Tag Archives: Conditions and Diseases

Straight, No Chaser: Bacterial Vaginosis – No, That's Not an STD

Medical Treatment, Obstetrics and Gynecology, Public Health, Health Prevention, , , , , , , , , , , , , ,

BV1 BV

I try to give you straight talk but never crudely. Therefore as I wade into conditions involving the genitalia, I’ll be sure to respect various sensitivities. That doesn’t mean I’m sugar-coating your information, it just means I am aware that you’re suffering and concerned by different scenarios.
One of those is bacterial vaginosis. There is an age after which women invariably start discovering that various things they do can disrupt the appearance, smell and content of their vaginal fluid. It’s certainly human nature to wonder if something has gone terribly wrong. Let’s pick up our Doctor-Couple conversation from earlier…
Patient: Yep! I have this grayish/whitish discharge that only happens after sex. And sometimes it itches around there. And it burns when I pee! No rashes or that other stuff, though.
Doctor: Ok. Let’s examine you…
All humans have various microorganisms that normally reside inside us at relatively low levels; different microorganisms inhabit different part of the body. They’ve set up a delicate balance (like an ecosystem, if you will) that, once settled doesn’t disturb us (their hosts) at all. If external or internal circumstances disturb that balance such that one set of organisms is disproportionately affected, overgrowth of the other organisms may occur. Many of you will recognize this as happening when you get a ‘yeast’ infection. It’s also what occurs when you develop bacterial vaginosis (BV). BV is the most common vaginal infection in the U.S. It’s more likely to be seen when you start having unprotected sex with a new partner, have multiple sex partners, are pregnant or douche (therefore, women who are not sexually active can have BV also). By the way, you don’t get BV from toilet seats or swimming pools.
The question everyone always has is “What’s the role of sex, especially sperm, in it?”. That’s asked because BV is often noticed after unprotected sex that includes ejaculation. Here’s where you learn the difference between ‘sexually transmitted’ and ‘sexually associated’. It is unclear what role sex has in the development of BV, but common thoughts include alterations in the pH of the vaginal fluid based on interactions with sperm/semen. It is known that the pH of women become more alkaline (less acidic) after exposure to semen, and that environment produces compounds causing the ‘fishy smell’. Yes, that’s real.  We even have a real thing call a ‘whiff test’ as part of making the diagnosis.
The good news is BV is easily treated. The bad news is it needs to be treated, and it can recur even if it’s treated. Remember, it’s just an overgrowth syndrome.  There are complications to not getting BV treated, especially if you’re pregnant. This makes it especially important that medication be taken to completion, even though you may feel better prior to that. Male partners do not need to be treated.
So this couple gets ‘off the hook’, even though they may decide to start using condoms.  Unfortunately, some of the next sets of couples aren’t so lucky.
I welcome any questions or comments.

Straight, No Chaser: Blood Clots in Your Legs – Deep Venous Thrombosis (DVT)

Hematology & Oncology/Blood Disorders/Cancer, Medical Treatment, Musculoskeletal System, , , , , , ,

DVT_clot_illustration
When patients talk about blood clots, they’re describing a blockage of a blood vessel somewhere in the body, usually the lower extremities (legs and thighs), the lungs (pulmonary embolus) or the brain. Today we’ll discuss the variety that occurs in the lower extremities, which are generally referred to as deep venous thrombosis (DVTs). In case you’re thinking that a clot in the leg doesn’t sound as bad as a clot in the lungs or the head, you’re correct – until you understand that DVTs break off and travel to other body sites, leading to blockage elsewhere (This is called embolism.).
Your challenge is to appreciate the risks of developing DVTs and the symptoms. Risk factors include the following:

  • Birth control pills or other estrogen use (this combined with cigarette smoking pushes the risk even higher)
  • Cancer
  • Cigarette smoking
  • Family history of blood clots
  • Obesity
  • Prolonged immobilization
  • Recent pelvic or leg fracture
  • Recent surgery (most often the pelvis or lower extremities)
  • Recent travel involving long periods of sitting
  • Certain medical conditions, most notably lupus

Symptoms most commonly are in one leg or the other, and reflect the fact that the vein is being blocked. These include pain, swelling, redness and warmth.
Diagnosis and treatment are relatively straightforward as long as they occur in time (meaning before the clots have broken off). Diagnosis is usually accomplished by an ultrasound of the lower extremities; once discovered, you’ll be placed on blood thinners. It’s important to know that blood thinners prevent the formation of new clots. They do not dissolve existing clots. That’s usually not necessary, as many DVTs simply dissolve. If it doesn’t, DVTs that embolize are life-threatening (more so from the pelvis and thigh than the legs). Unfortunately pulmonary emboli are among the most missed medical diagnoses and causes of death. Try to manage your controllable risk factors, and be aware when you’re dealing with a risk factor that you can’t control (like surgery).
I welcome any questions or comments.
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Straight, No Chaser: Appendicitis – A Whole Lot over Quite a Little…

