Thursday, October 27, 2011

Carpal Tunnel Syndrome

Immediately Post-op Carpal Tunnel release
Carpal Tunnel Syndrome (CTS) is common and is the result of the median nerve becoming squeezed or "entrapped" as it passes through the wrist down into the palm of the hand.  Because this is a sensory nerve, the compression causes tingling, burning and itching numbness in the palm of the hand and fingers. A different nerve goes to the little finger and the lateral half of the 4th finger so the sensation there would feel normal.  There is often a sensation of swelling even though there is rarely any true edema that can be seen in CTS.

The symptoms of Carpal Tunnel Syndrome  usually start at night when people sleep with flexed wrists.  As it progresses, the tingling and numbness can be felt on and off during the day.  It can cause decreased grip strength and weakness in the hands.

CTS can be worsened by medical conditions like rheumatoid arthritis, diabetes, pregnancy or wrist trauma.  Women are three times more likely to develop CTS than men,  and it is rare in children.  Most of the time no cause is found.  The space that the median nerve traverses is very tiny and it doesn't take much to compress the nerve.  Even small amounts of tissue swelling such as occurs in pregnancy can cause severe symptoms.

The treatment for Carpal Tunnel Syndrome starts with simple remedies like aspirin or NSAIDs.  Some people are helped by wearing wrist splints at night to avoid flexion.  Stretching and strengthening exercises can help, but if the nerve is inflamed exercises are not going to help.

For severe CTS, a corticosteroid injection into the wrist to reduce swelling can provide prolonged symptom relief (4-12 months).  If injections fail or if there are signs of hand weakness, carpal tunnel surgery that releases the trapped nerve can be the answer. This surgery, done under local anesthesia, is quick and usually provides permanent cure.

Thanks to my patient, SP, for providing this photo immediately post-op after undergoing endoscopic surgery.  Two tiny incisions are made in the wrist and the palm,  and a camera attached to a tube visualizes the carpal ligament that can then be cut by the hand surgeon.  The patient can resume normal activities within days.

Tuesday, October 25, 2011

Teens and Soda and Junk Science

The headlines of a number of newspapers say "Soda Boosts Violence Among Teenagers."  A new study out of Harvard's Public Health Division analyzed data from 1878 14 to 18 year olds and found those who drank over 5 cans of non-diet soda a week consumed more alcohol and smoked more cigarettes.  Additionally those teens were more likely to carry a knife and exhibit violence toward family and peers.

According to the Washington Post,  "About 23 percent of those who drank one or no cans of soda a week carried a gun or knife, and 15 percent had perpetrated violence toward a partner. In comparison, among those who consumed 14 or more cans a week, 43 percent carried a gun or knife and 27 percent had been violent toward a partner, the researchers found. Similarly, violence towards peers rose from 35 percent to 58 percent while violence towards siblings rose from 25.4 percent to 43 percent."

The study was published online in something called "Injury Prevention". Despite the fact that I've never heard of this "journal", somehow the study got National coverage in the news.  To the author's credit, they admitted that the study did not prove causality and there may be other factors that weren't accounted for.  The students self reported their soft drink consumption and their "violent" tendencies. 

As the mother of a teen, I can tell you that teen boys think they are "badder" than they are and I would guess some of the self-reporting would be questionable.  Just sayin'....

This story, with it's sensational headlines, should make us all take pause with the hundreds of pseudo-science reports that come out daily as "breakthroughs" or "news".   With 24 hour news shows, the Internet and the need for content that will grab the reader, a big dose of skepticism should be our first thought.

Sunday, October 23, 2011

Robots Bring Care to Remote Places

Both in the United States and around the globe there is a mismatch between needed medical care and the doctors who can provide it.  Most physicians are located in urban areas where there are hospitals, teaching schools, lab and Xray and specialists to deal with most every medical condition.  Rural areas in the United States lack these resources and patients either do without,  or must travel far to be seen.  In developing countries there may be no services at all for hundreds of miles.  That is where telehealth can play a huge role in bringing medicine to the  people.

