Memorial Day is this weekend and the country honors those who have sacrificed for our freedom. Many of us will travel and enjoy the outdoors. However, according to a study by the National Coalition for Safer Roads, Memorial Day Weekend is the most dangerous holiday for road and highway accidents. Additionally, water injuries, including drownings may rise this weekend. Grill injuries can occur, and throughout the US we are seeing record high temperatures. We need to stay safe out in the sun, by the grill, in the water and on the roads.
Record heat and extended time outdoors can increase the risk of heat illness. Hydrate, stay in the shade and protect your skin from damaging UV rays.
Sunscreen with an SPF of 30 or greater should be applied 15-30 minutes prior to going outside and reapplied every two hours or more often if swimming.
Avoid excessive alcohol as it could accelerate dehydration and put one at greater risk of injuries and heat exhaustion.
For more on heat exhaustion and heat stroke read here.
In 2012, a man caught on fire after spraying sunscreen prior to heading over to the grill. He sustained multiple second degree burns.
Sunscreen may be flammable, so make sure it is dry prior to grilling or use a lotion instead of spray on.
Keep the grill outdoors but away from low roofing, branches, and trees. Watch the little kids and keep them and the pets away from the barbecue.
Assign someone to watch the grill if you need to step a way during grilling.
Do not add lighter fluid to already ignited coals.
If someone does catch on fire, remember to have them stop, drop and roll on the ground until the flames expire. Call 9-1-1 and remove any jewelry or tight clothes around the area..
If a minor burn injury does occur, run it under cool (not cold) water for 10-20 minutes. Avoid applying ice to the burn as it can damage the skin. Also remove nearby jewelry.
Bandage and see a medical provider if concerned with your injury.
Avoid drinking alcohol when swimming or engaging in water sports.
Make sure you are in arm’s reach of your kids in the water.
Use life vests while boating and make sure the kids are wearing appropriate sized vests.
Never swim alone. Always have a buddy.
Know your route to avoid you checking your GPS app while you drive.
Allow extra travel time and don’t rush. Expect travel delays coming home as well.
Consider leaving a day or two early or a day or two late to avoid congested traffic.
Drive the speed limit and avoid tailgating, leaving at least 2 seconds between you and the car ahead of you.
Make sure you have plenty of water, supplies and a first aid kit in the car in case you get stuck on the highway.
Have a happy and safe Memorial Day Weekend!
One of the leading causes of death in hospitalized patients is much more complex than once thought.
Septicemia is an infection that enters one’s blood stream. This can result in Sepsis, a life threatening condition that occurs in response to the blood infection. Its definition has been fluid over the years as more research reveals it’s a disease process.
IMAGE FROM TRISTATEHOSPITAL.ORG
Now researchers in a study published in JAMA describe 4 separate subtypes of Sepsis. These include:
α phenotype had fewer abnormal laboratory values and less organ dysfunction;
those with the β phenotype were older, had greater chronic illness, and were more likely to present with renal dysfunction;
those with the γ phenotype were more likely to have elevated measures of inflammation (eg, white blood cell count, premature neutrophil count [bands], erythrocyte sedimentation rate, or C-reactive protein), lower albumin level, and higher temperature; and those with the δ phenotype had elevated serum lactate levels, elevated levels of transaminases, and hypotension
Dr. Christopher Seymour of the University of Pittsburgh School of Medicine, states in Medical Express, “Right now, our treatment approach to sepsis is basically ‘one size fits all,’ whether you are a 40-year-old with influenza complicated by [a] staff infection or an 80-year-old with multiple comorbidities and biliary sepsis,” he said, adding that international sepsis practice guidelines recommend the same bundle of care for everyone.”
Current goals in medicine aim to treat the patient rather than the disease, and as we need to individualize treatment for those with high blood pressure, cancer and diabetes, we need to as well with acute, deadly diseases such as sepsis.
The Trump Administration has vowed to put an end to “surprise medical bills.” But this may be easier said than done.