Gastrointestinal, Medical Treatment, , , , , , ,

appendicitis
There’s not much that causes as much legitimate angst in parents as a child with appendicitis. In case you don’t know what the fuss is all about, the appendix is a 3 1/2 inch pouch on the edge of the large intestine near the right lower part of your abdomen. It’s actually like a long, skinny skin tag that (as best as we know) has no purpose other than to seemingly get inflamed, rupture and require surgery. The problem with it is that it’s a pouch (Pouches are bad things in the body. They always seem to twist or otherwise get blocked, leading to problems. This happens with aneurysms and hemorrhoids; twisting otherwise occurs with torsion of ovarian cysts or the testes. These stories don’t end well.). This particular pouch has the misfortune of being filled with stool, so if it gets sufficiently blocked or inflamed to the point where it ruptures, your abdomen will contain loose stool, which as you can imagine will cause a nasty infection rapidly (This is called peritonitis.). Appendicitis is a surgical emergency, because left untreated, the peritonitis caused by rupture will lead to septic shock.
Appendicitis is very common, occurring in one of fifteen individuals, usually between ages 10-30. It is more dangerous in the young and old, because they are both less able to describe symptoms and more likely to have abnormal presentations. Both of these scenarios lead to delayed diagnosis and treatment, which as you might imagine, doesn’t give patients the best opportunity for good outcomes.
Symptoms classically involve abdominal pain, followed by nausea, vomiting and fever, although other symptoms involving the digestive and urinary systems may be present. Often, the pain begins near the umbilicus (belly button) and seemingly migrates to the right lower portion of the abdomen. The pain may lead to a ‘board-like’ feel of the abdomen. This is a bad sign when it happens.
Treatment involves surgery (an appendectomy) in the overwhelming majority of cases. Your job is to maintain a high level of suspicion and remember a few very important pearls of wisdom. First is seek medical attention without delay. Also, don’t eat, drink or take any medicine if you think this is what’s going on. Surgery requires an empty stomach, and certain medicines may mask the pain (leading to diagnostic difficulties) or facilitate early rupture of the appendix. In case you were wondering, there’s no definitive way to prevent appendicitis, but it is less frequent in those on high fiber diets. Score another point for fruits and vegetables.
I welcome any questions or comments you may have.
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Straight, No Chaser: Low Blood Sugar (Hypoglycemia)

Endocrine/Metabolic, General Health and Wellness, Medical Treatment, , , , , , , ,

hypoglycemia1
In the last post, I provided an overview of diabetes. Everyone knows about diabetes, and most understand how dangerous diabetes is over the long-term. However, as an emergency physician, I’m more concerned with what will kill you immediately, and on that front, low blood glucose (sugar) is usually much more concerning. I want you to know up front that a low enough blood glucose will kill you – now. As we say in the ER, a high glucose level will hurt you and may kill you, but a glucose level that goes to zero means ‘Cancel Christmas’.
Therefore I will start with a simple statement. Any diabetic (or individual known to have low glucose levels) with altered mental status needs to be given juice or if they can handle it, some soft food to chew on. If they’re in the midst of a high sugar reaction, it won’t make much of a difference, but if that glucose level was zero, you’ve just saved a life. Now let’s briefly discuss symptoms and causes.
Low glucose levels can present many different ways including dizziness, jitteriness, numbness, tingling, blackouts, seizures and other symptoms. However, it’s usually the confusion or other change in mental status that’s most predominant and concerning. Just remember, this is not something about which you should wait around to see if it gets better.
Regarding causes, unintentional overdosing of insulin or oral medication (particular the sulfonylureas class of medicines) are especially concerning and common. Sometimes a family member, particularly a child, may take such a medicine to disastrous effects. Beyond that, heavy alcohol consumption on an empty stomach is another common cause due to its effects on the liver (Alcohol locks glucose stores in the liver, preventing release to the blood; as a result you have less to use.).
Other causes are more exotic and fortunately less common; they will be evaluated upon arrival to the hospital when a rapid response isn’t seen with simple administration of glucose. Dysfunction of certain organs (the adrenal and pituitary glands, the liver due to hepatitis, or tumors of the pancreas – the organ that produces the insulin that drives glucose into your cells – can cause problems with regulating either glucose itself or insulin. These conditions can drive your blood glucose dangerously low.
So, the causes are varied, but the message is simple. Be careful with insulin administration, remember to check those blood sugar levels and act promptly in the face of mental status changes. Usually I note that time is tissue, but in this example, you’ll run out of time before your tissues are damaged.
I welcome your questions or comments.
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Straight, No Chaser: The Tragedy of Septic Shock

Cardiology/Heart, Infectious Disease, Medical Treatment, , , , , , ,

Septic Shock
There are bad days and then there are really bad days. In many ways, the occurrence of septic shock is a culmination of a lot of bad things that can happen to you. Septic shock is the condition your body finds itself in as a result, progression and complication of a serious infection (The most common cause is pneumonia, but urinary tract and abdominal infections are also major causes.). This infection overwhelms your body, producing a massive inflammatory reaction, bringing many complications along. These complications include a significant drop in your blood pressure and can also include organ failure, most notably of the heart and lungs. Septic shock doesn’t occur to just anyone. It most often occurs in those with weakened immunity in one form or other (elderly, immunocompromised, diabetics, recent surgery, infection or prolonged hospital stay, burn victims, newborns and the pregnant), and it is the single most common cause of death in intensive care units in the U.S.
Signs and symptoms are routine and include low blood pressure, confusion or other signs of altered mental status, fever, chills and a fast heart rate, weakness, shortness of breath and noticeably diminished urination. Don’t focus on that list, though. Septic shock is a situation where your physician will know it when s/he sees it. If something like this happened at home, you’d recognize that something horrible was wrong, and you’d find yourself in an emergency room.

In terms of treatment, the ‘when’ is just as the important as ‘how’. The earlier this is diagnosed and treatment is started, the better chances of survival are. And let there be no doubt. Life is in the balance with this condition. Treatment simultaneously seeks to hold the patient up and support him/her while the underlying condition is being addressed. This is when the big guns are pulled in, including major antibiotics, intravenous fluids to rehydrate you, medications to support and enhance blood pressure and possible use of a breathing machine (ventilator) to ensure optimal oxygenation. Even surgery may be necessary to remove dead abdominal tissue, burn tissue or an abscess that may be the source of an infection.