The "In-touch" robot is one technology that can work all over the world.  Through a simple lap-top computer a doctor and reach out across the globe and "see and be seen" by the patient and have a conversation with the patient.  The robot is mobile and can be remotely navigated from room to room (or hospital bed to hospital bed) and "visit" the patient.  A dermatologist can see the skin and recommend treatment.  The robot can perform electronic stethoscope, otoscope and ultrasound and transmit that data back to the physician.

We are using this technology to provide care to rural community hospitals in Northern California that cannot get certain specialists in the community.  We are also able to provide remote night medical coverage so patients can stay in their own community and not be transferred to larger hospitals for care.  Many conditions can be managed well in the rural hospital with physician expertise to evaluate the patient and prescribe treatment.  Patients and their families love it and it saves in cost, transportation and inconvenience.

The robot is also providing needed expert consultation for a hospital in Haiti and a rural hospital in Kolwezi, Democratic Republic of Congo.   Specialists are donating their time to be "on call" and provide support to the patients and care-givers there.  Imagine the benefit of having consultation for a high-risk pregnancy or neurology or pediatrics or any number of medical conditions.

I wrote about this technology  way back in 2007 and now the robot is being used far and wide.

Thursday, October 20, 2011

Kid's Allergies and Asthma

There never seems to be enough time for parents to ask all of the questions they want of their kid's pediatrician.  And parents whose children have allergies or asthma have lots of questions and new concerns that pop up all of the time.  The American Academy of Pediatrics has published an updated guide called "Allergies and Asthma - What Every Parent Needs to Know."   This paperback should go a long way toward answering those questions and letting parents know how to deal with health problems.

This book is easy to navigate and is written in language that will be understood by the reader, yet it is not a "dummy guide" but a real source of information.   It starts with basic physiology and  explains what happens with the immune system when an allergen is encountered.  Those allergens can cause skin allergies, hay fever, food allergies, killer allergies (anaphylaxis) and asthma.  The authors advise how to identify, prevent and treat these conditions.

Childhood asthma is one of the most common chronic conditions in the United States, yet it is poorly understood by parents.  The numbers of young people and children with asthma is rising and no one can say exactly why.  "Allergies and Asthma" helps parents understand the disease and it dispels outdated beliefs like "Asthma is an emotional disorder; it's all in the mind" or "People with asthma should use medication only when they have attacks."

The book is well written, has a glossary of commonly used terms and definitions and contains an extensive lists of foods that may have allergic potential for some children.  The foods that contain egg protein is quite surprising, like processed meat products and breakfast cereals.  And milk protein can be found in sausages and packaged soups.  (This is another reason to eat simple foods without additives as much as possible)

I recommend "Allergies and Asthma" for anyone who is interested in learning more about allergic reactions or wants to know if allergies could be causing a problem with their child.  It is a great resource written by the experts.

"Allergies and Asthma - What Every Parent Needs to Know." (Michael J. Welch, MD, FAAAAI, FAAP, CPI, Editor in Chief.)

Tuesday, October 18, 2011

Ovarian Cancer Screening of No Value

If you want to create an outcry of indignation,  just inform people that certain screening tests are of no value and do not increase time on this earth.  People love the idea that if they do all the right things and get all the medical tests at the right time, they can prevent disease (, tests don't prevent anything) or catch cancer early and cure it.

The furor over the lack of benefit for men of the screening Prostate Specific Antigen test (PSA) is still being heard.  It seems everyone knows someone who was "saved" by getting a PSA and don't try to tell me there is evidence to suggest otherwise, dammit!

There is a new report in the Journal of the American Medical Association (JAMA) that confirms previous studies and shows there is no benefit for women to obtaining screening ultrasounds and Ca125 for ovarian cancer.  This is bad news because every year over 21,000 women are diagnosed with ovarian cancer.   Most of them are diagnosed in advanced stages and the 5 year survival rate is only 30%.  Of course we want a safe, effective screening test that can detect abnormalities early.

