three dot medicine

Saturday, June 24, 2017

Time for three dot medical journalism, with a nod of respect to Herb Caen.

Fractures...Just because you can move it, doesn’t mean that it isn’t broken. All it means is that the muscles and tendons surrounding an injured bone still work…If you thought that a normal x-ray means that the bone is okay, think again. In some circumstances, regular x-rays miss significant breaks and CT or MRI are needed if the clinical suspicion of a fracture is high…And by the way, fractured, broken and cracked all mean the same thing.

Strep…People equate a sore throat and strep infection…Most sore throats are caused by a virus and do not need antibiotics…When an antibiotic is prescribed for strep, it is not to make the throat feel better faster…Once upon a time, untreated strep throat could lead to rheumatic fever and then rheumatic heart disease, an inflammation of the heart valves…Now, rheumatic fever is so rare in the US that the Centers for Disease Control and Prevention don’t require it to be reported…There is an exception for children of Samoan or Fijian descent who live in Hawaii have an increased predisposition to post strep heart disease.

Narcotics...The downside to the national opioid prescription crisis…If you wonder why it might be taking longer to get your narcotic pain prescription written… many states now require providers to log onto controlled substance registries to check how often and how many prescriptions have been filled in the recent past…The goal is to limit the abuse of narcotics and sedatives but it also makes patients wait…Some of the websites can be more than a little slow.

Drug interactions...Summer is the time to travel and included in the packing list should be an update list of medications including names and dosage…Having just returned from giving a talk in Pinehurst NC, a mecca for golf vacationers, I had an earful from local docs whose ability to care for patients is hamstrung by a lack of information…Many medications, including antibiotics can interact with each other causing problems… Remember that herbal and over the counter medications count.

Wound infections...Summer is also the time to hang out on the water…Cuts and scrapes will happen but it’s important to avoid the reflex of washing them in the natural water…What was a simple laceration that could be sutured can be turned into a complicated mess if the wound was dunked into a river…Each region of the country has its own bad bacteria and the “do no harm” caveat holds especially true when it comes to sewing up wounds.

Watching…And for those who wonder why medical care takes so long to happen…A reminder that on television, most medical dramas have 40-45 minutes of action, 15 minutes of more of commercials and a minute tease for the next episode…in the real world, going straight to a high tech test or treatment may not be appropriate…Sometimes, time is an important part of the diagnosis and observation may be the way to go…Watching  what happens to a patient over time may not make great television but it may make great medicine.



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Saturday, June 10, 2017

The problem with fame is that privacy is hard to come by. The problem with social media is the willingness of people to give up any privacy that they might have. Michael Oher, a lineman for the Carolina Panthers, posted an Instagram picture of the 10 prescription medications that he takes for concussion symptoms, and then quickly deleted the post. Nothing is ever truly deleted on the internet and the photo made its rounds. The need for ten prescriptions is a private matter between Mr. Oher and his physician, but that numbers of medications is not a rare occurrence but it is a big problem, especially in the elderly.

Many people suffer from multiple chronic conditions that can be interlinked and each might need specific treatment. Polypharmacy describes a patient taking more than four medications at a time and it especially affects the older population. Up to 40% of people older than 65 take that many pills and more than 10% take ten or more. Those aren’t just prescriptions, but also include over-the-counter medicines, herbal medications, and dietary and vitamin supplements. While each pill may have a benefit, interactions and complications increase with each added drug.

Ideally, chronic illnesses would not need any medication treatment. Some patients with high blood pressure and diabetes might be able to be treated with diet, exercise and weight loss, but may need medications to maintain lifelong control of their disease to prevent complications like heart attack and stroke. Some patients with high blood pressure (hypertension) may need two or three medications to keep their blood pressure controlled. In addition to insulin, some diabetics may need oral medications to lower blood sugar. Add high cholesterol and then the need for aspirin to help prevent heart disease and the number of pills needed on a daily basis grows quickly.

With each medication added, the risk of a significant complication or interaction increases. Drug interactions can happen inadvertently, even with over the counter pills.

  • patients with kidney disease or ulcers shouldn’t take ibuprofen or naproxen. NSAIDs can worsen kidney function and can cause bleeding in the esophagus, stomach or intestine
  • patients with liver issues should avoid acetaminophen (Tylenol), since it can be toxic to the liver. If there is major liver disease like cirrhosis, the NSAIDs might not be a good idea either because of the potential risk of bleeding. Patients with cirrhosis cannot make enough blood clotting factors and can have varices (swollen veins that can bleed)
  • those with high blood pressure should avoid cold medications containing phenylephrine, because it looks like adrenaline to the body increasing blood pressure readings
  • people on antidepressants that can cause drowsiness should not take Benadryl (diphenhydramine) which is used for allergies but is also the active ingredient in over the counter sleeping medications

There are plenty of drug interaction between prescription drugs. So many exist that electronic medical records and computer programs continually remind and warn doctors and pharmacists about what is safe to prescribe and what might cause problems. There are so many warning that error fatigue can occur…there are so many warning that they get ignored.

All may be well and good if there is just one provider coordinating medical care, but too often, there are lots of specialists trying to look after their one part of the body and nobody is charged with looking after the whole person. Adding to the confusion and potential for error is the mail-order pharmacy and lack of face time with the patient. But most importantly, it’s the patient who may not keep track of their pills and thinks nothing of walking into a convenience store to pick up a cold or pain medication without appreciating the potential harm that might occur.

And then there is Michael Oher. 10 prescription medications for a concussion is a whole bunch. He signed off his Instagram post with “SMH”, shaking my head…well, we are too.


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