The truth is septic shock carries a death (mortality) rate of 50%. It is always a bad situation and is best viewed as a medical miracle when survived as opposed to a treatment failure when death occurs. I can only wish you and your family the best if you find yourselves in this situation. Time is tissue.
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Straight, No Chaser: The Week in Review

General Health and Wellness, The Week In Review, , , , ,

week_in_review915
Another information packed week is in the bag.  Thanks for all the comments and suggestions for posts.  I’ll try to get to them as the schedule allows.  In the meantime, be sure to use the information I’m giving you.  I’m not just doing this for fun!  On to the week…
On Sunday, we began the week with a review of MRSA, a variant of the bacteria Staph Aureus, made into a ‘superbug’ by resistance to many traditionally used penicillin-class antibiotics.  We only talked about the skin infections (believe me, it gets much worse), but those are very important as a portal of entry to the rest of your body.  Pay attention to the tips given to stay clear of it.
On Monday, we began a ‘Life Over 40’ series by reviewing changes in the aging skin.  Remember to hydrate, moisturize and limit naked exposure to the damaging effects of the sun.  We also looked at folliculitis, another skin infection caused by Staph and often attributed to shaving and hot tubs.  You’ll think of me the next time a hotel wants you to reuse a towel.
On Tuesday, we looked at changes to your muscles and tendons as you age.  I didn’t mean to scare anyone, but it did appear that I sent some of you to the gym!  Get a personal trainer, and don’t hurt yourself.  We also taught some readers a new word: vaginismus.  This serious, painful and very treatable condition is a cause of much damage and destruction to relationships.  Think Kegels, and get help.
On Wednesday, we looked at changes to your genital system as you age.  The good news is good overall health leads to continued good sexual health as you age.  Even with your hormones seemingly working against you, there’s no reason for you not to stay sexually active as long as you desire.  We also started a series on erectile dysfunction, driving home the same points.  Keep that blood flowing throughout your body, and a lot of good things will happen.
On Thursday, we looked at changes to your heart and lungs as you age.  This really is a great topic with good news for you.  Remember that your heart and lungs will last a lot longer than you typically allow them to if you avoid the toxins that affect you.  We also reviewed the various disease entities that can cause erectile dysfunction.  The common thread is bad health that affects your blood flow will diminish your ability to stay sexually active.
On Friday, we addressed the ways your brain is affected by aging.  Let this serve as a warning to you.  The physical, mental and social effects of brain damage are devastating and epitomizes the stigma of aging.  This is to be forestalled as best you can for as long as you can.  We also gave a look at the treatment options for erectile dysfunction.  Did you know anything about injections, suppositories and pumps?  Did you recognize Smiling Bob?
On Saturday, we gave you a best practices tool many physicians use to determine the need for treatment of strep throat.  Although you may try this at home, as always, if you have concerns, ask your physician what should be done.  The week came full circle with a discussion about inappropriate antibiotic use.  We truly underestimate the body’s ability to cure most illness and too often rush for a solution in a pill.  We’d be better off saving that option for when we really need it, as that gives the highest probability that antibiotics will remain effective.
Thanks as always for your readership and support.  Your feedback and comments are much appreciated.
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Straight, No Chaser: Life Begins (To End) at 40 (Unless It Doesn’t) – The Cerebrovascular System (Your Brain)

General Health and Wellness, Neurology, Health Prevention, , , , , , ,

brainaging

Last but not least, in the first part of this series, let’s talk about your brain. But first a summary comment. Life after 40 poses both opportunity and obstacles. 35 to 40 is either the age when your lifestyle begins to catch up with you, or the work you’ve put in begins to pay off. For those who’ve lived life smartly and healthily, 40 really is the new 30. For those who’ve lived life less diligently, 40 may as well be 60, and your health probably reflects that. It’s really not that difficult. Diet, exercise, don’t smoke and alcohol in moderation keeps a body strong. Now to your brain…

Changes: As you age, cholesterol based blockages (plaque formation) inside the arteries and hardening of the arteries in the blood vessels that supply the brain is called cerebrovascular disease, and it causes strokes. These changes begin in earnest at about age 35. Prior to the complete blockage of the blood vessels, the brain is deprived of adequate blood flow (and oxygen) resulting in less than optimal brain functioning, such as confusion, disorientation, memory loss and ‘mini-strokes’ (TIAs). Strokes may result in paralysis, speech disorder, and sensory deprivation in varying degrees.
Challenges: Unlike many of the other systems I’ve discussed, the effects of these changes on our brain health status can be drastic, ranging from slight discomfort to death, and they involve major physical as well as social components. The social implications of these effects can be just as severe as the physical, as those suffering become less functional both mentally and physically. Unfortunately, in varying degrees stroke survivors become or perceive themselves to be a burden to others. Social interactions are doubly inhibited: internally, the patient is less able to interact; and externally, family, friends, and others may be less interested in interacting with them. This is sad, but true (think about the lives of the stroke survivors you may know…).
Solutions: The alternatives are twofold: after the fact, education is essential by a loved one’s support group and community, otherwise a stroke becomes a different type of life sentence. Physical and occupational therapy save lives and the quality of lives. Continuing to value and show value to your loved ones can make all the difference in the world. Before the fact, again, it’s preventive measures such as diet and exercise that have been shown to decrease or even prevent strokes. I cannot overemphasize how vital diet, exercise and the avoidance of toxins are to your long-term health.
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Straight, No Chaser: Erectile Dysfunction, Part Two – Causes

General Health and Wellness, Genital/Urinary, Health Prevention, , , , , ,

Causes-of-Erectile-Dysfunction-ED-Treament-Today
In my last post on erectile dysfunction (ED), I gave a simplistic way to understand and address it.  However, the truth of the matter is the overwhelming majority of cases of ED are not related to stress or other psychological issues.  First, some sense of ‘reasonable’, expected performance should be established, especially as one ages (as discussed here).  Beyond that, you should know that approximately 90% of ED cases involve an underlying medical concern, including, but not limited to, the following:

Diabetes

High blood pressure

Changes/disease to your blood vessels

Low testosterone

Kidney disease

Smoking

Alcohol and Drug abuse

Obesity and High cholesterol

Effects of your medications

Therefore, today’s message is simple and brief, but I’d suggest it’s probably more important than you have previously thought. You should consult your physician if and when you or your partner’s sexual performance becomes an issue. You may actually discover something that will not only save his performance, but his life.
Finally, in the next post we will review the wide variety of treatment options for ED.
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Straight, No Chaser: Erectile Dysfunction, Part One

General Health and Wellness, Genital/Urinary, Health Prevention, , , , , , ,

erectile-dysfunction
It seems appropriate to follow-up a post on age-related changes in your genitourinary system with a discussion on erectile dysfunction (ED).  The nature of the topic is such that I’m going to approach this in two different ways.  Today, I’ll give you a functional, overly simplistic view of ED and tomorrow, I’ll look at it from more of a clinical orientation, because there really are nuances involved. So keep in mind the lead picture. There are many medical and psychological issues that can lead to problems having erections.  I’ll get into that more tomorrow.
In many ways, your health is related to the quality of your blood flow, both in quantity (successful circulation to tissues) and quality (relative absence of toxins we ingest and deliver throughout). This is true for the brain (mental health, absence of strokes), the heart (stamina, absence of heart disease/attacks), and your penis (sexual function, lack of impotence), as well as every other organ.

Excluding truly medical considerations, the two surest ways I know to be a sexual stud (without implants or being of a certain age) are to have a legitimately healthy ego (psychologic health) and more importantly, to be in good physical shape and otherwise healthy. However, for now, given that an erection simply results from strong blood flow to the penis, your overall health better enables that process (the first time as well as if you want multiple contiguous encounters). Everything being equal, the best way for a guy to be able to have sex for whatever you define as a ‘sufficient’ period of time (besides being of a certain young age) is to maintain good cardiovascular health by spending that physician-recommended 20-30″ or more at a time on a treadmill, bike, running, etc.

Drugs like Viagra, Cialis, etc. are really nothing more than drugs that lower blood pressure (and resulting demands by other bodily organs on your blood), such that your penis’ call for an erection is otherwise unimpeded.  Sounds good?  The risk is varying forms of a ‘steal syndrome’, where that blood isn’t being distributed to your heart and brain, which could result in a heart attack or stroke.  That’s why you must “ask your doctor if you’re healthy enough for sex” before using…
Bottom line: practice for good sex and stamina during sex by working out.  It’s just another benefit to being healthy.
I welcome any questions or comments you may have.
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Straight, No Chaser: The Week In Review

General Health and Wellness, The Week In Review, , , , , , ,

week-in-review-header3-589x237
Happy Sunday, everyone. In the midst another all-time best week here, I got to discuss the topics I spend most of my time discussing with patients in the emergency department: high blood pressure, smoking and obesity. What that triad has in common is how they manifest in many different disease presentations. Well, at least now you know. I guess drinking and STDs will have to wait for another time. Here’s your week in review. Feel free to click the underlined topics to access the original posts.
We started the week on Sunday reviewing how the nerve gas sarin, allegedly used against the citizens of Syria, creates death and disease. Someone actually asked me why the victim in the lead picture was wearing shaving cream. That’s not shaving cream, folks. Victims wallow in their own secretions from everywhere, including salivation, excessive tearing, runny nose, diarrhea, urination, vomiting and lung secretions before they die of respiratory failure. We certain wish the best for the people of Syria and the country as a whole.
We spent Monday reviewing high blood pressure (hypertension), also known as the silent killer because yes, it can cause you to drop dead without knowing what happened. Just remember to try not to poison the pump that delivers oxygen and nourishment throughout the body (That would be your heart!). In part two of our hypertension review, we gave you numbers to know for monitoring your blood pressure and cues as to when that high pressure warrants a visit to the ER. I’d suggest you commit a few brain cells to that information. That’s information that could save your life, given the time dependent nature of treating the strokes and heart attacks that result from high blood pressure.
On Tuesday, we began reviewing smoking cessation and the benefits associated with it. We also discussed best practices in achieving smoking cessation. It remains interesting that many more people use the patch to stop (and many do so successfully), but stopping cold turkey remains the most effective way of stopping, for those able to pull it off. Consider the 10 Quick Tips I offered and consider working with your physician on the START method. I know this is a struggle. Over two-thirds of smokers want to stop, and over half attempt to stop every year. I wish you the best if you’re in that group.
On Wednesday, we took a look at obesity in America. Based on the data, it’s clear more people are choosing the pursuit of happiness (in excess) over the pursuit of health. That said, we’re still doing something right, as our life expectancy continues to increase despite approximately two-thirds of us being overweight (although we’re living longer with more disease).
On Thursday, we reviewed the health risks of obesity and introduced you to the caloric equation, which largely determines if you’re gaining or losing weight. It’s actually a pretty simple concept that you might consider learning, because every bit you lose reduces the load on your heart (in particular) and other organs. These relative, incremental amounts do matter.
Friday was a fun day, because we discussed solutions instead of just problems. We talked about how to lose weight the good old-fashioned way, reviewing how to pace yourself, set reasonable expectations and lose healthily. Just remember it’s going to take a lifestyle change, not a fad. The tortoise always did beat the hare. On Friday, we also discussed how to jump-start your metabolism, regardless of age. The Quick Tips I gave you couldn’t be simpler and do make a difference.
On Saturday, we completely switched gears and reviewed the painful topic of hemorrhoids. Don’t forget the self-help tip ‘WASH’, and trust me, your goal is to stay away from the ER or surgeon with these. Deal with them sooner rather than later, before it becomes a pain for everyone involved! Saturday, we returned to smoking – this time of the cigar variety. I had to bring the Surgeon General along to point out the cigar smoking is not a safe alternative to cigarettes. Can you believe a single large cigar contains as much nicotine as an entire pack of cigarettes? Who knew?
Your comments, concerns and disagreements are welcome. My goal is always to provide you information that you incorporate into making your lives happier and healthier, not to be the ‘health morality police’. As the obesity posts noted, there is too often a crossroads between health and happiness. When you’re younger, you really are investing in your health to secure your future happiness, because as you age, there is a much higher correlation being your health and your happiness. My mental health colleagues will be quick to tell you how the lack of health as you age leads to higher rates of depression and suicide in the elderly. Your goal is to head down the road that offers both health and happiness. And speaking of aging…
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Straight No Chaser: Got Hemorrhoids?