Reports of “sticker shock” have exponentially grown over the years and consumers want transparency of what their health care visit is going to cost. However, the average physician, nurse practitioner, physician assistant, hospital, medical center, etc. don’t know themselves until the insurance company sends an EOB “Explanation of Benefits” delineating what is discounted, what is covered, and what is the patient responsibility.
So to start, President Trump is asking Congress to address those charges incurred by “out of network” facilities to which patients go to in an emergency setting. Wanting to hold “insurance companies and hospitals accountable,” President Trump wants to put an end to patients getting charged for “services they did not know anything about, and sometimes services they did not have any information on.”
Can he do it? Politicians on both sides of the aisle want to help curb health care costs, but both sides want to get the credit. There’s race to see who could do more for healthcare before the 2020 election.
There’s a few reasons why cost transparency in an emergency medical setting is challenging.
Firstly, insurance companies aren’t transparent to hospitals. They only inform the medical facility of the out of pocket costs once they take weeks to review the claim. This can be streamlined and cut down in time with software, but same day pricing by an insurance company is impeded by the need to see if the patient paid (or will pay) their premiums that month, or if they are still employed and have the same active insurance.
Secondly, patients don’t always know what their diagnosis is when they walk up to the front counter. Some may think they have a “cold,” but actually end up having a bout of pneumonia. Some may think they have a “stomach bug,” but after CT confirmation, learn they have appendicitis. Hence until the medical provider performs the evaluation and testing, a diagnosis and then “cost to treat”, cannot be given.
Finally, patients may not prefer the “cost factor” added into their facilities’ decision making. If they pay a certain amount for a visit and end up needing more pain control, a repeat breathing treatment, or some extra bandages, they may not want to have to take out their wallet, sort of speak, each time they need more services.
As a physician who, for years, pleaded with insurance companies to give us an idea of what they would want a patient to pay, I’m for any campaign to increase price transparency and offer patient’s more choice. However, since medicine and health can be unpredictable, coming up with predictable “costs” may prove difficult.
Those who have had their appendix removed may be at 3X greater risk of later developing Parkinson’s.
Researchers at Case Western Reserve University and University Hospitals Cleveland Medical Center looked at 62 million health records from 26 institutions throughout the US and found that those who had an appendectomy, surgical removal of the appendix, had a 3-fold risk of developing Parkinson’s later in life.
Internal medicine second year resident and study author, Dr. Mohammed Z. Sheriff, states,
Researchers suggest more research to be done, with investigational focus on gut health as it relates to neurological health.
Parkinson’s disease is the second most common neurodegenerative disorder, next to Alzheimer’s, and the most common movement disorder that affects 1% of the world’s population over 60 years old. In the US, 60,000 new cases are diagnosed each year. It affects several areas of the brain, primarily the substantia nigra, altering balance and movement by affecting dopamine producing cells.
It was first described in 1817 by James Parkinson as a “shaking palsy.”
Common symptoms of Parkinson’s include:
and patients may later develop…
Most cases are idiopathic, meaning the disease arises with no specific cause. However some cases are genetic and multiple genes have been identified that are associated with the disease.
The average age of onset is 60, but some cases may occur as “early onset”, before the age of 50, and if before the age of 20, it is known as juvenile-onset Parkinson’s.
Men appear to be more affected than women at twice the rate.
Risk may be enhanced with a history of head trauma.
Exposure to herbicides and pesticides has been linked to an increase risk of Parkinson’s as well.
Average progression rates can last years to decades, however, earlier onset disease may manifest much quicker.
Although there is no cure for Parkinson’s, symptoms can be treated by a variety of measures.
A Peek into How Doctors Think – An Introduction to “Columns”
Anyone who is on their path to becoming a successful physician needs to be able to take a good history and perform a thorough physical. However in this day and age, patient care is performed in a very speedily process and thus the boards test a medical student on how succinctly they can perform a patient history.
Thus students and licensed medical providers need to be adept at “data gathering” no matter what the patient presents with. Our job is to figure out what’s going on, no matter how difficult the task, and do so quickly. So how do we accomplish this?
We start by looking at the cause and then breaking down what could be occurring resulting in that cause, or in other words, forming a differential diagnosis. So if someone has chest pain, one may form a differential consisting of heart attack, pericarditis and costochondritis. But other issues may be at play such as a pneumonia or an esophagitis.
