quickly.   Epidemics spread rapidly in disaster areas because of overcrowding and contagion. 

The treatment for Cholera is rapid re-hydration through inexpensive IV solution powders that are mixed with water.  With treatment, the number of deaths can be reduced to 1%.  Chronic dehydration is common in Haiti to begin with and the rapid fluid loss from Cholera strikes children and older people dramatically if they can't get immediate help.

Cholera is a huge threat of spreading throughout Haiti because the disease has not been seen there for decades, meaning its potential victims have no immunity against the germ.  The last major outbreak of Cholera in the Western Hemisphere was in Peru in the early 1990s.

How Do You Hide $100 From a Doctor?

How do you hide $100 from a surgeon?  
        Put it in the patient's chart, next to the lab.
How do you hide $100 from an orthopedist?  
        Put it in a text book.
How do you hide $100 from a neurosurgeon?  
        Tape it to his kid.
How do you hide $100 from an OB/Gyn?  
        Tape it to the patient's head.
How do you hide $100 from an internist?  
        Stick it under the patient's bandage.
How do you hide $100 from a radiologist? 
        Give it to the patient.
How do you hide $100 from a cardiologist?  
        You can't.
How do you hide $100 from a plastic surgeon?  
        You definitely can't.

Compliments of The Happy Hospitalist

Thursday, October 21, 2010

Wednesday, October 20, 2010

Should You Share a Bed With Baby?

I've watched the pendulum swing back and forth on the wisdom of mom sharing her bed with a baby.  The American Pediatric Society has come out against the practice, because of a higher incidence of Sudden Infant Death.   But nearly half of all British moms sleep at times with their baby and 1/5 share a bed regularly during the first year.


According to a British study published in Pediatrics, the value of breast-feeding should be considered before advising mothers not to share  beds with their infants.  The results showed that mothers who shared a bed with their newborns were better educated and of a higher socioeconomic status, and that those whose children routinely slept in their beds during the first 15 months of life reported a significantly greater incidence of breast-feeding.

"Both cross-sectional epidemiological and sleep laboratory studies showed close links between the frequency and duration of breastfeeding and the practice of bed sharing," writes Peter Blair, PhD, Community-Based Medicine and Social Medicine, University of Bristol, United Kingdom, the author of the study.

 This study mentioned that women who bed share with infants were more highly educated and, thus, are more likely to follow other infant safety guidelines.  Unsafe infant care practices are sleeping on sofas, bed sharing after use of alcohol or  drugs and bed sharing by parents who smoke.

I can still remember my two children as newborns and how wonderful it was to bring them into bed with me throughout the night to breast feed.  It made no sense to get up in a chair and one of the advantages of breast feeding is that you don't need to get up and warm bottles.  As the babies get older, however, they squirm around too much and getting a good nights sleep is pretty hard.

The "family bed" is a practice in most parts of the world and this study shows why it might be preferable for new moms.

Tuesday, October 19, 2010

Cool Medical Apps

The best thing about the iphone and ipad are the cool apps.  I am learning about new ones all the time but here are a few Medical Apps that I like and I think they are all free.

  • Lose it!  This is a great app for dieters.  It is easy to use and intuitive and you can track your caloric intake and exercise.  Just set your goal and how many calories you want to eat a day and it maps out how long it will take you to get there.
  • EyeChart  I've never had the chance to use it with patients but it looks like it would work well.
  • Speed Bones Lite (Quiz)  For those of us who still like to test ourselves on anatomy.  Name the bones while the clock is ticking.  I do pretty well on this one!
  • PoWorkout    A cool app that takes you through an entire fitness workout with video on how to do it right and info on what muscle groups are working.  Abs, cardio, total body.  It's all here.
  • MPR  This app has a lot of drug information, prescribing, doses, interactions arranged by organ system or with a simple search function.  Its better than carrying around a PDR and easier for me to use than epocrates which requires me to sign in each time I want to look something up.
  • ICD9pcp  I love this app. I'm constantly having to look up ICD9 codes and this really helps me out.
  • Fluid  Just a cool little app that calms me down.
  • Bump  What's not to like about an app that allows you to exchange contact information by just bumping phones.
  • AwesmFacts If you like trivia, you will like this app.
  • Merck Manual Home Edition  Curious about a symptom or a medical term you heard?  you can find everything in the Merck Manual.  Treatments for injuries and emergencies are all here.
Please let me know about your favorite apps...medical or not.