Gastrointestinal, Genital/Urinary, , , , , , , , , , ,

hemorrhoid Bath reading

Yes, you do.  I can hear you now.  Aww, doc!  Why are you talking about this first thing in the morning?  Well, a lot of you have them 24 hours a day, so now is as good as a time as any.  I know this topic is a pain (no pun intended), but you should consider reading this before your next bowel movement.
Let’s talk about hemorrhoids, and we’re gonna make this simple.
1. What are they?  Hemorrhoids are swollen veins either inside (internal hemorrhoids) or outside (external hemorrhoids) the anal canal.  It’s not uncommon for people to have both types at the same time.  You should wonder if you have them if and when you experience pain, bleeding and itching to the perianal area.
2. Why do you get them?  It’s all about pressure.  The blood that is circulating to the skin near the anus finds itself in outpoutchings when you strain and stretch the skin while having a bowel movement.  Pregnancy is another time when hemorrhoids become common.  I’ve literally seen hemorrhoids form before my eyes during the straining of childbirth.  The table is set for that in advance, as the pressure of the last two trimesters on the pelvic vessels also causes development of hemorrhoids.  The same goes for the obese.  Plus, you sit too much.
3. How can I prevent them?  You should start with ensuring that you’re eating a high fiber diet (fruits, vegetables and whole grains), exercising and drinking a lot of water.  Becoming constipated and having to strain is a sure way to developing hemorrhoids.  Does anyone remember Al Bundy from Married with Children?  Notice how he always took a newspaper to the toilet?  That’s the other part of prevention.  Allowing your bowel movements to occur on their time-table without you straining keeps you without hemorrhoids.
4. How can I treat them?  The problem with hemorrhoids is they hurt, and hurting causes a vicious cycle.  Because they hurt (and bleed), you don’t want to have another bowel movement.  If you’re not having bowel movements, chances are you’ll get constipated.  If you get constipated, you’ll have to strain and endure pain.  And the cycle continues…  So, in order to break the cycle – WASH yourself (like the young lady in the lead picture).

  • Water (sitz bath)
  • Analgesics (pain medication, either topically or by mouth)
  • Stool softeners
  • High fiber diet

5. How will your physician treat them?  Treatment in an emergency room setting is largely dependent on whether or not the external hemorrhoid has developed a blood clot (as shown in the lead picture).  These are the type that are especially painful and are called thrombosed external hemorrhoids.

  • Non-thrombosed internal hemorrhoids usually are initially treated conservatively as described above.
  • Sometimes internal hemorrhoids will need to be tied off with a surgical band, eliminating the blood supply to the hemorrhoid and forcing it to shrink or fall away.  Alternatively, the tissue around the internal hemorrhoid may be surgically scarred (ouch!) to the same effect.
  • Thrombosed external hemorrhoids need to have the clot removed.  This is done by the physician with a particular type of incision.

By this point, you should be thinking “I’ll take the prevention!”.  Trust me, that’s the correct choice.
As an emergency physician, I’m even more concerned about the possibility of something else being wrong.  Given that 10 million Americans are walking around with hemorrhoids anyway, that rectal bleeding could be due to something else, such as rectal, anal or colon cancer.  You may receive additional examinations specifically to rule out those considerations (they may involve tubes, probes and/or scoping).  Feel free to ask if you really want details.
Feel free to read this again as motivation during your next bowel movement.
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Straight, No Chaser: The Week In Review