Ca125 (blood test) and transvaginal ultrasounds should work...but they don't.  The 13 year old study confirmed a prior report that the predictive value of these tests was low and additionally it confirmed there was no difference in mortality in women who underwent screening compared with those who did not.  Additionally they found a high number of false positive tests and 15% of women with false positives suffered serious complications of surgery.

The discouraging findings may be because ovarian tumors are aggressive and annual screening is ineffective.  The serious complications associated with false positive tests also makes it a bad screening test for the population.

Someday we will find good tests to detect these cancers.  Right now patients and doctors should just say "No".


Saturday, October 15, 2011

Male Circumcision

Male circumcision has been practiced for cultural and religious reasons since ancient times and it is estimated that about 1/4 of the world's men are circumcised.  It is a controversial topic and the debate about medical benefits of circumcision has not been fully resolved.   The Journal of the American Medical Association (JAMA) has recently published three randomized trials from Africa that demonstrated  adult male circumcision decreases HIV acquisition in men by 51-60%.   That is a huge decrease for a virus that is ravaging the continent.  Observational studies in the United States also show such declines in heterosexual circumcised men.

In addition to HIV, male circumcision has been shown to reduce other STDs.  Herpes and HVP contagion were reduced in men and the female partners of circumcised men had a lower risk of bacterial vaginosis and trichomoniasis.   Since STDs are a significant problem in the United States, there may be societal benefits for male circumcision.

Opponents of male circumcision have a strong and passionate voice against genital mutilation performed without the consent of an infant.  They say it is an unnecessary procedure that can affect sexual satisfaction and has its own risks.  Anecdotal reports about circumcision are strong on both sides of the argument.


The cultural reasons for male circumcision are long entrenched and there does not seem to be an outcry from adult men who were circumcised as infants and are resenting or regretting it.

The medical evidence for male circumcision is growing with these new studies that show both individual and public health benefit.   Parents should be provided with information derived from evidence-based medicine about the risks and benefits of male circumcision so they can make an informed choice for their children.

Tuesday, October 11, 2011

Doctors Charging Add On Fees

 My telecom bill is pretty high when you take the basic rate and then add on "additional bundled services ($4.99)", "Internet Services ($7.00)", "Additional Voice Service ($25.72)", Taxes, surcharges and fees ($10.47), "911 fee ($.24)" and "other charges and credits ($2.99).  One way doctors could deal with their declining incomes (down 7%-25% adjusted for inflation depending upon the specialty) is to mimic the phone company.  Just add additional fees and taxes to their charges.

How about:
CLIA lab compliance fee
Electronic medical record maintenance fee
business tax fee
Medical license renewal fee
DEA fee
State mandated pain management course fee
State mandated end of life course fee
Hospital Med Staff application fee
Continuing Medical Education fee

Get the point?  The cost of doing business keeps escalating as does the number of mandated regulations.  Other businesses can adjust by raising prices or charging add on fees.   Physicians cannot. 

We already know health care costs too darn much.  I wish the rest of the "free market" would cooperate by lowering my cost of doing business.


All is Well

Saturday, October 8, 2011

Answer to Medical Challenge

The answer to the Medical Challenge this week is #3 - Graves' disease.

The skin changes seen on the lower legs are typical of Graves' dermopathy.  The skin has a leathery texture, thickening and fissuring.

Graves' disease, named after the Irish doctor Robert James Graves, who first described it in 1835 is caused by an overactive thyroid gland.  Thyroid auto-antibodies stimulate thyroid hormone synthesis and secretion and the thyroid gland grows into a goiter.  (A goiter can occur with an overactive or underactive thyroid or even a normal functioning gland)  The hyperthyroidism causes tremor, hyperactivity, heat intolerance, weight loss and insomnia.  The eyes can bulge out and tear excessively and this is called Graves' ophthalmology.