Monday, October 18, 2010

Medicare Fraud

There are few things that grind my gears more than Medicare Fraud.  These scams pop up every couple of years and I am so glad when the perpetrators get caught and arrested.  The latest is a large crime syndicate lead by Armen Kazarian, the godfather of Armenian gangsters.  More than $160 million fake  Medicare invoices were generated from 118 fake medical clinics in 25 states, said U.S. Attorney Preet Bharara.  Most of these "clinics" didn't even exist and were Mail Boxes, Etc. addresses.

As part of this fraud, Endeavor Diagnostics billed more than $1million in medical lab tests for Medicare patients.   Endeavor Diagnostics was an empty office with a desk and a fax machine in San Fernando Valley, California.  The complex operation recruited people and paid them a small fee to become a fake patient and then they would bill Medicare for services supposedly rendered.  Corrupt doctors were also part of the scam that carried out unnecessary tests on "fake" accident victims and then billed the  government for the treatment.  The majority of this fraud was with stolen identities and completely bogus claims.

"These are hardcore crooks, and we got to do something about this," said Peter Budetti, the Deputy Administrator  for Program Integrity, Centers for Medicare and Medicaid Services.  He reported that 18,000 new applications come into the Medicare program every month, and many of them are criminal elements and fraudsters.

I am staggered by that number.  Did he really mean 18,000 a month?  How is that even possible?  There can't possibly be that many new Medicare providers (labs, doctors, clinics).  CMS simply must look at each new application and do random site visits to see if they are real.  It is a huge waste of  taxpayers money if even a fraction of these are fraudulent.

Most Medicare providers are honest and are truly underpaid for their work.  That includes physicians and hospitals.  Durable Medical Equipment companies are highly regulated and physicians have to sign a number of forms  to even get a cane for a Medicare patient.  How this type of fraud can slip under the radar is a huge mystery to me.  Surely there is software that can identify billing outliers and claims data analysis should be able to spot fraudulent activity before it reaches millions in paid claims!  Even if the doctor's identity was stolen, the number of claims and amount of paid claims should have raised a red flag.

Someone was asleep at the wheel.  Unfortunately it is the taxpayer's car!

Wednesday, October 13, 2010

Drug Shortages in the United States

One of our pharmacists asked me "Are we now in Sudan?"

It seems like we are a third world country because we are dealing with serious and nationwide pharmaceutical shortages for needed drugs.  Medications like Propofol (yes, the one that killed Michael Jackson) and Succinylcholine, a neuromuscular drug that is commonly used in surgery, are in such short supply that we are canceling surgeries and trading those drugs between hospitals. It is just the tip of the iceberg.  Other drugs like metoclopramide, vecuronium and even ephedrine are limited.  Every week we find a new shortage.

What the heck is going on?  Because these drugs are generic, only a few companies manufacture them.  If one stops, it creates a shortage that is not easy to rapidly correct.  In the case of Propofol (used in anesthesia and even for conscious sedation in emergency rooms and for colonoscopies), two of the three manufacturers stopped making it and that left only one to supply the entire market.   The situation was only resolved when the Food and Drug Administration (FDA) stepped in and allowed the temporary importation of a European drug called Fresenius Propoven to enter the Country and ease the shortage.

Most of these medications are sterile injectibles and are generic.  When a decrease in the number of companies making an older, less profitable drug is coupled with problems in manufacturing, shortages occur and that is what is happening right now.

In my health care organization, we are monitoring shortages weekly and developing ways to ensure the most sick and acute patients get the treatment they need.  I hand carried 2 vials of Succinylcholine to one of our rural hospitals last week, 400 miles round trip.  Today I was told that one of our Surgi-centers is getting a few vials from a hospital that just got a shipment.  We are learning to share and that is a good thing.

Yesterday I listened to the deliberations going on in the Supreme Court, dealing with lawsuits against vaccine manufacturers, who have already set up a no-fault Vaccine Injury Compensation Fund for injured children.  Although this fund has paid over $1 billion for vaccine related complications,  the attorneys believe that does not protect the companies from further litigation.  If the Courts allow people  to tap into a monetary fund and then sue on top of that, I predict we will slip into a true third world country where mumps, measles and chickenpox ravage our population.  The vaccine manufacturers will just stop making the drug.