Medical Treatment, Public Health, Health Prevention, , , , , , , , ,

WeekInReview_thumb2
Based on the response to this week’s posts, I’d say it was an informative week for you.  Remember to click the underlined topics to go to the mentioned post.  Let’s recap the week.
On Sunday, we reviewed night terrors and differentiated them from nightmares.  Remember, if your child develops these, it’s very important to protect them from harm during the episode, and try to identify the source of any increased stress.
On Monday, we reviewed the late Dr. Martin Luther King, Jr.’s comments on healthcare and its relevance today.  Injustice in healthcare is still shocking and inhuman, as health care disparities abound.  Monday also brought a review of the Patient Protection and Affordable Care Act (ACA), also known as Obamacare.  As the time of implementation gets closer, I will revisit implementation of the ACA, particularly health care exchanges, what your options are, and what’s to be done with the 20 million Americans who will still be uninsured.  I will also be discussing how this blog and my national efforts will dovetail into these considerations.  Stay tuned.
On Tuesday, we began our series on toxins and detoxification.  The first post discussed the power our body naturally and normally has to detoxify and to defend us from harm.  The second post offered specific, natural Quick Tips to enhance your body’s capabilities.  Taken together, I strongly recommend you internalize this information (no put intended).  All the other exotic methods typically promoted are, at best, enhancements to what we already do unless disease limits us.  At worst, they can cause damage themselves.
On Wednesday, we looked at some of the environmentally toxic dangers to our bodies, focusing on various toxins affecting our lungs, skin, kidneys, liver and intestines.  If knowledge is power, your brain should be stuffed after reading that post.  Stop smoking (Yes, you.).  Wednesday also brought a review of detox diets.  My advice is simple.  Proceed with caution, and don’t expect any miracle cures.  In fact, the better course of action is to use any such efforts as a launch into a more modest long-term regimen of healthy diet and exercise.
On Thursday, we reviewed colon cleansing, looking at oral solutions and rectal colonics.  These were turbulent topics, to say the least.  Please consult your physician before starting any of these diets or cleansing programs.  They are not without risk and consequence in certain patients.  Thursday also brought a review and wrap-up of the toxin/detoxification series.  I enjoyed your questions, comments and thoughts.
On Friday, we reviewed insomnia.  Do you remember the difference between primary and secondary insomnia?  There are important treatment considerations attached to each, so consider reviewing.  I also gave you 10 Quick Tips to help your difficulty sleeping and answered your questions. 
On Saturday, we peeled back the brains of physicians and taught you how we decide if and when ankle x-rays are needed.  I really do want your feedback when you mention the Ottawa Ankle Rules to your physicians.  I’m sure you’ll have stories about hearing them muttering “Damn internet!” under their breath!  Saturday also brought a review of a normal calorie intake.  I think this is a pretty important topic for several reasons.  I hope you learned the different between sedentary, moderately active and active lifestyles.  Also, many of us have no idea how much we should be eating and how many calories we should have daily.  Also, this will serve as a nice launching pad for my review of obesity next week.
Speaking of the next two weeks, I will be focusing on revisiting some fundamental bread and butter topics (no pun intended).  I continue to hope you enjoy Straight, No Chaser and appreciate your supporting this blog, which has now reached readers in 60 countries around the world in every continent.  I’ll keep bringing the information, and you keep taking advantage of it.

Straight, No Chaser: Your Rebuttals and Questions about Insomnia

Medical Treatment, Sleep, Health Prevention, , , , , , , , , , ,

You are certainly an entertaining group behind the scenes. Here are some of your questions on insomnia. Be reminded that should you want to leave me a private question, just go to the Home Page, or type https://jeffreysterlingmd.com into your browser. Here’s five questions from this morning’s post on insomnia.
1. Aw, hell! You’re telling me I can be dying from something causing insomnia?

  • It’s way more likely that level of stress you’re displaying is keeping you awake at night.

2. How is it that sex makes you sleepy?

  • When you do exert yourself vigorously, the greater utilization of muscles will deplete glycogen (energy) stores and make you drowsy. Also, it’s well established that certain hormones (e.g. prolactin, GABA and oxytocin) that promote sleep are released after an orgasm.

3. You mentioned tea. A good cup of tea at bedtime helps me sleep.

  • If that works for you, go for it. Some people have paradoxical effects to stimulants (In fact, stimulants are the most common treatment for ADHD – a topic for another day.)

4. What about giving my baby Benadryl?
I’m giving information here, not practicing medicine, so that’s a question for your physician. I will say there are many drugs (most notably those in the anticholingeric class) that have drowsiness as a side effect, and many emergency departments will give Benadryl to adults for that purpose. That said, these medications are not primarily used for drowsiness, and you’ll have to deal with other drug effects (such as the intended purpose for the medication) in addition to any possible drowsiness that occurs.
5. Sex at night keeps me wide awake.
That’s why a lot of you are shy about putting comments in the inbox… Sorry, but the answer to that question was not meant for public consumption.
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Straight, No Chaser: Insomnia – You are Not Getting Sleepy…

Medical Treatment, Sleep, Health Prevention, , , , , , , ,

insomniahypnosis

Talking about insomnia makes me well, tired. You know what the problem is. You either can’t fall asleep, or you can’t stay asleep. You’re tired when you wake and all throughout the day. Lack of sleep saps your energy and your productivity.
Insomnia really isn’t very cool to deal with, either as a person or as a physician. Patients are frustrated and sometimes cranky from being tired, or they can be extremely nervous and stressed, which will perpetuate a vicious cycle. There are so many mental factors that can disrupt your ability to sleep.
Medical professionals tend to think of insomnia in two forms for purposes of evaluation. Either the insomnia is the main problem (primary insomnia), or it’s secondary to another condition (secondary insomnia) such as reflux, uncontrolled asthma, arthritis or other pain syndromes. It could be due to medications, depression or just stress. It could be due to some undiagnosed condition, such as cancer, an enlarged prostate (making you have to get up to urinate throughout the night), thyroid disease or sleep apnea. Then there’s the caffeine (coffee/tea), nicotine (cigarettes) and drunk scene (alcohol).
The thing is, whether acute, intermittent or chronic, any insomnia really is an inconvenience and can even be incapacitating. Before you subject yourself to a million dollar medical workup, just remember, if it’s secondary insomnia, and you know (for example) that your pain is keeping you awake, try dealing with the primary issue. Alternatively, if it’s primary insomnia, there are a lot of things you might consider trying. In fact, consider this my Top Ten Tips, presented in the order you might consider implementing them.

