BLEEDING

Bleeding, from any part of the body, is abnormal and demands attention (unless it is from an expected menstrual period).  I am always amazed when I receive a call from a patient who has been bleeding for “awhile”.  The call usually occurs after hours or on weekends.  “Doc, I’m bleeding rectally.  It looks like a lot!  It started last week.”

I don’t know about you but I hate the sight of my own blood pouring out of my body.  The instinct for survival should cause an individual who is bleeding to seek help immediately.  What is amazing is the number of excuses my patients have for ignoring their blood loss.

“I have hemorrhoids.”  “I drank too much alcohol last weekend.”  “I thought it was because I fell down two flights of stairs last week.”  “I have a family history of a bleeding disorder.”  “I have irregular periods and didn’t think much about it.”

Bleeding is abnormal and “I think” is not a good enough answer.  Bleeding demands a definite answer (why) and treatment plan.  In my experience, hemorrhoidal bleeding is the most common cause of bleeding.   Bleeding hemorrhoids rarely cause significant blood loss.  The harm lies in the fact that patients who have hemorrhoids learn to ignore the bleeding.  Patients self treat by using suppositories and over the counter remedies and fail to ever mention their hemorrhoids to their doctors.  No one wants a rectal exam.  While the patient ignores his/her rectal bleeding, the unseen tumor that lies above the hemorrhoid grows silently.  It is a mistake to assume your rectal bleeding is simply a hemorrhoid.  Hemorrhoids are curses that demand yearly follow-up visits and, sometimes, more definitive treatments.

“I drank too much.”  If you are bleeding from the effects of alcohol, you are in big trouble.  Varicose veins of the esophagus from chronic alcohol abuse, tears in the esophagus from retching, and ulcers are all potentially life threatening causes of bleeding.  Please don’t ignore bleeding.

“I fell last week.”  If you fell and injured yourself causing internal bleeding, don’t call me; call 911.  If you cut your hand with a knife, pressure on the wound should stem the flow of blood long enough to get help.  There is no way to put pressure on a bleeding organ.  If you fell and subsequently have bleeding from your stomach or bowel, call 911!

If you have a family history of bleeding problems, seek help before you are bleeding.  There are tests that can help diagnose familial bleeding problems; and, then treatments and precautions can be taken.  Again, do not ignore bleeding.

“My periods are heavier than usual.”  Most women are familiar with their “normal” menstrual flow.  If your bleeding pattern changes and you are suddenly using an excessive number of pads, see your doctor.  Women with heavy “normal” menses may lose enough blood to become anemic.  Treatment may include iron supplements and hormonal manipulation.

Signs of anemia vary.  Often fatigue is the first symptom.  As anemia worsens, pallor (pasty yellow or white skin), shortness of breath, and even chest pain may occur.  Bleeding from the stomach often causes nausea, loss of appetite, and black tarry stools.  A gush of bright red blood rectally should be followed by a call to 911.  Bright red blood on the toilet paper demands a visit to your doctor’s office.

Err on the safe side.  If you are bleeding, see a doc.  If you are bleeding bad, see an emergency room doc.  If your friends are telling you look bad (pale), believe them!  Remember, the life you save may be your own.

FEVER

Do you really want to treat a fever?  After all, isn’t fever a part of the body’s natural defenses?  The answers to these questions aren’t as clear cut as you may think.  Yes, fever is part of the body’s defenses; but, at times, it can be harmful. 

As with everything in medicine, what to do about fever boils down to the individual situation.  Each and every individual is unique; and each and every time an individual gets sick, his/her illness is unique.  In the old days, there wasn’t much that could be done for a fever.  Actually, many used to “sweat” the illness out by wrapping the infirmed in heavy blankets.  I always thought that Dorothy, in the “Wizard of Oz,” was hallucinating due to fever, her family waiting at her bedside hoping she would recover.

While fever can lead to dehydration, hallucinations, and seizures, most fevers will resolve spontaneously and are harmless.  Fevers up to 101 are generally well tolerated and may actually be helpful.  Since one of the risks of fever is dehydration, patients are advised to stay well-hydrated.  I recommend “sports” drinks for febrile illnesses, as they help replace essential salts often lost due to profuse sweating.  When the body’s core temperature goes up, so does the body’s metabolic rate.  “Sports” drinks are also a good source of carbohydrates.

Fever should be treated aggressively if there are any signs of dehydration.  One of the best ways to judge hydration is by measuring urine output.  In children, diminished urine output (dry diapers) is a potentially threatening sign.  Fever should also be treated aggressively if you have other, concomitant illnesses.  

