Tuesday, February 28, 2012

Dark Spots in Eye and Skin

I must admit, being a physician, I notice unusual skin changes where ever I go and I'm fascinated with the variety of conditions I see.

 Thanks to the Captain of our snorkeling trip in Hawaii for allowing these photos of his congenital condition called Nevus of Ota. (Originally described by Ota and Tanino in 1939). As you can see, there is a gray or blueish patch on the skin around the eye and hyperpigmentation on his sclera. This is in the distribution of the opthalmic and maxillary branches of the trigeminal nerve and consists of increased pigment producing melanocytes. Because he works in the sun, the pigmentation is probably more noticeable.

 This condition causes no problems. Ninety percent are unilateral (one side only) as is his. There is a slightly higher incidence of developing melanoma, but that is rare and it does not affect his vision. Another condition called ocular melanosis looks the same but does not involve the skin. BTW...the snorkeling and whale watching were just great.

Sunday, February 26, 2012

Overuse of Cardiac Stents

One of my patients is in the hospital in another city (where he lives part of the year) after suffering a GI bleed.  He had a black stool, had lost blood, was quite anemic and experienced weakness and chest tightening before he came to the ER.   In the emergency room his Cardiologist was called and admitted him under the cardiology service.  When I called the Cardiologist to identify myself as his Internist, he told me the patient was getting a transfusion and he wanted to do an angiogram to see if his prior stents were open and possibly put in more stents. 

What?  Stop right there.

The patient has chronic renal failure,  has low blood counts, was quite stable with no symptoms, was receiving a transfusion and the cardiologist wants to put in stents?  There are so many things wrong with this story I wanted to scream.

First of all, the workup should first zero in on the GI tract and find out why the patient had lost blood.  He was not experiencing any chest pain or tightness once he received blood and was feeling quite normal.  The cardiologist didn't even seem to be considering what the cause of the anemia was and had not called in a GI consultant.  Additionally, with compromised kidney function, an angiogram could put him into acute renal failure:

"Contrast nephropathy is a recognized complication after coronary angiography and intervention that has been associated with prolonged hospitalization and adverse clinical outcomes," write lead study author Jay Kay, MBBS, MRCP, from the University of Hong Kong in Aberdeen, and colleagues.

 Not only was the workup and plan completely wrong, but I wanted to ask the cardiologist if he was even aware of the COURAGE study that has rocked the medical world.  This large trial was published in The New England Journal of Medicine and presented at the 2007 Scientific Session of the American College of Cardiology.  The results showed there was no difference in the outcome (death or new non fatal heart attack) between patients with stable angina who received cardiac stents and those who did not.

Every patient is different and large trials like COURAGE give us information with which to make decisions.  Most patients think stents save their lives.  Most patients have never heard of these trials and still depend upon their physician to make the decision about what is needed.     In this case, the Cardiologist was making a really bad decision for my patient.

As the Internist, I am looking at the entire picture and trying to be the quarterback.  I respect the roles of the receiver, the half back and the guards but each of them are looking only at one part of the play, while I am viewing the entire field.  In this case a patient with a GI bleed (later found to be an ulcer), no signs of unstable angina and chronic renal failure should NOT have an angiogram or any invasive cardiac procedure.

I advised my patient to "just say no".  When he did, the Cardiologist replied, "Don't blame me if you go home tomorrow and have a heart attack."

Just jaw dropping!

Tuesday, February 14, 2012

Blogger Break

 EverythingHealth will be taking our own advice and renewing the spirit and soul for the next week. 

Check out the links on the right side for great blog reading and be sure to check back for more exciting health news in a week.  Aloha!

Sunday, February 12, 2012

Avoid Obesity and Let Babies Eat With Their Hands

Babies who feed themselves with their fingers chose less sugar and were less likely to become obese than spoon fed babies, according to a study in the British Medical Journal Open.  It was a small study based on recollection, but the findings were still interesting and give us clues about how children self regulate food.

When babies start eating solid food, parents often offer sweetened baby food or little sweet "treats", thinking babies will prefer that.  In fact, the babies who self fed chose carbohydrates like toast, pasta or potatoes and the spoon fed babies went for sweets when given a choice.