  • Good diet and exercise habits make your body perform as they should and will clean up a lot of potential problems that will affect sleep.
  • Avoid naps during the day. You want to be good, tired and ready to sleep when night comes.
  • Develop the habit of only using your bed for sleep or sex. That conditions your body to be ready to sleep when confronted with the stimulus of your bed.
  • Get your snoring partner some help if s/he is part of what keeps you awake. Check here for tips to deal with snoring.
  • Try not to eat for several (3-4) hours before you sleep. Nothing says ‘no sleep’ like heartburn all night (By the way, this is the real reason you shouldn’t eat after a certain hour – not concerns about your weight.).
  • Similarly, avoid nighttime stimulants (e.g. cigarettes, coffee, tea and exercise close to the time you want to sleep, if this proves to be a problem).
  • Although alcohol is a sedative, it’s also on the don’t-do list because it can cause restless sleep and interrupt the sleep cycle.
  • Find a way to relax before sleep. Consider a bath, sex, a book or soothing music. Or all of them.
  • Set the alarm for the morning, then hide your clock. You don’t need to have a clock to remind you that you aren’t sleeping all night.
  • Use ‘white noise’ for background if you’re bothered by other sounds.

Here’s a bonus tip: If you fell asleep during the reading of this post, keep it for future reference.
As Edward R. Murrow used to say (well before I was born): Good night, and good luck.
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Straight, No Chaser: Quick Tips – You Snore Too Much

Neurology, Sleep, Health Prevention, , , , , , ,

snoring
You snore too much.  What this means is your breathing is intermittently partially obstructed while you’re sleeping.  Snoring is the sound of air moving past that obstruction.  Whether serious or not, first you should know it’s common, occurring in about 50% of adults.    It could be serious or just positional.  Here are some Quick Tips for you.

  • Sleep on your side.  This should remove the tongue as a cause of a partial obstruction.
  • Avoid sedatives if possible.  Sedatives cause significant enough relaxation to the tissues in your throat to cause that partial obstruction.
  • Limit alcohol before sleeping (by about two hours).  Alcohol is a sedative.
  • Elevate the head of your bed or prop your head up by about 4-6 inches.  This should manually move partially obstructing tissue out of the way.
  • Fix what ails your nose.  If you have chronic problems with nasal obstruction or a deviated nasal septum, you’re more inclined to breathe through your mouth.  This will increase the chances that you snore.  Similarly, those nasal strips you may have seen work (when they do) by increase the area in the nose through which they can breathe.
  • Finally, losing weight (if you have it to lose) works by reducing the tissues in and around your throat that cause snoring.

It’s time to see your physician if you find yourself awakening from sleep choking, gasping or otherwise short of breath.  This could be an indicator of a serious condition, including sleep apnea.  Additionally, you may want to seek care if your sleeping causes functional problems (e.g. you or your partner have difficulty sleeping as a result of your snoring).
This is a significant enough issue that I will revisit it in the future.  In the meantime, sleep well.

Straight, No Chaser: Your Questions on When Fainting is Fatal

Neurology, , , , , , ,

fainting
1. So are faints deadly?

  • Potentially. There are three separate sets of considerations. The brain can’t survive very long without adequate oxygen. Whatever caused that faint, if it continues to deny oxygen to the brain, can lead to seizures, strokes and death.
  • The process that caused the faint could be deadly in and of itself. Such things would include heart attacks, strokes, seizures due to bleeding inside the brain.
  • Significant injuries may occur after the faint. Someone who falls may subsequently suffer a head or neck injury, which could be deadly, independent of the cause of the faint. It’s worth mentioning that it’s an especially odd behavior that people seem to travel to the bathroom when they feel dizzy. All things considered, it’s better to faint in your soft bed or surrounding carpeted floor than on the hard tile of a typical bathroom with even harder sinks, toilets and tubs in close proximity.

2. My doctor always warns me about high blood sugars. You mentioned low blood sugars as a cause of faints. Am I putting myself in danger if I’m taking sugar and my sugar level is already high?

  • If you know all of that, yes. More often, you know none of that. Here’s the deal. Both a high and low glucose (blood sugar) count can cause altered mental status, fainting and coma. If your glucose level is especially high, say 900, and you drink some orange juice, it won’t make much of a difference. If your glucose level is 0, and you are given some orange juice, your life just got saved. In other words, it’s medically worth the risk if you don’t know what the glucose level is.

3. Can a loved one really take my breath away?
Yes. Overstimulation can lead to syncope in a variety of ways as mentioned previously.
4. What’s with the goats?
If you’re referring to Tennessee fainting goats, they exist. The goats don’t actually faint. When startled, they become stiff to the point of being unable to move their legs. Subsequently, the terrified goats can’t run and just topple over. Here you go.
faintinggoats

Straight, No Chaser: This is Specifically For the Faint of Heart

Cardiology/Heart, Medical Treatment, Neurology, Health Prevention, , , , , , , , , , , , ,

faint
Don’t faints seem mysterious?  It’s as if your computer crashed and had to reboot.  Although we never seemingly figure out why computers are so crazy, fainting (syncope) is reducible to a common denominator: something causes a decrease in blood flow to your brain.  Recall that oxygen and other needed nutrients are carried in blood, so even a temporary stoppage or shortage of blood flow shuts things down.  Now extrapolate that to strokes and comas, which are often due to serious and prolonged causes of blockage to the blood vessels supplying the brain.  This is a prime example of why good blood flow and good health are so important.  The brain is a highly efficient, oxygen and energy-guzzling organ.  Shut it down for even a few seconds, and bad things start to happen.  Consider fainting a warning sign.
I’m going to start by offering some Quick Tips to help if you find yourself around someone who has fainted.  Then, I will get into the weeds of why these things happen for those interested.  I’m doing this so you can check these and determine where your risks may be.