In addition to hydration, acetaminophen and ibuprofen are the mainstays of treatment.  Ibuprofen can be used every 6 hours and acetaminophen can be used every 4 hours as needed.  Acetaminophen and ibuprofen can be used simultaneously when either product fails to adequately lower the temperature into a safe and comfortable range.  Remember, when treating fever, your target is under 101.

Fever without an obvious cause demands a visit to the doctor’s office.  I believe in erring on the safe side.  It’s better to be seen than be sorry.  Persistent fevers for days also require a visit to your doctor.  Shaking chills are a warning sign!

When bacteria is released into your blood stream (bacteremia), the immune system usually reacts strongly causing shaking chills.  If the bacteria survives your immune system’s response, sepsis (severe blood borne infection) ensues and is a life threatening event.  If you have shaking chills (rigors), see your doctor or go to the emergency room.

Remember, the life you save may be your own.   

YOUR DOCTOR THE MASTER CHEF

YOUR DOCTOR THE MASTER CHEF

As a doc, I wore lots of hats.  Over the years, I have developed analogies for most of the things I do and for the things I want my patients to do.  Analogies help people conceptualize the complexities of medicine in a way that makes sense.

Not long ago, I had my chef’s hat on.  I was actually treating a young chef and found myself talking about food and medicine.  There is a direct correlation.  My office medicine cabinet is no different than my home spice cabinet.  As each spice has a specific taste and texture and effect on your body, each medication has a different personality and effect.  

Cooking is all about getting just the right mixtures of taste and textures and sensation to put a smile on your face.   No matter how many times you make a recipe, you have to season, then simmer, then taste, then season, then simmer, then taste, then season until you get it right.  Once you’ve gotten it right, you have to let your guests taste your version of what you believe is a perfect recipe.  I make an amazing chili con carne!  At least, I think it is amazing.  If I fed it to ten different people, I might get ten different opinions.  Some may think it is perfect.  Some may complain I use to much chili powder.  Some may complain I do not use enough chili powder.

When I cook with medications, I know exactly what results I am looking for.  When I was treating a case of newly diagnosed hypertension, I would go to my drug closet (spice rack) and pick out my favorite medication (seasoning).  I had made this recipe thousands of times but never for this unique individual.  I picked my favorite spice.  It is my favorite because it is often successful and rarely causes any adverse reactions.  I would send him home on one tablet a day and asked him to see me in 2-3 weeks.  In this case, 2-3 weeks is the simmer phase and the follow up visit is the taste test.  If his blood pressure is controlled and he has no distasteful problems, the recipe is good and I will let him simmer for 3 months before I take another taste.  If his pressure is not controlled or he does not like the recipe, I will adjust the mix by adding or removing medication.  Sometimes the recipe is so bad you have to throw it out and start from scratch.  Eventually, if my patient is compliant and works with me, we can achieve perfection.

As a chef, I take great pride in being the best on the block.  I am very particular when it comes to choosing ingredients, using the best quality available.  I like to taste frequently and adjust spices often in order to find perfection.  When I serve you chili, I don’t mind you adding some chopped onion, cheese or even salt. When I am cooking up a recipe for hypertension, I mind the addition of salt and prefer that you not add any other medications or nutraceuticals without my knowledge.  You know the old adage of too many cooks in the kitchen!

So, the next time you are in your physician’s office, imagine him wearing a chef’s hat.  Decide whether you are willing to settle for a mediocre dish or you want the gourmet version.  If you want perfection, go home and simmer and then follow up and let the chef taste and adjust.  You really should demand the best in your food and your health.  

GENERICS

Generics

I’ve finally done it.  I’ve come up with that once in a lifetime idea that will make me independently wealthy.  It’s ingenious, fail proof, and won’t cost much to get up and running.  Guaranteed success!  

I don’t know why I never thought of it before.  I’m shocked no one else has ever done it.  I’m barraged with requests for it on a daily basis.  The whole world is in love with generics.  They are cheap and satisfy a base need.  They are readily available.  Demand is so high they are in short supply.

Are you ready for the future?  Picture this; a chain of cheap generic restaurants!  Cheap, no thrills diners offering nothing special other than generic food on generic paper plates with generic plastic forks and knifes.  I won’t even need to invest in décor!

Once my generic restaurants are open, no one will want that expensive branded food anymore.  The big names in the business won’t know what hit them.  Why go to Gibson’s for a fantastic prime steak when you can eat my generic round steak for a tenth of the price.  I won’t need chefs.  At “Gino Generic’s”, I will throw on a little government surplus garlic, some generic mashed potato mix and serve up a nice salad (ingredients purchased daily on the final sale cart at the local grocer).  Wow, a generic, cost conscious meal!