Graves' disease is an auto-immune disorder and it is more common in women and in people with a family history of endocrine disorders.  Treatment consists of inhibiting the production of thyroid hormones, either by radioactive iodine therapy to shut it off or surgery to remove the thyroid (thyroidectomy).  Other drug treatments can block the effects of hyperthyroidism and interfere with the thyroid's use of iodine to produce hormones.

The patient in the Medical Challenge had his thyroid removed.  When that happens, the patient takes thyroid replacement therapy forever.

You got it right, Solitary Diner.  You are ready for board exams!

Thursday, October 6, 2011

Michael Jackson's Doctor

The 2nd degree manslaughter trial of Dr. Conrad Murray, the doctor who attended Michael Jackson at the time of his death June 25, 2009,  is now underway in LA.  The testimony that is taking place is certainly revealing of the last day of Mr. Jackson's life.  Michael Jackson died of an acute Propofol overdose and the toxicology report also revealed Valium, Lorezepam, Versed, Lidocaine  and Ephedrine in his system.  There were no illegal drugs.

Propofol is used as a powerful anesthetic and is given intravenously.  It is not a drug that would be used outside of a medical facility or hospital.  Versed (Midazolam) is also a drug that is used for conscious sedation for procedures in hospitals.

Dr. Conrad Murray is a cardiologist and served as Michael's personal physician.  He was trained at Meharry Medical College and did post graduate work at Mayo Clinic and Loma Linda University Medical Center in California.  He studied Cardiology at my alma mater, University of Arizona, and he was the associate director for the interventional cardiology fellowship training program at Sharp Memorial Hospital in San Diego.

All of this sounds pretty sterling!

He was hired by Michael Jackson in 2009 for his upcoming concert tour for $150,000/month. 

Early testimony in the trial reveals the doctor ordered drugs from a pharmacy that were delivered not to a clinic, but to his girlfriend's home.  It included 225 vials of Propofol, 20 vials of Lorezepam and 60 vials of Versed.  He admits that he routinely hooked Michael Jackson up to an IV and administered drugs to help him sleep.  The day he died, Dr. Conrad was in another room making phone calls to various girlfriends. According to testimony of Jackson's cook, when Conrad found the pop star unresponsive and not breathing he panicked and called for help from body guards and even Jackson's children.

Witnesses reported that he called out to the bodyguards in the room "Does anyone know CPR?", and then attempted mouth to mouth breathing.  He stopped and said "I've never done mouth to mouth before."  911 or paramedics were not called for a full 25 minutes.  Instead Murray called Jackson's personal assistant and said "Call me right away, right away, thank you".

When paramedics arrived there was no chance at reviving Michael Jackson and the Emergency Room physician at UCLA Medical Center also testified that "Mr. Jackson died long before he became a patient."  Strangely, Dr. Conrad did not tell any medical people about the IV drugs that led to his death and only said he had given him a small 25 milligram dose of Lorazepam.

This case is just beginning and much more will be revealed over the next few weeks, both for the prosecution and the defense. 

Medically,  he is going to have a hard time explaining how a cardiologist would not be up to the current standards of CPR.  Mouth to mouth resuscitation is no longer the standard of care and cardiac compressions are the lifesaving protocol that all current physicians know.   IV Propofol and Versed are dangerous for use outside of a hospital setting and close 1:1 nurse monitoring and sometimes anesthesia stand by is required.   The fact that this would be used without an external defibrillator nearby or even used at all is shocking.

Many questions will need answers. I trust the jury is listening closely.

Wednesday, October 5, 2011

This Weeks Medical Challenge

Avert your eyes if you can't stand this weeks Medical Challenge  from the New England Journal of Medicine.  Click on the image for a better view.