So when we look at a person with chest pain, we consider all the body parts or causes that could be causing the symptoms.
Hence with a patient presenting with chest pain, one would consider a cardiovascular cause, pulmonary cause, gastrointestinal cause, musculoskeletal cause, and even psychiatric cause.
This is the basis of forming one’s columns. For every chief complaint we form columns either mentally or on paper and then ask associated symptoms (or pertinent positives or negatives) to determine which column we’re in. Usually a few “power questions” will help discriminate which column you are in. Once you hit the correct column you will ask further questions along that line.
True there are many more questions we could ask than just the “power questions,” but during a time crunch we need to ask very specific ones to determine if we are on the right track. If we receive multiple “no”s along a column, we know to move onto the next column.
Hence if a patient with chest pain denies dizziness and diaphoresis or sternal pain upon palpation but admits to cough, shortness of breath and sputum production, we have just narrowed down the chest pain patient to a pulmonary cause as opposed to assuming it was cardiac in nature. Then we would continue down the pulmonary column, thinking our differential may be a pneumonia/bronchitis/pulmonary embolism, and ask about hemoptysis, fever, chills, etc.
So for each patient one must create columns depending on the chief complaint and then ask power questions to help focus down your differential.
Now these columns can also assist with the physical exam component of data gathering. If the above patient presenting with chest pain could have a cardiac/pulmonary/GI/musculoskeletal condition, one would examine his heart, lungs, upper abdomen and palpate the sternum and ribs.
For an added bonus, the columns can additionally assist one in forming their differential for the SOAP note.
Chest pain r/o
If a case involves a not so clear-cut symptom, columns could be used as well.
For example a patient presenting with hair loss. If one complains of hair loss, a variety of differentials could be at play. One column could be an endocrinology source (such as hypothyroidism or diabetes), another could be psychological (such as stress or trichotillomania), a third could be medications (such as chemotherapy agents), and a fourth could include genetics. Narrowing these down with power questions could exclude non-contributing columns.
So whether it’s a direct body system or cause, columns help one focus down the differential and allow an easy visual that enables one during a timed test to think quickly and know which questions to ask.
Again these columns are instituted after the History of Present Illness in which a student obtains onset/chronology, palliative/provocative factors, quality of symptoms, radiation, severity and timing (OPQRST).
They will be written down in the SOAP note after the HPI.
Example: Mary is a 25-year-old female presenting with acute onset right foot pain. It began 6 hours ago after she went for a job. Ice provides some relief but walking on it worsens the pain. The pain is sharp, constant with a severity of 7/10. She denies fever, chills, open wounds, swelling, redness, temperature changes, numbness or tingling.
Since during this step in the history most medical students find it challenging to know “which questions to ask.” The columns and power questions simplify this.
To learn this method to improve one’s data gathering skills click here.
The latest challenge sweeping social media is the “Shell On” challenge in which teens Snapchat videos of themselves eating through fruit skin, cardboard boxes and plastic bags containing their food.
Although this appears to not be as dangerous as the Tide Pod or Boiling Water Challenge, it can cause choking and asphyxiation.
In the video linked on the front page the teen takes bites out of fruit with their peel, and then bites through a cereal box.
Last year we learned of the “Boiling Water Challenge” in which kids drink boiling water from a straw or have it poured all over their body. Then they topped it off with a more dangerous challenge, the “Fire Challenge.”
The Fire Challenge is executed by pouring rubbing alcohol on one’s body and then setting oneself on fire. A video records the victim running into a tub or shower to wash it off, and this trend has gone viral.
Unfortunately it’s one of the most dangerous. A 12 year-old girl from Detroit who participated in this challenge is undergoing multiple surgeries to repair burns afflicting close to 50% of her body.
Multiple cases of the “Fire Challenge” have been reported over the years, including a 12 year-old boy from Georgia.
One would think children, especially teens, innately know that fire is dangerous but maybe the younger generation has been so protected that they haven’t experienced the basic concepts of danger and inadvertently underestimate its force.