Tuesday, October 12, 2010

Get Healthy Compliments of Uncle Sam

It makes my blogging life easier if I can just direct readers to a cool site compliments of....drumroll...the U.S. Government! 

This site, called Smallstep Adult and Teen,  is filled with great health, eating and exercise tips.  Check it out and click around a bit.  Don't ya' just love the internet?

Monday, October 11, 2010

Positively Quit Smoking

I hold my breath when I walk into the hospital and see a small group of people in the "smoking area" puffing hard on cigarettes. The hospital (and other office buildings) are smoke free, but that doesn't mean everyone has stopped smoking.  They just have to stand out in the fog or the cold like lepers.  I know in other parts of the country, smoking is more tolerated and even more smoking occurs. Unfortunately, after declining for a few years, the number of smokers in the U.S.  has now remained stable at 21%. About 438,000 Americans die each year because of tobacco use, the CDC said. The agency estimated that for every death, there are 20 people living with a tobacco-related illness.

A study was just published that showed U.S. smokers are exposed to higher levels of cancer-causing compounds than smokers in other countries.  The researchers compared the levels of nitrosamines in cigarette butts and dangerous metabolites in smoker's urine and found the levels were significantly higher in cigarettes manufactured in the U.S. compared to smokers in other countries.

Is there anything about the dangers of cigarettes that we haven't heard over and over?  It is time for all smokers to quit and a new small book by Cassius Cheong called Positively Quit! Manual -The Thinking Person's Guide to Stop Smoking is a new tool that can help.

This tiny book engages the reader to answer some easy questions about how and why they smoke and why they want to quit.  Just the process of thinking clearly about why and writing it down can help with behavior change.  And the author addresses some common misconceptions people have about quitting that can hang them up.

The book is short and gives some tips for how to handle the first few days of quitting.  Coupled with other aids like nicotine patches or gum, it makes stopping cigarettes an active process that takes planning and day by day attention.

If you smoke or know someone who does, this little book may be the first step in getting healthier and reducing the terrible risks that we know smokers have.  Buy it as a gift.  It is the nicest thing you can do for someone you care about.

Saturday, October 9, 2010

Internal Medicine Poem

I am frequently asked:  What is Internal Medicine?  The answer: "I am the doctor for adults" or I am the primary care physician", just doesn't seem to cover it.  I think this poem from the Journal of American Medical Association (JAMA) does:

Today I Saw

diabetes in a brown pantsuit
recently widowed, bringing her daughter
for the first time.

Bladder cancer still working
full time after surgery
with two sons to get through college.

A stroke crying and embarrassed
to be unmanly since his release
from the hospital.

A health care checkup squeezed in
before her insurance runs out.
Downsized out of a job.

High blood pressure out of control
from the stress of a daughter
raped at age sixteen.

Recurrent breast cancer smiling.
Thin but happy to be leaving on her first cruise.
To her I say bon voyage.

Barbara Fleming-Phillips, MD
Lexington, Kentucky

Tuesday, October 5, 2010

Flossing Toothbrush

Being the world famous popular blog it is, EverythingHealth gets lots of solicitations to place ads, promote books, authors, medical supplies, drugs and other websites.  The answer to most of these requests is "Thanks, but no-thanks".  I like to keep the blog pure and you know that my advice is not tainted by outside influence. (Also known as $$$$)

But since October is National Dental Hygiene month, I took SoFresh Oral Care up on their offer to try their flossing toothbrush.  After my last visit with the dental hygienist, I knew I needed all the help I could get.  Good dental and gum care is not just for a good smile and fresh breath.  Studies show there is a direct link between mouth bacteria and systemic diseases like cardiovascular disease (heart attack and stroke), diabetes complications, bacterial pneumonia and even osteoporosis.

Ok, enough of the background.  So I tried the flossing toothbrush and the OraSweeet tongue cleaner and I liked it a lot.  I gave one to my mom and, without prompting, that senior citizen said she "really liked the new toothbrush" and it felt different to her than her old one.  My teenage son also thought it was cool. It gives a flossing sensation and the tongue scraper (followed by whitening mouth wash for me) made my mouth feel sparkling clean.

These oral care products can only be purchased online but they are reasonably priced so check it out and buy a bunch for the family.  You can focus on good oral hygiene all month.

Probiotics - What and When?

Probiotics contain microorganisms that are similar to the beneficial bacterial that occur naturally in our intestinal tract.  There is so...