This Patient is being treated for an endocrine disease.  What is it?
1.  Acromegaly ("giantism")
2.  Cushing's disease (excess cortisol)
3.  Graves' Disease (hyperthyroidism)
4.  Hashimoto's thyroiditis (a thyroid disorder)
5.  Type 1 diabetes

  The answer will be posted tomorrow so post your diagnosis in the comment section, smarty pants!

(In case you wondered...I did get it right.)

Monday, October 3, 2011

scintillating scotoma

image from myaspiebrain
Nothing like experiencing a medical condition first-hand to really help a doctor understand it from the patient's point of view.  After all these years, I had my first (and hopefully last) scintillating scotoma while sitting on the couch playing "words with friends" on my ipad and watching TV.  A scotoma is a partial loss of vision in a normal visual field.  Scintillate is flashing, sparkles.  Put them together and you have moving, flashing sparkles with a blind spot in your eyes.

This visual aura was first described in the 19th century  by a Dr. Hubert Airy who had migraine headaches.  The visual sparks and flashes are in a zig-zag pattern and they can precede a migraine headache or occur without any pain.   The scotoma affects both eyes and closing one or the other does not make it go away.  Sometimes the term "ocular migraine" or "retinal migraine"  are used to describe this phenomenon but these involve only one eye, not both.  The terms are often used interchangeably but they are not the same.

The cause of these migraine auras are not understood.  Only 20-30% of people with migraine headache experience them.  The visual defect occurs not in the eyes, but in the visual cortex which is located in the back of the brain in the occipital lobe.

My scintillating scotoma lasted about 15 minutes and it took me awhile to figure out what it was.  I went outside and gazed into the distance and it persisted.  I closed one eye and then the other and it was still there.  I never got a headache or any other symptoms.  Then it just went away.

The next time a patient with classic migraine with aura comes in,  I will have a better understanding of the prodrome before the headache.  I hope I don't have to experience the entire headache.  I could do without that.

Saturday, October 1, 2011

Bedside Manners Worth $42 Million

A Chicago couple believes doctors should have good bedside manners and they have ponied up $42 million dollars to teach it.  Matthew and Carolyn Bucksbaum have donated to the Bucksbaum Institute for Clinical Excellence at the University of Chicago.  They made the donation for their own personal physician to lead it and say he's the kind of doctor students should emulate.  They were motivated to make the donation after Carolyn had a bad experience with an arrogant doctor who dismissed her illness and never apologized.

Large medical groups measure "patient satisfaction" with the physician and the medical office.  Doctors who are very good clinically can have horrible scores because of bad bedside manner.  There are many consultants who will come into an organization and "teach" better rapport.  And it is a well known fact that doctors with good communication and interpersonal skills get sued less...many times less or not at all!

Are empathy and interpersonal skills innate or can they be trained?  Does medical school select for self-absorbed students or do they become jaded and arrogant from years of training and working with demanding patients?   We know the science of medicine can be learned.  Can the art of medicine be taught too?  Is it OK to have an excellent surgeon who saves your life but has the personality of a warthog?

I think there are basic manners and ways of communicating that can be taught. (hopefully by parents at age 3 but later by consultants if that didn't happen).  A small percent of doctors, like in the general population, have a personality deficit or a narcissistic personality and will never learn empathy or good communication.

The remainder of good "bedside manners" starts with  giving patients information in a respectful way that they can understand.  That takes time (trainable) and intuition about how to communicate with different people's personalities (innate).  Good bedside manners means not badmouthing other caregivers (trainable) and also instilling confidence and trust in your ability to help the patient problem (innate).
Eye to eye contact, tone of voice are trainable, but the ability to have true respect for the patient and understanding the full context of his disease is innate.

Time will tell if the $42 million pays off.  Teaching young doctors how to communicate, how to be team players with other clinicians and how to follow the golden rule (Treat others as you would like to be treated yourself) sounds simple but would certainly improve patient care going forward.

What do you think?  Will it be $42 million well spent?  Can bedside manners be taught?

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...