Challenges that involve dangerous stunts have been around for some time. The Choking Challenge induced children to suffocate themselves for the high of feeling asphyxiated. The Tide Pod Challenge tempted kids to put colorful cleaning packets in their mouths, hoping they wouldn’t burst.
The Cinnamon Challenge sparked thousands to inhale the common kitchen spice and cough till they puked. Then the Condom Challenge offered two options where one dropped a condom filled with water on a friends face, or snorted one through the nose.
We adults can’t for the life of us figure out what the reward is in performing these challenges, but presume it's fame and awe among friends and social media followers. But these challenges prove dangerous and in some cases deadly. Unfortunately the YouTube Clips never show the after effects of these pranks…maybe they should.
36 lots of losartan potassium and losartan potassium/hydrochlorothiazide have been initiated by Torrent Ltd Pharmaceuticals due to a detection of N-Nitroso-N-methyl-4-aminobutyric acid (NMBA). NMBA, according to Toronto Research Chemicals, is a known carcinogen in a wide range of animal species. There have been no reports of users becoming ill and the recall is being done out of precaution.
N-Nitroso-N-methyl-4-aminobutyric acid (NMBA) was the third chemical detected resulting in the latest two recalls of losartan, an angiotensin receptor blocker commonly used to treat hypertension (high blood pressure). It is believed to have been created during the manufacturing process of the generic drug.
The FDA reports:
Earlier this Fall, ScieGen Pharmaceuticals, Inc. recalled certain lots of irbesartan, a similar angiotensin receptor blocker used in blood pressure management.
The recalls initially began last summer when FDA recalled a number of lots of valsartan due to an “impurity,” N-nitrosodimethylamine (NDMA) that is known to cause cancer in animals. Weeks later they additionally found traces of N-nitrosodiethylamine (NDEA).
According to Reuters, earlier last summer, the MHRA, Medicines and Healthcare Products Regulatory Agency, located in the UK, said the appearance of the impurity, NDMA, came after a change in the process for making valsartan at one facility owned by Zhejiang Huahai Pharmaceuticals, a company in Linhai, China.
In animals, NDMA is known to cause liver and lung cancer. In humans its carcinogenic risk is unknown, however the CDC states it may cause liver function impairment and cirrhosis.
With NDEA, data is limited, but due to its classification as a nitrosamine and its prevalence in tobacco smoke it is classified as a probable human carcinogen.
According to New Jersey Department of Health’s website, NDEA has been linked to liver, lung and gastrointestinal tract cancer in animals.
Losartan, valsartan and irbesartan are medications in the class of angiotensin receptor blockers (ARBs) used for high blood pressure and congestive heart failure.
Those taking either tablet for their blood pressure are urged to not abruptly stop their medication but rather check with their medical provider and pharmacy to see if their particular prescription is involved in the recall.
I suspect more recalls will follow as processes may be similar across multiple pharmaceutical facilities and NMBA, NDMA and NDEA are byproducts that may not be individually unique to just one “brand” of medication manufacturing.
On Passover, we read from the Book of Exodus in the Torah explaining the Hebrew’s years of enslavement and the struggle it took to free them. G-d sent Moses to ask Egyptian Pharaoh Ramses II to “Let my people go.” When the Pharaoh refused, the Lord sent down 10 plagues:
Scholars have debated how these occurred and scientists have interestingly found scientific explanations for each. This is what they found:
The water of the Nile turned to “blood”. It was undrinkable. One theory is the red clay could have been washed into the river and tributaries, or “Red Tide”, an algae bloom of Oscillatoria rubescens, for example, turned the water red. Moreover the algae can release toxins that kill nearby fish. Once the water is unlivable……
Frogs swarmed into the towns and homes. One theory suggests that since frogs like to live near the water, the toxicity and smell caused them to move from the waterways to the towns. The quantity of frogs still needs an explanation but how many of us see one spider in our house and claim the whole residence is “infested”……
Infestations occurred as the next plague and could be explained by the above two. The frogs eat insects and keep the populations in control when they hang out by the marshes and rivers. The drought and unlivable water conditions cause the frogs to leave and eventually die, so insects go unchecked.