Parents worry about  providing a balanced diet and also worry if a child is eating too much of one item.  Studies show, however, that self feeding babies will actually take care of their own nutrition if all options are provided like fruits, vegetables, proteins, and iron rich foods like hard-boiled eggs or strips of meat.  Pureed baby food is often filled with added sugar and salt and processed baby food is a modern invention.   There is no need to prepare special food for toddlers and they do better just eating what the family eats.

In many parts of the world everyone uses their fingers to eat.  Allowing a baby to self feed doesn't mean she won't develop good Western table manners.   As a child develops and sees her family using utensils, she will automatically try to copy  and will learn to use a fork and spoon.

This small study should give moms and dads the freedom to let junior get messy eating.

Friday, February 10, 2012

First Aid for Car Crashes

A big crash happened right in front of me today while I was at a stop light.  The sound of crunching metal and screeching brakes is truly frightening and it was clear help would be needed.  I crossed the intersection and parked my car and ran across the street to see if I could help.  Surprisingly, the man driving the car that was hit was not hurt.  The young woman in the car that struck him was on the side of the road sitting on the curb and profusely bleeding from her nose and face.   She appeared to be in shock.

What do you do in a situation like this?  The first thing to do as a first responder is to keep calm yourself.  Quickly assess who needs assistance first.  Do not move victims unless they are in a dangerous situation.  If the victim is conscious ask simple questions:  "What is your name?", "Are you in pain?" "Do you know the date?"  While you are doing this, make sure someone else is calling 911 for assistance.  If other people are around,  instruct them to make sure traffic is diverted to avoid more problems.

If someone is bleeding, try to find a clean cloth and apply direct pressure to the area.  Do not worry about hurting them if there is a wound.  The victim will not feel the pressure as pain and it may just save their life as blood loss is one of the more serious outcomes of trauma.  Try to be reassuring as much as possible with statements like, "You are going to be OK", "Help is on the way", "I will stay with you, don't worry".

If there are many victims try to deal with the most seriously injured first.  Try to keep the victims on the ground (sitting or lying) and calm.

Today, I practiced all of these techniques.  I  stopped the facial bleeding (with her own scarf)  and made sure there were no serious hidden injuries.  I assessed a broken hand and that there was no obvious neck or head injury.  She was crying but was able to answer simple questions.  I kept the victim quiet and reassured as much as possible until the paramedics arrived to transport her to the hospital.

It is unlikely you would be able to administer CPR at an accident scene.  Most victims that are unconscious are not flat on the ground where chest compressions can be given.  It is better not to move someone from the car until professional help arrives.

I will probably not know how this accident or the young woman who was hurt turned out.  When the paramedics arrived, I just removed myself from the scene and went on with my busy day.

Wednesday, February 8, 2012

Alternatives to Komen Foundation

Sometimes my fellow health bloggers get it so right...the best thing I can do for my readers is steer them to another blog.  And that is what I am doing.

The Blog That Ate Manhattan is written by Dr. P. and she did a great job of pointing out that we can still donate to the fight against breast cancer, now that the Komen Foundation has shown their true political leanings.  That debacle will certainly be a classic case study in how you can shut down a money-making brand in one day.  First it was a wrong decision by the board of directors, followed by their silence in the face of an internet storm.  Wasn't anyone paying attention to the "Arab Spring"?  The power of the people is strong.

Ah, but I digress.

Check out TBTAM and see how many other choices are out there besides fake pink.

Monday, February 6, 2012

Social Network Medicine is a Bad Idea

I like social networking as much as the next person and as an "early adopter" medical blogger no one can accuse me of not being dialed into "The World Wide Web" or "The Facebook".  But my embracing of mobile health stops when I read about a new start up that was mentioned in the New York Times  this week.  HealthTap is a concept that I hope doesn't make it.

HealthTap is a start-up based in Palo Alto, Calif (where all good start-ups are born) and consumers can post health questions  that are answered by physicians who log on.  After this free medical advice is given,  the readers can click the agree or thank button and the most popular doctors get a "Doogie Howser Award" or a "Dr. Healthcliff Huxtable Award."  Just writing this makes me feel so cheap!