  • Call 911.  Make sure the person is still breathing and has a pulse.  If not, start CPR.
  • Loosen clothing, especially around the neck.
  • Elevate the legs above the level of the chest.
  • If the fainter vomited, turn him/her to the side to help avoid choking and food going down the airway (aspiration).
  • A diabetic may have been given instructions to eat or drink something if s/he feels as if s/he is going to faint.  If you know this, a faint would be a good time to administer any glucose gel or supplies advised by a physician.  Prompt treatment of low blood sugar reactions is a life-saver.  Discuss and coordinate how you can perform this effort on behalf of your friends and family with their physicians.
  • If it’s possible that the faint is part of some heat emergency (heat exhaustion or heat stroke), follow these steps to save a life (click here).

Actually, faints are caused by all kinds of medical problems.  I list a few notable causes below, but whether the front end difficulty is with the heart pumping, the nerves conducting, or the content of oxygen or energy being delivered, the end result is the same.

  • Decreased nerve tone (vasovagal syncope): This is the most common cause of faints, and contrary to what you might think, it happens more often in kids and young adults than in the elderly.  Understand that your nerves actually regulate blood flow (analogous to a train conductor telling the heart to speed up or pump harder or not).  Changes in nerve tone can result in errant signals being sent, transiently resulting in low flow.
  • Diseases and conditions that affect the nervous system and/or ability to regulate blood pressure: Alcoholism, dehydration, diabetes and malnutrition are conditions that may depress the nervous system.  Alternatively, coughing, having a bowel movement (especially if straining) and urination may abnormally stimulate the system.  In the elderly and those bedridden, simply standing can cause fainting due to difficulty regulating blood pressure.  In this case, standing causes a sharp drop in blood pressure.
  • Anemia: A deficiency in blood cells can lead to a deficiency in oxygen delivery to the brain.
  • Arrhythmias (irregular heart beats): Inefficiency in your heartbeat leads to unstable delivery of blood to the brain.
  • Low blood sugar (hypoglycemia): Low energy states can deplete the body of what it needs to operate effectively, leading to low blood flow.
  • Medications (especially those treating high blood pressure): anything that lowers the heart’s ability to vigorously pump blood around the body can leave the brain inadequately supplied, leading to a blackout.  Let’s include illicit drugs and alcohol in this category.
  • Panic attacks: Hyperventilation caused by anxiety and panic upset the balance between oxygen and carbon dioxide in the brain, which can lead to fainting spells.
  • Seizures: Here’s a chicken and egg scenario.  A prolonged faint can lead to a seizure, and seizures lead to periods of unconsciousness, during and after the seizure.  The lack of oxygen is a common denominator.

Straight, No Chaser: Quick Tips on Bedwetting

Genital/Urinary, Neurology, Pediatrics/Kids Health, Health Prevention, , , , , , , , ,

bedwetting
Bedwetting (enuresis) is unintentional urination while asleep.  It could be part of normal bladder development or a cause for concern.  Most kids are toilet trained by 4 years old, and less than 5% of kids are still wetting the bed between ages 8-11.  Here’s some quick tips to help you figure out the difference.

  1. If your child is bedwetting below age 7, and no external cause is in play, you will most likely be reassured if you see a healthcare professional.  Specific treatments for bedwetting aren’t started until at or after age 7.
  2. If bedwetting occurs in conjunction with foul-smelling urine, pain or other discomfort with urine, urinary frequency or enhanced urge to go during the day, your child could have a bladder (urinary tract) infection.  Symptoms may be resolved with antibiotics.
  3. If bedwetting occurs in conjunction with a change in urinary color, this could be a medical issue.  Changes could include urine becoming pink, cloudy, bloody or clear.
  4. Many children who wet the bed also have constipation.  Resolving constipation has been shown to resolve bedwetting in up to 60% of children.  Be on the lookout for this.
  5. Is the bedwetting occurring with snoring?  This could be a sign of sleep apnea.
  6. It is very important for parents to appreciate the behavioral components in play.  Stress can be a significant contributor to bedwetting.  If you reinforce positive behaviors, resolution of bedwetting may occur sooner than otherwise.  If you are relatively unsupportive and critical, symptoms may linger and become more profound.  Techniques such as gold stars and other rewards have proven to be effective.

Despite the topic, this post was intentionally dry.  Good luck.

Straight, No Chaser: Quick Tips for the Drowning Victim

Medical Treatment, Trauma, Health Prevention, , , , , , ,

Drowning_safety_children_CPSC

  1. If the victim is still conscious, attempt to hand him something that can be used to pull him from the water. If you’re out of handing distance, throw either a floatable object or something he can hold onto and with which he can be pulled to safety.
  2. If the victim has fallen into solid ice, and you have enough individuals, consider forming a human rope, with each individual interconnected and at least two individuals safely connected back on firm land.
  3. The victim should be removed from the water at the earliest opportunity. Forego inclination to perform chest compressions or rescue breathing in the water.
  4. If possible, remove the victim from the water as flat (horizontal) as possible. You want to make every effort to avoid damage to the neck throughout this entire process (This actually would be additional injury to the neck; there’s a fair chance such an injury has already occurred.).
  5. Once victims are out of the water, NEVER assume death unless you’re a qualified medical professional. Begin CPR, as described in yesterday’s post (Click here to review.).
  6. If the victim has an altered mental status, check the airway for foreign material and vomitus. Use your fingers to sweep away any material visible between the mouth and throat.
  7. The Heimlich maneuver (abdominal thrusting) is not effective in removing swallowed water. Don’t waste valuable time with it.
  8. If you’ve successfully saved a drowning victim, don’t bother taking off wet clothes. It’s not worth the possible agitation to the neck, and recent medical thought suggests that cooling after certain likely types of cardiac arrest is especially beneficial in reducing brain injury and death. This consideration is much more important than any benefit to be gained from warming the patient. Sounds weird, but it’s the truth.

Regarding the lead picture, yes it’s true that one can drown in inches of water. Infant safety means keeping them at arm’s length while they’re in the water.

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