Swarms of flies encompassed the fourth plague. Scientists explain this from the lack of competing insects and frogs not around to eat them. They, in turn, fed on the dead frogs.
One would think the Pharaoh would have given in by now but he didn’t. The fifth plague caused death of Egyptian livestock. Insects carry disease and swarms of them could have caused the livestock to become diseased. Moreover, water sources were becoming scarce as well.
Egyptians became infected with boils on their skin. Insects carry disease, lack of clean water and food could make one susceptible and pathogens can enter into societies and cause epidemics. One theory suggested a smallpox outbreak occurred. Researchers found small pox scars on recovered mummies and postulated that 3000 years ago an epidemic could have occurred.
The plague of hail and fire must have been a scary one. Many have postulated that hail and fire raining from the sky could have occurred from a nearby volcano. If that’s the case why not make “volcano” the plague. But interestingly, 3500 years ago the Santorini volcano north of Crete in the Aegean Sea, erupted. And for those of us who saw Dante’s Peak, there was ash falling everywhere.
Locusts swarmed the landscape. If a volcano was nearby, I’d head south too.
The ninth plague was darkness. Without light, temperatures drop, work can’t be done, crops won’t grow. Scientists suggest this could have occurred from an eclipse, dust storm, or the plume of smoke from the volcano.
The tenth and final plague was the death of every Egyptian first-born. Scientists have some difficulty explaining this one except for many first born were out the fields helping the adults when the pestilence, boils, etc. ensued. Another theory suggests the grain stores became contaminated and the first born might have had first pick of the grain, becoming sick first.
The Bible is rich with history and lessons and such a work needs no explaining. But there are those who like to mesh science with the Bible. So for all of us celebrating our ancestor’s exodus and freedom from slavery, Happy Passover.
Most of us squirt one pump of hand sanitizer, slap it together in our palms and then dry the rest off on our pants. But researchers say there is a protocol and choreography that must be performed in order to prevent the spread of millions of pathogens that could be lurking on our hands.
The World Health Organization recommends the following steps to be taken when using hand sanitizer:
The process takes about 30 seconds. However, in a study released this week, researchers from the University Hospital Basel found that if all steps were taken but performed in 15 seconds, the same results will be obtained. However, if fewer steps were taken, more bacteria/viruses/pathogens will remain on the hands.
For those who have eczema or sensitive skin, they may not tolerate the alcohol based hand sanitizers and should use soap and water instead.
Emilia Clarke, who plays Daenerys Targaryen on HBO's wildly popular Game of Thrones, revealed in an essay published by the The New Yorker she suffered two potentially fatal attacks while filming the popular series.
In 2011, she reports that while she was exercising, she felt a severe headache and then began vomiting violently. An ambulance took her to the hospital and her MRI showed she had a subarachnoid hemorrhage (SAH). She describes the ordeal:
"...Then my trainer had me get into the plank position, and I immediately felt as though an elastic band were squeezing my brain. I tried to ignore the pain and push through it, but I just couldn’t. I told my trainer I had to take a break. Somehow, almost crawling, I made it to the locker room. I reached the toilet, sank to my knees, and proceeded to be violently, voluminously ill. Meanwhile, the pain—shooting, stabbing, constricting pain—was getting worse. At some level, I knew what was happening: my brain was damaged..."
Clarke had to undergo surgery and recovered but then suffered another one in 2013, that was found on repeat brain scan.
She in detail describes the painful recovery but fortunately survived and was able to film one the most successful series in TV history and become one of the most beloved characters on the show.
An aneurysm is a “ballooning” or swelling of an artery. Theses may occur where the artery junction weakens. High blood pressure can contribute to aneurysm formation as can smoking. Some aneurysms may have no symptoms at all but others could rupture, causing a hemorrhage in the brain, stroke. Elevated blood pressure, heaving lifting, and trauma could cause these to rupture.
According to the Brain Aneurysm Foundation, 15% of people with a ruptured brain aneurysm die before they reach the hospital. 40% can be fatal.
Surgery or endovascular coiling is done to prevent further blood flow to the aneurysm.