I never did understand why people took their families out to those overpriced, branded, chain restaurants.  They are the reason the nation is in the midst of an obesity crisis.  All of those high-end chefs cooking up those fat laden, calorie rich meals are destroying the economy.

At “Generic Joes”, our motto is “You’ll never get fat eating our bland, generic meals.”  We base our menus on real food, the way G-d intended it to be: raw, with very little prep.  After all, food is food, isn’t it?

Seriously, aren’t generics the same as branded?  You’ll love our road kill stew.  Our crews are out 24 hours a day, shopping the highway to bring you the best generics on the market at the cheapest price.

So the next time you are headed out with your loved ones for a $75 a person feast at Stoney River, think about the economy, your waist line and the national financial crisis, and go to “Generic Stew’s” for a really generic, cheap, and really fresh, road kill stew.  Just good generic eating!

CHEST PAIN

Last night a dear friend called seeking advice.  Her friend who lives in Virginia was having chest pain.  The following is my standard advice.

If you are having chest pain associated with any of the following:

  1. Shortness of breath
  2. Radiation of pain to neck, jaw, shoulder or arm
  3. Radiation of pain to your upper back
  4. Nausea or indigestion associated with any of the above
  5. Pain on exertion or after eating
  6. Sweating with pain
  7. A history of heart disease, hypertension, diabetes or high cholesterol
  8. Family history of heart disease
  9. If you are a smoker

DIAL 911.  DO NOT GET BEHIND THE WHEEL OF A CAR!  DO NOT HAVE SOMEONE TAKE YOU TO THE DOCTOR’S OFFICE!  THE LIFE YOU SAVE MAY BE YOUR OWN.

While the advice above pertains to both sexes, women are notorious for having atypical symptoms of heart disease and need to be even more cautious.

Most  men and women underestimate (deny) chest pain! A denial or underestimation of chest pain can be lethal.  Heart attacks damage the heart and cause dangerous rhythm disturbances.  If treated early, much or all of the damage can be avoided.  Driving with chest pain not only threatens your life, but also is a direct threat to the other motorists on the road.  It is one thing to die behind the wheel of your car when it careens into a tree; it is quite something else when your car strikes a minivan loaded with children.

The paramedics are well trained professionals who can institute treatment the moment they see you.  The ambulance is a mobile intensive care unit.  Your family car is not.  Your spouse cannot perform CPR while driving.  Your spouse cannot dispense life threatening medicine.  

The number one reason that people do not call the paramedics is people worry that they are overreacting and causing too much of a fuss.  Dying causes a fuss.  One of my favorite things to tell you is that all the tests are normal and you did not have a heart attack.  One of the worse things to tell you or your family is, “If only we had gotten to you (him) sooner!

One last point.  When your spouse shouts, “If you call the paramedics, I’ll never speak to you again,” call the paramedics.  If you don’t call 911 and your spouse dies, they’ll never speak to you again!

CURSE OR BLESSING?

One of the best lessons I have learned is if you can make something good come from something bad, the bad was not so bad after all!  I have taught that lesson to countless patients over the last 40 years.  Today, I want to share my lesson with those readers who have been branded with “learning disabilities” (LD).

Yes, I said “Branded.”  Like those individuals with attention deficit disorder (ADD), individuals with LD often feel branded, even cursed.  During the formative years of life, patients with LD often struggle in school.  LD students receive “accommodations” in the form of special classes, tutors, and attend special testing centers.  Accommodations can make an adolescent feel inferior and damaged.  

I have a learning disability.  When I went to school, there were no special classes, accommodations; you either survived on your own or you failed.  I have a form of Dyslexia.  Reading has always been agonizing for me.  My disability is not readily apparent; I can read aloud to an audience and they will not detect a single problem.  I just can’t process what I read!  I always failed standardized tests.  Not because I didn’t know the answers, but because I could not process the questions.

I have the gift of being able to process and retain everything I hear.  Over the years, I have learned many tricks that help me deal with my dyslexia.  Modern technology has been a Godsent blessing for me.  My texts and journal are now available in audio format.

One of the most traumatic events in my life was my failure to get into the University of Virginia Medical School.  I was an honors student with a 3.5 something average and medical school was a slam dunk!  I was a cocky young man and only applied to three top East Coast schools.  Unfortunately, I bombed on my MCATs (entrance exam).  Scoring in the 14th percentile in English should not have been a surprise.  I can’t read!  Ultimately, I moved to Mexico and graduated from La Universidad Autonoma de Guadalajara Medical School.