What is the  point of all of this?  I am not really sure.  There are social network features on the site and maybe they will develop games and quizzes.  There are phone numbers and maps so you can make appointments with physicians...an d of course lots of health advertising.   HealthTap  doesn't list the physicians specialty but the doctor can accumulate a "reputation level" depending upon the number of awards and "agrees" they get from other activities.  It is really corny.

The only requirement for a physician to participate (I can't imagine any busy qualified physician participating!) is that he/she has a license in the U.S.  HealthTap answers are limited to 400 characters so it is a bit like twitter advice from a stranger who may or may not have knowledge about a topic.

I don't know if this new site (mobile app available too) will catch on or not.  There does seem to be an insatiable need for medical knowledge and people do like to ask health questions and get answers for free. The problem is that credible information doesn't come in 400 character sound bites from people who just happen to have a medical degree.

I love the idea of sharing knowledge on the internet but I'm not interested in a Doogie Howser award, especially since he was a 14 year old and not even real.

Saturday, February 4, 2012

Polio Survivors

Poliomyelitis is a contagious viral disease that affects nerves and can lead to paralysis.  Most people under the age of 50 don't know that polio was once an epidemic that killed and paralyzed millions of people between 1840 and the 1950's.  It was one of the most feared infections world wide. Modern polio vaccination has almost wiped out the disease.

It is rare for physicians in the  United States to see the effects of polio and most will never encounter it in their career.  There are reported to be about 450,000 polio survivors in the U.S. who have some disability from prior polio infection.

My patient (now in her 70's) was kind enough to allow these photos of her left arm paralysis from polio she contracted at age 9.  Her story is amazing.  She was kept bedridden in  a "crippled childrens home" in New Jersey for over a year.  During that year every one of her children roommates died.  She did not attend school and even though she could walk, she was kept in bed.  Her weight ballooned up to 250 lbs from eating and lack of activity.  Her parents finally took her home because they could see her health declining and her muscles wasting.

Post polio syndrome is a well recognized diagnosis that occurs years after polio recovery.  Polio survivors experience new muscle weakening and atrophy.  General fatigue and weakness is common in post polio syndrome,  as it is in my patient.

When parents are afraid of vaccinating their children, they should look back at history and realize how far we have come from epidemics and killed and maimed.

Wednesday, February 1, 2012

Concussion Management

It's football, soccer and ice-hockey season and that means concussions.  Concussion is a mild traumatic brain injury that is the result of a blow to the head. It is so common that over 1 million visits annually to emergency rooms are for concussions.  And most people don't even go to the emergency room so it is estimated that 3 times as many occur as are reported.  Sports related activities and accidents are the main cause of concussions in children and adolescents.

Concussions can be difficult to recognize and there is no specific definition or test that can diagnose it.  Clinical judgment and specific symptoms after an injury define concussion.  The patient does not need to lose consciousness and the symptoms can come on gradually but usually appear immediately or shortly after the injury.   Headache, dizziness, balance disturbance and disorientation are the most common symptoms.   Cognitive defects can occur like confusion, delayed verbal responses, difficulty concentrating and feeling foggy.

Fortunately there is better understanding of concussion now by coaches and sports professionals and some states even require concussion training for coaches, athletes and parents.   The first evaluation usually begins at the sideline and there are tools the coach can use to assess the severity.  If there is any suggestion that the athlete has a concussion he/she should not return to play.  Most of the time concussions do not require neuro-imaging (CT scans) unless there is suspicion of more serious injury like fracture or cervical spine involvement.  CT scans and MRIs cannot diagnose concussion.

There is no medical treatment for concussion, which is a shearing force that disrupts neural membranes and affects blood flow and brain chemistry.  Recovery may take 7-10 days in adults and even longer in children and adolescents.  The patient should rest and avoid physical activity.  Resting the brain is important too and that means no reading, computers or video games.  Children should be allowed to miss school tests and homework during the recovery period.  It is important that the teachers know a head injury has occurred so school work can be limited.

  Most children will recover fully but concussion is a serious event and little is known about the extent of time recovery will take so it needs to be individualized to the patient.  Prolonged headache would indicate that the student is recovering slowly.

Don't hesitate to see a physician if you or a child has suffered a concussion.

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...