Making something good come from something bad is today’s lesson!  Going to a Mexican medical school was an embarrassment.  It also was one of the best things to ever happen to me.  During my four years in Mexico, I learned a lot about myself and the world I lived in.  I learned to talk and think in a different language.  I learned that what Americans believed was not what the rest of the world believed.  It was a humbling experience and I needed to be humbled.

I also learned that I had a learning disability.  I learned that, if you work hard enough, you can learn to live with LD and you can make LD work for you and others.  This article is proof positive.  I have had a long career helping others and working with many of my patients and their children.  I help remove the stigma of ADD and LD by finding the good in the bad.  

If you have a reading disability, develop your listening skills.  If you have problems with the spoken word, thrive on the written word.  All of us are blessed with being unique individuals.  Within all of us is a gift.  Don’t get bogged down with being labeled LD or ADD.  Find your gift and celebrate it.  Don’t be ashamed of needing accommodations.  Use them as tools the same as I use the CD/DVD player.  Most of all, learn to be happy with yourself.  Yes, it may be harder for you to succeed but success will come.

If you are having problems coping, see your doctor or counselor.  If you are envious of others, recognize that they are unique individuals and have their own problems.  If others mock you, feel sorry for them, not for yourself.  They mock you out of ignorance and you are not ignorant.  

OMG

September 26, 2019

It’s another miserable day.  Why?  Today I picked up my med refills from the pharmacy.  OMG (yes, I’m yelling)!  Despite having insurance, I’m spending a fortune on medications.  I use GoodRx.  I use Kroger’s discount plan.  Use my insurance.  I’m still hemorrhaging money every 3 months. I’m retired, getting older and sicker and have to have my meds.

I feel blessed to be able to take the financial hit.  I don’t know how people afford to live.  On New Amsterdam’s (TV show) season opener, they portrayed an out of control diabetic. She was out of control due to the outrageous cost of her insulin.  She could not afford to buy it!

The writers did a great job at portraying the sad reality of the situation.  The hospital administrator/Doc fired the drug company that provided the way too expensive insulin and tried to get it from Canada.  That failed miserably.  He enlisted the press in his cause.  That failed, too.  In the end, the pharmaceutical manufacturer of insulin bought him off by supplying his patient with her insulin for one year.  When the patient asked her doc what about all the other patients who could not afford their insulin, he had no answer.

Reality is depressing.  Patients need their medications and often are left with the choice of paying the pharmacist or paying the landlord.  Retirees living on fixed incomes get hit the hardest.

I wrote the following article 3 years ago.  The only thing that has changed is that now I’m spending too much of my retirement income and understand the plight of my patients firsthand.

February 24, 2016

Dear Pharma,

I’ve known you for years. We’ve been the best of friends.  You’ve brought me miraculous medications over the last 32 years and helped legions of patients enjoy longer and healthier lives.  In many ways, you’ve been a knight in shining armor.

It hurts me to say this, but you’ve been bad lately: really bad!  You’ve priced your medications so high that the average patient can no longer have them.  Your antidepressants eat up so much of a patient’s budget that it is depressing!

I know that there are many factors contributing to the outrageous cost of your most miraculous medication. I’ve previously written about the cost of liability insurance.  I know that the cost of bringing a new medication to market is massive.  I also know that your need to increase your corporate profits has led you down the wrong path!

As your friend and longtime admirer, I’m telling you it’s time to change your ways. It’s time to scrap the sample and discount card programs and reduce the upfront cost of your medications.  Everyone is coming after you.  You are Hillary’s villain.  She openly avowed that she was coming for you in her last debate.

The PBM (Pharmacy Benefits Manager) is your avowed enemy and they are all powerful.  They simply are denying access to your medications. You are the patients’ avowed enemy.  They see you, not as a knight in shining armor, but as a greedy pusher who has what they need but demands their life’s blood to purchase it.

Just how much do you spend on those Viagra commercials? Discount cards? How does a medicine that sells for nine dollars in Mexico, sell for fifty dollars here?  Why is a medicine that costs eight Euros sell for eighty dollars here?  As your friend, I’m telling you it’s time to think out of the box and sell more units for less, here, in the US.

As your friend, I’m warning you. My patients are fed up.  I’m fed up!  Time to buff up your armor and get on your stallion and rescue us!

(Unfortunately, Hillary, Obama and Trump have all failed us and there is NO relief in sight.)

RETROSPECTOSCOPE

During the next few months, many of us will be busy preparing for the holidays, excited to be with family and friends, looking forward to the New Year.  The New Year brings many things, starting with the New Year’s resolutions.  While most of us look forward to a new beginning, hopeful that things will be better, many spend time pondering about the past and saying, “what if?” and “If only I had”.

Forty years in practice has taught me that ruminating on the past and the “What if” question and the “If only I had” reply, is detrimental to your health.  After all, you cannot change the past.  While you are busy regretting past errors, you may be missing future opportunity.  Today, a friend told me that one of the most important moments in her life was when I helped her through a moment of self-doubt and self-recrimination.  She had made a decision many years ago that had long term consequences for her child’s health.  At the time she made that decision, it was the right decision.  Many years later, it was still the right decision, but when viewed through the “retrospectascope” could be questioned.

All of us are called on to make decisions on a daily basis. As individuals and parents who do not have a crystal ball with which to look into the future, we make the best decision we can.  All of us, when looking back in time through the “retrospectascope”, realize that some of those decisions turned out to be wrong, some foolish, and some absurd.  What is critical is to remember they were right at the time we made them.  

When you make a decision that affects you or a love one, take the time to gather as much knowledge as you can.  Follow your heart and your mind!  Give pause, then decide and carry out that decision with great care.  Later, if the decision turns out to be the wrong choice, live with it.  Learn from it.  Do not do the “What ifs”.  “What ifs” serve no purpose.  They lead to self-doubt, anxiety and depression.  They make you less capable and, therefore, more likely to err in the future.  Residing too long in the past steals your future.  Look forward to the future and all of its possibilities.

WHAT’S EASIER?

WHAT’S EASIER?

What’s easier; caulking and painting your house’s exterior or letting it rot and eventually replacing it? The answer is simple, isn’t it?

What’s easier; checking and replacing the brakes on your car when they are worn or dealing with the carnage when the brakes fail? Again, the answer is obvious!

So, what makes sense; taking care of your body by eating the right foods, exercising and seeing your doc for yearly physicals and routine maintenance or letting your body go to fat, your belly sag over your belt and your muscles atrophy from disuse. The answer should be obvious, shouldn’t it? Unfortunately, it’s not!

Many of my patients take their health for granted! They feel well! They’ve never been sick a day of their lives. They work hard at making a living but invest little in staying healthy. Then catastrophe hits and they are sick! Their blood pressure is elevated. They are diabetic or worse; they have a heart attack or stroke. Recovery is a bitch!

It’s no secret. It’s easier to maintain your health than to restore it once you’ve lost it. So, this year, work hard at maintaining your health. Make sure your spring-cleaning list entails cleaning up your diet, tightening up your waistline and exercising. The life you save may be your own.

SMILES

Yesterday was a lousy day. My trip to Tennessee to visit my brother was at its end.  He is recovering from a stroke and I hated to leave him.  I also hate going to the airport (I used to love flying the friendly sky) as there are always delayed flights which leads to angry people. Angry passengers mean tension and stressed filled hours in the waiting area and on the plane.

In fact, the early flight to Chicago was delayed 2 hours and they had room for Renee and I.  I was hesitant to switch flights as I was in no mood to deal with others’ frustration and anger.  Nonetheless, we switched.  Sitting at the gate I realized, to my amazement, that there were no angry, complaining passengers.  If they had spiked Kool-Aid, I wanted some.

So, why weren’t people angry, frustrated, acting out and pumping up their blood pressure as usual?  The answer became obvious when I noted that the flight attendants, M.W. and B.H., were smiling.  Both had disarming smiles.  It’s hard to have a bad day when someone is smiling at you, engaging you while sincerely apologizing to you and keeping you updated on conditions. 

Once on the plane I looked around the cabin and found lots of smiling passengers. Apparently, smiles really are contagious and the flight crew had infected everyone.  So, what does this have to do with health?

In my case, they helped alleviate some of the sadness I was feeling as I left my brother to head home.  My depressed mood was lighter and my anxiety about being in a tin can with angry individuals vanished.

I have been a doc for 40 years and the one thing my patients and colleagues agree on is that stress causes illness.  I’ve seen people who looked like they were going to stroke out screaming at gate agents and flight crews.  I’m sure some have. 

All this brings me to my point.  Many of my patients seek relief from stress in a pill.  Today, it was obvious that the treatment for stress is to find a great smile and spend enough time with it to let it infect you.  Your job is to nurture that smile and pass it on!

I hope United Airlines recognizes how precious these two flight attendants are.  I certainly do.  If you work for United Express, pass this article on.